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 symptomsAccount for needs and performance status of

patientEstablish clear outcome goalCommunicate expected outcomeEnsure minimal radiation side effectsAccount for treatment complexity

Bone MetastasesCommon cause of pain and other symptomsBone metastases in 85% of people dying from

lung, breast and breast cancerLess 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 yearsIndications 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 localizedPain may be worse at nightWorsen with weight bearing or ambulationMay 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 functionMaintain structural integrityMaintain quality of life

Early 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: SurgerySurgical 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 statusControl of primaryAge < 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 monthsRTOG studies

CorticosteroidsUsual dose 4mg to 16mg dailyGive with concurrent RanitidineUsually improvement of PFS over first 7 daysReduce dose over 4 weeksAsymptomatic patients with limited oedema:

reserve for neurologic symptoms

Management

Whole Brain RadiotherapySurgical resectionRadiosurgery boostPost operative RTStereotactic 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 RadiotherapyLimited stage Small Cell Carcinoma Lung

Cumulative 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 Complications

Nausea/vomitingHair lossSomnolenceChange taste and smell

Late ComplicationsMost 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 expertiseappropriate 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 RadiotherapyOesophagitis: dysphagia and dyspepsiaNon productive coughL’Hermittes syndromeSkin reactionLethargy and malaise

Late complications of Radiotherapy

Pneumonitis (15%)Pulmonary fibrosis (30%)Oesophageal stricture, perforation or fistulae (1% -

2%)Cardiac

pericardial effusion, constrictive pericarditis, cardiomyopathy

Spinal cord myelopathy (usually < 1%)Brachial plexopathy (<1%)