The Role of Palliative Radiotherapy for

Patients with Cancer

John ChildsRadiation OncologistAuckland District Health Board20th June 2012

Principles of Pallative Treatment with Radiotherapy

Ensure metastasis is cause of symptoms

Account for needs and performance status of patient

Establish clear outcome goal

Communicate expected outcome

Ensure minimal radiation side effects

Account for treatment complexity

Bone Metastases

Common cause of pain and other symptoms

Bone metastases in 85% of people dying from lung, breast and breast cancer

Less common thyroid, melanoma, kidney and bowel cancer (3% to 15%)

Haematologic malignancy can be significant cause of bone pain (Myeloma and Lymphoma)

Bone Metastases: Prognosis

Median survival is usually short despite advances in system therapyLung cancer 6 monthsBreast and prostate (with bone metastases only) 2

to 4 years

Indications for radiotherapy

Pain, difficulty with ambulation and immobility, hypercalcaemia, pathologic fractures, neurologic deficits, anxiety, depression, spinal cord or nerve root compression, and general deterioration of quality of life

Clinical Features: Bone Metastases

Slowly progressive

Insidious pain

Often well localized

Pain may be worse at night

Worsen with weight bearing or ambulation

May radiate to other areas (does not necessarily indicate nerve impingement because radicular pain can also be caused by spasm of muscles that originate or insert near the area of disease)

Bone Metastases: Goal of Radiotherapy

Pain reliefComplete 50% to 60%Overall 80% to 90%

Preservation of function

Maintain structural integrity

Maintain quality of lifeEarly interventionMinimise side effects of analgesics

Bone Metastases: Radiotherapy Schedules

Various RT fractionation schedules 30 Gy in 10 fractions 20 Gy in five fractions single-fraction of 8 Gy

Single fraction using 8 Gy Equal palliation Improved patient convenience and cost effectiveness

compared Retreatment was necessary in approximately 20

percent

Bone Metastases: Radiotherapy Schedules

The EvidenceThree randomised trials comparing fractionated RT with single 8Gy

Dutch multicenter 8Gy vs. 24Gy/6 Pain relief 69% and 72% Median time to response 3 weeks Retreatment 25% vs. 7%

RTOG 8Gy vs. 30Gy/10 Pain relief 66% Retreatment 18% v. 9%

British 8Gy vs. 20Gy vs. 30Gy 78% response rate Median time to response 1 month

Bone Metastases: Surgery

Surgical fixation

Prior to EBRT to decrease pain and facilitate rehabilitation in symptomatic bone metastases causing

Fixation pathologic fracture involving the long bones or other weigh- bearing bones

Prophylactic fixation to prevent pathologic fractures prior to EBRT.

Inoperable fractures: EBRT may achieve pain relief alone

Bone Metastases: Other Approaches

Stereotactic radiotherapy (SBRT): especially spinal and paraspinal tumours

Radiopharmaceuticals: eg: strontium-89 [89Sr], samarium- 153

Bisphosphonates: Good evidence for breast and multiple myeloma. Current trials for prostate cancer.

Hemibody Irradiation

Cerebral Metastases

Very common site of metastases (autopsy studies 10% to 30%)

Common primary sites are lung, breast and melanoma

Increasing incidence in other cancers following chemotherapy

Increased detection with MRI scanning

Prognostic Assessment

Performance status

Control of primary

Age < 65 years

I (Karnofsky Performance score [KPS] ≥70, controlled primary, age <65 years, brain metastasis only) 7.1 month

II (not meeting requirements of classes I or III) 4.2 months

III (KPS <70) 2.3 months

RTOG studies

Corticosteroids

Usual dose 4mg to 16mg daily

Give with concurrent Ranitidine

Usually improvement of PFS over first 7 days

Reduce dose over 4 weeks

Asymptomatic patients with limited oedema: reserve for neurologic symptoms

Management

Whole Brain Radiotherapy

Surgical resection

Radiosurgery boost

Post operative RT

Stereotactic radiotherapy

Favourable Prognosis

Surgery: Single metastasis in a surgically accessible location Limited number of metastases.

Stereotactic RS:metastasis is smaller than 3 cm in a surgically inaccessible location, not suitable/declines more than one small metastasisOther disease stable

WBRT or SRS post surgeryDelay recurrence Impact on survival uncertain

Unfavourable Prognosis

Whole Brain RTImprove neurologic deficits Prevent any further deterioration of neurologic

function. Extent of improvement after WBRT directly related to

the time from diagnosis to radiation therapy: early treatment associated with a better outcome

EfficacyNeurologic symptoms improve in 70%Neurologic deficits improve in 40% to 50%

Dose Schedule

Randomised trials have not shown significant differences with varying dose and fractions

Common schedules are:20Gy in 5 fractions30 GY in 10 fractions40 Gy in 15 fractions

Approach depends on:Anticipated survivalClinical performance status

Stereotactic RadiosurgeryAbility to treat surgically inaccessible areas of

the brain, such as the brainstem

Noninvasiveness and suitability for outpatient treatment

Potential to treat multiple lesions

Cost-effectiveness compared to neurosurgical resection

Prophylactic Cranial Radiotherapy

Limited stage Small Cell Carcinoma LungCumulative incidence of brain metastases decreased

46%Absolute decrease in three-year cumulative incidence

of brain metastases (33% versus 59%) Increase in the three-year survival rate from 15.3% to

20.7%

Advanced Stage Small Cell Carcinoma LungBenefits less clear

The benefits of PCI must be balanced against the toxicity and potential impact on quality of life

Complications of Radiation

Acute ComplicationsNausea/vomitingHair lossSomnolenceChange taste and smell

Late Complications

Most patients have a limited survival however with longer survival there is a risk for debilitating late complications.

Leukoencephalopathy and brain atrophy, leading to neurocognitive deterioration and dementia

 Radiation necrosis, with symptoms related to the site of necrosis Normal pressure hydrocephalus, causing cognitive, gait and bladder

dysfunction Neuroendocrine dysfunction, most commonly hypothyroidism Cerebrovascular disease

Carcinoma Lung: Superior Venacaval

ObstructionCarcinoma lung most common cause (80%)

Initial investigation and priority of treatment

depends on severity of symptoms

Radiotherapy: relief of symptoms 80%

Most patients poor prognosis (<10%-15%

survive 2 years)

Carcinoma Lung: superior venacaval

obstructionEmergency management

severe or rapidly progressive symptoms

gross facial oedema and cerebral symptoms,

or associated stridor

Management High dose corticosteroid

considered for palliative radiotherapy

Other techniques ( venous and tracheobronchial stents, endobrachial laser or cryotherapy)

Where there is local expertise

appropriate for selected patients.

Carcinoma Lung Major Airway Obstruction with

Stridor

Severe symptoms require urgent treatment

There are no randomised trialsPalliative radiotherapy: 20Gy in 5

fractions or 30Gy in 10 fractions with high dose corticosteroids (grade c)

Endobronchial therapy is an option (laser and brachytherapy)

One randomised study no advantage over external beam: risk of major haemoptysis

Acute Complications of Radiotherapy

Oesophagitis: dysphagia and dyspepsia

Non productive cough

L’Hermittes syndrome

Skin reaction

Lethargy and malaise

Late complications of Radiotherapy

Pneumonitis (15%)

Pulmonary fibrosis (30%)

Oesophageal stricture, perforation or fistulae (1% -2%)

Cardiacpericardial effusion, constrictive pericarditis,

cardiomyopathy

Spinal cord myelopathy (usually < 1%)

Brachial plexopathy (<1%)