Use of palliative radiotherapy in brain and bone metastases (VARA II study)

The efficacy of three-dimensional conformal radiation therapy on pain and quality of life in patients with painful bone metastases: a prospective study

AIM

To evaluate the efficacy of radiation therapy in alleviating pain and improving the quality of life (QoL) with validated questionnaires in patients with painful bone metastases (BoM).

METHODS

This prospective, observational study recruited 167 patients with painful BoM who were treated with palliative radiotherapy (PRT) from February 2015 to February 2018. After the first clinical assessment, the patients filled out specific questionnaires and underwent a fast radiotherapy treatment within 48 hours. The patients were followed up for eight weeks.

RESULTS

The median age was 66.30 years. The most common primary cancer was lung cancer (31.1%). The most often prescribed scheme was 8 Gy in one fraction (70%). The patients experienced significant pain response and improved QoL compared with baseline, especially in the first two weeks after radiation. Overall, reduced pain and drug score were reported at two weeks of PRT in 68 (51.5%) and 37 (28%) of patients, respectively.

CONCLUSIONS

PRT is an effective treatment option for patients with painful BoM.

Evaluation of the utilization of external radiotherapy in the treatment of localized prostate cancer in Andalusia, Spain

BACKGROUND

Around 27,000 new cases of prostate cancer are diagnosed every year in Spain and 5400 die from this disease. Radiotherapy (RT), alone or combined, has proven to be effective as initial treatment in patients with localized disease. Our objective was to evaluate the use of external beam RT (EBRT) in our region, comparing the indication rate and irradiation rate and examining variability in its application among hospitals.

METHODS

We conducted a review of RT guidelines and indication studies for prostate cancer (% expected irradiation). Data were gathered from all twelve public healthcare centers in Andalusia (Spain) on RT-treated prostate cancer patients during 2013 (% actual irradiation) and from nine of the centers on RT discharge reports. Information was classified according to type of hospital, tumor risk category and RT treatment (technique, dosage, volume, toxicity).

RESULTS

The estimated RT rate was 67 % (1289/1917), 43 % were aged > 70 years, 44.7 % had ECOG performance status of 0); 44.7 % had high-risk tumors; 57 % underwent RT associated with hormone therapy; 70 % of patients receiving RT were treated with 3D planning (30 % IGRT); and doses were 70-76 Gy in 70 % of cases and >76 Gy in 10.7 %. Acute gastrointestinal and genitourinary toxicities were < grade 2 in 79 and 89 % of patients, respectively. An irradiation rate significantly below the mean for the study was found in four provinces. There was a significant difference among provinces in the distribution of risk groups.

CONCLUSIONS

Underutilization of EBRT was estimated to be around 30 % in prostate cancer patients, with an elevated variability in irradiation rates among hospitals related to differences in available technology and in the distribution of patients with different risk levels. These data should be a matter of concern to regional health managers, given the negative and measurable impact on the survival of patients.

Palliative Radiotherapy for the Management of Metastatic Cancer: Bone Metastases, Spinal Cord Compression, and Brain Metastases

Life expectancy and tumor characteristics should be considered when making treatment recommendations for palliative radiotherapy, which can be cost-effective and provide symptom relief.

Palliative radiotherapy for bone metastases from lung cancer: Evidence-based medicine?

To review current recommendations for palliative radiotherapy for bone metastases secondary to lung cancer, and to analyze surveys to examine whether global practice is evidence-based, English language publications related to best practice palliative external beam radiotherapy (EBRT) for bone metastases (BM) from lung cancer were sought via literature search (2003-2013). Additional clinical practice guidelines and consensus documents were obtained from the online Standards and Guidelines Evidence Directory. Eligible survey studies contained hypothetical case scenarios which required participants to declare whether or not they would administer palliative EBRT and if so, to specify what dose fractionation schedule they would use. There is no convincing evidence of differential outcomes based on histology or for spine vs non-spine uncomplicated BM. For uncomplicated BM, 8Gy/1 is widely recommended as current best practice; this schedule would be used by up to 39.6% of respondents to treat a painful spinal lesion. Either 8Gy/1 or 20Gy/5 could be considered standard palliative RT for BM-related neuropathic pain; 0%-13.2% would use the former and 5.8%-52.8% of respondents the latter (range 3Gy/1-45Gy/18). A multifraction schedule is the approach of choice for irradiation of impending pathologic fracture or spinal cord compression and 54% would use either 20Gy/5 or 30Gy/10. Survey results regarding management of complicated and uncomplicated BM secondary to lung cancer continue to show a large discrepancy between published literature and patterns of practice.

Health Resource Utilization Associated with Skeletal-Related Events in Patients with Advanced Prostate Cancer: A European Subgroup Analysis from an Observational, Multinational Study

This study aimed to increase the understanding of health resource utilization (HRU) associated with skeletal-related events (SREs) occurring in patients with bone metastases secondary to advanced prostate cancer. A total of 120 patients from Germany, Italy, Spain and the United Kingdom were enrolled in this observational study. They had bone metastases secondary to prostate cancer and had experienced at least one SRE in the 97 days before giving informed consent. HRU data were collected retrospectively for 97 days before enrolment and prospectively for up to 18–21 months. HRU, including the number and duration of inpatient hospitalizations, number of outpatient and emergency department visits and procedures, was independently attributed by investigators to an SRE. Of the 222 SREs included in this analysis, 26% were associated with inpatient stays and the mean duration per SRE was 21.4 days (standard deviation (SD) 17.8 days). Overall, 174 SREs (78%) required an outpatient visit and the mean number of visits per SRE was 4.6 (SD 4.6). All SREs are associated with substantial HRU. Preventing SREs in patients with advanced prostate cancer and bone metastases may help to reduce the burden to both patients and European healthcare systems.

Health resource utilization associated with skeletal-related events in patients with advanced breast cancer: results from a prospective, multinational observational study

Patients with breast cancer and bone metastases often experience skeletal complications (skeletal-related events [SREs]: pathologic fracture, radiation to bone, surgery to bone or spinal cord compression). Prospective data on the health resource burden of SREs are needed for planning healthcare requirements and estimating the value of new treatments, but limited data are available. This prospective, observational study collected health resource utilization (HRU) data independently attributed to SREs by investigators. Eligible patients had bone metastases secondary to breast cancer, life expectancy ≥6 months, Eastern Cooperative Oncology Group (ECOG) performance status ≤2, and at least one SRE in the 97 days before enrollment. Data, collected retrospectively for 97 days before enrollment and prospectively for 18–21 months, included number and duration of inpatient stays, outpatient visits, emergency room visits and procedures. Altogether, 223 patients were enrolled from Germany, Italy, Spain and the UK. Of the 457 SREs, 118 (25.8%) were associated with inpatient stays. The mean duration of stay was 19.5 (standard deviation [SD] 19.2) days per SRE (based on 117 SREs). Surgery to bone and spinal cord compression were the SREs most likely to require inpatient stays (77.8% and 57.9% of SREs, respectively), while radiation to bone was the least likely (9.7%). Spinal cord compression required the longest inpatient stay per event (34.2 [SD 30.2] days) and radiation to bone the shortest (14.3 [SD 10.2] days). Overall, 342 SREs (74.8%) required an outpatient visit, with radiation to bone the most likely (85.7%), and surgery to bone the least likely (42.6%). Radiation to bone was also associated with the greatest number of outpatient visits per event (6.8 [SD 6.7] visits). All SREs were associated with substantial HRU therefore, preventing SREs in patients with breast cancer may reduce the burden imposed on healthcare systems.

Cabazitaxel in castration resistant prostate cancer with brain metastases: 3 case reports

Prostate cancer is the most common non-cutaneous malignancy for men. The skeleton is the most common metastatic site but, following an improvement in survival, metastases in uncommon sites are being found more frequently in clinical practice, especially brain metastases. Despite the new drugs now available for metastatic castration resistant prostate cancer, no clinical evidence exists about their effectiveness on brain metastases. We describe the clinical history of 3 patients treated with cabazitaxel plus whole brain radiotherapy. These case reports demonstrate that cabazitaxel is highly active and well tolerated in brain metastases.

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?

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.