1
|
Keit E, Nanda R, Johnstone PAS. Thirty-day mortality as a metric for palliative radiotherapy in pediatric patients. Curr Opin Support Palliat Care 2024; 18:65-69. [PMID: 38170195 DOI: 10.1097/spc.0000000000000686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2024]
Abstract
PURPOSE OF REVIEW Thirty-day mortality (30DM) is an emerging consideration for determining whether terminally ill adult patients may benefit from palliative radiotherapy (RT). However, the efficacy and ethics of delivering palliative RT at the end of life (EOL) in children are seldom discussed and not well-established. RECENT FINDINGS Palliative RT is perhaps underutilized among patients ≤21 years old with rates as low as 11%. While effective when delivered early, clinical benefit decreases when administered within the last 30 days of life. Pediatric 30DM rates vary widely between institutions (0.7-30%), highlighting the need for standardized practices. Accurate prognosis estimation remains challenging and prognostic models specific to palliative pediatric patients are limited. Discordance between provider and patient/parent perceptions of prognosis further complicates decision-making. SUMMARY RT offers effective symptom control in pediatric patients when administered early. However, delivering RT within the last 30 days of life may provide limited clinical benefit and hinder optimal EOL planning and care. Early referral for palliative RT, preferably with fewer fractions (five or fewer), along with multidisciplinary supportive care, optimizes the likelihood of maintaining patients' quality of life. Prognosis estimation remains difficult, and improving patient and family understanding is crucial. Further research is needed to refine prognostic models and enhance patient-centered care.
Collapse
Affiliation(s)
- Emily Keit
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida, USA
| | | | | |
Collapse
|
2
|
Defining the expected 30-day mortality for patients undergoing palliative radiotherapy: a meta-analysis. Radiother Oncol 2022; 168:147-210. [DOI: 10.1016/j.radonc.2022.01.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Revised: 01/16/2022] [Accepted: 01/18/2022] [Indexed: 11/22/2022]
|
3
|
Tsang DS, Vargo JA, Goddard K, Breneman JC, Kalapurakal JA, Marcus KJ. Palliative radiation therapy for children with cancer. Pediatr Blood Cancer 2021; 68 Suppl 2:e28292. [PMID: 33818881 DOI: 10.1002/pbc.28292] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Revised: 03/03/2020] [Accepted: 03/14/2020] [Indexed: 11/08/2022]
Abstract
Radiation therapy (RT) is often used as a palliative treatment for children with recurrent malignant disease to ameliorate or prevent symptoms. However, no guidelines exist regarding the clinical indications or dose fractionation for palliative RT. The goal of this report is to provide guidelines for the use of palliative RT in children with cancer. In this guideline, appropriate indications for palliative RT, recommended dose-fractionation schedules, relevant toxicities, and avenues for future research are explored. RT is an effective palliative treatment for bone, brain, liver, lung, abdominopelvic and head-and-neck metastases, spinal cord compression, superior vena cava syndrome, and bleeding. Single-fraction regimens (8 Gy in one fraction) for children with short life expectancy are recommended for simple, uncomplicated bone metastases and can be considered for some patients with lung or liver metastases. A short, hypofractionated regimen (20 Gy in five fractions) may be used for other indications to minimize overall burden of therapy. There are little data supporting use of more prolonged fractionation regimens, though they may be considered for patients with very good performance status. Future research should focus on response and outcomes data collection, and to rigorously evaluate the role of stereotactic body RT in well-designed, prospective studies.
Collapse
Affiliation(s)
- Derek S Tsang
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, Canada
| | - John Austin Vargo
- Department of Radiation Oncology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Karen Goddard
- Department of Surgery, University of British Columbia, Vancouver, Canada
| | - John C Breneman
- Department of Radiation Oncology, University of Cincinnati, Cincinnati, Ohio
| | - John A Kalapurakal
- Department of Radiation Oncology, Northwestern Medicine, Chicago, Illinois
| | - Karen J Marcus
- Division of Radiation Oncology, Boston Children's Hospital and Dana-Farber Cancer Institute, Boston, Massachusetts
| |
Collapse
|
4
|
Rao AD, Figueiredo MLS, Yegya-Raman N, Sehgal S, Chen Q, Alcorn SR, Chen MJ, Ladra M, Villar R, Terezakis SA. Clinical practice and outcomes of palliative radiation therapy in pediatric oncology patients: An international comparison of experiences from two distinct countries and health care systems. Radiother Oncol 2019; 140:1-5. [PMID: 31174104 DOI: 10.1016/j.radonc.2019.05.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 05/15/2019] [Accepted: 05/17/2019] [Indexed: 12/25/2022]
Abstract
BACKGROUND AND PURPOSE This study describes clinical outcomes of palliative radiation therapy (RT) for children treated in distinct health-care environments-the US where there is advanced integration of palliative resources and Brazil, a country in the process of developing provisions for pediatric palliative care. METHODS AND MATERIALS Palliative RT cases of pediatric oncology patients aged ≤21-years from 2010 to 2016 in two Brazil-based and one US-based (Johns Hopkins Hospital, JHH) academic centers were reviewed in this study. RESULTS Eighty-eight pediatric patients were treated to 131 lesions with palliative RT. Forty-nine patients from the JHH cohort comprised 84 cases and 39 patients from the Brazil cohort comprised 46 cases. The most common indication for palliative RT was pain (55% overall, 39% Brazil, 63% JHH). Sixty-seven percent of patients experienced a complete (CR) or partial response (PR) to palliative RT, 12% reported stable symptoms (SS), and 22% reported progressive symptoms (PS). The median survival from the end of palliative RT was 3.6 months (95% confidence interval (CI), 2.3-4.8 months). When treated with palliative RT for pain, 83% of patients experience CR/PR, facilitating reduction or discontinuation of opiates in 46% of these patients. CONCLUSION Despite different practices, the clinical results using palliative RT for pediatric patients treated in two unique healthcare environments demonstrated it is an effective tool for pediatric oncology patients across systems.
Collapse
Affiliation(s)
- Avani Dholakia Rao
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins School of Medicine, Baltimore, USA
| | | | | | - Shuchi Sehgal
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins School of Medicine, Baltimore, USA
| | - Qinyu Chen
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins School of Medicine, Baltimore, USA
| | - Sara R Alcorn
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins School of Medicine, Baltimore, USA
| | - Michael J Chen
- Department of Radiation Oncology, Grupo de Apoio ao Adolescente e à Criança com Câncer, Brazil
| | - Matthew Ladra
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins School of Medicine, Baltimore, USA
| | - Rosangela Villar
- Department of Radiation Oncology, Centro Infantil Boldrini, São Paulo e Região, Brazil
| | - Stephanie A Terezakis
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins School of Medicine, Baltimore, USA.
| |
Collapse
|
5
|
Tseng YD, Gouwens NW, Lo SS, Halasz LM, Spady P, Mezheritsky I, Loggers E. Use of Radiation Therapy Within the Last Year of Life Among Cancer Patients. Int J Radiat Oncol Biol Phys 2018; 101:21-29. [PMID: 29487025 DOI: 10.1016/j.ijrobp.2018.01.056] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Revised: 01/03/2018] [Accepted: 01/16/2018] [Indexed: 12/18/2022]
Abstract
PURPOSE We examined radiation therapy (RT) use within the last year of life (LYOL). As palliative RT (PRT) has been well studied in patients with ≥6-week life expectancies, we hypothesized that PRT use would be constant over the LYOL, except for the last 30 days, when use would decline given lack of prospective data supporting it. MATERIALS AND METHODS At a single institution, 870 cancer patients died between October 2, 2014, and September 30, 2015, and had ≥3 evaluation and management visits within the LYOL. Claims and RT data were extracted and linked. Over the LYOL, we evaluated RT use by intent (curative vs palliative) and indications. RESULTS Within the LYOL, one-third of patients underwent RT in the last 365 days of life to 444 sites, which decreased to 24.3% and 8.5% in the last 180 and 30 days of life, respectively. Patients who received any RT in the last 365 days of life were younger at death and had a higher proportion of lung, sarcoma, and transplant disease groups. One-quarter of sites were irradiated with curative intent, which remained constant over the LYOL. In contrast, PRT was used at a supralinear rate, in which treatment of bone metastases and use of single-fraction PRT increased closer to death. CONCLUSIONS PRT appears to be disproportionately used closer to death, with an increasing proportion of irradiated sites being bone metastases. This may be secondary to increased symptoms from advanced cancer toward the end of life. As patients with very poor prognoses (eg, within 30 days of death) are generally not included in RT clinical trials, further studies are warranted to assess whether PRT for bone metastases at the end of life is efficacious.
Collapse
Affiliation(s)
- Yolanda D Tseng
- Department of Radiation Oncology, University of Washington, Seattle, Washington.
| | | | - Simon S Lo
- Department of Radiation Oncology, University of Washington, Seattle, Washington
| | - Lia M Halasz
- Department of Radiation Oncology, University of Washington, Seattle, Washington
| | - Phil Spady
- Department of Radiation Oncology, University of Washington, Seattle, Washington
| | | | - Elizabeth Loggers
- Seattle Cancer Care Alliance, Seattle, Washington; Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington; Division of Oncology, Department of Medicine, University of Washington, Seattle, Washington
| |
Collapse
|
6
|
Mak KS, Lee SW, Balboni TA, Marcus KJ. Clinical outcomes and toxicity following palliative radiotherapy for childhood cancers. Pediatr Blood Cancer 2018; 65. [PMID: 28853208 DOI: 10.1002/pbc.26764] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2017] [Revised: 07/04/2017] [Accepted: 07/15/2017] [Indexed: 12/25/2022]
Abstract
BACKGROUND Few reports of palliative radiotherapy (RT) for pedialltric malignancies have been published. We described clinical indications, outcomes, and toxicities for children who received palliative RT. PROCEDURE Pediatric patients (age ≤18 years) treated with palliative RT for incurable cancer from January 1 2008 to February 26, 2014 were included. Diagnosis, details of RT, treatment response, toxicity, and survival were retrospectively reviewed. RESULTS Forty-six patients received 76 RT courses. Fifteen patients (33%) had ≥2 courses. Median age at palliative RT was 10.3 years; 54% were male. The most common diagnoses were neuroblastoma (20%) and diffuse intrinsic pontine glioma (17%). The most common indications for RT were oligometastatic disease in asymptomatic patients (39%) and pain (25%). The most common treatment sites were brain (32%) and bone (29%). Median RT dose was 30 Gy. Median number of RT fractions was 12. Sixty-five treatment courses (86%) were delivered with fraction sizes ≥2.5 Gy. Twenty-seven treatment courses (36%) were given under general anesthesia. Median follow-up was 3.9 months. Grade 1-2 RT-related toxicity occurred in 21% of treatment courses and 4-8% up to 12 months after RT. Two patients had Grade 3 toxicity during RT (esophagitis). Of symptomatic patients, 91%, 73%, 58%, and 43% had improved or stable symptoms during RT and 0-3, 3-6, and 6-12 months afterwards, respectively. Median survival after palliative RT was 4.2 months. Four of 21 surviving patients (19%) had hospice care at last follow-up. CONCLUSIONS Palliative RT was well tolerated in children with incurable malignancies, with most cases associated with acceptable toxicity, and improved or stable symptoms.
Collapse
Affiliation(s)
- Kimberley S Mak
- Department of Radiation Oncology, Boston Medical Center, Boston University School of Medicine, Boston, MA
| | - Stephanie W Lee
- Department of Radiation Oncology, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA
| | - Tracy A Balboni
- Department of Radiation Oncology, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA.,Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA
| | - Karen J Marcus
- Department of Radiation Oncology, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA.,Department of Pediatric Oncology, Dana Farber/Boston Children's Cancer and Blood Disorders Center, Boston, MA
| |
Collapse
|
7
|
Park KR, Lee CG, Tseng YD, Liao JJ, Reddy S, Bruera E, Yennurajalingam S. Palliative radiation therapy in the last 30 days of life: A systematic review. Radiother Oncol 2017; 125:193-199. [DOI: 10.1016/j.radonc.2017.09.016] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Revised: 09/15/2017] [Accepted: 09/15/2017] [Indexed: 12/18/2022]
|
8
|
Varma S, Friedman DL, Stavas MJ. The role of radiation therapy in palliative care of children with advanced cancer: Clinical outcomes and patterns of care. Pediatr Blood Cancer 2017; 64. [PMID: 28000411 DOI: 10.1002/pbc.26359] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2016] [Revised: 09/01/2016] [Accepted: 09/09/2016] [Indexed: 12/25/2022]
Abstract
BACKGROUND There are few published data to guide the use and timing of palliative radiation therapy (RT) in children. We aimed to determine the clinical outcomes of palliative RT in children and the relationship with palliative care and hospice referrals. PROCEDURE A retrospective chart review was performed on all patients younger than 18 years who received palliative RT in our clinic from January 2005 to January 2015. RESULTS In the specified time period, 50 children underwent 83 courses of palliative RT. Median survival after treatment was 124 days (range, 1-1141 days). Fifteen courses were delivered to children in the last 30 days of life (dol). Palliative RT was successful in 89% of courses delivered before the last 30 dol versus 28% of courses delivered in the last 30 dol (p < 0.0001, Fisher's exact test). At the time of data collection, 43 children were deceased. Altogether, 88% of children who received palliative RT were also referred to our institution's pediatric palliative care team or to hospice at some time in their course. Of the children who died, 74% were referred to hospice and 34% were on hospice while receiving palliative RT. For children not already on hospice, the median time to hospice referral was 96 days after the last fraction (range, 0-924 days). CONCLUSIONS Palliative RT is effective in children with advanced cancer, although less so in the last 30 dol. With careful care coordination and multidisciplinary collaboration, RT can be successfully integrated into supportive and end-of-life care for children with advanced cancer.
Collapse
Affiliation(s)
- Sumeeta Varma
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Debra L Friedman
- Division of Pediatric Hematology-Oncology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Mark J Stavas
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, Tennessee
| |
Collapse
|
9
|
Palliative radiation therapy for superior vena cava syndrome in metastatic Wilms tumor using 10XFFF and 3D surface imaging to avoid anesthesia in a pediatric patient-a teaching case. Adv Radiat Oncol 2017; 2:101-104. [PMID: 28740919 PMCID: PMC5514223 DOI: 10.1016/j.adro.2016.12.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Accepted: 12/23/2016] [Indexed: 12/20/2022] Open
|