Radiation Therapy in Palliative Care Spring 2012

RADIATION THERAPYIN PALLIATIVE CARE

Christian Sinclair, MD, FAAHPM

Gentiva Health Systems

Spring 2012

Credits and Creative Commons Adopted with permission from

Jerry Baker, MD, Texas Oncology, Fort Worth, TXOriginally presented at the 2010 AAHPM Assembly

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Objectives

Understand the fundamentals of radiation therapy

Manage commonly expected side effects from radiation therapy

Identify three situations where palliative radiation may be effective in hospice patients

Questions

I don’t understand how radiation works to treat cancer. Can you explain it to me?

In which clinical situations is palliative radiation truly effective?

How do you decide how many treatments? Does radiation have to be so expensive? Any tips for working with a radiation

oncologist, or for simplifying the radiation process for patients?

Outline

Conventional Radiation Therapy Psychology of A Radiation Oncologist Palliative Radiation Therapy Hospice collaboration

Fundamentals

Curie’s discover Radium 1898 Biologic effects of ionizing radiation 1st ‘cure from radiation therapy 1899 1st radiation oncologists

DermatologistsLow-energy, low-output machines

Tissue Absorption

At any energy, x-rays are attenuated by tissue Absorbed dose decreases with depth Early treatments for deep tumors overdosed

superficial tissues

Advances in WWII

Higher energy toolsCobalt-60Linear accelerators

Penetrating radiationSkin-sparing effect

Without advanced imaging treatment focused on tumors easily seen

Volume-dose relationship

Greater tumor volume

requires

greater radiation dose

Dose-Damage Relationship

Higher radiation dose

increases risk for

damage to normal tissues

Finding BalanceBenefit of tumor control

versus

Risk of normal tissue injury

Selectivity of radiation effect:

Radiation damages DNALeads to cell death

Radiation not selective Variable DNA damage repair

Normal tissues repair damageMalignant cells do not repair well

Fractionation

Small does of radiation over time Most cancers sensitive to fractionated XRT Normal tissues protected by fractionation

↑ dose/fraction = ↑ risk late toxicity ↓ dose/fraction = ↓ risk late toxicity

3000 cGy in 15 fractions

(200 cGy/fraction)

≠3000 cGy in 10 fractions

(300 cGy/fraction)

Late Effects - Hypofractionation

YearsBrain and spinal cordFibrosisBowel

Months-yearsLung tissuelymphedema

Benefits - Hypofractionation

Radiation dose given quickly Faster tumor response Avoid multiple trips

Cancer Symptoms for XRT

Bleeding Pain Obstruction – Airway/Visceral Spinal cord compression Impending fractures Wounds Skin metastases

Bone Metastases

65-75% of advanced breast/prostate CA 30-40% of advanced lung cancer Skeletal-related events: pain, fracture,

compression, hypercalcemia SRE’s impact on QOL

Mobility and functional wellbeingDecrease ADL’sIncrease depression/anxietyIncrease opioid needs

Costa L et al. Support Care Cancer 2008;16:879‐889

Bone Metastases

HistoricallyPalliative XRT fractionated daily over 2-3 weeks

Over past 20 years9 large RCT (>4000 patients) all demonstrate

effectiveness of single fraction courses

Lutz ST et al. Cancer 2007;109:1462‐1470;

Coia LR et al. IJROBP 1988;14:1261‐1269.

Longer courses of treatment to higher total doses remain the most commonly use schedules in the United States. In a survey of 268 radiation oncologists in the United States

the physicians were asked about the management of a patient with bone metastases from breast cancer. The respondents recommended a median dose of 30 Gy given in

10 fractions, none recommended fewer than 7 treatments.

RTOG 97-14 – Painful Bone

Breast or Prostate cancer Painful bone mets Confirmed met by imaging Prognosis > 3 mos, KPS ≥ 40

RTOG 97-14 Results 1998-2002; 897 eligible patients 56% weight-bearing site, 72% pain score 7-10 ( severe), 27% receiving bisphosphonates, 57% solitary site Grade 2-4 toxicity: 17% (30 Gy) vs. 10% (8 Gy), p<.0001 Late toxicity: 4% overall, p=NS. Same path fx rates. Median survival 9 months, 41% 1y-OS

Pain relief: (e.g., pain inventory, narcotic use, ambulation) CR+PR 65% (1 fraction) vs. CR+PR 66% (10 fractions)

p=NS

ASTRO plenary: “800 cGy x 1 fraction is the new standard of care for palliation of painful bony metastases”

Cancer Care Ontario 2004

Practice guidelines “Where the treatment objective is pain relief, a

single 8 Gy treatment, prescribed to the appropriate target volume, is recommended as the standard dose-fractionation schedule for the treatment of symptomatic and uncomplicated bone metastases.”

Survey (Ontario practitioners)83% agreed with evidence interpretation75% agreed approved of guideline

Wu JS-Y et al. BMC Cancer 2004;4:71-78

Intl Survey of Practice Patterns Rad Onc in ASTRO, CARO, RANZCR 5 scenarios

101 schedules recommendedMedian dose 3000 cGy/10 fractionsUS Rad Onc 3x the number of fractions for same

indication

Fairchild A et al. IJROBP 2009;75:1501‐1510

RVU for XRT

3D Conformal XRT - $6,000-10,000 IMRT $12,000-20,000

10 vs. 1 Fraction

10 vs. 1 Fraction

Spinal Cord Compression

Previous concern with large doses per fraction in this setting (‘double injury’ of radiation and physical injury to cord)

Cochrane ReviewAmbulatory patient, stable spine: palliative

radiotherapy (short course suffices in patients with predicted survival <6 months)

Non-ambulatory patient, paraplegia <48 hrs, survival > 3 mos, 1 area of spine involved: consider surgery

All others: palliative radiotherapyGeorge R et al. Cochrane Database Syst Rev 2008;4:CD006716

Pathologic/Impending Fracture Very little published data Case‐by‐case decision making for palliative

radiotherapy Pain is better relieved with

surgery/stabilization in some cases

Trivia: Bone Mets Response to radiotherapy is not related to severity

of pretreatment pain [Kirou‐Mauro A et al. Int J Radiat Oncol Biol Phys 2008;71:1208‐

1212]

Pain flare occurs in 10‐25% of patients treated with radiotherapy (1‐2 days post‐treatment); readily controlled/prophylaxed with steroids [Hird A et al. Clin Oncol 2009;21:329‐335. Hird A et al. Int J Radiat

Oncol Biol Phys 2009]

QOL improves after radiotherapy for bone mets (pain, anxiety, sense of well‐being) [Chow E et al. Support Cancer Ther 2004;1:179‐184]

Lung Cancer

Second to bone metastases in available published data for hypofractionated radiotherapy: 13 RCTsShort courses [800 cGy x 1; 800 cGy x2) and long

courses of radiotherapy are comparable in relieving symptoms from advanced lung cancer (dyspnea, pain, hemoptysis, cough, SVC syndrome)

Total symptom score improved more with long courses (65.4% v. 77.1% at 1yr), and with a slight survival advantage (26.5% v. 21.7%)

Fairchild 2008; Lester 2006; Salvo 2009

Pelvic (and other) Bleeding

Single or hypofractionated regimens reported effective in prospective and retrospective reviews (RTOG: 1000 cGy x 1‐3 monthly; RTOG: 370 cGy BID x 2 days repeated q3 wks x2‐3; 800 cGy weekly x 3)

Hemoptysis improved in ~ 80% pts Pelvic bleeding improved in ~ 90‐100%

Cervix/vagina/vulvar/endometrial cancersBladder/prostate/urethral cancersColorectal cancer

Onsrud 2001; Pereira 2004; Tinger 2001

Gastrointestinal Cancers

Retrospective studies suggest hypofractionated radiotherapy is effective in:improving pain (86%)bleeding (70%)dysphagia (81%)

Acute nausea when treating upper abdomen may limit short courses MDACC: 14 fractions (3500 cGy) used most

commonly

Kim 2008; Murakami 2008; Hashimoto 2009

Head/Neck Cancers

Prospective and retrospective studies suggest hypofractionated radiotherapy is effective in improving pain, bleeding, airway obstruction,

wound progression, hoarseness, otalgia, dysphagia/odynophagiaRTOG regimen: 370 cGy BID x 2 days, repeated

q3 weeks up to 3 cycles‘Christie scheme’: 312 cGy x 12AIIMS regimen: 400 cGy x 5

Agarwal 2008; Al-mamgani 2009; Chen 2008; Mohanti 2004

Brain Metastases

Radiotherapy prolongs survivalSteroids: 1-2 months median OSXRT: 4-6 months median OS (RTOG)

Prevents death from neurologic progression Reduces/resolves neurologic symptoms

200 cGy x 20300 cGy x 10 (most common, ‘standard’)400 cGy x 5850 cGy x 2

Medical Director Strategies Meet in advance of need with your local radiation

oncologistConditional referrals: your group will refer patients when

patient convenience is maximized and cost is controlledReview cases with radiation oncologist prior to a formal

consult (prevents unnecessary patient transfers) Description of problem Any available imaging Records of previous cancer treatment

ESPECIALLY PRIOR RADIATION RECORDS

Rapid Access Palliative XRT

Canadian approach: combining separate clinic visitshypofractionated radiotherapy

2004‐2008, >3200 pts treated 52% pts bone mets Pain rapidly improved for >75% pts 100% patient satisfaction

Fairchild A et al. Support Care Cancer 2009;17:163‐70

Conclusions

Hospices and palliative care programs are providing care for patients with symptomatic advanced cancers

Palliative radiotherapy is effective, with limited side effects, and benefits some of these patients, when . . .

. . . it is convenient . . . it is reasonably priced . . . it is available

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