7 INDICATIONS Pain relief from bone mets. Prevention of pathological # Spinal cord compression.Impending or actual obstruction hollow viscera.Brain mets.Control of Haemorrhage.Control of ulceration/ fungation.
8 A single treatment session Conventionally 1.8 – 2.0 Gy FractionA single treatment sessionConventionally 1.8 – 2.0 Gy
9 Hypofractionation Fewer fractions than conventional Higher dose per fractionShorter treatment timeIncreased probability of late effectsDecreased radiotherapy waiting times
10 Hypofractionationclinical evidence suggests that shorter fractionation schedules compared to more protracted schedules have the same effectiveness in symptom control of incurable cancer patients, particularly, for metastatic bone pain and multiple brain metastases.
12 Bony mets can cause: Pain Pathological fracture Spinal cord compressionHypercalcemiaLeading to debilitation and impaired quality of life
13 External beam radiation provides significant relief in 50-80% of patients and complete pain relief in 30 % of patients (ASTRO)
14 Factors affecting choice of fractionation regimen Performance statusPrognosisRisk for fracture or cord compressionSite to be treated
15 A literature review confirms similar rates of pain control using a single fraction versus a multiple fractions (50-85%). There are however higher retreatment rates for single fraction regimens.
16 Fractionation regimens 8 Gy in 1 fraction20 Gy in 5 fractions30 Gy in 10 fractions24 Gy in 6 fractionsEndpoints using pain relief, narcotic relief and quality of life measures show consistent similarity in the regimens
21 Comparison of median survival in 7 studies using the recursive partitioning analyses (RPA) classes (treatment was WBRT with or without local measures, none of the studies is limited to one particular cancer type).
22 Clinical Recommendations of DEGRO Breast Care (Basel). 2010; 5(6): 401–407.Published online 2010 December 8. doi: /
23 Cochrane Database Syst Rev. 2010 Jun 16;(6):CD006121. “Analysis of all included patients, SRS plus WBRT, did not show a survival benefit over WBRT alone. However, performance status and local control were significantly better in the SRS plus WBRT group. Furthermore, significantly longer OS was reported in the combined treatment group for RPA Class I patients as well as patients with single metastasis.”Cochrane Database Syst Rev Jun 16;(6):CDWhole brain radiation therapy (WBRT) alone versus WBRT and radiosurgery for the treatment of brain metastases
24 conventional fractionation can be used to avoid late neurotoxicity dexamethasone is the corticosteroid of choice for cerebral edemaanticonvulsants should not be prescribed prophylactically
26 Inform patients at high risk of developing bone metastases, patients with diagnosed bone metastases, or patients with cancer who present with spinal pain about the symptoms of MSCC(NICE)
27 Patients with cancer and any of the following symptoms suggestive of spinal metastases should seek medical attention immediately for assessment:• pain in the middle (thoracic) or upper (cervical) spine• progressive lower (lumbar) spinal pain• severe unremitting lower spinal pain• spinal pain aggravated by straining (for example, at stool, or when coughing or sneezing)• localized spinal tenderness• nocturnal spinal pain preventing sleep
28 Patient should be nursed flat with neutral spine alignment (including ‘log rolling’ with use of a bed pan for toilet) until bony and neurological stability are ensured and cautious remobilisation may begin
29 For patients with MSCC, once any spinal shock has settled and neurology is stable, carry out close monitoring and interval assessment during gradual sitting from supine to 60 degrees over a period of 3–4 hours
30 Offer conventional analgesia (including NSAIDs, non-opiate and opiate medication) as required to patients with painful spinal metastases in escalating doses as described by the WHO three-step pain relief ladder
31 Offer patients with vertebral involvement from myeloma or breast cancer bisphosphonates to reduce pain and the risk of vertebral fracture/collapse
32 Unless contraindicated (including a significant suspicion of lymphoma) offer all patients with MSCC a loading dose of at least 16 mg of dexamethasone as soon as possible after assessment, followed by a short course of 16 mg dexamethasone daily while treatment is being planned
33 If surgery is appropriate in patients with MSCC, attempt to achieve both spinal cord decompression and durable spinal column stabilityPatients with MSCC who have been completely paraplegic or tetraplegic for more than 24 hours should only be offered surgery if spinal stabilisation is required for pain relief
34 There should be urgent (within 24 hours) access to and availability of radiotherapy and simulator facilities in daytime sessions, 7 days a week for patients with MSCC requiring definitive treatment or who are unsuitable for surgery
35 Fractionation regimens 8 Gy in 1 fraction20 Gy in 5 fractions30 Gy in 10 fractions24 Gy in 6 fractions
37 Palliative radiotherapy a slice of the palliative pie
38 Palliative radiotherapy should be aimed as a “one stop approach”
39 Factors affecting utilization of palliative radiotherapy services Poor performance statusShort predicted life expectancyAccess to radiotherapy centresLimited oncology training of attending physiciansWaiting time for radiotherapy