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Harris JP, Ku E, Harada G, Hsu S, Chiao E, Rao P, Healy E, Nagasaka M, Humphreys J, Hoyt MA. Severity of Financial Toxicity for Patients Receiving Palliative Radiation Therapy. Am J Hosp Palliat Care 2024; 41:592-600. [PMID: 37406195 PMCID: PMC10772523 DOI: 10.1177/10499091231187999] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/07/2023] Open
Abstract
Introduction: Financial toxicity has negative implications for patient well-being and health outcomes. There is a gap in understanding financial toxicity for patients undergoing palliative radiotherapy (RT). Methods: A review of patients treated with palliative RT was conducted from January 2021 to December 2022. The FACIT-COST (COST) was measured (higher scores implying better financial well-being). Financial toxicity was graded according to previously suggested cutoffs: Grade 0 (score ≥26), Grade 1 (14-25), Grade 2 (1-13), and Grade 3 (0). FACIT-TS-G was used for treatment satisfaction, and EORTC QLQ-C30 was assessed for global health status and functional scales. Results: 53 patients were identified. Median COST was 25 (range 0-44), 49% had Grade 0 financial toxicity, 32% Grade 1, 15% Grade 2, and 4% Grade 3. Overall, cancer caused financial hardship among 45%. Higher COST was weakly associated with higher global health status/Quality of Life (QoL), physical functioning, role functioning, and cognitive functioning; moderately associated with higher social functioning; and strongly associated with improved emotional functioning. Higher income or Medicare or private coverage (rather than Medicaid) was associated with less financial toxicity, whereas an underrepresented minority background or a non-English language preference was associated with greater financial toxicity. A multivariate model found that higher area income (HR .80, P = .007) and higher cognitive functioning (HR .96, P = .01) were significantly associated with financial toxicity. Conclusions: Financial toxicity was seen in approximately half of patients receiving palliative RT. The highest risk groups were those with lower income and lower cognitive functioning. This study supports the measurement of financial toxicity by clinicians.
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Affiliation(s)
- Jeremy P Harris
- Department of Radiation Oncology, University of California Irvine, Orange, CA, USA
| | - Eric Ku
- Department of Radiation Oncology, University of California Irvine, Orange, CA, USA
| | - Garrett Harada
- Department of Radiation Oncology, University of California Irvine, Orange, CA, USA
| | - Sophie Hsu
- Department of Radiation Oncology, University of California Irvine, Orange, CA, USA
| | - Elaine Chiao
- Department of Radiation Oncology, University of California Irvine, Orange, CA, USA
| | - Pranathi Rao
- Department of Radiation Oncology, University of California Irvine, Orange, CA, USA
| | - Erin Healy
- Department of Radiation Oncology, University of California Irvine, Orange, CA, USA
| | - Misako Nagasaka
- Department of Medicine, Division of Hematology/Oncology, University of California Irvine, Orange, CA, USA
| | - Jessica Humphreys
- Department of Geriatrics and Extended Care, Division of Palliative Care, Tibor Rubin VA Medical Center, Long Beach, CA, USA
- Department of Medicine, Division of Palliative Medicine, University of California, San Francisco, CA, USA
| | - Michael A Hoyt
- Department of Population Health & Disease Prevention, University of California Irvine, Irvine, CA, USA
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Aitken GL, Motta M, Samuels S, Reynolds PT, Gannon CJ, Llaguna OH. Impact of Palliative Interventions on Survival of Patients with Unresected Pancreatic Cancer: Review of the 2010-2016 National Cancer Database. Am J Hosp Palliat Care 2023; 40:1357-1364. [PMID: 37132387 DOI: 10.1177/10499091231174620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/04/2023] Open
Abstract
INTRODUCTION Palliative interventions (PI) are offered to patients with pancreatic cancer with the aim of enhancing quality of life and improving overall survival (OS). The purpose of this study was to determine the impact of PI on survival amongst patients with unresected pancreatic cancer. METHODS Patients with stage I-IV unresected pancreatic adenocarcinoma were identified using the 2010-2016 National Cancer Database. The cohort was stratified by PI received: palliative surgery (PS), radiation therapy (RT), chemotherapy (CT), pain management (PM), or a combination (COM) of the preceding. Kaplan-Meier method with log-rank test was used to compare and estimate OS based on the PI received. A multivariate proportional hazards model was utilized to identify predictors of survival. RESULTS 25,995 patients were identified, of which 24.3% received PS, 7.7% RT, 40.8% CT, 16.6% PM, and 10.6% COM. The median OS was 4.9 months, with stage III patients having the highest and stage IV the lowest OS (7.8 vs 4.0 months). Across all stages, PM yielded the lowest median OS and CT the highest (P < .001). Despite this, the stage IV cohort was the only group in which CT (81%) accounted for the largest proportion of PI received (P < .001). Although all PI were identified as positive predictors of survival on multivariate analysis, CT had the strongest association (HR .43; 95% CI, .55-.60, P = .001). CONCLUSION PI offers a survival advantage to patients with pancreatic adenocarcinoma. Further studies to examine the observed limited use of CT in earlier disease stages are warranted.
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Affiliation(s)
- Gabriela L Aitken
- Department of Surgery, Memorial Healthcare System, Hollywood, FL, USA
| | - Monique Motta
- Department of Surgery, Memorial Healthcare System, Hollywood, FL, USA
| | - Shenae Samuels
- Office of Human Research, Memorial Healthcare System, Hollywood, FL, USA
| | - Patrick T Reynolds
- Oncology Supportive Care Services, Memorial Healthcare System, Hollywood, FL, USA
| | | | - Omar H Llaguna
- Division of Surgical Oncology, Memorial Healthcare System, Hollywood, FL, USA
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Keit E, Lee SF, Woodward M, Rembielak A, Shiue K, Desideri I, Oldenburger E, Bienz M, Rades D, Theodorou M, Agyeman MB, Yarney J, Bryant JM, Yu HHM, Simone CB, Hoskin P, Johnstone PAS. Palliative whole brain radiation therapy: an international state of practice. Ann Palliat Med 2023; 12:1155-1164. [PMID: 37731303 DOI: 10.21037/apm-23-448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 08/24/2023] [Indexed: 09/22/2023]
Abstract
BACKGROUND Improvements in radiation delivery and systemic therapies have resulted in few remaining indications for palliative whole brain radiation therapy (WBRT). Most centers preferentially use stereotactic radiotherapy (SRT) and reserve WBRT for those with >15 lesions, leptomeningeal presentation, rapidly progressive disease, or limited estimated survival. Despite regional differences among preferred dose, fractionation, and treatment technique, we predict survival post-WBRT will remain poor-indicating appropriate application of WBRT in this era of SRT and improved systemic therapies. METHODS A multi-center, international retrospective analysis of patients receiving WBRT in 2022 was performed. Primary end point was survival after WBRT. De-identified data were analyzed centrally. Patients receiving WBRT as part of a curative regimen, prophylactically, or as bridging therapy were excluded. The collected data consisted of patient parameters including prescription dose and fractionation, use of neurocognitive sparing techniques and survival after WBRT. Survival was calculated via the Kaplan-Meier method. RESULTS Of 29,943 international RT prescriptions written at ten participating centers in 2022, 462 (1.5%) were for palliative WBRT. Participating centers were in the United States (n=138), the United Kingdom (n=111), Hong Kong (n=72), Italy (n=49), Belgium (n=45), Germany (n=27), Ghana (n=15), and Cyprus (n=5). Twenty-six different dose regimens were used. The most common prescriptions were for 3,000 cGy over 10 fractions (45.0%) and 2,000 cGy over 5 fractions (43.5%) with significant regional preferences (P<0.001). Prior SRT was delivered in 32 patients (6.7%), hippocampal avoidance (HA) was used in 44 patients (9.5%), and memantine was prescribed in 93 patients (20.1%). Survival ranged from 0 days to still surviving at 402 days post-treatment. The global median overall survival (OS) was 84 days after WBRT [95% confidence interval (CI): 68.0-104.0]. Actuarial survival at 7 days, 1 month, 3 months, and 6 months were 95%, 78%, 48%, and 32%, respectively. Twenty-seven patients (5.8%) were unable to complete their prescribed WBRT. CONCLUSIONS This moment-in-time analysis confirms that patients with poor expected survival are being appropriately selected for WBRT-illustrating the dwindling indications for WBRT-and demonstrates the variance in global practice. Since poor survival precludes patients from deriving benefit, memantine and HA are best suited in carefully selected cases.
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Affiliation(s)
- Emily Keit
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Shing Fung Lee
- Department of Radiation Oncology, National University Cancer Institute, National University Hospital, Singapore, Singapore; Department of Clinical Oncology, Tuen Mun Hospital, New Territories West Cluster, Hospital Authority, Hong Kong, China
| | - Melissa Woodward
- Department of Radiotherapy, The Christie at Oldhman, The Christie NHS Foundation Trust, Manchester, UK
| | - Agata Rembielak
- Department of Clinical Oncology, The Christie NHS Foundation Trust, Manchester, UK; Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - Kevin Shiue
- Department of Radiation Oncology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Isacco Desideri
- Department of Experimental Clinical and Biomedical Sciences "Mario Serio", University of Florence, Florence, Italy
| | - Eva Oldenburger
- Department of Radiation Oncology, University Hospitals Leuven, Leuven, Belgium
| | - Maya Bienz
- Mount Vernon Cancer Centre, Northwood, UK
| | - Dirk Rades
- Department of Radiation Oncology, University Medical Center Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | | | - Mervin B Agyeman
- National Centre for Radiotherapy and Nuclear Medicine, Accra, Ghana
| | - Joel Yarney
- National Centre for Radiotherapy and Nuclear Medicine, Accra, Ghana; University of Cape Coast, Cape Coast, Ghana
| | - John Michael Bryant
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Hsiang-Hsuan Michael Yu
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | | | - Peter Hoskin
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK; Mount Vernon Cancer Centre, Northwood, UK
| | - Peter A S Johnstone
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
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Zaki P, Barbour A, Zaki MM, Tseng YD, Amin AG, Venur V, McGranahan T, Vellayappan B, Palmer JD, Chao ST, Yang JT, Foote M, Redmond KJ, Chang EL, Sahgal A, Lo SS, Schaub SK. Emergent radiotherapy for spinal cord compression/impingement-a narrative review. Ann Palliat Med 2023; 12:1447-1462. [PMID: 37817502 DOI: 10.21037/apm-23-342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/25/2023] [Accepted: 08/28/2023] [Indexed: 10/12/2023]
Abstract
BACKGROUND AND OBJECTIVE Malignant epidural spinal cord compression (MESCC), often presenting with back pain and motor/sensory deficits, is associated with poor survival, particularly when there is loss of ambulation. The purpose of this review is to evaluate the literature and discuss appropriate workup and management of MESCC, specifically in the emergent setting. METHODS A PubMed search was conducted on "spinal cord compression" and "radiation therapy." Articles were analyzed for the purpose of this narrative review. KEY CONTENT AND FINDINGS If MESCC is suspected, neurologic examination and complete spine imaging are recommended. Emergent treatment is indicated if there is radiographic evidence of high-grade compression and/or clinically significant motor deficits. Treatment involves a combination of medical management, surgical decompression, radiation therapy (RT), and rehabilitation. For motor deficits, emergent initiation of high dose steroids is recommended. Circumferential surgical decompression ± stabilization followed by RT provides superior clinical outcomes than RT alone. For patients whom surgery is not reasonable, RT alone may provide significant treatment response which depends on radioresponsiveness of the pathology. Systemic therapy, if indicated, is typically reserved till after primary treatment of MESCC, but patients with chemoresponsive tumors may receive primary chemotherapy. The selected RT schedule should be personalized to each patient and commonly is 30 Gy in 10 fractions (fx), 20 Gy in 5 fx, or 8 Gy in 1 fx. MESCC recurrence may be treated with additional RT, if within the spinal cord tolerance, or surgery. Stereotactic body radiation therapy (SBRT) has been used for high grade MESCC in patients with relatively intact neurologic function at a few centers with a very robust infrastructure to support rapid initiation of treatment within a short period of time, but is generally not feasible for most clinical practices. SBRT may be advantageous for low grade MESCC, recurrence, or in the post-operative setting. Detection of MESCC prior to development of high-grade compression or deterioration of neurologic function may allow patients to benefit more from advanced therapies and improve prognosis. CONCLUSIONS MESCC is a devastating condition; optimal treatment should be personalized to each patient and approached collaboratively by a multidisciplinary team.
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Affiliation(s)
- Peter Zaki
- Department of Radiation Oncology, University of Washington, Seattle, WA, USA
| | - Andrew Barbour
- Department of Radiation Oncology, University of Washington, Seattle, WA, USA
| | - Mark M Zaki
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, USA
| | - Yolanda D Tseng
- Department of Radiation Oncology, University of Washington, Seattle, WA, USA
| | - Anubhav G Amin
- Department of Neurological Surgery, University of Washington, Seattle, WA, USA
| | - Vyshak Venur
- Division of Medical Oncology, Fred Hutchinson Cancer Center/University of Washington, Seattle, WA, USA
| | - Tresa McGranahan
- Department of Neurology, Alvord Brain Tumor Center/University of Washington, Seattle, WA, USA
| | - Balamurugan Vellayappan
- Department of Radiation Oncology, National University Cancer Institute of Singapore, Singapore, Singapore
| | - Joshua D Palmer
- Department of Radiation Oncology, Arthur G. James Cancer Hospital/The Ohio State University, Columbus, OH, USA
| | - Samuel T Chao
- Department of Radiation Oncology, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Jonathan T Yang
- Department of Radiation Oncology, University of Washington, Seattle, WA, USA
| | - Matthew Foote
- Department of Radiation Oncology, Princess Alexandra Hospital, University of Queensland, and ICON Cancer Centre, Brisbane, Queensland, Australia
| | - Kristin J Redmond
- Department of Radiation and Molecular Oncology, John Hopkins University, Baltimore, MD, USA
| | - Eric L Chang
- Department of Radiation Oncology, Keck School of Medicine and Norris Cancer Center at University of Southern California, CA, USA
| | - Arjun Sahgal
- Department of Radiation Oncology, Sunnybrook Health Science Centre, University of Toronto, Toronto, Ontario, Canada
| | - Simon S Lo
- Department of Radiation Oncology, University of Washington, Seattle, WA, USA
| | - Stephanie K Schaub
- Department of Radiation Oncology, University of Washington, Seattle, WA, USA
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Arabandi PR, Slade AN, Fernandez EV, Carroll NV. The relationship between palliative radiotherapy and opioid prescribing patterns among patients with metastatic cancer. Ann Palliat Med 2023; 12:912-918. [PMID: 37859425 DOI: 10.21037/apm-22-802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/03/2022] [Accepted: 05/09/2023] [Indexed: 10/21/2023]
Abstract
BACKGROUND While randomized trials have established that palliative radiotherapy, especially to bone, can improve qualitative measures of pain, its quantitative relationship to opioid prescribing patterns has remained underexplored. We aimed to identify the association of palliative radiotherapy on opioid prescriptions received among patients with metastatic cancer. METHODS The Virginia Commonwealth University Institutional Review Board approved retrospective analysis extracted prescription data from all adult patients with metastatic cancer who underwent outpatient palliative external beam radiation therapy at Virginia Commonwealth University Health System from 2008-2018. Institutional prescribing data were used to calculate the average opioid oral morphine milligram equivalent (MME) dose 30, 60 and 90 days both before and after radiotherapy. Univariate and bivariate ordinary least squares (OLS) regression models were used to estimate the relationship of MME changes with clinical, radiation-related, and demographic patient factors. RESULTS A total of 182 patients met inclusion criteria. Overall, patients required higher opioid doses after radiotherapy, with mean MME 30, 60, and 90 days prior to radiotherapy of 24.6, 20.2, and 16.8 mg, respectively; which increased to 62.9, 77.7 and 82.4 mg post-radiation therapy (P<0.01). Multivariate OLS models predicting the change of MME 60 days pre- and post-radiation treatment showed that younger age and comorbid depression predicted increased MME after radiotherapy. CONCLUSIONS Patients with metastatic cancer face a relatively high opioid burden, which increases over time, even among those who receive palliative radiation therapy. Patients who are younger and have comorbid depression may have a higher risk of increased opioid burden after radiotherapy.
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Affiliation(s)
| | - Alexander N Slade
- Department of Radiation Oncology, Stony Brook University Renaissance School of Medicine, Stony Brook, NY, USA
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Bergman DT, Zaki L, Pettus JR, Zaki BI, Amin M. Genomic profile of Pancoast syndrome due to hepatocellular carcinoma: A case report. Thorac Cancer 2023. [PMID: 37160416 DOI: 10.1111/1759-7714.14923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 04/19/2023] [Accepted: 04/20/2023] [Indexed: 05/11/2023] Open
Abstract
Hepatocellular carcinoma (HCC) is a common cancer and is frequently diagnosed at a late and unresectable stage with limited effective treatment options. Here, we present the fifth reported case of a 77 year-old male with metastatic HCC presenting as a symptomatic superior sulcus lung tumor and discuss the genomic profile of this rare presentation of HCC for the first time, which included multiple classic mutations in HCC such as TERT, TP53, and WNT/β-catenin signaling as well as in the DNA repair gene ATM. The patient was treated with palliative radiotherapy to the Pancoast tumor followed by atezolizumab plus bevacizumab and passed away 6 months after diagnosis. This rare case highlights the need for effective treatment in aggressive and unresectable HCC and the utility of early genomic studies to allow for targeted therapy such as poly (ADP-ribose) polymerase (PARP)-inhibitors.
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Affiliation(s)
- Drew T Bergman
- Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
- Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | | | - Jason R Pettus
- Pathology and Laboratory Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - Bassem I Zaki
- Radiation Oncology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - Manik Amin
- Hematology/Oncology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
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7
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Chow Z, Amoah E, Hao Z, Kudrimoti M. Radiotherapy in Managing Metastatic Hepatocellular Carcinoma With Cardiac Involvement and Pulmonary Tumor Thromboemboli: A Case Report. Cureus 2023; 15:e36547. [PMID: 37095816 PMCID: PMC10121482 DOI: 10.7759/cureus.36547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/22/2023] [Indexed: 04/26/2023] Open
Abstract
Hepatocellular carcinoma (HCC) is the most common liver cancer and presents various degrees of aggressiveness. In this case study, we reported the management of an aggressive HCC patient who was a young immigrant from a hepatitis B endemic country with locally advanced HCC with portal involvement at presentation. Patient was initially managed with Yttrium-90 (Y-90) instillation, then systemic treatment when he had disease progression. Despite multiple lines of systemic treatments, patient continued to progress and developed significant cardiac involvement and pulmonary tumor thromboemboli. His course of treatment was further complicated by hemoptysis, presumably from hemorrhagic tumor thromboemboli. Patient became ineligible for systemic treatment due to the risk of hemoptysis, thus, subsequently managed with a course of palliative radiotherapy. Unfortunately, patient developed hemorrhagic shock, cardiac failure, and septic shock during radiation treatment and expired shortly afterward. In this case report, we discussed multi-modal treatments, including Y-90, systemic treatment, and radiotherapy, in managing complicated and aggressive HCC. We also reported risk factors, prognostic factors, efficacy of Y-90 instillation and the necessity of a personalized treatment approach. In conclusion, there is no consensus on managing patients with metastatic HCC with cardiac and pulmonary involvement currently. Treatment modalities are often highly personalized and require multi-disciplinary discussion.
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Affiliation(s)
- Zeta Chow
- Radiation Medicine, University of Kentucky College of Medicine, Lexington, USA
| | - Evans Amoah
- Radiation Oncology, University of Kentucky College of Medicine, Lexington, USA
| | - Zhonglin Hao
- Medical Oncology, University of Kentucky College of Medicine, Lexington, USA
| | - Mahesh Kudrimoti
- Radiation Oncology, University of Kentucky College of Medicine, Lexington, USA
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Farris JC, Johnson AG, Carriere PP, Patel ZA, Nagatsuka M, Farris MK, Hughes RT. Palliative Appropriateness Criteria: A Pragmatic Method to Evaluate the Suitability of Palliative Radiotherapy Fractionation. J Palliat Med 2023; 26:67-72. [PMID: 35881861 PMCID: PMC9810497 DOI: 10.1089/jpm.2022.0173] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
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.
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Affiliation(s)
- Joshua C. Farris
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston Salem, North Carolina, USA
| | - Adam G. Johnson
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston Salem, North Carolina, USA
| | - Patrick P. Carriere
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston Salem, North Carolina, USA
| | - Zachary A. Patel
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston Salem, North Carolina, USA
| | - Moeko Nagatsuka
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston Salem, North Carolina, USA
| | - Michael K. Farris
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston Salem, North Carolina, USA
| | - Ryan T. Hughes
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston Salem, North Carolina, USA.,Address correspondence to: Ryan T. Hughes, MD, Department of Radiation Oncology, Wake Forest School of Medicine, 1 Medical Center Boulevard, Winston-Salem, NC 27157, USA
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Muacevic A, Adler JR, Coyne MD, Aldridge W, Zeiler S, Stuhr K, Waxweiler TV, Robin TP, Schefter TE, Kavanagh BD, Nath SK. Practical Implementation of Emergent After-Hours Radiation Treatment Process Using Remote Treatment Planning on Optimized Diagnostic CT Scans. Cureus 2022; 14:e33100. [PMID: 36721584 PMCID: PMC9884138 DOI: 10.7759/cureus.33100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/27/2022] [Indexed: 12/31/2022] Open
Abstract
The purpose of this report is to present the implementation of a process for after-hours radiation treatment (RT) utilizing remote treatment planning based on optimized diagnostic computed tomography (CT) scans for the urgent palliative treatment of inpatients. A standardized operating procedure was developed by an interprofessional panel to improve the quality of after-hours RT and minimize the risk of treatment errors. A new diagnostic CT protocol was created that could be performed after-hours on hospital scanners and would ensure a reproducible patient position and adequate field of view. An on-call structure for dosimetry staff was created utilizing remote treatment planning. The optimized CT protocol was developed in collaboration with the radiology department, and a novel order set was created in the electronic health system. The clinical workflow begins with the radiation oncologist notifying the on-call team (therapist, dosimetrist, and physicist) and obtaining an optimized diagnostic CT scan on a hospital-based scanner. The dosimetrist remotely creates a plan; the physicist checks the plan; and the patient is treated. Plans are intentionally simple (parallel opposed fields, symmetric jaws) to expedite care and reduce the risk of error. Education on the new process was provided for all relevant staff. Our process was successfully implemented with the use of an optimized CT protocol and remote treatment planning. This approach has the potential to improve the quality and safety of emergent after-hours RT by better approximating the normal process of care.
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Atallah RP, Zhang Y, Zakka K, Jiang R, Huang Z, Shaib WL, Diab M, Akce M, Wu C, El-Rayes BF, Alese OB. Role of local therapy in the management of patients with metastatic anal squamous cell carcinoma: a National Cancer Database study. J Gastrointest Oncol 2022; 13:2306-2321. [PMID: 36388688 PMCID: PMC9660037 DOI: 10.21037/jgo-22-125] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Accepted: 07/04/2022] [Indexed: 10/10/2023] Open
Abstract
BACKGROUND About 10-20% of patients with anal squamous cell carcinoma (SCCa) present with metastatic disease and are usually treated with systemic chemotherapy. However, primary tumor control is crucial as local failure is associated with significant morbidity. Using the largest cohort to date, we report the impact of local therapy on survival among patients with metastatic anal SCCa. METHODS Data were collected from US hospitals that contributed to the National Cancer Database (NCDB) between 2004 and 2015. Patients who did not receive palliative systemic chemotherapy were excluded from analysis. Univariate (UVA) and multivariable analyses (MVA) were performed to identify factors associated with patient outcome. Kaplan-Meier analysis and Cox proportional hazards models were used to evaluate the association between tumor/patient characteristics and overall survival (OS). RESULTS A total of 1,160 patients were identified over the 12 years of study. Median age was 57 years. Majority were female (64.9%), non-Hispanic Whites (79.1%) and had Charlson-Deyo Score of 0 (83.6%). Most common metastatic sites were liver (25.9%), lung (11.6%) and bone (8.5%). More than 79% of the patients had received radiation to the primary site, and 10.4% underwent surgical resection for local control. Use of local therapy correlated closely with OS on MVA (HR 0.66; 0.55-0.79; P<0.001), with a 12-month and 5-year OS rates of 72.8% and 25.7% respectively, compared with 61.1% and 14.6% for patients treated with chemotherapy only. Poor prognostic factors included male gender (HR 1.44; 1.24-1.67; P<0.001), age >70 years (HR 1.28; 1.02-1.62; P=0.034), lack of health insurance (HR 1.32; 1.02-1.71; P=0.034), and cloacogenic zone location (HR 4.02; 1.43-11.30; P=0.008). There was no benefit from abdominoperineal resection (mOS =19.7 months; HR 1.05; 0.48-2.29; P=0.909), but both local resection of the primary (mOS =24.8 months, HR 0.48; 0.29-0.80; P=0.005) and palliative radiation (mOS =22.6 months; HR 0.66; 0.55-0.79; P<0.001) were associated with improved OS. CONCLUSIONS In addition to systemic therapy, resection of the primary tumor or palliative radiation improved OS in patients with anal SCCa. Patients unlikely to benefit from local control were those >70 years of age, male, lack of health insurance and cloacogenic carcinoma.
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Affiliation(s)
- Rami P. Atallah
- Department of Hematology and Oncology, Winship Cancer Institute of Emory University, Atlanta, GA, USA
| | - Yining Zhang
- Winship Data and Technology Applications Shared Resource, Emory University, Atlanta, GA, USA
| | | | - Renjian Jiang
- Winship Data and Technology Applications Shared Resource, Emory University, Atlanta, GA, USA
| | - Zhonglu Huang
- Winship Data and Technology Applications Shared Resource, Emory University, Atlanta, GA, USA
| | - Walid L. Shaib
- Department of Hematology and Oncology, Winship Cancer Institute of Emory University, Atlanta, GA, USA
| | - Maria Diab
- Department of Hematology and Oncology, Winship Cancer Institute of Emory University, Atlanta, GA, USA
| | - Mehmet Akce
- Department of Hematology and Oncology, Winship Cancer Institute of Emory University, Atlanta, GA, USA
| | - Christina Wu
- Department of Hematology and Oncology, Winship Cancer Institute of Emory University, Atlanta, GA, USA
| | - Bassel F. El-Rayes
- Department of Hematology and Oncology, Winship Cancer Institute of Emory University, Atlanta, GA, USA
| | - Olatunji B. Alese
- Department of Hematology and Oncology, Winship Cancer Institute of Emory University, Atlanta, GA, USA
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11
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Sakaguchi T, Ito K, Fujiwara K, Nishii Y, Ochiai S, Nomoto Y, Hataji O. An oldest-old non-small cell lung cancer patient with abscopal effect in a single lesion. Thorac Cancer 2022; 13:2267-2270. [PMID: 35761777 PMCID: PMC9346180 DOI: 10.1111/1759-7714.14551] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Revised: 06/05/2022] [Accepted: 06/09/2022] [Indexed: 02/07/2023] Open
Abstract
The abscopal effect without concomitant immunotherapy is a rare event, including among cases of lung cancer. Furthermore, the occurrence of limited abscopal effect for only a single lesion in the metastatic organ consistent with the irradiated organ would be an even more rare event. A 94‐year‐old man was diagnosed with advanced lung cancer with osteolytic bone metastases in his right iliac bone, and the right side of his axial vertebrae. After palliative radiation therapy to the right iliac lesion for pain relief without other anticancer therapy, the axial vertebral osteolytic lesion disappeared despite no reduction in the other lesions. This case furthers our understanding of the pathogenesis of the abscopal effect.
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Affiliation(s)
| | - Kentaro Ito
- Matsusaka Municipal Hospital, Respiratory Center, Matsusaka, Japan
| | - Kentaro Fujiwara
- Matsusaka Municipal Hospital, Respiratory Center, Matsusaka, Japan
| | - Yoichi Nishii
- Matsusaka Municipal Hospital, Respiratory Center, Matsusaka, Japan
| | - Satoru Ochiai
- Department of Radiation Oncology, Japanese Red Cross Ise Hospital, Ise, Japan
| | - Yoshihito Nomoto
- Department of Radiology, Mie University School of Medicine, Tsu, Japan
| | - Osamu Hataji
- Matsusaka Municipal Hospital, Respiratory Center, Matsusaka, Japan
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12
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Tunceroglu AS, Gui B, Lu SE, Sison J, Parikh R, Goyal S, Haffty BG, Kim S, Jabbour SK. Does kV Image Guidance for Bone Metastases Improve Pain Control? Front Oncol 2021; 11:627282. [PMID: 34221957 PMCID: PMC8247921 DOI: 10.3389/fonc.2021.627282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Accepted: 05/10/2021] [Indexed: 11/13/2022] Open
Abstract
Purpose/Objectives Despite its widespread availability, the use of kilovoltage (kV) image guidance is often related to factors such as perceived adequacy of clinical patient setup and individual practice patterns. We sought to determine whether kV image guidance in the treatment of painful bone metastases would improve therapeutic efficacy. Materials/Methods Under an Institutional Review Board approved protocol, hospital records of 164 patients having received radiation therapy to 257 individual painful osseous metastases were retrospectively reviewed. Marginal logistic regression analyses using the generalized estimating equation (GEE) approach were used to investigate potential associations between pain reduction and several patient, disease, and treatment related variables. Correlation of kV image guidance with pain reduction was analyzed by univariate and multivariate GEE logistic regression analysis. Results Median time to pain reduction was 3 days (range 0~109 days) from the start of radiation therapy. Pain reduction ≥ 50% was noted in 196 (77%) metastatic lesions with 136 (53%) demonstrating complete pain relief. Patients with metastatic lesions from non-small cell lung cancer experienced less pain relief (p = 0.007). Disease extension outside of bone was a negative predictor for pain reduction (p = 0.02). On univariate and multivariate logistic regression, kV image guidance demonstrated a statistically significant correlation with improved pain control in cases involving treatment of the lower extremities (p = 0.03) and those with fewer treatment fractions (p = 0.01), particularly in the setting of extra-osseous disease extension (p = 0.003). Conclusions Kilovoltage image guidance in the treatment of painful bone metastases may offer greater pain control through improved patient setup, particularly for patients with tumors of the lower extremities, extraosseous disease extension, and fewer treatment fractions.
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Affiliation(s)
- Ahmet S Tunceroglu
- Department of Radiation Oncology, Metro Health Cancer Center, University of Michigan, Wyoming, MI, United States.,Rutgers Cancer Institute of New Jersey, Rutgers Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ, United States
| | - Bin Gui
- Rutgers Cancer Institute of New Jersey, Rutgers Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ, United States
| | - Shou-En Lu
- Rutgers School of Public Health, Rutgers University, Piscataway, NJ, United States
| | - Julian Sison
- Rutgers Cancer Institute of New Jersey, Rutgers Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ, United States
| | - Rahul Parikh
- Rutgers Cancer Institute of New Jersey, Rutgers Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ, United States
| | - Sharad Goyal
- Division of Radiation Oncology, The George Washington University Medical Faculty Associates, Washington, DC, United States
| | - Bruce G Haffty
- Rutgers Cancer Institute of New Jersey, Rutgers Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ, United States
| | - Sung Kim
- Rutgers Cancer Institute of New Jersey, Rutgers Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ, United States
| | - Salma K Jabbour
- Rutgers Cancer Institute of New Jersey, Rutgers Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ, United States
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13
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Vázquez M, Altabas M, Moreno DC, Geng AA, Pérez-Hoyos S, Giralt J. 30-Day Mortality Following Palliative Radiotherapy. Front Oncol 2021; 11:668481. [PMID: 33968775 PMCID: PMC8103895 DOI: 10.3389/fonc.2021.668481] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Accepted: 03/19/2021] [Indexed: 11/21/2022] Open
Abstract
Purpose 30-day mortality (30-DM) is a parameter with widespread use as an indicator of avoidance of harm used in medicine. Our objective is to determine the 30-DM followed by palliative radiation therapy (RT) in our department and to identify potential prognosis factors. Material/Methods We conducted a retrospective cohort study including patients treated with palliative RT in our center during 2018 and 2019. Data related to clinical and treatment characteristics were collected. Results We treated 708 patients to whom 992 palliative irradiations were delivered. The most frequent primary tumor sites were lung (31%), breast (14.8%), and gastrointestinal (14.8%). Bone was the predominant location of the treatment (56%), and the use of single doses was the preferred treatment schedule (34.4%). The 30-DM was 17.5%. For those who died in the first month the median survival was 17 days. Factors with a significant impact on 30-DM were: male gender (p < 0.0001); Eastern Cooperative Oncology Group (ECOG) Performance Status (PS) of 2–3 (p = 0.0001); visceral metastases (p = 0.0353); lung, gastrointestinal or urinary tract primary tumors (p = 0.016); and single dose RT (p = <0.0001). In the multivariate analysis, male gender, ECOG PS 2–3, gastrointestinal and lung cancer were found to be independent factors related to 30-DM. Conclusion Our 30-DM is similar to previous studies. We have found four clinical factors related to 30-DM of which ECOG was the most strongly associated. This data may help to identify terminally ill patients with poor prognosis in order to avoid unnecessary treatments.
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Affiliation(s)
- Miriam Vázquez
- Department of Radiation Oncology, Vall d'Hebron University Hospital, Vall d'Hebron Institute of Oncology, Barcelona, Spain
| | - Manuel Altabas
- Department of Radiation Oncology, Vall d'Hebron University Hospital, Vall d'Hebron Institute of Oncology, Barcelona, Spain
| | - Diana C Moreno
- Department of Radiation Oncology, Vall d'Hebron University Hospital, Vall d'Hebron Institute of Oncology, Barcelona, Spain
| | - Abraham A Geng
- Department of Radiation Oncology, Vall d'Hebron University Hospital, Vall d'Hebron Institute of Oncology, Barcelona, Spain
| | - Santiago Pérez-Hoyos
- Unit of Statistics and Bioinformatics, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Jordi Giralt
- Department of Radiation Oncology, Vall d'Hebron University Hospital, Vall d'Hebron Institute of Oncology, Barcelona, Spain
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14
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Mak DY, Fraser I, Ferris R, James K, Liu M, Thomas SD, McKenzie M, Lefresne S. Comparison of Rapid to Standard Volumetric Modulated Arc Therapy for Palliative Radiotherapy in Lung Cancer Patients. Cureus 2020; 12:e10055. [PMID: 32999778 PMCID: PMC7520402 DOI: 10.7759/cureus.10055] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Accepted: 08/26/2020] [Indexed: 11/05/2022] Open
Abstract
Patients with incurable lung cancer often present with debilitating symptoms that require urgent palliative radiotherapy. Volumetric modulated arc therapy (VMAT) provides several dosimetric advantages compared to basic non-conformal techniques, but involves complex planning resulting in a slower turn-around time for treatment. A simplified planning technique known as 'rapid VMAT' was developed with an aim to deliver palliative treatment to patients within 48 hours. The purpose of this study was to prospectively compare the dosimetric quality of rapid VMAT plans to standard VMAT plans. Fourteen consecutive rapid VMAT cases were re-planned de novo as per standard VMAT planning guidelines. Planning target volume (PTV) and organs at risk (OARs) were then compared. PTV coverage and dose to OARs including the spinal canal, lung, heart, and esophagus were similar between rapid and standard VMAT. Each plan was ready for treatment within 48 hours of the CT simulation. This study describes an expedited process for which palliative radiotherapy can be delivered to lung tumors with a similar robust quality that is provided for curative intent VMAT radiotherapy plans.
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Affiliation(s)
- David Y Mak
- Medicine, University of British Columbia, Vancouver, CAN
| | - Ian Fraser
- Radiation Oncology, British Columbia Cancer Agency, Vancouver, CAN
| | - Robynn Ferris
- Radiation Oncology, British Columbia Cancer Agency, Vancouver, CAN
| | - Kerry James
- Radiation Oncology, British Columbia Cancer Agency, Vancouver, CAN
| | - Mitchell Liu
- Radiation Oncology, British Columbia Cancer Agency, Vancouver, CAN
| | - Steven D Thomas
- Medical Physics, British Columbia Cancer Agency, Vancouver, CAN
| | - Michael McKenzie
- Radiation Oncology, British Columbia Cancer Agency, Vancouver, CAN
| | - Shilo Lefresne
- Radiation Oncology, British Columbia Cancer Agency, Vancouver, CAN
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15
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Mittauer KE, Hill PM, Geurts MW, De Costa AM, Kimple RJ, Bassetti MF, Bayouth JE. STAT-ART: The Promise and Practice of a Rapid Palliative Single Session of MR-Guided Online Adaptive Radiotherapy (ART). Front Oncol 2019; 9:1013. [PMID: 31696053 PMCID: PMC6817496 DOI: 10.3389/fonc.2019.01013] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2019] [Accepted: 09/20/2019] [Indexed: 12/27/2022] Open
Abstract
This work describes a novel application of MR-guided online adaptive radiotherapy (MRgoART) in the management of patients whom urgent palliative care is indicated using statum-adaptive radiotherapy (STAT-ART). The implementation of STAT-ART, as performed at our institution, is presented including a discussion of the advantages and limitations compared to the standard of care for palliative radiotherapy on conventional c-arm linacs. MR-based treatment planning techniques of STAT-ART for density overrides and deformable image registration (DIR) of diagnostic CT to the treatment MR are also addressed.
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Affiliation(s)
- Kathryn E. Mittauer
- Department of Human Oncology, UW Carbone Cancer Center, University of Wisconsin-Madison, Madison, WI, United States
- Department of Radiation Oncology, Baptist Health South Florida, Miami Cancer Institute, Miami, FL, United States
| | - Patrick M. Hill
- Department of Human Oncology, UW Carbone Cancer Center, University of Wisconsin-Madison, Madison, WI, United States
| | - Mark W. Geurts
- Department of Human Oncology, UW Carbone Cancer Center, University of Wisconsin-Madison, Madison, WI, United States
- Department of Radiation Oncology, Aspirus Wausau Hospital, Aspirus Inc., Wausau, WI, United States
| | - Anna-Maria De Costa
- Department of Human Oncology, UW Carbone Cancer Center, University of Wisconsin-Madison, Madison, WI, United States
| | - Randall J. Kimple
- Department of Human Oncology, UW Carbone Cancer Center, University of Wisconsin-Madison, Madison, WI, United States
| | - Michael F. Bassetti
- Department of Human Oncology, UW Carbone Cancer Center, University of Wisconsin-Madison, Madison, WI, United States
| | - John E. Bayouth
- Department of Human Oncology, UW Carbone Cancer Center, University of Wisconsin-Madison, Madison, WI, United States
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16
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George LS, Prigerson HG, Epstein AS, Richards KL, Shen MJ, Derry HM, Reyna VF, Shah MA, Maciejewski PK. Palliative Chemotherapy or Radiation and Prognostic Understanding among Advanced Cancer Patients: The Role of Perceived Treatment Intent. J Palliat Med 2019; 23:33-39. [PMID: 31580753 PMCID: PMC6931912 DOI: 10.1089/jpm.2018.0651] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: As patients' accurate understanding of their prognosis is essential for informed end-of-life planning, identifying associated factors is important. Objective: We examine if receiving palliative chemotherapy or radiation, and the perception of those treatments as curative or noncurative, is associated with prognostic understanding. Design: Cross-sectional analyses from a multisite, observational study. Setting/Subjects: Patients with advanced cancers refractory to at least one chemotherapy regimen (N = 334). Measurements: In structured interviews, patients reported whether they were receiving chemotherapy or radiation, and whether its intent was curative or not. Their responses were categorized into three groups: patients not receiving chemotherapy/radiation (no cancer treatment group); patients receiving chemotherapy/radiation and misperceiving it as curative (treatment misperception group); and patients receiving chemotherapy/radiation and accurately perceiving it as noncurative (accurate treatment perception group). Patients also reported on various aspects of their prognostic understanding (e.g., life expectancy). Results: Eighty-six percent of the sample was receiving chemotherapy or radiation; of those, 16.7% reported the purpose of treatment to be curative. The no-treatment group had higher prognostic understanding scores compared with the treatment misperception group (adjusted odds ratio [AOR] = 5.00, p < 0.001). However, the accurate treatment perception group had the highest prognostic understanding scores in comparison to the no-treatment group (AOR = 2.04, p < 0.05) and the treatment misperception group (AOR = 10.19, p < 0.001). Conclusions: Depending on patient perceptions of curative intent, receipt of palliative chemotherapy or radiation is associated with better or worse prognostic understanding. Research should examine if enhancing patients' understanding of treatment intent can improve accurate prognostic expectations.
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Affiliation(s)
- Login S George
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Holly G Prigerson
- Center for Research on End-of-Life Care, Department of Medicine, Weill Cornell Medicine, New York, New York
| | | | - Kristy L Richards
- Center for Research on End-of-Life Care, Department of Medicine, Weill Cornell Medicine, New York, New York
| | - Megan J Shen
- Center for Research on End-of-Life Care, Department of Medicine, Weill Cornell Medicine, New York, New York
| | - Heather M Derry
- Center for Research on End-of-Life Care, Department of Medicine, Weill Cornell Medicine, New York, New York
| | - Valerie F Reyna
- Center for Behavioral Economics and Decision Research, College of Human Ecology, Cornell University, Ithaca, New York
| | - Manish A Shah
- Meyer Cancer Center of Weill Cornell Medical College, Medical Oncology/Solid Tumor Program, New York, New York
| | - Paul K Maciejewski
- Center for Research on End-of-Life Care, Department of Medicine, Weill Cornell Medicine, New York, New York.,Department of Radiology, Weill Cornell Medicine, New York, New York
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17
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Martin EJ, Jones JA. Characterizing Palliative Radiotherapy Education in Hospice and Palliative Medicine Fellowship: A Survey of Fellowship Program Directors. J Palliat Med 2019; 23:275-279. [PMID: 31373879 DOI: 10.1089/jpm.2019.0119] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Educational deficiencies among hospice and palliative medicine (HPM) physicians contribute to suboptimal utilization of palliative radiotherapy (PRT) for patients with advanced cancer. Objective: To survey HPM fellowship program directors regarding the need for PRT education in HPM fellowship. Design: We conducted a cross-sectional survey of HPM fellowship program directors in June 2018. We used a 5-point Likert-type scale to assess agreement with statements related to PRT education. Setting/Subjects: Program directors for all United States Accreditation Council for Graduate Medical Education-accredited HPM fellowship programs with at least one enrolled fellow at the time of survey distribution were included. Results: Eighty-one of 120 eligible program directors completed the survey (68% response rate). Nearly all of the respondents agreed that HPM physicians should possess a working knowledge of PRT and that the principles of PRT should be formally taught in HPM fellowship. Thirty percent of HPM fellowship programs, however, lacked a PRT curriculum and only 14% of programs provided more than two hours of PRT education. Limited didactic time, lack of interest among fellows, and lack of collaboration with radiation oncologists were not perceived to be significant barriers to incorporating PRT education into HPM fellowship. More than 75% of program directors indicated that they would consider implementing a PRT curriculum designed specifically for HPM physicians if one were available. Conclusion: There is a need for PRT education in HPM fellowship. This need may be best addressed by developing a widely accessible PRT curriculum designed to meet the needs of HPM physicians.
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Affiliation(s)
- Emily J Martin
- Department of Medicine, University of California, Los Angeles (UCLA), Los Angeles, California
| | - Joshua A Jones
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania
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18
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Abstract
Background: Insufficient knowledge of palliative radiotherapy (PRT) among hospice and palliative medicine (HPM) physicians is thought to be a barrier to the provision of high-quality palliative care. Objective: To assess the need for PRT education in HPM fellowship. Design: A cross-sectional survey of HPM fellows was conducted in June 2018. Setting/Subjects: The survey was distributed to accredited HPM fellowship programs in the United States for distribution to enrolled fellows; 114 fellows responded to the survey. Results: Nearly all respondents agreed that the principles of PRT should be taught in HPM fellowship, yet 51% had received no PRT education and 35% had received only one or two hours. Only 25% of respondents rated their working knowledge of PRT as sufficient, 40% felt confident in identifying radiation oncology emergencies or managing radiotherapy side effects, and 52% felt confident in assessing which patients to refer for radiotherapy. More than 75% agreed that were they more knowledgeable about PRT, they would be more likely to consider referral to radiation oncology, to collaborate with radiation oncologists, and to advocate for a short course of treatment based on a patient's prognosis or goals or care. Fellows who received PRT education in fellowship had significantly greater knowledge of and more favorable attitudes toward the use of radiotherapy. This difference was the greatest among fellows who had received at least five hours of PRT education. Conclusion: There is a need for PRT education in HPM fellowship. Efforts to address this need may lead to more appropriate utilization of PRT for patients with advanced cancer.
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Affiliation(s)
- Emily J Martin
- Department of Medicine, University of California, Los Angeles (UCLA), Los Angeles, California
| | - Joshua A Jones
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania
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19
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Garcia de de Jesus K, Gupta S, Cisneros O, Hoque MR, Vigoda I. A Fatal Case of Large Cell Neuroendocrine Lung Cancer Metastatic to the Brain: A Case Report. Cureus 2019; 11:e4728. [PMID: 31355087 PMCID: PMC6649918 DOI: 10.7759/cureus.4728] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Large cell neuroendocrine carcinoma (LCNEC) is part of lung neuroendocrine tumors. LCNEC represents an extremely rare entity with aggressive behavior and poor prognosis. Primary surgery is the mainstream of treatment, although it is rarely amenable due to local or systemic tumor metastasis at the time of the diagnosis. We present a case report of a female patient diagnosed with large cell neuroendocrine lung cancer metastatic to the brain. Noting the low incidence of the disease, the lack of relevant clinical data has resulted in a challenge in diagnosis and management.
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Affiliation(s)
| | - Sorab Gupta
- Oncology, St. Barnabas Hospital Health System / Albert Einstein College of Medicine, Bronx, USA
| | - Oscar Cisneros
- Internal Medicine, St. Barnabas Hospital Health System / Albert Einstein College of Medicine, Bronx, USA
| | - Md Rezaul Hoque
- Internal Medicine, St. Barnabas Hospital Health System / Albert Einstein College of Medicine, Bronx, USA
| | - Ivette Vigoda
- Oncology, St. Barnabas Hospital Health System / Albert Einstein College of Medicine, Bronx, USA
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20
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Fischer-Valuck BW, Baumann BC, Apicelli A, Rao YJ, Roach M, Daly M, Dans MC, White P, Contreras J, Henke L, Gay H, Michalski JM, Abraham C. Palliative radiation therapy (RT) for prostate cancer patients with bone metastases at diagnosis: A hospital-based analysis of patterns of care, RT fractionation scheme, and overall survival. Cancer Med 2018; 7:4240-4250. [PMID: 30120817 PMCID: PMC6144149 DOI: 10.1002/cam4.1655] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Revised: 06/10/2018] [Accepted: 06/11/2018] [Indexed: 12/25/2022] Open
Abstract
Prostate cancer (PCa) is one of the most common malignancies associated with bone metastases, and palliative radiation therapy (RT) is an effective treatment option. A total of 2641 patients were identified with PCa and bone metastases at diagnosis from 2010 to 2014 in the NCDB. Fractionation scheme was designated as short course ([SC‐RT]: 8 Gy in 1 fraction and 20 Gy in 5 fractions) vs long course ([LC‐RT]: 30 Gy in 10 fractions and 37.5 Gy in 15 fractions). Patient characteristics were correlated with fractionation scheme using logistic regression. Overall survival was analyzed using the Kaplan‐Meier method, log‐rank test, Cox proportional hazards models, and propensity score‐matched analyses. A total of 2255 (85.4%) patients were included in the LC‐RT group and 386 (14.6%) patients in the SC‐RT group. SC‐RT was more common in patients over 75 years age (odds ratio [OR]: 1.70, 95% confidence interval [CI] 1.32‐2.20), treatment at an academic center (OR: 1.76, 1.20‐2.57), living greater than 15 miles distance to treatment facility (OR: 1.38, 1.05‐1.83), treatment to the rib (OR: 2.99, 1.36‐6.60), and in 2014 (OR: 1.73, 1.19‐2.51). RT to the spine was more commonly long course (P < .0001). In the propensity‐matched cohort, LC‐RT was associated with improved OS (P < .0001), but no OS difference was observed between 37.5 Gy and either 8 Gy in one fraction or 20 Gy in 5 fractions (P > .5). LC‐RT remains the most common treatment fractionation scheme for palliative bone metastases in PCa patients. Use of palliative SC‐RT is increasing, particularly in more recent years, for older patients, treatment at academic centers, and with increasing distance from a treatment center.
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Affiliation(s)
| | - Brian C Baumann
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, USA
| | - Anthony Apicelli
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, USA
| | - Yuan James Rao
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, USA
| | - Michael Roach
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, USA
| | - Mackenzie Daly
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, USA
| | - Maria C Dans
- Division of Hospice & Palliative Medicine, Department of Hospital Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Patrick White
- Division of Hospice & Palliative Medicine, Department of Hospital Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Jessika Contreras
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, USA
| | - Lauren Henke
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, USA
| | - Hiram Gay
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, USA
| | - Jeff M Michalski
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, USA
| | - Christopher Abraham
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, USA
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21
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Cushman TR, Shirvani S, Khan M, Kumar R. The effect of early versus delayed radiation therapy on length of hospital stay in the palliative setting. Ann Palliat Med 2018; 7:368-372. [PMID: 29860859 DOI: 10.21037/apm.2018.05.07] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Accepted: 05/04/2018] [Indexed: 11/06/2022]
Abstract
BACKGROUND Radiation therapy (RT) can offer timely and effective treatment to oncology patients in the palliative setting. To date, there is sparse evidence investigating temporal relationships regarding the initiation of RT and subsequent hospital stay in the inpatient palliative setting. We aimed to assess whether times between admission, consultation, and initiation of treatment effected the length of hospital stay for patients receiving palliative radiation therapy (PRT). METHODS This was a retrospective chart review of patients who received a consult for PRT from August 2014 to October 2016. All data was collected from a single community cancer center. Data including demographics, radiation treatment details, and temporal data (e.g., length of stay, time from admission to consult, etc.) were recorded. RESULTS Of the 135 patients that received PRT, 60 of them were treated in the inpatient setting. The most common indications for PRT were pain (37%) and non-pain related neurologic symptoms (37%). The most common treatment sites were bone (58%), brain (22%), and lung (17%). There was a significant difference in duration of hospital stay between patients who were seen by palliative radiation oncology within two days versus greater than 2 days (P=0.02); and patients who were treated within 2 days of admission versus greater than 2 days (P=0.03). CONCLUSIONS Further research is needed to establish causal temporal relationships in palliative radiation oncology. However, this data suggests that early involvement of the radiation oncology team is associated with a reduced length of hospital stay.
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Affiliation(s)
- Taylor R Cushman
- University of Arizona College of Medicine-Phoenix, Phoenix, AZ, USA
| | - Shervin Shirvani
- Division of Radiation Oncology, Banner MD Anderson Cancer Center, Gilbert, AZ, USA
| | - Mohamed Khan
- Division of Radiation Oncology, Banner MD Anderson Cancer Center, Gilbert, AZ, USA
| | - Rachit Kumar
- Division of Radiation Oncology, Banner MD Anderson Cancer Center, Gilbert, AZ, USA.
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22
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Dharmarajan KV, Rich SE, Johnstone CA, Hertan LM, Wei R, Colbert LE, Jones JA, Kamal AH, Jones CA. Top 10 Tips Palliative Care Clinicians Should Know About Radiation Oncology. J Palliat Med 2018; 21:383-388. [PMID: 29431573 DOI: 10.1089/jpm.2018.0009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
As palliative care (PC) moves upstream in the course of advanced illness, it is critical that PC providers have a broad understanding of curative and palliative treatments for serious diseases. Possessing a working knowledge of radiation therapy (RT), one of the three pillars of cancer care, is crucial to PC providers given RT's role in both the curative and palliative settings. This article provides PC providers with a primer on the vocabulary of RT; the team of people involved in the planning of RT; and common indications, benefits, and side effects of treatment.
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Affiliation(s)
- Kavita V Dharmarajan
- 1 Department of Radiation Oncology, Brookdale Department of Geriatrics and Palliative Medicine, Mount Sinai Hospital , Icahn School of Medicine at Mount Sinai, New York, New York
| | | | - Candice A Johnstone
- 3 Department of Radiation Oncology, Medical College of Wisconsin , Milwaukee, Wisconsin
| | - Lauren M Hertan
- 4 Department of Radiation Oncology, Beth Israel Deaconess Medical Center , Boston, Massachusetts
| | - Randy Wei
- 5 Memorial Radiation Oncology Medical Group , Long Beach, California
| | - Lauren E Colbert
- 6 Department of Radiation Oncology, MD Anderson Cancer Center , Houston, Texas
| | - Joshua A Jones
- 7 Department of Radiation Oncology, University of Pennsylvania Perelman School of Medicine , Philadelphia, Pennsylvania.,8 Palliative and Advanced Illness Research Center, University of Pennsylvania , Philadelphia, Pennsylvania
| | - Arif H Kamal
- 9 Division of Medical Oncology, Duke Cancer Institute, Duke Fuqua School of Business, Duke University , Durham, North Carolina
| | - Christopher A Jones
- 8 Palliative and Advanced Illness Research Center, University of Pennsylvania , Philadelphia, Pennsylvania.,10 Department of Medicine, University of Pennsylvania Perelman School of Medicine , Philadelphia, Pennsylvania
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23
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Quackenbush K, Amini A, Fisher CM, Rabinovitch R. Regression of a Fungating Tumor After Hypofractionated Radiation Therapy in a Patient With Metastatic Breast Cancer. Cureus 2017; 9:e1417. [PMID: 28875090 PMCID: PMC5580970 DOI: 10.7759/cureus.1417] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Radiation therapy is a well-established palliative treatment for symptomatic metastases from breast cancer. This is also true of symptomatic primary breast tumors in patients with metastatic disease or in those who are medically inoperable. Further, local progression in the chest wall can severely impair quality of life, with local pain, bleeding, and significant impact on one’s self-image. Here, we present the case of a patient who showed an exceptional response to a palliative hypofractionated radiation course to her bleeding, fungating breast primary.
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Affiliation(s)
- Kevin Quackenbush
- Department of Radiation Oncology, University of Colorado School of Medicine
| | - Arya Amini
- Department of Radiation Oncology, University of Colorado School of Medicine
| | - Christine M Fisher
- Department of Radiation Oncology, University of Colorado School of Medicine
| | - Rachel Rabinovitch
- Department of Radiation Oncology, University of Colorado School of Medicine
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24
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Johnstone C, Lutz ST. The role of hypofractionated radiation in the management of non-osseous metastatic or uncontrolled local cancer. Ann Palliat Med 2015; 3:291-303. [PMID: 25841909 DOI: 10.3978/j.issn.2224-5820.2014.10.01] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 09/03/2014] [Accepted: 09/12/2014] [Indexed: 11/14/2022]
Abstract
Radiation therapy is often used to palliate symptoms caused by cancer. Short course, or "hypofractionated" palliative radiation therapy provides equivalent palliation in the setting of non-osseous metastasis or uncontrolled localized cancer while being more convenient and cost-effective than longer courses of radiation. Hypofractionated palliative radiation plays a role in the management of obstruction due to tumor, neurologic symptoms, pain caused by localized bulky disease, and bleeding in patients with primary tumors of the lung, head and neck, bladder, rectum, gynecologic malignancies, and metastasis to the liver, lung and brain. Hypofractionated palliative radiation is well tolerated with minimal and self-limited side effects. The side effects that do occur are generally limited to the body region treated and last from a few days to a few weeks.
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Affiliation(s)
- Candice Johnstone
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, 9200 W. Wisconsin Ave, USA.
| | - Stephen T Lutz
- Department of Radiation Oncology, Blanchard Valley Regional Cancer Center, Findlay, Ohio, USA
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25
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Mitera G, Chan G, Mah K, Law R, Deangelis C, Dent R, Chow E. A rare adverse skin reaction after 8 Gy of radiation therapy to the thoracic spine: case report and review of the literature. ACTA ACUST UNITED AC 2010; 17:70-3. [PMID: 20975883 DOI: 10.3747/co.v17i5.593] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
A 60-year-old woman with breast cancer metastatic to the bones experienced no adverse skin reaction at the lumbar spine after a single 8-Gy photon-beam fraction prescribed to a depth of 5 cm. However, a subsequent treatment to the thoracic spine using the same dose, fractionation, and technique resulted in skin erythema and permanent hyperpigmentation. After careful investigation, no differences were identified in her concurrent use of possibly radiosensitizing medications during the various radiotherapy treatments nor in possible errors of treatment planning and radiation delivery. To our knowledge, this is the first case report to document that, with similar medications, a previous skin response to a given radiotherapy dose, fraction, and technique may not be predictive of subsequent skin response to similar radiotherapy.
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Affiliation(s)
- G Mitera
- Rapid Response Radiotherapy Program, Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON
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