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van der Velden J, Willmann J, Spałek M, Oldenburger E, Brown S, Kazmierska J, Andratschke N, Menten J, van der Linden Y, Hoskin P. ESTRO ACROP guidelines for external beam radiotherapy of patients with uncomplicated bone metastases. Radiother Oncol 2022; 173:197-206. [PMID: 35661676 DOI: 10.1016/j.radonc.2022.05.024] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Revised: 05/16/2022] [Accepted: 05/26/2022] [Indexed: 12/20/2022]
Abstract
After liver and lungs, bone is the third most common metastatic site (Nystrom et al., 1977). Almost all malignancies can metastasize to the skeleton but 80% of bone metastases originate from breast, prostate, lung, kidney and thyroid cancer (Mundy, 2002). Introduction of effective systemic treatment in many cancers has prolonged patients' survival, including those with bone metastases. Bone metastases may significantly reduce quality of life due to related symptoms and possible complications, such as pain and neurologic compromise. The most serious complications of bone metastases are skeletal-related events (SRE), defined as pathologic fracture, spinal cord compression, pain, or other symptoms requiring an urgent intervention such as surgery or radiotherapy. In turn, growing access to modern diagnostic tools allows early detection of asymptomatic bone metastases that could be successfully managed with local treatment avoiding development of SRE. The treatment for bone metastases should focus on relieving existing symptoms and preventing new ones. Radiotherapy is the standard of care for patients with symptomatic bone metastases, providing durable pain relief with minimal toxicity and reasonable cost-effectiveness. Historically, the dose was prescribed in one to five fractions and delivered using simple planning techniques. While 3D-conformal radiotherapy is still widely used for treating bone metastases, introduction of highlyconformal radiotherapy techniques such as stereotactic body radiotherapy (SBRT) have opened new therapeutic possibilities that should be considered in selected patients with bone metastases.
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Affiliation(s)
- Joanne van der Velden
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht 3584 CX, Netherlands
| | - Jonas Willmann
- Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Rämistrasse 100, 8091 Zurich, Switzerland
| | - Mateusz Spałek
- Department of Soft Tissue/Bone Sarcoma and Melanoma, Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Eva Oldenburger
- Department of Radiation Oncology, University Hospital Leuven, Herestraat 49, B3000 Leuven, Belgium
| | - Stephanie Brown
- Mount Vernon Cancer Centre, Northwood, UK and University of Manchester, United Kingdom
| | - Joanna Kazmierska
- Radiotherapy Department II, Greater Poland Cancer Centre, Poznan, Poland; Electroradiology Department, University of Medical Sciences, Poznan, Poland
| | - Nicolaus Andratschke
- Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Rämistrasse 100, 8091 Zurich, Switzerland
| | - Johan Menten
- Department of Radiation Oncology, University Hospital Leuven, Herestraat 49, B3000 Leuven, Belgium; Catholic University Leuven, B3000 Leuven, Belgium
| | - Yvette van der Linden
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht 3584 CX, Netherlands
| | - Peter Hoskin
- Mount Vernon Cancer Centre, Northwood, UK and University of Manchester, United Kingdom; Division of Cancer Sciences, University of Manchester, United Kingdom
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Alite F, Shaikh PM, Mahadevan A. Influence of Dexamethasone Premedication on Acute Lung Toxicity in Lung SBRT. Front Oncol 2022; 12:837577. [PMID: 35311107 PMCID: PMC8928771 DOI: 10.3389/fonc.2022.837577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 01/25/2022] [Indexed: 11/13/2022] Open
Abstract
Introduction The cooperative group experience of thoracic sterotactic body radiation therapy (SBRT) in medically inoperable patients with early stage non-small cell lung cancer (NSCLC) historically utilized corticosteroid premedication. Patterns of care have been mixed as to whether premedication adds benefit in terms of improved lung toxicity and treatment tolerance. Methods Patients treated for NSCLC from 2014 to 2017 with definitive thoracic SBRT (BED10≥100) at a single institution, in a prospectively collected database were evaluated. Pretreatment clinicopathologic characteristics, including Eastern Cooperative Oncology Group (ECOG) performance status, PFT parameters of FEV1, and diffusing capacity for carbon monoxide (DLCO) were collected. Treatment and dosimetric characteristics were collected, and patients were scored as to whether dexamethasone was prescribed and utilized with each fraction. Toxicity was graded on multiple domains including lung as during and 30 days after completion of treatment using Common Terminology Criteria for Adverse Events Version 4. Univariate analysis was performed with Fisher’s exact test for categorical variables and two-tailed Student’s t-test for continuous variables. Multivariate analysis was performed with Cox proportional hazards model to adjust for age, pretreatment DLCO, ECOG, tumor size, central versus peripheral location, and biological effective dose. Results A total of 86 patients treated with thoracic SBRT with 54–60 Gy in 3–8 fractions met inclusion criteria, with the majority (70%) receiving 5 fractions. Of these patients, 45 (52%) received 4 mg dexamethasone premedication prior to each fraction of SBRT and 41 (48%) were treated without dexamethasone premedication. Overall acute lung toxicity was low in both groups. Between the two groups of patients, 5/45 (11%) developed grade 2 or higher lung toxicity including hospital admission in the dexamethasone premedication arm vs. 2/41 (5%) without premedication (p = 0.4370, Fisher’s exact test). Freedom from acute SBRT lung toxicity was no different between dexamethasone premedication arm and no premedication (Log rank, p = 0.45). On multivariate Cox proportional hazard modeling adjusting for age, ECOG, tumor size, central vs. peripheral location, pretreatment DLCO, and BED, there was no difference in freedom from acute lung toxicity without dexamethasone premedication (HR: 0.305; 95% CI: 0.033, 2.792; p = 0.293). Conclusions In this retrospective analysis, pretreatment steroid prophylaxis with dexamethasone confers a similar acute toxicity profile and no added clinical benefit to treatment without pretreatment steroid prophylaxis.
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Affiliation(s)
- Fiori Alite
- Department of Radiation Oncology, Geisinger Cancer Institute, Danville, PA, United States
- *Correspondence: Fiori Alite,
| | - Parvez M. Shaikh
- Department of Radiation Oncology, West Virginia University, Morgantown, WV, United States
| | - Anand Mahadevan
- Department of Radiation Oncology, Geisinger Cancer Institute, Danville, PA, United States
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Development and internal validation of an RPA-based model predictive of pain flare incidence after spine SBRT. Pract Radiat Oncol 2022; 12:e269-e277. [DOI: 10.1016/j.prro.2022.01.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Revised: 01/10/2022] [Accepted: 01/24/2022] [Indexed: 12/14/2022]
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Senanayake TP, Fong HC, Millar BA, Barry A, Cummings B, Ringash J, Maganti M, Warde P, Wong R, Dawson LA. Variability in Steroid Prophylaxis for Radiation-Induced Pain Flare: Practice of Canadian Radiation Oncologists. J Palliat Med 2021; 24:965-966. [PMID: 34128714 DOI: 10.1089/jpm.2020.0761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Tivanka P Senanayake
- Allan and Ruth Kerbel Palliative Radiation Oncology Program, Department of Radiation Oncology, Princess Margaret Cancer Centre, University of Toronto, Ontario, Canada
| | - Heng C Fong
- Allan and Ruth Kerbel Palliative Radiation Oncology Program, Department of Radiation Oncology, Princess Margaret Cancer Centre, University of Toronto, Ontario, Canada
| | - Barbara-Ann Millar
- Allan and Ruth Kerbel Palliative Radiation Oncology Program, Department of Radiation Oncology, Princess Margaret Cancer Centre, University of Toronto, Ontario, Canada
| | - Aisling Barry
- Allan and Ruth Kerbel Palliative Radiation Oncology Program, Department of Radiation Oncology, Princess Margaret Cancer Centre, University of Toronto, Ontario, Canada
| | - Bernard Cummings
- Allan and Ruth Kerbel Palliative Radiation Oncology Program, Department of Radiation Oncology, Princess Margaret Cancer Centre, University of Toronto, Ontario, Canada
| | - Jolie Ringash
- Allan and Ruth Kerbel Palliative Radiation Oncology Program, Department of Radiation Oncology, Princess Margaret Cancer Centre, University of Toronto, Ontario, Canada
| | - Manjula Maganti
- Department of Biostatistics, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Padraig Warde
- Allan and Ruth Kerbel Palliative Radiation Oncology Program, Department of Radiation Oncology, Princess Margaret Cancer Centre, University of Toronto, Ontario, Canada
| | - Rebecca Wong
- Allan and Ruth Kerbel Palliative Radiation Oncology Program, Department of Radiation Oncology, Princess Margaret Cancer Centre, University of Toronto, Ontario, Canada
| | - Laura A Dawson
- Allan and Ruth Kerbel Palliative Radiation Oncology Program, Department of Radiation Oncology, Princess Margaret Cancer Centre, University of Toronto, Ontario, Canada
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Viani GA, Pavoni JF, De Fendi LI. Prophylactic corticosteroid to prevent pain flare in bone metastases treated by radiotherapy. ACTA ACUST UNITED AC 2021; 26:218-225. [PMID: 34211772 DOI: 10.5603/rpor.a2021.0031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Accepted: 02/02/2021] [Indexed: 11/25/2022]
Abstract
Background The aim of this study was to evaluate the effectiveness of prophylactic corticosteroids to prevent pain flare (PF) in bone metastases treated with radiotherapy performing a meta-analysis of randomized clinical trials (RCT). Materials and methods RCTs were identified on Medline, Embase, the Cochrane Library, and the proceedings of annual meetings through June 2020. We followed the PRISMA and MOOSE guidelines. A meta-analysis was performed to assess if corticosteroids reduce the PF, pain progression, and the mean of days with PF compared with the placebo. A p-value < 0.05 was considered significant. Results Three RCTs with a total of 713 patients treated were included. The corticosteroids reduced the occurrence of early PF 20.5% (51/248) versus 32% (80/250) placebo, OR = 0.55 (95% CI: 0.36-0.82, p = 0.002). The mean days of PF were reduced to 1.6 days (95% CI: 1.3-1.9, p = 0.0001). Prophylactic corticosteroids had more patients with no PF and no pain progression, OR = 1.63 (95% CI: 1.14-2.32, p = 0.007). No significant corticosteroids effect was observed for pain progression (p = ns) and late PF occurrence (p = ns). Conclusion Prophylactic corticosteroids reduced the incidence of early PF, the days with PF, resulting in a superior rate of patients with no PF and no pain progression, but with no significant benefit for reducing pain progression or late PF occurrence.
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Affiliation(s)
- Gustavo Arruda Viani
- Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo (FMRP-USP), Ribeirão Preto, Brazil
| | - Juliana Fernandes Pavoni
- Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo (FMRP-USP), Ribeirão Preto, Brazil
| | - Ligia Issa De Fendi
- Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo (FMRP-USP), Ribeirão Preto, Brazil
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van der Linden YM, Westhoff PG, Stellato RK, van Baardwijk A, de Vries K, Ong F, Wiggenraad R, Bakri B, Wester G, de Pree I, van Veelen L, Budiharto T, Schippers M, Reyners AK, de Graeff A. Dexamethasone for the Prevention of a Pain Flare After Palliative Radiation Therapy for Painful Bone Metastases: The Multicenter Double-Blind Placebo-Controlled 3-Armed Randomized Dutch DEXA Study. Int J Radiat Oncol Biol Phys 2020; 108:546-553. [DOI: 10.1016/j.ijrobp.2020.05.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Revised: 04/29/2020] [Accepted: 05/05/2020] [Indexed: 11/24/2022]
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Gaudet M, Linden K, Renaud J, Samant R, Dennis K. Effect of an electronic quality checklist on prescription patterns of prophylactic antiemetic and pain flare medications in the context of palliative radiotherapy for bone metastases. Support Care Cancer 2020; 28:4487-4492. [PMID: 31933067 DOI: 10.1007/s00520-020-05298-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2019] [Accepted: 01/03/2020] [Indexed: 11/29/2022]
Abstract
PURPOSE International guidelines are available to guide prescription of antiemetic and pain flare medications in patients receiving palliative radiotherapy for bone metastases, but prescription rates are quite variable. We hypothesized that a simple electronic quality checklist could increase the evidence-based use of these medications. MATERIALS AND METHODS We implemented an electronic quality checklist item in our center for all patients treated with palliative radiotherapy for lumbar spine bone metastases. We retrospectively reviewed patients in the 6-month pre- and post-intervention. Patients were stratified according to if they were treated within a dedicated rapid palliative (RPAL) radiotherapy program or not. Chi-square tests were used to compare rates of antiemetic and pain flare medications pre- and post-intervention and RPAL vs not. RESULTS A total of 375 patients were identified with 42 (11.2%) treated in dedicated RPAL program. The proportion of patients treated with prophylactic antiemetic and pain flare medications pre-intervention (n = 226) and post-intervention (n = 149) was respectively 34.1% vs 59.1% (p < 0.001) and 26.1% vs 43.0% (p = 0.01). Observed differences for antiemetic prescription rates were greater for patients who were not treated within a dedicated palliative radiotherapy program, but this was not the case for pain flare medications. CONCLUSIONS Our data shows that a simple quality checklist item can have a significant effect on the evidence-based use of prophylactic antiemetic and pain flare medications in patients treated with palliative radiotherapy for bone metastases. We believe such strategies should be routinely included in other clinical pathways to improve the use of symptom control medications.
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Affiliation(s)
- Marc Gaudet
- Division of Radiation Oncology, The Ottawa Hospital and the University of Ottawa, 501 Smyth Road, Ottawa, ON, K1H 8L6, Canada.
| | - Kelly Linden
- Radiation Medicine Program, The Ottawa Hospital, Ottawa, Canada
| | - Julie Renaud
- Radiation Medicine Program, The Ottawa Hospital, Ottawa, Canada
| | - Rajiv Samant
- Division of Radiation Oncology, The Ottawa Hospital and the University of Ottawa, 501 Smyth Road, Ottawa, ON, K1H 8L6, Canada
| | - Kristopher Dennis
- Division of Radiation Oncology, The Ottawa Hospital and the University of Ottawa, 501 Smyth Road, Ottawa, ON, K1H 8L6, Canada
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Flörcken A, Roch C, van Oorschot B. Pain Management. Radiat Oncol 2019. [DOI: 10.1007/978-3-319-52619-5_113-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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