The Role of Palliative Radiotherapy for Patients with Cancer

1. The Role of Palliative Radiotherapy for Patients with Cancer John Childs Radiation Oncologist Auckland District Health Board 20th June 2012

2. Principles of PallativeTreatment 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

3. 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)

4. Bone Metastases: Prognosis • Median survival is usually short despite advances in system therapy • Lung cancer 6 months • Breast 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

5. 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)

14. Bone Metastases: Goal of Radiotherapy • Pain relief • Complete 50% to 60% • Overall 80% to 90% • Preservation of function • Maintain structural integrity • Maintain quality of life • Early intervention • Minimise side effects of analgesics

15. 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

16. Bone Metastases: Radiotherapy SchedulesThe Evidence Three 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

17. 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

18. 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

19. 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

24. 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

25. 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

26. Management • Whole Brain Radiotherapy • Surgical resection • Radiosurgery boost • Post operative RT • Stereotactic radiotherapy

27. 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 metastasis • Other disease stable • WBRT or SRS post surgery • Delay recurrence • Impact on survival uncertain

28. Unfavourable Prognosis • Whole Brain RT • Improve 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 • Efficacy • Neurologic symptoms improve in 70% • Neurologic deficits improve in 40% to 50%

29. Dose Schedule • Randomised trials have not shown significant differences with varying dose and fractions • Common schedules are: • 20Gy in 5 fractions • 30 GY in 10 fractions • 40 Gy in 15 fractions • Approach depends on: • Anticipated survival • Clinical performance status

30. Stereotactic Radiosurgery • Ability 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

31. Prophylactic Cranial Radiotherapy • Limited 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 Lung • Benefits less clear The benefits of PCI must be balanced against the toxicity and potential impact on quality of life

32. Complications of Radiation • Acute Complications • Nausea/vomiting • Hair loss • Somnolence • Change 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

33. Carcinoma Lung: Superior Venacaval Obstruction • Carcinoma 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)

34. Carcinoma Lung: superior venacaval obstruction • Emergency 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.

35. Carcinoma Lung Major Airway Obstruction with Stridor • Severe symptoms require urgent treatment • There are no randomised trials • Palliative 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

36. Acute Complications of Radiotherapy • Oesophagitis: dysphagia and dyspepsia • Non productive cough • L’Hermittes syndrome • Skin reaction • Lethargy and malaise

37. 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%)