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International patterns of practice in palliative radiotherapy for painful bone metastases: evidence-based practice? Int J Radiat Oncol Biol Phys 2009; 75:1501-10. [PMID: 19464820 DOI: 10.1016/j.ijrobp.2008.12.084] [Citation(s) in RCA: 144] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2008] [Revised: 12/20/2008] [Accepted: 12/29/2008] [Indexed: 11/24/2022]
Abstract
PURPOSE Multiple randomized controlled trials have demonstrated the equivalence of multifraction and single-fraction (SF) radiotherapy for the palliation of painful bone metastases (BM). However, according to previous surveys, SF schedules remain underused. The objectives of this study were to determine the current patterns of practice internationally and to investigate the factors influencing this practice. METHODS AND MATERIALS The members of three global radiation oncology professional organizations (American Society for Radiology Oncology [ASTRO], Canadian Association of Radiation Oncology [CARO], Royal Australian and New Zealand College of Radiologists) completed an Internet-based survey. The respondents described what radiotherapy dose fractionation they would recommend for 5 hypothetical cases describing patients with single or multiple painful BMs from breast, lung, or prostate cancer. Radiation oncologists rated the importance of patient, tumor, institution, and treatment factors, and descriptive statistics were compiled. The chi-square test was used for categorical variables and the Student t test for continuous variables. Logistic regression analysis identified predictors of the use of SF radiotherapy. RESULTS A total of 962 respondents, three-quarters ASTRO members, described 101 different dose schedules in common use (range, 3 Gy/1 fraction to 60 Gy/20 fractions). The median dose overall was 30 Gy/10 fractions. SF schedules were used the least often by ASTRO members practicing in the United States and most often by CARO members. Case, membership affiliation, country of training, location of practice, and practice type were independently predictive of the use of SF. The principal factors considered when prescribing were prognosis, risk of spinal cord compression, and performance status. CONCLUSION Despite abundant evidence, most radiation oncologists continue to prescribe multifraction schedules for patients who fit the eligibility criteria of previous randomized controlled trials. Our results have confirmed a delay in the incorporation of evidence into practice for palliative radiotherapy for painful bone metastases.
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302
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Janjan N, Lutz ST, Bedwinek JM, Hartsell WF, Ng A, Pieters RS, Ratanatharathorn V, Silberstein EB, Taub RJ, Yasko AW, Rettenmaier A. Therapeutic Guidelines for the Treatment of Bone Metastasis: A Report from the American College of Radiology Appropriateness Criteria Expert Panel on Radiation Oncology. J Palliat Med 2009; 12:417-26. [DOI: 10.1089/jpm.2009.9633] [Citation(s) in RCA: 83] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Nora Janjan
- University of Texas, MD Anderson Cancer Center, Houston, Texas
| | | | | | | | - Andrea Ng
- Harvard University, Boston, Massachusetts
| | | | | | | | - Robert J. Taub
- Cedars Sinai Hospice Program, American Society of Clinical Oncology, Los Angeles, California
| | - Alan W. Yasko
- MED-Orthopedic Surgery, American Academy of Orthopaedic Surgeons, Chicago, Illinois
| | - Andrew Rettenmaier
- Department of Economics and the Private Enterprise Research Center, Texas A&M University, College Station, Texas
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303
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Gagnon GJ, Nasr NM, Liao JJ, Molzahn I, Marsh D, McRae D, Henderson FC. Treatment of spinal tumors using cyberknife fractionated stereotactic radiosurgery: pain and quality-of-life assessment after treatment in 200 patients. Neurosurgery 2009; 64:297-306; discussion 306-7. [PMID: 19057426 DOI: 10.1227/01.neu.0000338072.30246.bd] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE Benign and malignant tumors of the spine significantly impair the function and quality of life of many patients. Standard treatment options, including conventional radiotherapy and surgery, are often limited by anatomic constraints and previous treatment. Image-guided stereotactic radiosurgery using the CyberKnife system (Accuray, Inc., Sunnyvale, CA) is a novel approach in the multidisciplinary management of spinal tumors. The aim of this study was to evaluate the effects of CyberKnife stereotactic radiosurgery on pain and quality-of-life outcomes of patients with spinal tumors. METHODS We conducted a prospective study of 200 patients with benign or malignant spinal tumors treated at Georgetown University Hospital between March 2002 and September 2006. Patients were treated by means of multisession stereotactic radiosurgery using the CyberKnife as initial treatment, postoperative treatment, or retreatment. Pain scores were assessed by the Visual Analog Scale, quality of life was assessed by the SF-12 survey, and neurological examinations were conducted after treatment. RESULTS Mean pain scores decreased significantly from 40.1 to 28.6 after treatment (P < 0.001) and continued to decrease over the entire 4-year follow-up period (P < 0.05). SF-12 Physical Component scores demonstrated no significant change throughout the follow-up period. Mental Component scores were significantly higher after treatment (P < 0.01), representing a quality-of-life improvement. Early side effects of radiosurgery were mild and self-limited, and no late radiation toxicity was observed. CONCLUSION CyberKnife stereotactic radiosurgery is a safe and effective modality in the treatment of patients with spinal tumors. CyberKnife offers durable pain relief and maintenance of quality of life with a very favorable side effect profile.
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Affiliation(s)
- Gregory J Gagnon
- Department of Radiation Medicine, Georgetown University Hospital, Washington, District of Columbia, USA
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304
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Gutfeld O, Kretzler AE, Kashani R, Tatro D, Balter JM. Influence of rotations on dose distributions in spinal stereotactic body radiotherapy (SBRT). Int J Radiat Oncol Biol Phys 2009; 73:1596-601. [PMID: 19306757 PMCID: PMC2688767 DOI: 10.1016/j.ijrobp.2008.12.025] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2008] [Revised: 10/23/2008] [Accepted: 12/08/2008] [Indexed: 10/21/2022]
Abstract
PURPOSE To evaluate the impact of rotational setup errors on dose distribution in spinal stereotactic body radiotherapy (SBRT). METHODS AND MATERIALS Thirty-nine cone beam computed tomography (CBCT) scans from 16 SBRT treatment courses were analyzed. Alignment (including rotation) to the treatment planning computed tomography was performed, followed by translational alignment that reproduced the actual positioning. The planned fluence was then applied to determine the delivered dose to the targets and organs at risk. RESULTS The mean planning target volume (PTV) was 71.01 mL (SD +/- 60.05; range, 22.62-250.65 mL). Prescribed dose (to the 62-82% isodose) was 14-30 Gy in one to six fractions. The average rotational displacements were 0.38 +/- 1.21, 1.12 +/- 1.82, and -0.51 +/- 2.0 degrees with maximal rotations of -4.29, 5.76, and -6.64 degrees along the x (pitch), y (yaw), and z (roll) axes, respectively. PTV coverage changed by an average of -0.07 Gy (SD +/- 0.20 Gy) between the rotated and the original plan, representing 0.92% of prescription dose (SD +/- 2.65%). For the spinal cord, planned with 2-mm expansion to create a planning organ at risk volume (PRV), the difference in minimum dose to the upper 10% of the PRV volume was 0.03 +/- 0.3 Gy (maximum, 0.9 Gy). Other organs at risk saw insignificant changes in dose. CONCLUSIONS PRV expansion generally assures safe treatment delivery in the face of typically encountered rotations. Given the variability of delivered dose within this expansion for certain cases, caution should be taken to properly interpret doses to the cord when considering clinical dose limits.
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Affiliation(s)
- Orit Gutfeld
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI 48109-5010, USA
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305
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Sande TA, Ruenes R, Lund JA, Bruland OS, Hornslien K, Bremnes R, Kaasa S. Long-term follow-up of cancer patients receiving radiotherapy for bone metastases: results from a randomised multicentre trial. Radiother Oncol 2009; 91:261-6. [PMID: 19307034 DOI: 10.1016/j.radonc.2009.02.014] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2009] [Revised: 02/05/2009] [Accepted: 02/15/2009] [Indexed: 01/13/2023]
Abstract
BACKGROUND AND PURPOSE The aim of this study was to compare the need for re-irradiation, rates of pathological fractures, and spinal cord compressions in patients randomised to single-fraction radiotherapy (8 Gy x 1) or multiple-fraction therapy (3 Gy x 10) and with a long-term follow-up. The underlying hypothesis was that single-fraction and multiple-fraction regimens are equally effective. MATERIAL AND METHODS The present study reports on the Norwegian sub sample of an international large prospective-randomised multicentre study. One hundred and eighty patients with painful skeletal metastases in four Norwegian hospitals were randomised to receive single-fraction (8 Gy x 1) or multiple-fraction (3 Gy x 10) radiotherapy. RESULTS Patients in the single-fraction arm received significantly more re-irradiations as compared to the multiple-fraction arm (27% versus 9%, p=0.002). There were no significant differences in the rate of pathological fractures (5% versus 5%, p=1.00) or spinal cord compressions (1% versus 4%, p=0.37) between the two treatment groups. CONCLUSION The present study indicates no difference between radiotherapy with 8 Gy x 1 and 3 Gy x 10 for the majority of patients with painful bone metastases, also in a long-term perspective. Importantly, the patients in this study were followed up until death, and the trial showed no disadvantage for 8 Gy x 1 compared to 3 Gy x 10. Despite the fact that single-fraction treatment will imply an approximately 2.5-fold greater need for re-irradiation, single-fraction treatment is considered more convenient for the patients and more cost-effective for the radiotherapy departments.
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Affiliation(s)
- Tonje Anette Sande
- Faculty of Medicine, Norwegian University of Technology and Science, Trondheim, Norway
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306
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Papatheofanis FJ, Williams E, Chang SD. Cost-utility analysis of the cyberknife system for metastatic spinal tumors. Neurosurgery 2009; 64:A73-83. [PMID: 19165078 DOI: 10.1227/01.neu.0000341205.37067.de] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE Using decision analysis, a cost-utility study evaluated the cost-effectiveness of CyberKnife (Accuray, Inc., Sunnyvale, CA) stereotactic radiosurgery (SRS) in comparison to external beam radiation therapy in the treatment of metastatic spinal malignancies. METHODS The published literature provided evidence on the effectiveness of the comparator interventions in the absence of primary outcomes data. Costs of care were derived from Centers for Medicare and Medicaid Services fee schedules. A Markov model was constructed from the payer perspective to simulate the outcomes of patients undergoing nonchemotherapeutic interventions for metastatic spinal tumors. Because cancer therapies bear significant health and economic consequences, the impact of treatment-related toxicities was integrated into the model. Given the terminal nature of these conditions and the limited life expectancy of the patient population, the time horizon for the analysis was limited to 12 months. RESULTS Patients treated with CyberKnife SRS gained an additional net health benefit of 0.08 quality-adjusted life year; the calculated cost of CyberKnife SRS was $1933 less than external beam radiation therapy for comparable effectiveness. The incremental cost per benefit for this strategy ($41 500 per quality-adjusted life year) met payers' willingness-to-pay criteria. CONCLUSION Cost-utility analysis demonstrated that CyberKnife SRS was a superior, cost-effective primary intervention for patients with metastatic spinal tumors compared with conventional external beam radiation therapy.
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Affiliation(s)
- Frank J Papatheofanis
- Division of Health Policy, Department of Radiology and Economics, Rebecca and John Moores Cancer Center, University of California, San Diego, California 92103-8758, USA.
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307
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Thariat J, Castelli J, Chanalet S, Marcie S, Mammar H, Bondiau PY. CYBERKNIFE STEREOTACTIC RADIOTHERAPY FOR SPINAL TUMORS. Neurosurgery 2009; 64:A60-6. [DOI: 10.1227/01.neu.0000339129.51926.d6] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
OBJECTIVE
For para- and intraspinal tumors, precise spinal cord delineation is critical for CyberKnife (Accuray, Inc., Sunnyvale, CA) stereotactic radiotherapy. We evaluated whether computed tomographic (CT) myelography is superior to magnetic resonance imaging (MRI) for accurate spinal cord delineation. Treatment parameters and short-term outcome and toxicity are also presented.
METHODS
The planning CT scan, the gadolinium-enhanced, T1-weighted, 3-dimensional (3D) fast imaging employing steady-state acquisition MRI scan, and the CT myelogram were fused before volume-of-interest delineation. The planning target volume margin was less than 1 mm using the Xsight Spine tracking system (Accuray). We present data from 11 heavily pretreated patients who underwent CyberKnife stereotactic radiosurgery between November 2006 and January 2008.
RESULTS
Spatial resolution was 0.46 and 0.93 mm/pixel for CT myelography and 3D-fast imaging employing steady-state acquisition MRI, respectively. The contrast between cerebrospinal fluid and spinal cord was excellent with CT myelography. A transient postmyelography headache occurred in 1 patient. The mean gross tumor volume was 51.1 mL. The mean prescribed dose was 34 Gy in 4 fractions (range, 2–7 fractions) with 147 beams (range, 79–232 beams) to the 75% reference isodose line (range, 68–80%), covering 95% (range, 86–99%) of the gross tumor volume with a mean conformity index of 1.4 (range, 1.1–1.8). No short-term toxicity on the spinal cord was noted at 1- to 6-months of follow-up.
CONCLUSION
CT myelography was more accurate for spinal cord delineation than 3D-fast imaging employing steady-state acquisition MRI (used for its myelographic effect), particularly in the presence of ferromagnetic artifacts in heavily pretreated patients or in patients with severe spinal compression. Because other MRI sequences (T2 and gadolinium-enhanced T1) provide excellent tumor characterization, we suggest trimodality imaging for spinal tumor treatment to yield submillimetric delineation accuracy. Combined with CyberKnife technology, CT myelography can improve the feasibility of dose escalation or reirradiation of spinal tumors in selected patients, thereby increasing local control while avoiding myelopathy. Further follow-up and prospective studies are warranted.
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Affiliation(s)
- Juliette Thariat
- Department of Radiation Oncology, Antoine Lacassagne Anti-Cancer Center, Sophia Antipolis University, Nice, France
| | - Joel Castelli
- Department of Radiation Oncology, Antoine Lacassagne Anti-Cancer Center, Sophia Antipolis University, Nice, France
| | - Stephane Chanalet
- Department of Radiodiagnostics, University Hospital Pasteur, Nice, France
| | - Serge Marcie
- Department of Radiation Oncology, Antoine Lacassagne Anti-Cancer Center, Sophia Antipolis University, Nice, France
| | - Hamid Mammar
- Department of Radiation Oncology, Antoine Lacassagne Anti-Cancer Center, Sophia Antipolis University, Nice, France
| | - Pierre-Yves Bondiau
- Department of Radiation Oncology, Antoine Lacassagne Anti-Cancer Center, Sophia Antipolis University, Nice, France
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308
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A dosimetric comparison of different treatment plans of palliative spinal bone irradiation: analysis of dose coverage with respect to ICRU 50 Report. JOURNAL OF EXPERIMENTAL & CLINICAL CANCER RESEARCH : CR 2009; 28:2. [PMID: 19128500 PMCID: PMC2636764 DOI: 10.1186/1756-9966-28-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/17/2008] [Accepted: 01/07/2009] [Indexed: 11/10/2022]
Abstract
BACKGROUND This study aimed to analyze three-dimensional (3D) dosimetric data of conventional two-dimensional (2D) palliative spinal bone irradiation using different reference points and treatment plans with respect to the International Commission on Radiation Units and Measurements (ICRU) Report 50. METHODS Forty-five simulation CT scans of 39 patients previously treated for thoraco-lumbar spinal bone metastases were used. Three different treatment plans were created: (1) single posterior field plans using the ICRU reference points (ICRUrps); (2) single posterior field plans using the International Bone Metastasis Consensus Working Party reference points (IBMCrps); (3) two opposed anterior-posterior (AP-PA) field plans using the ICRUrps. The intended dose range for planning target volume (PTV) was 90% to 110% of the prescribed dose for AP-PA field plans. Cumulative dose-volume histograms were generated for each plan, and minimum, maximum and mean doses to the PTV, medulla spinalis, esophagus and intestines were analyzed. RESULTS The mean percentages of minimum, maximum and mean PTV doses +/- standard deviation were, respectively, 91 +/- 1.3%, 108.8 +/- 1.3% and 99.7 +/- 1.3% in AP-PA field plans; 77.3 +/- 2.6%, 122.2 +/- 4.3% and 99.8 +/- 2.6% in ICRUrp single field plans; and 83.7 +/- 3.3%, 133.9 +/- 7.1% and 108.8 +/- 3.3% in IBMCrp single field plans. Minimum doses of both single field plans were significantly lower (p < 0.001) while maximum doses were significantly higher (p < 0.001) than AP-PA field plans. Minimum, maximum and mean doses were higher in IBMCrp single field plans than in ICRUrp single field plans (p < 0.001). The mean medulla spinalis doses were lower in AP-PA field plans than single posterior field plans (p < 0.001). Maximum doses for medulla spinalis were higher than 120% of the prescribed dose in 22 of 45 (49%) IBMCrp single field plans. Mean esophagus and intestinal doses were higher (p < 0.001) in AP-PA field plans than single field plans, however, less than 95% of the prescribed dose. CONCLUSION In palliative spinal bone irradiation, 2D conventional single posterior field radiotherapy did not accomplish the ICRU Report 50 recommendations for PTV dose distribution, while the AP-PA field plans did achieve the intended dose ranges with a homogenous distribution and reasonable doses to the medulla spinalis, esophagus and intestines.
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309
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Abstract
Radiotherapeutic management of vertebral metastases varies based on the extent of disease within the spine and systemically, the histology of the tumor, and the life expectancy of the patient. The goals of pain reduction, structural stability of the axial skeleton, and maintenance of local control for the remainder of the patient's life guide the decision to proceed with a short simple course of standard therapy or a more complex approach with stereotactic regimens. The complex and rigorous processes involved in stereotactic radiotherapy for the spine require close cooperation among the radiation oncologist, neurosurgeon, orthopedic surgeon, and medical oncologist, but the clinical results show that the result is an enhanced quality of life for the patient.
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Affiliation(s)
- Patrick S Swift
- Radiation Oncology, Alta Bates Comprehensive Cancer Center, 2001 Dwight Way, Berkeley, CA 94704, USA.
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310
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Abstract
As survival time increases for many cancers, it is likely that the incidence and prevalence of spinal metastases will increase also. Given that most patients first present with solitary lesions in the spine, proper initial diagnosis and management are of paramount importance in minimizing pain, improving neurologic function, and potentially lengthening survival. Although pain control and standard radiation are still used, spinal stereotactic radiosurgery, vertebroplasty and kyphoplasty, and spinal cord decompression and fusion are now consistently used in aggressive management and offer exciting preliminary results.
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Affiliation(s)
- Daniel M Sciubba
- Department of Neurosurgery, Johns Hopkins University, Baltimore, MD, USA.
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311
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312
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Pradier O, Bouchekoua M, Albargach N, Muller M, Malhaire JP. Radiothérapie des métastases osseuses : quel est le meilleur schéma de radiothérapie ? Cancer Radiother 2008; 12:837-41. [DOI: 10.1016/j.canrad.2008.06.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2008] [Accepted: 06/05/2008] [Indexed: 11/27/2022]
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313
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Ratanatharathorn V, Peñagarícano JA. Management of Bone Metastases. Radiat Oncol 2008. [DOI: 10.1007/978-3-540-77385-6_43] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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314
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Randomised study of single dose (8 Gy vs. 6 Gy) of analgesic radiotherapy plus zoledronic acid in patients with bone metastases. Clin Transl Oncol 2008; 10:281-7. [PMID: 18490245 DOI: 10.1007/s12094-008-0198-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVE To assess the effectiveness of a single dose of radio therapy (8 Gy vs. 6 Gy) plus zoledronic acid in cancer patients with bone metastases in treating pain; quality of life, time to onset of skeletal events and functional status. MATERIAL AND METHODS A total of 139 patients from 22 Spanish hospitals were randomly assigned to: Group A, administered a single dose of 8 Gy+zoledronic acid (4 mg iv, in 15-min infusions), and Group B, administered a single dose of 6 Gy+zoledronic acid (4 mg iv, in 15-min infusions). The main variable was pain, which was assessed with the Visual Analogue Pain Scale (VAS) in supine, seated and standing positions. RESULTS There was a total of 118 patients for intention to treat (n=67 in Group A and n=51 in Group B). The most frequent primary neoplasms were the lung (29.66%), prostate (22.03%) and breast (21.19%). Sixty patients were analysed per protocol, n=34 in group A and n=26 in group B. Improvements were observed in the VAS scores for pain in all three positions. The mean time to onset of the event was greater (p=0.0211) in Group A than in Group B (122 vs. 81.62 days). Functional status improved in Group A, and quality of life improved in both groups. CONCLUSION The two groups achieved similar levels of pain control in supine, seated and standing positions. Quality of life also improved in both groups. However, the higher dose (8 Gy dose) in combination with zoledronic acid is associated with a longer period without skeletal events.
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315
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Lebret T, Méjean A. Physiopathologie, diagnostic et prise en charge des métastases osseuses du cancer de prostate. Prog Urol 2008; 18 Suppl 7:S349-56. [DOI: 10.1016/s1166-7087(08)74566-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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316
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Tharmalingam S, Chow E, Harris K, Hird A, Sinclair E. Quality of life measurement in bone metastases: A literature review. J Pain Res 2008; 1:49-58. [PMID: 21197288 PMCID: PMC3004617 DOI: 10.2147/jpr.s4572] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Quality of life (QOL) has become an important consideration in the care of patients with bone metastases as prevalence, incidence and patient survival are on the rise. As a result, more interventional studies now measure patient’s QOL as a meaningful endpoint. However, well-developed bone metastases specific quality of life instruments are lacking. A literature review was conducted to better understand the nature of QOL instruments used in bone metastases trials. A total of 47 articles evaluating QOL in patients with bone metastases were identified. Twenty-five different instruments were used to evaluate QOL with study-designed questionnaires and the EORTC QLQ-C30 being most commonly employed. Many studies used more than one scale or instrument to measure QOL. This makes it difficult to compare QOL in bone metastases patients across studies and come to any formal conclusions. Therefore, this review demonstrates the need to develop a bone module that can be used across countries in future clinical trials.
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Affiliation(s)
- Sukirtha Tharmalingam
- Rapid Response Radiotherapy Program, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
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317
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Abstract
PURPOSE OF REVIEW This review addresses the latest advances in radiation treatment for cancer pain. RECENT FINDINGS There is reluctance worldwide to adopt single fraction radiotherapy as standard practice. This is well summarized by a review article reporting on surveys on practice patterns among radiation oncologists worldwide. It was suggested by the Tasman Radiation Oncology Group trial, however, that patients with neuropathic pain may need multiple treatments. Patients with bone metastases may outlive the benefits of palliative radiation and require re-irradiation. A recent report from the Dutch Bone Metastasis Study confirmed the effectiveness of re-irradiation in both responders and nonresponders to initial radiation therapy. Effects of palliative radiotherapy on function and quality of life have been explored in various studies but with disparate conclusions. This may stem from a lack of a good, patient-based instrument with which to measure quality of life. A project by the European Organisation for Research and Treatment of Cancer Quality of Life Group is currently under way to develop a bone metastases module. Patients receiving single fraction radiotherapy may be at greater risk for pain flare. SUMMARY Patients with uncomplicated bone metastases can be effectively palliated with single fraction radiotherapy.
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Affiliation(s)
- Edward Chow
- Department of Radiation Oncology, University of Toronto, Toronto Sunnybrook Regional Cancer Centre, Toronto, Ontario, Canada.
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318
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Li KK, Sinclair E, Pope J, Farhadian M, Harris K, Napolskikh J, Yee A, Librach L, Wynnychuk L, Danjoux C, Chow E, Bone OBOT, Team M. A multidisciplinary bone metastases clinic at Toronto Sunnybrook Regional Cancer Centre - A review of the experience from 1999 to 2005. J Pain Res 2008; 1:43-8. [PMID: 21197287 PMCID: PMC3004611 DOI: 10.2147/jpr.s4573] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Our objective in this study was to review the experience of a one-stop multidisciplinary bone metastases clinic (BMC) that offers a coordinated multidisciplinary approach to the care of cancer patients with bone metastases in a tertiary cancer centre. Patients with symptomatic bone metastases were referred to BMC and assessed by a team of specialists in various disciplines - interventional radiology, orthopedic surgery, palliative medicine, and radiation oncology. At initial consultation, patient demographics, reasons for referral, and case disposition were recorded. From January 1999 to February 2005, a total of 272 patients with bone metastases were referred to the BMC. The median age was 65 years (range 28-95) and median KPS score at consultation was 60 (range 30-90). The majority of patients came from home (74%), while others came from a nursing home or the hospital (9%). Almost a third (28%) of patients had 2 or more reasons of referral, yielding a total of 354 reasons. The most common reason for referral was bone pain (42%), bone metastases (21%), high risk for pathological fracture (12%), and pathological fracture (10%). Of the 272 patients who received consultation, 40% received palliative radiotherapy, 19% received interventional surgery, 7% were referred to other support services such as palliative care, physiotherapy, and 7% had further investigation or imaging. A multidisciplinary clinic is useful for co-coordinating the management of bone metastatic disease in symptomatic patients.
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Affiliation(s)
- Kathy K Li
- Bone Metastases Site Group, Toronto- Sunnybrook Regional Cancer Centre, University of Toronto, Toronto, ON, Canada
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319
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Sheehan JP, Jagannathan J. Review of spinal radiosurgery: a minimally invasive approach for the treatment of spinal and paraspinal metastases. Neurosurg Focus 2008; 25:E18. [DOI: 10.3171/foc/2008/25/8/e18] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Intracranial radiosurgery has been proved effective for the treatment of brain metastasis. The treatment of paraspinal and spinal metastasis with spinal radiosurgery represents a natural extension of the principles of intracranial radiosurgery. However, spinal radiosurgery is a far more complicated process than intracranial radiosurgery. Larger treatment volumes, numerous organs at risk, and the inability to utilize rigid, frame-based immobilization all contribute to the substantially more complex process of spinal radiosurgery.
Beyond the convenience of a shorter duration of treatment for the patient, spinal radiosurgery affords a greater biological equivalent dose to a metastatic lesion than conventional radiotherapy fractionation schemes. This appears to translate into a high rate of tumor control and fast pain relief for patients. The minimally invasive nature of this approach is consistent with trends in open spinal surgery and helps to maintain or improve a patient's quality of life. Spinal radiosurgery has expanded the neurosurgical treatment armamentarium for patients with spinal and paraspinal metastasis.
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320
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Sahgal A, Larson DA, Chang EL. Stereotactic body radiosurgery for spinal metastases: a critical review. Int J Radiat Oncol Biol Phys 2008; 71:652-65. [PMID: 18514775 DOI: 10.1016/j.ijrobp.2008.02.060] [Citation(s) in RCA: 214] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2007] [Revised: 02/06/2008] [Accepted: 02/13/2008] [Indexed: 12/13/2022]
Affiliation(s)
- Arjun Sahgal
- Department of Radiation Oncology, Sunnybrook Odette Cancer Center, University of Toronto, Toronto, ON, Canada
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Randomized clinical trial with two palliative radiotherapy regimens in painful bone metastases: 30 Gy in 10 fractions compared with 8 Gy in single fraction. Radiother Oncol 2008; 89:150-5. [PMID: 18556080 DOI: 10.1016/j.radonc.2008.05.018] [Citation(s) in RCA: 133] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2007] [Revised: 05/14/2008] [Accepted: 05/17/2008] [Indexed: 01/13/2023]
Abstract
BACKGROUND AND PURPOSE The aim was to demonstrate similar pain relief with two schedules of radiotherapy for painful bone metastases. MATERIALS AND METHODS A total of 160 patients were assigned to receive a single 8-Gy fraction or 30 Gy in 10 fractions. Pain intensity was measured on an ordinal pain scale of 0-10. Partial response was defined as a pain reduction of two points or more and complete response as a pain score of zero at the treated area. Response follow-up was at 3, 12, 24 and 48 weeks. RESULTS The overall response was 75% in the 8-Gy arm and 86% in the 30-Gy arm. Complete response and partial response rates were 15% and 60% in the 8-Gy arm, 13% and 73% in the 30-Gy arm. Acute toxicity was of 18% in the 30-Gy arm and of 12% in the 8-Gy arm. These differences were not statistically significant. The re-treatment rate was 28% vs 2% in the 8-Gy and 30-Gy arms, respectively, these were statistically significant. CONCLUSIONS A single-fraction regimen of 8 Gy was as safe and effective as a multifraction regimen of 30 Gy for painful bone metastases in terms of pain relief.
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322
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Lagrange JL, Pan C, Calitchi É, Diana C, Muresan M, Wu JF, El Monkles H, Wang XW, Lu H. Radiothérapie pratique des métastases osseuses symptomatiques. ACTA ACUST UNITED AC 2008. [DOI: 10.1016/j.rhum.2008.02.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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323
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The changing landscape of the medical management of skeletal metastases in nonsmall cell lung cancer. Curr Opin Oncol 2008; 20:155-61. [PMID: 18300765 DOI: 10.1097/cco.0b013e3282f54cf2] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Skeletal metastases are a frequent site of involvement for patients with metastatic nonsmall cell lung cancer. Skeletal metastases may result in skeletal-related events. These complications typically result in significant morbidity for patients and substantially increase the economic costs associated with the treatment of patients with skeletal metastases. The management of skeletal metastases in patients with nonsmall cell lung cancer is evolving as improved treatments and monitoring become available. RECENT FINDINGS In recent years, bisphosphonates such as zoledronic acid have shown efficacy in preventing and delaying skeletal-related events in patients with a variety of solid tumors, including nonsmall cell lung cancer. Biochemical markers of bone turnover such as bone-specific alkaline phosphatase and N-terminal telopeptide of collagen type I have shown some utility in predicting which patients are at greatest risk of developing skeletal-related events. These biochemical markers may play a role in directing treatment of skeletal metastases with either bisphosphonates or newer targeted therapies such as denosumab. SUMMARY The management of skeletal metastases from nonsmall cell lung cancer is evolving as biochemical markers may be used to guide the treatment of these patients. Newer targeted therapies are also in development and may be used in the treatment of patients with skeletal metastases.
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324
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Ryu S, Jin R, Jin JY, Chen Q, Rock J, Anderson J, Movsas B. Pain control by image-guided radiosurgery for solitary spinal metastasis. J Pain Symptom Manage 2008; 35:292-8. [PMID: 18215498 DOI: 10.1016/j.jpainsymman.2007.04.020] [Citation(s) in RCA: 87] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2006] [Revised: 04/07/2007] [Accepted: 04/16/2007] [Indexed: 12/24/2022]
Abstract
Precision and accuracy of image-guided spinal radiosurgery has been previously demonstrated. This study was carried out to determine the clinical efficacy of spine radiosurgery for the treatment of solitary spinal metastases with or without cord compression. A total of 49 patients with 61 separate spinal metastases were treated with radiosurgery. All patients had pathologically proven primary cancers and had either synchronous or metachronous metastasis to the spine. The majority of the patients presented with back pain. All patients received single-dose radiosurgery to the involved spine only. The radiosurgery dose ranged from 10 to 16Gy. The primary endpoint was pain control, but outcomes in neurological status and radiological tumor control also were assessed. The median time to pain relief was 14 days and the earliest time of pain relief was within 24hours. Complete pain relief was achieved in 46%, partial relief in 18.9%, and stable symptoms in 16.2%. Relapse of pain at the treated spinal segment was 6.9%. Median duration of pain relief at the treated spine was 13.3 months. Overall pain control rate for one year was 84%. This experience demonstrates that spinal radiosurgery can achieve rapid and durable pain relief. Single-dose radiosurgery has a potential to be a viable treatment option for single spinal metastasis.
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Affiliation(s)
- Samuel Ryu
- Department of Radiation Oncology, Henry Ford Hospital, Detroit, MI 48202, USA.
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325
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Bradley NME, Husted J, Sey MSL, Sinclair E, Li KK, Husain AF, Danjoux C, Barnes EA, Tsao MN, Barbera L, Harris K, Chiu H, Doyle M, Chow E. Did the pattern of practice in the prescription of palliative radiotherapy for the treatment of uncomplicated bone metastases change between 1999 and 2005 at the rapid response radiotherapy program? Clin Oncol (R Coll Radiol) 2008; 20:327-36. [PMID: 18276125 PMCID: PMC7126631 DOI: 10.1016/j.clon.2008.01.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2007] [Revised: 12/19/2007] [Accepted: 12/20/2007] [Indexed: 01/15/2023]
Abstract
AIMS Since 1999, randomised clinical trials and meta-analyses have reported equal efficacy of pain relief from single- and multiple-fraction radiotherapy for bone metastases. A number of factors, including limited radiotherapy resources, waiting times, and patient convenience, suggest single fraction to be the treatment of choice for patients. However, international patterns of practice indicate that multiple fractions are still commonly used. This study examined whether dose-fractionation schemes used for the treatment of bone metastases at the Rapid Response Radiotherapy Program (RRRP) at the Odette Cancer Centre have changed since 1999. MATERIALS AND METHODS A retrospective review of the prospective RRRP database and hospital records were conducted for all patients treated with palliative radiotherapy for uncomplicated bone metastases at the RRRP in 1999 (or baseline), 2001, 2004 and from 1 January to 31 July 2005. Data were collected on patient demographics and clinical characteristics. RESULTS Of the 693 patients, 65 and 35% were prescribed single fraction (predominantly single 8 Gy) and multiple fractions (predominantly 20 Gy/five fractions), respectively. The administration of single treatments generally increased over time, from 51% in 1999 to 66% in 2005 (P=0.0001). On the basis of multiple logistic regression analyses, patients were more likely to be prescribed single-fraction radiotherapy if they had prostate cancer, had a poorer performance status, were treated to the limbs, hips, shoulders, pelvis, ribs, scapula, sternum, or clavicle (compared with the spine), were treated by a radiation oncologist who had been trained in earlier years, and who were treated after 1999. CONCLUSIONS Between 1999 and 2005, the use of single-fraction radiotherapy increased, corresponding to publications showing equal efficacy of pain relief between single and multiple fractions in the management of uncomplicated bone metastases. However, about a third of patients still received multiple fractions.
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Affiliation(s)
- N M E Bradley
- Department of Health Studies and Gerontology, Faculty of Applied Health Sciences, University of Waterloo, Waterloo, Ontario, Canada
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326
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Metastatic Cancer to Bone. Oncology 2007. [DOI: 10.1007/0-387-31056-8_95] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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327
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Management of Cancer Pain. Oncology 2007. [DOI: 10.1007/0-387-31056-8_82] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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328
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Abstract
Hundreds of thousands of Americans are affected every year by skeletal complications of oncologic disease. Recent developments in medical oncology, radiation oncology and radiology, particularly with respect to the use of bisphosphonate medication and radiofrequency techniques, have served to greatly lessen the morbidity associated with metastatic skeletal disease. Similarly, there has been significant advancement in the field of orthopaedic oncology in the areas of internal fixation, endoprosthetic implant design, and minimally invasive kyphoplasty technology. Given the palliative intent of intervention in this patient population, the goal of treatment of skeletal metastases must be optimization of limb function and ultimately, quality of life.
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Affiliation(s)
- Pamela M Aubert
- UCSF Comprehensive Cancer Center, Orthopaedic Oncology Service, 1600 Divisadero Street, San Francisco, CA 94115-1939, USA
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329
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Rades D, Kieckebusch S, Lohynska R, Veninga T, Stalpers LJA, Dunst J, Schild SE. Reduction of Overall Treatment Time in Patients Irradiated for More Than Three Brain Metastases. Int J Radiat Oncol Biol Phys 2007; 69:1509-13. [PMID: 17689033 DOI: 10.1016/j.ijrobp.2007.05.014] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2007] [Revised: 04/16/2007] [Accepted: 05/05/2007] [Indexed: 10/23/2022]
Abstract
PURPOSE Patients with multiple brain metastases usually receive whole brain radiotherapy (WBRT). A dose of 30 Gy in 10 fractions (10 x 3 Gy) in 2 weeks is the standard treatment in many centers. Regarding the poor survival of these patients, a shorter RT regimen would be preferable if it provides a similar outcome as that with 10 x 3 Gy. This study compared 20 Gy in five fractions (5 x 4 Gy) within 5 days to 10 x 3 Gy. METHODS AND MATERIALS Data from 442 patients treated with WBRT for multiple brain metastases were retrospectively analyzed. Survival and local control within the brain of 232 patients treated with 5 x 4 Gy were compared with the survival and local control within the brain of 210 patients treated with 10 x 3 Gy. Seven additional potential prognostic factors were investigated: age, gender, Karnofsky performance score, tumor type, interval from tumor diagnosis to RT, extracranial metastases, and recursive partitioning analysis class. RESULTS On univariate analysis, the WBRT program was not associated with survival (p = 0.29) or local control (p = 0.07). On multivariate analyses, improved survival was associated with a lower recursive partitioning analysis class (p < 0.001), age <or=60 years (p = 0.001), Karnofsky performance score >or=70 (p = 0.015), and the absence of extracranial metastases (p = 0.005). Improved local control was associated with a lower recursive partitioning analysis class (p < 0.001), Karnofsky performance score >or=70 (p < 0.001), and breast cancer (p = 0.043). Grade 3 acute toxicity rates were not significantly different between 5 x 4 Gy and 10 x 3 Gy. CONCLUSIONS Shorter course WBRT with 5 x 4 Gy was associated with similar survival and local control as "standard" WBRT with 10 x 3 Gy in patients with more than three brain metastases. The 5 x 4-Gy regimen appears preferable for most of these patients, because it is less time consuming and more convenient for patients than the 10 x 3-Gy regimen.
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Affiliation(s)
- Dirk Rades
- Department of Radiation Oncology, University Hospital Schleswig-Holstein, Luebeck, Germany.
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330
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Masala S, Roselli M, Manenti G, Mammucari M, Bartolucci DA, Simonetti G. Percutaneous Cryoablation and Vertebroplasty: A Case Report. Cardiovasc Intervent Radiol 2007; 31:669-72. [DOI: 10.1007/s00270-007-9223-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2007] [Revised: 06/20/2007] [Accepted: 08/01/2007] [Indexed: 12/01/2022]
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331
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Gagnon GJ, Henderson FC, Gehan EA, Sanford D, Collins BT, Moulds JC, Dritschilo A. Cyberknife radiosurgery for breast cancer spine metastases: a matched-pair analysis. Cancer 2007; 110:1796-802. [PMID: 17786939 DOI: 10.1002/cncr.22977] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND There are few options for breast cancer patients with spinal metastases recurrent within a previous radiation treatment field. CyberKnife radiosurgery has been used in our institution to treat such patients. To evaluate their outcomes, as there are no comparable radiation treatment options, the outcomes were compared between 18 patients with spinal metastases from breast cancer treated with CyberKnife stereotactic radiosurgery, 17 of which had prior radiotherapy to the involved spinal region and were progressing, and 18 matched patients who received conventional external beam radiotherapy (CRT) up-front for spinal metastases. METHODS Radiosurgery was delivered in 3 to 5 fractions to doses ranging from 2100 to 2800 cGy. Women were matched to patients in a CRT group with respect to time from original diagnosis to diagnosis of metastases, estrogen receptor / progesterone receptor (ER/PR) status, presence or absence of visceral metastases, prior radiotherapy, and prior chemotherapy. Survival and complications were compared between treatment groups. Surviving patients were followed out to 24 months. RESULTS The CyberKnife and CRT groups were comparable along all matching dimensions and in performance status before treatment. Outcomes of treatment were similar for patients in both groups; ambulation, performance status, and pain worsened similarly across groups posttreatment. Survival and the number of complications appeared to favor the CyberKnife group, but the differences did not reach statistical significance. CONCLUSIONS The statistical comparability of the CyberKnife and CRT groups reflects the small sample size and stringent requirements for significance of the matched-pair analysis. Nevertheless, comparability in these difficult cases shows that salvage CyberKnife treatment is as efficacious as initial CRT without added toxicity.
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Affiliation(s)
- Gregory J Gagnon
- Department of Radiation Oncology, Georgetown University Medical Center, Washington, DC 20007-2113, USA.
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332
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Sharma V, Gaye PM, Wahab SA, Ndlovu N, Ngoma T, Vanderpuye V, Sowunmi A, Kigula-Mugambe J, Jeremic B. Patterns of practice of palliative radiotherapy in Africa, Part 1: Bone and brain metastases. Int J Radiat Oncol Biol Phys 2007; 70:1195-201. [PMID: 17967515 DOI: 10.1016/j.ijrobp.2007.07.2381] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2007] [Revised: 07/24/2007] [Accepted: 07/27/2007] [Indexed: 01/15/2023]
Abstract
PURPOSE To provide data on the pattern of practice of palliative radiotherapy (RT) on the African continent. METHODS AND MATERIALS A questionnaire was distributed to participants in a regional training course of the International Atomic Energy Agency in palliative cancer care and sent by e-mail to other institutions in Africa. Requested information included both infrastructure and human resources available and the pattern of RT practice for metastatic and locally advanced cancers. RESULTS Of 35 centers contacted, 24 (68%) completed the questionnaire. Although RT is used by most centers for most metastatic cancers, liver and lung metastases are treated with chemotherapy. Of 23 centers, 14 (61%) had a single RT regimen as an institutional policy for treating painful bone metastases, but only 5 centers (23%) of 23 used 8 Gy in 1 fraction. Brain metastases were being treated by RT to the whole brain to 30 Gy in 10 fractions, either exclusively (n=13, 56%) or in addition to the use of 20 Gy in 5 fractions (n=3, 14%). CONCLUSION Radiotherapy is a major component of treatment of cancer patients in African countries. There is consensus among few centers for treatment schedules for almost all sites regarding time and dose-fractionation characteristics of RT regimens used and/or indications for the use of RT in this setting.
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Affiliation(s)
- Vinay Sharma
- Department of Radiation Oncology, Johannesburg Hospital, University of Witwatersrand, Johannesburg, South Africa.
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333
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Keeley PW, Waterhouse ET, Noble SIR. The evidence base of palliative medicine: is inpatient palliative medicine evidence-based? Palliat Med 2007; 21:623-7. [PMID: 17942501 DOI: 10.1177/0269216307082657] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND In 2001, Good and Stafford published a study attempting to show that inpatient palliative medicine is evidence-based. AIM To critically examine the papers cited in support of the claim that palliative medicine is evidence-based. METHOD All the papers cited were re-examined by at least two reviewers. The papers were graded using a tool used in the production of 22 evidence-based national clinical guidelines over the past three years. Differences of opinion about quality were resolved by discussion or independent arbitration. RESULTS The 41 papers cited by Good and Stafford included 25 randomized controlled trials (RCT), six other controlled studies and 10 uncontrolled studies. Sample size. Mean sample size was 160 (range 9-1404). The median sample size was 56; 19/41(46%) had <50 subjects; 30/41 (73%) had <100. Power calculations. 16/25 (64%) of RCTs, had no power calculations, making it difficult to draw conclusions about true differences between groups. Quality rating and grade of evidence: Of the RCTs 15/25 (60%) had a high risk of bias; of the other controlled studies 5/6 (83%) had a high risk of bias. Applicability. The studies were generally applicable to a population with advanced disease: 30/41 (73%) related with populations with advanced disease. CONCLUSIONS This study demonstrates that studies cited in support of palliative medicine as an evidence-based specialty are of variable, and at times poor quality. This study seems to show that the claim that inpatient palliative medicine is evidence-based is at best tenuous and at worst misleading. Palliative Medicine 2007; 21 : 623-627.
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334
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335
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Harris K, Li K, Flynn C, Chow E. Worst, Average or Current Pain in the Brief Pain Inventory: Which Should be Used to Calculate the Response to Palliative Radiotherapy in Patients with Bone Metastases? Clin Oncol (R Coll Radiol) 2007; 19:523-7. [PMID: 17566723 DOI: 10.1016/j.clon.2007.04.007] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2007] [Revised: 03/27/2007] [Accepted: 04/23/2007] [Indexed: 11/22/2022]
Abstract
AIMS To determine which pain intensity scale in the Brief Pain Inventory correlates best with functional interference and should be used to calculate the response to palliative radiotherapy. To determine the differences in functional interference scores for patients classified as responders and non-responders to palliative radiotherapy. PATIENTS AND METHODS All patients referred to the Rapid Response Radiotherapy Program for palliative radiotherapy of symptomatic bone metastases were considered for the study. Patients rated the intensity and functional interference of their pain at the irradiated sites according to the Brief Pain Inventory before and 2 months after radiotherapy. Worst, average and current pain scores were correlated with functional interference scores using Spearman rank coefficients. Responders and non-responders to palliative radiotherapy were defined for each pain intensity scale according to the end points specified by the International Bone Metastases Consensus Working Party. Average differences between responders and non-responders were compared using a Wilcoxon rank sum test. RESULTS Between May 2003 and June 2005, 199 patients enrolled in the study (102 men and 97 women). Ninety-five patients returned complete questionnaires at 2 months of follow-up. All pain intensity and interference scores for evaluable patients were significantly lower at 2 months (P<0.0021). Response rates differed depending on the definition of pain intensity. An overall response rate was observed in 66, 58 and 54% of patients for worst, average and current pain, respectively. Worst pain showed the best correlation with functional interference. Responders reported significantly larger decreases in functional interference scores at follow-up in general activity, normal work, enjoyment of life and average functional interference. CONCLUSION Worst pain intensity had higher correlations with all functional interference scores except relationships with others. Therefore, we recommend an 11-point scale measuring worst pain to evaluate response rates in future radiotherapy trials. The mean difference from baseline to follow-up in functional interference scores was significantly larger in patients who responded to radiotherapy treatment.
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Affiliation(s)
- K Harris
- Rapid Response Radiotherapy Program, Toronto Sunnybrook Regional Cancer Centre, University of Toronto, 2075 Bayview Avenue, Toronto, Ontario, Canada
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336
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Liepe K, Kotzerke J. A comparative study of 188Re-HEDP, 186Re-HEDP, 153Sm-EDTMP and 89Sr in the treatment of painful skeletal metastases. Nucl Med Commun 2007; 28:623-30. [PMID: 17625384 DOI: 10.1097/mnm.0b013e32825a6adc] [Citation(s) in RCA: 70] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
AIM The surface bone-seeking radiopharmaceuticals 188Re-HEDP, 186Re-HEDP and 153Sm-EDTMP, and the volume seeker 89Sr were investigated to determine the efficacy and toxicity in pain palliation of bone metastases. METHOD The effect of treatment with 188Re-HEDP, 186Re-HEDP, 153Sm-EDTMP and 89Sr on pain symptoms, quality of life, and bone marrow function were studied. In total, 79 patients (18 with breast cancer and 61 with prostate cancer) were treated (31 patients with 188Re-HEDP, 15 patients each with 186Re-HEDP and 153Sm-EDTMP, and 18 patients with 89Sr). All patients were interviewed using standardized sets of questions before and after therapy weekly for 12 weeks. Blood counts were taken weekly for 6 weeks and after 12 weeks. RESULTS In total, 73% of patients reported pain relief (77% after 188Re-HEDP, 67% after 186Re-HEDP 73% after 153Sm-EDTMP, and 72% after 89Sr). Fifteen percent of patients could discontinue their analgesics and were pain-free. Pain showed a decrease from 3.6+/-1.7 to a maximum of 2.2+/-1.8 at visual analogue scale in 10 steps (P<0.01). Patients described an improvement on the Karnofsky performance scale from 70+/-10% to 78+/-14% 12 weeks after treatment (P=0.15). There were eight patients with a thrombocytopenia grade I, two patients with grade II and one with grade III. The maximum nadir of platelet and leukocyte counts were observed between the 2nd to 5th week after treatment and was reversible within 12 weeks. There were no significant differences in pain palliation, Karnofsky performance status (KPS) and bone marrow toxicity between the different radionuclides (P=0.087-0.449). CONCLUSION All radiopharmaceuticals were effective in pain palliation, without induction of severe side effects or significant differences in therapeutic efficacy or toxicity.
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Affiliation(s)
- Knut Liepe
- Department of Nuclear Medicine, University Hospital Dresden, Germany.
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337
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Lutz ST, Chow EL, Hartsell WF, Konski AA. A review of hypofractionated palliative radiotherapy. Cancer 2007; 109:1462-70. [PMID: 17330854 DOI: 10.1002/cncr.22555] [Citation(s) in RCA: 74] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Radiotherapy commonly is employed to address symptoms in patients with symptoms caused by cancer. For this article, the authors reviewed data supporting the use of hypofractionated palliative radiotherapy. In addition to single-fraction treatment for painful bony metastasis, the available literature suggested that courses of 2 to 14 external-beam fractions may provide equivalent relief to longer course treatment in patients with a poor prognosis who have primary cancers of the lung, rectum, bladder, prostate, head and neck, spleen, and gynecologic system. Hypofractionated treatment delivers palliation that is time efficient, cost effective, and minimally toxic. Evidence suggests that the reluctance of radiation oncologists to provide single-fraction treatment acts as a barrier to referrals from palliative care professionals. Collaboration in education, research, and patient advocacy will advance the common objectives of the 2 specialties and lead to an appropriate increase in the use of palliative hypofractionated radiotherapy.
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Affiliation(s)
- Stephen T Lutz
- Department of Radiation Oncology, Blanchard Valley Regional Cancer Center, Findlay, Ohio 45840, USA.
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338
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Ramsey SD, Zeliadt SB, Hall IJ, Ekwueme DU, Penson DF. On the Importance of Race, Socioeconomic Status and Comorbidity When Evaluating Quality of Life in Men With Prostate Cancer. J Urol 2007; 177:1992-9. [PMID: 17509278 DOI: 10.1016/j.juro.2007.01.138] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2006] [Indexed: 01/12/2023]
Abstract
PURPOSE Clear and accurate information about health related quality of life outcomes for men diagnosed with prostate cancer is essential for men and their physicians to make appropriate care decisions. To determine the completeness and quality of available health related quality of life information we performed a review of health related quality of life studies, assessing what information was and was not reported. MATERIALS AND METHODS A structured literature search identified 184 relevant health related quality of life studies representing 40,931 subjects. RESULTS More than 95% of health related quality of life studies did not provide key information about factors known to influence outcomes. The most common omissions included information about treatments received, followup, socioeconomic status or demographic characteristics. Most data were obtained from well educated, high income socioeconomic groups, who are generally quite healthy. More than 60% of subjects were college graduates, 85% were currently married and 43% were currently employed. While black Americans comprised 15% of men studied in the 80% of studies reporting race, little information is available on Hispanic or Asian men. CONCLUSIONS Most of the available prostate cancer health related quality of life literature does not describe or does not account for factors known to influence health outcomes. These omissions limit their interpretability for patients trying to make decisions about treatment. More attention should be given to fully characterizing all dimensions of care that may influence quality of life outcomes and evaluating health related quality of life in Asian and Hispanic populations. Men and physicians should exercise caution when interpreting results that do not fully account for multiple factors that influence health related quality of life.
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Affiliation(s)
- Scott D Ramsey
- Fred Hutchinson Cancer Research Center, 1100 Fairview Avenue North, Seattle, WA 98109, USA.
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339
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Rades D, Schild SE. Is stereotactic radiosurgery the best treatment option for patients with spinal metastases? ACTA ACUST UNITED AC 2007; 4:400-1. [PMID: 17534288 DOI: 10.1038/ncponc0846] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2007] [Accepted: 04/19/2007] [Indexed: 11/08/2022]
Affiliation(s)
- Dirk Rades
- Department of Radiation Oncology, University Hospital, Schleswig-Holstein, Campus Luebeck, Luebeck, Germany.
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340
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Chow E, Harris K, Fan G, Tsao M, Sze WM. Palliative radiotherapy trials for bone metastases: a systematic review. J Clin Oncol 2007; 25:1423-36. [PMID: 17416863 DOI: 10.1200/jco.2006.09.5281] [Citation(s) in RCA: 582] [Impact Index Per Article: 32.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
PURPOSE The objective is to update previous meta-analyses with a systematic review of randomized palliative radiotherapy (RT) trials comparing single fractions (SFs) versus multiple fractions (MFs). METHODS The analysis includes all published reports from randomized trials comparing SF or MF schedules for the treatment of painful bone metastases with localized RT. A systematic review was performed using the random-effects model with Review Manager version 4.1 (Cochrane Collaboration, Oxford, UK). The odds ratio and 95% CI were calculated for each trial and presented in a forest plot. RESULTS A total of 16 randomized trials from 1986 onward were identified. For intention-to-treat patients, the overall response (OR) rates for pain were similar for SF at 1,468 (58%) of 2,513 patients and MF RT at 1,466 (59%) of 2,487 patients. The complete response (CR) rates for pain were 23% (545 of 2,375 patients) for SF and 24% (558 of 2,351 patients) for MF RT. No significant differences were found in response rates. Trends showing an increased risk for SF RT arm patients in terms of pathological fractures and spinal cord compressions were observed, but neither were statistically significant (P = .75 and P = .13, respectively). The likelihood of re-treatment was 2.5-fold higher (95% CI, 1.76 to 3.56) in SF RT arm patients (P < .00001). Repeated analysis of these end points, excluding dropout patients, did not alter the conclusions. Generally, no significant differences with respect to acute toxicities were observed between the arms. CONCLUSION No significant differences in the arms were observed for overall and CR rates in both intention-to-treat and assessable patients. However, a significantly higher re-treatment rate with SFs was evident.
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Affiliation(s)
- Edward Chow
- Department of Radiation Oncology, Toronto Sunnybrook Regional Cancer Centre, University of Toronto, Toronto, Ontario, Canada.
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341
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Abstract
Cancer metastasis to the bone develops commonly in patients with a variety of malignancies, and is a major cause of morbidity and diminished quality of life in a significant proportion of cancer patients. The effective treatment of bone metastasis requires cooperation between medical, surgical and radiation oncologists. Radiotherapy, either in the form of targeted external beam radiation therapy, or systemic administration of radionuclides, plays a central role in treatment of symptomatic bone metastases. The appropriate external beam treatment techniques, dose and fractionation regimens for the treatment of symptomatic, localized bone metastasis have been established in prospective clinical trials. Large-field, hemi-body irradiation has been utilized for treatment of symptoms related to more widely disseminated bone metastases, but has been associated with substantial toxicity. Strontium-89 and Samarium-153 are widely available systemically administered radionuclides that are useful for the treatment of widely disseminated disease, and have largely supplanted the use of hemi-body irradiation. Combined with appropriate medical and surgical interventions, as well as the appropriate use of analgesics, radiotherapy is a well-tolerated and highly effective treatment for the palliation of symptomatic bone metastases.
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Affiliation(s)
- Alexander Lin
- Department of Radiation Oncology, University of Michigan, UHB2C490 1500 East Medical Center Drive, Ann Arbor, MI 48109-0010, USA.
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342
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Agarawal JP, Swangsilpa T, van der Linden Y, Rades D, Jeremic B, Hoskin PJ. The role of external beam radiotherapy in the management of bone metastases. Clin Oncol (R Coll Radiol) 2007; 18:747-60. [PMID: 17168210 DOI: 10.1016/j.clon.2006.09.007] [Citation(s) in RCA: 106] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
External beam radiotherapy is effective in the management of bone metastases for both local and more widespread pain. It is effective in spinal canal compression and pathological fracture where it also may have a prophylactic role. Single dose radiotherapy for bone metastases is a highly cost effective palliative treatment.
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343
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Gibbs IC, Kamnerdsupaphon P, Ryu MR, Dodd R, Kiernan M, Chang SD, Adler JR. Image-guided robotic radiosurgery for spinal metastases. Radiother Oncol 2007; 82:185-90. [PMID: 17257702 DOI: 10.1016/j.radonc.2006.11.023] [Citation(s) in RCA: 132] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2006] [Revised: 11/27/2006] [Accepted: 11/29/2006] [Indexed: 11/18/2022]
Abstract
BACKGROUND AND PURPOSE To determine the effectiveness and safety of image-guided robotic radiosurgery for spinal metastases. MATERIALS/METHODS From 1996 to 2005, 74 patients with 102 spinal metastases were treated using the CyberKnife at Stanford University. Sixty-two (84%) patients were symptomatic. Seventy-four percent (50/68) of previously treated patients had prior radiation. Using the CyberKnife, 16-25 Gy in 1-5 fractions was delivered. Patients were followed clinically and radiographically for at least 3 months or until death. RESULTS With mean follow-up of 9 months (range 0-33 months), 36 patients were alive and 38 were dead at last follow-up. No death was treatment related. Eighty-four (84%) percent of symptomatic patients experienced improvement or resolution of symptoms after treatment. Three patients developed treatment-related spinal injury. Analysis of dose-volume parameters and clinical parameters failed to identify predictors of spinal cord injury. CONCLUSIONS Robotic radiosurgery is effective and generally safe for spinal metastases even in previously irradiated patients.
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Affiliation(s)
- Iris C Gibbs
- Department of Radiation Oncology, Stanford University, Stanford, CA 94305-5847, USA.
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344
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Timmermans LM, van der Maazen RWM, Leer JWH, Kraaimaat FW. Palliative or curative treatment intent affects communication in radiation therapy consultations. Psychooncology 2007; 15:713-25. [PMID: 16308906 DOI: 10.1002/pon.1008] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
OBJECTIVE To assess whether communication in radiotherapy consultations is affected by palliative or curative treatment intent. SUBJECTS AND METHODS The study involved 160 patients and 8 radiation oncologists. Eighty patients visited the radiation oncologist (RO) for palliative treatment and 80 for curative treatment. The consultation prior to radiation treatment was analyzed with the Roter Interaction Analysis System (RIAS). Within three days, patients completed a quality of life questionnaire (EORTC-QLQ-C30). RESULTS In palliative radiotherapy (PRT) consultations, ROs asked more (closed-ended) biomedical and psychosocial questions and provided more information on prognosis than in consultations for curative radiotherapy (CRT). Patients in both groups provided a great deal of psychosocial information but asked few questions. The ROs expressed more concerns in the PRT consultations, while patients did not. PRT patients received fewer supportive remarks than CRT patients. In both groups, explicit decision-making received little attention. Proxies who accompanied the patients took a more active role in PRT than in CRT consultations. CONCLUSION Communication in radiotherapy is affected by treatment intent with respect to the main contents of the consultation.
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Affiliation(s)
- Liesbeth M Timmermans
- Department of Medical Psychology, University Medical Centre Nijmegen, The Netherlands.
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345
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Cozad SC. Radiation Therapy in the Management of Cancer Pain. Pain Manag 2007. [DOI: 10.1016/b978-0-7216-0334-6.50034-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
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346
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Abstract
The treatment of bone metastases represents a paradigm for evaluating palliative care in terms of symptom relief, toxicities of therapy, and the financial burden to the patient, caregivers, and society. Despite enormous expenditures to treat metastases, patients continue to sustain symptoms of the disease, and uninterrupted aggressive therapies are pursued until death that incur toxicity in approximately 25% of patients. This approach is inconsistent with the goals of palliative care, which should efficiently provide comfort using antineoplastic therapies or supportive care approaches to the patient with the fewest treatment-related side effects, recognizing that the patient will die of the disease.The development of therapies such as bisphosphonates is important in advancing options for palliative care; however, clinical trials demonstrating the efficacy of bisphosphonates have not addressed important issues for clinical practice. The primary study endpoints should primarily address pertinent patient outcomes such as pain relief rather than asymptomatic radiographic findings. These studies should define clear indications of when to start and stop the therapy, the appropriate patient populations to receive the therapy, and the cost effectiveness of the treatment relative to other available therapies such as radiation. Cost-utility analyses, which account for a broader domain of cost effectiveness, need to be performed as part of clinical trials, especially for palliative care endpoints. Clinical trials that include these criteria are critical to future practice guideline development. As health care resources continue to become more limited, the criteria for care must be better defined to avoid administration of therapy with limited benefit. Leadership must come from the specialty as clinical trials and clinical practice increasingly interface with health care policy. Goals of therapy must remain clear for the benefit of the individual and all patients.
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Affiliation(s)
- Nora Janjan
- Department of Radiation Oncology, University of Texas, M.D. Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030, USA.
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347
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Wu JSY, Monk G, Clark T, Robinson J, Eigl BJC, Hagen N. Palliative radiotherapy improves pain and reduces functional interference in patients with painful bone metastases: a quality assurance study. Clin Oncol (R Coll Radiol) 2006; 18:539-44. [PMID: 16969984 DOI: 10.1016/j.clon.2006.05.003] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
AIMS To characterise the effect of palliative radiotherapy treatment outcomes as evaluated by the Brief Pain Inventory within a radiotherapy clinic, as a quality assurance initiative. MATERIALS AND METHODS Tumour and treatment parameters of patients with painful bone metastases treated through a dedicated bone pain radiotherapy clinic have been prospectively recorded since 2002. One hundred and nine ambulatory patients provided pre- and post-treatment pain assessments at 4-6 weeks after palliative radiotherapy. The self-administered Brief Pain Inventory questionnaire was completed by patients during their visits. Changes in pain and seven-item functional interference scores were analysed. RESULTS Most of the patients had prostate (n=42) or breast (n=42) cancer. The mean Karnofsky performance score was 70 before palliative radiation therapy. Sixty-eight per cent of patients were treated with a single fraction (6-8 Gy) and 25% received 20 Gy/five fractions. The overall response (reduction in worst pain by > or = 2/10) was 72%. Sixty-one per cent of patients had stable or reduced consumption of opioid analgesics. A significant reduction for all seven functional interference items was seen after treatment, the greatest improvement being general activity (-2.4/10). There was significant correlation between pain reduction and improvement in functional interference. CONCLUSION This quality assurance initiative showed that palliative radiotherapy reduced both pain and its interference on function among ambulatory patients with symptomatic bone metastases. The reduction in pain was correlated with reductions in functional interference. Clinical trials of palliative radiotherapy should provide data that allow an evaluation of various domains of chronic pain.
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Affiliation(s)
- J S Y Wu
- Division of Radiation Oncology, Tom Baker Cancer Centre, University of Calgary, Calgary, Alberta, Canada.
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348
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Abstract
Cancer pain assessment and management are integral to palliative medicine. This paper reviews recent publications in the period 1999-2004 in the broad categories of epidemiology, pain assessment, nonpharmacologic approaches to cancer pain (radiation therapy, anesthetic blocks, palliative surgery and chemotherapy, complementary and alternative medicine), and in nociceptive pain, neuropathic pain, visceral pain, and bone pain.
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Affiliation(s)
- Victor T Chang
- VA New Jersey Health Care System, PDIA Faculty Scholar, East Orange, New Jersey 07018, USA.
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349
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Callstrom MR, Atwell TD, Charboneau JW, Farrell MA, Goetz MP, Rubin J, Sloan JA, Novotny PJ, Welch TJ, Maus TP, Wong GY, Brown KJ. Painful metastases involving bone: percutaneous image-guided cryoablation--prospective trial interim analysis. Radiology 2006; 241:572-80. [PMID: 17057075 DOI: 10.1148/radiol.2412051247] [Citation(s) in RCA: 150] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE To prospectively determine the safety and effectiveness of percutaneous cryoablation for the reduction of pain, improvement in the activities of daily life, and reduction in the use of analgesic medications for patients with painful metastatic lesions involving bone. MATERIALS AND METHODS This study was compliant with HIPAA and was approved by the institutional review board. Written informed consent was obtained. During 18 months, 14 patients (eight men, six women; age range, 21-72 years; mean age, 54 years) with one or two painful metastatic lesions involving bone, with a score of 4 or greater out of 10 for worst pain in a 24-hour period, and who did not respond to or refused conventional radiation treatment or chemotherapy were treated with percutaneous cryoablation. Patient response was measured with the Brief Pain Inventory, and analgesic use was recorded before and after the procedure at days 1 and 4, weekly for 4 weeks, and then every other week for a total of 6 months. Complications were monitored. Analysis of the primary end points was undertaken with paired comparison procedures by using paired t tests across individual time points supplemented with repeated measures analysis of variance. RESULTS Treated lesions were 1-11 cm in diameter. Before cryoablation, the mean score for worst pain in a 24-hour period was 6.7 of 10; the score decreased to 3.8 (P = .003) 4 weeks after treatment. Mean pain interference with activities of daily living was 5.5 of 10 before treatment and decreased to 3.2 (P = .004) 4 weeks after treatment. All eight (100%) patients (exact 95% binomial confidence interval: 63%, 100%) for whom narcotics were prescribed prior to the procedure reported a reduction in these medications after cryoablation. No serious complications were observed. CONCLUSION Percutaneous cryoablation is a safe and effective method for palliation of pain due to metastatic disease involving bone.
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Affiliation(s)
- Matthew R Callstrom
- Department of Diagnostic Radiology, Oncology, Biostatistics, and Anesthesiology, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA.
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350
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Bruland ØS, Nilsson S, Fisher DR, Larsen RH. High-linear energy transfer irradiation targeted to skeletal metastases by the alpha-emitter 223Ra: adjuvant or alternative to conventional modalities? Clin Cancer Res 2006; 12:6250s-6257s. [PMID: 17062709 DOI: 10.1158/1078-0432.ccr-06-0841] [Citation(s) in RCA: 236] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The bone-seeking, alpha-particle-emitting radiopharmaceutical Alpharadin, 223RaCl2 (half-life=11.4 days), is under clinical development as a novel treatment for skeletal metastases from breast and prostate cancer. This article summarizes the current status of preclinical and clinical research on 223RaCl2. Potential advantages of 223Ra to that of external beam irradiation and registered beta-emitting bone seekers are discussed. Published data of 223Ra dosimetry in mice and a therapeutic study in a skeletal metastases model in nude rats have indicated significant therapeutic potential of bone-seeking alpha-emitters. This article provides short-term and long-term results from the first clinical single dosage trial. We also present data from a repeated dosage study of five consecutive injections of 50 kBq/kg body weight, once every 3rd week, or two injections of 125 kBq/kg body weight, 6 weeks apart. Furthermore, interim results are described for a randomized phase 2 trial involving 64 patients with hormone-refractory prostate cancer and painful skeletal metastases who received four monthly injections of 223Ra or saline as an adjuvant to external beam radiotherapy. Lastly, we present preliminary dose estimates for 223Ra in humans. Results indicate that repeated dosing is feasible and toxicity is low, and that opportunities are available for combined treatment strategies.
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Affiliation(s)
- Øyvind S Bruland
- Faculty of Medicine, University of Oslo and Department of Oncology, The Norwegian Radium Hospital, Norway.
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