radiation therapy in palliative care spring 2012
DESCRIPTION
Please see the Creative Commons License on the second slide. This slide deck is for medical education uses only and does not constitute medical advice. Please consult with your own health care provider.TRANSCRIPT
RADIATION THERAPYIN PALLIATIVE CARE
Christian Sinclair, MD, FAAHPM
Gentiva Health Systems
Spring 2012
Credits and Creative Commons Adopted with permission from
Jerry Baker, MD, Texas Oncology, Fort Worth, TXOriginally presented at the 2010 AAHPM Assembly
This talk is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License.
With attribution and sharing alike, you are free:to Share — to copy, distribute and transmit the work to Remix — to adapt the work to make commercial use of the work
Objectives
Understand the fundamentals of radiation therapy
Manage commonly expected side effects from radiation therapy
Identify three situations where palliative radiation may be effective in hospice patients
Questions
I don’t understand how radiation works to treat cancer. Can you explain it to me?
In which clinical situations is palliative radiation truly effective?
How do you decide how many treatments? Does radiation have to be so expensive? Any tips for working with a radiation
oncologist, or for simplifying the radiation process for patients?
Outline
Conventional Radiation Therapy Psychology of A Radiation Oncologist Palliative Radiation Therapy Hospice collaboration
Fundamentals
Curie’s discover Radium 1898 Biologic effects of ionizing radiation 1st ‘cure from radiation therapy 1899 1st radiation oncologists
DermatologistsLow-energy, low-output machines
Tissue Absorption
At any energy, x-rays are attenuated by tissue Absorbed dose decreases with depth Early treatments for deep tumors overdosed
superficial tissues
Advances in WWII
Higher energy toolsCobalt-60Linear accelerators
Penetrating radiationSkin-sparing effect
Without advanced imaging treatment focused on tumors easily seen
Volume-dose relationship
Greater tumor volume
requires
greater radiation dose
Dose-Damage Relationship
Higher radiation dose
increases risk for
damage to normal tissues
Finding BalanceBenefit of tumor control
versus
Risk of normal tissue injury
Selectivity of radiation effect:
Radiation damages DNALeads to cell death
Radiation not selective Variable DNA damage repair
Normal tissues repair damageMalignant cells do not repair well
Fractionation
Small does of radiation over time Most cancers sensitive to fractionated XRT Normal tissues protected by fractionation
↑ dose/fraction = ↑ risk late toxicity ↓ dose/fraction = ↓ risk late toxicity
3000 cGy in 15 fractions
(200 cGy/fraction)
≠3000 cGy in 10 fractions
(300 cGy/fraction)
Late Effects - Hypofractionation
YearsBrain and spinal cordFibrosisBowel
Months-yearsLung tissuelymphedema
Benefits - Hypofractionation
Radiation dose given quickly Faster tumor response Avoid multiple trips
Cancer Symptoms for XRT
Bleeding Pain Obstruction – Airway/Visceral Spinal cord compression Impending fractures Wounds Skin metastases
Bone Metastases
65-75% of advanced breast/prostate CA 30-40% of advanced lung cancer Skeletal-related events: pain, fracture,
compression, hypercalcemia SRE’s impact on QOL
Mobility and functional wellbeingDecrease ADL’sIncrease depression/anxietyIncrease opioid needs
Costa L et al. Support Care Cancer 2008;16:879‐889
Bone Metastases
HistoricallyPalliative XRT fractionated daily over 2-3 weeks
Over past 20 years9 large RCT (>4000 patients) all demonstrate
effectiveness of single fraction courses
Lutz ST et al. Cancer 2007;109:1462‐1470;
Coia LR et al. IJROBP 1988;14:1261‐1269.
Longer courses of treatment to higher total doses remain the most commonly use schedules in the United States. In a survey of 268 radiation oncologists in the United States
the physicians were asked about the management of a patient with bone metastases from breast cancer. The respondents recommended a median dose of 30 Gy given in
10 fractions, none recommended fewer than 7 treatments.
RTOG 97-14 – Painful Bone
Breast or Prostate cancer Painful bone mets Confirmed met by imaging Prognosis > 3 mos, KPS ≥ 40
RTOG 97-14 Results 1998-2002; 897 eligible patients 56% weight-bearing site, 72% pain score 7-10 ( severe), 27% receiving bisphosphonates, 57% solitary site Grade 2-4 toxicity: 17% (30 Gy) vs. 10% (8 Gy), p<.0001 Late toxicity: 4% overall, p=NS. Same path fx rates. Median survival 9 months, 41% 1y-OS
Pain relief: (e.g., pain inventory, narcotic use, ambulation) CR+PR 65% (1 fraction) vs. CR+PR 66% (10 fractions)
p=NS
ASTRO plenary: “800 cGy x 1 fraction is the new standard of care for palliation of painful bony metastases”
Cancer Care Ontario 2004
Practice guidelines “Where the treatment objective is pain relief, a
single 8 Gy treatment, prescribed to the appropriate target volume, is recommended as the standard dose-fractionation schedule for the treatment of symptomatic and uncomplicated bone metastases.”
Survey (Ontario practitioners)83% agreed with evidence interpretation75% agreed approved of guideline
Wu JS-Y et al. BMC Cancer 2004;4:71-78
Intl Survey of Practice Patterns Rad Onc in ASTRO, CARO, RANZCR 5 scenarios
101 schedules recommendedMedian dose 3000 cGy/10 fractionsUS Rad Onc 3x the number of fractions for same
indication
Fairchild A et al. IJROBP 2009;75:1501‐1510
RVU for XRT
3D Conformal XRT - $6,000-10,000 IMRT $12,000-20,000
10 vs. 1 Fraction
10 vs. 1 Fraction
Spinal Cord Compression
Previous concern with large doses per fraction in this setting (‘double injury’ of radiation and physical injury to cord)
Cochrane ReviewAmbulatory patient, stable spine: palliative
radiotherapy (short course suffices in patients with predicted survival <6 months)
Non-ambulatory patient, paraplegia <48 hrs, survival > 3 mos, 1 area of spine involved: consider surgery
All others: palliative radiotherapyGeorge R et al. Cochrane Database Syst Rev 2008;4:CD006716
Pathologic/Impending Fracture Very little published data Case‐by‐case decision making for palliative
radiotherapy Pain is better relieved with
surgery/stabilization in some cases
Trivia: Bone Mets Response to radiotherapy is not related to severity
of pretreatment pain [Kirou‐Mauro A et al. Int J Radiat Oncol Biol Phys 2008;71:1208‐
1212]
Pain flare occurs in 10‐25% of patients treated with radiotherapy (1‐2 days post‐treatment); readily controlled/prophylaxed with steroids [Hird A et al. Clin Oncol 2009;21:329‐335. Hird A et al. Int J Radiat
Oncol Biol Phys 2009]
QOL improves after radiotherapy for bone mets (pain, anxiety, sense of well‐being) [Chow E et al. Support Cancer Ther 2004;1:179‐184]
Lung Cancer
Second to bone metastases in available published data for hypofractionated radiotherapy: 13 RCTsShort courses [800 cGy x 1; 800 cGy x2) and long
courses of radiotherapy are comparable in relieving symptoms from advanced lung cancer (dyspnea, pain, hemoptysis, cough, SVC syndrome)
Total symptom score improved more with long courses (65.4% v. 77.1% at 1yr), and with a slight survival advantage (26.5% v. 21.7%)
Fairchild 2008; Lester 2006; Salvo 2009
Pelvic (and other) Bleeding
Single or hypofractionated regimens reported effective in prospective and retrospective reviews (RTOG: 1000 cGy x 1‐3 monthly; RTOG: 370 cGy BID x 2 days repeated q3 wks x2‐3; 800 cGy weekly x 3)
Hemoptysis improved in ~ 80% pts Pelvic bleeding improved in ~ 90‐100%
Cervix/vagina/vulvar/endometrial cancersBladder/prostate/urethral cancersColorectal cancer
Onsrud 2001; Pereira 2004; Tinger 2001
Gastrointestinal Cancers
Retrospective studies suggest hypofractionated radiotherapy is effective in:improving pain (86%)bleeding (70%)dysphagia (81%)
Acute nausea when treating upper abdomen may limit short courses MDACC: 14 fractions (3500 cGy) used most
commonly
Kim 2008; Murakami 2008; Hashimoto 2009
Head/Neck Cancers
Prospective and retrospective studies suggest hypofractionated radiotherapy is effective in improving pain, bleeding, airway obstruction,
wound progression, hoarseness, otalgia, dysphagia/odynophagiaRTOG regimen: 370 cGy BID x 2 days, repeated
q3 weeks up to 3 cycles‘Christie scheme’: 312 cGy x 12AIIMS regimen: 400 cGy x 5
Agarwal 2008; Al-mamgani 2009; Chen 2008; Mohanti 2004
Brain Metastases
Radiotherapy prolongs survivalSteroids: 1-2 months median OSXRT: 4-6 months median OS (RTOG)
Prevents death from neurologic progression Reduces/resolves neurologic symptoms
200 cGy x 20300 cGy x 10 (most common, ‘standard’)400 cGy x 5850 cGy x 2
Medical Director Strategies Meet in advance of need with your local radiation
oncologistConditional referrals: your group will refer patients when
patient convenience is maximized and cost is controlledReview cases with radiation oncologist prior to a formal
consult (prevents unnecessary patient transfers) Description of problem Any available imaging Records of previous cancer treatment
ESPECIALLY PRIOR RADIATION RECORDS
Rapid Access Palliative XRT
Canadian approach: combining separate clinic visitshypofractionated radiotherapy
2004‐2008, >3200 pts treated 52% pts bone mets Pain rapidly improved for >75% pts 100% patient satisfaction
Fairchild A et al. Support Care Cancer 2009;17:163‐70
Conclusions
Hospices and palliative care programs are providing care for patients with symptomatic advanced cancers
Palliative radiotherapy is effective, with limited side effects, and benefits some of these patients, when . . .
. . . it is convenient . . . it is reasonably priced . . . it is available
BibliographyCaissie A et al. Assessment of health-related quality of life with the European Organization for
Research and Treatment of Cancer QLQ-C15-PAL after palliative radiotherapy of bone metastases. Clin Oncol (R Coll Radiol). 2012 Mar;24(2):125-33. Epub 2011 Sep 13. PubMed PMID: 21917431.
Chow E et al. Update on the systematic review of palliative radiotherapy trials for bone metastases. Clin Oncol (R Coll Radiol). 2012 Mar;24(2):112-24. Epub 2011 Nov 29. PubMed PMID: 22130630.
Coia LR et al. Practice patterns of palliative care for the United States 1984-1985. Int J Radiat Oncol Biol Phys. 1988 Jun;14(6):1261-9. PubMed PMID: 2454905.
Costa L etal. Impact of skeletal complications on patients' quality of life, mobility, and functional independence. Support Care Cancer. 2008 Aug;16(8):879-89. Epub 2008 Apr 8. Review. Erratum in: Support Care Cancer. 2008 Oct;16(10):1201. PubMed PMID: 18392862.
Dennis K et al. Palliative radiotherapy for bone metastases in the last 3 months of life: worthwhile or futile? Clin Oncol (R Coll Radiol). 2011 Dec;23(10):709-15. Epub 2011 Jun 12. PubMed PMID: 21665446.
Bibliography - continuedFairchild A et al. The rapid access palliative radiotherapy program: blueprint for initiation of
a one-stop multidisciplinary bone metastases clinic. Support Care Cancer. 2009 Feb;17(2):163-70. Epub 2008 Jun 20. PubMed PMID: 18566840.
Fairchild A et al. Has the pattern of practice in the prescription of radiotherapy for the palliation of thoracic symptoms changed between 1999 and 2006 at the rapid response radiotherapy program? Int J Radiat Oncol Biol Phys. 2008 Mar 1;70(3):693-700. PubMed PMID: 18262087.
Fairchild A et al. Palliative thoracic radiotherapy for lung cancer: a systematic review. J Clin Oncol. 2008 Aug 20;26(24):4001-11. Review. PubMed PMID: 18711191.
Fairchild A, Chow E. Role of radiation therapy and radiopharmaceuticals in bone metastases. Curr Opin Support Palliat Care. 2007 Oct;1(3):169-73. Review. PubMed PMID: 18685358.
Bibliography - continuedGeorge R et al. Interventions for the treatment of metastatic extradural spinal cord
compression in adults. Cochrane Database Syst Rev. 2008 Oct 8;(4):CD006716. Review. PubMed PMID: 18843728.
Hashimoto K et al. Palliative radiation therapy for hemorrhage of unresectable gastric cancer: a single institute experience. J Cancer Res Clin Oncol. 2009 Aug;135(8):1117-23. Epub 2009 Feb 10. PubMed PMID: 19205735.
Higginson DS et al.Predicting the need for palliative thoracic radiation after first-line chemotherapy for advanced nonsmall cell lung carcinoma. Cancer. 2011 Sep 20. doi:10.1002/cncr.26495. [Epub ahead of print] PubMed PMID: 21935913.
Kim MM et al. Clinical benefit of palliative radiation therapy in advanced gastric cancer. Acta Oncol. 2008;47(3):421-7. PubMed PMID: 17899453.
Bibliography - ContinuedLester JF, Macbeth FR, Toy E, Coles B. Palliative radiotherapy regimens for non-small cell
lung cancer. Cochrane Database Syst Rev. 2006 Oct 18;(4):CD002143. Review. PubMed PMID: 17054152.
Lester JF, Macbeth FR, Brewster AE, Court JB, Iqbal N. CT-planned accelerated hypofractionated radiotherapy in the radical treatment of non-small cell lung cancer. Lung Cancer. 2004 Aug;45(2):237-42. PubMed PMID: 15246196.
Loblaw DA, Mitera G, Ford M, Laperriere NJ. A 2011 Updated Systematic Review and Clinical Practice Guideline for the Management of Malignant Extradural Spinal Cord Compression. Int J Radiat Oncol Biol Phys. 2012 Mar 13. [Epub ahead of print] PubMed PMID: 22420969.
Lutz S, Korytko T, Nguyen J, Khan L, Chow E, Corn B. Palliative radiotherapy: when is it worth it and when is it not? Cancer J. 2010 Sep-Oct;16(5):473-82. Review. PubMed PMID: 20890143.
Bibliography - continuedLutz ST, Chow EL, Hartsell WF, Konski AA. A review of hypofractionated palliative
radiotherapy. Cancer. 2007 Apr 15;109(8):1462-70. Review. PubMed PMID: 17330854.
Mehta RS, Arnold RM. Management of spinal cord compression #238. J Palliat Med. 2011 Mar;14(3):362-3. PubMed PMID: 21361838.
Mitera G, Zhang L, Sahgal A, Barnes E, Tsao M, Danjoux C, Holden L, Chow E. A survey of expectations and understanding of palliative radiotherapy from patients with advanced cancer. Clin Oncol (R Coll Radiol). 2012 Mar;24(2):134-8. Epub 2011 Oct 2. PubMed PMID: 21963448.
Murakami N, Nakagawa K, Yamashita H, Nagawa H. Palliative radiation therapy for advanced gastrointestinal cancer. Digestion. 2008;77 Suppl 1:29-35. Epub 2008 Jan 18. Review. PubMed PMID: 18204259.
Bibliography - continuedOnsrud M, Hagen B, Strickert T. 10-Gy single-fraction pelvic irradiation for palliation and life
prolongation in patients with cancer of the cervix and corpus uteri. Gynecol Oncol. 2001 Jul;82(1):167-71. PubMed PMID: 11426980.
Paes FM, Ernani V, Hosein P, Serafini AN. Radiopharmaceuticals: when and how to use them to treat metastatic bone pain. J Support Oncol. 2011 Nov-Dec;9(6):197-205. Review. PubMed PMID: 22055888.
Pereira J, Phan T. Management of bleeding in patients with advanced cancer. Oncologist. 2004;9(5):561-70. Review. PubMed PMID: 15477642.
Reinfuss M, Mucha-Małecka A, Walasek T, Blecharz P, Jakubowicz J, Skotnicki P, Kowalska T. Palliative thoracic radiotherapy in non-small cell lung cancer. An analysis of 1250 patients. Palliation of symptoms, tolerance and toxicity. Lung Cancer. 2011 Mar;71(3):344-9. Epub 2010 Jul 31. PubMed PMID: 20674068.
Bibliography - continuedRodrigues G et al. Consensus statement on palliative lung radiotherapy: third international
consensus workshop on palliative radiotherapy and symptom control. Clin Lung Cancer. 2012 Jan;13(1):1-5. doi: 10.1016/j.cllc.2011.04.004. Epub 2011 Jun 12. PubMed PMID: 21729656.
Salvo N, et al. Quality of life measurement in cancer patients receiving palliative radiotherapy for symptomatic lung cancer: a literature review. Curr Oncol. 2009 Mar;16(2):16-28. PubMed PMID: 19370175; PubMed Central PMCID: PMC2669235.
Salvo N et al. The role of plain radiographs in management of bone metastases. J Palliat Med. 2009 Feb;12(2):195-8. PubMed PMID: 19207068.
Sundstrøm S et al. Hypofractionated palliative radiotherapy (17 Gy per two fractions) in advanced non-small-cell lung carcinoma is comparable to standard fractionation for symptom control and survival: a national phase III trial. J Clin Oncol. 2004 Mar 1;22(5):801-10. PubMed PMID: 14990635.
Bibliography – the endTanner C. Palliative radiation therapy for cancer. J Palliat Med. 2011 May;14(5):672-3. Epub
2011 Apr 12. PubMed PMID: 21486147.
Tinger A, Waldron T, Peluso N, Katin MJ, Dosoretz DE, Blitzer PH, Rubenstein JH, Garton GR, Nakfoor BA, Patrice SJ, Chuang L, Orr JW Jr. Effective palliative radiation therapy in advanced and recurrent ovarian carcinoma. Int J Radiat Oncol Biol Phys. 2001 Dec 1;51(5):1256-63. PubMed PMID: 11728685.