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Haddad RI, Bischoff L, Ball D, Bernet V, Blomain E, Busaidy NL, Campbell M, Dickson P, Duh QY, Ehya H, Goldner WS, Guo T, Haymart M, Holt S, Hunt JP, Iagaru A, Kandeel F, Lamonica DM, Mandel S, Markovina S, McIver B, Raeburn CD, Rezaee R, Ridge JA, Roth MY, Scheri RP, Shah JP, Sipos JA, Sippel R, Sturgeon C, Wang TN, Wirth LJ, Wong RJ, Yeh M, Cassara CJ, Darlow S. Thyroid Carcinoma, Version 2.2022, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw 2022; 20:925-951. [PMID: 35948029 DOI: 10.6004/jnccn.2022.0040] [Citation(s) in RCA: 124] [Impact Index Per Article: 62.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Differentiated thyroid carcinomas is associated with an excellent prognosis. The treatment of choice for differentiated thyroid carcinoma is surgery, followed by radioactive iodine ablation (iodine-131) in select patients and thyroxine therapy in most patients. Surgery is also the main treatment for medullary thyroid carcinoma, and kinase inhibitors may be appropriate for select patients with recurrent or persistent disease that is not resectable. Anaplastic thyroid carcinoma is almost uniformly lethal, and iodine-131 imaging and radioactive iodine cannot be used. When systemic therapy is indicated, targeted therapy options are preferred. This article describes NCCN recommendations regarding management of medullary thyroid carcinoma and anaplastic thyroid carcinoma, and surgical management of differentiated thyroid carcinoma (papillary, follicular, Hürthle cell carcinoma).
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Affiliation(s)
| | | | - Douglas Ball
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins
| | | | | | | | | | - Paxton Dickson
- St. Jude Children's Research Hospital/The University of Tennessee Health Science Center
| | - Quan-Yang Duh
- UCSF Helen Diller Family Comprehensive Cancer Center
| | | | | | | | | | - Shelby Holt
- UT Southwestern Simmons Comprehensive Cancer Center
| | - Jason P Hunt
- Huntsman Cancer Institute at the University of Utah
| | | | | | | | - Susan Mandel
- Abramson Cancer Center at the University of Pennsylvania
| | - Stephanie Markovina
- Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine
| | | | | | - Rod Rezaee
- Case Comprehensive Cancer Center/University Hospitals Seidman Cancer Center and Cleveland Clinic Taussig Cancer Institute
| | | | - Mara Y Roth
- Fred Hutchinson Cancer Research Center/Seattle Cancer Care Alliance
| | | | | | - Jennifer A Sipos
- The Ohio State University Comprehensive Cancer Center - James Cancer Hospital and Solove Research Institute
| | | | - Cord Sturgeon
- Robert H. Lurie Comprehensive Cancer Center of Northwestern University
| | | | | | | | - Michael Yeh
- UCLA Jonsson Comprehensive Cancer Center; and
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Jaworski EM, Yin H, Griffith KA, Pandya R, Mancini BR, Jolly S, Boike TP, Moran JM, Dominello MM, Wilson M, Parker J, Burmeister J, Fraser C, Miller L, Baldwin K, Mietzel MA, Grubb M, Kendrick D, Spratt DE, Hayman JA. Contemporary Practice Patterns for Palliative Radiation Therapy of Bone Metastases: Impact of a Quality Improvement Project on Extended Fractionation. Pract Radiat Oncol 2021; 11:e498-e505. [PMID: 34048938 DOI: 10.1016/j.prro.2021.05.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 04/22/2021] [Accepted: 05/04/2021] [Indexed: 12/25/2022]
Abstract
PURPOSE Radiation therapy effectively palliates bone metastases, although variability exists in practice patterns. National recommendations advocate against using extended fractionation (EF) with courses greater than 10 fractions. We previously reported EF use of 14.8%. We analyzed practice patterns within a statewide quality consortium to assess EF use in a larger patient population after implementation of a quality measure focused on reducing EF. METHODS AND MATERIALS Patients treated for bone metastases within a statewide radiation oncology quality consortium were prospectively enrolled from March 2018 through October 2020. The EF quality metric was implemented March 1, 2018. Data on patient, physician, and facility characteristics; fractionation schedules; and treatment planning and delivery techniques were collected. Multivariable binary logistic regression was used to assess EF. RESULTS Twenty-eight facilities enrolled 1445 consecutive patients treated with 1934 plans. The median number of treatment plans per facility was 52 (range, 7-307). Sixty different fractionation schedules were used. EF was delivered in 3.4% of plans. Initially, EF use was lower than expected and remained low over time. Significant predictors for EF use included complicated metastasis (odds ratio [OR], 2.04; 95% confidence interval [CI], 1.04-4.02; P = .04), lack of associated central nervous system or visceral disease (OR, 2.27; 95% CI, 1.2-4.2; P = .01), nonteaching versus teaching facilities (OR, 8.97; 95% CI, 2.1-38.5; P < .01), and treating physicians with more years in practice (OR, 12.82; 95% CI, 3.9-42.4; P < .01). CONCLUSIONS Within a large, prospective population-based data set, fractionation schedules for palliative radiation therapy of bone metastases remain highly variable. Resource-intensive treatments including EF persist, although EF use was low after implementation of a quality measure. Complicated metastases, lack of central nervous system or visceral disease, and treatment at nonteaching facilities or by physicians with more years in practice significantly predict use of EF. These results support ongoing efforts to more clearly understand and address barriers to high-value radiation approaches in the palliative setting.
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Affiliation(s)
| | - Huiying Yin
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Kent A Griffith
- Department of Biostatistics, University of Michigan, Ann Arbor, Michigan
| | - Raveena Pandya
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Brandon R Mancini
- Department of Radiation Oncology, West Michigan Cancer Center, Kalamazoo, Michigan
| | - Shruti Jolly
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Thomas P Boike
- Department of Radiation Oncology, MHP Radiation Oncology Institute/21st Century Oncology, Clarkston, Michigan
| | - Jean M Moran
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Michael M Dominello
- Department of Radiation Oncology, Barbara Ann Karmanos Cancer Center, Wayne State University School of Medicine, Detroit, Michigan
| | - Melissa Wilson
- Department of Radiation Oncology, MHP Radiation Oncology Institute/21st Century Oncology, Troy, Michigan
| | - Jan Parker
- Department of Radiation Oncology, Henry Ford Allegiance, Jackson, Michigan
| | - Jay Burmeister
- Department of Radiation Oncology, Barbara Ann Karmanos Cancer Center, Wayne State University School of Medicine, Detroit, Michigan
| | - Correen Fraser
- Department of Radiation Oncology, Henry Ford Health System, Detroit, Michigan
| | - Lynne Miller
- Department of Radiation Oncology, Sparrow Herbert-Herman Cancer Center, Lansing, Michigan
| | - Kaitlyn Baldwin
- Department of Radiation Oncology, Munson Medical Center, Traverse City, Michigan
| | - Melissa A Mietzel
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Margaret Grubb
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Danielle Kendrick
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Daniel E Spratt
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - James A Hayman
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan.
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Kubota H, Nakamura N, Shikama N, Tonari A, Wada H, Harada H, Nagakura H, Heianna J, Ito K, Nozaki M, Tago M, Fushiki M, Uchida N, Araki N, Sekii S, Kosugi T, Takahashi T, Kawamoto T, Saito T, Yamada K. Practice patterns for postoperative radiation therapy in patients with metastases to the long bones: a survey of the Japanese Radiation Oncology Study Group. JOURNAL OF RADIATION RESEARCH 2021; 62:356-363. [PMID: 33454759 PMCID: PMC7948830 DOI: 10.1093/jrr/rraa133] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Revised: 11/19/2020] [Indexed: 06/12/2023]
Abstract
Evidence regarding postoperative radiation therapy (PORT) for metastases to the long bones is lacking. Characterizing the current practice patterns and identifying factors that influence dose-fractionation schedules are essential for future clinical trials. An internet-based survey of the palliative RT subgroup of the Japanese Radiation Oncology Study Group was performed in 2017 to collect data regarding PORT prescription practices and dose-fractionation schedules. Responders were also asked to recommend dose-fractionation schedules for four hypothetical cases that involved a patient with impending pathological fractures and one of four clinical features (poor prognosis, solitary metastasis, radio-resistant primary tumor or expected long-term survival). Responders were asked to indicate their preferred irradiation fields and the reasons for the dose fractionation schedule they chose. Responses were obtained from 89 radiation oncologists (67 institutions and 151 RT plans) who used 22 dose-fractionation schedules, with the most commonly used and recommended schedule being 30 Gy in 10 fractions. Local control was the most common reason for preferring longer-course RT. High-dose fractionated schedules were preferred for oligometastasis, and low-dose regimens were preferred for patients with a poor prognosis; however, single-fraction RT was not preferred. Most respondents recommended targeting the entire orthopedic prosthesis. These results indicated that PORT using 30 Gy in 10 fractions to the entire orthopedic prosthesis is preferred in current Japanese practice and that single-fraction RT was not preferred. Oligometastasis and poor prognosis influenced the selection of high- or low-dose regimens.
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Affiliation(s)
- Hikaru Kubota
- Corresponding author. Department of Radiation Oncology, Kobe University Hospital, 7-5-2 Kusunoki-cho, Chuo-ku, Kobe, Hyogo 650-0017, Japan. Fax: +81-78-382-5265;
| | - Naoki Nakamura
- Department of Radiation Oncology, St. Marianna University School of Medicine, 2-16-1 Sugao Kawasaki City, Kanagawa prefecture 216-8511, Japan
| | - Naoto Shikama
- Department of Radiation Oncology, Juntendo University Hospital, 3-1-3 Hongo, Bunkyo-ku, Tokyo 113-8431, Japan
| | - Ayako Tonari
- Department of Radiation Oncology, Kyorin University Hospital, 6-20-2 Shinkawa, Mitaka-shi, Tokyo 181-8611, Japan
| | - Hitoshi Wada
- Department of Radiation Oncology, Southern TOHOKU Proton Therapy Center, 172-7, Yatsuyamada,Koriyama,Fukushima 963-8563, Japan
| | - Hideyuki Harada
- Division of Radiation Therapy, Radiation and Proton Therapy Center, Shizuoka Cancer Center Hospital, 1007 Shimonagakubo, Nagaizumi-cho, Sunto-gun, Shizuoka Prefecture 411-8777, Japan
| | - Hisayasu Nagakura
- Department of Radiology, KKR Sapporo Medical Center, 6-3-40 Hiragishi-1, Toyohira-ku, Sapporo 062-0931, Japan
| | - Joichi Heianna
- Department of Radiation Oncology, Ryukyu University Hospital
| | - Kei Ito
- Department of Radiation Oncology, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, 3-18-22 Honkomagome, Bunkyo-ku, Tokyo 113-8677, Japan
| | - Miwako Nozaki
- Department of Radiation Oncology, Dokkyo Medical University Saitama Medical Center, 2-1-50 Minamikoshigaya, Koshigaya, Saitama, Japan
| | - Masao Tago
- Department of Radiology, Teikyo University Mizonokuchi Hospital, 3-8-3, Mizokuchi, Takatsu-ku, Kawasaki city, Kanagawa pref., Japan
| | - Masato Fushiki
- Department of Radiation Oncology, Nagahama City Hospital, 313 Oinuicho, Nagahama, Shiga 526-8580, Japan
| | - Nobue Uchida
- Department of Radiation Oncology, Tokyo Saiseikai Central Hospital, 1-4-17 Mita, Minato-ku, Tokyo 108-0073, Japan
| | - Norio Araki
- Department of Radiation Oncology, Kyoto Medical Center, 1-1 Fukakusamukaihatacho, Fushimi-ku, Kyoto-shi, Kyoto 612-8555, Japan
| | - Shuhei Sekii
- Department of Radiation Oncology, Kobe University Hospital, 7-5-2 Kusunoki-cho, Chuo-ku, Kobe City, Hyogo Prefecture 650-0017, Japan
| | - Takashi Kosugi
- Department of Radiation Oncology, Fujieda Municipal General Hospital, 4-1-11 Surugadai, Fujieda City, Shizuoka Prefecture 426-8677, Japan
| | - Takeo Takahashi
- Department of Radiation Oncology, Saitama Medical University Saitama Medical Center, 1981 kamoda,kawagoeshi, saitama 350-8550, Japan
| | - Terufumi Kawamoto
- Department of Radiation Oncology, Juntendo University Hospital, 3-1-3 Hongo, Bunkyo-ku, Tokyo 113-8431, Japan
| | - Tetsuo Saito
- Department of Radiation Oncology, Arao Municipal Hospital, 2600 Arao, Arao City, Kumamoto 864-0041, Japan
| | - Kazunari Yamada
- Department of Radiation Oncology, Seirei Mikatahara General Hospital, 3453 Mikatahara-cho, Kita-ku, Hamamatsu, Shizuoka 433-8558, Japan
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Ishigaki T, Uruno T, Sugino K, Masaki C, Akaishi J, Hames KY, Suzuki A, Tomoda C, Matsuzu K, Ohkuwa K, Kitagawa W, Nagahama M, Miyazaki S, Ito K. Stereotactic radiotherapy using the CyberKnife is effective for local control of bone metastases from differentiated thyroid cancer. JOURNAL OF RADIATION RESEARCH 2019; 60:831-836. [PMID: 31423531 PMCID: PMC6873619 DOI: 10.1093/jrr/rrz056] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/21/2019] [Revised: 07/04/2019] [Indexed: 06/10/2023]
Abstract
Differentiated thyroid cancer (DTC) is associated with a good long-term prognosis, but bone metastases can adversely affect patients' quality of life and survival. Stereotactic radiotherapy (SRT) can deliver high-dose irradiation to target lesions and it has been reported to be useful for various cancers. However, few studies have examined the efficacy of SRT for thyroid cancer. In the present study, the aim was to investigate the efficacy of SRT using the CyberKnife for bone metastases from DTC. From September 2013 to April 2018, SRT with the CyberKnife system was used to treat 60 bone metastases from DTC in 13 patients. The patients' medical records were retrospectively reviewed to obtain information about the adverse events associated with SRT. Of the 60 lesions, 40 could be evaluated by follow-up CT for therapeutic effectiveness, and the RECIST criteria were used to assess the response. The cancers were papillary cancer in 3 patients, follicular cancer in 9 and poorly differentiated cancer in 1. SRT was delivered in 1-10 fractions, with a median dose of 27 Gy (range, 8-48 Gy). Adverse events were infrequent and mild. The median follow-up of the 40 lesions was 11 (range, 2-56) months. The responses were partial response in 2 lesions, stable disease in 37 lesions and progressive disease in 1 lesion, with a 1-year local control rate of 97.1%. The present study showed that SRT using the CyberKnife system was a feasible and effective treatment for bone metastases of DTC.
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Affiliation(s)
- Takayuki Ishigaki
- Department of Surgery, Ito Hospital, 4-3-6 Jingumae, Shibuya-ku, Tokyo 150-8308, Japan
- Department of Breast and Endocrine Surgery, The Jikei University School of Medicine, 3-25-8, Nishi-shinbashi, Minato-ku, Tokyo 105-8461, Japan
| | - Takashi Uruno
- Department of Surgery, Ito Hospital, 4-3-6 Jingumae, Shibuya-ku, Tokyo 150-8308, Japan
| | - Kiminori Sugino
- Department of Surgery, Ito Hospital, 4-3-6 Jingumae, Shibuya-ku, Tokyo 150-8308, Japan
| | - Chie Masaki
- Department of Surgery, Ito Hospital, 4-3-6 Jingumae, Shibuya-ku, Tokyo 150-8308, Japan
| | - Junko Akaishi
- Department of Surgery, Ito Hospital, 4-3-6 Jingumae, Shibuya-ku, Tokyo 150-8308, Japan
| | - Kiyomi Y Hames
- Department of Surgery, Ito Hospital, 4-3-6 Jingumae, Shibuya-ku, Tokyo 150-8308, Japan
| | - Akifumi Suzuki
- Department of Surgery, Ito Hospital, 4-3-6 Jingumae, Shibuya-ku, Tokyo 150-8308, Japan
| | - Chisato Tomoda
- Department of Surgery, Ito Hospital, 4-3-6 Jingumae, Shibuya-ku, Tokyo 150-8308, Japan
| | - Kenichi Matsuzu
- Department of Surgery, Ito Hospital, 4-3-6 Jingumae, Shibuya-ku, Tokyo 150-8308, Japan
| | - Keiko Ohkuwa
- Department of Surgery, Ito Hospital, 4-3-6 Jingumae, Shibuya-ku, Tokyo 150-8308, Japan
| | - Wataru Kitagawa
- Department of Surgery, Ito Hospital, 4-3-6 Jingumae, Shibuya-ku, Tokyo 150-8308, Japan
| | - Mitsuji Nagahama
- Department of Surgery, Ito Hospital, 4-3-6 Jingumae, Shibuya-ku, Tokyo 150-8308, Japan
| | - Shinichiro Miyazaki
- Department of Radiation Oncology, Shinyurigaoka General Hospital, 255, Furusawatsuko, Asou-ku, Kawasaki-shi, Kanagawa 215-0026, Japan
| | - Koichi Ito
- Department of Surgery, Ito Hospital, 4-3-6 Jingumae, Shibuya-ku, Tokyo 150-8308, Japan
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Yu JB, Pollack CE, Herrin J, Zhu W, Soulos PR, Xu X, Gross CP. Persistent Use of Extended Fractionation Palliative Radiotherapy for Medicare Beneficiaries With Metastatic Breast Cancer, 2011 to 2014. Am J Clin Oncol 2019; 42:493-499. [PMID: 31033511 PMCID: PMC6538429 DOI: 10.1097/coc.0000000000000548] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
INTRODUCTION With no evidence to support extended radiation courses for the palliation of bone metastases, multiple guidelines were issued discouraging its use. We assessed contemporary use and cost of prolonged palliative radiotherapy in Medicare beneficiaries with bone metastases from breast cancer. METHODS We conducted a retrospective, longitudinal study of palliative radiotherapy use among fee-for-service Medicare beneficiaries with bone metastasis from breast cancer who underwent palliative radiotherapy during 2011 to 2014. Patients were categorized according to the number of days (fractions) on which they received palliative radiotherapy: 1, 2 to 10, 11 to 19, or 20 to 30. We examined the association of clinical, demographic, and provider characteristics with the use of extended (≥11 fractions) or very extended (≥20 fractions) fractionation with logistic regression models. We also compared the cost of different fractionation schemes from the payer perspective. RESULTS Of the 7547 patients in the sample (mean age, 71 y), 3084 (40.8%) received extended fractionation. The proportion of patients receiving 11 to 19 (34.7% in 2011 and 28.1% in 2014, trend P<0.001) and 20 to 30 treatments (10.3% in 2011 to 9.0% in 2014, trend P=0.07) decreased modestly over time. Patients with comorbidities were less likely to undergo extended fractionation (34.4% for ≥3 comorbidities vs. 44.9% for 0 comorbidities; adjusted odds ratio 0.67 [95% confidence interval, 0.58-0.76]). Patients treated at free-standing practices were more likely to undergo extended fractionation (47.9%) compared with those treated at hospital-based practices (37.3%, P<0.001; adjusted odds ratio, 1.49 [95% confidence interval, 1.35-1.65]). The mean cost of treatment varied from $633 (SD $240) for single-fraction treatment, to $3566 (SD $1349) for 11 to 19 fractions, to $6597 (SD $2893) for 20 to 30 fractions. CONCLUSION The use of prolonged courses of palliative radiotherapy among Medicare beneficiaries with breast cancer remained high in 2011 to 2014. The association between free-standing facility status and use of extended fractionation suggests that provider financial incentives may impact choice of treatment.
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Affiliation(s)
- James B. Yu
- Department of Therapeutic Radiology, Yale School of Medicine, New Haven, CT
- Yale Cancer Center, New Haven, CT
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center at Yale, New Haven, CT
| | - Craig E. Pollack
- Johns Hopkins School of Medicine, Baltimore, MD
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Jeph Herrin
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center at Yale, New Haven, CT
- Section of Cardiology, Yale School of Medicine, New Haven, CT
| | - Weiwei Zhu
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center at Yale, New Haven, CT
- Department of Internal Medicine, Section of General Internal Medicine, Yale School of Medicine, New Haven, CT
| | - Pamela R. Soulos
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center at Yale, New Haven, CT
- Department of Internal Medicine, Section of General Internal Medicine, Yale School of Medicine, New Haven, CT
| | - Xiao Xu
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center at Yale, New Haven, CT
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine, New Haven, CT
| | - Cary P. Gross
- Yale Cancer Center, New Haven, CT
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center at Yale, New Haven, CT
- Department of Internal Medicine, Section of General Internal Medicine, Yale School of Medicine, New Haven, CT
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Chaaya G, Abdelghani R, Kheir F, Komiya T, Vander Velde N. NSCLC: State of the Art Diagnosis, Treatment, and Outcomes. CURRENT PULMONOLOGY REPORTS 2018. [DOI: 10.1007/s13665-018-0198-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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7
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Huisman M, Verkooijen H, van der Linden Y, van den Bosch M, van Vulpen M. Effectiveness of Repeat Radiotherapy for Painful Bone Metastases in Clinical Practice: A 10 Year Historical Cohort Study. Clin Oncol (R Coll Radiol) 2015; 27:472-8. [DOI: 10.1016/j.clon.2015.04.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2014] [Revised: 03/20/2015] [Accepted: 04/23/2015] [Indexed: 12/25/2022]
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Cheon PM, Wong E, Thavarajah N, Dennis K, Lutz S, Zeng L, Chow E. A definition of "uncomplicated bone metastases" based on previous bone metastases radiation trials comparing single-fraction and multi-fraction radiation therapy. J Bone Oncol 2015; 4:13-7. [PMID: 26579484 PMCID: PMC4620946 DOI: 10.1016/j.jbo.2014.12.001] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2014] [Revised: 12/01/2014] [Accepted: 12/31/2014] [Indexed: 12/25/2022] Open
Abstract
The most recent systematic review of randomized trials in patients with bone metastases has shown equal efficacy of single fraction (SF) and multiple fraction (MF) palliative radiation therapy in pain relief. It is important to determine the patient population to which the evidence applies. This study aims to examine the eligibility criteria of the studies included in the systematic review to define characteristics of “uncomplicated” bone metastases. Inclusion and exclusion criteria of 21 studies included in the systematic review were compared. Common eligibility criteria were documented in hopes of defining the specific features of a common patient population representative of those in the studies. More than half of the studies included patients with cytological or histological evidence of malignancy. Patients with impending and/or existing pathological fracture, spinal cord compression or cauda equina compression were excluded in most studies. Most studies also excluded patients receiving retreatment to the same site. “Uncomplicated” bone metastases can be defined as: presence of painful bone metastases unassociated with impending or existing pathologic fracture or existing spinal cord or cauda equina compression. Therefore, MF and SF have equal efficacy in patients with such bone metastases.
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Affiliation(s)
- Paul M. Cheon
- Rapid Response Radiotherapy Program, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Erin Wong
- Rapid Response Radiotherapy Program, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Nemica Thavarajah
- Rapid Response Radiotherapy Program, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Kristopher Dennis
- Division of Radiation Oncology, University of Ottawa, Ottawa, Ontario, Canada
| | - Stephen Lutz
- Department of Radiation Oncology, Blanchard Valley Regional Cancer Center, OH, USA
| | - Liang Zeng
- Rapid Response Radiotherapy Program, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Edward Chow
- Rapid Response Radiotherapy Program, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
- Correspondence to: Department of Radiation Oncology Odette Cancer Centre Sunnybrook Health Sciences Centre 2075 Bayview Avenue Toronto, ON, Canada M4N 3M5. Tel.: +1 416 480 4998; fax: +1 416 480 6002.
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Kim EY, Chapman TR, Ryu S, Chang EL, Galanopoulos N, Jones J, Kubicky CD, Lee CP, Teh BS, Traughber BJ, Van Poznak C, Vassil AD, Weber K, Lo SSM. ACR Appropriateness Criteria® Non-Spine Bone Metastases. J Palliat Med 2015; 18:11-7. [DOI: 10.1089/jpm.2014.9395] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Affiliation(s)
| | | | - Samuel Ryu
- Stony Brook University School of Medicine, Stony Brook, New York
| | - Eric L. Chang
- University of Southern California-Keck School of Medicine, Los Angeles, California
| | | | - Joshua Jones
- University of Pennsylvania Perelman Center, Philadelphia, Pennsylvania
| | | | | | | | - Bryan J. Traughber
- University Hospitals Seidman Cancer Center, Case Western Reserve University, Cleveland, Ohio
| | | | | | - Kristy Weber
- Department of Orthopedic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Simon Shek-Man Lo
- University Hospitals Seidman Cancer Center, Case Western Reserve University, Cleveland, Ohio
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10
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Blum T, Schönfeld N. The lung cancer patient, the pneumologist and palliative care: a developing alliance. Eur Respir J 2014; 45:211-26. [DOI: 10.1183/09031936.00072514] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Considerable evidence is now available on the value of palliative care for lung cancer patients in all stages and at all times during the course of the disease. However, pneumologists and their institutions seem to be widely in arrears with the implementation of palliative care concepts and the development of integrated structures.This review focuses on the available evidence and experience of various frequently unmet needs of lung cancer patients, especially psychological, social, spiritual and cultural ones. A PubMed search for evidence on these aspects of palliative care as well as on barriers to the implementation, on outcome parameters and effectiveness, and on structure and process quality was performed with a special focus on lung cancer patients.As a consequence, this review particularly draws pneumologists’ attention to improving their skills in communication with the patients, their relatives and among themselves, and to establish team structures with more far-reaching competences and continuity than existing multilateral cooperations and conferences can provide. Ideally, any process of structural and procedural improvement should be accompanied by scientific evaluation and measures for quality optimisation.
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11
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Moghanaki D, Cheuk AV, Fosmire H, Anscher MS, Lutz ST, Hagan MP, Dawson GA. Availability of single-fraction palliative radiotherapy for cancer patients receiving end-of-life care within the Veterans Healthcare Administration. J Palliat Med 2014; 17:1221-5. [PMID: 25188468 DOI: 10.1089/jpm.2014.0041] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Surveys demonstrate < 20% of radiation oncologists in the United States offer single-fraction palliative radiotherapy (RT) even though it is an acceptable standard of care. A study was conducted to investigate whether this held true for those practicing within the Veterans Healthcare Administration (VHA). METHODS All radiation oncologists currently practicing at VHA medical centers were surveyed. Comparisons and associations of responses were evaluated by Fisher's exact test. RESULTS The response rate was 90%. Half were full-time employees of the VHA, and the majority (70%) had thoroughly read guidelines on palliative RT for bone metastases recently published by either the American College of Radiology (ACR, 2009, 2012) or the American Society of Radiation Oncology (ASTRO, 2011). Single-fraction palliative RT for bone metastases had been prescribed by 76% of respondents, and 93% had prescribed a short course of ≤ 6 fractions. Respondents were less likely to have prescribed a single fraction for patients who had survival estimates of either > 6 months or > 12 months (66% versus 37%, p < 0.0001).Those not offering single-fraction palliative RT (24%) were more likely to be > 10 years out of training (37% versus 10%, p = 0.01), and to have worked in a private practice setting at some point in their career (36% versus 12%, p = 0.03). CONCLUSIONS A majority of radiation oncologists within the VHA offer single-fraction therapy to their patients. These data ensure access to palliative RT is not limited within this health care system by a preference for prolonged treatment courses that may discourage patients and clinicians from seeking this care.
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Affiliation(s)
- Drew Moghanaki
- 1 Hunter Holmes McGuire Veterans Affairs Medical Center , Richmond, Virginia
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12
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Safety and feasibility of STAT RAD: Improvement of a novel rapid tomotherapy-based radiation therapy workflow by failure mode and effects analysis. Pract Radiat Oncol 2014; 5:106-12. [PMID: 25413416 DOI: 10.1016/j.prro.2014.03.016] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2014] [Revised: 03/12/2014] [Accepted: 03/31/2014] [Indexed: 12/25/2022]
Abstract
PURPOSE The clinical challenge of radiation therapy (RT) for painful bone metastases requires clinicians to consider both treatment efficacy and patient prognosis when selecting a radiation therapy regimen. The traditional RT workflow requires several weeks for common palliative RT schedules of 30 Gy in 10 fractions or 20 Gy in 5 fractions. At our institution, we have created a new RT workflow termed "STAT RAD" that allows clinicians to perform computed tomographic (CT) simulation, planning, and highly conformal single fraction treatment delivery within 2 hours. In this study, we evaluate the safety and feasibility of the STAT RAD workflow. METHODS AND MATERIALS A failure mode and effects analysis (FMEA) was performed on the STAT RAD workflow, including development of a process map, identification of potential failure modes, description of the cause and effect, temporal occurrence, and team member involvement in each failure mode, and examination of existing safety controls. A risk probability number (RPN) was calculated for each failure mode. As necessary, workflow adjustments were then made to safeguard failure modes of significant RPN values. After workflow alterations, RPN numbers were again recomputed. RESULTS A total of 72 potential failure modes were identified in the pre-FMEA STAT RAD workflow, of which 22 met the RPN threshold for clinical significance. Workflow adjustments included the addition of a team member checklist, changing simulation from megavoltage CT to kilovoltage CT, alteration of patient-specific quality assurance testing, and allocating increased time for critical workflow steps. After these modifications, only 1 failure mode maintained RPN significance; patient motion after alignment or during treatment. CONCLUSIONS Performing the FMEA for the STAT RAD workflow before clinical implementation has significantly strengthened the safety and feasibility of STAT RAD. The FMEA proved a valuable evaluation tool, identifying potential problem areas so that we could create a safer workflow.
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13
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Hospice Providers Awareness of the Benefits and Availability of Single-Fraction Palliative Radiotherapy. J Hosp Palliat Nurs 2014. [DOI: 10.1097/njh.0000000000000035] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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14
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Kirkpatrick JP, Kelsey CR, Palta M, Cabrera AR, Salama JK, Patel P, Perez BA, Lee J, Yin FF. Stereotactic body radiotherapy: a critical review for nonradiation oncologists. Cancer 2013; 120:942-54. [PMID: 24382744 DOI: 10.1002/cncr.28515] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2013] [Revised: 11/11/2013] [Accepted: 11/12/2013] [Indexed: 12/25/2022]
Abstract
Stereotactic body radiotherapy (SBRT) involves the treatment of extracranial primary tumors or metastases with a few, high doses of ionizing radiation. In SBRT, tumor kill is maximized and dose to surrounding tissue is minimized, by precise and accurate delivery of multiple radiation beams to the target. This is particularly challenging, because extracranial lesions often move with respiration and are irregular in shape, requiring careful treatment planning and continual management of this motion and patient position during irradiation. This review presents the rationale, process workflow, and technology for the safe and effective administration of SBRT, as well as the indications, outcome, and limitations for this technique in the treatment of lung cancer, liver cancer, and metastatic disease.
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Affiliation(s)
- John P Kirkpatrick
- Department of Radiation Oncology, Duke Cancer Institute, and the Durham VA Medical Center, Durham, North Carolina
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15
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Owen D, Laack NN, Mayo CS, Garces YI, Park SS, Bauer HJ, Nelson K, Miller RW, Brown PD, Olivier KR. Outcomes and toxicities of stereotactic body radiation therapy for non-spine bone oligometastases. Pract Radiat Oncol 2013; 4:e143-e149. [PMID: 24890360 DOI: 10.1016/j.prro.2013.05.006] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2013] [Revised: 05/20/2013] [Accepted: 05/22/2013] [Indexed: 12/13/2022]
Abstract
PURPOSE Stereotactic body radiation therapy (SBRT) is being applied more widely for oligometastatic disease. This technique is now being used for non-spine bony metastases in addition to liver, spine, and lung. However, there are few studies examining the toxicity and outcomes of SBRT for non-spine bone metastases. METHODS AND MATERIALS Between 2008 and 2012, 74 subjects with oligometastatic non-spine bony metastases of varying histologies were treated at the Mayo Clinic with SBRT. A total of 85 non-spine bony sites were treated. Median local control, overall survival, and progression-free survival were described. Acute toxicity (defined as toxicity <90 days) and late toxicity (defined as toxicity ≥90 days) were reported and graded as per standardized Common Toxicity Criteria for Adverse Events 4.0 criteria. RESULTS The median age of patients treated was 60 years. The most common histology was prostate cancer (31%) and most patients had fewer than 3 sites of disease at the time of simulation (64%). Most of the non-spine bony sites lay within the pelvis (65%). Dose and fractionation varied but the most common prescription was 24 Gy/1 fraction. Local recurrence occurred in 7 patients with a median time to failure of 2.8 months. Local control was 91.8% at 1 year. With a median follow-up of 7.6 months, median SBRT specific overall survival and progression-free survival were 9.3 months and 9.7 months, respectively. Eighteen patients developed acute toxicity (mostly grade 1 and 2 fatigue and acute pain flare); 9 patients developed grade 1-2 late toxicities. Two patients developed pathologic fractures but both were asymptomatic. There were no late grade 3 or 4 toxicities. CONCLUSIONS Stereotactic body radiation therapy is a feasible and tolerable treatment for non-spine bony metastases. Longer follow-up will be needed to accurately determine late effects.
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Affiliation(s)
- Dawn Owen
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN
| | - Nadia N Laack
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN
| | - Charles S Mayo
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN
| | | | - Sean S Park
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN
| | - Heather J Bauer
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN
| | - Kathryn Nelson
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN
| | - Robert W Miller
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN
| | - Paul D Brown
- The University of Texas MD Anderson Cancer Center, Houston, TX
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16
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Nieder C, Pawinski A, Dalhaug A. Continuous controversy about radiation oncologists' choice of treatment regimens for bone metastases: should we blame doctors, cancer-related features, or design of previous clinical studies? Radiat Oncol 2013; 8:85. [PMID: 23574944 PMCID: PMC3643865 DOI: 10.1186/1748-717x-8-85] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2013] [Accepted: 04/07/2013] [Indexed: 12/25/2022] Open
Abstract
Recent studies from Italy, Japan and Norway have confirmed previous reports, which found that a large variety of palliative radiotherapy regimens are used for painful bone metastases. Routine use of single fraction treatment might or might not be the preferred institutional approach. It is not entirely clear why inter-physician and inter-institution differences continue to persist despite numerous randomized trials, meta-analyses and guidelines, which recommend against more costly and inconvenient multi-fraction regimens delivering total doses of 30 Gy or more in a large number of clinical scenarios. In the present mini-review we discuss the questions of whether doctors are ignoring evidence-based medicine or whether we need additional studies targeting specifically those patient populations where recent surveys identified inconsistent treatment recommendations, e.g. because of challenging disease extent. We identify open questions and provide research suggestions, which might contribute to making radiation oncology practitioners more confident in selecting the right treatment for the right patient.
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Affiliation(s)
- Carsten Nieder
- Department of Oncology and Palliative Medicine, Nordland Hospital, Bodø, 8092, Norway.
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17
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Abstract
Palliative care is cited as providing improved communication, symptom control, treatment knowledge, and survival. The authors feel primary palliative care skills should be part of a physician's armamentarium.
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Affiliation(s)
- M. Jennifer Cheng
- Johns Hopkins Medical Institutions, Baltimore, MD; and Virginia Commonwealth University, Richmond, VA
| | - Lauren M. King
- Johns Hopkins Medical Institutions, Baltimore, MD; and Virginia Commonwealth University, Richmond, VA
| | - Erin R. Alesi
- Johns Hopkins Medical Institutions, Baltimore, MD; and Virginia Commonwealth University, Richmond, VA
| | - Thomas J. Smith
- Johns Hopkins Medical Institutions, Baltimore, MD; and Virginia Commonwealth University, Richmond, VA
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Dennis K, Makhani L, Zeng L, Lam H, Chow E. Single fraction conventional external beam radiation therapy for bone metastases: A systematic review of randomised controlled trials. Radiother Oncol 2013; 106:5-14. [DOI: 10.1016/j.radonc.2012.12.009] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2012] [Revised: 12/10/2012] [Accepted: 12/10/2012] [Indexed: 12/25/2022]
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