Quality of life after palliative radiotherapy in bone metastases: A literature review

Health Utility of Pain Response Versus Nonresponse to Palliative Radiation Therapy for Symptomatic Bone Metastases: Analyses Based on Real-World Data from 26 Centers

Background: Utility values of responders and nonresponders are essential inputs in cost-effectiveness studies of radiation therapy for painful bone metastases but, to our knowledge, they have not been reported separately. Objective: We sought to determine the utility values of responders and nonresponders using data from a prospective observational study on bone metastases. Methods: The original prospective observational study was conducted at 26 centers in Japan. Of 232 enrolled patients, 181 whose pain scores at baseline were ≥2 were analyzed. Health-related quality of life (QOL) was measured using the EuroQol 5-dimensions 5-levels (EQ-5D-5L) instrument at baseline and 2- and 6-month follow-up assessments. At follow-up assessments, patients were categorized as responders or nonresponders. Pain response was assessed using the International Consensus Pain Response Endpoints. Results: Of the 181 patients analyzed, 133 (73%) and 84 (46%) were evaluable at the 2- and 6-month follow-up assessment, respectively. The EQ-5D-5L index score (utility) increased from baseline to the 2- and 6-month follow-up assessments; regarding opioid analgesic use, no clear trend was observed during the same period. The mean utility was significantly higher in responders than in nonresponders at both follow-up times. The mean daily oral morphine equivalent dose was significantly lower in responders than in nonresponders at both follow-up times. Conclusion: We determined utility values for responders and nonresponders. Pain response was associated with better QOL and less opioid use. Our utility values according to response status can be used for model input in future cost-effectiveness studies on radiation therapy for bone metastases.

A Comprehensive Perspective on Educational and Economic Barriers for Utilization of Palliative Radiation Therapy in Hospice: A Narrative Review

Purpose

Despite the agreed-on efficacy and benefits of palliative radiation therapy (PRT) to alleviate end-of-life complications related to cancer progression, PRT remains an underused treatment in the hospice-care setting.3-4,6-7 Common barriers for hospice patient use of PRT include educational and economic limitations. This paper discussed these barriers and ways to eliminate them based on previously published interventions.

Methods and Materials

Literature search on PubMed; 30 articles were selected by the authors. All articles included are published after the year 2000 in peer reviewed journals.

Results

Educational barriers for medical practitioners outside radiation oncology can be addressed by creating formal education programs that reduce knowledge gaps previously identified by survey-based research studies. For radiation oncologists, continued education should focus on increasing competence and comfort with end-of-life conversations and indications for use of single-fraction radiation for patients with advanced cancer. More information on radiation oncology options should be provided to patients. As for economic barriers, rapid-access programs that use advanced level practitioners can increase PRT access by the hospice population. Also, these programs can increase use of single-fraction radiation therapy (SFX RT) in patients with a shorter projected prognosis. SFX RT is beneficial in this setting because it decreases hospice expense and is as efficacious at palliating pain in patients with advanced cancer as multiple-fraction radiation.

Conclusions

The barriers of education and economic limitations can be addressed by: expanding the PRT curriculum for all practicing physicians, improving radiation oncologist palliative care knowledge, increasing PRT resources for patients, increasing number of rapid-access radiation therapy programs, and, when indicated, encouraging use of single-fraction radiation treatment for hospice patients.

Osteolytic Bone Metastasis: Different Radiotherapy Fractionation Schedules Compared Clinically and Radiographically

The purpose of this study is to compare three commonly used radiotherapy fractionation schedules for bone metastasis in terms of clinical and radiological effectiveness. A total of 93 patients with osteolytic bone metastasis were randomized to receive 8 Gyin a single fraction (group A), 20 Gy in 5 fractions (group B) and 30 Gy in 10 fractions (group C). Changes in bone density were measured using the Relative Electron Density (RED) type corrected by Thomas (pe = HU/1.950 + 1.0), where HU is Hounsfield Units. Pain response was assessed according to the Brief Pain Inventory tool. Quality of life was estimated using the EORTC QLQ-C30 and the MD Anderson Symptom (MDAS) tools.After RT, RED, together with the parameters of EORTC QLQ-C30, MDAS and SAT, significantly increased in all groups (p < 0.001).Specifically, the increase of RED was higher in group C compared to group Athree months post-RT (p = 0.014). Group C was also superior to group A in terms of QoL and BPI three months post-treatment. Multifractionated radiotherapy for osteolytic bone metastasis is superior to single fraction radiotherapy in terms of improvement in quality of life and bone remineralization three months post-RT.

Treatment of Pelvic and Spinal Bone Metastases: Radiotherapy and Hyperthermia Alone vs. in Combination

Painful pelvic and spinal bone metastases are a considerable challenge for doctors and patients. Conventional therapies include morphine-equivalent medication (MeM) and local radiotherapy (RT), but these interventions are not always successful. More recently, hyperthermia (HT) has been applied to complement RT and MeM, and this complex approach has shown promising synergistic results. The objective of our study was to present the results of RT combined with a special kind of HT (modulated electrohyperthermia, mEHT), in which some of the thermal effect is contributed by equivalent nonthermal components, drastically reducing the necessary power and energy. This retrospective study included 61 patients divided into three groups with pelvic and spinal bone metastases to compare the effects of RT and mEHT alone and in combination (RT + mEHT). A detailed evaluation of pain intensity, measured by the brief pain inventory score, MeM use, and breakthrough pain episodes, revealed no significant differences between RT and mEHT alone; thus, these individual methods were considered equivalent. However, RT + mEHT yielded significantly better results in terms of the above parameters. Clinically, mEHT has a lower risk of adverse thermal effects, and due to its efficacy, mEHT can be used to treat RT-resistant lesions.

Patient reported outcomes following whole brain radiotherapy in patients with brain metastases in NSIA-LUTH Cancer Center

BACKGROUND

Brain metastases (BM) are a common complication in advanced cancer patients, and extremely challenging to treat. Consequently, whole brain radiotherapy (WBRT) remains the standard palliative intervention for patients with BM. The present study set to evaluate the clinical benefits of WBRT by assessing the quality of life (QoL) in WBRT-treated patients with BM, in Nigeria.

METHODS

This was a prospective, longitudinal, hospital-based single-centre study. Consecutive sampling methodology was used to recruit 52 patients with BM undergoing WBRT. Patients were followed up on days 7, 30, 90 and 180 after WBRT. The EORTC QLQ-C15-PAL and EORTC QLQ-BN20 were employed to report patients' responses. The likert scale responses were linearly converted into 0 - 100 scores, and the descriptive analysis was conducted using IBM SPSS Statistics 29.0, at 95% confidence interval, using the two-tailed t-test for continuous variables or the chi-square test for categorical values. The overall survival was calculated with the Kaplan Maier method and the difference tested with Log-rank method, considering the interval from the baseline until death or end of the study.

RESULTS

The study cohort was predominantly females (82.7%), and accordingly, 65.4% of the respondents had a breast primary tumor. A goodness-of-fit test yielded non-significant Chi square Pearson (p = 0.325) and Deviance (p = 1.000) residuals, indicating the best fit. The median overall survival was 180 days (~ 6 months). A total of 20 patients (38%) that survived up to 180 days reported alleviated symptoms and better functioning. A significant improvement in physical functioning (p < 0.001) and emotional functioning (p = 0.031) was reported at 180 days post WBRT, compared to baseline.

CONCLUSIONS

WBRT is an effective palliative intervention in patients with BM, resulting in improved QoL. More than 50% of patients that survived ~ 3 months reported alleviation of pain, and 38% of patients that survived for ~ 6 months reported a significantly improved functioning. This demonstrated the clinical benefits of WBRT in palliative care and will add to the body of data on the use of WBRT, from Africa.

Management of non-hepatic distant metastases in neuroendocrine neoplasms

Neuroendocrine neoplasms represent an uncommon disease with an increasing incidence. Thanks to improvements in diagnostic and therapeutic methods, metastases previously considered uncommon, such as bone metastases, or even very rare, such as brain, orbital and cardiac metastases, are more frequently found in daily practice. Due to the great heterogeneity of these neoplasms, there is a lack of high-quality evidence on the management of patients with these types of metastases. The aim of this review is to provide the current state of the art, reviewing neuroendocrine neoplasm specific studies and useful information from other tumor types and to propose a treatment recommendation with algorithms to consider in daily clinical practice.

Comparison of pain-relieving effects by number of irradiations, through propensity score matching and the international consensus endpoint

Background

Palliative radiotherapy for bone metastases utilizes various dose fractionation schedules. The pain-relieving effects of a single fraction (SF) and multiple fractions (MF) are largely debated due to the difficulty in matching patients' backgrounds and in assessing the effectiveness of pain relief. This study aimed to compare the pain-relieving effects of SF and MF palliative radiotherapy for bone metastases using propensity score matching and the international consensus endpoint (ICE).

Materials and methods

Our study included 195 patients irradiated for bone metastasis. The primary endpoint was the pain-relieving effects used by ICE. In addition, the evaluation was performed by using responder (complete response/partial response) and non-responder (pain progression/indeterminate response) categorization. The secondary endpoints were the discharge or transfer rate at one month after irradiation and postirradiation pathological fracture rate. Propensity score matching was used to adjust patient's characteristics and reduce selection bias.

Results

After adapting propensity score matching, the total number of patients was 74. There was no significant difference in the pain-relieving effects between SF and MF (p = 0.184). There were no significant differences in them between SF and MF when using responder and non-responder categorization (p = 0.163). Furthermore, there were no differences in the discharge or transfer rates (p = 0.693) and pathological fracture rates (p = 1.00).

Conclusions

The combination of propensity score matching and ICE revealed no significant difference in the pain-relieving effects between SF and MF for bone metastases, thus, SF has no significant disadvantage compared to MF in pain-relieving effects.

The Burden of Metastatic Cancer-Induced Bone Pain: A Narrative Review

Bone pain is one of the most common forms of pain reported by cancer patients with metastatic disease. We conducted a review of oncology literature to further understand the epidemiology of and treatment approaches for metastatic cancer–induced bone pain and the effect of treatment of painful bone metastases on the patient’s quality of life. Two-thirds of patients with advanced, metastatic, or terminal cancer worldwide experience pain. Cancer pain due to bone metastases is the most common form of pain in patients with advanced disease and has been shown to significantly reduce patients’ quality of life. Treatment options for cancer pain due to bone metastases include nonsteroidal anti-inflammatory drugs, palliative radiation, bisphosphonates, denosumab, and opioids. Therapies including palliative radiation and opioids have strong evidence supporting their efficacy treating cancer pain due to bone metastases; other therapies, like bisphosphonates and denosumab, do not. There is sufficient evidence that patients who experience pain relief after radiation therapy have improved quality of life; however, a substantial proportion are nonresponders. For those still requiring pain management, even with available analgesics, many patients are undertreated for cancer pain due to bone metastases, indicating an unmet need. The studies in this review were not designed to determine why cancer pain due to bone metastases was undertreated. Studies specifically addressing cancer pain due to bone metastases, rather than general cancer pain, are limited. Additional research is needed to determine patient preferences and physician attitudes regarding choice of analgesic for moderate to severe cancer pain due to bone metastases.

Metastatic bone cancer: Consideration for optimal dose fractionation in radiation therapy

The bones are one of the most common sites for metastatic cancer spread. Unfortunately, there is no current known cure for many people affected by bone metastasis. Therefore, the treatment intent for radiotherapy remains a palliative objective, whereby treatments are meant to provide pain relief and alleviate symptoms. However, some debate has arisen in recent decades regarding the most appropriate dose prescription pertaining to dose protraction and fractionation. By delivering a larger dose in fewer fractions, patients can spend less time at the hospital and more time with loved ones. Additionally, many dose prescriptions were prioritized to be shortened during the COVID-19 pandemic, which may offer retrospective data on the treatment outcomes from providing shortened courses of radiotherapy.

Palliative Radiation for Cancer Pain Management

Bone metastases are the most common cause of cancer-related pain. Radiation therapy (RT) is a very common and effective treatment to relieve pain. Conventionally fractionated RT typically consists of the following regimens: 8 Gy in a single treatment, 20 Gy in five fractions, 24 Gy in six fractions, or 30 Gy in ten fractions. All treatment regimens have similar rates of pain relief (range 50-80%), with single-fraction treatment often requiring retreatment. While many painful bony metastases can be managed with RT alone, some may be more complex, often requiring multidisciplinary management, including the need for surgical stabilization or augmentation prior to RT. There are multiple assessment tools including the neurologic, oncologic, mechanical, and systemic (NOMS) decision framework, which allows clinicians to assess the proper course of treatment for these patients. For patients with good prognosis, oligometastatic disease, or those presenting with more radioresistant tumors, stereotactic body radiotherapy (SBRT) may be another option, which offers ablative doses of radiation delivered over several treatments. This chapter reviews the fundamentals of RT for palliation.

Feasibility of palliating recurrent gynecological tumors with MRGHIFU: comparison of symptom, quality-of-life, and imaging response in intra and extra-pelvic disease

OBJECTIVE

To document longitudinal symptom, quality-of-life and imaging response in patients with recurrent gynecological tumors treated with magnetic resonance guided high intensity focused ultrasound (MRgHIFU), and compare changes in patients with intra- versus extra-pelvic lesions.

METHODS

Eleven symptomatic patients with painful recurrent gynecological tumors were treated with MRgHIFU (Profound Sonalleve) in a prospective single center study (NCT02714621). Pain scores, analgesic intake and quality-of-life metrics, whole tumor volume, and perfused tumor volume from Gadolinium-enhanced T1W imaging documented before and up to 90 days after treatment were compared between patients with intra- and extra-pelvic tumors.

RESULTS

Two of five patients with intra-pelvic and three of six patients with extra-pelvic tumors were classified as responders (>2 point reduction in NRS pain score without analgesia increase or a > 25% reduction in analgesic use). Cohort reductions in worst pain scores were not significant for either group. Emotional functioning for the whole cohort improved, although physical functioning did not. Ablative thermal temperatures were achieved in three patients with extra-pelvic tumors, but in none whose tumors were intra-pelvic. Pain response did not correlate with thermal dose. Tumor volume increased by 18% immediately post-treatment in the extra-pelvic but not in the intra-pelvic group. Ratio of perfused to whole lesion volume decreased by >20% by day 30 in extra-pelvic, but not intra-pelvic tumors although at day 30 both extra-pelvic and intra-pelvic tumors increased in volume.

CONCLUSION

MRgHIFU treatments can be delivered safely to patients with recurrent gynecological tumors. Extra-pelvic tumors responded better than intra-pelvic tumors and showed immediate swelling and reduction in perfused volume by day 30.

Symptom Burden in Patients With Reduced Performance Status at the Start of Palliative Radiotherapy

BACKGROUND/AIM

Previous research has suggested that palliative radiotherapy is a useful measure, unless short survival reduces the time spent without active treatment, and in the case of a low likelihood of experiencing a net benefit in quality of life. Patients with reduced performance status (PS) may be especially at risk of futile treatment, despite having a relatively high symptom burden and thus a potential benefit. Therefore, we analyzed the symptom burden of patients with Eastern Cooperative Oncology Group (ECOG) PS 3-4 in our center.

PATIENTS AND METHODS

A retrospective study was performed of 102 consecutive patients who received palliative radiotherapy for different indications. The Edmonton Symptom Assessment Scale (ESAS) was employed to assess the pre-radiotherapy symptoms.

RESULTS

When applying the lowest threshold (ESAS ≥1), up to 97% of patients with PS 3-4 reported symptoms, such as fatigue and dry mouth. When focusing on moderate/severe symptoms (ESAS ≥4), still up to 77% of patients with PS 3-4 reported such a burden. The largest differences between patients with PS 3-4 and those with 0-1 were seen with regard to nausea, fatigue, dry mouth and reduced appetite. The median survival of patients with PS 3-4 was 2 months.

CONCLUSION

Given that many of the symptoms reported by patients with PS 3-4 tend to worsen temporarily after radiotherapy, patients with short survival may not experience a net benefit during the few weeks before death. However, if other symptoms such as dyspnea or pain prevail, short-course radiotherapy may result in worthwhile palliation and should, therefore, be considered on a case-by-case basis and after estimation of the remaining lifespan.

Index and Nonindex Pain Endpoints in Radiation Therapy for Painful Tumors: A Secondary Analysis of a Prospective Observational Study

Purpose

Improving pain interference in daily activities, rather than mere pain reduction, is a desirable endpoint for palliative radiation therapy. The association between pain response and pain interference has been studied almost exclusively in patients with painful bone metastases (PBMs), whereas nonindex pain has scarcely been explored in palliative radiation therapy. We investigated whether index and nonindex pain endpoints are associated with pain interference changes in patients with both PBMs and painful non-bone-metastasis tumors (PNTs).

Methods and Materials

Brief pain inventory data collected at baseline and at 2 months post-treatment were used to calculate differences in pain interference scores. Pain response in terms of the index pain was assessed using the international consensus endpoint. Patients were diagnosed with predominance of other pain (POP) if nonindex pain of malignant or unknown origin was present and had a greater pain score than the index pain.

Results

Of 302 patients, 127 (42%) had PBMs and 175 (58%) had PNTs. The median pain interference score, which is based on the mean of the 7 subscale items, decreased to a greater extent among responders than among nonresponders (PBM group: –3.43 vs –0.57 [P = .005]; PNT group: –2.43 vs –0.29 [P < .001]). Moreover, patients without POP experienced a greater reduction in their median pain interference score than did those with POP (PBM group: –2.71 vs +0.43 [P = .004]; PNT group: –2.00 vs +1.57 [P = .007]). The Jonckheere-Terpstra test showed a significant trend across 4 pain response categories in patients with PBMs and those with PNTs (P < .001 for both).

Conclusions

The index and nonindex pain endpoints were positively and negatively associated with improvement in pain interference, respectively. There was no apparent difference between patients with PBMs and PNTs in terms of the associations of these endpoints with pain interference.

Inconsistencies in assessment of pain endpoints in radiotherapy for painful tumors: Analysis of original articles in the Green and Red Journals

•

The frequency of use of the ICT has risen in research for PBMs.

•

The frequency of the ICT use has been considerably limited for PNTs.

•

None of the journal articles had investigated non-index pain.

Background and purpose

Consistent assessment of the pain response is essential for adequately comparing treatment efficacy between studies. We studied the assessment of pain endpoints in radiotherapy for painful bone metastases (PBMs) and painful non-bone-metastasis tumors (PNTs).

Material and methods

We performed a literature search in the Green (Radiotherapy and Oncology) and Red (International Journal of Radiation Oncology * Biology * Physics) Journals for full-length original articles published between 2009 and 2018. We only included articles that assessed palliation of tumor-related pain after radiotherapy. The data obtained included the definitions of pain response and assessment of non-index pain (pain other than that related to the irradiated tumors).

Results

Among the 1812 articles identified using the journals’ search function, 60 were included in the analysis. Thirty percent of the PBM articles and approximately half of the PNT articles did not report on analgesic use. Among the prospective studies, 68% of the articles on PBMs and 10% of the articles on PNTs used the International Consensus Endpoint. The PBM articles published in 2014–2018 utilized the International Consensus Endpoint more frequently than those published in 2009–2013 (p = 0.049). No articles reported information on non-index pain.

Conclusions

After the initial publication of the International Consensus Endpoint, the frequency of its use appears to have risen in PBM research; however, its use in PNT studies has been considerably limited. The International Consensus Endpoint should be consistently utilized in future studies on radiotherapy for painful tumors. Since none of the journal articles had investigated non-index pain, this issue may also needs to be addressed.

Medical Treatment of Advanced Pancreatic Neuroendocrine Neoplasms

Pancreatic neuroendocrine neoplasms (panNENs) are relatively rare but their incidence has increased almost sevenfold over the last four decades. Neuroendocrine neoplasms are classified according to their histologic differentiation and their grade. Their grade is based on their Ki-67 proliferation index and mitotic index. Their prognosis is highly variable according to these elements and treatments also vary according to their classification. Surgery is the only curative treatment for localized and advanced panNENs and offers a better prognosis than non-surgical treatments. In the case of an advanced panNEN without the possibility of resection and/or ablation, medical treatment remains the cornerstone for improving survival and preserving quality-of-life. PanNENs are considered as chemosensitive tumors, unlike midgut neuroendocrine tumors. Thus, panNENs can be treated with chemotherapy, but targeted therapies and somatostatin analogs are also treatment options. The scarcity and heterogeneity of NENs make their management difficult. The present review aims to clarify the medical treatments currently available for advanced panNENs, based on their characteristics, and to propose a treatment algorithm.

Role of Oxycodone Hydrochloride in Treating Radiotherapy-Related Pain

Radiotherapy is commonly used to treat cancer patients. Besides the curable effect, radiotherapy also could relieve the pain of cancer patients. However, cancer pain is gradually alleviated about two weeks after radiotherapy. In addition, cancer patients who receive radiotherapy may also suffer from pain flare or radiotherapy-induced side effects such as radiation esophagitis, enteritis, and mucositis. Pain control is reported to be inadequate during the whole course of radiotherapy (before, during, and after radiotherapy), and quality of life is seriously affected. Hence, radiotherapy is suggested to be combined with analgesic drugs in clinical guidelines. Previous studies have shown that radiotherapy combined with oxycodone hydrochloride can effectively alleviate cancer pain. In this review, we firstly presented the necessity of analgesia during the whole course of radiotherapy. We also sketched the role of oxycodone hydrochloride in radiotherapy of bone metastases and radiotherapy-induced oral mucositis. Finally, we concluded that oxycodone hydrochloride shows good efficacy and tolerance and could be used for pain management before, during, and after radiotherapy.

Identification of Areas for Improvement in the Management of Bone Metastases in Patients with Neuroendocrine Neoplasms

BACKGROUND

There is no global consensus on the optimal management of bone metastases (BMs) in neuroendocrine neoplasms (NENs).

OBJECTIVES

To review current management and outcomes of patients with BMs in NENs, in order to identify areas for improvement.

METHODS

A retrospective study of all patients with NENs, except Grade 3 lung NENs (April 2002 to March 2018) was conducted. Baseline characteristics, nature of BMs, treatment received and overall survival (OS) were evaluated. Statistical analyses were performed using SPSS version 23.0/STATA v12.

RESULTS

Of 1,212 patients, 85 (7%) had BMs; median age 58 years. The majority had a gastro-entero-pancreatic primary (49%, n = 42) followed by lung (25%, n = 21), unknown primary (20%, n = 17), and "others" (6%, n = 5). Two-thirds (n = 57) had G1-2 neuroendocrine tumours, and 41% (n = 35) had functional tumours. Overall, 28% (n = 24) presented with synchronous BMs at first NEN diagnosis, and 55% (n = 47) developed BMs at the same time as other distant metastases. For the subpopulation of patients in whom BMs developed metachronously to other distant metastases (45%, n = 38), median time to development of BMs was 14.0 months. BMs were "widespread" in 61% (n = 52). Although only 22% (n = 19) reported symptoms at initial diagnosis of BMs, most (78%) developed symptoms at some time during the follow-up period (pain/hypercalcaemia 64%, skeletal-related events 20%). BMs were mainly managed with analgesia (44%, n = 37). Radiotherapy and bisphosphonates were used in 34% (n = 29) and 22% (n = 19) respectively. Surgery was rarely performed (2%, n = 2). Median OS from identification of BMs was 31.0, and 18.9 months from development of BMs-related symptoms.

CONCLUSIONS

In this cohort study, most patients with BMs developed symptoms. The utility of radiotherapy and/or bisphosphonates should be prospectively and systematically explored further for its potential impact on patients' quality of life and survival outcomes.

BOMET-QoL-10 questionnaire for breast cancer patients with bone metastasis: the prospective MABOMET GEICAM study

Background

Bone metastasis (BM) is the most common site of disease in metastatic breast cancer (MBC) patients. BM impacts health-related quality of life (HRQoL). We tested prospectively the psychometric properties of the Bone Metastasis Quality of Life (BOMET-QoL-10) measure on MBC patients with BM.

Methods

Patients completed the BOMET-QoL-10 questionnaire, the Visual Analogue Scale (VAS) for pain, and a self-perceived health status item at baseline and at follow-up visits. We performed psychometric tests and calculated the effect size of specific BM treatment on patients´ HRQoL.

Results

Almost 70% of the 172 patients reported symptoms, 23.3% experienced irruptive pain, and over half were receiving chemotherapy. BOMET-QoL-10 proved to be a quick assessment tool performing well in readability and completion time (about 10 min) with 0–1.2% of missing/invalid data. Although BOMET-QoL-10 scores remained fairly stable during study visits, differences were observed for patient subgroups (e.g., with or without skeletal-related events or adverse effects). Scores were significantly correlated with physician-reported patient status, patient-reported pain, symptoms, and perceived health status. BOMET-QoL-10 scores also varied prospectively according to changes in pain intensity.

Conclusions

BOMET-QoL-10 performed well as a brief, easy-to-administer, useful, and sensitive HRQoL measure for potential use for clinical practice with MBC patients.

Trial registration

NCT03847220. Retrospectively registered on clinicaltrials.gov (February the 20th 2019).

Characterizing Palliative Radiotherapy Education in Hospice and Palliative Medicine Fellowship: A Survey of Fellowship Program Directors

Background: Educational deficiencies among hospice and palliative medicine (HPM) physicians contribute to suboptimal utilization of palliative radiotherapy (PRT) for patients with advanced cancer. Objective: To survey HPM fellowship program directors regarding the need for PRT education in HPM fellowship. Design: We conducted a cross-sectional survey of HPM fellowship program directors in June 2018. We used a 5-point Likert-type scale to assess agreement with statements related to PRT education. Setting/Subjects: Program directors for all United States Accreditation Council for Graduate Medical Education-accredited HPM fellowship programs with at least one enrolled fellow at the time of survey distribution were included. Results: Eighty-one of 120 eligible program directors completed the survey (68% response rate). Nearly all of the respondents agreed that HPM physicians should possess a working knowledge of PRT and that the principles of PRT should be formally taught in HPM fellowship. Thirty percent of HPM fellowship programs, however, lacked a PRT curriculum and only 14% of programs provided more than two hours of PRT education. Limited didactic time, lack of interest among fellows, and lack of collaboration with radiation oncologists were not perceived to be significant barriers to incorporating PRT education into HPM fellowship. More than 75% of program directors indicated that they would consider implementing a PRT curriculum designed specifically for HPM physicians if one were available. Conclusion: There is a need for PRT education in HPM fellowship. This need may be best addressed by developing a widely accessible PRT curriculum designed to meet the needs of HPM physicians.

Palliative Radiotherapy Education for Hospice and Palliative Medicine Fellows: A National Needs Assessment

Background: Insufficient knowledge of palliative radiotherapy (PRT) among hospice and palliative medicine (HPM) physicians is thought to be a barrier to the provision of high-quality palliative care. Objective: To assess the need for PRT education in HPM fellowship. Design: A cross-sectional survey of HPM fellows was conducted in June 2018. Setting/Subjects: The survey was distributed to accredited HPM fellowship programs in the United States for distribution to enrolled fellows; 114 fellows responded to the survey. Results: Nearly all respondents agreed that the principles of PRT should be taught in HPM fellowship, yet 51% had received no PRT education and 35% had received only one or two hours. Only 25% of respondents rated their working knowledge of PRT as sufficient, 40% felt confident in identifying radiation oncology emergencies or managing radiotherapy side effects, and 52% felt confident in assessing which patients to refer for radiotherapy. More than 75% agreed that were they more knowledgeable about PRT, they would be more likely to consider referral to radiation oncology, to collaborate with radiation oncologists, and to advocate for a short course of treatment based on a patient's prognosis or goals or care. Fellows who received PRT education in fellowship had significantly greater knowledge of and more favorable attitudes toward the use of radiotherapy. This difference was the greatest among fellows who had received at least five hours of PRT education. Conclusion: There is a need for PRT education in HPM fellowship. Efforts to address this need may lead to more appropriate utilization of PRT for patients with advanced cancer.

Evaluating the effectiveness of combined radiotherapy and hyperthermia for the treatment response of patients with painful bony metastases: A phase 2 clinical trial

INTRODUCTION

Since the survival time of patients with bony metastases has noticeably improved in recent years, these patients are at high risk of complications associated with this metastasis. Hence, the appropriate choice of treatment modality or combination of therapeutic approaches can lead to increasing bone pain relief, improving quality of life, etc. This study is aimed to evaluate the effectiveness of combined radiotherapy and hyperthermia for the treatment response of patients with painful bony metastases.

PATIENTS AND METHODS

In a single-arm clinical trial, 23 eligible patients (14 female and 9 male) with the mean age of 67 years old and suffering from bony metastases were enrolled in the study. Two hours after radiotherapy, the patients underwent hyperthermia for 1 h in the supine position. All the patients completed the brief pain inventory (BPI) assessment tool and quality of life questionnaire (QLQ-C30) from the European Organization for Research and Treatment of Cancer (EORTC) at the baseline, end of the treatment and 1, 2 and 3 months thereafter. The response to the treatment was assessed as the zero score (complete response) or two or more than two-point drop of the worst pain within the preceding 24 h (partial response) during the 3-month posttreatment.

RESULTS

All the pain intensity and interference scores, except the pain interference with the enjoyment of life score, significantly decreased. A total of 18 out of 23 patients (78%) achieved complete or partial response. The number of patients using pain relief medications decreased from 74% (n=17) at the baseline to 48% (n=11) 3 months later. Moreover, except for nausea and vomiting, appetite loss, diarrhea and financial impact problems, the patients' quality of life improved significantly in all the functional scales and symptoms within 3 months.

CONCLUSION

This study showed that using hyperthermia in combination with radiotherapy significantly ameliorated bone pain among the patients suffering from cancer with painful bony metastases.

Palliative care in gynecologic oncology

PURPOSE OF REVIEW

Patients with gynecologic malignancies face many difficult issues in the course of their diseases, ranging from physical symptoms to advance care planning in light of a poor prognosis. This review examines the evidence supporting integration of palliative care early in the course of disease and symptom management, and provides a framework for difficult conversations.

RECENT FINDINGS

Palliative care has been demonstrated to improve quality of life and promote survival if integrated early in the course of disease. An evidence-based approach should guide symptom management, such as pain and nausea. Advance care planning and goals of care discussions are enhanced by a framework guiding discussion and the incorporation of empathetic responses.

SUMMARY

Palliative care is a diverse multidisciplinary field that can provide significant benefit for patients with gynecologic malignancies.

Hypofractionated radiotherapy for complicated bone metastases in patients with poor performance status: a phase II international trial

Purpose:

To evaluate the efficacy and safety of hypofractionated radiotherapy (16 Gy in 2 fractions, 1 week apart) in patients with complicated bone metastases and poor performance status.

Methods:

A prospective single-arm phase II clinical trial was conducted from July 2014 to May 2016. The primary endpoint was pain response as defined in the International Consensus on Palliative Radiotherapy Endpoints. Secondary endpoints included quality of life as measured by quality of life questionnaire (QLQ) PAL-15 and QLQ-BM22 European Organisation for Research and Treatment of Cancer guidelines, pain flare, adverse events, re-irradiation, and skeletal complications.

Results:

Fifty patients were enrolled. There were 23 men with a median age of 58 years (range 26-86). Of the 50 patients, 38 had an extraosseous soft tissue component, 18 needed postsurgical radiation, 3 had neuropathic pain, and 3 had an impending fracture in a weight-bearing bone. At 2 months, 33 patients were alive (66%). Four (12.5%) had a complete response and 12 (37.5%) had a partial response. A statistically significant improvement was seen in the functional interference (p = 0.01) and psychosocial aspects (p = 0.03) of the BM22. No patient had spinal cord compression. One patient required surgery for pathologic fracture, and another re-irradiation.

Conclusions:

Hypofractionated radiotherapy (16 Gy in 2 fractions of 8 Gy 1 week apart) achieved satisfactory pain relief and safety results in patients with complicated bone metastases and poor performance status.

Predictors of Pain Palliation After Radiation Therapy for Painful Tumors: A Prospective Observational Study

PURPOSE

Although radiation therapy (RT) is an important part of treatment for cancer pain, prediction of the patient's pain response remains difficult. We evaluated the characteristics of patients, their tumors, and their pain to identify the predictors of pain palliation after RT for painful tumors.

METHODS

Our 3-center prospective observational study included patients scheduled for palliative or curative RT for painful tumors. Brief Pain Inventory data were collected at the start of RT and 1, 2, and 3 months thereafter. The pain response was assessed using the International Consensus Endpoint. The Mann-Whitney U-test was used to compare responders and nonresponders based on changes in the BPI scores. Predictors of the pain response were evaluated using the Fine-Gray model, in which death without a pain response was recorded as a competing risk. The independent variables were 11 a priori selected potential predictors with clinical relevance.

RESULTS

Of 302 analyzable patients, 262 (87%) had solid and 40 (13%) had hematologic tumors. The median total radiation dose was 30 Gy (range, 6-70.4 Gy). The pain response rate was 52% for 264 (87%) evaluable patients at 1-, 57% for 228 (75%) such patients at 2-, and 58% for 182 (60%) evaluable patients at 3-month follow-up. At 2-month follow-up, responders experienced a greater decrease in all 7 pain interference subscales of the Brief Pain Inventory compared to nonresponders. Multivariable analysis demonstrated that hematologic tumors (hazard ratio [HR], 1.85; 95% confidence interval [CI], 1.15-2.98), a neuropathic component of the index pain (HR, 1.50; 95% CI, 1.05-2.14), and opioid analgesic use before RT (HR, 0.65; 95% CI, 0.47-0.91) were independent significant predictors of pain response.

CONCLUSIONS

Patients with hematologic tumors, a neuropathic component of the index pain, and no treatment with opioid analgesics before RT were more likely to experience pain palliation after RT.

Evaluation of Quality of Life Outcomes Following Palliative Treatment of Bone Metastases with Magnetic Resonance-guided High Intensity Focused Ultrasound: An International Multicentre Study

AIMS

To determine quality of life (QoL) outcomes after palliation of pain from bone metastases using magnetic resonance-guided high intensity focused ultrasound (MR-guided HIFU), measured using the European Organization for Research and Treatment of Cancer (EORTC) QLQ-C15-PAL and the QLQ-BM22 questionnaires.

MATERIALS AND METHODS

Twenty patients undergoing MR-guided HIFU in an international multicentre trial self-completed the QLQ-C15-PAL and QLQ-BM22 questionnaires before and on days 7, 14, 30, 60 and 90 post-treatment. Descriptive statistics were used to represent changes in symptom and functional scales over time and to determine their clinical significance. QoL changes were compared in pain responders and non-responders (who were classified according to change in worst pain score and analgesic intake, between baseline and day 30).

RESULTS

Eighteen patients had analysable QoL data. Clinically significant improvements were seen in the QoL scales of physical functioning, fatigue, appetite loss, nausea and vomiting, constipation and pain in the 53% of patients who were classified as responders at day 30. No significant changes were seen in the 47% of patients who were non-responders at this time point.

CONCLUSION

Local treatment of pain from bone metastases with MR-guided HIFU, even in the presence of disseminated malignancy, has a substantial positive effect on physical functioning, and improves other symptomatic QoL measures. This indicated a greater response to treatment over and above pain control alone. MR-guided HIFU is non-invasive and should be considered for patients with localised metastatic bone pain and poor QoL.

Update of the systematic review of palliative radiation therapy fractionation for bone metastases

PURPOSE

Radiation therapy is an effective modality for pain management of symptomatic bone metastases. We update the previous meta-analyses of randomized trials comparing single fraction to multiple fractions of radiation therapy in patients with uncomplicated bone metastases.

METHODS

A literature search was conducted in Ovid Medline, Embase, and Cochrane Central Register. Ten new randomized trials were identified since 2010, five with adequate and appropriate data for inclusion, resulting in a total of 29 trials that were analyzed. Forest plots based on each study's odds ratios were computed using a random effects model and the Mantel-Haenszel statistic.

RESULTS

In intention-to-treat analysis, the overall response rate was similar in patients for single fraction treatments (61%; 1867/3059) and those for multiple fraction treatments (62%; 1890/3040). Similarly, complete response rates were nearly identical in both groups (23% vs 24%, respectively). Re-treatment was significantly more frequent in the single fraction treatment arm, with 20% receiving additional treatment to the same site versus 8% in the multiple fraction treatment arm (p < 0.01). No significant difference was seen in the risk of pathological fracture at the treatment site, rate of spinal cord compression at the index site, or in the rate of acute toxicity.

CONCLUSION

Single fraction and multiple fraction radiation treatment regimens continue to demonstrate similar outcomes in pain control and toxicities, but re-treatment is more common for single fraction treatment patients.

Solitary breast cancer metastasis to pelvic bone treated with a unique method of surgery combined with local doxorubicin administration

Treatment of bone metastasis is a major challenge for current and future orthopedic and oncology specialists. For the treatment of single metastases, there is a continuing search for effective local treatments that do not affect the whole patient. The current report describes the case of single breast cancer metastasis to the pelvic bone in a 50-year-old woman treated surgically by bone osteotomy combined with local doxorubicin application. The presence of cancer cells was confirmed by histopathological examination. After 6 months, the same defect was operated on again and a successful therapeutic result was confirmed by negative tumor pathology tests. The bone defect caused by osteotomy was reconstructed with allogenic bone grafts that healed completely over 14 months. To the best of our knowledge, this report is the first to combine the removal bone metastasis with direct local cytostatic drug administration without the use of a specific carrier, followed by successful bone reconstruction 6 months later using bone allografts. Thus, single bone metastasis may be successfully treated with resection and local cytostatic administration, enabling bone reconstruction in the postoperative period. The potential benefits of such treatments must be evaluated by considering the potential risks involved, including necrosis of surrounding soft tissues and general reactions to the chemotherapy. No data has been available until now regarding the risk of cancer disease generalization being influenced by such treatments, but patient quality of life can be improved significantly by the successful removal of a solitary bone metastasis. The present case report supports the continuation of research on improving local cytostatic drug administration during the treatment of bone metastasis.

Targeted α Therapies for the Treatment of Bone Metastases

The skeleton is the target tissue for many types of tumors, and, recently, the survival of patients with prostate cancer metastasis has been increased using α-emitting drugs known as targeted α therapies. The use of α-radiopharmaceuticals in medicine was hypothesized at the beginning of the nineteenth century after the observation that α-radionuclides were associated with high cell-killing energy and low tissue penetration in healthy tissues. In the prostate cancer (PC) scenario, current research suggests that this class of radiopharmaceuticals has limited toxicity, and that the mechanism of action does not overlap with pre-existing drugs, allowing us to extend therapeutic armaments and address medical oncology towards personalized and precision medicine. Ongoing studies may extend these benefits also to bone metastases deriving from other neoplasms. The aim of this review is to summarize the current research on targeted α therapies and try to identify the right patient to be treated in the right time in order to integrate in these medications in the every-day clinical practice.

Screening for psychological distress before radiotherapy for painful bone metastases may be useful to identify patients with high levels of distress

BACKGROUND

Psychological distress (PD) has a major impact on quality of life. We studied the incidence of PD before and after radiotherapy for painful bone metastases. Furthermore, we aimed to identify factors predictive for PD.

METHODS

Between 1996 and 1998, the Dutch Bone Metastasis Study included 1157 patients with painful bone metastases. Patients were randomized between two fractionation schedules. The study showed a pain response of 74% in both groups. Patients filled out weekly questionnaires for 13 weeks, then monthly for two years. The questionnaires included a subscale for PD on the Rotterdam Symptom Checklist. We used generalized estimating equations and multivariable logistic regression analyses.

RESULTS

At baseline, 290 patients (27%) had a high level of PD. For the entire group, the level of PD remained constant over time. The majority of patients with a low level of PD at baseline remained at a low level during follow-up. In patients with a high level of PD at baseline, the mean level of PD decreased after treatment and stabilized around the cutoff level. Female patients, higher age, worse performance, lower pain score and worse self-reported QoL were associated with an increased chance of PD, although the model showed moderate discriminative power.

CONCLUSIONS

A substantial proportion of patients had a high level of PD before and after radiotherapy for painful bone metastases. Most patients who reported high levels of PD when referred for palliative radiotherapy remained at high levels thereafter. Therefore, screening of PD prior to treatment seems appropriate, in order to select patients requiring intervention.

A Pilot Study in the Use of Activity Trackers for Assessing Response to Palliative Radiotherapy

Purpose Radiation therapy (RT) has been a frequently used treatment for painful bone metastasis. The aim of this study was to determine the feasibility of using activity trackers (AT) to assess the patient prognosis and the effects of palliative RT. Methods and materials Twelve patients planned to receive palliative RT for axial metastases and were prospectively recruited to participate in this pilot clinical trial. The patients were eligible if there was no intent to change the analgesic medications prior to or within seven days of palliative RT. All the patients were lent a Misfit FlashTM activity tracker (Misfit, Burlingame, California, United States of America) and were asked to wear it from the time of baseline assessment prior to RT until seven days after RT. The patients completed the European Organisation for Research and Treatment of Cancer quality of life (QOL) questionnaire (EORTC-QLQ C30) and the Short Form Brief Pain Inventory (SF-BPI) before the treatment and at days seven, 30 and 90 after completion of the RT. The patients' Karnofsky Performance Status (KPS) was assessed at each visit. The patients' overall survival at the end of the RT was recorded. Average daily steps before and after RT were compared using paired Wilcoxon signed-rank test. The patients' overall survival was estimated using the Kaplan-Meier curve and analyzed using the Log-Rank test. Results The median age of the patients was 62 years (range: 40-79 years). Of the 12 patients, there were five prostate, three breasts, three lungs, and one colon cancer-related patients. Six patients received 20 Gray (Gy) in five fractions and six received 8 Gy in one fraction. By day seven, post-RT, there was a 30% (p <0.02) reduction in the patients' daily activity level. There was no correlation between improvements in the QOL or with the level of pain and with the number of daily steps. While baseline KPS was not prognostic of the patient survival, the patients who on average took more than 7800 steps per day prior to RT lived significantly (p=0.034) longer than those who were less active. Conclusions The baseline activity level is associated with the patient prognosis. A significant decline in the physical activity was observed at one week after palliative RT. The use of activity trackers was to prognosticate and to monitor the patients' response to the palliative RT and should be evaluated further.

Predictors of care for patients with cancer of unknown primary site in three Australian hospitals

AIM

Cancer of unknown primary site (CUP) is a medically challenging malignancy with a poor prognosis. We describe an incident tertiary CUP patient cohort and identify factors predictive of specific types of health care.

METHODS

We reviewed the medical records of 217 patients diagnosed with CUP (2006-2011) in three public hospitals in New South Wales, Australia. We systematically abstracted data and performed multivariable logistic regression to identify factors predictive of tumor biopsy, surgery, chemotherapy, radiotherapy and palliative care.

RESULTS

The median age at CUP diagnosis was 75 years (range 23-98) and 52% were male. The most common mode of presentation was emergency department admission (57%). Serum tumor markers were performed in 42%, fine needle aspiration alone in 15% and core biopsy in 52%. Younger age, health service referral, oncologist review and a family history of cancer predicted receipt of a biopsy (77%). Cancer-related surgery (17%) was more likely in younger patients, those presenting with pain, and those with single lymph node metastases. Younger age and good performance score predicted receipt of chemotherapy (22%). The location of metastases predicted receipt of radiotherapy (28%). Older age, emergency presentation, poor performance score and no oncology review predicted receipt of palliative care only (52%); 77% were referred for palliative care during hospitalization.

CONCLUSION

The determinants of care were generally consistent with international CUP clinical guidelines. Areas of future research include potential underinvestigation and undertreatment of older patients, overuse of certain low-value diagnostic tests, suboptimal use of immunohistochemistry and mammography and underreferral to palliative care.

Gender and age make no difference in the re-irradiation of painful bone metastases: A secondary analysis of the NCIC CTG SC.20 randomized trial

BACKGROUND AND PURPOSE

Patient's gender and age may influence physicians in prescribing palliative radiotherapy. The purpose of this secondary analysis of the National Cancer Institute of Canada Clinical Trials Group Symptom Control Trial SC.20 was to explore the gender and age differences in pain and patient reported outcomes in cancer patients with bone metastases undergoing re-irradiation.

MATERIALS AND METHODS

Response to radiation was evaluated using the International Bone Metastases Consensus Endpoint Definitions. Patients completed the Brief Pain Inventory (BPI) and European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 (C30) before and 2 months after re-irradiation.

RESULTS

A total of 847 patients were analyzed. At baseline, men had more dyspnea, and mild pain. Older patients consumed less analgesic. More women reported clinically significant improvement in mood and enjoyment of life in the BPI after radiation. Similarly, younger patients reported better improvement in enjoyment of life. There were no significant gender or age differences in overall survival, response to radiation, or in C30 scores at 2 months.

CONCLUSION

Similar benefit in terms of pain relief was observed across all patient groups. Cancer patients with bone metastases should be offered palliative re-irradiation irrespective of gender or age.

TRIAL REGISTRATION

NCT00080912; https://clinicaltrials.gov/ct2/show/NCT00080912.

Diffusion-weighted magnetic resonance imaging in painful bone metastases: Using quantitative apparent diffusion coefficient as an indicator of effectiveness of single fraction versus multiple fraction radiotherapy

PURPOSE

Bone metastases are a common cause of cancer-related pain. The aim of this study is to determine the optimal radiotherapy schedule for the treatment of painful bone metastases and verify if could cause different biological effects on bone. This has been achieved using functional Magnetic Resonance Imaging (MRI) with diffusion-weighted imaging (DWI).

PATIENTS AND METHODS

Fifteen patients received Multiple Fractions Radiation Therapy (MFRT) with a total dose of 30Gy in 10 daily fractions of 3Gy given over 2 weeks and 15 patients received a Single Fraction Radiation Therapy (SFRT) with a dose of 8Gy. Quantitative Apparent Diffusion Coefficient (ADC) values after SFRT or MFRT were compared with response to treatment (pain relief), assessed by Visual Analogue Scale (VAS) before radiotherapy and at 1 and 3 months after the completion of treatment.

RESULTS

The two schedules had equal efficacy in terms of pain control, without any difference at 1 and 3 months post radiotherapy. In both treatments, pain reduction was related to an increase in the ADC. However, the median ADC value had an increase of 575 points between the baseline and 3 months (from 1010 to 1585, p=0.02) in the 30Gy group, while it was only 178 points (from 1417 to 1595) in the 8Gy group.

CONCLUSIONS

The increase in the ADC values after radiotherapy corresponds to increased cell death. Despite an equal pain control, MFRT treatment seems to be more effective to achieve cancer cells kill. Our preliminary data could also explain the higher retreatment rates in SFRT vs MFRT in long survivors.

The Src family kinase inhibitor dasatinib delays pain-related behaviour and conserves bone in a rat model of cancer-induced bone pain

Pain is a severe and debilitating complication of metastatic bone cancer. Current analgesics do not provide sufficient pain relief for all patients, creating a great need for new treatment options. The Src kinase, a non-receptor protein tyrosine kinase, is implicated in processes involved in cancer-induced bone pain, including cancer growth, osteoclastic bone degradation and nociceptive signalling. Here we investigate the role of dasatinib, an oral Src kinase family and Bcr-Abl tyrosine kinase inhibitor, in an animal model of cancer-induced bone pain. Daily administration of dasatinib (15 mg/kg, p.o.) from day 7 after inoculation of MRMT-1 mammary carcinoma cells significantly attenuated movement-evoked and non-evoked pain behaviour in cancer-bearing rats. Radiographic - and microcomputed tomographic analyses showed significantly higher relative bone density and considerably preserved bone micro-architecture in the dasatinib treated groups, suggesting a bone-preserving effect. This was supported by a significant reduction of serum TRACP 5b levels in cancer-bearing rats treated with 15 mg/kg dasatinib. Furthermore, immunoblotting of lumbar spinal segments showed an increased activation of Src but not the NMDA receptor subunit 2B. These findings support a role of dasatinib as a disease modifying drug in pain pathologies characterized by increased osteoclast activity, such as bone metastases.

The spine instability neoplastic score (SINS) in the assessment of response to radiotherapy for bone metastases

BACKGROUND

Vertebral metastases are often causing pain and spine instability. Radiotherapy is of significant benefit for painful spine metastases but the response can be very variable. The spine instability neoplastic score (SINS) is a recent classification system for diagnosis of spinal instability caused by vertebral metastases. We analysed the degree of pain relief, the need of drug therapy and the imaging features and the SINS before and after radiotherapy. In particular, we investigated the possible correlation of spine instability defined by pre-treatment SINS with pretreatment pain and with response to radiotherapy.

MATERIAL/METHODS

This study included 121 patients with spine metastases treated with palliative 3D conformal radiotherapy. Pain "at rest" and "breakthrough pain", need for drug therapy in terms of "anti-inflammatory", "weak opioid", "strong opioid", imaging studies and SINS were assessed before and after radiotherapy. Statistical analysis was performed by the correlation coefficient of Spearman and Kruskal-Wallis test.

RESULTS

Pain relief after radiotherapy was observed in 50.4 and 57.8% of patients in terms of pain at rest and breakthrough pain, respectively. The correlation between pain before radiotherapy and SINS was not statistically significant for both pain at rest (p = 0.4) and breakthrough pain (p = 0.49). The correlation between pain response after radiotherapy and SINS was statistically significant for both pain at rest (p = 0.007) and breakthrough pain (p = 0.047).

DISCUSSION/CONCLUSION

The degree of instability, classified according to SINS, resulted to be predictive factor for pain response after radiotherapy. SINS might become a valid tool to identify those patients who can benefit the most from radiotherapy.

Bone Pain and Muscle Weakness in Cancer Patients

PURPOSE OF REVIEW

In this article, we will discuss the current understanding of bone pain and muscle weakness in cancer patients. We will describe the underlying physiology and mechanisms of cancer-induced bone pain (CIBP) and cancer-induced muscle wasting (CIMW), as well as current methods of diagnosis and treatment. We will discuss future therapies and research directions to help patients with these problems.

RECENT FINDINGS

There are several pharmacologic therapies that are currently in preclinical and clinical testing that appear to be promising adjuncts to current CIBP and CIMW therapies. Such therapies include resiniferitoxin, which is a targeted inhibitor of noceciptive nerve fibers, and selective androgen receptor modulators, which show promise in increasing lean mass. CIBP and CIMW are significant causes of morbidity in affected patients. Current management is mostly palliative; however, targeted therapies are poised to revolutionize how these problems are treated.

Attitudes of radiation oncologists toward palliative and supportive care in the United States: Report on national membership survey by the American Society for Radiation Oncology (ASTRO)

PURPOSE

Radiation oncologists are frequently involved in providing palliative and supportive care (PSC) for patients with advanced cancers through delivery of palliative radiation. Whether they are confident in their ability to assess and initiate treatments for pain, nonpain, and psychosocial distress is unknown. The American Society for Radiation Oncology surveyed its practicing members in the United States on self-assessment of their primary PSC skills and access to continuing medical education on PSC.

METHODS

We electronically surveyed 4093 practicing radiation oncologists in the United States. The survey consisted of 16-questions in 5 sections¹: demographics,² PSC training,³ domains of PSC,⁴ perceived barriers as a radiation oncologist to initiate advanced care planning, and⁵ discussion of prognosis.

RESULTS

The survey was e-mailed to 4093 American Society for Radiation Oncology members, and 649 responses were received (response rate 16%). The majority (91%) of radiation oncologists surveyed believe PSC is an important competency for radiation oncologists. Most radiation oncologists reported that they are moderately confident in their ability to assess and manage pain and gastrointestinal symptoms, but less confident in their ability to manage anorexia, anxiety, and depression. Despite areas of decreased confidence, a large number (42%) of radiation oncologists do not receive any additional PSC education beyond their residency training. Lastly, a perceived fear of upsetting referring medical oncologists and lack of clinic time are concerns for radiation oncologists who may want to initiate goals of care/advance care planning discussions with patients and their families.

CONCLUSION

Radiation oncologists are more confident in their ability to assess and manage pain than in their ability to manage depression, anxiety, anorexia, and fatigue. There is a need for increasing continuing medical educational efforts in PSC for practicing radiation oncologists, and strengthening PSC training in residency programs.

A prospective study validating the EORTC QLQ-BM22 bone metastases module in patients with painful bone metastases undergoing palliative radiotherapy

PURPOSE

Quality of life (QOL) can be compromised in patients with bone metastases, and validated QOL instruments are required to accurately measure QOL outcomes in this population. This study investigated the validity, reliability and responsiveness of the EORTC QLQ-BM22 module with the EORTC QLQ-C15-PAL instrument in bone metastases.

METHODS

The studied patients underwent palliative radiotherapy to bone metastases in the randomized NCIC CTG SC 23 trial. Multi-trait scaling analysis was performed to determine convergent and divergent validity among scales. Pearson coefficients were calculated to determine the correlation between items of the two instruments. The clinical validity and responsiveness of the QLQ-BM22 was tested by known group comparisons of different performance status and response to radiotherapy.

RESULTS

204 patients completed both questionnaires at baseline and 42day follow-up. On multi-trait scaling analysis, there was mixed evidence of construct validity (explained by the questionnaire format and population characteristics). There was little correlation between most QLQ-BM22 and QLQ-C15-PAL items (except for conceptually related scales) validating their complementary nature. There were statistically significant differences in all QLQ-BM22 scale scores in groups with KPS<80 vs. KPS⩾80 and three out of four QLQ-BM22 scale scores in "responders" vs. "non-responders" to radiotherapy. In patients who responded to radiotherapy, there were statistically significant differences in all QLQ-BM22 scale scores between baseline and follow-up.

CONCLUSION

This study further validates the use of the QLQ-BM22 as a robust and sensitive instrument to assess QOL in patients with bone metastases treated with palliative radiotherapy.

Percutaneous kyphoplasty for the treatment of spinal metastases

The bones are the most common location for metastases, which may cause severe pain and damage, including osteolytic destruction and fractures. Pathological fractures of the spine are extremely painful and cause significant disability and morbidity in patients. Traditional open surgery has numerous complications, and radiation therapy may take weeks to become effective. To avoid the trauma and complication of open surgery, percutaneous kyphoplasty (PKP) is a minimally invasive procedure that has played a great role in the treatment of spinal metastases over the past several years. To evaluate the efficacy and safety of the treatment of spinal metastasis using PKP, the present study evaluated 282 patients who had received PKP between April 2009 and June 2014. The efficacy of PKP was evaluated using the visual analog scale for pain (VAS), Karnofsky performance score (KPS) and quality of life (QOL) score (short form with 36 questions). The KPS and QOL were measured pre-operatively and 3 months post-operatively. In addition, radiographical data, including the degree of restoration of the kyphotic angle and the anterior vertebral height, and leakage of bone cement, were measured. The safety of the surgery was assessed by complications and side effects reported during or subsequent to surgery. The present study measured the parameters prior to the surgery and at 24 h, 3 months, 6 months and 1 year post-surgery, as well as at the last follow-up date. The range of the follow-up time was between 105 days and 15 months (mean, 401 days). The 282 patients underwent successful operations and the pain felt by the patients prior to the surgery was significantly alleviated. In addition, the analgesic intake of patients greatly decreased following PKP. KPS improved prior to and 3 months after the surgery. QOL also improved prior to and 3 months after the surgery. Radiographical data demonstrated that the kyphotic angle decreased following PKP, and the anterior vertebral height increased. Paravertebral leakage of bone cement occurred in 10 patients through a cortical defect, but without spinal cord compression or pulmonary embolism. Therefore, as a minimally invasive procedure, PKP may not only rapidly relieve the pain and disability experienced by patients, but it may also restore the kyphotic angle observed at the 1-year follow-up. Notably, PKP may safely improve the QOL of patients.