Palliative Radiotherapy

“the active total care of patients whose disease is not responsive to curative treatment ….” WHO

About 30-45 % of patients receiving radiotherapy are palliative

GOALS OF PALLIATIVE RT control symptoms enhance quality of life optimize the patient’s limited remaining time guided by basic ethical principles and clinical based evidence

EMERGENCY INDICATIONS: Spinal cord compression Haemorrhage/bleeding Superior Vena caval obstruction Seizures/ Fitting

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.

A single treatment session Conventionally 1.8 – 2.0 Gy Fraction A single treatment session Conventionally 1.8 – 2.0 Gy

Hypofractionation Fewer fractions than conventional Higher dose per fraction Shorter treatment time Increased probability of late effects Decreased radiotherapy waiting times

Hypofractionation clinical 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.

Bony Metastases

Bony mets can cause: Pain Pathological fracture Spinal cord compression Hypercalcemia Leading to debilitation and impaired quality of life

External beam radiation provides significant relief in 50-80% of patients and complete pain relief in 30 % of patients (ASTRO)

Factors affecting choice of fractionation regimen Performance status Prognosis Risk for fracture or cord compression Site to be treated

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.

Fractionation regimens 8 Gy in 1 fraction 20 Gy in 5 fractions 30 Gy in 10 fractions 24 Gy in 6 fractions Endpoints using pain relief, narcotic relief and quality of life measures show consistent similarity in the regimens

The frequency and severity of side effects especially mucosal are a more of a function of radiation planning than radiotherapy dose

BRAIN METASTASES

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).

Clinical Recommendations of DEGRO Breast Care (Basel). 2010; 5(6): 401–407. Published online 2010 December 8. doi: 10.1159/000322661

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. 2010 Jun 16;(6):CD006121. Whole brain radiation therapy (WBRT) alone versus WBRT and radiosurgery for the treatment of brain metastases

conventional fractionation can be used to avoid late neurotoxicity dexamethasone is the corticosteroid of choice for cerebral edema anticonvulsants should not be prescribed prophylactically

Spinal cord compression

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)

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

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

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

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

Offer patients with vertebral involvement from myeloma or breast cancer bisphosphonates to reduce pain and the risk of vertebral fracture/collapse

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

If surgery is appropriate in patients with MSCC, attempt to achieve both spinal cord decompression and durable spinal column stability Patients 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

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

Fractionation regimens 8 Gy in 1 fraction 20 Gy in 5 fractions 30 Gy in 10 fractions 24 Gy in 6 fractions

Palliative radiotherapy a slice of the palliative pie

Palliative radiotherapy should be aimed as a “one stop approach”

Factors affecting utilization of palliative radiotherapy services Poor performance status Short predicted life expectancy Access to radiotherapy centres Limited oncology training of attending physicians Waiting time for radiotherapy