The role of radiotherapy in palliative care

Overview of Radiation Therapy in the Management of Localized and Metastatic Prostate Cancer

PURPOSE OF REVIEW

The goal is to describe the evolution of radiation therapy (RT) utilization in the management of localized and metastatic prostate cancer.

RECENT FINDINGS

Long term data for a variety of hypofractionated definitive RT dose-fractionation schemes has matured, allowing patients and providers many standard-of-care options to choose from. Post-prostatectomy, adjuvant RT has largely been replaced by an early salvage approach. Multiparametric MRI and PSMA PET have enabled increasingly targeted RT delivery to the prostate and oligometastatic tumors. Areas of active investigation include determining the value of proton beam therapy and perirectal spacers, and optimally incorporate genomic tumor profiling and next generation hormonal therapies with RT in the curative setting. The use of radiation therapy to treat prostate cancer is rapidly evolving. In the coming years, there will be continued improvements in a variety of areas to enhance the value of RT in multidisciplinary prostate cancer management.

Analysis of Oncology and Radiation Therapy Representation on the National Board of Medical Examiners Official Practice Material for the United States National Standardized Medical Board Examinations

Radiation therapy (RT) is a critical component of multidisciplinary cancer care, but has inconsistent curricular exposure. We characterize the radiation oncology (RO) content on the standardized undergraduate medical examinations by comparing its context and prevalence with other domains in oncology. National Board of Medical Examiners (NBME) self-assessments and sample questions for the United States Medical Licensing Exam (USMLE) Steps 1-3 and NBME clinical science shelf examinations were accessed (n = 3878). Questions were inductively analyzed for content pertaining to oncology and treatment modalities of RT, systemic therapy (ST), and surgical intervention (SI). Questions were coded using USMLE Physician Tasks/Competencies and thematic analysis. Descriptive statistics and analyses using the Kruskal-Wallis test are reported. A total of 337 questions (8.6%) within the USMLE and shelf exams included oncology content, with 101 questions (2.6%) referencing at least one cancer treatment modality (n = 35 RT, 45 ST, 57 SI). Treatment questions were more common on USMLE Step 2 CK (n = 35/101, 32%) compared to Step 1 (n = 23/101, 23%) and Step 3 (n = 8/101, 8%) (p < 0.001). RT was significantly less likely to be the correct answer (2/35, 6%) compared to ST (4/45, 9%) and SI (18/57, 32%) (p = 0.003). Therapeutic oncology questions are uncommon on the examination material, with an under-representation of radiation-related content, and contextual bias favoring surgical approaches. We advocate for greater RO involvement in the content creation of such examinations to help trainees better understand multidisciplinary cancer care.

The Efficacy of Hemostatic Radiotherapy for Advanced Malignancies Assessed by World Health Organization Bleeding Status

Purpose 

This retrospective study aimed to evaluate the efficacy of radiotherapy for the palliation of bleeding symptoms of advanced malignancies.

Patients and methods

We included 36 consecutive patients treated for hemostatic intent by radiotherapy at our institution, from August 2013 to January 2019. Patient bleeding status was assessed according to the World Health Organization (WHO) bleeding status before and after radiotherapy.

Results

We identified 36 consecutive patients, consisting of 14 men and 22 women. The median follow-up period after radiotherapy for all cases was 2.5 months (range: 0.4-37.7 months), and the one-year OS was 47.1% (95% confidence interval: 23.5%-67.6%). Of the 36 patients, 29 (81%) showed improvement by one point or more in the WHO bleeding status. A total of 15 patients received 30 Gy in 10 fractions with a biologically effective dose (BED10) of 39 Gy (high BED arm). The remaining 21 patients had received radiotherapy with a BED10 of less than 39 (low BED arm, range of BED10: 11.2-30 Gy). In the high BED arm, 14 of the 15 patients (91%) showed improvement on the WHO bleeding status. In the low BED arm, 15 of the 21 patients (71%) showed improvement on the WHO bleeding status. There was no statistically significant difference in the improvement rate between the high and low BED arms (p = 0.200).

Conclusion

There is no universal standard to evaluate the hemostatic effect of palliative radiotherapy. In this retrospective study, we investigated the clinical outcomes of hemostatic irradiation as assessed by WHO bleeding status.

Palliative Radiotherapy Produced Spectacular Improvement in a Terminally Ill Colorectal Carcinoma Patient With Severe Pain and Duodenal Bleeding

Colorectal cancer has a devastating effect on the quality of life, and the treatment of active intestinal bleeding in colorectal cancer is a real challenge at the end of life. This case report presents a spectacular effect of an unusual palliative treatment strategy in a middle-aged home hospice patient with severe pain and persistent duodenal bleeding secondary to its neoplastic infiltration. Palliative radiotherapy (RT) significantly improved pain control, terminated the duodenal bleeding, and allowed successful treatment of deep vein thrombosis, previously impossible because of the bleeding. It also made the patient independent of otherwise unavoidable transfusions, thus improving his quality of life. In our patient, RT played a leading role in restoring general fitness and, accordingly, mental state improvement. Our case demonstrates that palliative RT may be a valuable treatment option in cases similar to ours. Still, careful assessment of risks and benefits is always mandatory.

A targeted needs assessment to improve referral patterns for palliative radiation therapy

Radiation therapy (RT) can effectively palliate a variety of symptoms in patients with metastatic cancer, using relatively low doses that infrequently cause major side effects. However, palliative radiation is often underutilized and sub-optimally implemented. In this study, we surveyed the Society of Palliative Radiation Oncology (SPRO) membership to identify barriers to appropriate referral for palliative RT that they encounter in their practice, and identify specific groups of physicians who radiation oncologists believed would benefit most from further education on when to refer patients. A total of 28 radiation oncologists responded to the survey with a response rate of 20.5%. On average, participants felt that referrals for palliative RT were inappropriately delayed 46.5% [standard deviation (STD) 20.2%] of the time. The most common barrier to referral for medical oncologists was thought to be potential interference with systemic therapy (33%); for primary care physicians and surgeons it was a lack of knowledge about the benefit (42%), and for palliative care physicians it was concern for patient convenience (25%). For brain metastases and spinal cord compression radiation oncology was felt to be part of the initial referral sequence more than 50% of the time, but less so for thoracic airway obstruction/bleeding (38%), esophageal obstruction (16%), or urinary obstruction/bleeding (8%), where another subspecialist was more often consulted first. Primary care, geriatric medicine, and emergency medicine were considered among the least knowledgeable specialties about palliative radiation. These hypothesis-generating findings can guide approaches to improve referral patterns for this important aspect of supportive care.

Improvement in pain interference after palliative radiotherapy for solid and hematologic painful tumors: a secondary analysis of a prospective observational study

Background

We previously demonstrated that patients with painful hematologic tumors were more likely to experience pain response after palliative radiotherapy (RT) than those with painful solid tumors. However, it is unknown whether change in pain interference differs between these two tumor types. In the present study, we carried out a secondary analysis of our previous prospective observational study to investigate this matter.

Methods

From patients undergoing palliative RT to treat painful tumors, Brief Pain Inventory data were collected at the start of RT and at the 1-, 2-, and 3- month follow-ups. The Mann-Whitney U test was used to compare changes in pain interference score from baseline between the two groups.

Results

Of the 237 patients, 203 (86%) had solid and 34 (14%) had hematologic index tumors planned to receive RT. At baseline, the groups did not differ significantly in terms of pain score, analgesic use, or pain interference score. At the 1-, 2-, and 3-month follow-ups, the changes in pain interference score from baseline did not differ significantly between the two groups. In both groups, all seven pain interference items, other than sleep in patients with hematologic tumors at the 2-month follow-up, were significantly improved (P < 0.05).

Conclusions

The two groups showed comparable benefit from RT in terms of improvement in pain interference. Patients with tumor-related pain should be offered the option of palliative RT, irrespective of whether the painful tumor is solid or hematologic.

Estimating the need for palliative radiotherapy for non-small cell lung cancer: A criterion-based benchmarking approach

BACKGROUND AND PURPOSE

Estimates of appropriate treatment rates are required for monitoring and improving access to cancer care. Optimal utilization rates for palliative radiotherapy (PRT) for patients with non-small cell lung cancer (NSCLC) remain undefined. We aim to estimate the appropriate PRT rate for the general NSCLC population.

MATERIALS AND METHODS

Ontario's population-based cancer registry identified patients with NSCLC who died of their disease between 2006 and 2010. Multivariate analysis identified factors affecting PRT use, enabling us to define a benchmark population with unimpeded access to PRT. Proportion of cases treated in the last 2 years of life (PRT_2y) was standardized to overall population characteristics. Benchmarks were compared to province-wide PRT_2y rates.

RESULTS

Availability of RT at the diagnosing hospital was the dominant determinant of increased PRT utilization. Patients diagnosed at hospitals with on site RT were therefore designated the benchmark population. The standardized benchmark for PRT_2y was 56%, compared to the province-wide rate of 49%. The gap between actual and optimal rates varied across patient ages, treatment indications, and geographic regions.

CONCLUSIONS

Approximately 56% of patients who die of NSCLC in Ontario need PRT, but many are never treated.

Palliative radiotherapy for breast cancer patients with skin invasion: a multi-institutional prospective observational study

Purpose

To clarify the efficacy of palliative radiotherapy for the relief of symptoms due to skin invasion in patients with breast cancer.

Materials and methods

We conducted a multi-institutional prospective observational study of patients who received palliative radiotherapy for skin invasion due to a primary lesion or chest wall recurrence. Bleeding/discharge, offensive odor, pain and QOL scores were evaluated before and 1, 3 and 6 months after radiotherapy.

Results

Twenty-one patients were assessed. Sixteen patients (76%) received 36 Gy in 12 fractions. The mean (±1 SD) score of bleeding/discharge was 1.90 ± 0.89 before radiotherapy, 1.50 ± 0.74 at 1 month, 0.47 ± 0.58 at 3 months, and 0.82 ± 1.04 at 6 months (P = 0.001). The mean score of offensive odor was 1.21 ± 1.38 before radiotherapy, 0.71 ± 0.92 at 1 month, 0.20 ± 0.41 at 3 months, and 0.27 ± 0.62 at 6 months (P = 0.008). The mean score of pain was 2.90 ± 1.22 before radiotherapy, 3.05 ± 1.36 at 1 month, 3.29 ± 1.10 at 3 months, and 3.31 ± 1.54 at 6 months (P = 0.431). The mean total score of QOL-ACD/QOL-ACD-B was 126.2 ± 24.5 before radiotherapy, 130.3 ± 26.3 at 1 month, 136.2 ± 26.6 at 3 months, and 126.6 ± 32.8 at 6 months (P = 0.178).

Conclusion

Palliative radiotherapy for skin invasion in patients with breast cancer might be effective, especially for the relief of bleeding/discharge and offensive odor.

Is Weekend Radiation Therapy Always Justified?

BACKGROUND

Patients presenting with an oncology emergency should be assessed and treated promptly to address symptoms, preserve function, and maintain quality of life. In some circumstances, this requires treatment of patients on weekends. The primary objective of this study was to review the delivery of urgent radiotherapy (RT) at our institution to determine the proportion of courses with a documented indication for which weekend RT could be justified based on comparison with published literature.

METHODS

Patients undergoing RT on weekends (January 2009-July 2009) were reviewed retrospectively for demographics, disease site, functional status, and documented reason for after-hours treatment. Data were obtained from both the electronic and paper medical records and input into an Excel spreadsheet after being anonymized. Summary statistics were calculated. A literature search was conducted to supplement the Alberta Health Services Palliative Radiotherapy clinical practice guidelines, which included review of relevant publications from the Standards and Guidelines Evidence database.

RESULTS

A total of 108 patients (73 males, 35 females) received RT to 132 sites over this period, primarily on both Saturday and Sunday (87.8%). Of these, 37.9% had a lung primary, 97.0% were treated with palliative intent, and 46.2% received spine RT. On average, 18.9 weekend treatment courses took place each month (range, 2-12). 67.1% had a planned anteroposterior field arrangement, and the dose-fractionation schedule was 2000 cGy in five fractions in the majority (68.9%). Based on the reason documented for emergency RT, 72.1% of all after-hours treatments could be justified by comparison to published literature.

CONCLUSIONS

Given resource and technical considerations, delivery of RT during weekends requires specific clinical justification. Presently at our center, decision to institute after-hours RT is at the discretion of the treating radiation oncologist. The majority of indications for weekend treatment of these patients could be justified based on published evidence.

Knowledge and utilization of palliative radiotherapy by pediatric oncologists

Background and Purpose

Palliative radiotherapy (prt) is a routine part of oncology care in adult patients, but it is used much less frequently among children with incurable cancer. We surveyed Canadian pediatric oncologists to learn about their knowledge and use of prt and to identify potential barriers to referral.

Methods

A 13-item questionnaire assessing prt knowledge and utilization was sent to 80 Canadian pediatric oncologists.

Results

The survey completion rate was 80%, with most respondents being providers of palliative care for children and making referrals for prt. Although 62% had received training in radiation oncology, only 28% had received formal palliative care training. Respondents with palliative care training were found to be significantly more knowledgeable about prt and were more likely to refer children for prt (p < 0.01). Only 59% of respondents thought that they had adequate knowledge about the indications for prt. A positive correlation was found between knowledge about the indications for prt and referral for treatment (p < 0.01). Among survey respondents, 51% believed that prt was underutilized, and the perceived barriers to prt referral included patient or family reluctance, distance to the cancer centre, belief that prt has little impact on quality of life, and concerns about toxicity.

Conclusions

Palliative radiotherapy is considered to be underutilized among children. This situation appears to be related, in part, to inadequate knowledge and training among pediatric oncologists, suggesting that more emphasis needs to be placed on pediatric palliative care education.

Palliative management of malignant bowel obstruction in terminally ill patient

Mr. P was a 57-year-old man who presented with symptoms of bowel obstruction in the setting of a known metastatic pancreatic cancer. Diagnosis of malignant bowel obstruction was made clinically and radiologically and he was treated conservatively (non-operatively)with octreotide, metoclopromide and dexamethasone, which provided good control over symptoms and allowed him to have quality time with family until he died few weeks later with liver failure. Bowel obstruction in patients with abdominal malignancy requires careful assessment. The patient and family should always be involved in decision making. The ultimate goals of palliative care (symptom management, quality of life and dignity of death) should never be forgotten during decision making for any patient.

Barriers to palliative radiotherapy referral: a Canadian perspective

Radiotherapy is an effective but underutilized treatment modality for cancer patients. We decided to investigate the factors influencing radiotherapy referral among family physicians in our region. A 30-item survey was developed to determine palliative radiotherapy knowledge and factors influencing referral. It was sent to 400 physicians in eastern Ontario (Canada) and the completed surveys were evaluated. The overall response rate was 50% with almost all physicians seeing cancer patients recently (97%) and the majority (80%) providing palliative care. Approximately 56% had referred patients for radiotherapy previously and 59% were aware of the regional community oncology program. Factors influencing radiotherapy referral included the following: waiting times for radiotherapy consultation and treatment, uncertainty about the benefits of radiotherapy, patient age, and perceived patient inconvenience. Physicians who referred patients for radiotherapy were more than likely to provide palliative care, work outside of urban centres, have hospital privileges and had sought advice from a radiation oncologist in the past. A variety of factors influence the referral of cancer patients for radiotherapy by family physicians and addressing issues such as long waiting times, lack of palliative radiotherapy knowledge and awareness of Cancer Centre services could increase the rate of appropriate radiotherapy patient referral.

The management of pain due to amputation

Current approaches to the management of pain due to amputation are presented by two Spanish pain specialists with additional commentaries on care of such patients by pain specialists from Belgium and the United Kingdom. Contemporary pharmacotherapy and nondrug interventions are described.

Family physicians' perspectives regarding palliative radiotherapy

PURPOSE

To assess family physicians' views on common indications for palliative radiotherapy and to determine whether this influences patient referral.

METHODS AND MATERIALS

A 30-item questionnaire evaluating radiotherapy knowledge and training developed at the Ottawa Regional Cancer Centre (ORCC) was mailed to a random sample of 400 family physicians in eastern Ontario, Canada. The completed surveys were collected and analyzed, and form the basis of this study.

RESULTS

A total of 172 completed surveys were received for a net response rate of 50% among practicing family physicians. Almost all of the physicians (97%) had recently seen cancer patients in their offices, with 85% regularly caring for patient with advanced cancer. Fifty-four percent had referred patients in the past for radiotherapy and 53% had contacted a radiation oncologist for advice. Physicians who were more knowledgeable about the common indications for palliative radiotherapy were significantly more likely to refer patients for radiotherapy (P < 0.01). Inability to contact a radiation oncologist was correlated with not having referred patients for radiotherapy (P < 0.01). Only 10% of the physicians had received radiotherapy education during their formal medical training.

CONCLUSIONS

Many of the family physicians surveyed were unaware of the effectiveness of radiotherapy in a variety of common palliative situations, and radiotherapy referral was correlated with knowledge about the indications for palliative radiotherapy. This was not surprising given the limited education they received in this area and the limited contact they have had with radiation oncologists. Strategies need to be developed to improve continuing medical education opportunities for family physicians and to facilitate more interaction between these physicians and radiation oncologists.

Symptom duration and delay in referral for palliative radiotherapy in cancer patients: a pilot study

OBJECTIVE

To estimate the frequency of delay in referral for palliative radiotherapy (PRT), and to identify factors associated with delay.

DESIGN

Prospective survey over three months in 1997.

SETTING

Radiotherapy department of a cancer centre in Melbourne, Victoria.

PARTICIPANTS

158 consecutive patients prescribed PRT in the lung, breast, urology and haematology units.

MAIN OUTCOME MEASURES

Duration of symptoms; incidence of "unreasonable" delay in referral; and incidence of negative clinical outcome associated with referral delay.

RESULTS

The median duration of symptoms before prescription of radiotherapy was four weeks. Thirty-eight patients (24%) were considered to have had an unreasonable delay in referral, with median symptom duration of 15 weeks, and median delay in referral of 12 weeks. Causes of delay were classified as "diagnostic uncertainty" (29%), "other treatment given" (18%), "patient related" (18%), "language difficulty" (3%), and "unexplained" (32%). Twenty-seven of these 38 patients (71%) had negative outcomes, including persistent pain, neurological deterioration and persistent respiratory symptoms.

CONCLUSIONS

These data suggest that delay in referral for PRT is not uncommon, has a variety of causes and can result in negative clinical outcomes. There appears to be a need for greater awareness of patients' symptoms and of the role of PRT among clinicians caring for patients with cancer.

Causes and treatment of bone pain of malignant origin

Pain relief has been one of the oldest and most important duties of the physician. There has been little change with regard to this obligation of all caregivers. One-third of patients with advanced cancer will develop clinically relevant skeletal metastases and chronic pain during the course of their disease. All physicians involved in the treatment of cancer patients should know the basic principles of pain treatment. These are described in the following article with special regard to bone pain of malignant origin. Correct assessment of pain intensity and frequency, as well as of the probable causes of pain, and the administration of adequate analgesic treatment should achieve satisfactory results in the vast majority of patients. Every physician should obtain detailed knowledge of the indications and adequate administration of pain-killing therapy as well as possible adverse effects and their successful treatment. It is important in particular to concentrate on a few nonsteroidal anti-inflammatory drugs (NSAIDs) as well as opiates. Knowledge of adequate doses, maximal recommended daily doses, pharmacological properties, important adverse effects and interactions is essential for success in the daily routine. Only by selecting 2 or 3 drugs from each step in the analgesic ladder (WHO) will the nonspecialised physician obtain sufficient experience for optimal analgesia. Physicians should also not hesitate to contact other specialists (medical oncologists, radiotherapists, neurosurgeons, anaesthesiologists and others) in order to maximise benefit for an individual patient.

Palliative medicine and the medical oncologist. Defining the purview of care

The fusion of palliative medicine and medical oncology, in practice and in education, can provide a better standard of patient care, reduce the risk of oncologist burnout, and increase the likelihood of patient family and physician satisfaction. There need be no gulf between these disciplines, and only together do they represent truly comprehensive cancer care. The realization of this fusion will require the participation of individual clinicians, program directors, and the policy makers for cancer centers, professional organizations, and the health care regulatory authorities. It is a logical next step in the evolution of medical oncology.

A study of acute side-effects related to palliative radiotherapy treatment of lung cancer

Two recent studies carried out by the Medical Research Council Lung Cancer Working Party have suggested that large fraction radiotherapy to the chest in either 10-Gy single fraction or 17-Gy two-fraction doses, 1 week apart, is safe and effective for patients who require palliation for bronchogenic cancer. The Beatson Oncology Centre, Glasgow, participated in the original MRC trial and anecdotal reports of acute chest pains, fevers, sweats and rigors in some patients during the first 24-hour period after radiotherapy treatment were noted. These acute side-effects were not monitored during the Medical Research Council trials. It was felt that this area warranted further evaluation in order to identify the incidence of such acute side-effects and to what extent they caused a reduction in the patients' remaining quality of life. A pilot study of 10 patients confirmed the manifestation of the side-effects reported anecdotally in the MRC trial. It was on this basis that the study was extended, with a further 51 patients being invited to participate over a 4-month period. The findings indicate a significant incidence of adverse side-effects in patients receiving large fraction radiotherapy to the chest in either 10-Gy single fraction or 17-Gy two-fraction doses, but that these are transient and do not cause unacceptable disruption to the patients over an extended period.

Radiotherapy for painful bone metastases

Bone metastases are a frequent cause of morbidity in patients with malignant disease. Pain is the commonest symptom; it can be treated successfully in the majority of patients by local external beam irradiation. Controversy exists over which regimen should be used, with a single dose necessitating only one treatment visit to the radiotherapy department, or a fractionated course requiring several visits. Many radiotherapists continue to use fractionated regimens despite the current evidence that single fractions are as effective. Many reasons exist for this, including departmental policy and training, fears of recurrence, problems with retreatment of previously treated areas, fears of increased early and late morbidity, and attempts at promoting recalcification. The majority of these reasons are theoretical and have yet to be substantiated. In many patients, symptomatic bone metastases are widespread, and hemibody irradiation, although more toxic, should be considered in order to avoid the need for repeated courses of local treatment.