Palliation and supportive care in radiation medicine

Effect of lower esophageal gastric tube implantation in postoperative enteral nutritional support in patients with laryngeal cancer: A study protocol for a randomized controlled trial

BACKGROUND

For a long time, postoperative nutritional support for laryngeal cancer patients has depended on the gastric tube for enteral nutrition. Silica gel gastric tube is often used in clinical practice; however, the gastric tube placed in the conventional depth often leads to various complications in the stomach, thus damaging the nutritional status of patients and leading to the poor prognosis.

METHODS/DESIGN

A total of 80 patients with laryngeal cancer in otolaryngology, head and neck surgery department of Deyang people's hospital from May 2020 to April 2022 will be selected and randomly divided into control group and experimental group according to the numerical table. Patients in the control group will receive conventional gastric tube placement, with a depth of 45 to 55 cm, which can extract gastric juice. B-ultrasound accurately positioned the gastric tube in the stomach instead of the cardia, and postoperative nasal feeding nutrition will be provided. In the experimental group, the gastric tube will be pulled out 10 cm after conventional placement and no gastric juice will be extracted. B-ultrasonography verified that the gastric tube will be located below the esophagus or above the cardia, and routine nasal feeding will be performed postoperatively. Analysis for comfort and prognosis were performed by general comfort questionnaire and various index including height, body mass index, albumin value, electrolyte, wound healing, pharyngeal fistula.

DISCUSSION

In this study, visual simulation scale and general comfort questionnaire developed by Kolaba, an American comfort nursing specialist, were used to evaluate the comfort level of the 2 groups of patients, including pain, acid reflux, upper abdominal burning sensation, and hiccup. Objective indexes such as height, body mass index, albumin value, electrolyte, wound healing, and pharyngeal fistula were used to evaluate the prognosis of the 2 groups of patients. The visual simulation scale can preliminarily judge the subjective feelings of patients.

TRIAL REGISTRATION

It has been registered at http://www.chictr.org.cn/listbycreater.aspx (Identifier: ChiCTR2000030378), Registered February 29, 2020.

188Re-HEDP therapy in the therapy of painful bone metastases

For bone-targeted radionuclide therapy (BTRT), different commercial radiopharmaceuticals are available such as strontium-89, 186Rhenium-hydroxyethylidene diphosphonate (186Re-HEDP), Samarium-153-ethylenediamine tetramethylene phosphonic acid, and radium-223. Unfortunately, the commercial available radiopharmaceuticals are very expensive (from 1,200 to 36,000€ per patient in Europe). The 188W/188Re generator is an ideal source for the long-term (4-6 months) continuous availability of 188Re suitable for the preparation of radiopharmaceuticals for different radionuclide therapies. Labeling at HEDP, it can use cost-effective for BTRT, if enough patients are available for therapy. And so, 188Re-HEDP is the ideal candidate in developing countries which high population to replace the other agents. Two German groups documented a response rate of 80% without any severe side effects and similar bone marrow toxicity compared to the other compounds for 188Re-HEDP. Using 188Re-HEDP in repeated treatments, a prolonged overall survival of repeated to single application was observed (from 4.5 months for single to 15.7 months using ≥≥3 applications).

From palliative therapy to prolongation of survival: (223)RaCl2 in the treatment of bone metastases

Patients with hormone-refractory prostate cancer often have multiple bone metastases. The resulting bone pain is associated with reduced life quality, increased cost of therapy and impairment of overall survival. Trials with bone-targeting β-emitters have mostly showed an effect on alleviation of bone pain along with prolongation in survival, documented in only a limited number of patients. A randomized phase III trial (ALSYMPCA) using the α-emitter (223)RaCl2 (Xofigo®) showed for the first time, a longer overall survival of 3.6 months in treated patients as a sign of an antitumor effect. The time to first skeletal-related events was also significantly longer in the therapy group compared with placebo. Because of the short range of α-emitter, the bone marrow toxicity of radium therapy is low, and so this radionuclide could also be a candidate for combination with chemotherapy. The elimination of (223)RaCl2 is mainly through the gastrointestinal tract and side effects are mainly in this area. The procedure is similar to treatment with other bone-seeking agents and consists of six administrations of 50 kBq/kg bodyweight Xofigo®, repeated every 4 weeks. At present Xofigo® is only approved for hormone-refractory prostate cancer.

Rapid access palliative radiation therapy programs: an efficient model of care

Palliating symptoms of advanced and metastatic cancers are one of the most common indications for radiation therapy (RT), and the demand for palliative RT is increasing. Dedicated rapid access palliative RT programs improve access to care, and can deliver RT in a more efficient and evidence-based manner than standard RT programs. In this narrative review, we discuss the role of palliative RT in comprehensive cancer care, and challenges that have faced patients trying to access it. We describe how rapid access programs developed to address these challenges and provide an overview of dedicated programs worldwide. Finally, we show how these programs can serve as models for multidisciplinary care and education, and sources of exciting research opportunities in clinical care and advanced technologies.

Cost of palliative radiation to the bone for patients with bone metastases secondary to breast or prostate cancer

BACKGROUND

To estimate the costs (paid amounts) of palliative radiation episodes of care (REOCs) to the bone for patients with bone metastases secondary to breast or prostate cancer.

METHODS

Claims-linked medical records from patients at 98 cancer treatment centers in 16 US states were analyzed. Inclusion criteria included a primary neoplasm of breast or prostate cancer with a secondary neoplasm of bone metastases; ≥2 visits to ≥1 radiation center during the study period (1 July 2008 through 31 December 2009) on or after the metastatic cancer diagnosis date; radiation therapy to ≥1 bone site; and ≥1 complete REOC as evidenced by a >30-day gap pre- and post-radiation therapy.

RESULTS

The total number of REOCs was 220 for 207 breast cancer patients and 233 for 213 prostate cancer patients. In the main analysis (which excluded records with unpopulated costs) the median number of fractions per a REOC for treatment of metastases was 10. Mean total radiation costs (i.e., radiation direct cost + cost of radiation-related procedures and visits) per REOC were $7457 for patients with breast cancer and $7553 for patients with prostate cancer. Results were consistent in sensitivity analyses excluding patients with unpopulated costs.

CONCLUSIONS

In the US, current use of radiation therapy for bone metastases is relatively costly and the use of multi-fraction schedules remains prevalent.

The clinical value of routine whole-body magnetic resonance imaging (MRI) in palliative care

BACKGROUND

Whole-body MRI (WBMRI) has become an accessible method for detecting different types of pathologies both in the skeleton and the viscera, which may explain painful conditions, for example tumors and inflammation.

PURPOSE

To assess a possible value of using WBMRI in order to improve palliative care.

MATERIAL AND METHODS

Twenty patients (all eligible patients) admitted to the Department for Palliative Care were consecutively included in this study. They underwent a modified WBMRI, with fewer and shorter pulse sequences than in a standard WBMRI, to reduce patient stress. However, the patients' physicians were to exclude patients where little might be obtained and discomfort, distress, and pain could be induced. The treating physicians registered clinical utility directly after receiving the MRI report in a questionnaire. The registration was repeated after ended treatment.

RESULTS

Eighty percent had new findings detected, and 40% of the patients had a change in treatment due to the MRI result, mainly changes in analgesics and/or radiation therapy.

CONCLUSION

The WBMRI helped the clinicians to improve treatment and a majority of the patients benefited from this. In eight patients the treatment was changed due to the results. The clinical value (utility) was indicated to be high.

Functional Interference due to Pain Following Palliative Radiotherapy for Bone Metastases Among Patients in Their Last Three Months of Life

Background

To compare the self-reported ratings of functional interference caused by pain between patients who did and did not respond to palliative radiotherapy for bone metastases during their last three months of life.

Methods

A prospectively gathered Brief Pain Inventory (BPI) database compiled from patients receiving palliative radiotherapy for painful bone metastases was reviewed. Demographic and clinical data, pain response rates and self-reported ratings of functional interference caused by pain were analyzed for those patients who died within three months of beginning radiotherapy.

Results

From 400 patients in the database, 83 died within 3 months of beginning radiotherapy. There were 54 male and 29 female patients. Their median age was 69 years and their median KPS was 70. The three most common primary cancers were lung (40%), gastrointestinal (16%) and breast (14%). For patients with available follow-up information the 1-month overall pain response rate was 78% and the 2-month rate was 83%, which include both complete and partial responses as defined by the International Bone Metastases Consensus. At 1 month, patients responding to treatment reported significantly less interference by pain on their general activity, walking ability, normal work, sleeping, and enjoyment of life than did patients not responding to treatment.

Conclusions

Patients that responded to treatment reported less functional interference due to pain than did patients who did not respond. Despite being very near the end of life, patients responding to palliative radiotherapy for painful bone metastases may benefit from more than pain relief alone.

Samarium lexidronam (153Sm-EDTMP): skeletal radiation for osteoblastic bone metastases and osteosarcoma

Radiation therapy can be an effective means to treat bone metastases, which occur in more than 50% of cancer patients. (153)Samarium lexidronam ((153)Sm-EDTMP; Quadramet, Cytogen) is a radiopharmaceutical designed for deposition into bone metastases. Bone scans can identify patients that may benefit from targeted radiation therapy with (153)Sm-EDTMP. As an unsealed source of radiation therapy, (153)Sm-EDTMP is simple to administer: 1 mCi/kg is given in a similar fashion to a bone scan injection ((99m)Tc-MDP bone scan injection is given at 0.2-0.35 mCi/kg. Therefore, both are administered intravenously. However, the radiation-absorbed dose and radiopharmaceutical energy are different). Nevertheless, despite simplicity of administration, (153)Sm-EDTMP is underutilized for improving cancer pain in the skeleton. Repeated cycles and combined treatment with other modalities such as bisphosphonates, chemotherapy and/or external beam radiation are possible. (153)Sm-EDTMP combined with bisphosphonates, chemotherapy and/or radiation may provide better palliation of bone metastases and also in bone-forming tumors (osteosarcoma). Encouraging experience using high-dose (153)Sm-EDTMP for total marrow irradiation in hematologic malignancies involving the bones (e.g., myeloma or acute leukemia) is also reviewed.

Management of painful bone metastases

PURPOSE OF REVIEW

This review examines recent data on the pathophysiology and mechanisms of bone pain; it highlights the use of multiple and interdisciplinary treatments rather than sole use of traditional analgesics.

RECENT FINDINGS

Bone pain has been shown to have a unique pathophysiology. Recent experimental (animal) models have revealed that, parallel to increased bone destruction, ipsilateral spinal cord segments that receive primary input from the cancerous femur exhibit several notable neurochemical changes. These mandate the use of opioid doses sufficient to inhibit the observed nociceptive behaviours; these doses are greater than those required to alleviate pain behaviours of comparable magnitude generated by inflammatory pain. Several substances have been tested in this animal model.

SUMMARY

According to new preclinical data, treatment of bone cancer pain requires multidisciplinary therapies such as radiotherapy applied to the painful area along with systemic treatment (hormone therapy or chemotherapy) and supportive care (analgesic therapy and bisphosphonates). In some selected cases use of radioisotopes and other noninvasive or minimally invasive techniques may be useful in the management of metastatic bone pain. The treatment should be individualized according to the patient's clinical condition, life expectancy, and quality of life.