Palliative Radiotherapy

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Palliative Radiotherapy
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the active total care of patients whosedisease
is not responsive to curative treatment . WHO
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About 30-45 of patients receiving radiotherapy
are palliative
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GOALS OF PALLIATIVE RT

• control symptoms
• enhance quality of life
• optimize the patients limited remaining time
• guided by basic ethical principles and clinical
  based evidence

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EMERGENCY INDICATIONS

• Spinal cord compression
• Haemorrhage/bleeding
• Superior Vena caval obstruction
• Seizures/ Fitting

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INDICATIONS

• Pain relief from bone mets.
• Prevention of pathological
• Spinal cord compression.
• Impending or actual obstruction hollow viscera.
• Brain mets.
• Control of Haemorrhage.
• Control of ulceration/ fungation.

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Fraction

• A single treatment session
• Conventionally 1.8 2.0 Gy

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Hypofractionation

• Fewer fractions than conventional
• Higher dose per fraction
• Shorter treatment time
• Increased probability of late effects
• Decreased radiotherapy waiting times

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Hypofractionation

• clinical evidence suggests that shorter
  fractionation schedules compared to more
  protracted schedules have the same effectiveness
  in symptom control of incurable cancer patients,
  particularly, for metastatic bone pain and
  multiple brain metastases.

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Bony Metastases
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Bony mets can cause

• Pain
• Pathological fracture
• Spinal cord compression
• Hypercalcemia
• Leading to debilitation and impaired quality of
  life

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• External beam radiation provides significant
  relief in 50-80 of patients and complete pain
  relief in 30 of patients (ASTRO)

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Factors affecting choice of fractionation regimen

• Performance status
• Prognosis
• Risk for fracture or cord compression
• Site to be treated

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• A literature review confirms similar rates of
  pain control using a single fraction versus a
  multiple fractions (50-85). There are however
  higher retreatment rates for single fraction
  regimens.

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Fractionation regimens

• 8 Gy in 1 fraction
• 20 Gy in 5 fractions
• 30 Gy in 10 fractions
• 24 Gy in 6 fractions
• Endpoints using pain relief, narcotic relief and
  quality of life measures show consistent
  similarity in the regimens

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• The frequency and severity of side effects
  especially mucosal are a more of a function of
  radiation planning than radiotherapy dose

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BRAIN METASTASES
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Comparison of median survival in 7 studies using
the recursive partitioning analyses (RPA) classes
(treatment was WBRT with or without local
measures, none of the studies is limited to one
particular cancer type).
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Clinical Recommendations of DEGRO
Breast Care (Basel). 2010 5(6) 401407.
Published online 2010 December 8.
doi 10.1159/000322661
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• Analysis of all included patients, SRS plus
  WBRT, did not show a survival benefit over WBRT
  alone. However, performance status and local
  control were significantly better in the SRS plus
  WBRT group. Furthermore, significantly longer OS
  was reported in the combined treatment group for
  RPA Class I patients as well as patients with
  single metastasis.

Cochrane Database Syst Rev. 2010 Jun
16(6)CD006121. Whole brain radiation therapy
(WBRT) alone versus WBRT and radiosurgery for the
treatment of brain metastases
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• conventional fractionation can be used to avoid
  late neurotoxicity
• dexamethasone is the corticosteroid of choice for
  cerebral edema
• anticonvulsants should not be prescribed
  prophylactically

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Spinal cord compression
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• Inform patients at high risk of developing bone
  metastases, patients with diagnosed bone
  metastases, or patients with cancer who present
  with spinal pain about the symptoms of MSCC
• (NICE)

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Patients with cancer and any of the following
symptoms suggestive of spinal metastases should
seek medical attention immediately for assessment
pain in the middle (thoracic) or upper
(cervical) spine progressive lower (lumbar)
spinal pain severe unremitting lower spinal
pain spinal pain aggravated by straining (for
example, at stool, or when coughing or sneezing)
localized spinal tenderness nocturnal
spinal pain preventing sleep
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• Patient should be nursed flat with neutral spine
  alignment (including log rolling with use of a
  bed pan for toilet) until bony and neurological
  stability are ensured and cautious remobilisation
  may begin

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• For patients with MSCC, once any spinal shock has
  settled and neurology is stable, carry out close
  monitoring and interval assessment during gradual
  sitting from supine to 60 degrees over a period
  of 34 hours

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• Offer conventional analgesia (including NSAIDs,
  non-opiate and opiate medication) as required to
  patients with painful spinal metastases in
  escalating doses as described by the WHO
  three-step pain relief ladder

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• Offer patients with vertebral involvement from
  myeloma or breast cancer bisphosphonates to
  reduce pain and the risk of vertebral
  fracture/collapse

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• Unless contraindicated (including a significant
  suspicion of lymphoma) offer all patients with
  MSCC a loading dose of at least 16 mg of
  dexamethasone as soon as possible after
  assessment, followed by a short course of 16 mg
  dexamethasone daily while treatment is being
  planned

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• If surgery is appropriate in patients with MSCC,
  attempt to achieve both spinal cord decompression
  and durable spinal column stability
• Patients with MSCC who have been completely
  paraplegic or tetraplegic for more than 24 hours
  should only be offered surgery if spinal
  stabilisation is required for pain relief

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• There should be urgent (within 24 hours) access
  to and availability of radiotherapy and simulator
  facilities in daytime sessions, 7 days a week for
  patients with MSCC requiring definitive treatment
  or who are unsuitable for surgery

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Fractionation regimens

• 8 Gy in 1 fraction
• 20 Gy in 5 fractions
• 30 Gy in 10 fractions
• 24 Gy in 6 fractions

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Palliative radiotherapy a slice of the palliative
pie
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Palliative radiotherapy should be aimed as a one
stop approach
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Factors affecting utilization of palliative
radiotherapy services

• Poor performance status
• Short predicted life expectancy
• Access to radiotherapy centres
• Limited oncology training of attending physicians
• Waiting time for radiotherapy

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