Role of radiation therapy in palliative care of the patient with cancer

Outcomes After Palliative Radiation Therapy in Patients With Symptomatic Locoregionally Advanced Breast Cancer

PURPOSE

Symptomatic locoregionally advanced breast cancer (SLABC) can cause troublesome pain or wound complications that negatively impact quality of life. Although palliative radiation therapy (RT) can minimize tumor-related symptoms, how best to tailor RT to achieve the most meaningful and durable response is not well defined.

METHODS AND MATERIALS

This is a single institution, multi-site retrospective review of patients with SLABC treated between 2016 and 2023 with palliative RT to symptomatic disease in the breast, chest wall, and/or regional lymph node basins. Overall survival (OS), locoregional control (LC), clinical and radiographic treatment response, overall pain scores, and treatment-related toxicities were analyzed.

RESULTS

A total of 164 patients with a median age of 57 years were analyzed with a median follow-up time of 4.97 months. In total, 86% had distant metastases. The most common presenting symptom was pain (87%), followed by ulcerating or fungating lesion (76%) and discharge (45%). The median cumulative biologically effective dose to the gross tumor volume (BEDGTV) was 69 Gy. The 1-year OS and LC rates were 37% and 63%, respectively. Eighty-one percent experienced improvement in symptoms within 3 months after RT, the odds of which increased per Gy BEDGTV (odds ratio, 1.029; P = .003). Acute toxicities were associated with number of fractions and BEDGTV (both P < .001), but not with concurrent systemic therapy or reirradiation (both P > .05). Trends in pain scores showed a significant change in pain trajectory that was sustained during the first year after RT. OS and LC were not different among patients who received 1 versus 2 to 10 versus >10 fractions, and between ≤70 and >70 Gy BEDGTV.

CONCLUSIONS

In this large series of patients with SLABC, palliative RT was effective at relieving locoregional symptoms with acceptable toxicity, with the likelihood of symptom improvement associated with radiation dose. Survival of these patients remains poor, highlighting the importance of palliative care strategies that minimize overall symptom burden while maximizing quality of life.

A Practice Model for Palliative Radiotherapy

Despite well-recognized challenges in implementing palliative radiation therapy (PRT), progress remains slow, and conventional approaches have yielded limited success. A transformative strategy is required to overcome systemic barriers and establish a sustainable PRT infrastructure. This proposal presents a novel model to improve accessibility, affordability, and integration into palliative care by addressing key obstacles in training, regulation, facility development, and treatment protocols. A specialized certification track within radiation oncology residency programs is proposed, enabling palliative care physicians to obtain limited PRT licenses under the supervision of fully licensed radiation oncologists. Regulatory adjustments should facilitate this framework, ensuring compliance while expanding the PRT workforce. Dedicated PRT facilities-affiliated with comprehensive radiation therapy centers (CRTCs) and integrated into hospice settings-will enhance accessibility by reducing logistical and financial burdens. These facilities will utilize cost-effective infrastructure, including refurbished linear accelerators, modular construction, and remote physics and dosimetry support, ensuring operational costs remain significantly lower than those of conventional radiotherapy centers. Optimizing PRT delivery requires shifting clinical strategies toward single-fraction treatment as the primary approach, followed by hypofractionation treatment when necessary. Systematic studies with a PRT-oriented mindset should establish PRT-specific treatment recommendations and recommendations, moving away from conventional radiation therapy protocols. By addressing key barriers in education, regulation, infrastructure, and clinical strategy, this model offers a path toward sustainable PRT implementation. While requiring initial investment and regulatory adjustments, it has the potential to improve end-of-life care for terminally ill cancer patients, ensuring greater dignity and comfort while establishing a robust foundation for future reimbursement models.

The Impact of Race and Ethnicity on Location and Delivery of Palliative Radiotherapy

OBJECTIVES

Among patients that underwent palliative RT (pRT) at a single institution, we evaluated whether differences exist across race and ethnicity in location of pRT consultation and delivery of pRT.

METHODS

This retrospective study included cancer patients aged 18 years or older who received pRT between 10/2021 and 10/2022. Logistic regression models were used to examine univariable (UVA) and multivariable (MVA) associations between race and pRT consult in the inpatient (vs. outpatient) setting. A subset analysis of quality metrics for pRT delivery was limited to patients who had outpatient consults for pain.

RESULTS

Four hundred forty patients underwent 548 pRT consults (104 inpatient and 444 outpatient) followed by a course of pRT. Most patients were male (58.2%), White non-Hispanic (WNH) (72.6%), and English-speaking (92.9%). On MVA adjusting for histology, language, and insurance type, consults for Black/African American (BAA) patients had 2.92 higher odds of being performed in the inpatient setting compared with consults for WNH patients (95% CI: 1.28-6.70, P=0.011), although the global P-value was P=0.217. Among 290 outpatient consults for painful lesions, no differences in time to pRT start (global P=0.84), number of prescribed fractions of RT (global P=0.94), or new prescriptions for opioids (global P=0.69) were noted by race and ethnicity.

CONCLUSIONS

In this study, BAA race was associated with the location of pRT consultation, but no discernible differences were noted regarding the outpatient delivery of pRT for pain. These findings support the importance of inpatient pRT programs to ensure equitable access. More research is needed to understand barriers to outpatient consult.

Development of an automated CBCT-based simulation-free platform for expedited palliative radiotherapy on a conventional linear accelerator

BACKGROUND

Conventional approaches for emergent or expedited palliative radiotherapy (RT) involve the application of cumbersome vendor-provided solutions and/or multiple patient appointments to complete the RT workflow within a compressed timeframe.

PURPOSE

This report delineates the clinical development of an in-house, semi-automated Cone-beam computed tomography (CBCT)-based simulation-free platform for expedited palliative RT on conventional linacs, intended to supplant existing techniques employed at this institution.

METHODS

The internal software, termed SimFree Wizard (SFW), was engineered utilizing a C#-based application programming interface integrated within the treatment planning system (TPS). Generated scripts were compiled as stand-alone executables, with a graphical user interface (GUI) customized via an integrated development environment. The platform was conceived as a framework for accelerated CBCT-based RT, bypassing the requirement for standard simulation imaging. SFW employs full automation where feasible to minimize user intervention, supplemented by graphical instructions for tasks requiring manual execution. During development, relevant temporal metrics from 10 end-to-end tests for palliative spine RT were quantified. User feedback was solicited via a simple questionnaire assessing the overall platform usability. Automated in-house secondary verification software was developed for validation of the TPS-calculated monitor units (MUs).

RESULTS

The mean duration for workflow execution was 41:42 ± 3:18 [mm:ss] (range ∼37-46 min). SFW satisfactorily generated simple, multi-field CBCT-based 3D treatment plans within seconds following delineation of the desired treatment area. User feedback indicated enhanced usability compared to previously employed solutions. Validation of the secondary verification software demonstrated accurate results for palliative spine RT and other simple cases wherein the dose calculation point resides in a predominantly homogenous medium.

CONCLUSION

A novel in-house solution for expedited CBCT-based RT was successfully developed, facilitating completion of the entire workflow within approximately 1-hour or less for simple palliative/emergent scenarios. Overall, this application is expected to improve the quality and safety of palliative RT while greatly reducing workflow duration, thereby improving access to palliative care.

Implications of primary tumor site and fraction size on outcomes of palliative radiation for osseous metastases

Purpose

This study reviewed palliative radiation therapy (RT) practices and outcomes and compared the percentage of remaining life spent receiving RT (PRLSRT) in patients treated for osseous metastases.

Methods

A retrospective analysis was conducted using the National Cancer Database (2010-2016) to evaluate metastatic patients who received palliative bone RT. Common palliative RT schemes were analyzed to determine treatment patterns and outcomes. Palliative outcomes, including median PRLSRT, RT completion, and mortality rates, were calculated. Binary logistic regression was performed to identify factors affecting RT completion, and a scoring system was developed to identify patients at risk for poor palliative outcomes.

Results

A total of 50,929 patients were included, with the majority diagnosed with NSCLC (45.2%), breast cancer (15.1%), or prostate cancer (10.8%). The median overall survival after palliative RT was 5.74 months. Patients receiving lower doses per fraction (2.5 Gy/Fx) tended to be younger, healthier, and yet experienced worse palliative outcomes. Binary logistic regression identified age, race, income quartile, and Gy/Fx as significant factors affecting RT completion. Median PRLSRTs were as follows: 14.95% for GI NOS, 9.89% for upper GI, 9.46% for NSCLC, 8.67% for skin, 7.06% for SCLC, 6.10% for lower GI, 5.59% for GYN, 5.44% for GU, 5.35% for HNC, 2.05% for endocrine, 2.03% for prostate cancer, and 1.82% for breast cancer. Patients receiving 2.5 and 3 Gy/Fx were less likely to complete RT compared to those receiving 4 Gy/Fx (OR, 1.429 and 3.780, respectively; p < 0.001). Age, comorbidities, primary tumor, target location, and metastatic burden were associated with PRLSRT ≥ 25%.

Conclusion

Dose regimens and patient selection influence palliative bone RT outcomes. Both factors should be carefully considered to minimize the burden of care and maximize treatment benefits.

Validation of the prognostic model for palliative radiotherapy in older patients with cancer

BACKGROUND

Older patients are more likely to have a poor performance status and comorbidities. There is a reluctance to extensively investigate and treat older patients. As elderly individuals and patients with neoplasms each increase in number, palliative treatment of older patients is expected to grow as an issue.

AIM

To investigated the role of palliative radiotherapy in older patients and patients who were expected to demonstrate a therapeutic effect.

METHODS

From February 2019 to February 2022, 33 patients aged ≥ 80 years underwent palliative radiotherapy. The prognosis in palliative care study predictor (PiPS), palliative prognostic index (PPI), and delirium-palliative prognostic score (D-PaP) models were used for prognosis prediction. D-PaP scores calculated according to the doctor's prediction of clinical prediction of survival (CPS) were excluded and then analyzed for comparison. Radiation was prescribed at a dose of 2.5-7 Gy per fraction, up to a median of 39 Gy10 (range, 28-75 Gy10).

RESULTS

The median follow-up was 2.4 months (range, 0.2-27.5 months), and 28 patients (84.8%) showed subjective symptom improvements following treatment. The 2- and 6-month survival rates of all patients were 91.5% and 91.5%, respectively. According to regression analysis, the performance status index, symptom type, and radiation dose all showed no significant correlation with the treatment response. When survival was expected for > 55 days in the PiPS model, the 2-month survival rate was 94.4%. For patients with PPI and D-PaP-CPS values of 0-3.9 points, the 2-month survival rates were 90.0% and 100%, respectively. For patients with a score of ≥ 4 points, the 2-month survival rates were 37.5% and 0%, respectively.

CONCLUSION

This study shows that the prognosis prediction model used in palliative care can be used to identify patients suitable for treatment.

Barriers to radiotherapy completion in breast cancer patients: A retrospective analysis from a tertiary hospital in Indonesia

INTRODUCTION

Breast cancer is the most common malignancy among women and a leading cause of cancer-related mortality in Indonesia. Radiotherapy is a crucial treatment modality to improve local control, reduce recurrence, and enhance survival rates. However, access to radiotherapy remains limited, leading to prolonged waiting times and potential treatment incompletion. This study aims to identify key predictors influencing radiotherapy completion and analyze waiting times in a resource-limited setting METHODS: A retrospective study was conducted on breast cancer patients who underwent radiotherapy between January 2018 and December 2019 at Hasan Sadikin General Hospital, Indonesia. Data were obtained from the Hospital-Based Cancer Registry (HBCR). Statistical analyses were performed using chi-square and Mann-Whitney U tests to assess factors influencing radiotherapy completion and waiting time.

RESULTS

279 Breast cancer patients were included. 77.8 % (n = 217) completed their prescribed radiotherapy. Significant predictors of completion include age, those older than 65 years old tend to do not complete their radiation treatment (p = 0.035). Those receiving treated using Linac radiotherapy had higher completion rates than those treated with Co-60. However, waiting time was not significantly associated with treatment completion (p = 0.427). The median radiotherapy waiting time was 8 weeks (0-40 weeks). Patients with metastatic disease (p < 0.001) and those receiving palliative intent radiotherapy (p < 0.001) experienced significantly shorter waiting times.

CONCLUSION

Radiotherapy completion rates among breast cancer patients in Indonesia remain suboptimal, with access disparities affecting treatment adherence. Addressing logistical and systemic barriers could improve outcomes and enhance cancer care delivery in resource-limited settings.

PLAIN LANGUAGE SUMMARY

Breast cancer is the most common cancer among women in Indonesia. Many patients require radiotherapy to prevent the disease from coming back and to improve survival. However, some patients do not complete their treatment due to long waiting times and other challenges. This study looks at how long patients wait for radiotherapy and what factors influence whether they complete treatment. We analyzed the medical records of 279 breast cancer patients who received radiotherapy at Hasan Sadikin General Hospital between 2018 and 2019. We examined their age, radiation therapy tools, waiting time, and whether they completed radiotherapy. We used statistical methods to find patterns and associations between these factors. Our findings suggest that certain groups of patients, especially older individuals and those undergoing curative treatment, may need additional support to complete their radiotherapy.

Palliative radiotherapy for the hemostasis of bleeding tumors: an overview of the most recent literature

PURPOSE OF REVIEW

Palliative radiotherapy is frequently applied for various indications, with hemostasis being a quite common one. However, while bleeding can occur at different sites and arise from various primary tumor types, clear guidelines for administering hemostatic radiotherapy are lacking. Additionally, most available data on hemostatic radiotherapy are retrospective, and often studies do not focus on hemostasis specifically. This review provides an overview of the most recent data on hemostatic radiotherapy to identify any research trends and focus areas for this specific topic.

RECENT FINDINGS

This review confirms the value of radiation for tumor bleeding. Unfortunately, research in hemostatic radiotherapy predominantly continues to focus on retrospective analyses of treated patients. However, at least two prospective trials specifically investigating hemostasis have been published recently, both conducted in low-income countries.

SUMMARY

Radiotherapy is an effective and well-tolerated treatment for bleeding tumors. As the incidence of advanced cancer rises in low- and middle-income countries, where resources are limited, further research should focus on hypofractionated regimens. Additionally, there is a need for comprehensive descriptions of contouring and treatment planning to optimize outcomes in these settings.

Real-World Implementation of Simulation-Free Radiation Therapy (SFRT-1000): A Propensity Score-Matched Analysis of 1000 Consecutive Palliative Courses Delivered in Routine Care

PURPOSE

The feasibility of simulation-free radiation therapy (SFRT) has been demonstrated but information regarding its routine care impact and scalability is lacking.

METHODS AND MATERIALS

In this single-institution, retrospective cohort study, all patients receiving palliative radiation therapy at an Australian tertiary cancer center were eligible for consideration of SFRT unless mask immobilization, a stereotactic technique, or a definitive dose was indicated. Coprimary endpoints were SFRT utilization, impact on consultation-to-RT time, and on-couch treatment duration. Timing metrics were compared with a contemporary local cohort that received simulation-based palliative radiation therapy using unadjusted Wilcoxon rank-sum tests and a propensity score-matched regression. Electronic patient-reported outcomes captured 2-week toxicity and pain response.  RESULTS:  Between April 2018 and February 2024, 2849 palliative radiation courses were delivered, of which 1904 were eligible. Of the 1904 courses, 1000 (52.5% SFRT utilization) received SFRT, including 668 using intensity-modulated radiation therapy/volumetric-modulated arc therapy. A total of 788 individual patients received SFRT and the median age was 71 years (IQR, 61-80) with 59% being male and 42% being Eastern Collaborative Oncology Group 2-4. SFRT utilization increased from 41% to 54% between years 2018-2019 and 2022-2024.  SFRT reduced median consultation-to-RT time from 7.0 to 5.1 days (P < .0001) corresponding to an adjusted average treatment effect in the treated of -2.1 days (95% CI, -2.8 to -1.3). SFRT increased median on-couch treatment duration from 17.8 to 20.5 minutes (P < .0001; adjusted average treatment effect in the treated 2.6 minutes, 95% CI, 1.3-3.9). Patient-Reported Outcomes Version of the Common Terminology Criteria for Adverse Events grade 3 acute toxicity was 9% and at 4 weeks after RT, patients with moderate/severe pain at baseline (≥5/10) had a mean pain reduction of 3.5 points (7.1-3.6; P < .0001).  CONCLUSIONS:  Using widely available technologies, the SFRT-1000 cohort demonstrates routine care scalability with patient-centered and workflow benefits. SFRT is an attractive new paradigm implementable in most settings following adaptation to local requirements. Thus, SFRT opens new avenues to potentially improve access to palliative RT, which remains a global area of need.

The Role of Radiation Therapy for Palliation of Hematologic Malignancies

Palliative RT is an effective tool in management and treatment of patients with hematologic malignancies. Even relatively low doses of palliative RT can quickly and effectively relieve pain and other symptoms impairing quality of life and function. As so many diseases are represented by the umbrella term, "hematologic malignancies," and each disease has its own natural history and prognosis, the indications for palliative RT are heterogeneous. The following review provides a discussion of when palliative RT should be considered, as well as data-supported dose/fractionation schemes, for non-cutaneous lymphomas and leukemias. It also offers a suggested approach to the patient with a hematologic malignancy requiring palliative RT.

Current situation and trends of radiation therapy in Japan based on the National Database Open Data

This study aimed to visualize the current situation and trends in radiation therapy in Japan using open data from the Japanese National Database of Health Insurance Claims and Specific Health Checkups (NDB). We downloaded the NDB open data from the website of Japan's Ministry of Health, Labor and Welfare and used Python libraries to analyze the receipt data related to radiation therapy from fiscal year 2014 to 2022. The number of radiation therapy plans peaked in 2019, temporarily declined and subsequently showed a gradual increase. Conversely, the total points associated with radiation therapy have consistently increased without any decline. The use of high-precision radiation therapies such as intensity-modulated radiation therapy (IMRT) has increased over time. Significant regional differences exist, with the Chubu and Kyushu regions showing higher total points and receipts per certified radiation oncologist. A correlation was observed between the number of IMRT plans per population and the number of certified radiation oncologists. Males exhibited a sharp peak in their early 70s, while females demonstrated a mild peak from their 40s to 80s. In recent years, the points for males in their early 70s have rapidly increased. We used the NDB open data to illustrate the current situation and trends in radiation therapy in Japan, highlighting reduced costs and workloads. This study underscored the regional differences in radiation therapy and emphasized the need to discuss strategies for meeting future demand.

Ablative Radiation Therapy to Restrain Everything Safely Treatable (ARREST): A Phase 1 Study of Stereotactic Ablative Radiation Therapy for Polymetastatic Disease

PURPOSE

This phase 1 study aimed to assess the safety and feasibility of SABR therapy delivery to all sites of polymetastatic disease (>10 metastases).

METHODS AND MATERIALS

A 3 + 3 study design was used with 5 dose levels from 6 Gy (6 Gy × 1) to 30 Gy (6 Gy weekly × 5). Dose-limiting toxicity (DLT) was defined as any grade 4 or 5 toxicity or more than 3 grade 3 toxicities within 6 weeks of treatment. The primary endpoint was the maximal tolerated dose, defined as the dose level where ≥2/6 of patients experienced DLT. Secondary endpoints included quality of life (Functional Assessment of Cancer Therapy - General and European Quality of Life 5 Dimension 5 Level) at 6 weeks posttreatment, progression-free survival, and overall survival.

RESULTS

Thirteen patients were accrued: 12 Gy (n = 3), 18 Gy (n = 3), 24 Gy (n = 4), and 30 Gy (n = 3), and 207 lesions were treated. Nine patients (69%) had acute toxicity: grade 1 (n = 6, 46%), grade 2 (n = 2, 15%; n = 1 pneumonitis and n = 1 fatigue), and grade 3 (n = 1, 7.7% neutropenia). There were no grade 4 or 5 toxicities. Mean ± SD quality of life (Functional Assessment of Cancer Therapy - General and European Quality of Life 5 Dimension 5 Level health state) was 80.4 ± 21.9 and 77.4 ± 20.9 at baseline versus 76.4 ± 21.8 and 68.0 ± 24.2 at 6-week follow-up, respectively (p = .009 and p = .055, respectively). With a median follow-up of 8.7 months posttreatment (IQR, 2.4-24 months), 8 of 13 patients had disease progression (62%). The median and 12-month progression-free survival were 3.6 months and 11.3%, respectively. The median and 12-month overall survival were 13.8 months and 62%, respectively.

CONCLUSIONS

In this phase 1 trial, SABR therapy for polymetastatic disease was technically feasible with acceptable acute toxicity at dose levels up to 30 Gy (6 Gy weekly × 5). DLT was not observed.

Once-a-Week Ablative Radiotherapy as Replacement of Prolonged Fractionation in Frail Patients: Feasibility and Toxicity Results

INTRODUCTION

The aim of this work was to explore the use of an original once-weekly radiotherapy fractionation in elderly or frail patients with recurrence or metastasis from different solid malignancies.

MATERIAL AND METHODS

A retrospective analysis was conducted on 29 patients treated from 2011 to 2019 with a once-weekly radiotherapy schedule. Patients received a median dose of 27.5 Gy, with weekly fractions of 4-5 Gy over 7-10 weeks. The treatment aimed at both palliative and cytoreductive objectives. Primary endpoints were feasibility and compliance, secondary outcome was acute toxicity.

RESULTS

All patients completed the planned radiotherapy without interruptions. Acute toxicity was mild, with only one patient developing grade 3 toxicity (bowel perforation). Three months post-treatment, 74% of patients experienced symptom relief and tumor response. One-year local control rates were 26.7%, and treatment was generally well-tolerated.

CONCLUSION

This once-weekly hypofractionated radiotherapy regimen demonstrated feasibility, good tolerance, and promising tumor response in frail and elderly patients. Although limited by a small sample size, the approach offers a practical alternative for patients unable to undergo conventional daily radiotherapy. Further studies on larger cohorts are required to validate these findings.

Inpatient Care and Outcomes Among People With Cancer Experiencing Homelessness

Importance

Cancer is a leading cause of death among people experiencing homelessness (PEH) in the US. Acute care settings are important sources of care for PEH; however, the association of housing status with inpatient care remains understudied, particularly in the context of cancer.

Objective

To assess whether housing status is associated with differences in the inpatient care of hospitalized adults with cancer.

Design, Setting, and Participants

This cross-sectional study included hospitalized inpatient adults aged 18 years or older diagnosed with cancer who were identified using data from the 2016 to 2020 National Inpatient Sample. Propensity score matching was used to create a cohort of PEH and housed individuals matched according to age, sex, race and ethnicity, insurance type, cancer diagnosis, number of comorbidities, substance use disorder, severity of illness, year of admission, hospital location, hospital ownership, region, and hospital bed size. Matched pairs were identified using a 1:1 nearest neighbor matching algorithm without replacement, accounting for survey weights. Data were analyzed from August 1, 2022, to April 30, 2024.

Exposure

Housing status.

Main Outcomes and Measures

The associations of receipt of invasive procedures, systemic therapy, or radiotherapy during hospitalization (primary outcomes) as well as inpatient death, high cost of stay, and discharge against medical advice (AMA) (secondary outcomes) with housing status. Odds ratios and 95% CIs were estimated with multivariable logistic regression, with adjustment for patient, disease, and hospital characteristics of the matched cohort.

Results

The unmatched cohort comprised 13 838 612 individuals (median [IQR] age, 67 [57-76] years; 7 329 473 males [53.0%]) and included 13 793 462 housed individuals (median [IQR] age, 68 [58-77] years) and 45 150 (median [IQR] age, 58 [52-64] years) individuals who were experiencing homelessness after accounting for survey weights. The PEH cohort had a higher prevalence of lung (17.3% vs 14.5%) and upper gastrointestinal (15.2% vs 10.5%) cancers, comorbid substance use disorder (70.2% vs 15.3%), and HIV (5.3% vs 0.5%). Despite having higher rates of moderate or major illness severity (80.1% vs 74.0%) and longer length of stay (≥5 days: 62.2% vs 49.1%), PEH were less likely to receive invasive procedures (adjusted odds ratio [AOR], 0.53; 95% CI, 0.49-0.56), receive systemic therapy (AOR, 0.73; 95% CI, 0.63-0.85), or have a higher-than-median cost of stay (AOR, 0.71; 95% CI, 0.65-0.77). Although PEH had lower rates of inpatient death (AOR, 0.79; 95% CI, 0.68-0.92), they were 4 times more likely to be discharged AMA (AOR, 4.29; 95% CI, 3.63-5.06).

Conclusions and Relevance

In this nationally representative cross-sectional study of hospitalized adults with cancer, disparities in inpatient care of PEH highlight opportunities to promote equitable cancer care in this socioeconomically vulnerable population.

Sustainability in radiation oncology: opportunities for enhancing patient care and reducing CO2 emissions in breast cancer radiotherapy at selected German centers

BACKGROUND AND OBJECTIVE

Radiotherapy often entails a substantial travel burden for patients accessing radiation oncology centers. The total travel distance for such treatments is primarily influenced by two factors: fractionation schedules and the distances traveled. Specific data on these aspects are not well documented in Germany. This study aims to quantify the travel distances for routine breast cancer patients of five radiation oncology centers located in metropolitan, urban, and rural areas of Germany and to record the CO2 emissions resulting from travel.

METHODS

We analyzed the geographic data of breast cancer patients attending their radiotherapy treatments and calculated travelling distances using Google Maps. Carbon dioxide emissions were estimated assuming a standard 40-miles-per-gallon petrol car emitting 0.168 kg of CO2 per kilometer.

RESULT

Addresses of 4198 breast cancer patients treated between 2018 and 2022 were analyzed. Our sample traveled an average of 37.2 km (minimum average: 14.2 km, maximum average: 58.3 km) for each radiation fraction. This yielded an estimated total of 6.2 kg of CO2 emissions per visit, resulting in 156.2 kg of CO2 emissions when assuming 25 visits (planning, treatment, and follow-up).

CONCLUSION

Our study highlights the environmental consequences associated with patient commutes for external-beam radiotherapy, indicating that reducing the number of treatment fractions can notably decrease CO2 emissions. Despite certain assumptions such as the mode of transport and possible inaccuracies in patient addresses, optimizing fractionation schedules not only reduces travel requirements but also achieves greater CO2 reductions while keeping improved patient outcomes as the main focus.

A single centre service evaluation of patients' experiences participating in radiotherapy clinical trials during and post COVID-19 in Northern Ireland, UK

INTRODUCTION

Radiotherapy (RT) clinical trials allow patients to access cutting-edge innovative cancer treatments. Clinical Research Therapy Radiographers (CRRs) play an important role in the management and care of RT trial patients. The COVID-19 pandemic caused major disruption to RT trial delivery. Measures to mitigate COVID-19 risk continue to have an effect on patient contact and communication within cancer centres in the United Kingdom (UK). This study aimed to explore patient perspectives regarding their recent RT trial experience in Northern Ireland (NI), UK.

METHODS

A single centre service evaluation was conducted in NI. Patients who were recruited into a RT clinical trial from January 2020 to January 2023 were invited to participate. Surveys were posted to 50 participants in April 2023. Quantitative and qualitative data was captured and analysed using descriptive statistics and Braun and Clarke's six-step thematic analysis framework respectively. Ethical approval was obtained through Ulster University and the NHS Trust.

RESULTS

Forty-three of the 50 invited participants responded (86%). Forty-two respondents (79%) had a prostate cancer diagnosis. Forty-one (98%) participants indicated that CRRs were always approachable, polite and courteous and would recommend taking part in a RT trial to friends and family. Identified areas for improvement included aspects regarding consent and participant decision-making.

CONCLUSION

This study suggests that despite the implemented measures to suspend research and mitigate COVID-19 risk, patients remained highly satisfied with the quality of care that they received through their participation in RT trials.

IMPLICATIONS FOR PRACTICE

The results of this service evaluation will facilitate maintenance and improvement of patient focused delivery of cancer trials within the host centre. This study builds on evidence highlighting the importance of the CRR role and role development for radiographers.

Innovative therapeutic strategies to overcome radioresistance in breast cancer

Despite a comparatively favorable prognosis relative to other malignancies, breast cancer continues to significantly impact women's health globally, partly due to its high incidence rate. A critical factor in treatment failure is radiation resistance - the capacity of tumor cells to withstand high doses of ionizing radiation. Advancements in understanding the cellular and molecular mechanisms underlying radioresistance, coupled with enhanced characterization of radioresistant cell clones, are paving the way for the development of novel treatment modalities that hold potential for future clinical application. In the context of combating radioresistance in breast cancer, potential targets of interest include long non-coding RNAs (lncRNAs), micro RNAs (miRNAs), and their associated signaling pathways, along with other signal transduction routes amenable to pharmacological intervention. Furthermore, technical, and methodological innovations, such as the integration of hyperthermia or nanoparticles with radiotherapy, have the potential to enhance treatment responses in patients with radioresistant breast cancer. This review endeavors to provide a comprehensive survey of the current scientific landscape, focusing on novel therapeutic advancements specifically addressing radioresistant breast cancer.

Pain response in single-fraction 8-Gy radiotherapy for painful non-bone-metastasis tumors: a single-center retrospective study

The effectiveness of single-fraction 8-Gy radiotherapy for painful bone metastases has been verified in numerous randomized controlled trials. However, few reports have described the effectiveness of single-fraction 8-Gy radiotherapy in painful tumors other than bone metastases. We conducted a retrospective analysis to evaluate the pain response to single-fraction 8-Gy radiotherapy in painful non-bone-metastasis tumors. We included patients who had received single-fraction 8-Gy radiotherapy for such tumors between January 2017 and December 2022, excluding those with brain metastases, hematological tumors and those who received re-irradiation. Pain response assessment was based on the best responses documented in the medical records and conducted by two radiation oncologists. A total of 36 eligible patients were included in this study. The irradiation sites included primary lesions in eight patients, lymph node metastases in eight, muscle metastases in seven, pleural dissemination in four, skin/subcutaneous metastases in four and other sites in five. Pain response was assessed in 24 patients after radiotherapy. Pain response rate was 88% in evaluable patients; 21 of the 24 patients experienced response. The median assessment date for pain response was 37 days (range: 8-156 days) after radiotherapy. Re-irradiation was performed in four patients (11%). Single-fraction 8-Gy radiotherapy seemed to be a promising treatment option for painful non-bone-metastasis tumors and warrants further investigation.

Palliative radiotherapy and the introduction of a Rapid Access Palliative Clinic in a national radiation oncology network

BACKGROUND

Palliative radiotherapy (PRT) is commonly used to treat symptoms of advanced cancer. PRT has been associated with elevated 30-day mortality (30DM). A Rapid Access Palliative Clinic (RAPC) can streamline the treatment process for patients receiving treatment.

AIMS

We reviewed the PRT practices in a radiation oncology network in Ireland, and the implementation of a RAPC. Patient outcomes were assessed to inform future treatment decisions.

METHODS

A retrospective review of all patients who received PRT over 6 months in 2018 in St. Luke's Radiation Oncology Network (SLRON) was undertaken. We assessed 30DM rates, demographics and referral to specialist palliative care (SPC) services. Subsequently, a retrospective analysis was conducted of a RAPC which ran for 6 months from 2019 to 2020. We assessed treatment data and mortality.

RESULTS

Over 6 months, 645 patients commenced PRT in the SLRON. The 30DM for this cohort was 15.8% (n = 102), with most patients having lung primaries. Of the 30DM cohort, only 55% (n = 56) were referred to SPC services and only 26.4% (n = 27) had performance status recorded. Over 6 months, 40 patients attended 28 RAPCs. Of these, 88% (n = 35) received PRT. Single fraction therapy was utilised in 60% and 48% of patients underwent CT simulation and treatment on the same day. Ultimately, 75% of patients received SPC referral.

CONCLUSIONS

Referral rates to SPC services and documentation of performance status were low in our 30DM retrospective review cohort. The RAPC facilitated quick treatment turnaround, fewer hospital visits and referral to SPC services.

Five-Fraction High-Conformal Ultrahypofractionated Radiotherapy for Primary Tumors in Metastatic Breast Cancer

PURPOSE

To report on the local control and toxicity of 5-fraction, high-conformal ultrafractionated radiation therapy (RT) for primary tumors in patients with metastatic breast cancer (MBC) who did not undergo planned surgical intervention.

METHODS

We retrospectively reviewed 27 patients with MBC who underwent 5-fraction high-dose ultrafractionated intensity-modulated RT for their primary tumors between 2017 and 2022 at our institution. A median dose of 66.8 Gy (range, 51.8-83.6 Gy) was prescribed to the gross tumor, calculated in 2-Gy equivalents using an α/β ratio of 3.5, along with a simultaneous integrated boost of 81.5%. The primary endpoint of this study was local control.

RESULTS

The median tumor size and volume were 5.1 cm and 112.4 cm3, respectively. Treatment was generally well tolerated, with only 15% of the patients experiencing mild acute skin toxicity, which resolved spontaneously. The best infield response rate was 82%, with the objective response observed at a median time of 10.8 months post-RT (range, 1.4-29.2), until local progression or the last follow-up. At a median follow-up of 18.3 months, the 2-year local control rate was 77%. A higher number of prior lines of systemic therapy was significantly associated with poorer 2-year local control (one-two lines, 94% vs three or more lines, 34%; p = 0.004). Post-RT, 67% of the patients transitioned to the next line of systemic therapy, and the median duration of maintaining the same systemic therapy post-RT was 16.3 months (range, 1.9-40.3).

CONCLUSION

In our small dataset, 5-fraction, high-conformal ultrahypofractionated breast RT offered promising 2-year local control with minimal toxicity. Further studies are warranted to investigate the optimal dose and role in this setting.

Metastasectomy and Stereotactic Body Radiotherapy for Colorectal Cancer With Liver and Lung Oligometastases: A Case Report of Complete Remission in a 96-Year-Old Patient

We report a rare case of an extremely old colorectal cancer (CRC) patient who had complete remission after liver metastasectomy and stereotactic body radiotherapy (SBRT) to lung oligometastases (OM), with good quality of life and no evidence of recurrence 12 years after the initial diagnosis. An 83-year-old male patient had a right hemicolectomy for stage pT3 pN0 adenocarcinoma of the colon. Soon he was found to have liver metastasis treated with radiofrequency ablation and then liver metastasectomy with clear margins, followed by chemotherapy in the form of FOLFIRI for six months. Six years later, positron emission tomography (PET) showed 1.6 cm OM in the left upper lobe lung. He was not considered a good candidate for surgery. We offered him SBRT 48 Gy in four fractions every other day. The lesion disappeared with no recurrence in the same location on PET and serial computed tomography (CT) scans. Three years later, PET-CT found a new OM in the left lingular lung measuring 1.2 cm. A CT-guided lung biopsy confirmed invasive adenocarcinoma favoring OM from the CRC. SBRT planning failed due to its proximity to the heart. He accepted the longer course of conventional volumetric modulated arc therapy at 60 Gy in 15 fractions with daily cone-beam CT guidance. Again, he tolerated treatment very well with no significant side effects, despite his age. He did not require any chemotherapy or other systemic treatment in the last 11 years, so he did not experience any toxicities related to such treatment. This case is important to show that old age alone should not be considered a contraindication for metastasectomy and SBRT for CRC with liver and lung OM.

Deterioration of Performance Status during Palliative Radiotherapy Suggests a Significant Short Survival Duration: Indicating the Necessities for Considering Radiotherapy Discontinuation

Discontinuation of palliative radiotherapy due to a patient's declining general condition poses a clinical dilemma for palliative care physicians. This study aimed to investigate the survival duration of patients whose performance status (PS) deteriorated during palliative radiotherapy and inform decisions regarding early treatment discontinuation. We retrospectively analyzed data from patients referred from our institute's palliative care department who underwent ≥10 fractions of palliative radiotherapy between March 2017 and December 2021. PS was assessed using the Eastern Cooperative Oncology Group (ECOG) scale. Survival duration was calculated from the final day of palliative radiotherapy to death using the Kaplan-Meier method. A total of 35 patients underwent palliative radiotherapy. Seven (20%) experienced deterioration in ECOG PS during treatment. Their median survival duration was significantly shorter at 22 days (95% confidence interval: 1-94 days) compared to 125 days (95% confidence interval: 82-150 days) for the 28 patients whose PS remained stable (p = 0.0007). Deterioration in ECOG PS during palliative radiotherapy signifies a markedly shorter survival duration. Careful assessment of a patient's condition throughout treatment is crucial, and early discontinuation should be considered if their general health worsens rather than strictly adhering to the initial schedule.

Aggressive anticancer treatment in the last 2 weeks of life

BACKGROUND

There is a concern that terminally ill cancer patients may be aggressively treated due to the rapidly growing possibilities of anticancer treatment. The aim of this study was to evaluate the use of anticancer treatment at the end of life (EoL).

MATERIALS AND METHODS

This retrospective study included adult patients with advanced solid cancers who were treated at the Institute of Oncology Ljubljana and died of cancer between January 2015 and December 2019. A multiple logistic regression model was used to assess an association between the aggressiveness of anticancer treatment (i.e. systemic therapy, radiotherapy and surgery) in the last 2 weeks of life and year of death, age at death, sex, prognosis of cancer and enrolment into the specialist palliative care (SPC).

RESULTS

We included 1736 patients in our analysis. Overall, 13.7% of patients were enrolled into the SPC and 14.4% received anticancer treatment in the last 2 weeks of life. The odds of receiving anticancer treatment significantly increased over time [odds ratio (OR) 1.15, 95% confidence interval (CI) 1.04-1.27]. There was an increased use of novel systemic therapy (e.g. small-molecule targeted therapy and immunotherapy) at the EoL. Older patients had significantly lower odds to receive anticancer treatment in the last 2 weeks of life as compared to younger patients (OR 0.96, 95% CI 0.95-0.98). As compared to patients receiving only a standard oncology care, those also enrolled into the SPC had significantly lower odds for anticancer treatment in the last 2 weeks of life (OR 0.22, 95% CI 0.12-0.43).

CONCLUSIONS

Terminally ill cancer patients have increased odds for receiving anticancer treatment, especially novel systemic therapies, in the last 2 weeks of life. Younger patients and those not enrolled into the SPC are at particular risk for anticancer treatment at the EoL.

Prompt Pain Relief From Bone Metastases: The Virtual Simulation Program

Purpose

Rapid pain relief for patients with bone metastases can be a challenge due to the lengthy and complex radiation therapy workflow. The purpose of this study was to evaluate the time (in days) between initial radiation oncology consultation and start of palliative radiation treatment after implementing an alternative virtual simulation palliative workflow.

Methods and Materials

Patients meeting strict criteria were selected for virtual simulation, which included only those with painful bone metastases who were recommended palliative radiation therapy using standard anterior-posterior/posterior-anterior or opposed lateral fields. A recent (within 30 days) diagnostic computed tomography (CT) scan clearly visualizing the target volume was required for treatment planning. For comparison, a reference group of 40 consecutive patients with bone metastases who underwent in-person CT simulation before virtual simulation implementation was reviewed.

Results

Forty-five patients were treated for painful bone metastases as part of the virtual simulation program from May 2021 to October 2022. Regarding travel distance, 23 patients lived locally (<50 miles from the treatment center) and 22 patients were distant (≥50 miles from the treatment center). Average time from consultation to treatment for all patients undergoing virtual simulation was 3.7 days, compared with 7.5 days for patients undergoing in-person CT simulation (3.8 days sooner, on average; P ≤ .001). Before full implementation of the virtual simulation program, 5 eligible patients participated in a virtual simulation pilot from April 2021 to May 2021, in which each patient was contoured and planned on both a pre-existing diagnostic CT scan and a standard CT simulation scan. For virtual simulation-based plans, the average V90, V95, and V99 were 99.99%, 99.87%, and 96.70%. No significant planning target volume (PTV) coverage difference was found on subsequent in-person CT simulation scans.

Conclusions

The virtual simulation program decreased the time from consultation to start of treatment by more than 50% for patients recommended palliative radiation therapy for painful bone metastases. This benefit was most significant for outpatients traveling ≥50 miles for treatment. Virtual simulation-based planning can be considered for patients anxious to proceed with radiation therapy quickly or in underserved settings with limited transportation options to regional treatment centers.

Prophylactic Radiotherapy Of MInimally Symptomatic Spinal Disease (PROMISSeD): study protocol for a randomized controlled trial

BACKGROUND

Early palliative/pre-emptive intervention improves clinical outcomes and quality of life for patients with metastatic cancer. A previous signal-seeking randomized controlled trial (RCT) demonstrated that early upfront radiotherapy to asymptomatic or minimally symptomatic high-risk osseous metastases led to reduction in skeletal-related events (SREs), a benefit driven primarily by subgroup of high-risk spine metastasis. The current RCT aims to determine whether early palliative/pre-emptive radiotherapy in patients with high-risk, asymptomatic or minimally symptomatic spine metastases will lead to fewer SREs within 1 year.

METHODS

This is a single-center, parallel-arm, in-progress RCT in adults (≥ 18 years) with ECOG performance status 0-2 and asymptomatic or minimally symptomatic (not requiring opioids) high-risk spine metastases from histologically confirmed solid tumor malignancies with > 5 sites of metastatic disease on cross-sectional imaging. High-risk spine metastases are defined by the following: (a) bulkiest disease sites ≥ 2 cm; (b) junctional disease (occiput to C2, C7-T1, T12-L2, L5-S1); (c) posterior element involvement; or (d) vertebral body compression deformity > 50%. Patients are randomized 1:1 to receive either standard-of-care systemic therapy (arm 1) or upfront, early radiotherapy to ≤ 5 high-risk spine lesions plus standard-of-care systemic therapy (arm 2), in the form of 20-30 Gy of radiation in 2-10 fractions. The primary endpoint is SRE, a composite outcome including spinal fracture, spinal cord compression, need for palliative radiotherapy, interventional procedures, or spinal surgery. Secondary endpoints include (1) surrogates of health care cost, including the number and duration of SRE-related hospitalizations; (2) overall survival; (3) pain-free survival; and (4) quality of life. Study instruments will be captured pre-treatment, at baseline, during treatment, and at 1, 3, 6, 12, and 24 months post-treatment. The trial aims to accrue 74 patients over 2 years to achieve > 80% power in detecting difference using two-sample proportion test with alpha < 0.05.

DISCUSSION

The results of this RCT will demonstrate the value, if any, of early radiotherapy for high-risk spine metastases. The trial has received IRB approval, funding, and prospective registration (NCT05534321) and has been open to accrual since August 19, 2022. If positive, the trial will expand the scope and utility of spine radiotherapy.

TRIAL REGISTRATION

ClinicalTrials.Gov NCT05534321 . Registered September 9, 2022.

TRIAL STATUS

Version 2.0 of the protocol (2021-KOT-002), revised last on September 2, 2022, was approved by the WCG institutional review board (Study Number 1337188, IRB tracking number 20223735). The trial was first posted on ClinicalTrials.Gov on September 9, 2022 (NCT05534321). Patient enrollment commenced on August 19, 2022, and is expected to be completed in 2 years, likely by August 2024.

Pilot Study Evaluating Cross-Disciplinary Educational Material to Improve Patients' Knowledge of Palliative Radiation Therapy

Palliative radiation therapy (PRT) is underutilized, partially due to misconceptions about its risks, benefits, and indications. The objective of this pilot study was to determine if patients with metastatic cancer would gain knowledge from educational material describing PRT and perceive it as useful in their care. A one-page handout conveying information about the purpose, logistics, benefits, risks, and common indications for PRT was offered to patients undergoing treatment for incurable, metastatic solid tumors in one palliative care clinic and four medical oncology clinics. Participants read the handout, then completed a questionnaire assessing its perceived value. Seventy patients participated between June and December 2021. Sixty-five patients (93%) felt they learned from the handout (40% learned "lots"), and 69 (99%) felt the information was useful (53% "very useful"). Twenty-one patients (30%) were previously unaware that PRT can relieve symptoms, 55 (79%) were unaware that PRT can be delivered in five treatments or less, and 43 (61%) were unaware that PRT usually has few side effects. Sixteen patients (23%) felt they currently had symptoms not being treated well enough, and 34 (49%) felt they had symptoms that radiation might help with. Afterwards, most patients felt more comfortable bringing symptoms to a medical oncologist's (n = 57, 78%) or radiation oncologist's (n = 51, 70%) attention. Patient-directed educational material about PRT, provided outside of a radiation oncology department, was perceived by patients as improving their knowledge and adding value in their care, independent of prior exposure to a radiation oncologist.

Palliative short-course radiotherapy (RAPASH study) in patients with rectal cancer

Background

Palliative radiation therapy (RT) is used to treat symptomatic rectal cancer although clinical benefits and toxicities are poorly documented. There is no consensus about the optimal RT regimen and clinical practice undergoes significant changes. Our aim was to evaluate the efficacy and toxicity of short-course (SC) RT in this setting of patients.

Materials and methods

Charts from patients with locally advanced disease not candidates for standard treatment or with symptomatic metastatic rectal cancer treated with SCRT (25 Gy/5 fractions in 5 consecutive days) were retrospectively reviewed. Clinical outcome measures were symptomatic response rate and toxicity.

Results

From January 2007 to December 2017, 59 patients (median age 80 years) received SCRT; 53 were evaluable. The median follow-up was 8 months (range, 1-70). Clinical response to RT for bleeding, pain and tenesmus was 100%, 95% and 89%, respectively. The compliance with the treatment was 100% and no patient experienced acute severe (≥ grade 3) toxicities. Median time to symptoms recurrence was 11 months (range 3-69). Globally, the median overall survival was 12 months.

Conclusions

SCRT is a safe and effective regimen in symptomatic rectal cancer and may be considered the regimen of choice for standard treatment in unfit patients.

Evaluation of the ESMO-Magnitude of Clinical Benefit Scale version 1.1 (ESMO-MCBS v1.1) for adjuvant radiotherapy in breast cancer

BACKGROUND

The European Society of Medical Oncology (ESMO) has suggested using the ESMO-Magnitude of Clinical Benefit Scale (MCBS) to grade the magnitude of clinical benefit of cancer therapies. This approach has not been applied to radiation therapy (RT) yet. We applied the ESMO-MCBS to experiences describing the use of RT to assess (1) the 'scoreability' of the data, (2) evaluate the reasonableness of the grades for clinical benefit and (3) identify potential shortcomings in the current version of the ESMO-MCBS in its applicability to RT.

MATERIALS AND METHODS

We applied the ESMO-MCBS v1.1 to a selection of studies in radiotherapy that had been identified as references in the development of American Society for Radiation Oncology (ASTRO) evidence-based guidelines on whole breast radiation. Of the 112 cited references, we identified a subset of 16 studies that are amenable to grading using the ESMO-MCBS.

RESULTS

Of the 16 studies reviewed, 3/16 were scoreable with the ESMO tool. Six of 16 studies could not be scored because of shortcomings in the ESMO-MCBS v1.1: (1) in 'non-inferiority studies', there is no credit for improved patient convenience, reduced patient burden or improved cosmesis; (2) in 'superiority studies' evaluating local control as a primary endpoint, there is no credit for the clinical benefit such as reduced need for further interventions. In 7/16 studies, methodological deficiencies in the conduct and reporting were identified.

CONCLUSIONS

This study represents a first step in determining the utility of the ESMO-MCBS in the evaluation of clinical benefit in radiotherapy. Important shortcomings were identified that would need to be addressed in developing a version of the ESMO-MCBS that can be robustly applied to radiotherapy treatments. Optimization of the ESMO-MCBS instrument will proceed to enable assessment of value in radiotherapy.

Hemostatic Radiotherapy for Gastric Cancer: MRI as an Alternative to Endoscopy for Post-Treatment Evaluation

INTRODUCTION

Pretreatment diagnosis by diffusion-weighted magnetic resonance imaging (DW-MRI) is useful to determine the effect of chemotherapy for gastric cancer. Here, we investigated the relationship among DW-MRI, endoscopy, and tumor markers.

PATIENTS

Eight patients underwent hemostatic radiotherapy (RT) for gastric cancer in this prospective study from 2019 to 2021. The patients completed MRI, endoscopy, and blood tests before RT; MRI, endoscopy, and blood tests 1 month after RT; and MRI and blood tests 3 months after RT. Correlations between changes in apparent diffusion coefficient (ADC) derived from DW-MRI and the tumor marker carcinoembryonic antigen (CEA) were investigated.

RESULTS

Univariate analysis of overall survival showed that sex and chemotherapy treatment were statistically significant factors. The CEA values before and 1 month after RT decreased significantly. There was no statistical difference between the CEA value 1 and 3 months after RT. The ADC value before and 1 month after RT increased significantly but not between 1 and 3 months after RT. Comparing the ratio of ADC before RT to 1 (or 3) month(s) after RT with that of CEA before RT to 1 (or 3) month(s) after RT, we found an inverse relationship between the two ratios.

CONCLUSIONS

Therefore, changes in ADC and CEA are correlated. Additionally, 3 months after RT, the decrease in ADC appeared earlier than the decrease in CEA. ADC may indicate a biological change earlier than CEA, and the ratios of ADC and CEA may be important factors. These aspects warrant further confirmation in a larger sample population.

Platelet-rich Plasma Improves Radiotherapy-induced Emotional Disorder and Cognitive Dysfunction, Neuroinflammation in Aged Rats by Inhibiting the Activation of NLRP3 Inflammasomes

Although radiotherapy (RT) is the preferred treatment for elderly patients with brain tumors, certain negative effects can't be ignored. Fortunately, platelet-rich plasma (PRP) presents with a promising potential for the treatment of neurological diseases. Therefore, this study aimed to explore the effect of PRP on neuroinflammation, emotional disorder and cognitive dysfunction induced by RT in aged rats. Firstly, whole brain RT (WBRT) model was established by whole brain irradiation with 10 Gy of 6-MeV electron beam in rats. Next, twenty 20-month-old female SD rats were divided into four groups (sham group, PRP group, WBRT group, and WBRT + PRP group) according different treatments. After that, the cognitive dysfunction and depression-like behavior of rats were examined by novel object recognition test (NORT), Morris water maze test (MWM), open field test (OFT) and elevated plus maze test (EPM). Besides, immunohistochemistry was used to detect the expression of microglial marker protein Iba-1 in rat hippocampus; enzyme linked immunosorbent assay (ELISA) to examine the levels of pro-inflammatory cytokines tumor necrosis factor-alpha (TNF-α), interleukin (IL)-1 beta (IL-1β), IL-18, and monocyte chemoattractant protein 1 (MCP-1) in rat hippocampus; real-time quantitative reverse transcription PCR (qRT-PCR) and western blot to measure the levels of neurotrophic factors brain-derived neurotrophic factor (BDNF), tropomyosin-related kinase B receptor (TrkB), and nerve growth factor (NGF) in rat hippocampus; and western blot also to observe the protein expression levels of NOD-like receptor protein 3 (NLRP3), caspase-1, apoptosis-associated speck-like protein containing a CARD (ASC), and IL-1β in rat hippocampus. After experiments, some results obtained were shown as follows. PRP could significantly improve learning and memory ability and depression-like behavior, increase the level of neurotrophic factors, inhibit the activation of microglia and decrease the level of pro-inflammatory factors in WBRT rats. In addition, PRP significantly inhibited the activation of NLRP3 inflammasomes. To sum up, PRP can ameliorate neuroinflammation, emotional disorder and cognitive dysfunction induced by RT in aged rats, and the mechanism may be related to its inhibitory effect on NLRP3 inflammasome activation.

Retrospective comparison of side effects and outcomes of three-dimensional conformal vs. intensity-modulated radiation therapy in the palliative-intent treatment (4 Gy × 5 daily fractions) of canine intranasal tumors (2010–2017)

Objective

To compare the occurrence of radiation side effects and treatment outcomes in dogs with intranasal tumors treated with a total dose of 20 Gy delivered in 5 daily 4 Gy fractions using computer-based 3D conformal (3DCRT) or intensity-modulated (IMRT) radiation therapy plans.

Design

Retrospective case series.

Materials and methods

Medical records for dogs with intranasal tumors treated with 4 Gy × 5 fractions between 2010 and 2017 were reviewed. Radiation side effects, time to local progression (TTLP), progression-free survival (PFS) and survival time (OS) were evaluated.

Results

Thirty-six dogs (24 carcinomas, 10 sarcomas and 2 others) met the inclusion criteria. Sixteen were treated with 3DCRT and 20 with IMRT. Clinical signs improvement or resolution were reported in 84% of dogs. The median time to clinical signs improvement was 12 days (1–88 days) after the end of treatment. Eight dogs treated with 3DCRT (8/16, 50%) and 5 with IMRT (5/20, 25%) were documented acute radiation side effects. Almost all were classified as grade 1 skin, oral or ocular acute side effects. Only one dog in 3DCRT group was demonstrated grade 2 skin acute effects. The median TTLP for dogs treated with 3DCRT or IMRT was 238 days and 179 days, respectively (p = 0.967). The median PFS for 3DCRT or IMRT was 228 days and 175 days, respectively (p = 0.940). The median OS for 3DCRT or IMRT was 295 days and 312 days, respectively (p = 0.787). No significantly differences were observed in side effects, TTLP, PFS and OS between 3DCRT and IMRT groups.

Conclusions

Palliative-intent conformal radiation therapy given in five daily 4 Gy fractions relieved clinical signs with minimal radiation side effects, with no statistical difference in occurrence between 3DCRT and IMRT dogs.

Safety and efficacy of radiotherapy/chemoradiotherapy combined with immune checkpoint inhibitors for non-small cell lung cancer: A systematic review and meta-analysis

Background

It is now widely accepted that radiotherapy (RT) can provoke a systemic immune response, which gives a strong rationale for the combination of RT and immune checkpoint inhibitors (ICIs). However, RT is a double-edged sword that not only enhances systemic antitumor immune response, but also promotes immunosuppression to some extent. Nevertheless, many aspects regarding the efficacy and safety of this combination therapy remain unknown. Therefore, a systematic review and meta-analysis was performed in order to assess the safety and efficacy of RT/chemoradiotherapy (CRT) and ICI combination therapy for non-small cell lung cancer (NSCLC) patients.

Methods

PubMed and several other databases were searched (according to specific criteria) to find relevant studies published prior to the 28th of February 2022.

Results

3,652 articles were identified for screening and 25 trials containing 1,645 NSCLC patients were identified. For stage II-III NSCLC, the one- and two-year overall survival (OS) was 83.25% (95% confidence interval (CI): 79.42%-86.75%) and 66.16% (95% CI: 62.3%-69.92%), respectively. For stage IV NSCLC, the one- and two-year OS was 50% and 25%. In our study, the pooled rate of grade 3-5 adverse events (AEs) and grade 5 AEs was 30.18% (95% CI: 10.04%-50.33%, I2: 96.7%) and 2.03% (95% CI: 0.03%-4.04%, I2: 36.8%), respectively. Fatigue (50.97%), dyspnea (46.06%), dysphagia (10%-82.5%), leucopenia (47.6%), anaemia (5%-47.6%), cough (40.09%), esophagitis (38.51%), fever (32.5%-38.1%), neutropenia (12.5%-38.1%), alopecia (35%), nausea (30.51%) and pneumonitis (28.53%) were the most common adverse events for the combined treatment. The incidence of cardiotoxicity (0%-5.00%) was low, but it was associated with a high mortality rate (0%-2.56%). Furthermore, the incidence of pneumonitis was 28.53% (95% CI: 19.22%-38.88%, I2: 92.00%), grade ≥ 3 pneumonitis was 5.82% (95% CI: 3.75%-8.32%, I2: 57.90%) and grade 5 was 0%-4.76%.

Conclusion

This study suggests that the addition of ICIs to RT/CRT for NSCLC patients may be both safe and feasible. We also summarize details of different RT combinations with ICIs to treat NSCLC. These findings may help guide the design of future trials, the testing of concurrent or sequential combinations for ICIs and RT/CRT could be particularly useful to guide the treatment of NSCLC patients.

European Association of Urology-American Society of Clinical Oncology Collaborative Guideline on Penile Cancer: 2023 Update

CONTEXT

Penile cancer is a rare disease but has a significant impact on quality of life. Its incidence is increasing, so it is important to include new and relevant evidence in clinical practice guidelines.

OBJECTIVE

To provide a collaborative guideline that offers worldwide physician and patient guidance for the management of penile cancer.

EVIDENCE ACQUISITION

Comprehensive literature searches were performed for each section topic. In addition, three systematic reviews were conducted. Levels of evidence were assessed, and a strength rating for each recommendation was assigned according to the GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) methodology.

EVIDENCE SYNTHESIS

Penile cancer is a rare disease but its global incidence is increasing. Human papillomavirus (HPV) is the main risk factor for penile cancer and pathology should include an assessment of HPV status. The main aim of primary tumour treatment is complete tumour eradication, which has to be balanced against optimal organ preservation without compromising oncological control. Early detection and treatment of lymph node (LN) metastasis is the main determinant of survival. Surgical LN staging with sentinel node biopsy is recommended for patients with a high-risk (≥pT1b) tumour with cN0 status. While (inguinal) LN dissection remains the standard for node-positive disease, multimodal treatment is needed in patients with advanced disease. Owing to a lack of controlled trials and large series, the levels of evidence and grades of recommendation are low in comparison to those for more common diseases.

CONCLUSIONS

This collaborative penile cancer guideline provides updated information on the diagnosis and treatment of penile cancer for use in clinical practice. Organ-preserving surgery should be offered for treatment of the primary tumour when feasible. Adequate and timely LN management remains a challenge, especially in advanced disease stages. Referral to centres of expertise is recommended.

PATIENT SUMMARY

Penile cancer is a rare disease that significantly impacts quality of life. While the disease can be cured in most cases without lymph node involvement, management of advanced disease remains challenging. Many unmet needs and unanswered questions remain, underlining the importance of research collaborations and centralisation of penile cancer services.

Palliative Care in Breast Cancer During the COVID-19 Pandemic: A Scoping Review

BACKGROUND

The COVID-19 pandemic has harmed the provision of palliative care (PC) services for women with breast cancer due to all the restrictions that came along with the virus.

OBJECTIVE

To map the available evidence on the situation of PC in breast cancer during the COVID-19 pandemic.

METHODS

A scoping review was carried out based on the methodology proposed by the Joanna Briggs Institute. The search was conducted in nine databases, one electronic repository, and one library, using controlled vocabularies.

RESULTS

Twenty-nine articles and seven documents were included. The majority (11.4% each) were published in the United Kingdom, Italy, and the United States, 38.9% addressed palliative radiotherapy (RT), and 47.2% consisted of recommendations. From the content analysis, five categories were obtained focused on the recommendations on changes in palliative treatment guidelines and the response of PC teams to the evolving crisis.

CONCLUSIONS

The evidence pointed to the management of general PC, palliative RT, palliative chemotherapy, management of metastatic breast cancer, and use of technologies in palliative care. No recommendations were found to manage frequent symptoms in PC, indicating the need to develop primary studies that investigate these aspects in detail in this vulnerable group.

IMPLICATIONS

The results contained in this document can provide professionals working in this field of care with a global view of how other teams have dealt with the pandemic, thereby identifying the best guidelines to apply in their reality, taking into account the clinical and social situation of each patient.

Radiotherapy and palliative care outpatient clinic: a new healthcare integrated model in Italy

BACKGROUND

On the basis of substantial evidence demonstrate that palliative care combined with standard care improves patient, caregiver, and society outcomes, we have developed a new healthcare model called radiotherapy and palliative care (RaP) outpatient clinic were a radiation oncologist and a palliative care physician make a joint evaluation of advanced cancer patients.

METHODS

We performed a monocentric observational cohort study on advanced cancer patients referred for evaluation at the RaP outpatient clinic. Measures of quality of care were carried out.

RESULTS

Between April 2016 and April 2018, 287 joint evaluations were performed and 260 patients were evaluated. The primary tumor was lung in 31.9% of cases. One hundred fifty (52.3%) evaluations resulted in an indication for palliative radiotherapy treatment. In 57.6% of cases was used a single dose fraction of radiotherapy (8 Gy). All the irradiated cohort completed the palliative radiotherapy treatment. An 8% of irradiated patients received the palliative radiotherapy treatment in the last 30 days of life. A total of 80% of RaP patients received palliative care assistance until the end of life.

CONCLUSION

At the first descriptive analysis, the radiotherapy and palliative care model seem to respond to the need of multidisciplinary approach in order to obtain an improvement on quality of care for advanced cancer patients.

Palliative Appropriateness Criteria: A Pragmatic Method to Evaluate the Suitability of Palliative Radiotherapy Fractionation

Purpose: To describe a novel metric to aid clinical decision making between shorter versus longer palliative radiotherapy (PRT) regimens using objective patient factors. Materials and Methods: Patients receiving PRT at a single institution between 2014 and 2018 were reviewed. The time between PRT start and finish was calculated and divided by overall survival (in days from start of PRT) to generate the percent of remaining life (PRL). This value was compared across various clinical factors using the Kruskal-Wallis test. Factors identified with a significance level p < 0.01 were included in a novel Palliative Appropriateness Criteria Score (PACS) and were included in an online risk assessment tool to assist clinicians in patient-specific fractionation decisions. Results: Totally 1027 courses of PRT were analyzed. Median age was 64 years; Eastern Cooperative Oncology Group (ECOG) performance status was 3-4 in 22%. Primary malignancies included were lung (38%), breast (13.8%), prostate (9.3%), and other (39%). The indication for PRT was pain (61%), neurological (21%), or other (18%). Palliative regimens included 199 (19.4%) receiving single fraction, 176 (17.1%) receiving 2-5 fractions, and 652 (63.5%) receiving 10 fractions. Median follow-up was 83 days overall and 437 days for patients alive at last follow-up. Factors significantly associated with increased PRL (and included in the PACS) were male gender, ECOG 3-4, lung or "other" primary diagnosis (vs. breast or prostate), PRT indication (neurological dysfunction vs. pain/other), inpatient status, and extraosseous sites treatment. Death within 30 days was significantly associated with high-risk PACS categorization, regardless of fractionation scheme (p < 0.001). Conclusions: The PACS is a novel metric for evaluating the utility of PRT regimens to improve clinical decision making. Single fraction is associated with low PRL. When considering multifraction PRT regimens, the PACS identifies patients who may benefit from shorter courses of PRT and alternatively, low-risk patients for whom a more protracted course is reasonable. Prospective external validation is warranted.

Geriatric impairments are associated with reduced quality of life and physical function in older patients with cancer receiving radiotherapy - A prospective observational study

INTRODUCTION

Quality of life (QoL) and function are important outcomes for older adults with cancer. We aimed to assess differences in trends in patient-reported outcomes (PROs) during radiotherapy (RT) between (1) groups with curative or palliative treatment intent and (2) groups defined according to the number of geriatric impairments.

MATERIALS AND METHODS

A prospective observational study including patients aged ≥65 years receiving curative or palliative RT was conducted. Geriatric assessment (GA) was performed before RT, and cut-offs for impairments within each domain were defined. Patients were grouped according to the number of geriatric impairments: 0, 1, 2, 3, and ≥ 4. Our primary outcomes, global QoL and physical function (PF), were assessed by The European Organisation for Research and Treatment of Cancer Quality-of-Life Core Questionnaire (EORTC) (QLQ-C30) at baseline, RT completion, and two, eight, and sixteen weeks later. Differences in trends in outcomes between the groups were assessed by linear mixed models.

RESULTS

301 patients were enrolled, mean age was 73.6 years, 53.8% received curative RT. Patients receiving palliative RT reported significantly worse global QoL and PF compared to the curative group. The prevalence of 0, 1, 2, 3 and ≥ 4 geriatric impairments was 16.6%, 22.7%, 16.9%, 16.3% and 27.5%, respectively. Global QoL and PF gradually decreased with an increasing number of impairments. These group differences remained stable from baseline throughout follow-up without any clinically significant changes for any of the outcomes.

DISCUSSION

Increasing number of geriatric impairments had a profound negative impact on global QoL and PF, but no further decline was observed for any group or outcome, indicating that RT was mainly well tolerated. Thus, geriatric impairments per se should not be reasons for withholding RT. GA is key to identifying vulnerable patients in need of supportive measures, which may have the potential to improve treatment tolerance. Registered at clinicaltrials.gov (NCT03071640).

Bias due to statistical handling of death and reirradiation in the assessment of duration of response after palliative radiotherapy: a scoping review and analysis of clinical data

OBJECTIVES

We investigated the influence of handling death and reirradiation on the estimation of duration of response (DOR).

METHODS

First, we performed a scoping review on methods to assess DOR in palliative radiotherapy. Second, we performed three different analyses on a subgroup of patients from a previously published prospective study. The first analysis was a competing risks analysis considering relapse of pain as the event of interest and death and reirradiation as competing events (Analysis A). The second and third analyses were standard survival analyses where the event of interest was a composite outcome of relapse of pain, death, or reirradiation (Analysis B) and relapse of pain (Analysis C), respectively.

RESULTS

Death was considered as an event of interest in less than half of the papers, while reirradiation was not considered in any of the studies. Competing risks analysis was not performed in any of the studies. In the analysis of clinical data, competing risks analysis showed that relapse of pain predominated as the cause of the end of response. Median DOR was correctly estimated to be 4.1 months in Analyses A and B, but was overestimated to be 8.1 months in Analysis C.

CONCLUSIONS

Death and reirradiation should be treated as the events of interest that mark the end of response (as in Analyses A and B) to avoid overestimation of treatment efficacy and an invalid assumption of independent censoring.

ADVANCES IN KNOWLEDGE

The definition of end of response remains inconclusive in the assessment of DOR. We recommend competing risks analysis (Analysis A), by which we can estimate cumulative incidence of each event type and evaluate the necessity of reirradiation.

A pilot study of same-day MRI-only simulation and treatment with MR-guided adaptive palliative radiotherapy (MAP-RT)

We conducted a prospective pilot study evaluating the feasibility of same day MRI-only simulation and treatment with MRI-guided adaptive palliative radiotherapy (MAP-RT) for urgent palliative indications (NCT#03824366). All (16/16) patients were able to complete 99% of their first on-table attempted fractions, and no grades 3-5 toxicities occurred.

DART: diagnostic-CT-enabled planning: a randomized trial in palliative radiation therapy (study protocol)

BACKGROUND

Palliative radiotherapy (PRT) is an effective treatment for managing symptoms of advanced cancer. At least half of all radiation treatments are delivered with palliative intent, aimed at relieving symptoms, such as pain or shortness of breath. Symptomatic patients must receive PRT quickly, therefore expeditious treatment planning is essential. Standard radiation planning requires a dedicated CT scan acquired at the cancer centre, called a 'CT simulation', which facilitates treatment planning (i.e. tumor delineation, placement of radiation beams and dose calculation). However, the CT simulation process creates a bottleneck and often leads to delays in starting treatment. Other researchers have indicated that CT simulation can be replaced by the use of standard diagnostic CT scans for target delineation and planning, which are normally acquired through the radiology department as part of standard patient workup. The goals of this feasibility study are to assess the efficacy, acceptability and scalability of diagnostic-CT-enabled planning, compared to conventional CT simulation planning, for patients receiving PRT to bone, soft tissue and lung disease.

METHODS

This is a randomized, phase II study, with 33 PRT patients to be randomized in a 1:2 ratio between conventional CT simulation (Arm 1), and the diagnostic CT enabled planning workflow (Arm 2). Patients will be stratified by treatment target volume (bone and soft tissue metastasis vs. primary or metastatic intrathoracic disease targets). The primary endpoint is the amount of time the patient spends at the cancer centre. Secondary endpoints include efficacy (rate of plan deliverability and rate of plan acceptability on blinded dose distribution review), stakeholder acceptability (based on patient and clinician perception of acceptability questionnaires) and scalability.

DISCUSSION

This study will investigate the efficacy, acceptability and scalability of a "sim-free" PRT pathway compared to conventional CT simulation. The workflow may provide opportunity for resource optimization by using pre-existing diagnostic imaging and requires minimal investment due to its similarity to current PRT models. It also offers potential benefit to patients by eliminating an imaging procedure, reducing the amount of time spent at the cancer centre, and expediting time to treatment.

TRIAL REGISTRATION

Clinicaltrials.gov identifier: NCT05233904. Date of registration: February 10, 2022; current version: 1.4 on April 29, 2022.

Improving the Effect of Cancer Cells Irradiation with X-rays and High-Energy Protons Using Bimetallic Palladium-Platinum Nanoparticles with Various Nanostructures

Nano-sized radiosensitizers can be used to increase the effectiveness of radiation-based anticancer therapies. In this study, bimetallic, ~30 nm palladium-platinum nanoparticles (PdPt NPs) with different nanostructures (random nano-alloy NPs and ordered core-shell NPs) were prepared. Scanning transmission electron microscopy (STEM), selected area electron diffraction (SAED), energy-dispersive X-ray spectroscopy (EDS), zeta potential measurements, and nanoparticle tracking analysis (NTA) were used to provide the physicochemical characteristics of PdPt NPs. Then, PdPt NPs were added to the cultures of colon cancer cells and normal colon epithelium cells in individually established non-toxic concentrations and irradiated with the non-harmful dose of X-rays/protons. Cell viability before and after PdPt NPs-(non) assisted X-ray/proton irradiation was evaluated by MTS (3-(4,5-dimethylthiazol-2-yl)-5-(3-carboxymethoxyphenyl)-2-(4-sulfophenyl)-2H-tetrazolium) assay. Flow cytometry was used to assess cell apoptosis. The results showed that PdPt NPs significantly enhanced the effect of irradiation on cancer cells. It was noticed that nano-alloy PdPt NPs possess better radiosensitizing properties compared to PtPd core-shell NPs, and the combined effect against cancer cells was c.a. 10% stronger for X-ray than for proton irradiation. Thus, the radio-enhancing features of differently structured PdPt NPs indicate their potential application for the improvement of the effectiveness of radiation-based anticancer therapies.

An Automated Treatment Planning Framework for Spinal Radiation Therapy and Vertebral-Level Second Check

PURPOSE

Complicating factors such as time pressures, anatomic variants in the spine, and similarities in adjacent vertebrae are associated with incorrect level treatments of the spine. The purpose of this work was to mitigate such challenges by fully automating the treatment planning process for diagnostic and simulation computed tomography (CT) scans.

METHODS AND MATERIALS

Vertebral bodies are labeled on CT scans of any length using 2 intendent deep-learning models-mirroring 2 different experts labeling the spine. Then, a U-Net++ architecture was trained, validated, and tested to contour each vertebra (n = 220 CT scans). Features from the CT and auto-contours were input into a random forest classifier to predict whether vertebrae were correctly labeled. This classifier was trained using auto-contours from cone beam computed tomography, positron emission tomography/CT, simulation CT, and diagnostic CT images (n = 56 CT scans, 751 contours). Auto-plans were generated via scripting. Each model was combined into a framework to make a fully automated clinical tool. A retrospective planning study was conducted in which 3 radiation oncologists scored auto-plan quality on an unseen patient cohort (n = 60) on a 5-point scale. CT scans varied in scan length, presence of surgical implants, imaging protocol, and metastatic burden.

RESULTS

The results showed that the uniquely designed convolutional neural networks accurately labeled and segmented vertebral bodies C1-L5 regardless of imaging protocol or metastatic burden. Mean dice-similarity coefficient was 85.0% (cervical), 90.3% (thoracic), and 93.7% (lumbar). The random forest classifier predicted mislabeling across various CT scan types with an area under the curve of 0.82. All contouring and labeling errors within treatment regions (11 of 11), including errors from patient plans with atypical anatomy (eg, T13, L6) were detected. Radiation oncologists scored 98% of simulation CT-based plans and 92% of diagnostic CT-based plans as clinically acceptable or needing minor edits for patients with typical anatomy. On average, end-to-end treatment planning time of the clinical tool was less than 8 minutes.

CONCLUSIONS

This novel method to automatically verify, contour, and plan palliative spine treatments is efficient and effective across various CT scan types. Furthermore, it is the first to create a clinical tool that can automatically verify vertebral level in CT images.

No oncology patient left behind: Challenges and solutions in rural radiation oncology

Health inequities and decreasing median American lifespan, potentiated by the worldwide COVID 19 crisis, have taken centre stage in the public consciousness. Specifically, for this discourse, rural radiation oncology challenges external to the pandemic and unique to the rural American radiation oncology care delivery result from a confluence of the following: a) increased incidence of cancer in the United States;¹ b) recent legislative emphasis on rural healthcare equity initiatives;² c) pandemic-associated delays in cancer screening, diagnosis, and treatment^3,4 with resultant presentation of advanced oncologic stages; d) social spotlight on healthcare equity and inclusion for disenfranchised populations.⁵

We will attempt to delineate these issues and propose widely applicable common-sense solutions. We will review what has transpired at the University of Kentucky over the last two decades, specifically at radiation oncology centre in Morehead, a clinic in eastern Kentucky in the Appalachian foothills. While much more work remains ahead, this clinic has successfully applied many of the initiatives discussed.

Funding

No relevant funding of any research was involved in the preparation of data or the manuscript.

Comparison of survival outcomes after CyberKnife® radiotherapy in Taiwan using preapproved insurance-based reimbursement versus out-of-pocket expenditure

BACKGROUND

With technological advances, radiotherapy has progressed from simple irradiation to robotic arm-based stereotactic radiosurgery systems (SRS, in this case, CyberKnife®). This equipment is high-priced and might be cost-effective or not. The National Health Insurance (NHI) in Taiwan has a premedical claims review process for approving CyberKnife® treatment; however, patients might have to pay for the procedure themselves if the NHI rejects the practice. Under the high treatment cost and such an insurance system, a sketch of patients treated by these high-cost machines and whether the prereview of insurance for reimbursement is reasonable without hindering the patient's right to undergo treatment should be investigated. In this study, the patients of CyberKnife® radiotherapy in our institute were investigated as an example for this purpose.

METHODS

Patients who underwent CyberKnife® radiotherapy in our department were investigated retrospectively. Their demographic characteristics, disease patterns, and treatment sites were analyzed. Survivals were compared according to clinical features, and treatment expenses were reimbursed after prereview or out-of-pocket.

RESULTS

From October 19, 2014, to January 30, 2018, there were 331 patients included in this study, 205 (55.3%) of whom underwent CyberKnife® radiotherapy at their own expense, while 166 (44.7%) had their expenses approved for reimbursement after prereview by NHI. Most patients were treated for metastatic tumors (37.5%), and the brain was the most frequent treatment site (46.1%). The 1-year overall survival was 67.1%, and the 2-year overall survival was 56.3% after CyberKinfe® radiotherapy. The best survival rate (96.8% at 1 year) was for patients with brain tumors. In patient's characteristics, A better Eastern Cooperative Oncology Group (ECOG) performance status, treatment for primary tumors, and outpatient treatment were independent factors for superior survival after CyberKnife® radiotherapy. The survivals for patients whose treatment expenses were approved for reimbursement after prereview by NHI were also better than out-of-pocket.

CONCLUSIONS

Besides the patients' characteristics, the treatment expense could be approved or rejected for reimbursement by the NHI prereview was an independent factor for survival in CyberKnife® radiotherapy. Prereview to reimburse expensive treatment is not an unreasonable requirement.

Prognostication in palliative radiotherapy—ProPaRT: Accuracy of prognostic scores

Background

Prognostication can be used within a tailored decision-making process to achieve a more personalized approach to the care of patients with cancer. This prospective observational study evaluated the accuracy of the Palliative Prognostic score (PaP score) to predict survival in patients identified by oncologists as candidates for palliative radiotherapy (PRT). We also studied interrater variability for the clinical prediction of survival and PaP scores and assessed the accuracy of the Survival Prediction Score (SPS) and TEACHH score.

Materials and methods

Consecutive patients were enrolled at first access to our Radiotherapy and Palliative Care Outpatient Clinic. The discriminating ability of the prognostic models was assessed using Harrell’s C index, and the corresponding 95% confidence intervals (95% CI) were obtained by bootstrapping.

Results

In total, 255 patients with metastatic cancer were evaluated, and 123 (48.2%) were selected for PRT, all of whom completed treatment without interruption. Then, 10.6% of the irradiated patients who died underwent treatment within the last 30 days of life. The PaP score showed an accuracy of 74.8 (95% CI, 69.5–80.1) for radiation oncologist (RO) and 80.7 (95% CI, 75.9–85.5) for palliative care physician (PCP) in predicting 30-day survival. The accuracy of TEACHH was 76.1 (95% CI, 70.9–81.3) and 64.7 (95% CI, 58.8–70.6) for RO and PCP, respectively, and the accuracy of SPS was 70 (95% CI, 64.4–75.6) and 72.8 (95% CI, 67.3–78.3).

Conclusion

Accurate prognostication can identify candidates for low-fraction PRT during the last days of life who are more likely to complete the planned treatment without interruption.

All the scores showed good discriminating capacity; the PaP had the higher accuracy, especially when used in a multidisciplinary way.

Superior Vena Cava Syndrome: A Palliative Approach to Treatment

Superior vena cava (SVC) syndrome is an oncologic emergency of venous congestion due to impaired venous flow through the SVC to the right atrium, leading to potential hemodynamic instability. We report a case of a 78-year-old female patient with a non-symptomatic lung nodule that exhibited rapid growth from its discovery to an enlarging tumor impinging the SVC in less than one month. The short time span from computed tomography (CT) image of the tumor to oncologic emergency required our team to act quickly to identify the source of the tumor and halt its progression, utilizing a multidisciplinary team approach while dealing with a patient that executed their right of autonomy to refusal of care, thus focusing on management with palliative goals since SVC syndrome has a life expectancy of six months post-diagnosis.

Pembrolizumab-related Immune Thrombocytopenia in a Patient with Lung Adenocarcinoma Treated by Radiotherapy: Potential Immune-related Adverse Event Elicited by Radiation Therapy

The effect of radiotherapy during immunotherapy on immune-related adverse events (irAEs) is not fully understood. We herein report a 74-year-old woman diagnosed with lung adenocarcinoma with programmed death ligand 1 expression ≥50% and treated with pembrolizumab. She developed fatal immune thrombocytopenia associated with pembrolizumab immediately following radiotherapy. A flow cytometry analysis of peripheral blood detected an increased expression of programmed death-1 (PD-1) and Ki-67 in CD4⁺ and CD8⁺ T cells after radiotherapy, compared with pre-irradiation measurements. This case suggests that radiotherapy may evoke irAEs during treatment with anti-PD-1 antibodies, which physicians should consider when using radiotherapy in patients treated with these drugs.

The survival impact of radiotherapy on synchronous metastatic rectal cancer: metastatic site can serve for radiotherapy-decision

Purpose: The metastatic site seems to represent a malignancy with a different biological characteristic. Radiotherapy, as a successful, well-tolerated, cost-effective and time-efficient intervention, is able to provide clear benefits for the treatment of locally advanced rectal cancer and has become an essential component of palliative oncology care. The real-world effect of radiotherapy on the survival outcomes of metastatic rectal cancer (mRC) patients might do exist and was worth exploring. Patients and methods: Data were extracted from the Surveillance, Epidemiology, and End Results (SEER) database in this retrospective analysis. The statistical methods included Pearson's chi-square test, Log-rank test, Cox regression model and propensity score matching (PSM). Results: The multivariable Cox regression displayed that radiotherapy may not be used as a prognostic factor for mRC (p=0.057). However, radiotherapy may be associated with the prognosis if the metastatic site was excluded from the multivariate analysis (p<0.001). Radiotherapy seemed to fail to improve OS before PSM (p<0.001) and after PSM without the metastatic site as a matching factor (p<0.001). Nevertheless, there was no significant survival difference between radiotherapy and non-radiotherapy cohort after PSM with the metastatic site as a matching factor (p=0.057). All of M1a rectal cancer patients appear to obtain survival benefit from radiotherapy without the impact of PSM (p<0.001). Notwithstanding, radiotherapy was associated with improved OS of patients with rectal liver-limited metastasis (p=0.023) and did not appear to provide survival benefit for rectal lung-limited (p=0.386) and other-limited metastasis (p=0.385). Both of M1b mRC with and without liver metastasis did not seem to obtain survival benefit from radiotherapy. Conclusions: Carefully selected data from the SEER database suggested that radiotherapy appears to improve overall survival only in patients with rectal liver-limited metastasis.