1
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Nåhls NS, Anttonen A, Löyttyniemi E, Jekunen A, Akrén O, Saarto T. End-of-Life Care and Use of Hospital Resources in Radiotherapy-Treated Cancer Patients with Brain Metastases: A Single-Institution Retrospective Study. Palliat Med Rep 2024; 5:316-323. [PMID: 39144132 PMCID: PMC11319853 DOI: 10.1089/pmr.2024.0017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/07/2024] [Indexed: 08/16/2024] Open
Abstract
Purpose The aim of this single-institution retrospective study of patients treated with radiotherapy for brain metastases (BM) was to evaluate the timing of the palliative care (PC) decision, the use of health care services, i.e., emergency department (ED) visits and hospitalizations, and the implementation of radiotherapy at the end of life (EOL). Methods Data on all cancer patients with BM treated in Finland at the Vaasa Central Hospital Radiotherapy Department between March 2011 and November 2020 were retrospectively reviewed. The follow-up period lasted until November 2021. Altogether, 91 patients (54 men, mean age 67 years [range 23-91 years]) were analyzed. Data on timing of PC decision, visits to the PC outpatient unit, and ED and hospitalization periods were collected retrospectively from patients' records. Results The median overall survival from diagnosis of BM was 3.7 months (range 1-62 months) and, after radiotherapy, 2 months (0-61 months). Thirty-two percent of the patients received radiotherapy in the last month of life. During the last 30 days of life, 44 patients (48%) visited the ED and 38 (42%) were hospitalized. Patients with an early PC decision (>30 days before death) had fewer hospitalizations (22% vs. 53%; p = 0.005) and died less often during the hospitalization period (9% vs. 27%; p = 0.047) at EOL. No significant difference was found in ED visits (41% vs. 53%; p = 0.28). Conclusion For a large proportion of patients with BM, the prognosis is very poor. It is important to identify these patients and abstain from radiotherapy at EOL to reducing inappropriate health care utilization.
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Affiliation(s)
- Nelli-Sofia Nåhls
- Department of Oncology, Vaasa Central Hospital, The Wellbeing Services County of Ostrobothnia, Vaasa, Finland
- Department of Oncology, Comprehensive Cancer Centre, University of Helsinki, Helsinki, Finland
| | - Anu Anttonen
- Department of Radiotherapy, Comprehensive Cancer Center, Helsinki University Hospital, Helsinki, Finland
| | - Eliisa Löyttyniemi
- Department of Biostatistics, University of Turku and Turku University Hospital Turku, Turku Finland
| | - Antti Jekunen
- Department of Oncology, Vaasa Central Hospital, The Wellbeing Services County of Ostrobothnia, Vaasa, Finland
- Department of Oncology, Turku University, Vaasa, Finland
| | - Outi Akrén
- Palliative Center, Tyks Hospital Services, Turku University Hospital, Turku, Finland
- Department of General Medicine, University of Turku, Turku, Finland
| | - Tiina Saarto
- Department of Palliative Care, Comprehensive Cancer Center, Helsinki University Hospital, and Faculty of Medicine, Helsinki University, Helsinki, Finland
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2
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Cho S, Chu MK. Headache in Brain Tumors. Neurol Clin 2024; 42:487-496. [PMID: 38575261 DOI: 10.1016/j.ncl.2023.12.004] [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] [Indexed: 04/06/2024]
Abstract
The prevalence of brain tumors in patients with headache is very low; however, 48% to 71% of patients with brain tumors experience headache. The clinical presentation of headache in brain tumors varies according to age; intracranial pressure; tumor location, type, and progression; headache history; and treatment. Brain tumor-associated headaches can be caused by local and distant traction on pain-sensitive cranial structures, mass effect caused by the enlarging tumor and cerebral edema, infarction, hemorrhage, hydrocephalus, and tumor secretion. This article reviews the current findings related to epidemiologic details, clinical manifestations, mechanisms, diagnostic approaches, and management of headache in association with brain tumors.
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Affiliation(s)
- Soomi Cho
- Department of Neurology, Yonsei University College of Medicine, Republic of Korea
| | - Min Kyung Chu
- Department of Neurology, Yonsei University College of Medicine, Republic of Korea.
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3
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Ning C, Zhang X, Wang Y, Yang X, Yang X, Chao J, Xun Z, Xue J, Wang Y, Sun H, Li Y, Zhang N, Zhu C, Hou X, Sang X, Zhao H. Radiation Therapy With Combination Therapy of Immune Checkpoint Inhibitors and Antiangiogenic Therapy for Hepatocellular Carcinoma. Int J Radiat Oncol Biol Phys 2024; 118:1461-1471. [PMID: 37433375 DOI: 10.1016/j.ijrobp.2023.07.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 06/23/2023] [Accepted: 07/02/2023] [Indexed: 07/13/2023]
Abstract
PURPOSE Immune checkpoint inhibitors (ICIs) combined with antiangiogenic therapy have limited efficacy in treating advanced hepatocellular carcinoma (HCC). The synergistic effect of systemic therapy and radiation therapy (RT) might resolve this problem. We aimed to investigate the effect of RT on the treatment outcomes of ICIs and antiangiogenic combination therapy in patients with advanced-stage HCC. METHODS AND MATERIALS This retrospective observational study analyzed the medical records of 194 patients with Barcelona Clinic Liver Cancer stage C HCC who were admitted to our center from August 2018 to June 2022 and received ICIs combined with antiangiogenic therapy as the first-line treatment. Patients who were administered RT for tumor thrombus or symptomatic metastases within 8 weeks of the commencement of combination therapy were allocated to the RT group, whereas those who did not receive RT were assigned to the non-radiation therapy (NRT) group. Propensity score matching was used to mitigate selection bias. The primary endpoints were progression-free survival (PFS) and overall survival (OS). The secondary endpoints included objective response rate, disease control rate (DCR), local PFS, out-of-field PFS, and treatment-related adverse events. RESULTS A total of 76 patients diagnosed with advanced-stage HCC and treated with ICIs and antiangiogenic therapy were included in the study, with 33 patients in the RT group and 43 patients in the non-RT group. After propensity score matching, 29 matched patient pairs were generated. The median follow-up was 15.5 months, and the RT sites were mainly located on the tumor thrombus (55.2%) and extrahepatic metastatic lesions (48.3%). The median PFS was 8.3 months (95% CI, 5.4-11.3) in the RT group and 4.2 months (95% CI, 3.4-5.0) in the NRT group (P < .001). The median OS was not reached in the RT group and was 9.7 months (95% CI, 4.1-15.3) in the NRT group (P = .002). The objective response rate was 75.9% (95% CI, 56.5-89.7) in the RT group and 24.1% (95% CI, 10.3-43.5) in the NRT group (P < .001). The DCR was 100% in the RT group and 75.9% (95% CI, 56.5-89.7) in the NRT group (P = .005). The median local PFS and out-of-field PFS were 13.2 months (95% CI, 6.3-20.1) and 10.8 months (95% CI, 7.0-14.7), respectively. RT was an independent prognostic factor for PFS (hazard ratio = 0.33; 95% CI, 0.17-0.64; P < .001) and OS (hazard ratio = 0.28; 95% CI, 0.11-0.68; P = .005), respectively. The rates of any grade treatment-related adverse events were similar between the 2 groups. CONCLUSIONS In comparison to the combination of ICIs and antiangiogenic therapy, the inclusion of RT has been observed to improve the DCR and survival outcomes in patients with advanced-stage HCC. The safety profile of this triple therapy was satisfactory.
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Affiliation(s)
- Cong Ning
- Department of Liver Surgery, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College (CAMS & PUMC), Beijing, China
| | - Xinmu Zhang
- Department of Liver Surgery, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College (CAMS & PUMC), Beijing, China
| | - Yanyu Wang
- Department of Liver Surgery, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College (CAMS & PUMC), Beijing, China
| | - Xu Yang
- Department of Liver Surgery, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College (CAMS & PUMC), Beijing, China
| | - Xiaobo Yang
- Department of Liver Surgery, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College (CAMS & PUMC), Beijing, China
| | - Jiashuo Chao
- Department of Liver Surgery, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College (CAMS & PUMC), Beijing, China
| | - Ziyu Xun
- Department of Liver Surgery, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College (CAMS & PUMC), Beijing, China
| | - Jingnan Xue
- Department of Liver Surgery, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College (CAMS & PUMC), Beijing, China
| | - Yunchao Wang
- Department of Liver Surgery, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College (CAMS & PUMC), Beijing, China
| | - Huishan Sun
- Department of Liver Surgery, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College (CAMS & PUMC), Beijing, China
| | - Yiran Li
- Department of Liver Surgery, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College (CAMS & PUMC), Beijing, China
| | - Nan Zhang
- Department of Liver Surgery, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College (CAMS & PUMC), Beijing, China
| | - Chengpei Zhu
- Department of Liver Surgery, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College (CAMS & PUMC), Beijing, China
| | - Xiaorong Hou
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College (CAMS & PUMC), Beijing, China.
| | - Xinting Sang
- Department of Liver Surgery, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College (CAMS & PUMC), Beijing, China.
| | - Haitao Zhao
- Department of Liver Surgery, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College (CAMS & PUMC), Beijing, China.
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Matsuda R, Hasegawa M, Tamamoto T, Inooka N, Morimoto T, Maeoka R, Nakazawa T, Ochi T, Miyasaka T, Hontsu S, Yamaki K, Miura S, Yamada S, Nishimura F, Nakagawa I, Park YS, Nakase H. Clinical Results and Hematologic Predictors of Linear Accelerator-Based Stereotactic Radiosurgery or Fractionated Stereotactic Radiotherapy for Brain Metastasis in Patients Aged 75 Years or Older: A Retrospective Study. World Neurosurg 2024; 183:e944-e952. [PMID: 38244685 DOI: 10.1016/j.wneu.2024.01.069] [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] [Received: 07/03/2023] [Revised: 01/11/2024] [Accepted: 01/12/2024] [Indexed: 01/22/2024]
Abstract
OBJECTIVE This study aimed to evaluate prognostic factors including pre-radiosurgical blood count in elderly patients (EPs) with brain metastasis (BM) who were treated using linear accelerator (LINAC)-based stereotactic radiosurgery (SRS) and fractionated stereotactic radiotherapy (fSRT) with a micro-multileaf collimator. METHODS Between January 2011 and November 2021, 101 consecutive EPs with BM were treated by LINAC-based SRS or fSRT using LINAC with a micro-multileaf collimator. EPs were defined as patients aged ≥75 years. RESULTS The tumors originated from the lungs (n = 90; 89.1%), colon (n = 2; 2.0%), and others (n = 9; 8.8%) in these EPs. The median pretreatment Karnofsky Performance Status was 80 (range, 40-100). The median follow-up time was 10 months (range, 0-76), as was the median survival. The 6-month, 1-year, and 2-year survival in the EP group was 58.3%, 43.2%, and 28.5%, respectively. Freedom from local failure at 6 months and 1 and 2 years was 97%, 95%, and 91.5%, respectively. Freedom from distant failure at 6 months and 1 and 2 years in EPs was 70.6%, 59.4%, and 54.2%, respectively. A high neutrophil/lymphocyte ratio >5.33 was an unfavorable predictor of prognosis for EPs with BMs treated with SRS and fSRT (P < 0.001). In the EPs, the prognostic factors associated with prolonged survival in the Cox proportional hazards model were being female and a good pretreatment Karnofsky Performance Status. CONCLUSIONS The findings of our study highlight the efficacy of LINAC-based SRS and fSRT with a micro-multileaf collimator in the treatment of EPs with BMs. Neutrophil/lymphocyte ratio can be an important factor in treatment decisions for EPs with BMs.
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Affiliation(s)
- Ryosuke Matsuda
- Department of Neurosurgery, Nara Medical University, Kashihara, Nara, Japan.
| | - Masatoshi Hasegawa
- Department of Radiation Oncology, Nara Medical University, Kashihara, Nara, Japan
| | - Tetsuro Tamamoto
- Department of Radiation Oncology, Nara Medical University, Kashihara, Nara, Japan; Department of Medical Informatics, Nara Medical University Hospital, Kashihara, Nara, Japan
| | - Nobuyoshi Inooka
- Department of Radiation Oncology, Nara Medical University, Kashihara, Nara, Japan
| | - Takayuki Morimoto
- Department of Neurosurgery, Nara Medical University, Kashihara, Nara, Japan
| | - Ryosuke Maeoka
- Department of Neurosurgery, Nara Medical University, Kashihara, Nara, Japan
| | - Tsutomu Nakazawa
- Department of Neurosurgery, Nara Medical University, Kashihara, Nara, Japan
| | - Tomoko Ochi
- Department of Respiratory Medicine, Nara Medical University, Kashihara, Nara, Japan
| | - Toshiteru Miyasaka
- Department of Respiratory Medicine, Nara Medical University, Kashihara, Nara, Japan
| | - Shigeto Hontsu
- Department of Respiratory Medicine, Nara Medical University, Kashihara, Nara, Japan
| | - Kaori Yamaki
- Department of Radiation Oncology, Nara Medical University, Kashihara, Nara, Japan
| | - Sachiko Miura
- Department of Radiation Oncology, Nara Medical University, Kashihara, Nara, Japan
| | - Shuichi Yamada
- Department of Neurosurgery, Nara Medical University, Kashihara, Nara, Japan
| | - Fumihiko Nishimura
- Department of Neurosurgery, Nara Medical University, Kashihara, Nara, Japan
| | - Ichiro Nakagawa
- Department of Neurosurgery, Nara Medical University, Kashihara, Nara, Japan
| | - Young-Soo Park
- Department of Neurosurgery, Nara Medical University, Kashihara, Nara, Japan
| | - Hiroyuki Nakase
- Department of Neurosurgery, Nara Medical University, Kashihara, Nara, Japan
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5
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Cuneo A, Murinova N. Headache Management in Individuals with Brain Tumor. Semin Neurol 2024; 44:74-89. [PMID: 38183973 DOI: 10.1055/s-0043-1777423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2024]
Abstract
Headache occurs commonly in individuals diagnosed with cerebral neoplasm. Though the features of a brain tumor-associated headache may vary, a progressive nature of headache and a change in headache phenotype from a prior primary headache disorder often are identified. Pathophysiologic mechanisms proposed for headache associated with brain tumor include headache related to traction on pain-sensitive structures, activation of central and peripheral pain processes, and complications from surgical, chemotherapeutic and/or radiotherapy treatment(s). Optimization of headache management is important for an individual's quality of life. Treatments are based upon patient-specific goals of care and may include tumor-targeted medical and surgical interventions, as well as a multimodal headache treatment approach incorporating acute and preventive medications, nutraceuticals, neuromodulation devices, behavioral interventions, anesthetic nerve blocks, and lifestyles changes.
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Affiliation(s)
- Ami Cuneo
- Department of Neurology, University of Washington, Seattle, Washington
| | - Natalia Murinova
- Department of Neurology, University of Washington, Seattle, Washington
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Kumar S, Islim AI, Moon R, Millward CP, Hennigan D, Thorpe A, Foster M, Pizer B, Mallucci CL, Jenkinson MD. Long term quality of life outcomes following surgical resection alone for benign paediatric intracranial tumours. J Neurooncol 2023; 161:77-84. [PMID: 36592264 DOI: 10.1007/s11060-022-04208-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Accepted: 12/04/2022] [Indexed: 01/03/2023]
Abstract
PURPOSE Survivors of paediatric intracranial tumours are at increased risk of psychosocial, neuro-developmental, and functional impairment. This study aimed to evaluate long-term health-related quality-of-life (HRQOL) outcomes in patients with benign paediatric brain tumours treated curatively with surgical resection alone. METHODOLOGY This was a cross-sectional study of patients with benign paediatric intracranial tumours managed with surgery alone between 2000 and 2015. Eligible patients with a minimum of 5-years follow-up after surgery were identified. Validated health-related quality of life (HRQOL) questionnaires were administered: SF-36, QLQ-BN20, QLQ-C30 and PedsQL™. RESULTS Twenty-three patients participated (median age at surgery 13 years; range 1-18; 12 male). The most common diagnosis was pilocytic astrocytoma (n = 15). Median time from surgery to participation was 11 years(range 6-19). Fourteen patients achieved A-level qualifications and two obtained an undergraduate degree. Twelve patients were employed, eight were studying and three were unemployed or volunteering. HRQOL outcomes demonstrated significant limitation from social functioning (p = 0.03) and cognitive functioning (p = 0.023) compared to the general population. Patients also experienced higher rates of loss of appetite (p = 0.009) and nausea and vomiting (p = 0.031). Ten patients were under transitional teenager and young-adult (TYA) clinic follow-up. TYA patients achieved higher levels of education (p = 0.014), were more likely to hold a driver's license (p = 0.041) compared to patients not followed-up through these services. CONCLUSIONS Childhood brain-tumour survivors have a greater risk of developing psychological, neuro-cognitive and physical impairment. Early comprehensive assessment, specialist healthcare and TYA services are vital to support these patients.
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Affiliation(s)
- Siddhant Kumar
- Department of Neurosurgery, The Walton Centre NHS Foundation Trust, Fazakerley, Liverpool, L9 7LJ, UK. .,Institute of Systems, Molecular and Integrative Biology, The University of Liverpool, Liverpool, UK.
| | - Abdurrahman I Islim
- Department of Neurosurgery, Salford Royal Hospital Foundation Trust, Manchester, UK.,Academic Health Science Centre, University of Manchester, Manchester, UK
| | - Richard Moon
- Department of Neurosurgery, North Bristol NHS Trust, Bristol, UK
| | - Christopher P Millward
- Department of Neurosurgery, The Walton Centre NHS Foundation Trust, Fazakerley, Liverpool, L9 7LJ, UK.,Institute of Systems, Molecular and Integrative Biology, The University of Liverpool, Liverpool, UK
| | - Dawn Hennigan
- Department of Neurosurgery, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Antonia Thorpe
- Department of Neurosurgery, The Walton Centre NHS Foundation Trust, Fazakerley, Liverpool, L9 7LJ, UK
| | - Mitchell Foster
- Department of Neurosurgery, The Walton Centre NHS Foundation Trust, Fazakerley, Liverpool, L9 7LJ, UK
| | - Barry Pizer
- Department of Paediatric Oncology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Conor L Mallucci
- Department of Neurosurgery, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Michael D Jenkinson
- Department of Neurosurgery, The Walton Centre NHS Foundation Trust, Fazakerley, Liverpool, L9 7LJ, UK.,Institute of Systems, Molecular and Integrative Biology, The University of Liverpool, Liverpool, UK
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7
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Otto-Vollaard L, Quint S, de Pree IMN, Steinvoort IN, Tims OJL, Nuyttens JJ. Brain Metastases: Patient-Reported Outcome and Quality of Life After Whole-Brain Radiotherapy. J Palliat Med 2022; 25:1533-1539. [PMID: 35482284 DOI: 10.1089/jpm.2021.0533] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Purpose: The aim of this prospective cohort study was to determine the outcome and quality of life (QoL) for patients with brain metastases treated with whole-brain radiotherapy (WBRT). Materials and Methods: WBRT was given to 162 patients. Treatment outcome was reported through telephone consultation at four and eight weeks after the last fraction of the treatment. Treatment outcome was scored as a benefit when patients reported positively on the question whether radiotherapy of the whole brain did relieve their complaints. Patients who scored the treatment as beneficial were categorized as responders. The European Organization for Research and Treatment of Cancer (EORTC) questionnaire QLQ-C15-PAL was scored at day 0 and eight weeks after the last fraction of WBRT. Results: Patients who were alive after 2 months and reported benefit from treatment had a median survival of 8.1 months compared with 2.9 months for patients who reported no benefit. Forty-three patients died within two months (27%). Median overall survival was 3.5 months. Improvement of neurological symptoms was the most commonly reported benefit of the treatment. The responders had significantly better sleep (p = 0.032) and were less tense (p = 0.014). The nonresponders were also less tense (p = 0.042), but had less appetite (p = 0.023), felt weaker (p = 0.011), and experienced more fatigue (p = 0.001). Conclusions: WBRT is effective in a selected group of patients. Forty-nine percent of the patients surviving two months reported benefit from the treatment, resulting in a significantly increased survival rate for this group. However, 27% of patients died within two months. QoL increased in responders, but decreased in nonresponders.
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Affiliation(s)
| | - Sandra Quint
- Department of Radiotherapy, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Ilse M N de Pree
- Department of Radiotherapy, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Illona N Steinvoort
- Department of Radiotherapy, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Olijn J L Tims
- Department of Radiotherapy, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Joost J Nuyttens
- Department of Radiotherapy, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
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8
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Wu A, Colón GR, Lim M. Quality of Life and Role of Palliative and Supportive Care for Patients With Brain Metastases and Caregivers: A Review. Front Neurol 2022; 13:806344. [PMID: 35250815 PMCID: PMC8893046 DOI: 10.3389/fneur.2022.806344] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Accepted: 01/07/2022] [Indexed: 12/25/2022] Open
Abstract
Brain metastases (BM) are the most commonly diagnosed secondary brain lesions in adults, influencing these patients' symptoms and treatment courses. With improvements in oncologic treatments, patients with BM are now living longer with their advanced cancers, and issues pertaining to quality of life become more pressing. The American Society of Clinical Oncology has recommended early implementation of palliative care for cancer patients, though incorporation and implementation of palliative and other supportive services in the setting of true multidisciplinary care requires additional attention and research for patients with intracranial metastases. We review the physical, cognitive, and psychosocial challenges patients with BM and their caregivers face during their cancer course as well as the current published research on quality of life metrics relating to this patient population and the diverse roles specialty palliative care, rehabilitation services, and other healthcare providers play in a comprehensive multidisciplinary care model.
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Affiliation(s)
- Adela Wu
- Department of Neurosurgery, Stanford Healthcare, Stanford, CA, United States
- *Correspondence: Adela Wu
| | - Gabriela Ruiz Colón
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, United States
| | - Michael Lim
- Department of Neurosurgery, Stanford Healthcare, Stanford, CA, United States
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9
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Asano K, Hasegawa S, Matsuzaka M, Ohkuma H. Brain tumor-related epilepsy and risk factors for metastatic brain tumors: analysis of 601 consecutive cases providing real-world data. J Neurosurg 2021; 136:76-87. [PMID: 34271546 DOI: 10.3171/2020.11.jns202873] [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] [Received: 07/26/2020] [Accepted: 11/30/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE It is necessary to accurately characterize the epidemiology and trends of brain tumor-related epilepsy (BTE) in patients with metastatic brain tumors. This study aimed to determine the incidence of BTE associated with metastatic brain tumors and retrospectively investigate the risk factors for BTE. METHODS This retrospective analysis included 601 of 631 consecutive patients with metastatic brain tumors who received treatment, including surgery, radiotherapy, and/or other treatments. BTE and the clinical course were examined retrospectively. Logistic regression multivariate analyses were performed to identify risk factors for BTE. RESULTS BTE was reported in 148 (24.6%) of 601 patients during the entire course. Of these 148 patients, 81 (54.7%) had first-onset epilepsy (13.5% of all patients). Of the 520 cases of nonepileptic onset, 53 were in the prophylactic antiepileptic drug (AED) group. However, 12 of these patients and 55 of the no-prophylactic AED group developed epilepsy during the course of the study. Including these 67 patients, 148 patients were examined as the group of all epilepsy cases during the entire course. In 3 patients, the seizure progressed to status epilepticus. In most patients, the BTE (n = 83, 56.1%) manifested as focal aware seizures. Logistic regression analysis identified young age (p = 0.037), male sex (p = 0.026), breast cancer (p = 0.001), eloquent area (p < 0.001), peritumoral edema (p < 0.001), dissemination (p = 0.013), and maximum tumor volume (p = 0.021) as significant risk factors for BTE. BTE was more common with tumor volumes greater than the cutoff value of 1.92 ml. CONCLUSIONS BTE appears to be more likely to occur in cases with young age, male sex, breast cancer, tumors involving eloquent areas, brain edema, dissemination, and giant tumors.
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Affiliation(s)
- Kenichiro Asano
- 1Department of Neurosurgery, Hirosaki University Graduate School of Medicine, Hirosaki
| | - Seiko Hasegawa
- 2Department of Neurosurgery, Kuroishi General Hospital, Kuroishi; and
| | - Masashi Matsuzaka
- 3Clinical Research Support Center, and.,4Department of Medical Informatics, Hirosaki University Hospital, Hirosaki, Aomori, Japan
| | - Hiroki Ohkuma
- 1Department of Neurosurgery, Hirosaki University Graduate School of Medicine, Hirosaki
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10
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Socha J, Rychter A, Kepka L. Management of brain metastases in elderly patients with lung cancer. J Thorac Dis 2021; 13:3295-3307. [PMID: 34164222 PMCID: PMC8182516 DOI: 10.21037/jtd-2019-rbmlc-05] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The incidence of brain metastases (BM) is continuing to grow in the elderly population with lung cancer, but these patients are seriously under-represented in clinical trials. Thus, their treatment is not based on the evidence from randomized prospective studies. Age is a well recognized poor prognostic factor for survival in patients with BM from lung cancer, which is reflected in prognostic scales, but its impact on the patients' prognosis reflected by its value in gradually updated grading indices seems to decrease. The reason for poorer outcomes in the elderly is unknown—it may result from the influence of the age per se, simplified staging work-up and suboptimal treatment in this patient subgroup or the excess toxicity of the aggressive anticancer treatment secondary to the impaired physiological regulation mechanisms and comorbidities. The main goal of treatment of BM is to ameliorate neurological symptoms and delay neurological progression, with the focus on the improvement and maintenance of the patients’ quality of life. The possible treatment options for BM from lung cancer are whole-brain radiotherapy, stereotactic radiosurgery, surgery, chemotherapy, targeted therapies and best supportive care. The aim of this review is to summarize the problems related to the management of BM in elderly patients with lung cancer, to analyze the value of the above mentioned treatment options, and to provide an insight into the influence of age-related clinical factors on the patients’ outcomes.
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Affiliation(s)
- Joanna Socha
- Department of Radiotherapy, Military Institute of Medicine, Warsaw, Poland.,Department of Radiotherapy, Regional Oncology Centre, Czestochowa, Poland
| | - Anna Rychter
- Department of Radiotherapy, Military Institute of Medicine, Warsaw, Poland
| | - Lucyna Kepka
- Department of Radiotherapy, Military Institute of Medicine, Warsaw, Poland
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Ning MS, Das P, Rosenthal DI, Dabaja BS, Liao Z, Chang JY, Gomez DR, Klopp AH, Gunn GB, Allen PK, Nitsch PL, Natter RB, Briere TM, Herman JM, Wells R, Koong AC, McAleer MF. Early and Midtreatment Mortality in Palliative Radiotherapy: Emphasizing Patient Selection in High-Quality End-of-Life Care. J Natl Compr Canc Netw 2021; 19:805-813. [PMID: 33878727 DOI: 10.6004/jnccn.2020.7664] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 09/28/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND Palliative radiotherapy (RT) is effective, but some patients die during treatment or too soon afterward to experience benefit. This study investigates end-of-life RT patterns to inform shared decision-making and facilitate treatment consistent with palliative goals. MATERIALS AND METHODS All patients who died ≤6 months after initiating palliative RT at an academic cancer center between 2015 and 2018 were identified. Associations with time-to-death, early mortality (≤30 days), and midtreatment mortality were analyzed. RESULTS In total, 1,620 patients died ≤6 months from palliative RT initiation, including 574 (34%) deaths at ≤30 days and 222 (14%) midtreatment. Median survival was 43 days from RT start (95% CI, 41-45) and varied by site (P<.001), ranging from 36 (head and neck) to 53 days (dermal/soft tissue). On multivariable analysis, earlier time-to-death was associated with osseous (hazard ratio [HR], 1.33; P<.001) and head and neck (HR, 1.45; P<.001) sites, multiple RT courses ≤6 months (HR, 1.65; P<.001), and multisite treatments (HR, 1.40; P=.008), whereas stereotactic technique (HR, 0.77; P<.001) and more recent treatment year (HR, 0.82; P<.001) were associated with longer survival. No difference in time to death was noted among patients prescribed conventional RT in 1 to 10 versus >10 fractions (median, 40 vs 47 days; P=.272), although the latter entailed longer courses. The 30-day mortality group included 335 (58%) inpatients, who were 27% more likely to die midtreatment (P=.031). On multivariable analysis, midtreatment mortality among these inpatients was associated with thoracic (odds ratio [OR], 2.95; P=.002) and central nervous system (CNS; OR, 2.44; P=.002) indications, >5-fraction courses (OR, 3.27; P<.001), and performance status of 3 to 4 (OR, 1.63; P=.050). Conversely, palliative/supportive care consultation was associated with decreased midtreatment mortality (OR, 0.60; P=.045). CONCLUSIONS Earlier referrals and hypofractionated courses (≤5-10 treatments) should be routinely considered for palliative RT indications, given the short life expectancies of patients at this stage in their disease course. Providers should exercise caution for emergent thoracic and CNS indications among inpatients with poor prognoses due to high midtreatment mortality.
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Affiliation(s)
| | | | | | | | | | | | - Daniel R Gomez
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | | | | | | | - Paige L Nitsch
- Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | | | - Tina M Briere
- Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Joseph M Herman
- Department of Radiation Medicine, Zucker School of Medicine at Hofstra/Northwell, Lake Success, New York
| | - Rebecca Wells
- Department of Management, Policy, and Community Health, University of Texas Health Science Center School of Public Health, Houston, Texas; and
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12
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Mavroidis P, Pearlstein KA, Moon DH, Xu V, Royce TJ, Weiner AA, Shen CJ, Marks LB, Chera BS, Das SK, Wang K. NTCP modeling and dose-volume correlations for acute xerostomia and dry eye after whole brain radiation. Radiat Oncol 2021; 16:56. [PMID: 33743773 PMCID: PMC7981795 DOI: 10.1186/s13014-021-01786-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Accepted: 03/12/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Whole brain radiation (WBRT) may lead to acute xerostomia and dry eye from incidental parotid and lacrimal exposure, respectively. We performed a prospective observational study to assess the incidence/severity of this toxicity. We herein perform a secondary analysis relating parotid and lacrimal dosimetric parameters to normal tissue complication probability (NTCP) rates and associated models. METHODS Patients received WBRT to 25-40 Gy in 10-20 fractions using 3D-conformal radiation therapy without prospective delineation of the parotids or lacrimals. Patients completed questionnaires at baseline and 1 month post-WBRT. Xerostomia was assessed using the University of Michigan xerostomia score (scored 0-100, toxicity defined as ≥ 20 pt increase) and xerostomia bother score (scored from 0 to 3, toxicity defined as ≥ 2 pt increase). Dry eye was assessed using the Subjective Evaluation of Symptom of Dryness (SESoD, scored from 0 to 4, toxicity defined as ≥ 2 pt increase). The clinical data were fitted by the Lyman-Kutcher-Burman (LKB) and Relative Seriality (RS) NTCP models. RESULTS Of 55 evaluable patients, 19 (35%) had ≥ 20 point increase in xerostomia score, 11 (20%) had ≥ 2 point increase in xerostomia bother score, and 13 (24%) had ≥ 2 point increase in SESoD score. For xerostomia, parotid V10Gy-V20Gy correlated best with toxicity, with AUC 0.68 for xerostomia score and 0.69-0.71 for bother score. The values for the D50, m and n parameters of the LKB model were 22.3 Gy, 0.84 and 1.0 for xerostomia score and 28.4 Gy, 0.55 and 1.0 for bother score, respectively. The corresponding values for the D50, γ and s parameters of the RS model were 23.5 Gy, 0.28 and 0.0001 for xerostomia score and 32.0 Gy, 0.45 and 0.0001 for bother score, respectively. For dry eye, lacrimal V10Gy-V15Gy were found to correlate best with toxicity, with AUC values from 0.67 to 0.68. The parameter values of the LKB model were 53.5 Gy, 0.74 and 1.0, whereas of the RS model were 54.0 Gy, 0.37 and 0.0001, respectively. CONCLUSIONS Xerostomia was most associated with parotid V10Gy-V20Gy, and dry eye with lacrimal V10Gy-V15Gy. NTCP models were successfully created for both toxicities and may help clinicians refine dosimetric goals and assess levels of risk in patients receiving palliative WBRT.
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Affiliation(s)
- Panayiotis Mavroidis
- Department of Radiation Oncology, University of North Carolina, 101 Manning Dr., Chapel Hill, NC, 27599-7512, USA.
| | - Kevin A Pearlstein
- Department of Radiation Oncology, University of North Carolina, 101 Manning Dr., Chapel Hill, NC, 27599-7512, USA
| | - Dominic H Moon
- Department of Radiation Oncology, University of North Carolina, 101 Manning Dr., Chapel Hill, NC, 27599-7512, USA
| | - Victoria Xu
- Department of Radiation Oncology, University of North Carolina, 101 Manning Dr., Chapel Hill, NC, 27599-7512, USA
| | - Trevor J Royce
- Department of Radiation Oncology, University of North Carolina, 101 Manning Dr., Chapel Hill, NC, 27599-7512, USA
| | - Ashley A Weiner
- Department of Radiation Oncology, University of North Carolina, 101 Manning Dr., Chapel Hill, NC, 27599-7512, USA
| | - Colette J Shen
- Department of Radiation Oncology, University of North Carolina, 101 Manning Dr., Chapel Hill, NC, 27599-7512, USA
| | - Lawrence B Marks
- Department of Radiation Oncology, University of North Carolina, 101 Manning Dr., Chapel Hill, NC, 27599-7512, USA
| | - Bhishamjit S Chera
- Department of Radiation Oncology, University of North Carolina, 101 Manning Dr., Chapel Hill, NC, 27599-7512, USA
| | - Shiva K Das
- Department of Radiation Oncology, University of North Carolina, 101 Manning Dr., Chapel Hill, NC, 27599-7512, USA
| | - Kyle Wang
- Department of Radiation Oncology, University of North Carolina, 101 Manning Dr., Chapel Hill, NC, 27599-7512, USA
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13
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Abstract
Headache is one of the leading symptoms often associated with brain tumours. Secondary headaches attributed to intracranial neoplasias have been included in subchapter 7.4 of the third edition of the International Classification of Headache Disorders (ICHD-3). According to ICHD-3, the headache may be attributed to a brain tumour if it has developed in close temporal relation with the development of the neoplasia, has significantly worsened in parallel with the worsening of the tumour, and/or has significantly improved following the successful treatment of the neoplasia. Brain tumour headache was traditionally thought to display some specific clinical characteristics, including worsening in the morning and/or when lying down, being aggravated by Valsalva-like manoeuvres and accompanied by nausea and/or vomiting; however, the studies performed after the advent of modern neurodiagnostic techniques have pointed out that the "classic" brain tumour headache is uncommon, particularly at the time of clinical presentation. Therefore, it becomes critical to seek some specific factors associated with the presence of an intracranial mass (the so-called "red flags") that can guide the physician to establish an accurate diagnosis.
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Affiliation(s)
- Antonio Palmieri
- Headache Centre, Neurological Division, Portogruaro Hospital, Portogruaro, Venice, Italy
| | - Luca Valentinis
- Headache Centre, Neurological Division, Portogruaro Hospital, Portogruaro, Venice, Italy
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14
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Xia X, Li K, Wu R, Lv Q, Deng X, Fei Z, Zou C, Yang X. Predictive value of neuron-specific enolase, neutrophil-to-lymphocyte-ratio and lymph node metastasis for distant metastasis in small cell lung cancer. CLINICAL RESPIRATORY JOURNAL 2020; 14:1060-1066. [PMID: 32750207 DOI: 10.1111/crj.13242] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/21/2019] [Revised: 07/03/2020] [Accepted: 07/27/2020] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To investigate the value of neuron-specific enolase (NSE), neutrophil-to-lymphocyte ratio (NLR) and lymph node metastasis in predicating distant metastasis in patients with limited-stage small cell lung cancer (LD-SCLC). METHODS Clinical pathological data of LD-SCLC patients in the First Affiliated Hospital of Wenzhou Medical University between August 2009 and October 2017 were retrospectively analyzed. The age, gender, smoking, TNM, NSE, NLR, chemotherapy cycle, radiotherapy, surgery and new metastasis of lymph nodes of 47 cases with distant metastasis and 47 cases without distant metastasis in 1 year were compared. Finally, factors influencing distant metastasis were determined as the predictors. The receiver operating characteristic (ROC) curve model was established based on logistic regression analysis of the factors obtained. RESULTS Distant metastasis mainly involved brain (17/47), liver (17/47) and bone (17/47). Univariate analysis showed that patients with new lymph node metastasis, high NSE, pretreatment hilar lymph node metastasis and NLR were more prone to have distant metastasis. Multivariate analysis showed that new lymph node metastasis, high NSE, NLR and pretreatment hilar lymph node metastasis were independent predictors. The predictive model established using these predictors had an AUC of 0.872 (95%CI: 0.803-0.941), a sensitivity of 76.60% and a speciality of 80.85%. CONCLUSION The new lymph node metastasis, NLR and NSE are predictors of distant metastasis, and thus, may have a profound impact on treatment decision making. Patients with lower NLR and NSE expression levels and less new metastasis of lymph nodes have a lower distant metastasis rate.
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Affiliation(s)
- Xiaofang Xia
- Department of Radiotherapy, The Fifth Affiliated Hospital of Wenzhou Medical University, Affiliated Lishui Hospital of Zhejiang University, The Central Hospital of Zhejiang Lishui, Lishui, China
| | - Kejie Li
- Department of Radiotherapy and Chemotherapy, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Ruoqi Wu
- Department of Radiotherapy and Chemotherapy, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Qiyuan Lv
- Department of Radiotherapy and Chemotherapy, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Xia Deng
- Department of Radiotherapy and Chemotherapy, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Zhenghua Fei
- Department of Radiotherapy and Chemotherapy, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Changlin Zou
- Department of Radiotherapy and Chemotherapy, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Xujing Yang
- Department of Radiotherapy and Chemotherapy, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
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15
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Silvestre J, Gosse T, Read P, Gentzler R, Purow B, Asthagiri A, Gaughan E, Dillon PM, Larner JM, Anderson RT, Sheehan JP, Fadul CE. Genesis of Quality Measurements to Improve the Care Delivered to Patients With Brain Metastases. JCO Oncol Pract 2020; 17:e397-e405. [PMID: 32780641 DOI: 10.1200/op.20.00233] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE High-value and high-quality health care requires outcome measurements to inform treatment decisions, but, to our knowledge, no standardized measurements exist to evaluate brain metastases (BMs) care. We propose a set of measurements and report on their implementation in the care of patients with BMs. METHODS On the basis of a stakeholders' needs assessment and review of the literature, we identified outcome and process measurements to assess the care of patients with BMs according to treatment modality. Retrospectively, we applied these indicators of care to all patients diagnosed and treated at our institution over 2 years. RESULTS We ascertained 5 outcome and 6 process measurements of relevance in the care of BMs. When applied to 209 patients (89.7%) who received cancer treatment, 77% were alive > 90 days after diagnosis. The proportion alive at 90 days after surgery, whole-brain radiation therapy (WBRT), and stereotactic radiosurgery (SRS) was 82%, 59%, and 81%, respectively. Other performance measurements included 30-day postoperative readmission rate (6%), SRS within 30 days of surgery (79%), use of memantine with WBRT (41%), advance directives within 6 months of diagnosis (53%), and palliative care consultation for patients with poor prognosis or receiving WBRT (45%). Measurements for the 24 patients (10.3%) receiving best supportive care were advance directives documentation (67%) and referral to palliative or hospice care (83%). CONCLUSION We propose a set of measurements to apprise quality improvement efforts, inform treatment decision-making, and to use in evaluation of the performance of interdisciplinary BMs programs. Their refinement can potentially enhance the quality and value of care delivered to patients with BMs.
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Affiliation(s)
- Julio Silvestre
- Department of Medicine, Palliative Care Medicine Section, University of Virginia Health System, Charlottesville, VA
| | - Tracey Gosse
- Department of Neurology, Division of Neuro-Oncology, University of Virginia Health System, Charlottesville, VA
| | - Paul Read
- Department of Radiation Oncology, University of Virginia Health System, Charlottesville, VA
| | - Ryan Gentzler
- Department of Medicine, Division of Hematology/Oncology, University of Virginia Health System, Charlottesville, VA
| | - Benjamin Purow
- Department of Neurology, Division of Neuro-Oncology, University of Virginia Health System, Charlottesville, VA
| | - Ashok Asthagiri
- Department of Neurosurgery, University of Virginia Health System, Charlottesville, VA
| | - Elizabeth Gaughan
- Department of Medicine, Division of Hematology/Oncology, University of Virginia Health System, Charlottesville, VA
| | - Patrick M Dillon
- Department of Medicine, Division of Hematology/Oncology, University of Virginia Health System, Charlottesville, VA
| | - James M Larner
- Department of Radiation Oncology, University of Virginia Health System, Charlottesville, VA
| | - Roger T Anderson
- Department of Public Health Sciences, University of Virginia, Charlottesville, VA
| | - Jason P Sheehan
- Department of Neurosurgery, University of Virginia Health System, Charlottesville, VA
| | - Camilo E Fadul
- Department of Neurology, Division of Neuro-Oncology, University of Virginia Health System, Charlottesville, VA
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16
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Oldenburger E, Oldenburger F, Coolbrandt A, Isebaert S, Neyens I, Sevenants A, Van Audenhove C, Haustermans K. The use of patient reported outcome measures (PROMs) in palliative radiotherapy: A topical review. Radiother Oncol 2020; 149:94-103. [DOI: 10.1016/j.radonc.2020.04.045] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Revised: 04/24/2020] [Accepted: 04/24/2020] [Indexed: 01/11/2023]
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17
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Wang K, Pearlstein KA, Moon DH, Mahbooba ZM, Deal AM, Wang Y, Sutton SR, Motley BB, Judy GD, Holmes JA, Sheets NC, Kasibhatla MS, Pacholke HD, Shen CJ, Zagar TM, Marks LB, Chera BS. Assessment of Risk of Xerostomia After Whole-Brain Radiation Therapy and Association With Parotid Dose. JAMA Oncol 2019; 5:221-228. [PMID: 30489607 DOI: 10.1001/jamaoncol.2018.4951] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Importance Whole-brain radiation therapy (WBRT) delivers a substantial radiation dose to the parotid glands, but the parotid glands are not delineated for avoidance and xerostomia has never been reported as an adverse effect. Minimizing the toxic effects in patients receiving palliative treatments, such as WBRT, is crucial. Objective To assess whether xerostomia is a toxic effect of WBRT. Design, Setting, and Participants This observational cohort study enrolled patients from November 2, 2015, to March 20, 2018, at 1 academic center (University of North Carolina Hospitals) and 2 affiliated community hospitals (High Point Regional Hospital and University of North Carolina Rex Hospital). Adult patients (n = 100) receiving WBRT for the treatment or prophylaxis of brain metastases were enrolled. Patients who had substantial baseline xerostomia or did not complete WBRT or at least 1 postbaseline questionnaire were prospectively excluded from analysis and follow-up. Patients received 3-dimensional WBRT using opposed lateral fields covering the skull and the C1 or C2 vertebra. Per standard practice, the parotid glands were not prospectively delineated. Main Outcomes and Measures Patients completed the University of Michigan Xerostomia Questionnaire and a 4-point bother score at baseline, immediately after WBRT, at 1 month, at 3 months, and at 6 months. The primary end point was the 1-month xerostomia score, with a hypothesized worsening score of 10 points from baseline. Results Of the 100 patients enrolled, 73 (73%) were eligible for analysis and 55 (55%) were evaluable at 1 month. The 73 patients included 43 women (59%) and 30 men (41%) with a median (range) age of 61 (23-88) years. The median volume of parotid receiving at least 20 Gy (V20Gy) was 47%. The mean xerostomia score was 7 points at baseline and was statistically significantly higher at each assessment period, including 21 points immediately after WBRT (95% CI, 16-26; P < .001), 23 points (95% CI, 16-30; P < .001) at 1 month, 21 points (95% CI, 13-28; P < .001) at 3 months, and 14 points (95% CI, 7-21; P = .03) at 6 months. At 1 month, the xerostomia score increased by 20 points or more in 19 patients (35%). The xerostomia score at 1 month was associated with parotid dose as a continuous variable and was 35 points in patients with parotid V20Gy of 47% or greater, compared with only 9 points in patients with parotid V20Gy less than 47% (P < .001). The proportion of patients who self-reported to be bothered quite a bit or bothered very much by xerostomia at 1 month was 50% in those with parotid V20Gy of 47% or greater, compared with only 4% in those with parotid V20Gy less than 47% (P < .001). At 3 months, this difference was 50% vs 0% (P = .001). Xerostomia was not associated with medication use. Conclusions and Relevance Clinically significant xerostomia occurred by the end of WBRT, appeared to be persistent, and appeared to be associated with parotid dose. The findings from this study suggest that the parotid glands should be delineated for avoidance to minimize these toxic effects in patients who undergo WBRT and often do not survive long enough for salivary recovery.
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Affiliation(s)
- Kyle Wang
- Department of Radiation Oncology, University of North Carolina Hospitals, Chapel Hill
| | - Kevin A Pearlstein
- Department of Radiation Oncology, University of North Carolina Hospitals, Chapel Hill
| | - Dominic H Moon
- Department of Radiation Oncology, University of North Carolina Hospitals, Chapel Hill
| | - Zahra M Mahbooba
- Department of Radiation Oncology, University of North Carolina Hospitals, Chapel Hill
| | - Allison M Deal
- Lineberger Comprehensive Cancer Center Biostatistics Core, University of North Carolina Hospitals, Chapel Hill
| | - Yue Wang
- Lineberger Comprehensive Cancer Center Biostatistics Core, University of North Carolina Hospitals, Chapel Hill
| | - Stephanie R Sutton
- Department of Radiation Oncology, University of North Carolina Hospitals, Chapel Hill
| | - Britni B Motley
- Department of Radiation Oncology, University of North Carolina Hospitals, Chapel Hill
| | - Gregory D Judy
- Department of Radiation Oncology, University of North Carolina Hospitals, Chapel Hill
| | - Jordan A Holmes
- Department of Radiation Oncology, University of North Carolina Hospitals, Chapel Hill
| | - Nathan C Sheets
- Department of Radiation Oncology, University of North Carolina Hospitals, Chapel Hill
| | - Mohit S Kasibhatla
- Department of Radiation Oncology, University of North Carolina Hospitals, Chapel Hill
| | - Heather D Pacholke
- Department of Radiation Oncology, University of North Carolina Hospitals, Chapel Hill
| | - Colette J Shen
- Department of Radiation Oncology, University of North Carolina Hospitals, Chapel Hill
| | | | - Lawrence B Marks
- Department of Radiation Oncology, University of North Carolina Hospitals, Chapel Hill
| | - Bhishamjit S Chera
- Department of Radiation Oncology, University of North Carolina Hospitals, Chapel Hill
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18
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Wang K, Tobillo R, Mavroidis P, Pappafotis R, Pearlstein KA, Moon DH, Mahbooba ZM, Deal AM, Holmes JA, Sheets NC, Kasibhatla MS, Pacholke HD, Royce TJ, Weiner AA, Shen CJ, Zagar TM, Marks LB, Chera BS. Prospective Assessment of Patient-Reported Dry Eye Syndrome After Whole Brain Radiation. Int J Radiat Oncol Biol Phys 2019; 105:765-772. [PMID: 31351194 DOI: 10.1016/j.ijrobp.2019.07.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2019] [Revised: 06/20/2019] [Accepted: 07/15/2019] [Indexed: 10/26/2022]
Abstract
PURPOSE Dry eye is not typically considered a toxicity of whole brain radiation therapy (WBRT). We analyzed dry eye syndrome as part of a prospective study of patient-reported outcomes after WBRT. METHODS AND MATERIALS Patients receiving WBRT to 25 to 40 Gy were enrolled on a study with dry mouth as the primary endpoint and dry eye syndrome as a secondary endpoint. Patients received 3-dimensional WBRT using opposed lateral fields. Per standard practice, lacrimal glands were not prospectively delineated. Patients completed the Subjective Evaluation of Symptom of Dryness (SESoD, scored 0-4, with higher scores representing worse dry eye symptoms) at baseline, immediately after WBRT (EndRT), and at 1 month (1M), 3 months, and 6 months. Patients with baseline SESoD ≥3 (moderate dry eye) were excluded. The endpoints analyzed were ≥1-point and ≥2-point increase in SESoD score at 1M. Lacrimal glands were retrospectively delineated with fused magnetic resonance imaging scans. RESULTS One hundred patients were enrolled, 70 were eligible for analysis, and 54 were evaluable at 1M. Median bilateral lacrimal V20Gy was 79%. At 1M, 17 patients (32%) had a ≥1-point increase in SESoD score, and 13 (24%) a ≥2-point increase. Lacrimal doses appeared to be associated with an increase in SESoD score of both ≥1 point (V10Gy: P = .042, odds ratio [OR] 1.09/%; V20Gy: P = .071, OR 1.03/%) and ≥2 points (V10Gy: P = .038, OR 1.15/%; V20Gy: P = .063, OR 1.04/%). The proportion with increase in dry eye symptoms at 1M for lacrimal V20Gy ≥79% versus <79% was 46% versus 15%, respectively, for ≥1 point SESoD increase (P = .02) and 36% versus 12%, respectively, for ≥2 point SESoD increase (P = .056). CONCLUSIONS Dry eye appears to be a relatively common, dose/volume-dependent acute toxicity of WBRT. Minimization of lacrimal gland dose may reduce this toxicity, and patients should be counseled regarding the existence of this potential side effect and treatments for dry eye.
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Affiliation(s)
- Kyle Wang
- Department of Radiation Oncology, University of North Carolina Hospitals, Chapel Hill, North Carolina.
| | - Rachel Tobillo
- Florida Atlantic University College of Medicine, Boca Raton, Florida
| | - Panayiotis Mavroidis
- Department of Radiation Oncology, University of North Carolina Hospitals, Chapel Hill, North Carolina
| | - Ryan Pappafotis
- Department of Radiation Oncology, University of North Carolina Hospitals, Chapel Hill, North Carolina
| | - Kevin A Pearlstein
- Department of Radiation Oncology, University of North Carolina Hospitals, Chapel Hill, North Carolina
| | - Dominic H Moon
- Department of Radiation Oncology, University of North Carolina Hospitals, Chapel Hill, North Carolina
| | - Zahra M Mahbooba
- Department of Radiation Oncology, University of North Carolina Hospitals, Chapel Hill, North Carolina
| | - Allison M Deal
- Lineberger Comprehensive Cancer Center Biostatistics Core, University of North Carolina Hospitals, Chapel Hill, North Carolina
| | - Jordan A Holmes
- Department of Radiation Oncology, University of North Carolina Hospitals, Chapel Hill, North Carolina
| | - Nathan C Sheets
- Department of Radiation Oncology, University of North Carolina Hospitals, Chapel Hill, North Carolina
| | - Mohit S Kasibhatla
- Department of Radiation Oncology, University of North Carolina Hospitals, Chapel Hill, North Carolina
| | - Heather D Pacholke
- Department of Radiation Oncology, University of North Carolina Hospitals, Chapel Hill, North Carolina
| | - Trevor J Royce
- Department of Radiation Oncology, University of North Carolina Hospitals, Chapel Hill, North Carolina
| | - Ashley A Weiner
- Department of Radiation Oncology, University of North Carolina Hospitals, Chapel Hill, North Carolina
| | - Colette J Shen
- Department of Radiation Oncology, University of North Carolina Hospitals, Chapel Hill, North Carolina
| | | | - Lawrence B Marks
- Department of Radiation Oncology, University of North Carolina Hospitals, Chapel Hill, North Carolina
| | - Bhishamjit S Chera
- Department of Radiation Oncology, University of North Carolina Hospitals, Chapel Hill, North Carolina
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19
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Clément-Zhao A, Luu M, Bibault JE, Daveau C, Kreps S, Jaulmes H, Dessard-Diana B, Housset M, Giraud P, Durdux C. Effective delivery of palliative radiotherapy: A prospective study. Cancer Radiother 2019; 23:365-369. [PMID: 31300329 DOI: 10.1016/j.canrad.2018.09.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Revised: 09/14/2018] [Accepted: 09/27/2018] [Indexed: 12/25/2022]
Abstract
PURPOSE The main goal of palliative radiotherapy is to reduce patient's discomfort. But sometimes patients do not receive any benefits from this treatment because of rapid worsening of their general condition. This prospective monocentric study assessed the effective delivery of palliative radiotherapy. MATERIALS AND METHODS From 1st December 2015 to 29th February 2016, all consecutive patients receiving palliative radiotherapy in our hospital were included. The primary endpoint was the effective delivery of palliative radiotherapy according to the initial prescription (total dose, overall treatment time and fractionation). The secondary endpoints were the number of treatment breaks, the clinical benefit, the number of deaths and the delays for admission in the palliative care unit. RESULTS Fifty-nine patients were included and 64 treatments were analysed. The treatment sites were: bone (70.3%) and brain (21.9%). The treatment goals were: pain control only (43.8%), decompression only (21.9%), pain control and decompression (32.8%), haemostatic aim (1.6%). Palliative treatment was achieved in 57 cases (89%). Temporary interruption of the radiotherapy treatment was necessary in six cases (9.4%; three for medical reason, three for logistic reason). The main reason of permanent interruption was worsening of performance status (seven cases). Palliation of symptoms (complete or partial responses) was obtained in 44 cases (68.8%). Seven patients (11.9%) died during the month after the end of the treatment. No delay or cancellation for admission in the palliative care unit were observed. CONCLUSION Palliative radiotherapy was completed as originally planned in 51 cases (79.9%) with a clinical benefit for 44 cases (68.8%). Radiation therapy must not be neglected as a palliative treatment at the end-of-life.
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Affiliation(s)
- A Clément-Zhao
- Department of radiotherapy, hôpital européen Georges-Pompidou, 20, rue Leblanc, 75015 Paris, France; Department of radiotherapy, institut Curie, 35 rue Dailly, 92210 Saint-Cloud, France.
| | - M Luu
- Mobile palliative care unit, hôpital européen Georges-Pompidou, 20, rue Leblanc, 75015 Paris, France
| | - J-E Bibault
- Department of radiotherapy, hôpital européen Georges-Pompidou, 20, rue Leblanc, 75015 Paris, France
| | - C Daveau
- Department of radiotherapy, hôpital européen Georges-Pompidou, 20, rue Leblanc, 75015 Paris, France
| | - S Kreps
- Department of radiotherapy, hôpital européen Georges-Pompidou, 20, rue Leblanc, 75015 Paris, France
| | - H Jaulmes
- Mobile palliative care unit, hôpital européen Georges-Pompidou, 20, rue Leblanc, 75015 Paris, France
| | - B Dessard-Diana
- Department of radiotherapy, hôpital européen Georges-Pompidou, 20, rue Leblanc, 75015 Paris, France
| | - M Housset
- Department of radiotherapy, hôpital européen Georges-Pompidou, 20, rue Leblanc, 75015 Paris, France
| | - P Giraud
- Department of radiotherapy, hôpital européen Georges-Pompidou, 20, rue Leblanc, 75015 Paris, France
| | - C Durdux
- Department of radiotherapy, hôpital européen Georges-Pompidou, 20, rue Leblanc, 75015 Paris, France
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Julie DAR, Ahmed Z, Karceski SC, Pannullo SC, Schwartz TH, Parashar B, Wernicke AG. An overview of anti-epileptic therapy management of patients with malignant tumors of the brain undergoing radiation therapy. Seizure 2019; 70:30-37. [PMID: 31247400 DOI: 10.1016/j.seizure.2019.06.019] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Revised: 05/28/2019] [Accepted: 06/12/2019] [Indexed: 01/01/2023] Open
Abstract
As our surgical, radiation, chemotherapeutic and supportive therapies for brain malignancies improve, and overall survival is prolonged, appropriate symptom management in this patient population becomes increasingly important. This review summarizes the published literature and current practice patterns regarding prophylactic and perioperative anti-epileptic drug use. As a wide range of anti-epileptic drugs is now available to providers, evidence guiding appropriate anticonvulsant choice is reviewed. A particular focus of this article is radiation therapy for brain malignancies. Toxicities and seizure risk associated with cranial irradiation will be discussed. Epilepsy management in patients undergoing radiation for gliomas, glioblastoma multiforme, and brain metastases will be addressed. An emerging but inconsistent body of evidence, reviewed here, indicates that anti-epileptic medications may increase radiosensitivity, and therefore improve clinical outcomes, specifically in glioblastoma multiforme patients.
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Affiliation(s)
- Diana A R Julie
- Department of Radiation Oncology, Weill Medical College of Cornell University, New York, NY, United States
| | | | - Stephen C Karceski
- Department of Neurology, Weill Medical College of Cornell University, New York, NY, United States
| | - Susan C Pannullo
- Department of Neurosurgery, Weill Medical College of Cornell University, New York, NY, United States
| | - Theodore H Schwartz
- Department of Neurosurgery, Weill Medical College of Cornell University, New York, NY, United States
| | - Bhupesh Parashar
- Department of Radiation Oncology, Northwell Health, New Hyde Park, NY, United States
| | - A Gabriella Wernicke
- Department of Radiation Oncology, Weill Medical College of Cornell University, New York, NY, United States; Department of Neurosurgery, Weill Medical College of Cornell University, New York, NY, United States.
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21
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Hadidchi S, Surento W, Lerner A, Liu CSJ, Gibbs WN, Kim PE, Shiroishi MS. Headache and Brain Tumor. Neuroimaging Clin N Am 2019; 29:291-300. [DOI: 10.1016/j.nic.2019.01.008] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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22
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Comparison of Diagnosis-Specific Survival Scores for Patients with Small-Cell Lung Cancer Irradiated for Brain Metastases. Cancers (Basel) 2019; 11:cancers11020233. [PMID: 30781513 PMCID: PMC6406817 DOI: 10.3390/cancers11020233] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Revised: 02/12/2019] [Accepted: 02/14/2019] [Indexed: 12/20/2022] Open
Abstract
Diagnosis-specific survival scores including a new score developed in 157 patients with brain metastases from small-cell lung cancer (SCLC) receiving whole-brain radiotherapy (WBRT) with 30 Gy in 10 fractions (WBRT-30-SCLC) were compared. Three prognostic groups were designed based on the 6-month survival probabilities of significant or almost significant factors, (age, performance score, number of brain metastases, extra-cerebral metastasis). Six-month survival rates were 6% (6–11 points), 44% (12–14 points) and 86% (16–19 points). The WBRT-30-SCLC was compared to three disease-specific scores for brain metastasis from SCLC, the original and updated diagnosis-specific graded prognostic assessment DS-GPA classifications and the Rades-SCLC. Positive predictive values (PPVs) used to correctly predict death ≤6 months were 94% (WBRT-30-SCLC), 88% (original DS-GPA), 88% (updated DS-GPA) and 100% (Rades-SCLC). PPVs to predict survival ≥6 months were 86%, 75%, 76% and 100%. For WBRT-30-SCLC and Rades-SCLC, differences between poor and intermediate prognoses groups and between intermediate and favorable prognoses groups were significant. For both DS-GPA classifications, only the difference between poor and intermediate prognoses groups was significant. Of these disease-specific tools, Rades-SCLC appeared to be the most accurate in identifying patients dying ≤6 months and patients surviving ≥6 months after irradiation, followed by the new WBRT-30-SCLC and the DS-GPA classifications.
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Nassif EF, Arsène-Henry A, Kirova YM. Brain metastases and treatment: multiplying cognitive toxicities. Expert Rev Anticancer Ther 2019; 19:327-341. [PMID: 30755047 DOI: 10.1080/14737140.2019.1582336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
INTRODUCTION Thirty per cent of cancer patients develop brain metastases, with multiple combination or sequential treatment modalities available, to treat systemic or central nervous system (CNS) disease. Most patients experience toxicities as a result of these treatments, of which cognitive impairment is one of the adverse events most commonly reported, causing major impairment of the patient's quality of life. Areas covered: This article reviews the role of cancer treatments in cognitive decline of patients with brain metastases: surgery, radiotherapy, chemotherapy, targeted therapies, immunotherapies and hormone therapy. Pathological and molecular mechanisms, as well as future directions for limiting cognitive toxicities are also presented. Other causes of cognitive impairment in this population are discussed in order to refine the benefit-risk balance of each treatment modality. Expert opinion: Cumulative cognitive toxicity should be taken into account, and tailored to the patient's cognitive risk in the light of the expected survival benefit. Standardization of cognitive assessment in this context is needed in order to better appreciate each treatment's responsibility in cognitive impairment, keeping in mind disease itself impacts cognition in this context.
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Affiliation(s)
- Elise F Nassif
- a Department of Radiotherapy , Institut Curie , Paris , France
| | | | - Youlia M Kirova
- a Department of Radiotherapy , Institut Curie , Paris , France
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24
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Achrol AS, Rennert RC, Anders C, Soffietti R, Ahluwalia MS, Nayak L, Peters S, Arvold ND, Harsh GR, Steeg PS, Chang SD. Brain metastases. Nat Rev Dis Primers 2019; 5:5. [PMID: 30655533 DOI: 10.1038/s41572-018-0055-y] [Citation(s) in RCA: 544] [Impact Index Per Article: 108.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
An estimated 20% of all patients with cancer will develop brain metastases, with the majority of brain metastases occurring in those with lung, breast and colorectal cancers, melanoma or renal cell carcinoma. Brain metastases are thought to occur via seeding of circulating tumour cells into the brain microvasculature; within this unique microenvironment, tumour growth is promoted and the penetration of systemic medical therapies is limited. Development of brain metastases remains a substantial contributor to overall cancer mortality in patients with advanced-stage cancer because prognosis remains poor despite multimodal treatments and advances in systemic therapies, which include a combination of surgery, radiotherapy, chemotherapy, immunotherapy and targeted therapies. Thus, interest abounds in understanding the mechanisms that drive brain metastases so that they can be targeted with preventive therapeutic strategies and in understanding the molecular characteristics of brain metastases relative to the primary tumour so that they can inform targeted therapy selection. Increased molecular understanding of the disease will also drive continued development of novel immunotherapies and targeted therapies that have higher bioavailability beyond the blood-tumour barrier and drive advances in radiotherapies and minimally invasive surgical techniques. As these discoveries and innovations move from the realm of basic science to preclinical and clinical applications, future outcomes for patients with brain metastases are almost certain to improve.
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Affiliation(s)
- Achal Singh Achrol
- Department of Neurosurgery and Neurosciences, John Wayne Cancer Institute and Pacific Neuroscience Institute, Santa Monica, CA, USA.
| | - Robert C Rennert
- Department of Neurosurgery, University of California-San Diego, San Diego, CA, USA.
| | - Carey Anders
- Division of Hematology/Oncology, Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, USA
| | | | - Manmeet S Ahluwalia
- Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, OH, USA
| | - Lakshmi Nayak
- Center for Neuro-Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Solange Peters
- Medical Oncology, Lausanne University Hospital, Lausanne, Switzerland
| | - Nils D Arvold
- Department of Radiation Oncology, St. Luke's Cancer Center, Duluth, MN, USA
| | - Griffith R Harsh
- Department of Neurosurgery, University of California-Davis, School of Medicine, Sacramento, CA, USA
| | - Patricia S Steeg
- Women's Malignancies Branch, Center for Cancer Research, National Cancer Center, Bethesda, MD, USA
| | - Steven D Chang
- Department of Neurosurgery, University of California-Davis, School of Medicine, Sacramento, CA, USA.
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Chooback N, Lefresne S, Lau SC, Ho C. CNS Metastases in Epidermal Growth Factor Receptor Mutation-Positive Non-Small-Cell Lung Cancer: Impact on Health Resource Utilization. J Oncol Pract 2018; 14:e612-e620. [PMID: 30216125 DOI: 10.1200/jop.18.00054] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
PURPOSE Patients with epidermal growth factor receptor (EGFR) mutation-positive (EGFRm) non-small-cell lung cancer commonly experience disease progression in the CNS. Here, we assess the impact of CNS disease on resource utilization and outcomes in patients who are EGFRm. METHODS We completed a retrospective review of all advanced patients who were EGFRm, referred to BC Cancer, and treated with a first- and/or second-generation EGFR tyrosine kinase inhibitor from 2010 to 2015. Baseline characteristics, systemic treatment, and CNS management were collected. We compared health resource utilization (HRU) between patients with CNS-negative disease and those with CNS metastases from the median time of CNS metastases diagnosis to death or last follow-up (9.1 months) and at 9 months preceding death or last follow-up for the CNS-negative group. RESULTS Four hundred ninety-nine patients were referred, of which 68% were female; 51% were of Asian ethnicity; and 57%, 37%, and 6% were exon 19, 21, or other, respectively; with a median age of 66 years. Two hundred twenty-nine (46%) of 499 patients developed CNS metastases-39% at diagnosis and 61% over the course of disease. CNS metastases were managed with surgery with or without whole-brain radiotherapy (WBRT; 13%) WBRT alone (73%), stereotactic radiosurgery with or without WBRT (5%), or no CNS-directed therapy (9%). The median time from the development of CNS metastases diagnosis to death was 9.1 months. CNS-negative patients used less HRU versus patients that were CNS-positive in the 9 months preceding death or last follow-up-in the average number of clinic visits (8.53 v 12.71, respectively; P < .001), hospitalizations (0.43 v 0.76, respectively; P < .001), CNS imaging investigations (0.52 v 2.65, respectively; P < .001), emergency room visits (0.03 v 0.14, respectively; P = .001), palliative care unit admission (8% v 10%, respectively; P = .64), and hospice admission (3% v 19%, respectively; P < .001). CONCLUSION The incidence of CNS metastases in patients with EGFRm is high and associated with increased HRU. Prevention or delay of CNS metastases with newer systemic therapy options may translate into lower resource utilization.
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Affiliation(s)
- Negar Chooback
- Belleville General Hospital, Belleville, Ontario; and BC Cancer, Vancouver, British Columbia, Canada
| | - Shilo Lefresne
- Belleville General Hospital, Belleville, Ontario; and BC Cancer, Vancouver, British Columbia, Canada
| | - Sally C Lau
- Belleville General Hospital, Belleville, Ontario; and BC Cancer, Vancouver, British Columbia, Canada
| | - Cheryl Ho
- Belleville General Hospital, Belleville, Ontario; and BC Cancer, Vancouver, British Columbia, Canada
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Walker MS, Wong W, Ravelo A, Miller PJE, Schwartzberg LS. Effect of Brain Metastasis on Patient-Reported Outcomes in Advanced NSCLC Treated in Real-World Community Oncology Settings. Clin Lung Cancer 2017; 19:139-147. [PMID: 29103883 DOI: 10.1016/j.cllc.2017.10.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Revised: 08/16/2017] [Accepted: 10/04/2017] [Indexed: 11/12/2022]
Abstract
INTRODUCTION Health-related quality of life (HRQOL) in advanced non-small-cell lung cancer (NSCLC) might be affected by the presence of brain metastasis (BM). We report findings from a prospective observational study that examined HRQOL in patients newly diagnosed with advanced NSCLC, with or without baseline BM, through 1 year of follow-up. PATIENTS AND METHODS Patients starting first-line treatment of stage IIIB/IV NSCLC were prospectively enrolled and consented at 34 US-based community oncology practices. Data on patient-reported outcomes (PROs) were collected once per cycle during treatment, and at each visit after discontinuation. PROs included the European Organization for Research and Treatment of Cancer Core Quality of Life Questionnaire (QLQ-C30) and Lung Cancer Module (QLQ-LC13), the Lung Cancer Module of the M.D. Anderson Symptom Inventory (MDASI-LC), and the Rotterdam Activity Level Scale (RALS). Linear mixed models were used to examine the effect of baseline BM, including differences in change over time. RESULTS One hundred forty-five patients provided follow-up PRO data, comprising 1100 individual surveys and 32 PRO end points. The patient group was 58.6% (n = 85) male, and 86.2% (n = 125) Caucasian. Patients with baseline BM were younger (61.3 vs. 65.8 years; P = .040) with more concurrent radiotherapy (59.4% [n = 19] vs. 15.9% [n = 18]; P < .0001). Results showed minimal differences in baseline HRQOL. Of the 20 measures that showed significant group differences in HRQOL over time, 18 showed greater deterioration for patients with baseline BM. These 18 measures included all QLQ-C30 composite measures except Global Health Status, all MDASI-LC measures, and the RALS (all P < .05). For these measures, the average 1-year deterioration in patients with baseline BM was 19.4%. CONCLUSION Newly diagnosed advanced NSCLC patients with baseline BM experienced a significantly faster and clinically meaningful deterioration in PRO-based HRQOL compared with those without baseline BM.
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Liu Y, Liu XH, Wang Y, Zhu J, Xin Y, Niu K, Wang S, Cheng Y. A study on different therapies and prognosis-related factors for 101 patients with SCLC and brain metastases. Cancer Biol Ther 2017; 18:670-675. [PMID: 28812423 DOI: 10.1080/15384047.2017.1360450] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
OBJECTIVE There is a need to explore multi-discipline general treatment modes to improve the survival period of patients with SCLC and brain metastases undergoing standard radiotherapy treatment. METHODS A total of 101 patients with SCLC and brain metastases were included into this study. These patients were classified into 4 groups, based on different treatment modes: chemotherapy group, brain radiotherapy group, brain radiotherapy combined with sequential chemotherapy, and chemotherapy combined with sequential brain radiotherapy. Recent and long-term curative effects were compared among the 4 groups. RESULTS A RR of 42.57% was determined for all 4 groups, and median PFS and OS was 11.56 and 17.32 months, respectively. After SCLC with brain metastases manifested in the limited stage, the difference in median survival period was not statistically significant among the 4 treatment groups (P = 0.29). At the extensive stage of SCLC, survival period was superior in the brain radiotherapy combined with sequential chemotherapy group, compared with other groups (P<0.05). Furthermore, median survival period in the brain radiotherapy combined with sequential chemotherapy group was 15.5 ± 1.03 months. This was followed by 12.0 ± 3.06 months in the chemotherapy combined with sequential brain radiotherapy group, 8.0 ± 1.49 months in the chemotherapy group, and 8.0 ± 0.43 months in the brain radiotherapy group. CONCLUSION Combining chemotherapy with brain radiotherapy is a better treatment mode compared with single therapy for treating SCLC with brain metastases. Furthermore, it is recommended for patients in the extensive stage to initially receive brain radiotherapy.
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Affiliation(s)
- Ying Liu
- a Department of Oncology , Jinlin provincial Cancer Hospital , Changchun , China
| | - Xian-Hong Liu
- a Department of Oncology , Jinlin provincial Cancer Hospital , Changchun , China
| | - Ying Wang
- a Department of Oncology , Jinlin provincial Cancer Hospital , Changchun , China
| | - Jing Zhu
- a Department of Oncology , Jinlin provincial Cancer Hospital , Changchun , China
| | - Ying Xin
- a Department of Oncology , Jinlin provincial Cancer Hospital , Changchun , China
| | - Kai Niu
- a Department of Oncology , Jinlin provincial Cancer Hospital , Changchun , China
| | - Sheng Wang
- a Department of Oncology , Jinlin provincial Cancer Hospital , Changchun , China
| | - Ying Cheng
- a Department of Oncology , Jinlin provincial Cancer Hospital , Changchun , China
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Abstract
The incidence of brain tumors in the elderly population has increased over the last few decades. Current treatment includes surgery, radiotherapy and chemotherapy, but the optimal management of older patients with brain tumors remains a matter of debate, since aggressive radiation treatments in this population may be associated with high risks of neurological toxicity and deterioration of quality of life. For such patients, a careful clinical status assessment is mandatory both for clinical decision making and for designing randomized trials to adequately evaluate the optimal combination of radiotherapy and chemotherapy. Several randomized studies have demonstrated the efficacy and safety of chemotherapy for patients with glioblastoma or lymphoma; however, the use of radiotherapy given in association with chemotherapy or as salvage therapy remains an effective treatment option associated with survival benefit. Stereotactic techniques are increasingly used for the treatment of patients with brain metastases and benign tumors, including pituitary adenomas, meningiomas and acoustic neuromas. Although no randomized trials have proven the superiority of SRS over other radiation techniques in older patients with brain metastases or benign brain tumors, data extracted from recent randomized studies and large retrospective series suggest that SRS is an effective approach in such patients associated with survival advantages and toxicity profile similar to those observed in young adults. Future trials need to investigate the optimal radiation techniques and dose/fractionation schedules in older patients with brain tumors with regard to clinical outcomes, neurocognitive function, and quality of life.
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Affiliation(s)
- Giuseppe Minniti
- Department of Neurological Sciences, IRCCS Neuromed, Via Atinense, Pozzilli, (IS), Italy. .,UPMC San Pietro FBF, Radiotherapy Center, Rome, Italy.
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Skeie BS, Eide GE, Flatebø M, Heggdal JI, Larsen E, Bragstad S, Pedersen PH, Enger PØ. Quality of life is maintained using Gamma Knife radiosurgery: a prospective study of a brain metastases patient cohort. J Neurosurg 2017; 126:708-725. [DOI: 10.3171/2015.10.jns15801] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
OBJECTIVE
Gamma Knife radiosurgery (GKRS) is increasingly used in the management of brain metastases (BMs), but few studies have evaluated how GKRS impacts quality of life (QOL). The aim of this study was to monitor QOL as the primary end point following GKRS in a patient cohort with BM.
METHODS
The study included 97 consecutive patients with 1–6 BMs treated with GKRS between May 2010 and September 2011. QOL was assessed at baseline and at 1, 3, 6, 9, and 12 months postoperatively using the Functional Assessment of Cancer Therapy–Brain (FACT-BR) questionnaire with the brain cancer subscale (BRCS) questionnaire. Factors predicting QOL were identified by mixed linear regression analyses. Local control and toxicity were evaluated according to Response Evaluation Criteria in Solid Tumors (RECIST) and the European Organisation for Research and Treatment/Radiation Therapy Oncology Group (EORTC/RTOG) criteria of late effects, respectively.
RESULTS
Compliance was high from baseline (97%) to 12-month follow-up (78%). Mean BRCS scores remained high during follow-up: they improved in 66% of patients and remained unchanged in 6% at 9 months. Local control (p = 0.018), improved symptoms (p = 0.005), and stable extracerebral disease (p = 0.001) correlated with high QOL-BRCS score. High baseline recursive partitioning analysis class predicted improved QOL (p = 0.031), whereas high Karnofsky Performance Scale score (p = 0.017), asymptomatic BMs (p = 0.001), and no cognitive deficits (p = 0.033) or seizures (p = 0.040) predicted high, stable QOL-BRCS during the 12-month follow-up.
CONCLUSIONS
QOL remained stable for up to 12 months following GKRS for the total cohort. High QOL was reported if local control occurred, cerebral symptoms improved/stabilized, or the need for steroids declined, which all reflected successful GKRS. Conversely, low QOL accompanied progression of intra- and extracerebral disease. Based on the study findings, GKRS appears to be a safe and effective treatment option for patients with BMs.
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Affiliation(s)
| | - Geir Egil Eide
- 5Global Public Health and Primary Care, University of Bergen, Norway
- 6Centre for Clinical Research, Haukeland University Hospital; and
| | | | | | | | | | | | - Per Øyvind Enger
- Departments of 1Neurosurgery and
- 3Biomedicine, Oncomatrix Research Lab, and
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Chan V, Sahgal A, Egeto P, Schweizer T, Das S. Incidence of seizure in adult patients with intracranial metastatic disease. J Neurooncol 2016; 131:619-624. [PMID: 27878505 DOI: 10.1007/s11060-016-2335-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2016] [Accepted: 11/12/2016] [Indexed: 12/11/2022]
Abstract
Seizures have considerable impact on a patient's quality of life. While guidelines have been articulated to direct clinicians in their management of patients with IMD who suffer from seizure, there have been few attempts to identify the seizure rate in IMD and to determine which primary cancers may be associated with an increased seizure incidence. To determine the incidence of seizure in patients with IMD. A systematic review on seizure incidence in patients with IMD from the magnetic resonance imaging (MRI) era was performed. Articles published between January 2000 and July 2014 with thirty or more consecutive adult patients were included in this study. Seizure rate was calculated using a pooled data analysis. Differences between observed and expected seizure rates between primary tumour sites were examined using the Chi square statistic and adjusted standardized residuals. The systematic search produced 18 relevant studies, with a total study population of 2012 patients. 14.6% (n = 294) had seizures. There was a significant association between primary tumour site and seizure rates. The seizure rate in patients with primary melanoma tumours was significantly greater than expected (z = 2.7; p = .006). The seizure rate in patients with primary prostate tumours was significantly lower than expected (z = -2.6; p = .008). Patients with intracranial metastasis are at significant risk for developing seizure, though at a significantly lower incidence than was estimated by studies performed during the CT era. Seizure rates appear to be greater in certain primary tumours, such as melanoma.
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Affiliation(s)
- Vivien Chan
- Keenan Research Centre, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1W8, Canada.,University of Toronto, Toronto, ON, Canada
| | - Arjun Sahgal
- Department of Radiation Oncology, Sunnybrook Hospital, Toronto, ON, Canada.,University of Toronto, Toronto, ON, Canada
| | - Peter Egeto
- Keenan Research Centre, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1W8, Canada.,University of Toronto, Toronto, ON, Canada
| | - Tom Schweizer
- Faculty of Medicine, Toronto, ON, Canada.,University of Toronto, Toronto, ON, Canada
| | - Sunit Das
- Keenan Research Centre, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1W8, Canada. .,Division of Neurosurgery, Department of Surgery, Toronto, ON, Canada. .,University of Toronto, Toronto, ON, Canada.
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Rades D, Schild SE. Lung cancer: Best supportive care - a reasonable option for patients with brain metastases? Nat Rev Clin Oncol 2016; 13:722-724. [PMID: 27824047 DOI: 10.1038/nrclinonc.2016.179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Dirk Rades
- Department of Radiation Oncology, University of Lübeck, Ratzeburger Allee 160, 23562 Lübeck, Germany
| | - Steven E Schild
- Department of Radiation Oncology, Mayo Clinic, 13400 East Shea Boulevard, Scottsdale, Arizona 85259, USA
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32
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Teke F, Bucaktepe P, Kıbrıslı E, Demir M, Ibiloglu A, Inal A. Quality of Life, Psychological Burden, and Sleep Quality in Patients With Brain Metastasis Undergoing Whole Brain Radiation Therapy. Clin J Oncol Nurs 2016; 20:AE-2. [DOI: 10.1188/16.cjon.ae-02] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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33
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The impact of brain metastasis on quality of life, resource utilization and survival in patients with non-small-cell lung cancer. Cancer Treat Rev 2016; 45:139-62. [DOI: 10.1016/j.ctrv.2016.03.009] [Citation(s) in RCA: 137] [Impact Index Per Article: 17.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2015] [Revised: 03/08/2016] [Accepted: 03/09/2016] [Indexed: 01/17/2023]
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Pulenzas N, Ray S, Zhang L, McDonald R, Cella D, Rowbottom L, Sahgal A, Soliman H, Tsao M, Danjoux C, Lechner B, Chow E. The Brain Symptom and Impact Questionnaire in brain metastases patients: a prospective long-term follow-up study. CNS Oncol 2015; 5:31-40. [PMID: 26680680 DOI: 10.2217/cns.15.41] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
AIMS To assess the ability of the Brain Metastases Symptom and Impact Questionnaire (BASIQ) in evaluating symptoms and impact on daily life. PATIENTS & METHODS Patients with brain metastases completed BASIQ, Functional Assessment of Cancer Therapy-General, FACT-Brain at baseline and at 1, 2 and 3 months follow-ups. RESULTS Thirty-six patients completed all follow-ups. BASIQ correlated well (r ≥ 0.40) with FACT subscales, except for social/family and emotional wellbeing. Linear regression analysis found no significant changes in quality of life (QOL) over time in both the BASIQ and FACT scales. Therefore, the two questionnaires coincide as both detected nonchanges. CONCLUSION The ability of the BASIQ in evaluating symptoms and impact on over longer assessment periods was supported by the FACT questionnaires.
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Affiliation(s)
- Natalie Pulenzas
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | | | - Liying Zhang
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Rachel McDonald
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - David Cella
- Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA
| | - Leigha Rowbottom
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Arjun Sahgal
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Hany Soliman
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - May Tsao
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Cyril Danjoux
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Breanne Lechner
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Edward Chow
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
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35
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Thavarajah N, Ray S, Bedard G, Zhang L, Cella D, Wong E, Danjoux C, Tsao M, Barnes E, Sahgal A, Soliman H, Pulenzas N, Lechner B, Chow E. Psychometric validation of the Brain Symptom and Impact Questionnaire (BASIQ) version 1.0 to assess quality of life in patients with brain metastases. CNS Oncol 2015; 4:11-23. [PMID: 25586422 DOI: 10.2217/cns.14.49] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVE To test the reliability, clinical and psychometric validity of the Brain Symptom and Impact Questionnaire (BASIQ) in patients with brain metastases. METHODS Brain metastases patients were interviewed using the BASIQ, Functional Assessment of Cancer-Brain (FACT-Br) and FACT-General (FACT-G) at baseline, with a follow-up assessment at 1 month. RESULTS Forty patients had complete one data and the median age was 64 years. Patients with higher KPS, ECOG of 2, primary breast cancer, or >3 brain metastases, scored higher on the symptom scale of the BASIQ. All subscales showed no significant change in patient symptoms from baseline to follow-up. CONCLUSION This study supports that the reliability, clinical and psychometric validity of BASIQ to be used in brain metastases patients.
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Affiliation(s)
- Nemica Thavarajah
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON, M4N3M5 Canada
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Wong E, Tsao M, Zhang L, Danjoux C, Barnes E, Pulenzas N, Vuong S, Chow E. Survival of patients with multiple brain metastases treated with whole-brain radiotherapy. CNS Oncol 2015; 4:213-24. [PMID: 26118428 DOI: 10.2217/cns.15.17] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
AIM To report the survival outcomes of patients with multiple brain metastases treated with whole-brain radiotherapy. PATIENTS & METHODS From 2004 to 2012, patients with brain metastases treated with whole-brain radiotherapy were included. Overall survival (OS) was calculated from the start of radiation treatment. Univariate and multivariate proportional hazard model of OS was conducted. Generalized R(2) statistic (ranged from 0 to 1) was calculated to determine the association with the outcome. RESULTS Nine-hundred-ninety-one patients were included. The actuarial median OS time was 2.7 months (95% CI: 2.5-2.9). Patients of older age (>65 years), lower Karnofsky performance status, not postoperative and patients with gastrointestinal, genitourinary or lung as opposed to breast cancer were more likely to have a shorter survival. CONCLUSION Short median survival of 2.7 months may reflect poorer prognosis of patients referred due to large amount of referrals for radiosurgery. Prognostic factors for survival should be considered at consultation.
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Affiliation(s)
- Erin Wong
- Rapid Response Radiotherapy Program, Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Toronto, ON, Canada
| | - May Tsao
- Rapid Response Radiotherapy Program, Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Toronto, ON, Canada
| | - Liying Zhang
- Rapid Response Radiotherapy Program, Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Toronto, ON, Canada
| | - Cyril Danjoux
- Rapid Response Radiotherapy Program, Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Toronto, ON, Canada
| | - Elizabeth Barnes
- Rapid Response Radiotherapy Program, Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Toronto, ON, Canada
| | - Natalie Pulenzas
- Rapid Response Radiotherapy Program, Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Toronto, ON, Canada
| | - Sherlyn Vuong
- Rapid Response Radiotherapy Program, Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Toronto, ON, Canada
| | - Edward Chow
- Rapid Response Radiotherapy Program, Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Toronto, ON, Canada
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Kimmell KT, LaSota E, Weil RJ, Marko NF. Comparative Effectiveness Analysis of Treatment Options for Single Brain Metastasis. World Neurosurg 2015; 84:1316-32. [PMID: 26100168 DOI: 10.1016/j.wneu.2015.06.021] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2015] [Revised: 06/10/2015] [Accepted: 06/11/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Brain metastases (BMs) occur in up to 30% of patients with cancer. Treatments include surgery, whole-brain radiotherapy (WBRT), and stereotactic radiosurgery (SRS), alone or in combination. Although guidelines exist, data to inform individualized approaches to therapy remain sparse. We sought to compare semiquantitatively the effectiveness of various modalities in the treatment of single brain metastasis. METHODS We performed a comparative effectiveness analysis (CEA) that integrated efficacy, cost, and quality of life (QoL) data for alternate BM treatments. Efficacy data were obtained from a comprehensive review of current literature. Cost estimates were based on publicly available data. QoL data included the Karnofsky Performance Status (KPS) and other questionnaires. Six treatment strategies using combinations of surgery, WBRT, and SRS were compared with decision tree software. RESULTS The clinical efficacy, cost, and QoL effects of each strategy were scored semiquantitatively. We constructed a model to integrate individual preferences regarding the relative importance of efficacy, QoL, and cost to provide personalized rankings of the effectiveness of each strategy. CONCLUSION The choice of strategy must be individualized for patients with a single BM. Our CEA and decision model combines empirical data with patient priorities to produce a ranking of alternate management strategies.
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Affiliation(s)
- Kristopher T Kimmell
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, New York, USA.
| | - Emily LaSota
- Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Robert J Weil
- Department of Neurosurgery, Geisinger Health System, Danville, Pennsylvania, USA
| | - Nicholas F Marko
- Department of Neurosurgery, Geisinger Health System, Danville, Pennsylvania, USA
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Weil RJ, Mavinkurve GG, Chao ST, Vogelbaum MA, Suh JH, Kolar M, Toms SA. Intraoperative radiotherapy to treat newly diagnosed solitary brain metastasis: initial experience and long-term outcomes. J Neurosurg 2015; 122:825-32. [PMID: 25614945 DOI: 10.3171/2014.11.jns1449] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The authors assessed the feasibility of intraoperative radiotherapy (IORT) using a portable radiation source to treat newly diagnosed, surgically resected, solitary brain metastasis (BrM). METHODS In a nonrandomized prospective study, 23 patients with histologically confirmed BrM were treated with an Intrabeam device that delivered 14 Gy to a 2-mm depth to the resection cavity during surgery. RESULTS In a 5-year minimum follow-up period, progression-free survival from the time of surgery with simultaneous IORT averaged (± SD) 22 ± 33 months (range 1-96 months), with survival from the time of BrM treatment with surgery+IORT of 30 ± 32 months (range 1-96 months) and overall survival from the time of first cancer diagnosis of 71 ± 64 months (range 4-197 months). For the Graded Prognostic Assessment (GPA), patients with a score of 1.5-2.0 (n = 12) had an average posttreatment survival of 21 ± 26 months (range 1-96 months), those with a score of 2.5-3.0 (n = 7) had an average posttreatment survival of 52 ± 40 months (range 5-94 months), and those with a score of 3.5-4.0 (n = 4) had an average posttreatment survival of 17 ± 12 months (range 4-28 months). A BrM at the treatment site recurred in 7 patients 9 ± 6 months posttreatment, and 5 patients had new but distant BrM 17 ± 3 months after surgery+IORT. Six patients later received whole-brain radiation therapy, 7 patients received radiosurgery, and 2 patients received both treatments. The median Karnofsky Performance Scale scores before and 1 and 3 months after surgery were 80, 90, and 90, respectively; at the time of this writing, 3 patients remain alive with a CNS progression-free survival of > 90 months without additional BrM treatment. CONCLUSIONS The results of this study demonstrate the feasibility of resection combined with IORT at a dose of 14 Gy to a 2-mm peripheral margin to treat a solitary BrM. Local control, distant control, and long-term survival were comparable to those of other commonly used modalities. Surgery combined with IORT seems to be a potential adjunct to patient treatment for CNS involvement by systemic cancer.
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Affiliation(s)
- Robert J Weil
- The Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center
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Gao Y, Gao F, Ma JL, Zhao DL. Palliative whole-brain radiotherapy and health- related quality of life for patients with brain metastasis in cancer. Neuropsychiatr Dis Treat 2015; 11:2185-90. [PMID: 26346192 PMCID: PMC4552255 DOI: 10.2147/ndt.s87109] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE To assess the use of palliative whole-brain radiotherapy (WBRT) in the treatment of brain metastases (BMs) and to evaluate the health-related quality of life (HRQOL) of these patients. MATERIALS AND METHODS We conducted a retrospective study of 46 patients with BMs who were treated with WBRT at the First Affiliated Hospital of Xi'an Jiaotong University between January 2013 and January 2015. External beam radiotherapy techniques were used to deliver 40 Gy in 20 fractions or 30 Gy in ten fractions with a 10 MV photon beam from a linear accelerator to the whole brain. Data were stored and analyzed using SPSS version 17.0. RESULTS Of the 46 patients, the survival time of patients in our study was 10.8±0.55 months: 11.8±0.46 months in patients with WBRT, 11.75±1.00 in patients with WBRT + chemotherapy, and 3±0.79 months in patients with supportive care, respectively (P<0.01). The HRQOL scores of all the patients were 70±1.16 (before therapy) and 76.83±1.04 (after therapy) (P<0.01). The HRQOL scores of the patients with WBRT were 72.23±0.88 (before therapy) and 78.49±0.87 (after therapy) (P<0.01). There was no central nervous system toxicity; only two (4.3%) patients were found to have BM hemorrhage. Radiation necrosis happened in one patient (2.2%). CONCLUSION Effective treatment options for patients with BMs are important. WBRT was evaluated to ensure survival outcomes and QOL were enhanced after therapy for patients with BMs.
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Affiliation(s)
- Ying Gao
- Department of Radiotherapy Oncology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, People's Republic of China
| | - Fei Gao
- Department of Neurology, First Affiliated Hospital of Xi'an Medical University, Xi'an, People's Republic of China
| | - Jin-Lu Ma
- Department of Radiotherapy Oncology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, People's Republic of China
| | - Dong-Li Zhao
- Department of Radiotherapy Oncology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, People's Republic of China
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Hendriks LEL, Troost EGC, Steward A, Bootsma GP, De Jaeger K, van den Borne BEEM, Dingemans AMC. Patient selection for whole brain radiotherapy (WBRT) in a large lung cancer cohort: Impact of a new Dutch guideline on brain metastases. Acta Oncol 2014; 53:945-51. [PMID: 24754845 DOI: 10.3109/0284186x.2014.906746] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Median survival after diagnosis of brain metastases is, depending on the Recursive Partitioning Analysis (RPA) classes, 7.1 (class I) to 2.3 months (class III). In 2011 the Dutch guideline on brain metastases was revised, advising to withhold whole brain radiotherapy (WBRT) in RPA class III. In this large retrospective study, we evaluated the guideline's use in daily practice. MATERIAL AND METHODS Data of 428 lung cancer patients undergoing WBRT for brain metastases (2004-2012) referred from three Dutch hospitals were retrospectively analyzed. Details on Karnofsky performance score (KPS), age, control of primary tumor, extracranial metastases, histology, and survival after diagnosis of brain metastases were collected. RPA class was determined using the first four items. RESULTS In total 327 patients had non-small cell lung cancer (NSCLC) and 101 small cell lung cancer (SCLC). For NSCLC, 6.1%, 71.9%, and 16.2% were classified as RPA I, II, and III, respectively, and 5.8% could not be classified. For SCLC this was 8.9%, 66.3%, 14.9%, and 9.9%, respectively. Before the revised guideline was implemented, 11.3-21.3% of WBRT patients were annually classified as RPA III. In the year thereafter, this was 13.0% (p = 0.646). Median survival (95% CI) for NSCLC RPA class I, II, and III was 11.4 (9.9-12.9), 4.0 (3.4-4.7), and 1.7 (1.3-2.0) months, respectively. For SCLC this was 7.9 (4.1-11.7), 4.7 (3.3-6.1), and 1.7 (1.5-1.8) months. CONCLUSIONS Although it is advised to withhold WBRT in RPA class III patients, in daily practice 11.3-21.3% of WBRT-treated patients were classified as RPA III. The new guideline did not result in a decrease. Reasons for referral of RPA III patients despite a low KPS were not found. Despite WBRT, survival of RPA III patients remains poor and this poor outcome should be stressed in practice guidelines. Therefore, better awareness amongst physicians would prevent some patients from being treated unnecessarily.
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Affiliation(s)
- Lizza E L Hendriks
- Department of Pulmonary Diseases, GROW - School for Oncology and Developmental Biology, Maastricht University Medical Center , Maastricht , The Netherlands
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Armstrong AE, Gillan E, DiMario FJ. SMART syndrome (stroke-like migraine attacks after radiation therapy) in adult and pediatric patients. J Child Neurol 2014; 29:336-41. [PMID: 23364656 DOI: 10.1177/0883073812474843] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
SMART syndrome (stroke-like migraine attacks after radiation therapy) is a rare condition that involves complex migraines with focal neurologic findings in patients following cranial irradiation for central nervous system malignancies. Little is known about the mechanisms behind the disorder, making successful treatment challenging. We report 2 new cases of SMART syndrome in pediatric patients as well as review all documented cases of the syndrome. Each of our 2 pediatric patients suffered multiple episodes. Attacks were characterized by severe headache, visual disturbance, aphasia, and weakness. Recovery occurred over several days to weeks. The data from all documented reports of SMART syndrome indicate a greater prevalence for male gender. An age-dependent pattern of onset was also observed, with a greater variability of syndrome onset in patients who received cranial irradiation at a younger age. SMART appears to be a reversible, recurrent long-term complication of radiation therapy with possible age- and gender-related influences.
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Affiliation(s)
- Amy E Armstrong
- 1University of Connecticut School of Medicine, Farmington, CT, USA
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Fatigue scores in patients with brain metastases receiving whole brain radiotherapy. Support Care Cancer 2014; 22:1757-63. [DOI: 10.1007/s00520-014-2140-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2013] [Accepted: 01/20/2014] [Indexed: 10/25/2022]
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Psychometric validation of the functional assessment of cancer therapy—brain (FACT-Br) for assessing quality of life in patients with brain metastases. Support Care Cancer 2013; 22:1017-28. [DOI: 10.1007/s00520-013-2060-8] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2013] [Accepted: 11/15/2013] [Indexed: 10/26/2022]
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The Use of Palliative Whole Brain Radiotherapy in the Management of Brain Metastases. Clin Oncol (R Coll Radiol) 2012; 24:e149-58. [PMID: 23063070 DOI: 10.1016/j.clon.2012.08.004] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2011] [Revised: 06/25/2012] [Accepted: 06/26/2012] [Indexed: 11/20/2022]
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Fernandez G, Pocinho R, Travancinha C, Netto E, Roldão M. Quality of life and radiotherapy in brain metastasis patients. Rep Pract Oncol Radiother 2012; 17:281-7. [PMID: 24669309 DOI: 10.1016/j.rpor.2012.08.003] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2011] [Revised: 08/02/2012] [Accepted: 08/10/2012] [Indexed: 11/15/2022] Open
Abstract
AIM The primary objective of this study was to assess whether there was an improvement in QoL for patients with brain metastases after radiotherapy treatments. BACKGROUND Assessment of quality of life (QoL) in brain metastasis patients has become increasingly recognized as an important outcome. MATERIALS AND METHODS Patients treated for brain metastasis in our department during 2010 were included in our prospective study. QoL assessments were conducted at baseline, 1 month, and 3 months after completion of whole-brain radiotherapy (WBRT). Wilcoxon test for multiple comparisons was calculated to detect significant differences in global QoL scores. RESULTS Thirty-nine patients with brain metastases completed the EORTC QLQ-C30/BN-20 questionnaire independently. Median age was 59.9 years (from 37 to 81 years). Our results report differences between the baseline and 3 months in worsening of a global health status (p = 0.034) and cognitive function (p = 0.004), as well as drowsiness (p = 0.001), appetite loss (p = 0.031) and hair loss (p = 0.005). There is a tendency for deterioration of physical function (p = 0.004), communication deficit (p = 0.012), and weakness of legs (p = 0.024), between the baseline and 1 month evaluation. There was no difference in a global cognitive status between different evaluations. Median survival time was 3 months (CI 95% 1.85; 4.15). CONCLUSIONS Our findings indicate a small deterioration for a global QoL status, and large deterioration for cognitive function after radiation treatments, as well as worsening of brain metastasis related symptom items. Further research is necessary to refine treatment selection for patients with brain metastases, since it may at least contribute to the stabilization of their QoL status.
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Affiliation(s)
- Gonçalo Fernandez
- Radiotherapy Department at Instituto Português de Oncologia de Lisboa - Francisco Gentil, Portugal
| | - Rute Pocinho
- Radiotherapy Department at Instituto Português de Oncologia de Lisboa - Francisco Gentil, Portugal
| | - Catarina Travancinha
- Radiotherapy Department at Instituto Português de Oncologia de Lisboa - Francisco Gentil, Portugal
| | - Eduardo Netto
- Radiotherapy Department at Instituto Português de Oncologia de Lisboa - Francisco Gentil, Portugal
| | - Margarida Roldão
- Radiotherapy Department at Instituto Português de Oncologia de Lisboa - Francisco Gentil, Portugal
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Steinmann D, Paelecke-Habermann Y, Geinitz H, Aschoff R, Bayerl A, Bölling T, Bosch E, Bruns F, Eichenseder-Seiss U, Gerstein J, Gharbi N, Hagg J, Hipp M, Kleff I, Müller A, Schäfer C, Schleicher U, Sehlen S, Theodorou M, Wypior HJ, Zehentmayr F, van Oorschot B, Vordermark D. Prospective evaluation of quality of life effects in patients undergoing palliative radiotherapy for brain metastases. BMC Cancer 2012; 12:283. [PMID: 22780988 PMCID: PMC3434068 DOI: 10.1186/1471-2407-12-283] [Citation(s) in RCA: 67] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2012] [Accepted: 06/21/2012] [Indexed: 11/12/2022] Open
Abstract
Background Recently published results of quality of life (QoL) studies indicated different outcomes of palliative radiotherapy for brain metastases. This prospective multi-center QoL study of patients with brain metastases was designed to investigate which QoL domains improve or worsen after palliative radiotherapy and which might provide prognostic information. Methods From 01/2007-01/2009, n=151 patients with previously untreated brain metastases were recruited at 14 centers in Germany and Austria. Most patients (82 %) received whole-brain radiotherapy. QoL was measured with the EORTC-QLQ-C15-PAL and brain module BN20 before the start of radiotherapy and after 3 months. Results At 3 months, 88/142 (62 %) survived. Nine patients were not able to be followed up. 62 patients (70.5 % of 3-month survivors) completed the second set of questionnaires. Three months after the start of radiotherapy QoL deteriorated significantly in the areas of global QoL, physical function, fatigue, nausea, pain, appetite loss, hair loss, drowsiness, motor dysfunction, communication deficit and weakness of legs. Although the use of corticosteroid at 3 months could be reduced compared to pre-treatment (63 % vs. 37 %), the score for headaches remained stable. Initial QoL at the start of treatment was better in those alive than in those deceased at 3 months, significantly for physical function, motor dysfunction and the symptom scales fatigue, pain, appetite loss and weakness of legs. In a multivariate model, lower Karnofsky performance score, higher age and higher pain ratings before radiotherapy were prognostic of 3-month survival. Conclusions Moderate deterioration in several QoL domains was predominantly observed three months after start of palliative radiotherapy for brain metastases. Future studies will need to address the individual subjective benefit or burden from such treatment. Baseline QoL scores before palliative radiotherapy for brain metastases may contain prognostic information.
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Affiliation(s)
- Diana Steinmann
- Radiation Oncology, Medical School Hannover, Hannover, Germany.
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Cahill J, LoBiondo-Wood G, Bergstrom N, Armstrong T. Brain Tumor Symptoms as Antecedents to Uncertainty: An Integrative Review. J Nurs Scholarsh 2012; 44:145-55. [DOI: 10.1111/j.1547-5069.2012.01445.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Chen E, Nguyen J, Zhang L, Zeng L, Holden L, Lauzon N, Bedard G, Koo K, Mingay A, Danjoux C, Sahgal A, Tsao M, Barnes E, Chow E. Quality of life in patients with brain metastases using the EORTC QLQ-BN20 and QLQ-C30. ACTA ACUST UNITED AC 2012. [DOI: 10.1007/s13566-012-0016-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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