Yes, the Medicare hospice benefit allows for chemotherapy and radiotherapy as long as the purpose is symptom relief. Medicare’s hospice rules do not allow for hospice and treatments intended as a cure at the same time. However, the amount Medicare pays hospice agencies makes it very unlikely for patients to be able to receive palliative radiotherapy under the hospice benefit.

Can Chemotherapy Be Palliative?

Yes. In certain types of cancer, even when no cure is expected, chemotherapy has been shown to slow the rate of declining appetite, delay pain during breathing, and delay constipation.¹ However, chemotherapy itself may make patients feel bad. Dr. Shi-Wi Wang of the Yale School of Public Health has stated that chemotherapy is used less often in symptom control because the harms of the toxicity can outweigh the benefits.²

Can Radiation Be Palliative?

On the other hand, Dr. Wang describes the side effects of radiotherapy as minor. The majority of patients with uncurable cancers suffer symptoms related to tumor growth.² Radiotherapy shrinks the tumors and relieves the symptoms. A study out of the Netherlands found that 61% of cancer patients received full or partial symptom relief from radiotherapy.⁴ However, that also means nearly four out of ten patients had no response or low response. Also, if doctors are not using single fraction radiation therapy, the treatment can mean hours per day in clinics for five days to three weeks. After all of that, the median response time was four weeks – meaning half of all patients receiving radiotherapy may take five or more weeks before there is symptom relief. Many hospice patients may not find that to be a worthwhile time investment.   

Does Hospice Cover Palliative Radiotherapy?

Radiation therapy during hospice is uncommon and becoming rarer. From 2011 to 2019, the percentage of hospices with patients receiving radiotherapy dropped from 12.8% to 5.4%. Only one out of twenty hospices have at least one patient per year receive radiotherapy under the hospice benefit. One of the biggest obstacles to palliative radiotherapy is Medicare reimbursement. Hospice benefits cover the service but do not pay the actual cost of the service. The Medicare hospice benefit is intended to cover all pain management therapies related to the hospice diagnosis, but the benefit only pays the hospice agency about $160 per day for routine home hospice care. From this, Medicare expects the hospice agency to pay for home medical equipment, pain meds, nursing visits, and more. Multiple sessions of radiotherapy can cost around $10,000, or over $500 per day.⁵

The Single-Fraction Radiotherapy Alternative

In radiotherapy, patients get one-dose per day, and the term “fraction” refers to the number of doses. So single-fraction radiotherapy means a larger dose all at once. The goal of fractioning the dose over multiple days is to have a larger effect on the tumor, but this does not seem to matter in palliative care. In terms of symptom control, multiple studies show that single-fraction (one treatment) radiotherapy is not inferior to multiple days of treatment.⁶ While this data has been available for roughly two decades, in the U.S., the more expensive palliative multifraction radiotherapy is more common.   

References

1. Roeland EJ, LeBlanc TW. Palliative chemotherapy: oxymoron or misunderstanding?. BMC Palliative Care. 2016 Dec;15(1):1-3.
2. Hsu SH, Wang SY. Trends in Provision of Palliative Radiotherapy and Chemotherapy Among Hospices in the United States, 2011-2018. JAMA Oncology. 2020 Jul 1;6(7):1106-8.
3. Miller SC, Mor V, Teno J. Hospice enrollment and pain assessment and management in nursing homes. Journal of Pain and Symptom Management. 2003 Sep 1;26(3):791-9.
4. van der Velden JM, van der Linden YM, Versteeg AL, Verlaan JJ, Gerlich AS, Pielkenrood BJ, Kasperts N, Verkooijen HM. Evaluation of effectiveness of palliative radiotherapy for bone metastases: a prospective cohort study. Journal of Radiation Oncology. 2018 Dec;7(4):325-33.
5. Schuster JM, Smith TJ, Coyne PJ, Lutz S, Anscher MS, Moghanaki D. Clinic offering affordable radiation therapy to increase access to care for patients enrolled in hospice. Journal of Oncology Practice. 2014 Nov;10(6):e390-5.
6. Nongkynrih A, Dhull AK, Kaushal V, Atri R, Dhankhar R, Kamboj K. Comparison of Single Versus Multifraction Radiotherapy in Palliation of Painful Bone Metastases. World Journal of Oncology. 2018 Jun;9(3):91.