Palliative radiotherapy: current status and future directions

Dosimetric analysis of patients receiving volumetric-modulated arc palliative radiotherapy to the thoracic spine: A comparison with conventional mono-isocentric parallel opposed pair treatment

PURPOSE

Volumetric modulated arc therapy (VMAT) has allowed for dose escalation and a decrease in radiation-induced toxicities for a variety of treatment sites, including spinal metastases. This article will compare the dosimetric impacts on normal lung tissue in patients treated with both VMAT and conventional treatment to the thoracic spine and determine if any significant difference exists among patient reported Edmonton Symptom Assessment System (ESAS) scores.

METHODS

This retrospective quality assurance study identified 288 patients who received palliative radiotherapy to the thoracic spine using VMAT or conventional planning techniques with various palliative dose fractionation schemes. V5 lung dose levels, treated planning target volume (PTV) cord length, patient-reported ESAS scores at the time of radiation oncology consultation, 3 months' post-treatment, and 6 months' post-treatment were analyzed. All symptoms on the ESAS survey were investigated, but shortness of breath (SOB) scores were the main focus of this study. Date of death for each patient was also included for analysis.

RESULTS

Patients treated with a VMAT technique had significantly higher V5 lung dose levels compared to those treated conventionally (right lung: p = 1.67e-14; left lung: p = 1.33e-6). Despite this, no significant differences were observed for SOB scores at all time points between groups and conventionally treated patients reported significantly worse pain, tiredness, depression, and wellbeing scores. A moderate correlation was observed between PTV length and nausea, SOB, appetite, and drowsiness scores in the VMAT group. Treatment technique was not found to have a significant impact on patient lifespan.

CONCLUSIONS

Despite higher V5 lung dose levels associated with a VMAT technique, no significant differences were found in patient-reported ESAS scores compared to patients treated with conventional techniques. This demonstrates that palliation of thoracic spinal metastases is feasible and safe using a VMAT technique.

Efficacy and safety of radiation therapy in advanced adrenocortical carcinoma

BACKGROUND

International guidelines emphasise the role of radiotherapy (RT) for the management of advanced adrenocortical carcinoma (ACC). However, the evidence for this recommendation is very low.

METHODS

We retrospectively analysed all patients who received RT for advanced ACC in five European centres since 2000.

PRIMARY ENDPOINT

time to progression of the treated lesion (tTTP). Secondary endpoints: best objective response, progression-free survival (PFS), overall survival (OS), adverse events, and the establishment of predictive factors by Cox analyses.

RESULTS

In total, 132 tumoural lesions of 80 patients were treated with conventional RT (cRT) of 50-60 Gy (n = 20) or 20-49 Gy (n = 69), stereotactic body RT of 35-50 Gy (SBRT) (n = 36), or brachytherapy of 12-25 Gy (BT) (n = 7). Best objective lesional response was complete (n = 6), partial (n = 52), stable disease (n = 60), progressive disease (n = 14). Median tTTP was 7.6 months (1.0-148.6). In comparison to cRT20-49Gy, tTTP was significantly longer for cRT50-60Gy (multivariate adjusted HR 0.10; 95% CI 0.03-0.33; p < 0.001) and SBRT (HR 0.31; 95% CI 0.12-0.80; p = 0.016), but not for BT (HR 0.66; 95% CI 0.22-1.99; p = 0.46). Toxicity was generally mild and moderate with three grade 3 events. No convincing predictive factors could be established.

CONCLUSIONS

This largest published study on RT in advanced ACC provides clear evidence that RT is effective in ACC.

Hypofractionated radiotherapy combined with targeted therapy or immunotherapy: Dutch survey on current practice, knowledge and challenges

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Radiotherapy referral during targeted therapy or immunotherapy occurs regularly.

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There is a knowledge gap regarding the implications of combined therapy.

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There is no consensus on expected toxicity of combined therapy.

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Multidisciplinary protocols regarding combined therapy are often not available.

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The application of radiotherapy treatment adaptations varies widely when combined with different systemic treatments.

Introduction

With the introduction of tyrosine kinase inhibitors and systemic antibodies, including immune checkpoint inhibitors, the survival of advanced-stage cancer patients has improved for many tumor types. These patients are increasingly referred for radiotherapy, but it is unclear whether radiotherapy combined with these drugs is safe. No international guidelines exist on whether or how to combine these drugs with radiotherapy. Therefore, we investigated the current clinical practice in the Netherlands regarding hypofractionated radiotherapy in patients using targeted drugs and immunotherapy.

Materials and methods

We sent a survey to all 21 Dutch radiotherapy institutes. Dedicated radiation oncologists, medical oncologists and pulmonologists were asked to fill out the survey. The questions explored their familiarity with the combination of targeted drugs and immunotherapy with radiotherapy, the encountered clinical difficulties and factors influencing treatment decisions.

Results

The survey was filled out by 54 respondents from 19 different institutes. The median annual number of patients per radiation oncologist referred for radiotherapy when using targeted drugs or immunotherapy was 10 and 15, respectively. Despite this high number, only 11% of the radiation oncologists stated that they had sufficient information (resources) for adequate treatment decision making. Among all physicians, 44% stated that there was insufficient knowledge within their institute regarding this topic. Only 17% stated that there was a multidisciplinary protocol available. The application of radiotherapy treatment adaptations (technique, dose, fractionation, field size) varied widely. Generally, there seemed to be no consensus regarding the expected toxicity of combined drug-radiotherapy treatments and the expected risk of tumor flare upon temporary drug discontinuation.

Conclusion

There is no consensus amongst involved medical specialties on expected toxicity. Consequently, it is necessary to perform clinical studies examining the safety of combined drug-radiotherapy treatments, to add radiotherapy to phase I-III clinical trials for new drugs and to incorporate outcomes into multidisciplinary, evidence-based guidelines.

Palliative Care Physicians and Palliative Radiotherapy, Knowledge and Barriers for Referring: A Cross-sectional Study

CONTEXT

Palliative radiotherapy is effective in the management of symptoms resulting from advanced cancer. However, it remains underutilized. In developed countries, many factors have been linked to this phenomenon but data in developing and low-income countries, particularly in Latin America, are lacking.

OBJECTIVES

To conduct a cross-sectional survey to explore palliative care physicians' knowledge of palliative radiotherapy and to investigate possible factors that limit patient referral.

METHODS

This is a cross-sectional survey. An online questionnaire was sent to palliative care physicians (n = 170) registered in the Chilean Medical Society of Palliative Care directory.

RESULTS

The overall response rate was 58.8%. Nearly all respondents (98%) considered radiotherapy to be a useful treatment. Less than half the respondents (43%) had good knowledge of palliative radiotherapy. Knowledge was correlated with self-reported knowledge (P = 0.015), discussing cases with radiation oncologist (P = 0.001), and having attended educational events on palliative radiotherapy (P = 0.001). Patient reluctance, poor performance status, and family reluctance were identified as major barriers to the use of palliative radiotherapy. Physicians from cities other than the capital were more likely to be concerned about barriers such as distance to radiotherapy facilities (P = 0.01), the duration of the referral process (P = 0.01), and the lack of a radiation oncologist available for discussing cases (P = 0.01).

CONCLUSIONS

Several barriers affect referral to palliative radiotherapy. Some barriers seem to be more significant for physicians practicing in cities far from cancer centers. Physicians' knowledge is less than optimal and has been identified as a barrier to referral. Educational interventions and broadening the availability of cancer treatment resources are needed to improve the referral process.

Patterns of practice of adaptive re-planning for anatomic variances during cone-beam CT guided radiotherapy

PURPOSE

Substantial, unanticipated anatomic variances during cone-beam CT (CBCT)-guided radiotherapy can potentially impact treatment accuracy and clinical outcomes. This study assessed patterns of practice of CBCT variances reported by RTTs and subsequent interventions for multiple-disease sites.

METHODS

A chart review was conducted at a large cancer centre for patients treated with daily online CBCT-guided radiotherapy. Patients selected for review were identified via RTT-reported variances that then triggered offline multi-disciplinary assessment. Cases were categorized by the type of anatomic variance observed on CBCT and any further interventions recorded such as un-scheduled adaptive re-planning.

RESULTS

Over a 1-year period, 287 variances from 261 patients were identified (6.2% of the 4207 patients treated with daily CBCT-guided radiotherapy), most often occurring within the first 5 fractions of the treatment course. Of these variances, 21% (59/287) were re-planned and 3.5% (10/287) discontinued treatment altogether. Lung was the most frequent disease-site (27% of 287 variances) reported with IGRT-related variances although head and neck and sarcoma were most frequently re-planned (19% of 59 re-plans for each site). Technical or clinical rationales for re-planning were not routinely documented in patient medical records. All disease-sites had numerous categories of variances. Three of the four most frequent categories were for tumor-related changes on CBCT, and the re-planning rate was highest for tumor progression at 25%. Normal tissue variances were the second most frequency category, and re-planned in 14% of those cases.

CONCLUSION

RTTs identified a wide range of anatomic variances during CBCT-guided radiotherapy. In a minority of cases, these substantially altered the care plan including ad hoc adaptive re-planning or treatment discontinuation. Improved understanding of the clinical decisions in these cases would aid in developing more routine, systematic adaptive strategies.

Palliative Radiotherapy: Inpatients, Outpatients, and the Changing Role of Supportive Care in Radiation Oncology

Palliative radiotherapy is an effective treatment in alleviating many symptoms of advanced cancer. Short courses of radiotherapy provide rapid symptom relief and minimize impact on patients. Patients referred for palliative radiotherapy have many concerns beyond radiotherapy; often, these concerns are not fully addressed in traditional radiotherapy clinics. Discussions of prognosis, patient goals, and concerns are areas for improved collaboration. Innovative, dedicated palliative radiotherapy programs have developed over the past 20 years to provide holistic care to patients referred for palliative radiotherapy and have improved patient-focused outcomes. Advanced radiotherapy techniques may provide opportunities to further improve palliative radiotherapy outcomes.

Palliative care in everyday practice of radiation oncologists : Results from a web-based survey among medical members of the German Society for Radiation Oncology (DEGRO)

PURPOSE

Little is known about the attitudes of radiation oncologists towards palliative care, about their competences in this field, and about the collaboration with palliative care specialists. Our aim was to close this gap and understand more about the importance of an additional qualification in palliative care.

METHODS

Medical members of the German Society for Radiation Oncology (DEGRO) were electronically surveyed during November-December 2016.

RESULTS

The survey was emailed successfully to 1110 addressees, whereas a total of 205 questionnaires were eligible for analysis (response rate 18.4%). 55 (26.8%) of the respondents had an additional qualification in palliative care. Physicians who had an additional qualification in palliative care (PC qualification) reported palliative care needs for their patients more frequently than the other respondents (89.0 vs. 82.7%, p = 0.008). Furthermore, they were most likely to report a high confidence in palliative care competences, such as "communication skills & support for relatives" (83.6 vs. 59.3%, p = 0.013), "symptom control," and "pain management" (94.5 vs. 67.7%, p < 0.001 and 90.9 vs. 73.3%, p = 0.008, respectively). Respondents with a PC qualification more often involved palliative care specialists than the other respondents (63.3 vs. 39.3%, p = 0.007). Perceived main barriers regarding palliative care in radiation oncology included time aspects (9.2%), stigmata (8.5%), and the lack of interdisciplinary collaboration (8.5%).

CONCLUSIONS

This analysis demonstrated that aspects of palliative care strongly impact on daily practice in radiation oncology. Additional qualifications and comprehensive training in palliative medicine may contribute to improved patient care in radiation oncology.

Top 10 Tips Palliative Care Clinicians Should Know About Radiation Oncology

As palliative care (PC) moves upstream in the course of advanced illness, it is critical that PC providers have a broad understanding of curative and palliative treatments for serious diseases. Possessing a working knowledge of radiation therapy (RT), one of the three pillars of cancer care, is crucial to PC providers given RT's role in both the curative and palliative settings. This article provides PC providers with a primer on the vocabulary of RT; the team of people involved in the planning of RT; and common indications, benefits, and side effects of treatment.

Profile of patients undergoing palliative radiotherapy: A single-institute study from a tertiary care oncology center

Background:

Palliative radiotherapy (PRT) plays a significant role in the palliation of symptoms in patients with cancer and constitutes nearly 50% of the workload in different settings.

Aims:

The aim is to study patient-, disease-, and treatment-related characteristics in locoregionally advanced and metastatic malignancies meriting palliative management.

Setting and Design:

This was a retrospective observational study in a tertiary care government institute with academic and research potential.

Methodology:

The electronic medical records, medical documents, and radiotherapy (RT) treatment charts were retrieved and studied.

Observations:

A total of 460 patients were included in the study over 2 years, forming 30% of the total number of patients treated during the study period. Three hundred and ninety-six patients received PRT to the metastatic sites, while 64 patients received extremely hypofractionated PRT to the primary for symptomatic relief. Totally 442 patients showed good symptomatic response to PRT. One hundred and thirty-eight patients underwent re-irradiation. Lung was the most common primary site seen in 155 cases. The most common indication for PRT was palliation of pain from painful metastases as seen in 240 cases, and the next common indication was palliative whole-brain RT for brain metastases as seen in 159 cases.

Conclusion:

PRT forms an integral and important aspect of palliative care to the vast number of patients harboring metastatic disease that warrants some form of treatment for symptomatic relief. Short course of PRT in outdoor setting is a preferred mode of treatment to improve the quality of life of these distressed patients.

Palliative radiotherapy during the last month of life: Predictability for referring physicians and radiation oncologists

Oncologists commonly overestimate the survival time of patients receiving palliative therapy, which may result in the administration of treatments that are too aggressive for patients near the end of their lives. Previous studies have discussed the negative implications of palliative radiotherapy if administered during the last month of life. Models predicting a limited survival time may improve the ability of the oncologists to tailor the treatment according to the needs of each individual patient. In the present study, prognostic factors for survival time, and the use of palliative radiotherapy during the last month of life, were analyzed in 873 patients. Models predicting the likelihood of administering such therapy were examined, and the risk of receiving radiotherapy during the last month of life was observed to be lower in patients with non-metastatic cancer than in those with metastatic cancer (7 vs. 13%, respectively; P=0.12). On multivariate analysis, 11 factors that significantly influenced the survival time were identified. These findings emphasize the complexity of potential prediction models. The most important risk factor regarding the prediction of extremely short survival times was observed to be an Eastern Cooperative Oncology Group performance status (ECOG PS) of 4, followed by an ECOG PS of 3 (median survival times, 14 and 64 days, respectively). A limited number of patients who received palliative radiotherapy during their last month of life died unexpectedly. Disease-specific prediction models were developed; however, the small number of events available for analysis limited their immediate clinical impact. Furthermore, these prediction models identified a minority of patients who received radiotherapy during the last month of life. In conclusion, the majority of the palliative radiotherapy courses administered to patients with advanced cancer during their last month of life may be preventable if accurate decision models for the clinic are developed. However, due to the complexity associated with the prediction of survival times in patients receiving palliative radiotherapy, large databases are required to allow accurate models to be established. The present study also discusses the recommendations of the Department of Oncology and Palliative Medicine of Nordland Hospital (Bodø, Nordland, Norway) with regard to the use of palliative radiotherapy during the last month of life of patients with terminal cancer.