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Roth C, Weiss K. Palliative Care Needs of Patients with Musculoskeletal Malignancies. Curr Oncol Rep 2024; 26:784-790. [PMID: 38789669 DOI: 10.1007/s11912-024-01543-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/03/2024] [Indexed: 05/26/2024]
Abstract
PURPOSE OF REVIEW This review aims to assess the literature regarding current treatment options for the palliative care of patients with advanced musculoskeletal malignancies whether primary or metastatic. RECENT FINDINGS The inclusion of specialized palliative care physicians, in conjunction with surgeons, medical oncologists, radiation oncologists, interventional radiologists, and mental health professionals, results in better control of end-of-life symptoms in both children and adults with terminal musculoskeletal malignancies. The palliative care of patients with musculoskeletal malignancies requires a multi-disciplinary team and benefits from specialized palliative care physicians. The unique impacts of musculoskeletal malignancies on ambulation and independence creates additional mental and physical burdens on patients and care-takers alike. Palliative care should focus on preserving ambulatory function and patient independence, in addition to managing chronic pain and other end-of-life symptoms common to these malignancies.
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Affiliation(s)
- Clark Roth
- Division of Orthopedic Oncology, Department of Orthopedic Surgery, The University of Pittsburgh, 3471 Fifth Avenue, Pittsburgh, PA, 15213, USA
| | - Kurt Weiss
- Division of Orthopedic Oncology, Department of Orthopedic Surgery, The University of Pittsburgh, 3471 Fifth Avenue, Pittsburgh, PA, 15213, USA.
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2
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Arsenijević T, Stepanović A, Milošević‐Maračić B, Poparić‐Bandjur B, Mišković I, Gavrilović D, Nikitović M. What did COVID-19 pandemics teach us about single-fraction radiotherapy for painful bone metastases-State of the art or undertreatment? Cancer Med 2023; 12:15912-15921. [PMID: 37317639 PMCID: PMC10469708 DOI: 10.1002/cam4.6231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 04/25/2023] [Accepted: 06/01/2023] [Indexed: 06/16/2023] Open
Abstract
BACKGROUND Choosing the optimal treatment approach for patients with painful bone metastases during the COVID-19 pandemic became challenging. A simple technique, single fraction radiotherapy was recommended for these patients usually referring to bone metastases as a single entity, although it is a very heterogeneous group of patients. AIM This study aimed to analyze the response to palliative single fraction radiotherapy in relation to age, performance status, primary tumor, histopathology, and bone localization in the group of patients with painful bone metastases. METHODS A clinical, prospective, non-randomized study was conducted at the Institute for Oncology and Radiology of Serbia, which included 64 patients with noncomplicated, painful bone metastases who underwent palliative, pain-relieving radiation therapy with a single tumor dose of 8Gy in a single hospital visit. Response to treatment was patient reported via telephone interview using visual analog scale. The response assessment was based on the international consensus panel of radiation oncologists. RESULTS In the entire group of patients, 83% responded to radiotherapy. No statistically significant difference was observed in response to therapy, time to reach the maximum response, degree of pain reduction, nor in response duration depending on the patient's age, performance status, the primary origin of the tumor, histopathology, or location of the metastasis (bone) that was irradiated. CONCLUSION Regardless of clinical parameters, palliative radiotherapy with a single dose of 8Gy can be considered very effective in quick pain relief in patients with noncomplicated painful bone metastases. Single fraction radiotherapy in a single hospital visit, as well as patient-reported outcome for these patients may be considered favorable beyond Covid pandemics.
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Affiliation(s)
- Tatjana Arsenijević
- University of Belgrade, Faculty of MedicineBelgradeSerbia
- Institute for Oncology and Radiology of SerbiaBelgradeSerbia
| | - Aleksandar Stepanović
- University of Belgrade, Faculty of MedicineBelgradeSerbia
- Institute for Oncology and Radiology of SerbiaBelgradeSerbia
| | | | | | - Ivana Mišković
- Institute for Oncology and Radiology of SerbiaBelgradeSerbia
| | | | - Marina Nikitović
- University of Belgrade, Faculty of MedicineBelgradeSerbia
- Institute for Oncology and Radiology of SerbiaBelgradeSerbia
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3
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Tseng YD. Radiation Therapy for Painful Bone Metastases: Fractionation, Recalcification, and Symptom Control. Semin Radiat Oncol 2023; 33:139-147. [PMID: 36990631 DOI: 10.1016/j.semradonc.2022.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/29/2023]
Abstract
Bone is a common site for metastases, which may cause pain and other skeletal-related events (SRE) in patients with advanced cancer. Since the 1980s, prospective clinical trials have demonstrated the high efficacy of external beam radiotherapy (EBRT) for pain relief from focal, symptomatic lesions. In uncomplicated bone metastases, which include those without pathologic fracture, evidence of cord compression, or prior surgical intervention, improvement or complete pain relief with radiotherapy is as high as 60%, with no difference in efficacy when radiotherapy is delivered in a single or multiple fractions. The ability to treat with a single fraction makes EBRT an attractive therapy even for patients with poor performance status and/or life expectancy. Even in patients with complicated bone metastases (eg cord compression), several randomized trials have demonstrated similar rates of pain relief in addition to improved functional outcomes such as ambulation. In this review, we summarize the role of EBRT for alleviating painful bone metastases and explore its role for other endpoints including functional outcomes, recalcification, and prevention of SREs.
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Affiliation(s)
- Yolanda D Tseng
- Department of Radiation Oncology, University of Washington, Seattle, WA; Clinical Research Division, Fred Hutch Cancer Center, Seattle, WA.
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4
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Tonneau M, Mouttet-Audouard R, Le Tinier F, Mirabel X, Pasquier D. Stereotactic body radiotherapy for intramedullary metastases: a retrospective series at the Oscar Lambret center and a systematic review. BMC Cancer 2021; 21:1168. [PMID: 34717570 PMCID: PMC8557534 DOI: 10.1186/s12885-021-08901-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Accepted: 10/14/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Intramedullary metastasis (IMM) is a rare disease with poor prognosis. The incidence of IMMs has increased, which has been linked to improved systemic treatment in many cancers. Surgery and/or radiotherapy are the most commonly used treatments; only small-sample retrospective studies and case reports on stereotactic body radiotherapy (SBRT) have reported acceptable results in terms of local control and clinical improvement, with no reported toxicity. Thus, we performed this monocentric retrospective study on five cases treated with SBRT for IMMs, which we supplemented with a systematic review of the literature. METHODS We included all patients treated for IMM with SBRT. The target tumor volume, progression-free survival, prescription patterns in SBRT, survival without neurological deficit, neurological functional improvement after treatment, and overall survival were determined. RESULTS Five patients treated with a median dose of 30 Gy in a median number of fractions of 5 (prescribed at a median isodose of 86%) included. The median follow-up duration was 23 months. Two patients showed clinical improvement. Three patients remained stable. Radiologically, 25% of patients had complete response and 50% had stable disease. No significant treatment-related toxicity was observed. CONCLUSION SBRT appears to be a safe, effective, and rapid treatment option for palliative patients.
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Affiliation(s)
- Marion Tonneau
- Département Universitaire de Radiothérapie - Centre Oscar Lambret, Lille, France. .,Centre de Recherche du Centre Hospitalier Universitaire de Montréal (CRCHUM), Qc, Montréal, Canada.
| | | | - Florence Le Tinier
- Département Universitaire de Radiothérapie - Centre Oscar Lambret, Lille, France
| | - Xavier Mirabel
- Département Universitaire de Radiothérapie - Centre Oscar Lambret, Lille, France
| | - David Pasquier
- Département Universitaire de Radiothérapie - Centre Oscar Lambret, Lille, France.,CRIStAL UMR CNRS 9189, Lille University, Lille, France
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5
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Marshall D, Aldridge MD, Dharmarajan K. Retrospective analysis of characteristics associated with higher-value radiotherapy episodes of care for bone metastases in Medicare fee-for-service beneficiaries. BMJ Open 2021; 11:e049009. [PMID: 34667003 PMCID: PMC8527129 DOI: 10.1136/bmjopen-2021-049009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 09/23/2021] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVES The Centers for Medicare & Medicaid Services' newly enacted Radiation Oncology Model ('RO Model') was designed to test the cost-saving potential of prospective episode-based payments for radiation treatment for 17 cancer diagnoses by encouraging high-value care and more efficient care delivery. For bone metastases, evidence supports the use of higher-value, shorter courses of radiation (≤10 fractions). Our goal was to determine the prevalence of short radiation courses (≤10 fractions) for bone metastases and the setting, treatment and patient characteristics associated with such courses and their expenditures. DESIGN Using the RO Model episode file, we evaluated receipt of ≤10 fractions of radiotherapy for bone metastases and expenditures by treatment setting for Medicare fee-for-service beneficiaries during calendar years 2015-2017.Using unadjusted and adjusted regression models, we determined predictors of receipt of ≤10 fractions and expenditures. Multivariable models adjusted for treatment and patient characteristics. RESULTS There were 48 810 episodes for bone metastases during the period. A majority of episodes for ≤10 fractions occurred in hospital-outpatient settings (62.8% (N=22 715)). After adjusting for treatment and patient factors, hospital-outpatient treatment setting remained a significant predictor of receiving ≤10 fractions (adjusted OR 2.03 (95% CI 1.95, 2.12; p<0.001) vs free-standing). The greatest adjusted contributors to total expenditures were number of fractions (US$-3424 (95% CI US$-3412 to US$-3435) for ≤10 fractions vs >10; p<0.001) and treatment type (including US$7716 (95% CI US$7424 to US$8018) for intensity modulated radiation therapy vs conventional external beam; p<0.001). CONCLUSIONS A measurable performance gap exists for delivery of higher-value bone metastases radiotherapy under an episode-based model, associated with increased expenditures. The RO Model may succeed in improving the value of bone metastases radiation. Increasing the capacity of free-standing centres to implement palliative-focused services may improve the ability of these practices to succeed under the RO Model.
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Affiliation(s)
- Deborah Marshall
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Melissa D Aldridge
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Kavita Dharmarajan
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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6
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Gouveia AG, Chan DCW, Hoskin PJ, Marta GN, Trippa F, Maranzano E, Chow E, Silva MF. Advances in radiotherapy in bone metastases in the context of new target therapies and ablative alternatives: A critical review. Radiother Oncol 2021; 163:55-67. [PMID: 34333087 DOI: 10.1016/j.radonc.2021.07.022] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 07/05/2021] [Accepted: 07/22/2021] [Indexed: 10/20/2022]
Abstract
In patients with bone metastases (BM), radiotherapy (RT) is used to alleviate symptoms, reduce the risk of fracture, and improve quality of life (QoL). However, with the emergence of concepts like oligometastases, minimal invasive surgery, ablative therapies such as stereotactic ablative RT (SABR), radiosurgery (SRS), thermal ablation, and new systemic anticancer therapies, there have been a paradigm shift in the multidisciplinary approach to BM with the aim of preserving mobility and function survival. Despite guidelines on using single-dose RT in uncomplicated BM, its use remains relatively low. In uncomplicated BM, single-fraction RT produces similar overall and complete response rates to RT with multiple fractions, although it is associated with a higher retreatment rate of 20% versus 8%. Complicated BM can be characterised as the presence of impending or existing pathologic fracture, a major soft tissue component, existing spinal cord or cauda equina compression and neuropathic pain. The rate of complicated BM is around 35%. Unfortunately, there is a lack of prospective trials on RT in complicated BM and the best dose/fractionation regimen is not yet established. There are contradictory outcomes in studies reporting BM pain control rates and time to pain reduction when comparing SABR with Conventional RT. While some studies showed that SABR produces a faster reduction in pain and higher pain control rates than conventional RT, other studies did not show differences. Moreover, the local control rate for BM treated with SABR is higher than 80% in most studies, and the rate of grade 3 or 4 toxicity is very low. The use of SABR may be preferred in three circumstances: reirradiation, oligometastatic disease, and radioresistant tumours. Local ablative therapies like SABR can delay change or use of systemic therapy, preserve patients' Qol, and improve disease-free survival, progression-free survival and overall survival. Moreover, despite the potential benefit of SABR in oligometastatic disease, there is a need to establish the optial indication, RT dose fractionation, prognostic factors and optimal timing in combination with systemic therapies for SABR. This review evaluates the role of RT in BM considering these recent treatment advances. We consider the definition of complicated BM, use of single and multiple fractions RT for both complicated and uncomplicated BM, reirradiation, new treatment paradigms including local ablative treatments, oligometastatic disease, systemic therapy, physical activity and rehabilitation.
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Affiliation(s)
- André G Gouveia
- Radiation Oncology Department, Américas Centro de Oncologia Integrado, Rio de Janeiro, Brazil; Latin America Cooperative Oncology Group (LACOG), Porto Alegre, Brazil.
| | - Dominic C W Chan
- Department of Oncology, Princess Margaret Hospital, Hong Kong, China
| | - Peter J Hoskin
- Mount Vernon Cancer Centre, London, United Kingdom; Radiation Oncology Department, University of Manchester, United Kingdom
| | - Gustavo N Marta
- Latin America Cooperative Oncology Group (LACOG), Porto Alegre, Brazil; Radiation Oncology Department, Hospital Sírio Libanês, São Paulo, Brazil
| | - Fabio Trippa
- Radiation Oncology Center, Santa Maria Hospital, Terni, Italy
| | | | - Edward Chow
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Canada
| | - Mauricio F Silva
- Latin America Cooperative Oncology Group (LACOG), Porto Alegre, Brazil; Radiation Oncology Unit, Santa Maria Federal University, Santa Maria, Brazil; Clínica de Radioterapia de Santa Maria, Brazil.
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7
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Donati CM, Nardi E, Galietta E, Alfieri ML, Siepe G, Zamagni A, Buwenge M, Macchia G, Deodato F, Cilla S, Strigari L, Cammelli S, Cellini F, Morganti AG. An Intensive Educational Intervention Significantly Improves the Adoption of Single Fractionation Radiotherapy in Uncomplicated Bone Metastases. CLINICAL MEDICINE INSIGHTS-ONCOLOGY 2021; 15:11795549211027148. [PMID: 34366683 PMCID: PMC8312156 DOI: 10.1177/11795549211027148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Accepted: 06/01/2021] [Indexed: 11/17/2022]
Abstract
Introduction: An education strategy was employed in our department to increase the rate of patients with uncomplicated painful bone metastases undergoing single fractionation radiotherapy (SFRT). The purpose of this report is to analyze the results of this strategy over a 5 year period. Materials and Methods: In January 2015, two meetings were organized in our department. In the first, data from an audit on the current SFRT rate were shown. In the second, evidence of SFRT efficacy in the relief of pain from uncomplicated bone metastases was presented. In addition, during the weekly discussion of clinical cases, the opportunity to use the SFRT was systematically recalled. Using our institutional database, all patients treated with radiotherapy for uncomplicated painful bone metastases in the period between 2014 (year considered as a reference) and 2019 were retrieved. Data regarding treatment date (year), radiotherapy fractionation, and tumor, patients, and radiation oncologists characteristics were collected. Results: A total of 627 patients were included in the analysis. The rate of patients undergoing SFRT increased from 4.0% in 2014 to 63.5% in 2019 (p < 0.001). At multivariable analysis, the delivery of SFRT was significantly correlated with older patients age (>80 years), lung cancer as the primary tumor, treatment prescribed by a radiation oncologist dedicated to palliative treatments, and treatment date (2014 vs 2015–2019). Conclusions: This retrospective single-center analysis showed that a simple but intensive and prolonged departmental education strategy can increase the rate of patients treated with SFRT by nearly 16 times.
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Affiliation(s)
- Costanza M Donati
- Radiation Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.,Department of Experimental, Diagnostic, and Specialty Medicine-DIMES, Alma Mater Studiorum Bologna University; Bologna, Italy
| | - Elena Nardi
- Medical Statistics, Department of Experimental, Diagnostic and Specialty Medicine, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Erika Galietta
- Radiation Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.,Department of Experimental, Diagnostic, and Specialty Medicine-DIMES, Alma Mater Studiorum Bologna University; Bologna, Italy
| | - Maria L Alfieri
- Radiation Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.,Department of Experimental, Diagnostic, and Specialty Medicine-DIMES, Alma Mater Studiorum Bologna University; Bologna, Italy
| | - Giambattista Siepe
- Radiation Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Alice Zamagni
- Radiation Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.,Department of Experimental, Diagnostic, and Specialty Medicine-DIMES, Alma Mater Studiorum Bologna University; Bologna, Italy
| | - Milly Buwenge
- Radiation Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.,Department of Experimental, Diagnostic, and Specialty Medicine-DIMES, Alma Mater Studiorum Bologna University; Bologna, Italy
| | - Gabriella Macchia
- Istituto di Radiologia, Università Cattolica del Sacro Cuore, Roma, Italy.,Radiation Oncology Unit, Gemelli Molise Hospital-Università Cattolica del Sacro Cuore, Campobasso, Italy
| | - Francesco Deodato
- Istituto di Radiologia, Università Cattolica del Sacro Cuore, Roma, Italy.,Radiation Oncology Unit, Gemelli Molise Hospital-Università Cattolica del Sacro Cuore, Campobasso, Italy
| | - Savino Cilla
- Medical Physics Unit, Gemelli Molise Hospital-Università Cattolica del Sacro Cuore, Campobasso, Italy
| | - Lidia Strigari
- Medical Physics, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Silvia Cammelli
- Radiation Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.,Department of Experimental, Diagnostic, and Specialty Medicine-DIMES, Alma Mater Studiorum Bologna University; Bologna, Italy
| | - Francesco Cellini
- Istituto di Radiologia, Università Cattolica del Sacro Cuore, Roma, Italy.,Fondazione Policlinico Universitario A. Gemelli, IRCCS, UOC di Radioterapia, Dipartimento di Scienze Radiologiche, Radioterapiche ed Ematologiche, Roma, Italy
| | - Alessio G Morganti
- Radiation Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.,Department of Experimental, Diagnostic, and Specialty Medicine-DIMES, Alma Mater Studiorum Bologna University; Bologna, Italy
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8
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Chen AB, Niu J, Cronin AM, Shih YCT, Giordano S, Schrag D. Variation in Use of High-Cost Technologies for Palliative Radiation Therapy by Radiation Oncologists. J Natl Compr Canc Netw 2021; 19:421-431. [PMID: 33578375 PMCID: PMC9109157 DOI: 10.6004/jnccn.2020.7633] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Accepted: 08/03/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND Understanding the sources of variation in the use of high-cost technologies is important for developing effective strategies to control costs of care. Palliative radiation therapy (RT) is a discretionary treatment and its use may vary based on patient and clinician factors. METHODS Using data from the SEER-Medicare linked database, we identified patients diagnosed with metastatic lung, prostate, breast, and colorectal cancers in 2010 through 2015 who received RT, and the radiation oncologists who treated them. The costs of radiation services for each patient over a 90-day episode were calculated, and radiation oncologists were assigned to cost quintiles. The use of advanced technologies (eg, intensity-modulated radiation, stereotactic RT) and the number of RT treatments (eg, any site, bone only) were identified. Multivariable random-effects models were constructed to estimate the proportion of variation in the use of advanced technologies and extended fractionation (>10 fractions) that could be explained by patient fixed effects versus physician random effects. RESULTS We identified 37,361 patients with metastatic lung cancer, 3,684 with metastatic breast cancer, 5,323 with metastatic prostate cancer, and 8,726 with metastatic colorectal cancer, with 34%, 27%, 22%, and 9% receiving RT within the first year, respectively. The use of advanced technologies and extended fractionation was associated with higher costs of care. Compared with the patient case-mix, physician variation accounted for a larger proportion of the variation in the use of advanced technologies for palliative RT and the use of extended fractionation. CONCLUSIONS Differences in radiation oncologists' practice and choices, rather than differences in patient case-mix, accounted for a greater proportion of the variation in the use of advanced technologies and high-cost radiation services.
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Affiliation(s)
- Aileen B. Chen
- The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jiangong Niu
- The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Angel M. Cronin
- Division of Population Sciences and the Center for Outcomes and Policy Research, Dana-Farber Cancer Institute, Boston, Massachusetts
| | | | - Sharon Giordano
- The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Deborah Schrag
- Division of Population Sciences and the Center for Outcomes and Policy Research, Dana-Farber Cancer Institute, Boston, Massachusetts
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9
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Pontoriero A, Lillo S, Caravatta L, Bellafiore F, Longo S, Lattanzi E, Parisi S, Fiorica F, Massaccesi M. Cumulative dose, toxicity, and outcomes of spinal metastases re-irradiation : Systematic review on behalf of the Re-Irradiation Working Group of the Italian Association of Radiotherapy and Clinical Oncology (AIRO). Strahlenther Onkol 2021; 197:369-384. [PMID: 33635395 DOI: 10.1007/s00066-021-01748-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2020] [Accepted: 01/22/2021] [Indexed: 11/30/2022]
Abstract
PURPOSE The aim of this study was to identify patient-, tumor-, or treatment-related factors which may affect disease-related outcomes of re-irradiation (reRT) in patients with previously irradiated vertebral metastases. METHODS A computerized search of the literature was performed by searching for terms related to reRT and spinal metastases in MEDLINE, EMBASE, OVID, and the Cochrane database from 1995 to 2019. Studies including at least 10 patients who had received reRT at the same site of initial radiotherapy for vertebral metastases with localized external beam radiotherapy were included. To determine the pooled ≥G3 acute and late toxicity rate, pain relief, local control, and overall survival, a meta-analysis technique of single-arm studies was performed. RESULTS Nineteen studies including 1373 patients met the inclusion criteria for this systematic review. The pooled pain relief, neurological improvement, 1‑year local control, and 1‑year overall survival rates were 74.3%, 73.8%, 78.8%, and 54.6%, respectively, with moderate to high heterogeneity among studies. No difference in heterogeneity was evidenced for pain relief or local control after omitting studies not using stereotactic body radiotherapy (SBRT) or studies delivering biologically effective dose (BED) < 45 Gy10, whereas heterogeneity for 1‑year OS was lower after omitting studies not using SBRT and delivering BED < 45 Gy10. The pooled results of grade ≥ 3 acute and late toxicity were 0.4% (95% confidence interval: 0.1-1.2%) and 2.2% (95% confidence interval: 1.2-37%), respectively, with low heterogeneity among studies. CONCLUSION While this systematic review confirmed that reRT is both safe and effective for treating patients with recurrent spinal metastases, it could not identify factors which may affect outcomes of reRT in this patient population.
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Affiliation(s)
| | - Sara Lillo
- Radiation Oncology Unit, Department of Biomedical, Dental Science and Morphological and Functional Images, University of Messina, Messina, Italy.
| | - Luciana Caravatta
- Radiation Oncology Unit, "SS Annunziata" Hospital, "G. D'Annunzio" University, Chieti, Italy
| | | | - Silvia Longo
- Università Cattolica del Sacro Cuore, Roma, Italy
| | | | - Silvana Parisi
- Radiation Oncology Unit, Department of Biomedical, Dental Science and Morphological and Functional Images, University of Messina, Messina, Italy
| | - Francesco Fiorica
- Radiotherapy and Nuclear Medicine Department, AULSS 9 Scaligera, Verona, Italy
| | - Mariangela Massaccesi
- Radiation Oncology Unit, Department of Diagnostic Imaging, Radiation Oncology and Hematology, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Roma, Italy
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10
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Better pain control with 8-gray single fraction palliative radiotherapy for skeletal metastases: a Bayesian network meta-analysis. Clin Exp Metastasis 2021; 38:197-208. [PMID: 33559808 PMCID: PMC7987640 DOI: 10.1007/s10585-020-10067-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 11/20/2020] [Indexed: 12/25/2022]
Abstract
External Beam Radiotherapy (EBRT) allows remarkable pain control in patients with skeletal metastases. We performed a Bayesian network meta-analysis comparing the most commonly used radiotherapy regimens for palliative management in patients with skeletal metastases. The main online databases were accessed in October 2020. All randomized clinical trials evaluating the irradiation of painful bone metastases were considered. The following irradiation patterns were analysed and included in the present network meta-analysis: 8 Gy- and 10 Gy/single fraction, 20 Gy/5 fractions, 30 Gy/10 fractions. The Bayesian hierarchical random-effect model analysis was adopted in all comparisons. The Log Odds-Ratio (LOR) statistical method for dichotomic data was adopted for analysis. Data from 3595 patients were analysed. The mean follow-up was 9.5 (1 to 28) months. The cumulative mean age was 63.3 ± 2.9. 40.61% (1461 of 3595 patients) were female. The 8Gy/single fraction protocol detected reduced rate of “no pain response” (LOR 3.39), greater rate of “pain response” (LOR-5.88) and complete pain remission (LOR-7.05) compared to the other dose patterns. The 8Gy group detected a lower rate of pathological fractures (LOR 1.16), spinal cord compression (LOR 1.31) and re-irradiation (LOR 2.97) compared to the other dose patterns. Palliative 8Gy/single fraction radiotherapy for skeletal metastases shows outstanding results in terms of pain control, re-irradiations, pathological fractures and spinal cord compression, with no differences in terms of survivorship compared to the other multiple dose patterns. Level of evidence: I, Bayesian network meta-analysis of RCTs.
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11
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Thureau S, Marchesi V, Vieillard MH, Perrier L, Lisbona A, Leheurteur M, Tredaniel J, Culine S, Dubray B, Bonnet N, Asselain B, Salleron J, Faivre JC. Efficacy of extracranial stereotactic body radiation therapy (SBRT) added to standard treatment in patients with solid tumors (breast, prostate and non-small cell lung cancer) with up to 3 bone-only metastases: study protocol for a randomised phase III trial (STEREO-OS). BMC Cancer 2021; 21:117. [PMID: 33541288 PMCID: PMC7863429 DOI: 10.1186/s12885-021-07828-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Accepted: 01/21/2021] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Stereotactic Body Radiation Therapy (SBRT) is an innovative modality based on high precision planning and delivery. Cancer with bone metastases and oligometastases are associated with an intermediate or good prognosis. We assume that prolonged survival rates would be achieved if both the primary tumor and metastases are controlled by local treatment. Our purpose is to demonstrate, via a multicenter randomized phase III trial, that local treatment of metastatic sites with curative intent with SBRT associated of systemic standard of care treatment would improve the progression-free survival in patients with solid tumor (breast, prostate and non-small cell lung cancer) with up to 3 bone-only metastases compared to patients who received systemic standard of care treatment alone. METHODS This is an open-labeled randomized superiority multicenter phase III trial. Patients with up to 3 bone-only metastases will be randomized in a 1:1 ratio.between Arm A (Experimental group): Standard care of treatment & SBRT to all bone metastases, and Arm B (Control group): standard care of treatment. For patients receiving SBRT, radiotherapy dose and fractionation depends on the site of the bone metastasis and the proximity to critical normal structures. This study aims to accrue a total of 196 patients within 4 years. The primary endpoint is progression-free survival at 1 year, and secondary endpoints include Bone progression-free survival; Local control; Cancer-specific survival; Overall survival; Toxicity; Quality of life; Pain score analysis, Cost-utility analysis; Cost-effectiveness analysis and Budget impact analysis. DISCUSSION The expected benefit for the patient in the experimental arm is a longer expectancy of life without skeletal recurrence and the discomfort, pain and drastic reduction of mobility and handicap that the lack of local control of bone metastases eventually inflicts. TRIALS REGISTRATION ClinicalTrials.gov NCT03143322 Registered on May 8th 2017. Ongoing study.
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Affiliation(s)
- Sébastien Thureau
- Radiation Oncology & Medical Physics Department, Henri-Becquerel Comprehensive Cancer Center, rue d'Amiens, F-76 000, Rouen, France. .,EA4108 QuantIf Litis, University of Rouen, 22 boulevard Gambetta, 76000, Rouen, France.
| | - Vincent Marchesi
- Academic Radiation Oncology & Brachytherapy Department, Lorraine Institute of Cancerology - Alexis-Vautrin Comprehensive Cancer Center, 6 avenue de Bourgogne, 54519, Vandœuvre-lès-Nancy, France
| | - Marie-Hélène Vieillard
- Rheumatology Department, University Hospital of Lille, 2 avenue Oscar Lambret, 59 000, Lille, France
| | - Lionel Perrier
- UMR CNRS 5824, Léon Bérard Comprehensive Cancer Center, 28 rue laennec, 69 373, Lyon, France
| | - Albert Lisbona
- Academic Radiation Oncology & Brachytherapy Department, Institut de Cancérologie de l'Ouest - René Gauducheau Comprehensive Cancer Center, Boulevard Professeur Jacques Monod, 44805, Saint-Herblain, France
| | - Marianne Leheurteur
- Medical Oncology Department, Henri-Becquerel Comprehensive Cancer Center, rue d'Amiens, 76000, Rouen, France
| | - Jean Tredaniel
- Pneumology Department, University Hospital of Paris (Groupe hospitalier Paris Saint-Joseph), 185 Rue Raymond Losserand, 75014, Paris, France
| | - Stéphane Culine
- Medical Oncology Department, University Hospital of Paris (Saint-Louis Hospital), 1 avenue Claude Vellefaux, 75010, Paris, France.,Paris Diderot University, 16 rue Huchard, 75018, Paris, France
| | - Bernard Dubray
- Radiation Oncology & Medical Physics Department, Henri-Becquerel Comprehensive Cancer Center, rue d'Amiens, F-76 000, Rouen, France.,EA4108 QuantIf Litis, University of Rouen, 22 boulevard Gambetta, 76000, Rouen, France
| | - Naïma Bonnet
- Unicancer, 101, rue de Tolbiac, F-75654, Paris, France
| | | | - Julia Salleron
- Biostatistics Department, Institut de Cancérologie de Lorraine - Alexis-Vautrin Comprehensive Cancer Center, 6 avenue de Bourgogne, F-54519, Vandœuvre-lès-Nancy, France
| | - Jean-Christophe Faivre
- Academic Radiation Oncology & Brachytherapy Department, Lorraine Institute of Cancerology - Alexis-Vautrin Comprehensive Cancer Center, 6 avenue de Bourgogne, 54519, Vandœuvre-lès-Nancy, France
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12
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Kotecha R, Schiro BJ, Sporrer J, Rubens M, Appel HR, Calienes KS, Boulanger B, Pujol MV, Suarez DT, Pena A, Kudryashev A, Mehta MP. Radiation therapy alone versus radiation therapy plus radiofrequency ablation/vertebral augmentation for spine metastasis: study protocol for a randomized controlled trial. Trials 2020; 21:964. [PMID: 33228756 PMCID: PMC7685662 DOI: 10.1186/s13063-020-04895-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 11/12/2020] [Indexed: 11/21/2022] Open
Abstract
Background Spine metastasis is a common occurrence in cancer patients and results in pain, neurologic deficits, decline in performance status, disability, inferior quality of life (QOL), and reduction in ability to receive cancer-directed therapies. Conventional external beam radiation therapy (EBRT) is associated with modest rates of pain relief, high rates of disease recurrence, low response rates for those with radioresistant histologies, and limited improvement in neurologic deficits. The addition of radiofrequency ablation/percutaneous vertebral augmentation (RFA/PVA) to index sites together with EBRT may improve pain response rates and corresponding quality of life. Methods/design This is a single-center, prospective, randomized, controlled trial in patients with spine metastasis from T5-L5, stratified according to tumor type (radioresistant vs. radiosensitive) in which patients in each stratum will be randomized in a 2:1 ratio to either RFA/PVA and EBRT or EBRT alone. All patients will be treated with EBRT to a dose of 20–30 Gy in 5–10 fractions. The target parameters will be measured and recorded at the baseline clinic visit, and daily at home with collection of weekly measurements at 1, 2, and 3 weeks after treatment, and at 3, 6, 12, and 24 months following treatment with imaging and QOL assessments. Discussion The primary objective of this randomized trial is to determine whether RFA/PVA in addition to EBRT improves pain control compared to palliative EBRT alone for patients with spine metastasis, defined as complete or partial pain relief (measured using the Numerical Rating Pain Scale [NRPS]) at 3 months. Secondary objectives include determining whether combined modality treatment improves the rapidity of pain response, duration of pain response, patient reported pain impact, health utility, and overall QOL. Trial registration ClinicalTrials.gov NCT04375891. Registered on 5 May 2020.
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Affiliation(s)
- Rupesh Kotecha
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Office 1R203, Miami, FL, 33176, USA. .,Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA.
| | - Brian J Schiro
- Vascular and Interventional Radiology, Miami Cardiac and Vascular Institute, Baptist Health South Florida, Miami, FL, USA
| | - Justin Sporrer
- Neuroscience Center, Baptist Health South Florida, Miami, FL, USA
| | - Muni Rubens
- Office of Clinical Research, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA
| | - Haley R Appel
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Office 1R203, Miami, FL, 33176, USA
| | - Kathleen S Calienes
- Office of Clinical Research, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA
| | - Belinda Boulanger
- Office of Clinical Research, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA
| | - Marietsy V Pujol
- Office of Clinical Research, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA
| | - Deborah T Suarez
- Office of Clinical Research, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA
| | - Ashley Pena
- Office of Clinical Research, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA
| | - Alex Kudryashev
- Office of Clinical Research, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA
| | - Minesh P Mehta
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Office 1R203, Miami, FL, 33176, USA.,Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
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13
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Rosen DB, Benjamin CD, Yang JC, Doyle C, Zhang Z, Barker CA, Vaynrub M, Yang TJ, Gillespie EF. Early palliative radiation versus observation for high-risk asymptomatic or minimally symptomatic bone metastases: study protocol for a randomized controlled trial. BMC Cancer 2020; 20:1115. [PMID: 33203426 PMCID: PMC7670812 DOI: 10.1186/s12885-020-07591-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2020] [Accepted: 10/30/2020] [Indexed: 12/25/2022] Open
Abstract
Background In patients with metastatic cancer, the bone is the third-most common site of involvement. Radiation to painful bone metastases results in high rates of pain control and is an integral part of bone metastases management. Up to one-third of inpatient consults are requested for painful bone metastases, and up to 60% of these patients had evidence of these lesions visible on prior imaging. Meanwhile recent advances have reduced potential side effects of radiation. Therefore, there is an opportunity to further improve outcomes for patients using prophylactic palliative radiation to manage asymptomatic bone metastases. Methods/study design In this trial, 74 patients with metastatic solid tumors and high-risk asymptomatic or minimally symptomatic bone metastases will be enrolled and randomized to early palliative radiation or standard of care. This will be the first trial to assess the efficacy of prophylactic palliative radiation in preventing skeletal related events (SREs), the primary endpoint. This endpoint was selected to encompass patient-centered outcomes that impact quality of life including pathologic fracture, spinal cord compression, and intervention with surgery or radiation. Secondary endpoints include hospitalizations, Bone Pain Index, pain-free survival, pain-related quality of life, and side effects of radiation therapy. Discussion In this study, we propose a novel definition of high-risk bone metastases most likely to benefit from preventive radiation and use validated questionnaires to assess pain and impact on quality of life and health resource utilization. Observations from early patient enrollment have demonstrated robustness of the primary endpoint and need for minor modifications to Bone Pain Index and data collection for opioid use and hospitalizations. With increasing indications for radiation in the oligometastatic setting, this trial aims to improve patient-centered outcomes in the polymetastatic setting. Trial registration ISRCTN Number/Clinical trials.gov, ID:NCT03523351. Registered on 14 May 2018. Supplementary Information The online version contains supplementary material available at 10.1186/s12885-020-07591-w.
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Affiliation(s)
- Daniel B Rosen
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, 1275 York Ave, Box 22, New York, NY, 10065, USA
| | - Cory D Benjamin
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, 1275 York Ave, Box 22, New York, NY, 10065, USA
| | - Joanna C Yang
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, 1275 York Ave, Box 22, New York, NY, 10065, USA
| | - Connor Doyle
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, 1275 York Ave, Box 22, New York, NY, 10065, USA
| | - Zhigang Zhang
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Chris A Barker
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, 1275 York Ave, Box 22, New York, NY, 10065, USA
| | - Max Vaynrub
- Department of Surgery, Orthopaedic Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - T Jonathan Yang
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, 1275 York Ave, Box 22, New York, NY, 10065, USA.
| | - Erin F Gillespie
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, 1275 York Ave, Box 22, New York, NY, 10065, USA. .,Center for Health Policy and Outcomes, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
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14
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Kotecha R, Dea N, Detsky JS, Sahgal A. Management of recurrent or progressive spinal metastases: reirradiation techniques and surgical principles. Neurooncol Pract 2020; 7:i45-i53. [PMID: 33299573 PMCID: PMC7705530 DOI: 10.1093/nop/npaa045] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
With the growing incidence of new cases and the increasing prevalence of patients living longer with spine metastasis, a methodological approach to the management of patients with recurrent or progressive disease is increasing in relevance and importance in clinical practice. As a result, disease management has evolved in these patients using advanced surgical and radiotherapy technologies. Five key goals in the management of patients with spine metastases include providing pain relief, controlling metastatic disease at the treated site, improving neurologic deficits, maintaining or improving functional status, and minimizing further mechanical instability. The focus of this review is on advanced reirradiation techniques, given that the majority of patients will be treated with upfront conventional radiotherapy and further treatment on progression is often limited by the cumulative tolerance of nearby organs at risk. This review will also discuss novel surgical approaches such as separation surgery, minimally invasive percutaneous instrumentation, and laser interstitial thermal therapy, which is increasingly being coupled with spine reirradiation to maximize outcomes in this patient population. Lastly, given the complexities of managing recurrent spinal disease, this review emphasizes the importance of multidisciplinary care from neurosurgery, radiation oncology, medical oncology, neuro-oncology, rehabilitation medicine, and palliative care.
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Affiliation(s)
- Rupesh Kotecha
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, Florida, US
| | - Nicolas Dea
- Combined Neurosurgical and Orthopaedic Spine Program, Vancouver General Hospital, University of British Columbia, Vancouver, Canada
| | - Jay S Detsky
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Ontario, Canada
| | - Arjun Sahgal
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Ontario, Canada
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15
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Hinduja RH, George K, Barthwal M, Pareek V. Radiation oncology in times of COVID-2019: A review article for those in the eye of the storm - An Indian perspective. Semin Oncol 2020; 47:315-327. [PMID: 32819712 PMCID: PMC7357513 DOI: 10.1053/j.seminoncol.2020.07.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 06/28/2020] [Accepted: 07/01/2020] [Indexed: 02/07/2023]
Abstract
The global COVID-2019 pandemic has presented to the field of radiation oncology a management dilemma in providing evidence-based treatments to all cancer patients. There is a need for appropriate measures to be taken to reduce infectious spread between the medical healthcare providers and the patient population. Such times warrant resource prioritization and to continue treatment with best available evidence, thereby reducing the risk of COVID-2019 transmission in times where the workforce is reduced. There has been literature presented in different aspects related to providing safety measures, running of a radiation department and for the management of various cancer subsites. In this article, we present a comprehensive review for sustaining a radiation oncology department in times of the COVID-2019 pandemic.
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Affiliation(s)
- Ritika Harjani Hinduja
- Associate Consultant, Department of Radiation Oncology, P.D Hinduja Hospital, Mumbai, India.
| | - Karishma George
- Junior Consultant, Department of Radiation Oncology, Vivekanand Cancer Hospital and Optimus Oncology Centre, Latur, India.
| | - Mansi Barthwal
- Senior Resident, Department of Radiation Oncology, National Cancer Institute, AIIMS, New Delhi, India.
| | - Vibhay Pareek
- Senior Resident, Department of Radiation Oncology, National Cancer Institute, AIIMS, New Delhi, India.
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16
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Zhang L, Zhang J, Li Z, Wu Y, Tong Z. Comparison of the clinicopathological characteristics and prognosis between Chinese patients with breast cancer with bone-only and non-bone-only metastasis. Oncol Lett 2020; 20:92. [PMID: 32831911 PMCID: PMC7439125 DOI: 10.3892/ol.2020.11953] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Accepted: 07/01/2020] [Indexed: 11/29/2022] Open
Abstract
Bone is the most common site of metastatic spread in patients with breast cancer. Patients with bone-only metastasis (BOM) are a unique group. The aim of the present study was to compare the clinicopathological characteristics, survival and prognostic factors of patients with BOM and non-BOM. The clinical data of 1,290 patients with metastatic breast cancer treated at the Tianjin Medical University Cancer Institute and Hospital (Tianjin, China) between January 2008 and December 2017 were reviewed. The clinical data were divided into a BOM group (n=208 cases) and a non-BOM group (n=1,082 cases). Patients with BOM had longer disease-free survival, progression-free survival (PFS) and overall survival (OS) compared with patients in the non-BOM group. The hormone receptor (HR) status and number of metastases were significant influencing factors of PFS in the BOM group. Furthermore, the HR status, location of bone metastasis and number of bone metastases were significantly associated with OS of patients in the BOM group. Age at diagnosis of metastasis, HR status and tumor stage were significantly associated with OS in the non-BOM group. In the BOM group, patients with HR+/human epidermal growth factor receptor 2 (HER2)− tumors had the most favorable prognosis. In the non-BOM group, patients with HR+/HER2− and HER2+ tumors had improved prognosis. In the BOM with HR+/HER2− subgroup, the PFS and OS of patients receiving endocrine therapy or sequential therapy (chemotherapy followed by endocrine therapy) was significantly improved compared with those receiving chemotherapy alone (P<0.05). Skeletal-related events were significantly associated with the number of bone metastases (P<0.001). The most common secondary metastatic site in the BOM group was the liver. The prognosis of the patients in the BOM group was improved compared with that in the non-BOM patients. HR− and multiple bone metastases, as well as combined axial and appendicular bone metastases, were significantly associated with poor prognosis in the patients with BOM. For patients in the HR+/HER2− BOM subgroup, endocrine therapy alone resulted in satisfactory results.
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Affiliation(s)
- Li Zhang
- Department of Breast Oncology, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin's Clinical Research Center for Cancer, Tianjin 300060, P.R. China
| | - Jie Zhang
- Department of Breast Oncology, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin's Clinical Research Center for Cancer, Tianjin 300060, P.R. China
| | - Zhijun Li
- Department of Breast Oncology, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin's Clinical Research Center for Cancer, Tianjin 300060, P.R. China
| | - Yansheng Wu
- Department of Maxillofacial and Otorhinolaryngology Head and Neck Surgery, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin's Clinical Research Center for Cancer, Tianjin 300060, P.R. China
| | - Zhongsheng Tong
- Department of Breast Oncology, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin's Clinical Research Center for Cancer, Tianjin 300060, P.R. China
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17
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Rades D, Haus R, Janssen S, Schild SE. An easy-to-use scoring system to estimate the survival of patients irradiated for bone metastases from lung cancer. Transl Lung Cancer Res 2020; 9:1067-1073. [PMID: 32953485 PMCID: PMC7481577 DOI: 10.21037/tlcr-19-642] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
Abstract
Background The remaining lifespan of patients with metastatic lung cancer should be considered when designing a personalized treatment program. To facilitate the estimation survival in lung cancer patients with bone metastases, a specific scoring system was created. Methods One-hundred-and-fifty-three patients receiving fractionated radiotherapy for bone metastases without spinal cord compression from lung cancer were included in this retrospective study. Age, gender, Eastern Cooperative Oncology Group (ECOG) performance score, histology, interval from lung cancer diagnosis until irradiation of bone metastases, visceral metastases, additional bone metastases, type and number of irradiated sites, pathological fracture, upfront surgery and previous systemic treatment were evaluated for potential associations with survival. Those factors that were significant (P<0.05) or showed a trend (P≤0.10) on multivariate analysis were used to create the scoring system. Results On multivariate analysis, ECOG performance score was significant (risk ratio: 2.77, P<0.001), and age showed a trend (risk ratio: 1.34, P=0.10). The following scoring points were assigned: age ≤65 years =1 point, age ≥66 years =0 points, ECOG performance score of 0–1 =1 point, and ECOG performance score of ≥2 =0 points. Three prognostic groups were obtained: 0 points (n=38), 1 point (n=71) and 2 points (n=44). Six-month survival rates were 21%, 41% and 75%, 12-month survival rates 7%, 27% and 56% (P<0.001). Conclusions This scoring system can help estimate the remaining lifespan of lung cancer patients to be irradiated for bone metastases and will contribute to the personalization of their treatment.
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Affiliation(s)
- Dirk Rades
- Department of Radiation Oncology, University of Lübeck, Lübeck, Germany
| | - Rapha Haus
- Department of Radiation Oncology, University of Lübeck, Lübeck, Germany
| | - Stefan Janssen
- Department of Radiation Oncology, University of Lübeck, Lübeck, Germany
| | - Steven E Schild
- Department of Radiation Oncology, Mayo Clinic, Scottsdale, AZ, USA
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18
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Spencer KL, van der Velden JM, Wong E, Seravalli E, Sahgal A, Chow E, Verlaan JJ, Verkooijen HM, van der Linden YM. Systematic Review of the Role of Stereotactic Radiotherapy for Bone Metastases. J Natl Cancer Inst 2020; 111:1023-1032. [PMID: 31119273 PMCID: PMC6792073 DOI: 10.1093/jnci/djz101] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Revised: 04/07/2019] [Accepted: 05/15/2019] [Indexed: 01/07/2023] Open
Abstract
Background Stereotactic radiotherapy (SBRT) might improve pain and local control in patients with bone metastases compared to conventional radiotherapy, although an overall estimate of these outcomes is currently unknown. Methods A systematic review was carried out following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Pubmed, Embase, and Cochrane databases were systematically searched to identify studies reporting pain response and local control among patients with bone metastases from solid-organ tumors who underwent SBRT in 1–6 fractions. All studies prior to April 15, 2017, were included. Study quality was assessed by predefined criteria, and pain response and local control rates were extracted. Results A total of 2619 studies were screened; 57 were included (reporting outcomes for 3995 patients) of which 38 reported pain response and 45 local control rates. Local control rates were high with pain response rates above those previously reported for conventional radiotherapy. Marked heterogeneity in study populations and delivered treatments were identified such that quantitative synthesis was not appropriate. Reported toxicity was limited. Of the pain response studies, 73.7% used a retrospective cohort design and only 10.5% used the international consensus endpoint definitions of pain response. The median survival within the included studies ranged from 8 to 30.4 months, suggesting a high risk of selection bias in the included observational studies. Conclusions This review demonstrates the potential benefit of SBRT over conventional palliative radiotherapy in improving pain due to bone metastases. Given the methodological limitations of the published literature, however, large randomized trials are now urgently required to better quantify this benefit.
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Affiliation(s)
- Katie L Spencer
- Correspondence to: Katie Spencer, MB, BChir, FRCR, Cancer Epidemiology Group, Level 11 Worsley Building, Clarendon Way, University of Leeds, Leeds LS2 9NL, West Yorkshire, UK (e-mail: )
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19
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Butt JL, Botha MH. Bone involvement in patients with cervical carcinoma: a single-institution cohort study. SOUTHERN AFRICAN JOURNAL OF GYNAECOLOGICAL ONCOLOGY 2019. [DOI: 10.1080/20742835.2019.1702299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Affiliation(s)
- JL Butt
- Department of Obstetrics and Gynaecology, Tygerberg Hospital, Stellenbosch University, Stellenbosch, South Africa
| | - MH Botha
- Department of Obstetrics and Gynaecology, Tygerberg Hospital, Stellenbosch University, Stellenbosch, South Africa
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20
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Rades D, Haus R, Schild SE, Janssen S. Prognostic factors and a new scoring system for survival of patients irradiated for bone metastases. BMC Cancer 2019; 19:1156. [PMID: 31779595 PMCID: PMC6883567 DOI: 10.1186/s12885-019-6385-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Accepted: 11/21/2019] [Indexed: 12/02/2022] Open
Abstract
Background Personalized therapy for bone metastases should consider the patients’ remaining lifespan. Estimation of survival can be facilitated with scoring tools. A new tool was developed, specifically designed to estimate 12-month survival. Methods In 445 patients irradiated for bone metastases, radiotherapy regimen plus 13 factors (age, gender, Karnofsky performance score (KPS), primary tumor type, interval between cancer diagnosis and RT of bone metastases, visceral metastases, other (non-irradiated) bone metastases, sites of bone metastases, number of irradiated sites, pathological fracture, fractionation of RT, pre-RT surgery, pre-RT administration of bisphosphonates/denosumab, pre-RT systemic anticancer treatment) were retrospectively analyzed for survival. Factors achieving significance (p < 0.05) or borderline significance (p < 0.055) on multivariate analysis were used for the scoring system. Twelve-month survival rates were divided by 10 (factor scores); factor scores were summed for each patient (patient scores). Results On multivariate analysis, survival was significantly associated with KPS (hazard ratio (HR) 1.91, p < 0.001) and primary tumor type (HR 1.12, p < 0.001); age achieved borderline significance (HR 1.14, p = 0.054). These factors were used for the scoring tool. Patient scores ranged from 8 to 17 points. Three groups were designated: 8–9 (A), 10–14 (B) and 15–17 (C) points. Twelve-month survival rates were 9, 38 and 72% (p < 0.001); median survival times were 3, 8 and 24 months. Conclusions This new tool developed for patients irradiated for bone metastases at any site without spinal cord compression allows one to predict the survival of these patients and can aid physicians when assigning the treatment to individual patients.
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Affiliation(s)
- Dirk Rades
- Department of Radiation Oncology, University of Lübeck, Ratzeburger Allee 160, D-23538, Lübeck, Germany.
| | - Rapha Haus
- Department of Radiation Oncology, University of Lübeck, Ratzeburger Allee 160, D-23538, Lübeck, Germany
| | - Steven E Schild
- Department of Radiation Oncology, Mayo Clinic Scottsdale, Scottsdale, AZ, USA
| | - Stefan Janssen
- Department of Radiation Oncology, University of Lübeck, Ratzeburger Allee 160, D-23538, Lübeck, Germany.,Medical Practice for Radiotherapy and Radiation Oncology, Hannover, Germany
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21
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Paravertebral Muscle Training in Patients with Unstable Spinal Metastases Receiving Palliative Radiotherapy: An Exploratory Randomized Feasibility Trial. Cancers (Basel) 2019; 11:cancers11111771. [PMID: 31717925 PMCID: PMC6896044 DOI: 10.3390/cancers11111771] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 10/23/2019] [Accepted: 11/05/2019] [Indexed: 12/22/2022] Open
Abstract
Background: Isometric paravertebral muscle training (IPMT) may improve mobility, pain, and quality of life (QOL) in cancer patients with spinal metastases. However, this regimen remains unproven in patients with unstable spinal metastases (USM), a population at high risk for clinical exacerbation with such interventions. Thus, we conducted this exploratory, non-blinded, randomized controlled trial (NCT02847754) to evaluate the safety/feasibility of IPMT and secondarily assess pain, bone density, pathologic fracture rate, and QOL. Methods: All patients had histologically/radiologically confirmed USM (per Taneichi score) and underwent non-operative management with 5–10 fractions of palliative radiotherapy (RT). Randomization (1:1) groups were IPMT (intervention, INT) or muscle relaxation (control, CON); both lasted 15 min/day and started concurrently with radiotherapy. The primary endpoint was feasibility (completion of training programs three months post-RT). Secondary endpoints were pain response (Visual Analog Scale) and opioid consumption, bone density and pathologic fracture rate, and QOL (European Organization for Research and Treatment of Cancer, EORTC questionnaires). Results: Sixty patients were randomized and 56 received protocol therapy. Mean survival in both groups was 4.4 months. There were no adverse events with either training regimen. Altogether, ≥80% of the planned sessions were completed by 55% (n = 16/29) in CON and 67% (n = 18/27) in INT. Regarding the post-radiotherapy home-based training, ≥80% of planned sessions were completed by 64% (n = 9/14) of the INT cohort. There were no differences in pain scores, opioid consumption, or bone density between arms (p > 0.05 for all). No difference was observed between groups regarding new pathological fractures (INT: n = 1 vs. CON: n = 3) after three months (p = 0.419). There were no QOL differences between arms (all parameters p > 0.05). Conclusions: IPMT is potentially feasible for high-risk USM patients. Future trials adequately powered for relevant endpoints are thus recommended.
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A phase III randomized-controlled, single-blind trial to improve quality of life with stereotactic body radiotherapy for patients with painful bone metastases (ROBOMET). BMC Cancer 2019; 19:876. [PMID: 31484505 PMCID: PMC6727408 DOI: 10.1186/s12885-019-6097-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Accepted: 08/26/2019] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Bone metastases represent an important source of morbidity in cancer patients, mostly due to severe pain. Radiotherapy is an established symptomatic treatment for painful bone metastases, however, when conventional techniques are used, the effectiveness is moderate. Stereotactic body radiotherapy (SBRT), delivering very high doses in a limited number of fractions in a highly conformal manner, could potentially be more effective and less toxic. METHODS This is a phase III, randomized-controlled, single-blind, multicenter study evaluating the response rate of antalgic radiotherapy for painful bone metastases and the acute toxicity associated with this treatment. A total of 126 patients will be randomly assigned to receive either the standard schedule of a single fraction of 8.0 Gy delivered through three-dimensional conformal radiotherapy or a single fraction of 20.0 Gy delivered through SBRT. Primary endpoint is pain response at the treated site at 1 month after radiotherapy. Secondary endpoints are pain flare at 24-48-72 h after radiotherapy, duration of pain response, re-irradiation need, acute toxicity, late toxicity, quality of life and subsequent serious skeletal events. In a supplementary analysis, patient-compliance for a paper-and-pencil questionnaire will be compared with an electronic mode. DISCUSSION If a dose-escalated approach within the context of single fraction stereotactic body radiotherapy could improve the pain response to radiotherapy and minimize acute toxicity, this would have an immediate impact on the quality of life for a large number of patients with advanced cancer. Potential disadvantages of this technique include increased pain flare or a higher incidence of radiation-induced fractures. TRIAL REGISTRATION The Ethics committee of the GZA Hospitals (B099201732915) approved this study on September 4th 2018. Trial registered on Clinicaltrials.gov ( NCT03831243 ) on February 5th 2019.
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Spencer K, Velikova G, Henry A, Westhoff P, Hall PT, van der Linden YM. Net Pain Relief After Palliative Radiation Therapy for Painful Bone Metastases: A Useful Measure to Reflect Response Duration? A Further Analysis of the Dutch Bone Metastasis Study. Int J Radiat Oncol Biol Phys 2019; 105:559-566. [PMID: 31344434 PMCID: PMC6859481 DOI: 10.1016/j.ijrobp.2019.07.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Revised: 06/10/2019] [Accepted: 07/04/2019] [Indexed: 12/11/2022]
Abstract
Purpose Pain response rates are equivalent after single 8 Gy and fractionated palliative radiation therapy for bone metastases. Reirradiation remains more frequent after a single fraction, although this does not simply reflect pain recurrence. Given the possible role of stereotactic radiation therapy in providing durable pain control, measures of durability are required. Net pain relief (NPR), the proportion of remaining life spent with pain response, may provide this. This study assesses the use of NPR as an outcome measure after palliative radiation therapy for bone metastases. Methods and Materials This is a secondary analysis of data collected in the Dutch Bone Metastasis Study, a randomized trial comparing palliative radiation therapy delivered as 8 Gy in a single fraction and 24 Gy in 6 fractions. NPR was assessed by survival cohorts, treatment regimen, and primary diagnoses. The consequences of missing data upon the use of NPR in future studies were considered within sensitivity analyses. Results Patients whose pain improved after palliative radiation therapy experienced improvement for 56.6% of their remaining lives. Missing responses in questionnaires mean the range of uncertainty in NPR is 36.1% to 62.1%. When response beyond reirradiation was excluded, NPR after treatments of single-fraction 8 Gy and 24 Gy in 6 fractions was 49.0% and 56.5%, respectively (P = .004). Differential willingness to reirradiate may be influencing this outcome. When response beyond reirradiation was included, this difference was not seen (NPR of 55.4% vs 57.7%, respectively [P = .191]). Conclusions Patients who responded to conventional radiation therapy experienced improved pain control for approximately half of their remaining life. NPR may provide valuable information in assessing pain response durability. Missing data are, however, inevitable in this population. This must be minimized and the consequences recognized and reported. Additionally, reirradiation protocols and the frequency and duration of trial follow-up may have a significant impact upon this outcome, requiring careful consideration during trial design if NPR is to be used in future studies.
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Affiliation(s)
- Katie Spencer
- Leeds Institute of Medical Research, University of Leeds, Leeds, United Kingdom; Leeds Cancer Centre, Leeds NHS Teaching Hospitals Trust, Leeds, Leeds, United Kingdom.
| | - Galina Velikova
- Leeds Institute of Medical Research, University of Leeds, Leeds, United Kingdom; Leeds Cancer Centre, Leeds NHS Teaching Hospitals Trust, Leeds, Leeds, United Kingdom
| | - Ann Henry
- Leeds Institute of Medical Research, University of Leeds, Leeds, United Kingdom; Leeds Cancer Centre, Leeds NHS Teaching Hospitals Trust, Leeds, Leeds, United Kingdom
| | - Paulien Westhoff
- Department of Radiation Oncology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Pe Ter Hall
- Edinburgh Cancer Research Centre, University of Edinburgh, Edinburgh, United Kingdom
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Yu JB, Pollack CE, Herrin J, Zhu W, Soulos PR, Xu X, Gross CP. Persistent Use of Extended Fractionation Palliative Radiotherapy for Medicare Beneficiaries With Metastatic Breast Cancer, 2011 to 2014. Am J Clin Oncol 2019; 42:493-499. [PMID: 31033511 PMCID: PMC6538429 DOI: 10.1097/coc.0000000000000548] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
INTRODUCTION With no evidence to support extended radiation courses for the palliation of bone metastases, multiple guidelines were issued discouraging its use. We assessed contemporary use and cost of prolonged palliative radiotherapy in Medicare beneficiaries with bone metastases from breast cancer. METHODS We conducted a retrospective, longitudinal study of palliative radiotherapy use among fee-for-service Medicare beneficiaries with bone metastasis from breast cancer who underwent palliative radiotherapy during 2011 to 2014. Patients were categorized according to the number of days (fractions) on which they received palliative radiotherapy: 1, 2 to 10, 11 to 19, or 20 to 30. We examined the association of clinical, demographic, and provider characteristics with the use of extended (≥11 fractions) or very extended (≥20 fractions) fractionation with logistic regression models. We also compared the cost of different fractionation schemes from the payer perspective. RESULTS Of the 7547 patients in the sample (mean age, 71 y), 3084 (40.8%) received extended fractionation. The proportion of patients receiving 11 to 19 (34.7% in 2011 and 28.1% in 2014, trend P<0.001) and 20 to 30 treatments (10.3% in 2011 to 9.0% in 2014, trend P=0.07) decreased modestly over time. Patients with comorbidities were less likely to undergo extended fractionation (34.4% for ≥3 comorbidities vs. 44.9% for 0 comorbidities; adjusted odds ratio 0.67 [95% confidence interval, 0.58-0.76]). Patients treated at free-standing practices were more likely to undergo extended fractionation (47.9%) compared with those treated at hospital-based practices (37.3%, P<0.001; adjusted odds ratio, 1.49 [95% confidence interval, 1.35-1.65]). The mean cost of treatment varied from $633 (SD $240) for single-fraction treatment, to $3566 (SD $1349) for 11 to 19 fractions, to $6597 (SD $2893) for 20 to 30 fractions. CONCLUSION The use of prolonged courses of palliative radiotherapy among Medicare beneficiaries with breast cancer remained high in 2011 to 2014. The association between free-standing facility status and use of extended fractionation suggests that provider financial incentives may impact choice of treatment.
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Affiliation(s)
- James B. Yu
- Department of Therapeutic Radiology, Yale School of Medicine, New Haven, CT
- Yale Cancer Center, New Haven, CT
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center at Yale, New Haven, CT
| | - Craig E. Pollack
- Johns Hopkins School of Medicine, Baltimore, MD
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Jeph Herrin
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center at Yale, New Haven, CT
- Section of Cardiology, Yale School of Medicine, New Haven, CT
| | - Weiwei Zhu
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center at Yale, New Haven, CT
- Department of Internal Medicine, Section of General Internal Medicine, Yale School of Medicine, New Haven, CT
| | - Pamela R. Soulos
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center at Yale, New Haven, CT
- Department of Internal Medicine, Section of General Internal Medicine, Yale School of Medicine, New Haven, CT
| | - Xiao Xu
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center at Yale, New Haven, CT
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine, New Haven, CT
| | - Cary P. Gross
- Yale Cancer Center, New Haven, CT
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center at Yale, New Haven, CT
- Department of Internal Medicine, Section of General Internal Medicine, Yale School of Medicine, New Haven, CT
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Wang Q, Sun B, Meng X, Liu C, Cong Y, Wu S. Density of bone metastatic lesions increases after radiotherapy in patients with breast cancer. JOURNAL OF RADIATION RESEARCH 2019; 60:394-400. [PMID: 30785994 PMCID: PMC6530615 DOI: 10.1093/jrr/rry098] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/27/2018] [Revised: 04/17/2018] [Indexed: 06/09/2023]
Abstract
The aim of this study was to assess local response to radiotherapy (RT) in a quantitative manner by evaluating the bone density of metastases. Spinal and pelvic bone metastases in 44 patients with breast cancer who were treated between May 2010 and December 2016 were retrospectively assessed. Bone density values of irradiated and unirradiated bone metastases before, 1-3 months after, 4-6 months after, and 7-9 months after RT were compared. At each time point, mean bone density ± standard deviation values were measured in Hounsfield units (HU) from computed tomography (CT) scans. Student's t-test was used for statistical analyses of the differences in bone density and for univariate analysis of the prognostic factors for differences in bone density at various time points after RT. Mean bone densities in irradiated and unirradiated bone metastases before RT were 297.31 ± 211.93 HU and 326.29 ± 228.61 HU, respectively. At the subsequent three time points examined, the mean bone density values in the irradiated and unirradiated bone metastases were: 61.97 ± 78.58 HU (P = 0.000) and 36.93 ± 52.49 HU (P = 0.001); 149.07 ± 133.27 HU (P = 0.000) and 68.40 ± 101.10 HU (P = 0.000); and 183.94 ± 168.30 HU (P = 0.000) and 88.21 ± 159.49 HU (P = 0.004), respectively, in each case. Patients receiving bisphosphonates exhibited greater increases in bone density in their metastases 1-3 months after RT (83.04 ± 82.18 HU vs 26.86 ± 60.55 HU, respectively; P = 0.044), whereas chemotherapy before RT was associated with significantly lower increases in bone density at the subsequent three time points [(37.53 ± 67.66 HU vs 93.63 ± 80.36 HU, P = 0.027), (99.30 ± 107.92 HU vs 180.24 ± 127.85 HU, P = 0.030), and (126.07 ± 141.77 HU vs 236.28 ± 158.22 HU, P = 0.024), respectively, in each case]. Comparing bone density values determined from CT scans appears to be a practicable and reproducible method for assessing local response to RT for bone metastasis of breast cancer. Increased bone density was also observed in the irradiated bone metastases.
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Affiliation(s)
- Qian Wang
- Department of Radiation Oncology, 307 Hospital of People’s Liberation Army, Beijing, China
| | - Bing Sun
- Department of Radiation Oncology, 307 Hospital of People’s Liberation Army, Beijing, China
| | - Xiangying Meng
- Department of Radiation Oncology, 307 Hospital of People’s Liberation Army, Beijing, China
| | - Chao Liu
- Department of Radiation Oncology, 307 Hospital of People’s Liberation Army, Beijing, China
| | - Yang Cong
- Department of Radiation Oncology, 307 Hospital of People’s Liberation Army, Beijing, China
| | - Shikai Wu
- Department of Radiation Oncology, 307 Hospital of People’s Liberation Army, Beijing, China
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Di Lalla V, Fortin B, Pembroke C, Freeman C, Yassa M, Hijal T. Are radiation oncologists following guidelines? An audit of practice in patients with uncomplicated bone metastases. Tech Innov Patient Support Radiat Oncol 2019; 9:13-17. [PMID: 32095590 PMCID: PMC7033799 DOI: 10.1016/j.tipsro.2018.12.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Revised: 12/12/2018] [Accepted: 12/22/2018] [Indexed: 12/18/2022] Open
Abstract
At our center single fraction radiotherapy is used in accordance with guidelines. Patient age, performance status and tumor histology influence treatment choice. We added a quality indicator to our performance dashboard to improve adherence. This strategy can be used in other complex practices and improve quality of care.
Background Best-practice guidelines recommend single-fraction (SFRT) instead of multi-fraction radiation therapy (MFRT) for uncomplicated symptomatic bone metastases. SFRT is comparable to MFRT in relieving pain, convenient for patients, and cost-effective. Patterns of practice in Canada reveal that SFRT is underused, with significant variability across the country. We audited SFRT use and studied factors that may influence treatment decisions at a large academic tertiary care center in Quebec, Canada. Methods Patients who received radiotherapy for uncomplicated bone metastases between February 2014 and March 2015 were reviewed. Age, gender, primary histology, site of metastases and performance status were identified as potential factors affecting fractionation. These were explored by Fisher's test on univariate analysis and logistic regression for multivariate analysis. Retreatment rates were analyzed with cumulative incidence and compared with Gray's test. Results 254 radiotherapy courses were administered to 165 patients, 85.4% of which were delivered using a single fraction of 8 Gy. Patients age less than 70 years and those with breast histology were more likely to receive MFRT (p = 0.04; p = 0.0046). Performance status (ECOG) was a significant predictor of fractionation because of high correlations between young age, breast histology, and ECOG status (p = 0.03). Follow-up was too short in 40% of patients to derive definitive conclusions on retreatment. Conclusions In accordance with current guidelines, our audit confirms that use of SFRT in patients with uncomplicated bone metastases at our center is high. We identified that patient age, primary histology, and performance status influenced fractionation. Incorporation of this quality indicator into our performance dashboard will allow assessment of retreatment differences and other criteria that may also influence treatment choice.
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Affiliation(s)
| | | | | | | | - Michael Yassa
- Hôpital Maisonneuve-Rosemont, Montreal, Quebec, Canada
| | - Tarek Hijal
- McGill University Health Centre, Montreal, Quebec, Canada
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27
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van der Velden JM, van der Linden YM, Versteeg AL, Verlaan JJ, Sophie Gerlich A, Pielkenrood BJ, Kasperts N, Verkooijen HM. Evaluation of effectiveness of palliative radiotherapy for bone metastases: a prospective cohort study. ACTA ACUST UNITED AC 2019; 7:325-333. [PMID: 30595809 PMCID: PMC6290653 DOI: 10.1007/s13566-018-0363-6] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Accepted: 10/29/2018] [Indexed: 01/16/2023]
Abstract
Objective Radiotherapy is the standard local treatment for patients with painful bone metastases, but effectiveness has primarily been evaluated in trial populations. The aim of this study was to study pain response to palliative radiotherapy in a prospective cohort of unselected patients with bone metastases. Methods Patients with painful bone metastases referred to the UMC Utrecht for radiotherapy and enrolled in the PRESENT cohort were included in this study. For all patients, pain response to radiotherapy was assessed, and responders were defined as patients with a complete or partial pain response. Patients with stable pain scores, pain increase, or undetermined response were regarded non-responders. Pain scores obtained at baseline and after 2, 4, 6, 8, and 12 weeks following radiotherapy were obtained. Pain response rates of the total treated population, as well as response rates of the assessable patients, were calculated. To measure the percentage of the remaining time spent with pain relief, the net pain relief (NPR) was calculated by dividing the period of pain relief by the period of survival. Results Of the 432 patients enrolled in this study, 262 patients (61%) experienced a complete or partial response. In the 390 assessable patients, this percentage was 67%. Median time to response was 4 weeks (range 1–15 weeks), and the NPR was 64%. Conclusion Compared to randomized trial populations, palliative radiotherapy in our unselected patients with bone metastases showed similar pain response rates (61%), with a reasonable duration of this effect.
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Affiliation(s)
- Joanne M van der Velden
- 1Department of Radiation Oncology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - Yvette M van der Linden
- 2Department of Radiation Oncology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Anne L Versteeg
- 3Department of Orthopedic Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - Jorrit-Jan Verlaan
- 3Department of Orthopedic Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - A Sophie Gerlich
- 1Department of Radiation Oncology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - Bart J Pielkenrood
- 1Department of Radiation Oncology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - Nicolien Kasperts
- 1Department of Radiation Oncology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - Helena M Verkooijen
- 1Department of Radiation Oncology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands.,4Department of Clinical Epidemiology, Julius Center for Health Sciences and Primary Care, Universiteitsweg 100, 3584 CG Utrecht, The Netherlands
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28
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Sprave T, Verma V, Förster R, Schlampp I, Hees K, Bruckner T, Bostel T, El Shafie RA, Welzel T, Nicolay NH, Debus J, Rief H. Bone density and pain response following intensity-modulated radiotherapy versus three-dimensional conformal radiotherapy for vertebral metastases - secondary results of a randomized trial. Radiat Oncol 2018; 13:212. [PMID: 30376859 PMCID: PMC6208115 DOI: 10.1186/s13014-018-1161-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Accepted: 10/22/2018] [Indexed: 12/19/2022] Open
Abstract
Background This was a prespecified secondary analysis of a randomized trial that analyzed bone density and pain response following fractionated intensity-modulated radiotherapy (IMRT) versus three-dimensional conformal radiotherapy (3DCRT) for palliative management of spinal metastases. Methods/materials Sixty patients were enrolled in the single-institutional randomized exploratory trial, randomly assigned to receive IMRT or 3DCRT (30 Gy in 10 fractions). Along with pain response (measured by the Visual Analog Scale (VAS) and Chow criteria), quantitative bone density was evaluated at baseline, 3, and 6 months in both irradiated and unirradiated spinal bodies, along with rates of pathologic fractures and vertebral compression fractures. Results Relative to baseline, bone density increased at 3 and 6 months following IMRT by a median of 24.8% and 33.8%, respectively (p < 0.01 and p = 0.048). These figures in the 3DCRT cohort were 18.5% and 48.4%, respectively (p < 0.01 for both). There were no statistical differences in bone density between IMRT and 3DCRT at 3 (p = 0.723) or 6 months (p = 0.341). Subgroup analysis of osteolytic and osteoblastic metastases showed no differences between groups; however, mixed metastases showed an increase in bone density over baseline in the IMRT (but not 3DCRT) arm. The 3-month rate of the pathological fractures was 15.0% in the IMRT arm vs. 10.5% in the 3DCRT arm. There were no differences in pathological fractures at 3 (p = 0.676) and 6 (p = 1.000) months. The IMRT arm showed improved VAS scores at 3 (p = 0.037) but not 6 months (p = 0.430). Using Chow criteria, pain response was similar at both 3 (p = 0.395) and 6 (p = 0.732) months. Conclusions This the first prospective investigation evaluating the impact of IMRT vs. 3DCRT on bone density. Along with pain response and pathologic fracture rates, significant rises in bone density after 3 and 6 months were similar in both cohorts. Future randomized investigations with larger sample sizes are recommended. Trial registration NCT, NCT02832830. Registered 14 July 2016
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Affiliation(s)
- Tanja Sprave
- University Hospital of Heidelberg, Department of Radiation Oncology, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), Im Neuenheimer Feld 280, 69120, Heidelberg, Germany
| | - Vivek Verma
- Department of Radiation Oncology, Allegheny General Hospital, Pittsburgh, PA, USA
| | - Robert Förster
- University Hospital of Heidelberg, Department of Radiation Oncology, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), Im Neuenheimer Feld 280, 69120, Heidelberg, Germany.,University Hospital Zurich, Department of Radiation Oncology, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Ingmar Schlampp
- University Hospital of Heidelberg, Department of Radiation Oncology, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), Im Neuenheimer Feld 280, 69120, Heidelberg, Germany
| | - Katharina Hees
- Department of Radiation Oncology, Allegheny General Hospital, Pittsburgh, PA, USA.,University Hospital of Heidelberg, Department of Medical Biometry, Im Neuenheimer Feld 305, 69120, Heidelberg, Germany
| | - Thomas Bruckner
- Department of Radiation Oncology, Allegheny General Hospital, Pittsburgh, PA, USA.,University Hospital of Heidelberg, Department of Medical Biometry, Im Neuenheimer Feld 305, 69120, Heidelberg, Germany
| | - Tilman Bostel
- University Hospital of Heidelberg, Department of Radiation Oncology, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - Rami Ateyah El Shafie
- University Hospital of Heidelberg, Department of Radiation Oncology, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), Im Neuenheimer Feld 280, 69120, Heidelberg, Germany
| | - Thomas Welzel
- University Hospital of Heidelberg, Department of Radiation Oncology, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - Nils Henrik Nicolay
- University Hospital of Heidelberg, Department of Radiation Oncology, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), Im Neuenheimer Feld 280, 69120, Heidelberg, Germany.,University Hospital of Freiburg, Department of Radiation Oncology, Robert-Koch-Strasse 3, 79106, Freiburg, Germany
| | - Jürgen Debus
- University Hospital of Heidelberg, Department of Radiation Oncology, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), Im Neuenheimer Feld 280, 69120, Heidelberg, Germany
| | - Harald Rief
- University Hospital of Heidelberg, Department of Radiation Oncology, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany. .,Heidelberg Institute of Radiation Oncology (HIRO), Im Neuenheimer Feld 280, 69120, Heidelberg, Germany.
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Kono M, Fujii T, Matsuda N, Harano K, Chen H, Wathoo C, Joon AY, Tripathy D, Meric-Bernstam F, Ueno NT. Somatic mutations, clinicopathologic characteristics, and survival in patients with untreated breast cancer with bone-only and non-bone sites of first metastasis. J Cancer 2018; 9:3640-3646. [PMID: 30310523 PMCID: PMC6171013 DOI: 10.7150/jca.26825] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2018] [Accepted: 07/07/2018] [Indexed: 02/01/2023] Open
Abstract
Background: Bone is the most common site of metastasis of breast cancer. Biological mechanisms of metastasis to bone may be different from mechanisms of metastasis to non-bone sites, and identification of distinct signaling pathways and somatic mutations may provide insights on biology and rational targets for treatment and prevention of bone metastasis. The aims of this study were to compare and contrast somatic mutations, clinicopathologic characteristics, and survival in breast cancer patients with bone-only versus non-bone sites of first metastasis. Methods: Primary tumor samples were collected before treatment from 389 patients with untreated primary breast cancer and distant metastasis at diagnosis. In each sample, 46 or 50 cancer-related genes were analyzed for mutations by AmpliSeq Ion Torrent next-generation sequencing. Fisher's exact test was used to identify somatic mutations associated with bone-only first metastasis. Logistic regression models were used to identify differences in detected somatic mutations, clinicopathologic characteristics, and survival between patients with bone-only first metastasis and patients with first metastasis in non-bone sites only (“other-only first metastasis”). Results: Among the 389 patients, 72 (18.5%) had bone-only first metastasis, 223 (57.3%) had other-only first metastasis, and 94 (24.2%) had first metastasis in both bone and non-bone sites. The most commonly mutated genes were TP53 (N=103), PIK3CA (N=79), AKT (N=13), and PTEN (N=2). Compared to patients with other-only first metastasis, patients with bone-only first metastasis had higher rates of hormone-receptor-positive disease, non-triple-negative subtype, and lower grade (grade 1 or 2; Nottingham grading system) (all three comparisons, p<0.001); had a lower ratio of cases of invasive ductal carcinoma to cases of invasive lobular carcinoma (p=0.002); and tended to have a higher 5-year overall survival (OS) rate (78.2% [95% confidence interval (CI), 68.6%-89.0%] vs 55.0% [95% CI, 48.1%-62.9%]; p=0.051). However, in the subgroup of patients with TP53 mutation and in the subgroup of patients with PIK3CA mutation, OS did not differ between patients with bone-only and other-only first metastasis (p=0.49 and p=0.68, respectively). In univariate analysis, the rate of TP53 mutation tended to be lower in patients with bone-only first metastasis than in those with other-only first metastasis (15.3% vs 29.1%; p=0.051). In multivariate analysis, TP53 mutation was not significantly associated with site of first metastasis (p=0.54) but was significantly associated with hormone-receptor-negative disease (p<0.001). Conclusions: We did not find associations between somatic mutations and bone-only first metastasis in patients with untreated breast cancer. Patients with bone-only first metastasis tend to have longer OS than patients with other-only first metastasis. More comprehensive molecular analysis may be needed to further understand the factors associated with bone-only metastatic disease in breast cancer.
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Affiliation(s)
- Miho Kono
- Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Takeo Fujii
- Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Naoko Matsuda
- Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Kenichi Harano
- Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Huiqin Chen
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Chetna Wathoo
- Sheikh Khalifa Zayed Al Nahyan Institute for Personalized Cancer Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Aron Y Joon
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Debu Tripathy
- Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Funda Meric-Bernstam
- Sheikh Khalifa Zayed Al Nahyan Institute for Personalized Cancer Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA.,Department of Investigational Cancer Therapeutics (Phase I Trials Department), The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Naoto T Ueno
- Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
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Sprave T, Verma V, Förster R, Schlampp I, Hees K, Bruckner T, Bostel T, El Shafie RA, Welzel T, Nicolay NH, Debus J, Rief H. Local response and pathologic fractures following stereotactic body radiotherapy versus three-dimensional conformal radiotherapy for spinal metastases - a randomized controlled trial. BMC Cancer 2018; 18:859. [PMID: 30170568 PMCID: PMC6119304 DOI: 10.1186/s12885-018-4777-8] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Accepted: 08/23/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND This was a prespecified secondary analysis of a randomized trial, which analyzed bone density following stereotactic body radiotherapy (SBRT) versus conventional three-dimensional conformal radiotherapy (3DCRT) as part of palliative management of painful spinal metastases. METHODS Fifty-five patients were enrolled in this single-institutional randomized exploratory trial (NCT02358720). Participants were randomly assigned to receive SBRT (single-fraction 24 Gy) or 3DCRT (30 Gy/10 fractions). Quantitative bone density was evaluated at baseline, 3 and 6 months in both irradiated and unirradiated spinal bodies, along with rates of pathologic fractures and vertebral compression fractures. RESULTS As compared to baseline, bone density became significantly higher at 3 and 6 months following SBRT by a median of 33.8% and 72.1%, respectively (p < 0.01 for both). These figures in the 3DCRT cohort were 32.9% and 41.2%, respectively (p < 0.01 for both). There were no statistical differences in bone density between SBRT and 3DCRT at 3 (p = 0.629) or 6 months (p = 0.327). Subgroup analysis of osteolytic metastases showed an increase in bone density relative to baseline in the SBRT (but not 3DCRT) arm. Bone density in unaffected vertebrae did not show substantial changes in either group. The 3-month incidence of new pathological fractures was 8.7% in the SBRT arm vs. 4.3% in the 3DCRT arm. CONCLUSIONS Despite high ablative doses in the SBRT arm, the significant increase in bone density after 3 and 6 months was similar to that of 3DCRT. Our trial demonstrated a moderate rate of subsequent pathological fracture after SBRT. Future randomized investigations with larger sample sizes are recommended. TRIAL REGISTRATION www.clinicaltrials.gov : NCT02358720 on 9nd of February 2015.
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Affiliation(s)
- Tanja Sprave
- Department of Radiation Oncology, University Hospital of Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), Im Neuenheimer Feld 280, 69120, Heidelberg, Germany
| | - Vivek Verma
- Department of Radiation Oncology, Allegheny General Hospital, Pittsburgh, PA, USA
| | - Robert Förster
- Department of Radiation Oncology, University Hospital of Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), Im Neuenheimer Feld 280, 69120, Heidelberg, Germany.,Department of Radiation Oncology, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Ingmar Schlampp
- Department of Radiation Oncology, University Hospital of Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), Im Neuenheimer Feld 280, 69120, Heidelberg, Germany
| | - Katharina Hees
- Department of Medical Biometry, University Hospital of Heidelberg, Im Neuenheimer Feld 305, 69120, Heidelberg, Germany
| | - Thomas Bruckner
- Department of Radiation Oncology, Allegheny General Hospital, Pittsburgh, PA, USA.,Department of Medical Biometry, University Hospital of Heidelberg, Im Neuenheimer Feld 305, 69120, Heidelberg, Germany
| | - Tilman Bostel
- Department of Radiation Oncology, University Hospital of Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), Im Neuenheimer Feld 280, 69120, Heidelberg, Germany
| | - Rami Ateyah El Shafie
- Department of Radiation Oncology, University Hospital of Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), Im Neuenheimer Feld 280, 69120, Heidelberg, Germany
| | - Thomas Welzel
- Department of Radiation Oncology, University Hospital of Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), Im Neuenheimer Feld 280, 69120, Heidelberg, Germany
| | - Nils Henrik Nicolay
- Department of Radiation Oncology, University Hospital of Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), Im Neuenheimer Feld 280, 69120, Heidelberg, Germany.,Department of Radiation Oncology, University Hospital of Freiburg, Robert-Koch-Strasse 3, 79106, Freiburg, Germany
| | - Jürgen Debus
- Department of Radiation Oncology, University Hospital of Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), Im Neuenheimer Feld 280, 69120, Heidelberg, Germany
| | - Harald Rief
- Department of Radiation Oncology, University Hospital of Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany. .,Heidelberg Institute of Radiation Oncology (HIRO), Im Neuenheimer Feld 280, 69120, Heidelberg, Germany. .,Department of Radiation Oncology, University of Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany.
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Xiang Z, Wang L, Yan H, Zhong Z, Liu W, Mo Z, Gao F, Zhang F. 125I seed brachytherapy versus external beam radiation therapy for the palliation of painful bone metastases of lung cancer after one cycle of chemotherapy progression. Onco Targets Ther 2018; 11:5183-5193. [PMID: 30214224 PMCID: PMC6118334 DOI: 10.2147/ott.s154973] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Purpose This study aimed to compare the outcomes of 125I seed brachytherapy versus external beam radiation therapy (EBRT) for the palliation of painful bone metastases of lung cancer after one cycle of chemotherapy progression. Materials and methods We analyzed retrospectively 158 patients with painful bone metastases secondary to lung cancer after one cycle of chemotherapy progression treated between June 2013 and May 2016. Seventy-six patients with 96 lesions received 125I brachytherapy (Group A), whereas 82 patients with 98 metastases received EBRT (Group B). Pain intensity on Brief Pain Inventory, percentage of patients with pain severity, and quality of life were recorded prior to treatment (T0), 2, 4, 6, 8, 12, 16, 20, and 24 weeks (T2, T4, T6, T8, T12, T16, T20, and T24) after treatment during a 24-hour period. Cost-effectiveness and number of treatment appointments were also compared between groups. Results One hundred and fifty-eight patients had been treated. Visual analog scale for worst pain in Group A was significantly lower than in Group B at T2, T4, T6, T16, T20, and T24. Group A was superior to group B concerning quality of life scores (T2, T4, T20, and T24), cost-effectiveness, and number of treatment appointments. No significant differences were observed for complications. Conclusion Compared with EBRT, 125I seed brachytherapy can be an alternative method for painful bone metastases from lung cancer after one cycle of chemotherapy progression.
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Affiliation(s)
- Zhanwang Xiang
- Department of Radiology, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Department of Interventional Radiology, Ling-nan Hospital, Sun Yat-sen University, Guangzhou, China.,Interventional Radiology Institute, Sun Yat-sen University, Guangzhou, China; Guangzhou, China
| | - Lifei Wang
- The Department of Radiology, The Third People's Hospital of Shenzhen, Shenzhen, China
| | - Huzheng Yan
- Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China, ;
| | - Zhihui Zhong
- Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China, ;
| | - Wangkai Liu
- The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Zhiqiang Mo
- Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China, ;
| | - Fei Gao
- Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China, ;
| | - Fujun Zhang
- Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China, ;
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Vellayappan BA, Chao ST, Foote M, Guckenberger M, Redmond KJ, Chang EL, Mayr NA, Sahgal A, Lo SS. The evolution and rise of stereotactic body radiotherapy (SBRT) for spinal metastases. Expert Rev Anticancer Ther 2018; 18:887-900. [DOI: 10.1080/14737140.2018.1493381] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Affiliation(s)
- Balamurugan A. Vellayappan
- Department of Radiation Oncology, National University Cancer Institute Singapore, National University Health System, Singapore
| | - Samuel T. Chao
- Department of Radiation Oncology, Cleveland Clinic, Cleveland, OH, USA
| | - Matthew Foote
- Department of Radiation Oncology, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Matthias Guckenberger
- Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Kristin J. Redmond
- Department of Radiation Oncology and Molecular Radiation Sciences, The Johns Hopkins University, Baltimore, MD, USA
| | - Eric L. Chang
- Department of Radiation Oncology, University of Southern California, Keck School of Medicine, Los Angeles, CA, USA
| | - Nina A. Mayr
- Department of Radiation Oncology, University of Washington School of Medicine, Seattle, WA, USA
| | - Arjun Sahgal
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Simon S. Lo
- Department of Radiation Oncology, University of Washington School of Medicine, Seattle, WA, USA
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Youland RS, Blanchard ML, Dronca R, Kottschade L, Markovic SN, Olivier KR, Park SS. Role of radiotherapy in extracranial metastatic malignant melanoma in the modern era. Clin Transl Radiat Oncol 2018; 6:25-30. [PMID: 29594220 PMCID: PMC5862645 DOI: 10.1016/j.ctro.2017.09.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2017] [Revised: 08/17/2017] [Accepted: 09/06/2017] [Indexed: 11/26/2022] Open
Abstract
Background To assess the role of radiotherapy in metastatic malignant melanoma (MM) patients in modern era. Materials and methods This is a retrospective study of MM patients treated with radiotherapy at Mayo Clinic from 1999 to 2014. Patients with pre- and post-treatment imaging studies (CT, MRI, and/or PET/CT) were assessed for metastasis failure (MF), regional/distant failure, and overall survival (OS). Results In 75 MM patients, 56 and 68 lesions were treated with conventional/hypofractionated radiotherapy (CHRT) and stereotactic body radiotherapy (SBRT), respectively. The median doses for CHRT and SBRT were 30 Gy and 50 Gy, respectively. 1-year MF was 17% (SBRT 6% vs CHRT 31%, p < 0.01). 1-year regional (5% vs 29%, p < 0.01) and distant progression (75% vs 89%, p < 0.01) were improved with SBRT. Median OS was 15.6 months (CHRT 7.0 vs SBRT 22.9, p < 0.01). Prognostic factors for OS included age ≤55 years (RR 0.25), oligometastatic disease (RR 0.34), SBRT (RR 0.38) and treating all lesions (RR 0.28, all p < 0.01). Conclusions SBRT for extracranial MM exhibited improved MF compared with CHRT, consistent with intracranial radiosurgery data. Though these data are retrospective and subject to selection bias, our findings support the prudent use of SBRT in a select group of favorable, oligometastatic MM patients, and should be discussed as an alternative to surgery and ablation.
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Affiliation(s)
- Ryan S Youland
- Department of Radiation Oncology, Mayo Clinic, 200 First Street, Rochester, MN 55905, United States
| | - Miran L Blanchard
- Department of Radiation Oncology, Mayo Clinic, 200 First Street, Rochester, MN 55905, United States
| | - Roxanna Dronca
- Division of Medical Oncology, Mayo Clinic, 200 First Street, Rochester, MN 55905, United States
| | - Lisa Kottschade
- Division of Medical Oncology, Mayo Clinic, 200 First Street, Rochester, MN 55905, United States
| | - Svetomir N Markovic
- Division of Medical Oncology, Mayo Clinic, 200 First Street, Rochester, MN 55905, United States
| | - Kenneth R Olivier
- Department of Radiation Oncology, Mayo Clinic, 200 First Street, Rochester, MN 55905, United States
| | - Sean S Park
- Department of Radiation Oncology, Mayo Clinic, 200 First Street, Rochester, MN 55905, United States
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Affiliation(s)
- Katie Spencer
- Leeds Institute of Cancer and Pathology, University of Leeds, Leeds LS2 9NL, UK
| | - Rhona Parrish
- Garforth Medical Centre, Garforth, Leeds LS25 1HB, UK
| | - Rachael Barton
- Queen's Centre for Oncology and Haematology, Castle Hill Hospital, Cottingham HU16 5JQ, UK
| | - Ann Henry
- Leeds Institute of Cancer and Pathology, University of Leeds, Leeds LS2 9NL, UK
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Dharmarajan KV, Rich SE, Johnstone CA, Hertan LM, Wei R, Colbert LE, Jones JA, Kamal AH, Jones CA. Top 10 Tips Palliative Care Clinicians Should Know About Radiation Oncology. J Palliat Med 2018; 21:383-388. [PMID: 29431573 DOI: 10.1089/jpm.2018.0009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
As palliative care (PC) moves upstream in the course of advanced illness, it is critical that PC providers have a broad understanding of curative and palliative treatments for serious diseases. Possessing a working knowledge of radiation therapy (RT), one of the three pillars of cancer care, is crucial to PC providers given RT's role in both the curative and palliative settings. This article provides PC providers with a primer on the vocabulary of RT; the team of people involved in the planning of RT; and common indications, benefits, and side effects of treatment.
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Affiliation(s)
- Kavita V Dharmarajan
- 1 Department of Radiation Oncology, Brookdale Department of Geriatrics and Palliative Medicine, Mount Sinai Hospital , Icahn School of Medicine at Mount Sinai, New York, New York
| | | | - Candice A Johnstone
- 3 Department of Radiation Oncology, Medical College of Wisconsin , Milwaukee, Wisconsin
| | - Lauren M Hertan
- 4 Department of Radiation Oncology, Beth Israel Deaconess Medical Center , Boston, Massachusetts
| | - Randy Wei
- 5 Memorial Radiation Oncology Medical Group , Long Beach, California
| | - Lauren E Colbert
- 6 Department of Radiation Oncology, MD Anderson Cancer Center , Houston, Texas
| | - Joshua A Jones
- 7 Department of Radiation Oncology, University of Pennsylvania Perelman School of Medicine , Philadelphia, Pennsylvania.,8 Palliative and Advanced Illness Research Center, University of Pennsylvania , Philadelphia, Pennsylvania
| | - Arif H Kamal
- 9 Division of Medical Oncology, Duke Cancer Institute, Duke Fuqua School of Business, Duke University , Durham, North Carolina
| | - Christopher A Jones
- 8 Palliative and Advanced Illness Research Center, University of Pennsylvania , Philadelphia, Pennsylvania.,10 Department of Medicine, University of Pennsylvania Perelman School of Medicine , Philadelphia, Pennsylvania
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Summers AR, Philipp T, Mikula JD, Gundle KR. The role of postoperative radiation and coordination of care in patients with metastatic bone disease of the appendicular skeleton. Orthop Rev (Pavia) 2017; 9:7261. [PMID: 29564074 PMCID: PMC5850070 DOI: 10.4081/or.2017.7261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Accepted: 09/30/2017] [Indexed: 11/29/2022] Open
Abstract
Metastatic bone disease affects approximately 300,000 people in the United States, and the burden is rising. These patients experience significant morbidity and decreased survival. The management of these patients requires coordinated care among a multidisciplinary team of physicians, including orthopaedic surgeons. This article reviews the role of radiation therapy after orthopaedic stabilization of impending or realized pathologic extremity fractures. Orthopaedic surgeons have an opportunity to benefit patients with metastatic bone disease by referring them for consideration of post-operative radiation therapy. Further research into rates of referral and the effect on clinical outcomes in this population is needed.
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Affiliation(s)
- Andrew R. Summers
- Department of Orthopaedics & Rehabilitation, Oregon Health & Science University, Portland, OR
| | - Travis Philipp
- Department of Orthopaedics & Rehabilitation, Oregon Health & Science University, Portland, OR
| | - Jacob D. Mikula
- Department of Orthopaedics & Rehabilitation, Oregon Health & Science University, Portland, OR
| | - Kenneth R. Gundle
- Department of Orthopaedics & Rehabilitation, Oregon Health & Science University, Portland, OR
- Operative Care Division, Portland Veterans Administration Medical Center, Portland, OR, USA
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Abstract
Metastatic disease to the bone is a common manifestation of advanced cancer, and can result in pain, pathologic fractures, hypercalcemia, and overall functional compromise. External beam radiation is a proven, highly efficacious, and noninvasive therapy that can provide symptomatic relief from painful osseous lesions. When deciding upon the best treatment regimen, it is important to consider patient factors such as overall life expectancy, performance status, disease burden, and site of osseous metastatic pain. Determination of best treatment ideally requires multidisciplinary input from radiologists, medical oncologists, surgeons, pain management, and palliative care specialists together with radiation oncologists.
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Affiliation(s)
- Josephine Kang
- Department of Radiation Oncology, New York Presbyterian Hospital/Weill Cornell Medical Center, New York, New York
| | - Silvia C. Formenti
- Department of Radiation Oncology, New York Presbyterian Hospital/Weill Cornell Medical Center, New York, New York
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Gdowski AS, Ranjan A, Vishwanatha JK. Current concepts in bone metastasis, contemporary therapeutic strategies and ongoing clinical trials. JOURNAL OF EXPERIMENTAL & CLINICAL CANCER RESEARCH : CR 2017; 36:108. [PMID: 28800754 PMCID: PMC5554406 DOI: 10.1186/s13046-017-0578-1] [Citation(s) in RCA: 80] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Accepted: 08/08/2017] [Indexed: 12/23/2022]
Abstract
Background Elucidation of mechanisms regulating bone metastasis has progressed significantly in recent years and this has translated to many new therapeutic options for patients with bone metastatic cancers. However, the rapid rate of progress in both the basic science literature and therapies undergoing clinical trials makes staying abreast with current developments challenging. This review seeks to provide an update on the current state of the science in bone metastasis research and give a snap shot of therapies in clinical trials for bone metastatic cancer. Main body Bone metastasis represents a difficult to treat clinical scenario due to pain, increased fracture risk, decreased quality of life and diminished overall survival outcomes. Multiple types of cancer have the specific ability to home to the bone microenvironment and cause metastatic lesions. This osteotropism was first described by Stephen Paget nearly 100 years ago as the ‘seed and soil’ hypothesis. Once cancer cells arrive at the bone they encounter a variety of cells native to the bone microenvironment which contribute to the establishment of bone metastatic lesions. In the first part of this review, the ‘seed and soil’ hypothesis is revisited while emphasizing recent developments in understanding the impact of native bone microenvironment cells on the metastatic process. Next, approved therapies for treating bone metastasis at the systemic level as well as those that target the bone microenvironment are discussed and current National Comprehensive Cancer Network (NCCN) guidelines relating to treatment of bone metastases are summarized. Finally, all open interventional clinical trials for therapies relating to treatment of bone metastasis have been complied and categorized. Conclusion Understanding the recent advancements in bone metastasis research is important for continued development of novel bone targeted therapies. The plethora of ongoing clinical trials will hopefully translate into improved treatments options for patients suffering from bone metastatic cancers.
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Affiliation(s)
- Andrew S Gdowski
- Institute for Molecular Medicine, University of North Texas Health Science Center, 3500 Camp Bowie Blvd, Fort Worth, TX, 76107, USA.
| | - Amalendu Ranjan
- Institute for Molecular Medicine, University of North Texas Health Science Center, 3500 Camp Bowie Blvd, Fort Worth, TX, 76107, USA
| | - Jamboor K Vishwanatha
- Institute for Molecular Medicine, University of North Texas Health Science Center, 3500 Camp Bowie Blvd, Fort Worth, TX, 76107, USA
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Walling AM, Beron PJ, Kaprealian T, Kupelian PA, Wenger NS, McCloskey SA, King CR, Steinberg M. Considerations for Quality Improvement in Radiation Oncology Therapy for Patients with Uncomplicated Painful Bone Metastases. J Palliat Med 2017; 20:478-486. [PMID: 28437208 DOI: 10.1089/jpm.2016.0339] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Background: There is an increasing need for evidence-based efficiency in providing a growing amount of cancer care. One example of a quality gap is the use of multiple-fraction palliative radiation for patients with advanced cancer who have uncomplicated bone metastases; evidence suggests similar pain outcomes for treatment regimens with a lower burden of treatments. Methods: During the first phase of quality improvement work, we used RAND/UCLA appropriateness methodology to understand how radiation oncologists at one academic medical center rate the appropriateness of different treatment regimens for painful uncomplicated bone metastases. We compared radiation oncologist appropriateness ratings for radiation treatments with radiation therapy provided by these oncologists to patients with painful bone metastases between July 2012 and June 2013. Results: Appropriateness ratings showed that single-fraction (8 Gy) treatment (a low burden treatment) was consistently considered an appropriate option to treat a variety of uncomplicated bone metastases. The use of >10 fractions was consistently rated as inappropriate regardless of other factors. Eighty-one patients receiving radiation therapy for painful bone metastases during the study period had an available medical record for chart abstraction. Almost one-third of metastases were considered complicated because of a concern of spinal cord compression, a history of prior irradiation, or an associated pathological fracture. Among uncomplicated bone metastases, 25% were treated with stereotactic body radiation treatment (SBRT). Among the 54 uncomplicated bone metastases treated with conformal radiation, only one was treated with single-fraction treatment and 32% were treated with greater than 10 fractions. Conclusions: Treatment at the study site demonstrates room for improvement in providing low-burden radiation oncology treatments for patients with painful bone metastases. Choosing a radiation treatment schedule for patients with advanced cancer and painful bone metastases requires consideration of many medical and patient-centered factors. Our experience suggests that it will take more than the existence of guidelines to change practice in this area.
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Affiliation(s)
- Anne M Walling
- VA Greater Los Angeles Healthcare System, Los Angeles, California.,Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at University of California, Los Angeles, California.,RAND Health, Santa Monica, California
| | - Phillip J Beron
- Department of Radiation Oncology, David Geffen School of Medicine at University of California, Los Angeles, California
| | - Tania Kaprealian
- Department of Radiation Oncology, David Geffen School of Medicine at University of California, Los Angeles, California
| | - Patrick A Kupelian
- Department of Radiation Oncology, David Geffen School of Medicine at University of California, Los Angeles, California
| | - Neil S Wenger
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at University of California, Los Angeles, California.,RAND Health, Santa Monica, California
| | - Susan A McCloskey
- Department of Radiation Oncology, David Geffen School of Medicine at University of California, Los Angeles, California
| | - Christopher R King
- Department of Radiation Oncology, David Geffen School of Medicine at University of California, Los Angeles, California
| | - Michael Steinberg
- Department of Radiation Oncology, David Geffen School of Medicine at University of California, Los Angeles, California
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Roqué i Figuls M, Martinez‐Zapata MJ, Scott‐Brown M, Alonso‐Coello P. WITHDRAWN: Radioisotopes for metastatic bone pain. Cochrane Database Syst Rev 2017; 3:CD003347. [PMID: 28334435 PMCID: PMC6464104 DOI: 10.1002/14651858.cd003347.pub3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND This is an update of the review published in Issue 4, 2003. Bone metastasis cause severe pain as well as pathological fractures, hypercalcaemia and spinal cord compression. Treatment strategies currently available to relieve pain from bone metastases include analgesia, radiotherapy, surgery, chemotherapy, hormone therapy, radioisotopes and bisphosphonates. OBJECTIVES To determine efficacy and safety of radioisotopes in patients with bone metastases to improve metastatic pain, decrease number of complications due to bone metastases and improve patient survival. SEARCH METHODS We sought randomised controlled trials (RCTs) in MEDLINE, EMBASE, CENTRAL, and the PaPaS Trials Register up to October 2010. SELECTION CRITERIA Studies selected had metastatic bone pain as a major outcome after treatment with a radioisotope, compared with placebo or another radioisotope. DATA COLLECTION AND ANALYSIS We assessed the risk of bias of included studies by their sequence generation, allocation concealment, blinding of study participants, researchers and outcome assessors, and incomplete outcome data. Two review authors extracted data. We performed statistical analysis as an "available case" analysis, and calculated global estimates of effect using a random-effects model. We also performed an intention-to-treat (ITT) sensitivity analysis. MAIN RESULTS This update includes 15 studies (1146 analyzed participants): four (325 participants) already included and 11 new (821 participants). Only three studies had a low risk of bias. We observed a small benefit of radioisotopes for complete relief (risk ratio (RR) 2.10, 95% CI 1.32 to 3.35; Number needed to treat to benefit (NNT) = 5) and complete/partial relief (RR 1.72, 95% CI 1.13 to 2.63; NNT = 4) in the short and medium term (eight studies, 499 participants). There is no conclusive evidence to demonstrate that radioisotopes modify the use of analgesia with respect to placebo. Leucocytopenia and thrombocytopenia are secondary effects significantly associated with the administration of radioisotopes (RR 5.03; 95% CI 1.35 to 18.70; Number needed to treat to harm (NNH) = 13). Pain flares were not higher in the radioisotopes group (RR 0.74; 95% CI 0.27 to 2.06). There are scarce data of moderate quality when comparing Strontium-89 (89Sr) with Samarium-153 (153Sm), Rhenium-186 (186Re) and Phosphorus-32 (32P). We observed no significant differences between treatments. Similarly, we observed no differences when we compared different doses of 153Sm (0.5 versus 1.0 mCi). AUTHORS' CONCLUSIONS This update adds new evidence on efficacy of radioisotopes versus placebo, 89Sr compared with other radioisotopes, and dose-comparisons of 153Sm and 188Re. There is some evidence indicating that radioisotopes may provide complete reduction in pain over one to six months with no increase in analgesic use, but severe adverse effects (leucocytopenia and thrombocytopenia) are frequent.
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Affiliation(s)
- Marta Roqué i Figuls
- CIBER Epidemiología y Salud Pública (CIBERESP)Iberoamerican Cochrane Centre, Biomedical Research Institute Sant Pau (IIB Sant Pau)Sant Antoni Maria Claret 171Edifici Casa de ConvalescènciaBarcelonaSpain08041
| | - Maria José Martinez‐Zapata
- CIBER Epidemiología y Salud Pública (CIBERESP)Iberoamerican Cochrane Centre, Biomedical Research Institute Sant Pau (IIB Sant Pau)Sant Antoni Maria Claret 171Edifici Casa de ConvalescènciaBarcelonaSpain08041
| | - Martin Scott‐Brown
- Gray Institute for Radiation Oncology & BiologyRadiobiology Research InstituteChurchill HospitalOxfordUKOX3 7LJ
| | - Pablo Alonso‐Coello
- Biomedical Research Institute Sant Pau (IIB Sant Pau)Iberoamerican Cochrane CentreCIBER Epidemiología y Salud Pública (CIBERESP), SpainSant Antoni Maria Claret 171 ‐ Edifici Casa de ConvalescenciaBarcelonaSpain08041
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Xiang Z, Mo Z, Li G, Gilani S, Zhong Z, Zhang T, Zhang F, Gao F. 125I brachytherapy in the palliation of painful bone metastases from lung cancer after failure or rejection of conventional treatments. Oncotarget 2017; 7:18384-93. [PMID: 26919235 PMCID: PMC4951295 DOI: 10.18632/oncotarget.7584] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2015] [Accepted: 02/11/2016] [Indexed: 12/02/2022] Open
Abstract
Purpose This study sought to assess the safety and effect of 125I seed implantation for palliation of painful bone metastases from lung cancer after failure or rejection of conventional treatments. Materials and Methods 89 patients with painful bone metastases secondary to lung cancer were consented and enrolled in this study from June 2013 to May 2015. All patients had failed or refused conventional treatments underwent percutaneous CT-guided 125I seed implantation. The Brief Pain Inventory (BPI) was used to measure pain intensity prior to treatment (T0), 2, 4, 6, 8 and 12 weeks (T2, T4, T6, T8 and T12) after treatment in a 24-hour period. Analgesic, quality of life (QOL) scores and complications were also recorded. Four patients were excluded as they were lost to follow-up or had incomplete data. Results 85 patients with 126 bone metastases from lung cancer were treated. There were significantly lower scores after treatment in the visual analog scale (VAS) and analgesic. The VAS scores for worst pain was 6.3±1.8 at T0. At T2, T4, T6, T8 and T12, the score in a 24-hour period decreased to 4.9±1.2 (P<0.01), 3.7±1.3 (P<0.01), 3.4±1.2 (P<0.01), 2.6±0.9 (P<0.01), and 1.4±0.8 (P<0.01) respectively. Comparison of QOL scores showed improvements including sleep, appetite, spiritual state, and fatigue at T2, T4, T6, T8 and T12 when compared to T0. No serious complications or massive bleeding were observed. Conclusions 125I brachytherapy is a safe and effective method for palliation of painful bone metastases from lung cancer after failure or rejection of conventional treatments.
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Affiliation(s)
- Zhanwang Xiang
- Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Imaging and Intervention Therapy Department, Guangzhou 510060, Guangdong, China
| | - Zhiqiang Mo
- Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Imaging and Intervention Therapy Department, Guangzhou 510060, Guangdong, China
| | - Guohong Li
- Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Imaging and Intervention Therapy Department, Guangzhou 510060, Guangdong, China
| | - Saba Gilani
- Midtown Medical Center, Columbus, GA 31901, USA
| | - Zhihui Zhong
- Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Imaging and Intervention Therapy Department, Guangzhou 510060, Guangdong, China
| | - Tao Zhang
- Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Imaging and Intervention Therapy Department, Guangzhou 510060, Guangdong, China
| | - Fujun Zhang
- Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Imaging and Intervention Therapy Department, Guangzhou 510060, Guangdong, China
| | - Fei Gao
- Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Imaging and Intervention Therapy Department, Guangzhou 510060, Guangdong, China
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Chang JH, Sangha A, Hyde D, Soliman H, Myrehaug S, Ruschin M, Lee Y, Sahgal A, Korol R. Positional Accuracy of Treating Multiple Versus Single Vertebral Metastases With Stereotactic Body Radiotherapy. Technol Cancer Res Treat 2016; 16:231-237. [PMID: 28279146 PMCID: PMC5616036 DOI: 10.1177/1533034616681674] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
The aim of this study is to determine whether stereotactic body radiotherapy for multiple vertebral metastases treated with a single isocenter results in greater intrafraction errors than stereotactic body radiotherapy for single vertebral metastases and to determine whether the currently used spinal cord planning organ at risk volume and planning target volume margins are appropriate. Intrafraction errors were assessed for 65 stereotactic body radiotherapy treatments for vertebral metastases. Cone beam computed tomography images were acquired before, during, and after treatment for each fraction. Residual translational and rotational errors in patient positioning were recorded and planning organ at risk volume and planning target volume margins were calculated in each direction using this information. The mean translational residual errors were smaller for single (0.4 (0.4) mm) than for multiple vertebral metastases (0.5 (0.7) mm; P = .0019). The mean rotational residual errors were similar for single (0.3° (0.3°) and multiple vertebral metastases (0.3° (0.3°); P = .862). The maximum calculated planning organ at risk volume margin in any direction was 0.83 mm for single and 1.22 for multiple vertebral metastases. The maximum calculated planning target volume margin in any direction was 1.4 mm for single and 1.9 mm for multiple vertebral metastases. Intrafraction errors were small for both single and multiple vertebral metastases, indicating that our strategy for patient immobilization and repositioning is robust. Calculated planning organ at risk volume and planning target volume margins were smaller than our clinically employed margins, indicating that our clinical margins are appropriate.
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Affiliation(s)
- Joe H Chang
- 1 Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, ON, Canada
| | - Arnjeet Sangha
- 1 Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, ON, Canada
| | - Derek Hyde
- 2 Department of Medical Physics, BC Cancer Agency, Sindi Ahluwalia Hawkins Centre for the Southern Interior, Kelowna, BC, Canada
| | - Hany Soliman
- 1 Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, ON, Canada
| | - Sten Myrehaug
- 1 Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, ON, Canada
| | - Mark Ruschin
- 1 Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, ON, Canada
| | - Young Lee
- 1 Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, ON, Canada
| | - Arjun Sahgal
- 1 Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, ON, Canada
| | - Renee Korol
- 1 Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, ON, Canada
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Chen K, Huang L, Cai Z, Shi J, You K, Shen H. Micro-invasive surgery combined with intraoperative radiotherapy for the treatment of spinal metastasis. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2016; 26:1893-1901. [PMID: 27807777 DOI: 10.1007/s00586-016-4826-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/01/2016] [Revised: 08/23/2016] [Accepted: 09/22/2016] [Indexed: 12/25/2022]
Abstract
PURPOSE This is a retrospective analysis of the strategy and clinical results of surgery combined with intraoperative radiotherapy (IORT) to treat spinal metastases. METHODS We delivered tumour-conformal IORT in 40 patients with 52 metastatic vertebrae based on our surgical classification system. The strategies were evaluated with respect to neurologic function and spinal stability. The EORTC QLQ-BM22, visual analogue scale (VAS) and the Frankel Scale were used to assess quality of life, pain and neurologic function. Local control was evaluated every 3 months using X-rays and MRI. RESULTS Micro-invasive IORT was performed in 42 vertebrae (80.8%), and open surgery with IORT was performed in 10 vertebrae (19.2%). Single-level, 2-level and 3-level IORT was performed in 30, 8 and 2 cases, respectively. The delivered dose was 9.2 ± 3.6 Gy (8-15 Gy) with a depth of 10.1 ± 2.1 mm. The actual IORT treatment time was 5 min and 16 s. The follow-up period was 6-23 months (mean: 12.5 months). The local control rate was 92.3%. The EORTC QLQ-BM22 scores showed that patients had significant improvements in pain location, degree and function after treatment (P < 0.01). Thirty-five patients (89.7%) achieved pain relief throughout the follow-up period. VAS scores were significantly reduced by 3.4 points 3 months after treatment. Neurological function was improved in 7 patients (87.5%). No radiation-related complications were observed. CONCLUSIONS Surgery combined with tumour-conformal IORT can effectively relieve pain, achieve good local control and improve QOL.
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Affiliation(s)
- Keng Chen
- Department of Orthopaedics, Research Center of Spinal and Pelvic Tumour, Sun Yat-sen Memorial Hospital, Sun Yat-Sen University, 107 Yanjiang West Road, Guangzhou, 510120, China.,Research Institute for Spinal Cord Injury of Sun Yat-sen University, Guangzhou, 510120, China.,Research Center of Spinal and Spinal Cord Disease, Guangzhou, 510120, China
| | - Lin Huang
- Department of Orthopaedics, Research Center of Spinal and Pelvic Tumour, Sun Yat-sen Memorial Hospital, Sun Yat-Sen University, 107 Yanjiang West Road, Guangzhou, 510120, China.,Research Institute for Spinal Cord Injury of Sun Yat-sen University, Guangzhou, 510120, China.,Research Center of Spinal and Spinal Cord Disease, Guangzhou, 510120, China
| | - Zhaopeng Cai
- Department of Orthopaedics, Research Center of Spinal and Pelvic Tumour, Sun Yat-sen Memorial Hospital, Sun Yat-Sen University, 107 Yanjiang West Road, Guangzhou, 510120, China.,Research Institute for Spinal Cord Injury of Sun Yat-sen University, Guangzhou, 510120, China.,Research Center of Spinal and Spinal Cord Disease, Guangzhou, 510120, China
| | - Juntian Shi
- Radiotherapy Department of Sun Yat-sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, 510120, China
| | - Kaiyun You
- Radiotherapy Department of Sun Yat-sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, 510120, China
| | - Huiyong Shen
- Department of Orthopaedics, Research Center of Spinal and Pelvic Tumour, Sun Yat-sen Memorial Hospital, Sun Yat-Sen University, 107 Yanjiang West Road, Guangzhou, 510120, China. .,Research Institute for Spinal Cord Injury of Sun Yat-sen University, Guangzhou, 510120, China. .,Research Center of Spinal and Spinal Cord Disease, Guangzhou, 510120, China.
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Body JJ, Pereira J, Sleeboom H, Maniadakis N, Terpos E, Acklin YP, Finek J, Gunther O, Hechmati G, Mossman T, Costa L, Rogowski W, Nahi H, von Moos R. Health resource utilization associated with skeletal-related events: results from a retrospective European study. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2016; 17:711-21. [PMID: 26253584 PMCID: PMC4899504 DOI: 10.1007/s10198-015-0716-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/08/2014] [Accepted: 07/22/2015] [Indexed: 06/04/2023]
Abstract
BACKGROUND Bone complications, also known as skeletal-related events (SREs), are common in patients with bone metastases secondary to advanced cancers. OBJECTIVE To provide a detailed estimate of the health resource utilization (HRU) burden associated with SREs across eight European countries. METHODS Eligible patients from centers in Austria, the Czech Republic, Finland, Greece, Poland, Portugal, Sweden, and Switzerland with bone metastases or lesions secondary to breast cancer, prostate, or lung cancer or multiple myeloma who had experienced at least one SRE (defined as radiation to bone, long-bone pathologic fracture, other bone pathologic fracture, surgery to bone or spinal cord compression) were entered into this study. HRU data were extracted retrospectively from the patients' charts from 3.5 months before the index SRE until 3 months after the index SRE (defined as an SRE preceded by an SRE-free period of at least 6.5 months). RESULTS Overall, the mean number of inpatient stays per SRE increased from baseline by approximately 0.5-1.5 stays, with increases in the total duration of inpatient stays of approximately 6-37 days per event. All SREs were associated with substantial increases from baseline in the frequency of procedures and the number of outpatient and day-care visits. CONCLUSIONS SREs are associated with substantial HRU owing to considerable increases in the number and duration of inpatient stays, and in the number of procedures, outpatient visits, and day-care visits. These data collectively provide a valuable summary of the real-world SRE burden on European healthcare systems.
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Affiliation(s)
| | - João Pereira
- Universidade Nova de Lisboa, National School of Public Health, Lisbon, Portugal
| | | | - Nikos Maniadakis
- Department of Health Services Management, National School of Public Health, Athens, Greece
| | - Evangelos Terpos
- University of Athens School of Medicine, Alexandra University Hospital, Athens, Greece
| | | | | | - Oliver Gunther
- Centre for Observational Research, Amgen Ltd, Uxbridge, UK
| | - Guy Hechmati
- Health Economics, Amgen (Europe) GmbH, Zug, Switzerland
| | | | - Luis Costa
- Serviço de Oncologia do Hospital de Santa Maria, Instituto de Medicina Molecular, Lisbon, Portugal
| | | | - Hareth Nahi
- Division of Hematology, Department of Medicine, Karolinska Institute, Huddinge, Stockholm, Sweden
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Shibata H, Kato S, Sekine I, Abe K, Araki N, Iguchi H, Izumi T, Inaba Y, Osaka I, Kato S, Kawai A, Kinuya S, Kodaira M, Kobayashi E, Kobayashi T, Sato J, Shinohara N, Takahashi S, Takamatsu Y, Takayama K, Takayama K, Tateishi U, Nagakura H, Hosaka M, Morioka H, Moriya T, Yuasa T, Yurikusa T, Yomiya K, Yoshida M. Diagnosis and treatment of bone metastasis: comprehensive guideline of the Japanese Society of Medical Oncology, Japanese Orthopedic Association, Japanese Urological Association, and Japanese Society for Radiation Oncology. ESMO Open 2016; 1:e000037. [PMID: 27843593 PMCID: PMC5070259 DOI: 10.1136/esmoopen-2016-000037] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2016] [Accepted: 02/02/2016] [Indexed: 01/14/2023] Open
Abstract
Diagnosis and treatment of bone metastasis requires various types of measures, specialists and caregivers. To provide better diagnosis and treatment, a multidisciplinary team approach is required. The members of this multidisciplinary team include doctors of primary cancers, radiologists, pathologists, orthopaedists, radiotherapists, clinical oncologists, palliative caregivers, rehabilitation doctors, dentists, nurses, pharmacists, physical therapists, occupational therapists, medical social workers, etc. Medical evidence was extracted from published articles describing meta-analyses or randomised controlled trials concerning patients with bone metastases mainly from 2003 to 2013, and a guideline was developed according to the Medical Information Network Distribution Service Handbook for Clinical Practice Guideline Development 2014. Multidisciplinary team meetings are helpful in diagnosis and treatment. Clinical benefits such as physical or psychological palliation obtained using the multidisciplinary team approaches are apparent. We established a guideline describing each specialty field, to improve understanding of the different fields among the specialists, who can further provide appropriate treatment, and to improve patients’ outcomes.
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Affiliation(s)
- H Shibata
- Department of Clinical Oncology , Akita University Graduate School of Medicine , Akita , Japan
| | - S Kato
- Department of Clinical Oncology , Juntendo University , Tokyo , Japan
| | - I Sekine
- Department of Clinical Oncology , University of Tsukuba , Tsukuba , Japan
| | - K Abe
- Department of Rehabilitation , Chiba Prefectural University of Health Sciences , Chiba , Japan
| | - N Araki
- Department of Orthopedic Surgery , Osaka Medical Center for Cancer and Cardiovascular Diseases , Osaka , Japan
| | - H Iguchi
- Department of Gastroenterology , National Hospital Organization Shikoku Cancer Center , Matsuyama , Japan
| | - T Izumi
- Division of Hematology , Tochigi Cancer Center , Utsunomiya , Japan
| | - Y Inaba
- Department of Diagnostic and Interventional Radiology , Aichi Cancer Center Hospital , Nagoya , Japan
| | - I Osaka
- Division of Palliative Medicine , Shizuoka Cancer Center , Sunto-gun , Japan
| | - S Kato
- Department for Cancer Chemotherapy , Iwate Prefectural Central Hospital , Morioka , Japan
| | - A Kawai
- Division of Musculoskeletal Oncology , National Cancer Center Hospital , Tokyo , Japan
| | - S Kinuya
- Department of Nuclear Medicine , Kanazawa University Hospital , Kanazawa , Japan
| | - M Kodaira
- Department of Breast and Medical Oncology , National Cancer Center Hospital , Tokyo , Japan
| | - E Kobayashi
- Division of Musculoskeletal Oncology , National Cancer Center Hospital , Tokyo , Japan
| | - T Kobayashi
- Department of Diagnostic and Interventional Radiology , Ishikawa Prefectural Central Hospital , Kanazawa , Japan
| | - J Sato
- Department of Clinical Pharmaceutics , School of Pharmacy, Iwate Medical University , Morioka , Japan
| | - N Shinohara
- Department of Renal and Genitourinary Surgery , Hokkaido University Graduate School of Medicine , Sapporo , Japan
| | - S Takahashi
- Department of Medical Oncology , Cancer Institute Hospital of Japanese Foundation for Cancer Research , Tokyo , Japan
| | - Y Takamatsu
- Division of Medical Oncology , Hematology and Infectious Diseases, Fukuoka University Hospital , Fukuoka , Japan
| | - K Takayama
- Seirei Christopher University , Hamamatsu , Japan
| | - K Takayama
- Research Institute for Diseases of the Chest, Graduate School of Medical Sciences, Kyushu University , Fukuoka , Japan
| | - U Tateishi
- Department of Diagnostic Radiology and Nuclear Medicine , Tokyo Medical and Dental University , Tokyo , Japan
| | - H Nagakura
- Department of Radiology , KKR Sapporo Medical Center , Sapporo , Japan
| | - M Hosaka
- Department of Orthopaedic Surgery , Tohoku University Graduate School of Medicine , Sendai , Japan
| | - H Morioka
- Department of Orthopaedic Surgery , Keio University School of Medicine , Tokyo , Japan
| | - T Moriya
- Department of Pathology 2 , Kawasaki Medical School , Kurashiki , Japan
| | - T Yuasa
- Department of Urology , Cancer Institute Hospital, Japanese Foundation for Cancer Research , Tokyo , Japan
| | - T Yurikusa
- Division of Dentistry and Oral Surgery , Shizuoka Cancer Center , Sunto-gun , Japan
| | - K Yomiya
- Department of Palliative Care , Saitama Cancer Center , Kitaadachi-gun , Japan
| | - M Yoshida
- Department of Hemodialysis and Surgery , Chemotherapy Research Institute, International University of Health and Welfare , Ichikawa , Japan
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Achary MP, Miyamoto CT. Fundamentals of Radiation Treatment for Prostate Carcinoma – Techniques, Radiation Biology, and Evidence Base. Prostate Cancer 2016. [DOI: 10.1016/b978-0-12-800077-9.00042-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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Versteeg AL, van der Velden JM, Verkooijen HM, van Vulpen M, Oner FC, Fisher CG, Verlaan JJ. The Effect of Introducing the Spinal Instability Neoplastic Score in Routine Clinical Practice for Patients With Spinal Metastases. Oncologist 2015; 21:95-101. [PMID: 26668252 DOI: 10.1634/theoncologist.2015-0266] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2015] [Accepted: 10/13/2015] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Stable spinal metastases are effectively treated with radiotherapy, whereas unstable spinal metastases often need surgical fixation followed by radiotherapy for local control. The Spinal Instability Neoplastic Score (SINS) was developed as a tool to assess spinal neoplastic related instability with the goal of helping to guide referrals among oncology specialists. We compare the average degree of spinal instability between patients with spinal metastases referred for surgery or for radiotherapy and evaluate whether this difference changed after introduction of the SINS in clinical practice. METHODS All patients with spinal metastases treated with palliative surgery or radiotherapy in the period 2009-2013 were identified in two spine centers. For all patients, the SINS was scored on pretreatment imaging. The SINS before and after introduction of the SINS in 2011 were compared within the surgical and radiotherapy group. Furthermore, the overall SINS was compared between the two groups. RESULTS The overall SINS was significantly higher in the surgical group, with a mean SINS of 10.7 (median 11) versus 7.2 (median 8) for the radiotherapy group. The mean SINS decreased significantly for both groups after introduction of the SINS in clinical practice from 11.2 to 10.3 in the surgical group and from 8.4 to 7.2 in the radiotherapy group. CONCLUSION The SINS differed significantly between patients treated with surgery or radiotherapy. The introduction of SINS led to a decrease in SINS score for both groups, suggesting that using SINS in metastatic spinal disease increases awareness for instability and may subsequently result in earlier referrals for surgical intervention. IMPLICATIONS FOR PRACTICE Spinal metastases can present with varying degrees of mechanical instability. Because unstable spinal metastases may respond insufficiently to palliative radiotherapy and can lead to loss of ambulation, timely detection and appropriate referral are important. The Spinal Instability Neoplastic Score (SINS) may help physicians caring for patients with metastasized disease to identify spinal instability before the onset of neurological deficits. In this study, it was shown that the introduction of SINS in routine practice led to a decrease in spinal instability in radiotherapy and surgical cohorts. The use of SINS may increase awareness of instability and subsequently result in earlier referrals.
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Affiliation(s)
- Anne L Versteeg
- Department of Orthopedic Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - Helena M Verkooijen
- Department of Radiotherapy, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Marco van Vulpen
- Department of Radiotherapy, University Medical Center Utrecht, Utrecht, The Netherlands
| | - F Cumhur Oner
- Department of Orthopedic Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Charles G Fisher
- Division of Spine, Department of Orthopedics, University of British Columbia, and the Combined Neurosurgical and Orthopedic Spine Program at Vancouver Coastal Health, Vancouver, British Columbia, Canada
| | - Jorrit-Jan Verlaan
- Department of Orthopedic Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
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Gomez-Iturriaga A, Cacicedo J, Navarro A, Morillo V, Willisch P, Carvajal C, Hortelano E, Lopez-Guerra JL, Illescas A, Casquero F, Del Hoyo O, Ciervide R, Irasarri A, Pijoan JI, Bilbao P. Incidence of pain flare following palliative radiotherapy for symptomatic bone metastases: multicenter prospective observational study. BMC Palliat Care 2015; 14:48. [PMID: 26427616 PMCID: PMC4589962 DOI: 10.1186/s12904-015-0045-8] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2015] [Accepted: 09/24/2015] [Indexed: 11/16/2022] Open
Abstract
Background Palliative radiotherapy (RT) is an effective treatment for symptomatic bone metastases. Pain flare, a transient worsening of the bone pain after RT, has been described in previous reports with different incidence rates. The aim of the study was to prospectively evaluate the incidence of pain flare following RT for painful bone metastases and evaluate its effects on pain control and functionality of the patients. Methods Between June 2010 and June 2014, 204 patients were enrolled in this study and 135 patients with complete data were evaluable. Pain flare was defined as a 2- point increase in worst pain score as compared with baseline with no decrease in analgesic intake or a 25 % increase in analgesic intake as compared with baseline with no decrease in worst pain score. All pain medications and worst pain scores were collected before, daily during, and for 10 days after RT. The Brief Pain Inventory (BPI) was filled out on the pretreatment and at the 4 weeks follow-up visit. Results There were 90 men (66.7 %) and 45 women (33.3 %). Mean age was 66 years (SD 9.8). The most common primary cancer site was lung in 42 patients (31.1 %), followed by prostate in 27 patients (20.0 %). Forty-two patients (31.1 %) patients received a single fraction of 8 Gy and 83 (61.5 %) received 20 Gy in five fractions. The overall pain flare incidence across all centers was 51/135 (37.7 %). The majority of pain flares occurred on days 1–5 (88.2 %). The mean duration of the pain flare was 3 days (SD: 3). There were no significant relationships between the occurrence of pain flare and collected variables. All BPI items measured four weeks after end of RT showed significant improvement as compared with pretreatment scores (p < 0.001). No significant differences in BPI time trends were found between patients with and without flare pain. Conclusion Pain flare is a common event, occurring in nearly 40 % of the patients that receive palliative RT for symptomatic bone metastases. This phenomenon is not a predictor for pain response.
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Affiliation(s)
- Alfonso Gomez-Iturriaga
- Department of Radiation Oncology, Hospital Universitario Cruces/ Biocruces Health Research Institute, Plaza Cruces 12, 48903, Barakaldo, Spain.
| | - Jon Cacicedo
- Department of Radiation Oncology, Hospital Universitario Cruces/ Biocruces Health Research Institute, Plaza Cruces 12, 48903, Barakaldo, Spain.
| | - Arturo Navarro
- Department of Radiation Oncology, Instituto Catalan de Oncología, Avinguda de la Gran via de l'Hospitalet, 199-203, 08907 L'Hospitalet de Llobregat, Barcelona, Spain.
| | - Virginia Morillo
- Department of Radiation Oncology, Hospital de Castellón, Carrer de les Useres, 1, 12006, Castelló de la Plana, Castelló, Spain.
| | - Patricia Willisch
- Department of Radiation Oncology, Hospital Meixoeiro, Meixoeiro, s/n, 36200 Vigo, Pontevedra, Spain.
| | - Claudia Carvajal
- Department of Radiation Oncology, Hospital Universitario Cruces/ Biocruces Health Research Institute, Plaza Cruces 12, 48903, Barakaldo, Spain
| | - Eduardo Hortelano
- Department of Radiation Oncology, Hospital Universitario Cruces/ Biocruces Health Research Institute, Plaza Cruces 12, 48903, Barakaldo, Spain
| | - Jose Luis Lopez-Guerra
- Department of Radiation Oncology, Hospital Virgen Del Rocío, Av Manuel Siurot, s/n, 41013, Sevilla, Spain.
| | - Ana Illescas
- Department of Radiation Oncology, Hospital Virgen Macarena, Avd. Dr Fedriani, 3, 41071, Sevilla, Spain.
| | - Francisco Casquero
- Department of Radiation Oncology, Hospital Universitario Cruces/ Biocruces Health Research Institute, Plaza Cruces 12, 48903, Barakaldo, Spain
| | - Olga Del Hoyo
- Department of Radiation Oncology, Hospital Universitario Cruces/ Biocruces Health Research Institute, Plaza Cruces 12, 48903, Barakaldo, Spain
| | - Raquel Ciervide
- Department of Radiation Oncology, Hospital San Chinarro, C/ Oña, 10, 28050, Madrid, Spain.
| | - Ana Irasarri
- Clinical Epidemiology Unit, Hospital Universitario Cruces/ Biocruces Heatlh Research Institute, Plaza Cruces 12, 48903, Barakaldo, Spain.
| | - Jose Ignacio Pijoan
- Clinical Epidemiology Unit, Hospital Universitario Cruces/ Biocruces Heatlh Research Institute, Plaza Cruces 12, 48903, Barakaldo, Spain.
| | - Pedro Bilbao
- Department of Radiation Oncology, Hospital Universitario Cruces/ Biocruces Health Research Institute, Plaza Cruces 12, 48903, Barakaldo, Spain
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Ellmann S, Beck M, Kuwert T, Uder M, Bäuerle T. Multimodal imaging of bone metastases: From preclinical to clinical applications. J Orthop Translat 2015; 3:166-177. [PMID: 30035055 PMCID: PMC5986987 DOI: 10.1016/j.jot.2015.07.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2015] [Revised: 06/17/2015] [Accepted: 07/22/2015] [Indexed: 01/02/2023] Open
Abstract
Metastases to the skeletal system are commonly observed in cancer patients, highly affecting the patients' quality of life. Imaging plays a major role in detection, follow-up, and molecular characterisation of metastatic disease. Thus, imaging techniques have been optimised and combined in a multimodal and multiparametric manner for assessment of complementary aspects in osseous metastases. This review summarises both application of the most relevant imaging techniques for bone metastasis in preclinical models and the clinical setting.
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Affiliation(s)
- Stephan Ellmann
- Institute of Radiology, University Medical Centre Erlangen, Erlangen, Germany
| | - Michael Beck
- Institute of Nuclear Medicine, University Medical Centre Erlangen, Erlangen, Germany
| | - Torsten Kuwert
- Institute of Nuclear Medicine, University Medical Centre Erlangen, Erlangen, Germany
| | - Michael Uder
- Institute of Radiology, University Medical Centre Erlangen, Erlangen, Germany
| | - Tobias Bäuerle
- Institute of Radiology, University Medical Centre Erlangen, Erlangen, Germany
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[Tumours and metastases of the spine : cavity/coblation surgery and vertebroplasty/kyphoplasty]. DER ORTHOPADE 2015. [PMID: 26205356 DOI: 10.1007/s00132-015-3138-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Radical surgery for metastases in the spine is in many cases not possible, includingthe higher risk of surgery in older patients with co-morbidities. The aims of treatment are: minimally invasive and maximally effective tumour removal, fracture position, stabilization, pain reduction, and improved quality of life. The specific features and problems of diagnosis and treatment using the cavity/coblation method, , the surgical technique, and the results of the treatment of 250 patients with spinal tumours/metastases are presented. MATERIALS AND METHODS Tumour resection is carried out by plasma field, via percutaneous trans-/extrapedicular access, followed by kyphoplasty. Clinical and radiological follow-up was carried out postoperatively, including data on pain reduction and improvement of quality of life. RESULTS Within 6 years (March 2008t February 2014) a total of 250 patients, or 812 spines were treated. In 59 cases dorsal percutaneous instrumentation and straightening were carried out. Minimal blood loss and a very low complication rate were recorded. After surgery, significant pain reduction, satisfaction, early mobilization, and improvement in quality of life were demonstrated in all patients. Immediate radio- and chemotherapy could be carried out. In 38 cases cement escaped laterally into the intervertebral space, but this had no clinical relevance. 188 patients have since died because of tumour manifestations. CONCLUSIONS The cavity/coblation method has been demonstrated to be a safe, minimally invasive procedure, with good short- and long-term results and lower complication rates. A comprehensive diagnostic, including tumour staging, the correct indication, and prognosis estimation, is important.
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