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Yaouanq M, Gibson N, Boudoussier A, Edouard L, Pouvreau P, Taleb I, Bouleftour W, Sargos P, Magné N, Benziane-Ouaritini N. Emergency radiation therapy in modern-day practice: Now or never, or never again ? Support Care Cancer 2024; 32:114. [PMID: 38240886 DOI: 10.1007/s00520-024-08322-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 01/11/2024] [Indexed: 01/23/2024]
Abstract
Radiation therapy plays a fundamental role in oncological emergencies such as superior vena cava syndrome (SVCS) and metastatic epidural spinal cord compression (MESCC). These are two examples of critical complications of metastatic cancer in terms of pain and functional impact (respiratory and/or neurological). The aim of this review is to explore the current indications, treatment options and outcomes for emergency radiotherapy regarding to these complications.Regarding SVCS, studies are mostly retrospective and unanimously demonstrated a beneficial effect of radiotherapy on symptom relief. Spinal cord compression remains an indication for urgent radiotherapy, and should be combined with surgery when possible. The innovative stereotactic body radiotherapy (SBRT) showed promising results, however this technique requires small volumes and more time preparation and therefore is often unsuitable for SVCS and MESCC emergencies.This review concluded that radiotherapy has a central role to play within a multimodal approach for SVCS and MESCC treatment. Further prospective studies are needed to confirm the effectiveness of radiation and establish the criteria for selecting patients to benefit from this treatment option.
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Affiliation(s)
- Margaux Yaouanq
- Department of Radiation Oncology, Institut Bergonié, Bordeaux, France
| | - Nyere Gibson
- Department of Radiation Oncology, Institut Bergonié, Bordeaux, France
| | | | - Lucas Edouard
- Department of Radiation Oncology, Institut Bergonié, Bordeaux, France
| | - Pierre Pouvreau
- Department of Radiation Oncology, Institut Bergonié, Bordeaux, France
| | - Imed Taleb
- Department of Radiation Oncology, Institut Bergonié, Bordeaux, France
| | - Wafa Bouleftour
- Cancerology and Hematology Institute, Department of Medical Oncology, Saint-Etienne University Hospital, 42055, Saint-Etienne, France.
| | - Paul Sargos
- Department of Radiation Oncology, Institut Bergonié, Bordeaux, France
| | - Nicolas Magné
- Department of Radiation Oncology, Institut Bergonié, Bordeaux, France
- Cellular and Molecular Radiobiology Laboratory, Lyon-Sud Medical School, Unité Mixte de Recherche CNRS5822/IP2I, University of Lyon, Lyon, France
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Goutam S, Ghosh S, Stosky J, Tam A, Quirk S, Fairchild A, Wu J, Kerba M. An Analysis of Clinical and Systemic Factors Associated with Palliative Radiotherapy Delivery and Completion at the End of Life in Alberta, Canada. Curr Oncol 2023; 30:10043-10056. [PMID: 38132364 PMCID: PMC10742975 DOI: 10.3390/curroncol30120730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Revised: 11/12/2023] [Accepted: 11/19/2023] [Indexed: 12/23/2023] Open
Abstract
Radiotherapy (RT) is often utilized for symptom control at the end of life. Palliative RT (pRT) may not be taken to completion by patients, thus decreasing clinical benefits and adversely impacting resource allocation. We determined rates of incomplete pRT and examined predictors of non-completion using an electronic questionnaire. Methods: A questionnaire was embedded within the RT electronic prescribing system for all five cancer centers of Alberta, Canada, between 2017 and 2020. Prescribing radiation oncologists (ROs) were tasked with completing the questionnaire. Treatment variables were collected for 2040 patients prescribed pRT. Details on pRT courses delivered and completed were used to determine rates of incomplete RT. Electronic medical records of a subset of 367 patients randomly selected from the 2040 patients were then analyzed to examine for association of non-completion of RT with patient, disease, and therapy-related factors. Results: Overall, 10% of patients did not complete pRT. The rate of single fractions prescribed as a proportion of all RT fractions increased from 18% (pre-2017: pre-study era) to 29% (2017-2020: study era) (p < 0.0001). After conducting multivariate analysis on the overall group, multiple lifetime malignancies (OR:0.64) or increasing the number of pRT fractions (OR:0.08-0.17) were associated with non-completion. Being selected for stereotactic RT (OR:3.75) or survival > 30 days post-RT prescription (OR:2.20-5.02) were associated with greater rates of RT completion. The ROs' estimates of life expectancy at the time of RT prescription were not predictive of RT completion. In the multivariate analysis of the 367-patient subset, the presence of hepatic metastases (OR 2.59), survival 30-59 days (OR 6.61) and survival 90+ days (OR 8.18) post-RT prescription were associated with pRT completion. Only increasing pRT fractionation (OR:0.05-0.2) was associated with non-completion. Conclusion: One in ten patients prescribed pRT did not complete their treatment course. Decreasing pRT fractionation and improving prognostication in patients near the end of life may decrease rates of incomplete RT courses.
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Affiliation(s)
- Siddhartha Goutam
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB T6G 2R7, Canada
| | - Sunita Ghosh
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB T6G 2R7, Canada
- Cross Cancer Institute, Edmonton, AB T6G 1Z2, Canada
| | - Jordan Stosky
- Department of Oncology, University of Calgary, Calgary, AB T2N 4N2, Canada
- Tom Baker Cancer Center, Calgary, AB T2N 4N2, Canada
| | - Alexander Tam
- Tom Baker Cancer Center, Calgary, AB T2N 4N2, Canada
| | - Sarah Quirk
- Department of Oncology, University of Calgary, Calgary, AB T2N 4N2, Canada
- Tom Baker Cancer Center, Calgary, AB T2N 4N2, Canada
- Department of Physics and Astronomy, University of Calgary, Calgary, AB T2N 1N4, Canada
| | - Alysa Fairchild
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB T6G 2R7, Canada
- Cross Cancer Institute, Edmonton, AB T6G 1Z2, Canada
| | - Jackson Wu
- Department of Oncology, University of Calgary, Calgary, AB T2N 4N2, Canada
- Tom Baker Cancer Center, Calgary, AB T2N 4N2, Canada
| | - Marc Kerba
- Department of Oncology, University of Calgary, Calgary, AB T2N 4N2, Canada
- Tom Baker Cancer Center, Calgary, AB T2N 4N2, Canada
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Yerramilli D, Johnstone CA. Radiation Therapy at the End of-Life: Quality of Life and Financial Toxicity Considerations. Semin Radiat Oncol 2023; 33:203-210. [PMID: 36990637 DOI: 10.1016/j.semradonc.2022.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/29/2023]
Abstract
In patients with advanced cancer, radiation therapy is considered at various time points in the patient's clinical course from diagnosis to death. As some patients are living longer with metastatic cancer on novel therapeutics, radiation oncologists are increasingly using radiation therapy as an ablative therapy in appropriately selected patients. However, most patients with metastatic cancer still eventually die of their disease. For those without effective targeted therapy options or those who are not candidates for immunotherapy, the time frame from diagnosis to death is still relatively short. Given this evolving landscape, prognostication has become increasingly challenging. Thus, radiation oncologists must be diligent about defining the goals of therapy and considering all treatment options from ablative radiation to medical management and hospice care. The risks and benefits of radiation therapy vary based on an individual patient's prognosis, goals of care, and the ability of radiation to help with their cancer symptoms without undue toxicity over the course of their expected lifetime. When considering recommending a course of radiation, physicians must broaden their understanding of risks and benefits to include not only physical symptoms, but also various psychosocial burdens. These include financial burdens to the patient, to their caregiver and to the healthcare system. The burden of time spent at the end-of-life receiving radiation therapy must also be considered. Thus, the consideration of radiation therapy at the end-of-life can be complex and requires careful attention to the whole patient and their goals of care.
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Alcorn SR, Elledge CR, LaVigne AW, Kleinberg L, Smith TJ, Levin AS, Fiksel J, Zeger S, McNutt T, DeWeese TL, Wright JL. Improving providers' survival estimates and selection of prognosis- and guidelines-appropriate treatment for patients with symptomatic bone metastases: Development of the Bone Metastases Ensemble Trees for Survival Decision Support Platform. J Eval Clin Pract 2022; 28:581-598. [PMID: 35090073 DOI: 10.1111/jep.13652] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Revised: 12/10/2021] [Accepted: 12/14/2021] [Indexed: 11/29/2022]
Abstract
RATIONALE, AIMS AND OBJECTIVES In the management of symptomatic bone metastases, current practice guidelines do not provide clear methodology for selecting palliative radiotherapy (RT) regimens based on specific patient and disease features. Decision support aids may offer an effective means for translating the complex data needed to render individualised treatment decisions, yet no such tools are available for use in this setting. Thus, we describe the development of the Bone Metastases Ensemble Trees for Survival-Decision Support Platform (BMETS-DSP), which aims to optimise selection of evidence-based, individualised palliative RT regimens. METHOD The Ottawa Decision Support Framework was used as the theoretical basis for development of BMETS-DSP. First, we utilised stakeholder input and review of the literature to assess determinants underlying the provider decision. Based on this assessment and iterative stakeholder feedback, we developed the web-based, provider-facing BMETS-DSP. Consistent with the underlying theoretical framework, our design also included assessment of decision quality using the International Patient Decision Aids Standards (IPDAS) certification checklist. RESULTS Stakeholder input and review of 54 evidence-based publications identified the following determinants of the provider decision: estimated prognosis, characteristics of the target symptomatic lesion and the primary cancer type, consideration of alternative interventions, access to patient-specific recommendations, and patient preferences. Based on these determinants, we developed the BMETS-DSP that (1) collects patient-specific data, (2) displays an individualised predicted survival curve, and (3) provides case-specific, evidence-based recommendations regarding RT, open surgery, systemic therapy, and hospice referral to aid in the decision-making process. The finalised tool met IPDAS quality requirements. Preliminary results of a pilot assessment suggest impact of clinical outcomes. CONCLUSIONS We describe the successful development of a provider-facing decision support platform to aid in the provision of palliative RT in better alignment with patient and disease features. Impact of the BMETS-DSP on decision outcomes will be further assessed in a randomised, controlled study.
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Affiliation(s)
- Sara R Alcorn
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Christen R Elledge
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Anna W LaVigne
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Lawrence Kleinberg
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Thomas J Smith
- Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Adam S Levin
- Department of Orthopedic Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jacob Fiksel
- Department of Biostatistics, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Scott Zeger
- Department of Biostatistics, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Todd McNutt
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Theodore L DeWeese
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jean L Wright
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Rispoli R, Reverberi C, Targato G, D'Agostini S, Fasola G, Trovò M, Calci M, Fanin R, Cappelletto B. Multidisciplinary Approach to Patients With Metastatic Spinal Cord Compression: A Diagnostic Therapeutic Algorithm to Improve the Neurological Outcome. Front Oncol 2022; 12:902928. [PMID: 35747823 PMCID: PMC9210572 DOI: 10.3389/fonc.2022.902928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 05/16/2022] [Indexed: 11/13/2022] Open
Abstract
Introduction The morbidity associated with metastatic spinal disease is significant because of spinal cord and/or nerve root compression. The purpose of this paper is to define a diagnostic-therapeutic path for patients with vertebral metastases and from this path to build an algorithm to reduce the devastating consequences of spinal cord compression. Materials and Methods The algorithm is born from the experience of a primary care center. A spine surgeon, an emergency room (ER) physician, a neuroradiologist, a radiation oncologist, and an oncologist form the multidisciplinary team. The ER physician or the oncologist intercept the patient with symptoms and signs of a metastatic spinal cord compression. Once the suspicion is confirmed, the following steps of the flow-chart must be triggered. The spine surgeon takes charge of the patient and, on the base of the anamnestic data and neurological examination, defines the appropriate timing for magnetic resonance imaging (MRI) in collaboration with the neuroradiologist. From the MRI outcome, the spine surgeon and the radiation oncologist consult each other to define further therapeutic alternatives. If indicated, surgical treatment should precede radiation therapy. The oncologist gets involved after surgery for systemic therapy. Results In 2021, the Spine and Spinal Cord Surgery department evaluated 257 patients with vertebral metastasis. Fifty-three patients presented with actual or incipient spinal cord compression. Among these, 27 were admitted due to rapid progression of symptoms, neurological deficits and/or spine instability signs. The level was thoracic in 21 cases, lumbar in 4 cases, cervical in 1 case, sacral in 1 case. Fifteen were operated on, 10 of these programmed and 5 in emergency. Discussion Patients with a history of malignancy can present to the ER or to the oncology department with symptoms that must be correctly framed in the context of a metastatic involvement. Even when there is no previous cancer history, the patient's pain characteristics and clinical signs must be interpreted to yield the correct diagnosis of vertebral metastasis with incipient or current spinal cord compression. The awareness of the alert symptoms and the application of an integrated paradigm consent to frame the patients with spinal cord compression, obtaining the benefits of a homogeneous step-by-step diagnostic and therapeutic path. Early surgical or radiation therapy treatment gives the best hope for preventing the worsening, or even improving, the deficits. Conclusions Metastatic spinal cord compression can cause neurological deficits compromising quality of life. Treatment strategies should be planned comprehensively. A multidisciplinary approach and the application of the proposed algorithm is of paramount importance to optimize the outcomes of these patients.
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Affiliation(s)
- Rossella Rispoli
- SOC Chirurgia Vertebro-Midollare, Azienda Sanitaria Universitaria Friuli Centrale, Presidio Ospedaliero Universitario "Santa Maria della Misericordia" di Udine, Udine, Italy
| | - Chiara Reverberi
- SOC Radioterapia, Azienda Sanitaria Universitaria Friuli Centrale, Presidio Ospedaliero Universitario "Santa Maria della Misericordia" di Udine, Udine, Italy
| | - Giada Targato
- SOC Oncologia, Azienda Sanitaria Universitaria Friuli Centrale, Presidio Ospedaliero Universitario "Santa Maria della Misericordia" di Udine, Udine, Italy
| | - Serena D'Agostini
- SOC Neuroradiologia, Azienda Sanitaria Universitaria Friuli Centrale, Presidio Ospedaliero Universitario "Santa Maria della Misericordia" di Udine, Udine, Italy
| | - Gianpiero Fasola
- SOC Oncologia, Azienda Sanitaria Universitaria Friuli Centrale, Presidio Ospedaliero Universitario "Santa Maria della Misericordia" di Udine, Udine, Italy
| | - Marco Trovò
- SOC Radioterapia, Azienda Sanitaria Universitaria Friuli Centrale, Presidio Ospedaliero Universitario "Santa Maria della Misericordia" di Udine, Udine, Italy
| | - Mario Calci
- SOC Pronto Soccorso e Medicina d'Urgenza, Azienda Sanitaria Universitaria Friuli Centrale, Presidio Ospedaliero Universitario "Santa Maria della Misericordia" di Udine, Udine, Italy
| | - Renato Fanin
- Clinica di Ematologia, Azienda Sanitaria Universitaria Friuli Centrale, Presidio Ospedaliero Universitario "Santa Maria della Misericordia" di Udine, Udine, Italy
| | - Barbara Cappelletto
- SOC Chirurgia Vertebro-Midollare, Azienda Sanitaria Universitaria Friuli Centrale, Presidio Ospedaliero Universitario "Santa Maria della Misericordia" di Udine, Udine, Italy
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Shahhat S, Hanumanthappa N, Chung YT, Beck J, Koul R, Bashir Bashir, Cooke A, Dubey A, Butler J, Nashed M, Hunter W, Rathod S, Ong A, Tran K, Kim JO. Do Coordinated Knowledge Translation Campaigns Persuade Radiation Oncologists to Use Single-Fraction Radiation Therapy Compared With Multiple-Fraction Radiation Therapy for Bone Metastases? Int J Radiat Oncol Biol Phys 2021; 109:365-373. [DOI: 10.1016/j.ijrobp.2020.08.056] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 08/21/2020] [Accepted: 08/25/2020] [Indexed: 12/25/2022]
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Donovan EK, Greenspoon J, Schnarr KL, Whelan TJ, Wright JR, Hann C, Whitton A, Chow T, Parpia S, Swaminath A. A pilot study of stereotactic boost for malignant epidural spinal cord compression: clinical significance and initial dosimetric evaluation. Radiat Oncol 2020; 15:267. [PMID: 33208170 PMCID: PMC7672889 DOI: 10.1186/s13014-020-01710-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Accepted: 11/06/2020] [Indexed: 12/25/2022] Open
Abstract
Purpose Metastatic epidural spinal cord compression (MESCC) is a devastating complication of advanced malignancy, which can result in neurologic complications and significant deterioration in overall function and quality of life. Most patients are not candidates for optimal surgical decompression and as a result, receive urgent 3D conformal radiotherapy (3DCRT) to prevent or attempt to reverse neurologic progression. Multiple trials indicate that response and ambulatory rates after 3DCRT are inferior to surgery. The advent of stereotactic body radiation therapy (SBRT) has created a method with which a “radiosurgical decompression” boost may facilitate improve outcomes for MESCC patients. Methods We are conducting a pilot study to investigate SBRT boost after urgent 3D CRT for patients with MESCC. The aim of the study is to establish feasibility of this two-phase treatment regimen, and secondarily to characterize post-treatment ambulation status, motor response, pain control, quality of life and survival. Discussion We describe the study protocol and present a case report of one patient. A quality assurance review was conducted after the first seven patients, and resultant dose-constraints were revised to improve safety and feasibility of planning through more conservative organ at risk constraints. There have been no severe adverse events (grade 3–5) to date. We have illustrated clinical and dosimetric data of an example case, where a patient regained full strength and ambulatory capacity. Conclusions Our study aims to determine if SBRT is a feasible option in addition to standard 3DCRT for MESCC patients, with the goal to consider future randomized trials if successful. Having a robust quality assurance process in this study ensures translatability going forward if future trials with multicenter and increased patient representation are to be considered. Trial registration clinicaltrials.gov; registration no. NCT03529708; https://clinicaltrials.gov/ct2/show/NCT03529708; First posted May 18, 2018.
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Affiliation(s)
- Elysia K Donovan
- Sunnybrook Odette Cancer Centre, Department of Radiation Oncology, University of Toronto, 2075 Bayview Avenue, T2 Wing, Toronto, ON, M4N3M5, Canada
| | - Jeffrey Greenspoon
- Juravinski Cancer Centre, Department of Radiation Oncology, McMaster University, 3rd Floor, 699 Concession Street, Hamilton, ON, L8V 5C2, Canada
| | - Kara L Schnarr
- Juravinski Cancer Centre, Department of Radiation Oncology, McMaster University, 3rd Floor, 699 Concession Street, Hamilton, ON, L8V 5C2, Canada
| | - Timothy J Whelan
- Juravinski Cancer Centre, Department of Radiation Oncology, McMaster University, 3rd Floor, 699 Concession Street, Hamilton, ON, L8V 5C2, Canada
| | - James R Wright
- Juravinski Cancer Centre, Department of Radiation Oncology, McMaster University, 3rd Floor, 699 Concession Street, Hamilton, ON, L8V 5C2, Canada
| | - Crystal Hann
- Juravinski Cancer Centre, Department of Radiation Oncology, McMaster University, 3rd Floor, 699 Concession Street, Hamilton, ON, L8V 5C2, Canada
| | - Anthony Whitton
- Juravinski Cancer Centre, Department of Radiation Oncology, McMaster University, 3rd Floor, 699 Concession Street, Hamilton, ON, L8V 5C2, Canada
| | - Tom Chow
- Juravinski Cancer Centre, Department of Medical Physics, McMaster University, 4th Floor, 699 Concession Street, Hamilton, ON, L8V 5C2, Canada
| | - Sameer Parpia
- Juravinski Cancer Centre, Department of Oncology, McMaster University, 1st Floor, 699 Concession Street, Hamilton, ON, L8V 5C2, Canada
| | - Anand Swaminath
- Juravinski Cancer Centre, Department of Radiation Oncology, McMaster University, 3rd Floor, 699 Concession Street, Hamilton, ON, L8V 5C2, Canada.
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Malignant spinal cord compression (MSCC) presentation before and during Covid-19. JOURNAL OF RADIOTHERAPY IN PRACTICE 2020. [DOI: 10.1017/s1460396920000709] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
AbstractIntroduction:Malignant spinal cord compression (MSCC) is a serious condition requiring urgent palliative radiotherapy to alleviate symptoms and avoid permanent paralysis. This audit compares the number of patients treated for MSCC before and during Covid-19, their treatment regimes and 30-day mortality rates to assess if the pandemic affected the treatment and the number of patients referred for palliative radiotherapy.Methods:A retrospective audit was performed (July–December 2019) and 101 patients were treated for MSCC, an average of 17 patients per month. A further audit was undertaken during Covid-19 (March–May 2020) and 36 patients were treated for MSCC, an average of 12 patients per month in this shorter cohort.Results:The results have demonstrated fewer patients presenting during the pandemic and this may be due to patients not wishing to utilise the National Health Service (NHS) during this time. It also highlighted the need to reduce the treatment duration to minimise hospital attendance and lessen the potential for exposure to Covid-19.Conclusion:Educating patients at risk of MSCC is essential and all cancer patients should be counselled on symptoms and what to do if they occur. Ensuring clinicians know the warning signs and the referral pathway for MSCC is also key to ensure early presentation and early referral for treatment.
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Wallace AS, Rocque GB. Why Aren’t We Choosing Wisely? JCO Oncol Pract 2020; 16:443-445. [DOI: 10.1200/op.20.00421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Audrey S. Wallace
- Department of Radiation Oncology, University of Alabama Birmingham, Birmingham, AL
| | - Gabrielle B. Rocque
- Division of Hematology and Oncology, University of Alabama Birmingham, Birmingham, AL
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Macdonald AG, Lynch D, Garbett I, Nazeer N. Malignant spinal cord compression. J R Coll Physicians Edinb 2020; 49:151-156. [PMID: 31188350 DOI: 10.4997/jrcpe.2019.217] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Malignant spinal cord compression (MSCC) is a potentially devastating consequence of cancer. Early recognition of the signs and symptoms of MSCC can allow diagnosis prior to the development of irreversible complications. Information provision to patients and doctors regarding the risk of MSCC and a streamlined pathway for further investigation are both key to improving the outcome for patients developing this condition. Described in this paper is the development of such a pathway at Aberdeen Royal Infirmary.
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Affiliation(s)
- A Graham Macdonald
- Clinic D, Aberdeen Royal Infirmary, Foresterhill, Aberdeen AB25 2ZN, UK,
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Non-inferiority randomised phase 3 trial comparing two radiation schedules (single vs. five fractions) in malignant spinal cord compression. Br J Cancer 2020; 122:1315-1323. [PMID: 32157242 PMCID: PMC7188681 DOI: 10.1038/s41416-020-0768-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Revised: 11/12/2019] [Accepted: 11/13/2019] [Indexed: 11/11/2022] Open
Abstract
Background The optimal EBRT schedule for MSCC is undetermined. Our aim was to determine whether a single fraction (SF) was non-inferior to five daily fractions (5Fx), for functional motor outcome. Methods Patients not proceeding with surgical decompression in this multicentre non-inferiority, Phase 3 trial were randomised to 10 Gy/SF or 20 Gy/5Fx. A change in mobility from baseline to 5 weeks for each patient, was evaluated by a Modified Tomita score: 1 = ‘Walk unaided’, 2 = ‘With walking aid’ and 3 = ‘Bed-bound’. The margin used to establish non-inferiority was a detrimental change of −0.4 in the mean difference between arms. Results One-hundred and twelve eligible patients were enrolled. Seventy-three patients aged 30–87 were evaluated for the primary analysis. The 95% CI for the difference in the mean change in mobility scores between arms was −0.12 to 0.6. Since −0.4 is not included in the interval, there is evidence that 10 Gy/SF is non-inferior to 20 Gy/5Fx. One grade 3 AE was reported in the 5Fx arm. Twelve (26%) patients in the 5Fx arm had a Grade 2–3 AE compared with six (11%) patients in the SF arm (p = 0.093). Conclusion For mobility preservation, one 10-Gy fraction is non-inferior to 20 Gy in five fractions, in patients with MSCC not proceeding with surgical decompression. Clinical Trial Registration Cancer Trials Ireland ICORG 05-03; NCT00968643; EU-20952.
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Sullivan PZ, Albayar A, Ramayya AG, McShane B, Marcotte P, Malhotra NR, Ali ZS, Chen HI, Janjua MB, Saifi C, Schuster J, Grady MS, Jones J, Ozturk AK. Association of spinal instability due to metastatic disease with increased mortality and a proposed clinical pathway for treatment. J Neurosurg Spine 2020; 32:950-957. [PMID: 32059185 DOI: 10.3171/2019.11.spine19775] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2019] [Accepted: 11/20/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Multidisciplinary treatment including medical oncology, radiation oncology, and surgical consultation is necessary to provide comprehensive therapy for patients with spinal metastases. The goal of this study was to review the use of radiation therapy and/or surgical intervention and their impact on patient outcomes. METHODS In this retrospective series, the authors identified at their institution those patients with spinal metastases who had received radiation therapy alone or had undergone surgery with or without radiation therapy within a 6-year period. Data on patient age, chemotherapy, surgical procedure, radiation therapy, Karnofsky Performance Status (KPS), primary tumor pathology, Spinal Instability Neoplastic Score (SINS), and survival after treatment were collected from the patient electronic medical records. N - 1 chi-square testing was used for comparisons of proportions. The Student t-test was used for comparisons of means. A p value < 0.05 was considered statistically significant. A survival analysis was completed using a multivariate Cox proportional hazards model. RESULTS Two hundred thirty patients with spinal metastases were identified, 109 of whom had undergone surgery with or without radiation therapy. Among the 104 patients for whom the surgical details were reviewed, 34 (33%) had a history of preoperative radiation to the surgical site but ultimately required surgical intervention. In this surgical group, a significantly increased frequency of death within 30 days was noted for the SINS unstable patients (23.5%) as compared to that for the SINS stable patients (2.3%; p < 0.001). The SINS was a significant predictor of time to death among surgical patients (HR 1.11, p = 0.037). Preoperative KPS was not independently associated with decreased survival (p > 0.5) on univariate analysis. One hundred twenty-six patients met the criteria for inclusion in the radiation-only analysis. Ninety-eight of these patients (78%) met the criteria for potential instability (PI) at the time of treatment, according to the SINS system. Five patients (5%) with PI in the radiation therapy group had a documented neurosurgical or orthopedic surgery consultation prior to radiation therapy. CONCLUSIONS At the authors' institution, patients with gross mechanical instability per the SINS system had an increased rate of 30-day postoperative mortality, which remained significant when controlling for other factors. Surgical consultation for metastatic spine patients receiving radiation oncology consultation with PI is low. The authors describe an institutional pathway to encourage multidisciplinary treatment from the initial encounter in the emergency department to expedite surgical evaluation and collaboration.
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Affiliation(s)
| | | | | | | | | | | | | | | | - M Burhan Janjua
- 3Orthopedic Surgery, Pennsylvania Hospital, Philadelphia, Pennsylvania; and
| | - Comron Saifi
- 4Department of Neurological Surgery, University of Texas Southwestern, Dallas, Texas
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13
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Rades D, Hansen O, Jensen LH, Dziggel L, Staackmann C, Doemer C, Cacicedo J, Conde-Moreno AJ, Segedin B, Ciervide-Jurio R, Rubio-Rodriguez C, Perez-Romasanta LA, Alvarez-Gracia A, Dennis K, Ferrer-Albiach C, Navarro-Martin A, Lopez-Campos F, Jankarashvili N, Janssen S, Olbrich D, Holländer NH. Radiotherapy for metastatic spinal cord compression with increased radiation doses (RAMSES-01): a prospective multicenter study. BMC Cancer 2019; 19:1163. [PMID: 31783816 PMCID: PMC6884857 DOI: 10.1186/s12885-019-6390-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Accepted: 11/21/2019] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Patients with metastatic spinal cord compression (MSCC) and favorable survival prognoses can benefit from radiation doses greater than 30Gy in 10 fractions in terms of improved local progression-free survival (LPFS) and overall survival (OS). METHODS/DESIGN This prospective study mainly investigates LPFS after precision radiotherapy (volumetric modulated arc therapy or stereotactic body radiotherapy) with 18 × 2.33Gy in 3.5 weeks. LPFS is defined as freedom from progression of motor deficits during radiotherapy and an in-field recurrence of MSCC following radiotherapy. The maximum relative dose allowed to the spinal cord is 101.5% of the prescribed dose, resulting in an equivalent dose in 2Gy-fractions (EQD2) for radiation myelopathy is 45.5Gy, which is below the tolerance dose of 50Gy according to the Quantitative Analyses of Normal Tissue Effects in the Clinic (QUANTEC). The EQD2 of this regimen for tumor cell kill is 43.1Gy, which is 33% higher than for 30Gy in 10 fractions (EQD2 = 32.5Gy). Primary endpoint is LPFS at 12 months after radiotherapy. Secondary endpoints include the effect of 18 × 2.33Gy on motor function, ambulatory status, sensory function, sphincter dysfunction, LPFS at other follow-up times, overall survival, pain relief, relief of distress and toxicity. Follow-up visits for all endpoints will be performed directly and at 1, 3, 6, 9 and 12 months after radiotherapy. A total of 65 patients are required for the prospective part of the study. These patients will be compared to a historical control group of at least 235 patients receiving conventional radiotherapy with 10x3Gy in 2 weeks. DISCUSSION If precision radiotherapy with 18 × 2.33Gy results in significantly better LPFS than 10x3Gy of conventional radiotherapy, this regimen should be strongly considered for patients with MSCC and favorable survival prognoses. TRIAL REGISTRATION Clinicaltrials.gov NCT04043156. Registered 30-07-2019.
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Affiliation(s)
- Dirk Rades
- Department of Radiation Oncology, University of Lübeck, Ratzeburger Allee 160, 23562 Lübeck, Germany
| | - Olfred Hansen
- Department of Oncology, Odense University Hospital, Odense, Denmark
| | | | - Liesa Dziggel
- Department of Radiation Oncology, University of Lübeck, Ratzeburger Allee 160, 23562 Lübeck, Germany
| | - Christian Staackmann
- Department of Radiation Oncology, University of Lübeck, Ratzeburger Allee 160, 23562 Lübeck, Germany
| | - Claudia Doemer
- Department of Radiation Oncology, University of Lübeck, Ratzeburger Allee 160, 23562 Lübeck, Germany
| | - Jon Cacicedo
- Department of Radiation Oncology, Cruces University Hospital, Barakaldo, Vizcaya Spain
| | - Antonio J. Conde-Moreno
- Department of Radiation Oncology, University and Polytechnic Hospital La Fe, Valencia, Spain
| | - Barbara Segedin
- Department of Radiotherapy, Institute of Oncology Ljubljana, Ljubljana, Slovenia
| | | | | | | | - Ana Alvarez-Gracia
- Department of Radiation Oncology, ICO - University Hospital Germans Trias i Pujol, Badalona, Spain
| | - Kristopher Dennis
- Division of Radiation Oncology, The Ottawa Hospital & University of Ottawa, Ottawa, Canada
| | - Carlos Ferrer-Albiach
- Department of Radiation Oncology, Consorcio Hospital Provincial de Castellón, Castellón, Spain
| | - Arturo Navarro-Martin
- Department of Radiation Oncology, Catalan Institute of Oncology, L’Hospitalet de Llobregat, Barcelona, Spain
| | | | | | - Stefan Janssen
- Medical Practice for Radiotherapy and Radiation Oncology, Hannover, Germany
| | | | - Niels Henrik Holländer
- Department of Oncology and Palliative Units, Zealand University Hospital, Naestved, Denmark
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14
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Patterns of practice in palliative radiotherapy for bone metastases in UK centres. JOURNAL OF RADIOTHERAPY IN PRACTICE 2019. [DOI: 10.1017/s1460396918000584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
AbstractBackgroundThere is abundant evidence of the comparative efficacy of single-fraction (SF) radiotherapy and multi-fraction (MF) radiotherapy when treating patients with bone metastases. Despite this, previous surveys have shown SF schedules to be underutilised.AimTo determine current patterns of practice in patients with bone metastasis and to investigate the factors that influence practice.MethodAn electronic audit was performed amongst 46 physicians, within 7 hospital trusts in the UK. The audit comprised of four hypothetical cases in which consultants and registrars chose which dose and fractionation they would recommend and their reasons for this recommendation.ResultsSF radiotherapy was the most common radiotherapy schedule in hypothetical cases 1, 3 and 4. SF radiotherapy was recommended by 65% of respondents in case 1, 47% in case 2, 89% in case 3 and 46% in case 4. For case 2, 50% proposed MF radiotherapy. For case 4, 22% of respondents recommended Stereotactic Body Radiotherapy (SABR). The following deciding factors were cited as influencing choice of an SF schedule: prognosis, published evidence, performance status and spinal cord compression.ConclusionThe most common radiotherapy schedule selected was SF. However, there were inter-institution differences regarding the use of SF radiotherapy. Furthermore, the survey had shown that a third of respondents recommended an MF regime, despite evidence supporting the efficacy of an SF schedule.
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15
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Levin AS, Alcorn SR, Neuman BJ, Meyer CF. Team Approach: Emergencies in Patients with Skeletal Metastases. JBJS Rev 2019; 7:e8. [PMID: 30920480 DOI: 10.2106/jbjs.rvw.18.00036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Affiliation(s)
- Adam S Levin
- Department of Orthopaedic Surgery (A.S.L. and B.J.N.), Department of Radiation and Molecular Radiation Sciences (S.R.A.), Sidney Kimmel Comprehensive Cancer Center (C.F.M.), The Johns Hopkins School of Medicine, Baltimore, Maryland
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16
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Fallon M, Giusti R, Aielli F, Hoskin P, Rolke R, Sharma M, Ripamonti CI. Management of cancer pain in adult patients: ESMO Clinical Practice Guidelines. Ann Oncol 2018; 29:iv166-iv191. [PMID: 30052758 DOI: 10.1093/annonc/mdy152] [Citation(s) in RCA: 370] [Impact Index Per Article: 61.7] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/08/2023] Open
Affiliation(s)
- M Fallon
- Edinburgh Cancer Research Centre, IGMM, University of Edinburgh, Edinburgh, UK
| | - R Giusti
- Medical Oncology Unit, Sant'Andrea Hospital of Rome, Rome
| | - F Aielli
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - P Hoskin
- Mount Vernon Cancer Centre, Northwood, Hertfordshire, UK
| | - R Rolke
- Department of Palliative Medicine, Medical Faculty RWTH Aachen University, Aachen, Germany
| | - M Sharma
- The Walton Centre NHS Foundation Trust, Liverpool, UK
| | - C I Ripamonti
- Department of Onco-Haematology, Fondazione IRCCS, Istituto Nazionale dei Tumori, Milano, Italy
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17
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Lee KA, Dunne M, Small C, Kelly PJ, McArdle O, O’Sullivan J, Hacking D, Pomeroy M, Armstrong J, Moriarty M, Clayton-Lea A, Parker I, Collins CD, Thirion P. (ICORG 05-03): prospective randomized non-inferiority phase III trial comparing two radiation schedules in malignant spinal cord compression (not proceeding with surgical decompression); the quality of life analysis. Acta Oncol 2018; 57:965-972. [PMID: 29419331 DOI: 10.1080/0284186x.2018.1433320] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND The optimal primary external beam radiation therapy (EBRT) radiation schedule for malignant epidural spinal cord compression (MSCC) remains to be determined. The ICORG 05-03 trial assessed if a 10 Gy single fraction radiation schedule was not inferior to one with 20 Gray (Gy) in five daily fractions, in terms of functional motor outcome, for the treatment of MSCC in patients not proceeding with surgical decompression. This article reports on two of the secondary endpoints, Quality of life (QoL), assessed according to the European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire Core 30 (QLQ-C30) version 3.0 (EORTC Data Center, Brussels, Belgium) and pain control assessed using a visual analog scale. METHODS A randomized, parallel group, multicenter phase III trial was conducted by Cancer Trials Ireland (formerly All-Ireland Cooperative Oncology Research Group, ICORG), across five hospital sites in Ireland and Northern Ireland. Patients were randomized to 10 Gy single fraction of EBRT or 20 Gy in five fractions in a 1:1 ratio. Patients with baseline and 5-week follow up QoL data are included in this analysis. FINDINGS From 2006 to 2014, 112 eligible patients were enrolled for whom 57 were evaluated for this secondary analysis. After adjusting for pre-intervention scores, there was no statistically significant difference in post-treatment Summary scores (excl. FI and QL), or pain scores between the two RT schedules at 5 weeks and 3 months following EBRT. There was a statistically significant relationship between the pretreatment and post-treatment Summary scores (p = .002) but not between the pre-treatment and post-treatment pain scores. INTERPRETATION Primary radiotherapy for the treatment of MSCC significantly improves QoL in patients not proceeding with surgical decompression. After adjusting for pre-intervention scores, there was no statistically significant difference between a 10 Gy single fraction radiation schedule and one with 20 Gy in five daily fractions on post-treatment QoL Summary scores. For most patients, an effective treatment with low burden would be desirable. A single fraction schedule should be considered for this group of patients.
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Affiliation(s)
- K. A. Lee
- Radiation Oncology Department, St Luke’s Radiation Oncology Network, Dublin, Ireland
| | - M. Dunne
- Clinical Trials Unit, St Luke’s Radiation Oncology Network, Dublin, Ireland
| | - C. Small
- Radiation Oncology Department, Galway University Hospital, Galway, Ireland
| | - P. J. Kelly
- Radiation Oncology Department, Cork University Hospital, Cork, Ireland
| | - O. McArdle
- Radiation Oncology Department, St Luke’s Radiation Oncology Network, Dublin, Ireland
| | - J. O’Sullivan
- Radiation Oncology Department, Belfast City Hospital, Belfast, UK
| | - D. Hacking
- Radiation Oncology Department, Whitfield Clinic, Waterford, Ireland
| | - M. Pomeroy
- Radiation Oncology Department, Galway University Hospital, Galway, Ireland
| | - J. Armstrong
- Radiation Oncology Department, St Luke’s Radiation Oncology Network, Dublin, Ireland
| | - M. Moriarty
- Radiation Oncology Department, St Luke’s Radiation Oncology Network, Dublin, Ireland
| | - A. Clayton-Lea
- Operational Services, St Luke’s Radiation Oncology Network, Dublin, Ireland
| | - I. Parker
- Radiation Oncology Department, All Ireland Cooperative Oncology Research Group, Dublin, Ireland
| | - C. D. Collins
- Radiology Department, St Luke’s Radiation Oncology Network, Dublin, Ireland
| | - P. Thirion
- Radiation Oncology Department, St Luke’s Radiation Oncology Network, Dublin, Ireland
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Vellayappan BA, Kumar N, Chang EL, Sahgal A, Sloan AE, Lo SS. Novel multidisciplinary approaches in the management of metastatic epidural spinal cord compression. Future Oncol 2018; 14:1665-1668. [PMID: 29939082 DOI: 10.2217/fon-2018-0133] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Affiliation(s)
- Balamurugan A Vellayappan
- Department of Radiation Oncology, National University Cancer Institute, National University Health System, Singapore 119228
| | - Naresh Kumar
- Department of Orthopaedic Surgery, National University Health System, Singapore 119228
| | - Eric L Chang
- Department of Radiation Oncology, University of Southern California, Keck School of Medicine, Los Angeles, CA 90089, USA
| | - Arjun Sahgal
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON M4N 3M5, Canada
| | - Andrew E Sloan
- Department of Neurological Surgery, Seidman Cancer Center & University Hospitals - Cleveland Medical Center, Cleveland, OH 44106, USA
| | - Simon S Lo
- Department of Radiation Oncology, University of Washington School of Medicine, Seattle, WA 98195, USA
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19
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Rades D, Conde-Moreno AJ, Cacicedo J, Veninga T, Segedin B, Stanic K, Rudat V, Schild SE. 1x8 Gy versus 5x4 Gy for metastatic epidural spinal cord compression: a matched-pair study of three prognostic patient subgroups. Radiat Oncol 2018; 13:21. [PMID: 29422106 PMCID: PMC5806232 DOI: 10.1186/s13014-018-0968-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Accepted: 01/24/2018] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND This study provides separate comparisons of 1 × 8 Gy to 5 × 4 Gy for metastatic epidural spinal cord compression (MESCC) in patients with poor, intermediate and favorable survival prognoses. METHODS Patients receiving 1 × 8 Gy were matched to patients receiving 5 × 4 Gy for age, gender, performance status, tumor type, involved vertebrae, other bone metastases, visceral metastases, interval between tumor diagnosis and MESCC, ambulatory status and time developing motor deficits. From a study including patients with poor (N = 156) or intermediate (N = 86) survival prognoses, subgroup analyses were performed. Furthermore, 232 new patients with favorable prognoses matched the same way were included. RESULTS In poor prognoses patients, 6-month survival rates were 10% after 1 × 8 Gy and 6% after 5 × 4 Gy (p = 0.38); in-field reRT rates in few patients alive at 6 months were 15 and 2% (p = 0.16). In intermediate prognoses patients, 6-month survival rates were 49% after 1 × 8 Gy and 58% after 5 × 4 Gy (p = 0.30). ReRT rates at 6 months were 23 and 13% (p = 0.25). In favorable prognoses patients, 6-month survival rates were 89% after 1 × 8 Gy and 91% after 5 × 4 Gy. ReRT rates at 6 months were 14 and 3% (p = 0.007). In no subgroup, RT regimen had a significant impact on motor function. CONCLUSIONS Since in patients with poor prognoses, outcomes after 1 × 8 Gy and 5 × 4 Gy were not significantly different, 1 × 8 Gy may be an option. In patients with intermediate prognoses, a trend was found in favor of 5 × 4 Gy. In patients with favorable prognoses, need for in-field reRT was greater after 1 × 8 Gy.
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Affiliation(s)
- Dirk Rades
- Department of Radiation Oncology, University of Lübeck, Ratzeburger Allee 160, 23538 Lübeck, Germany
| | - Antonio J. Conde-Moreno
- Department of Radiation Oncology, Consorcio Hospital Provincial de Castellón, Castellón, Spain
| | - Jon Cacicedo
- Department of Radiation Oncology, Cruces University Hospital, Vizcaya, Barakaldo, Spain
| | - Theo Veninga
- Department of Radiotherapy, Dr. Bernard Verbeeten Institute, Tilburg, Netherlands
| | - Barbara Segedin
- Department of Radiotherapy, Institute of Oncology Ljubljana, Ljubljana, Slovenia
| | - Karmen Stanic
- Department of Radiotherapy, Institute of Oncology Ljubljana, Ljubljana, Slovenia
| | - Volker Rudat
- Department of Radiation Oncology, Saad Specialist Hospital, Al-Khobar, Saudi Arabia
| | - Steven E. Schild
- Department of Radiation Oncology, Mayo Clinic Scottsdale, Scottsdale, AZ USA
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