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IS THERE STILL A ROLE FOR RADIOTHERAPY IN       METASTATIC BREAST CANCER?                       ALAN RODGER    SPECIALTY E...
ALTERNATIVE QUESTIONS?• HAVE BISPHOSPHONATES, CYTOTOXICS, TARGETED  THERAPIES AND AROMATASE INHIBITORS CURED  METASTATIC B...
SO IS THERE STILL A ROLE FOR  RADIOTHERAPY IN MBC?         UNDOUBTEDLY!   AND, WHAT’S MORE, THERE’S    EVIDENCE TO SUPPORT...
• KEY MESSAGES.RADIOTHERAPY HAS AN IMPORTANT ROLE IN MBC IN THEPALLIATION AND TREATMENT OF:•   BONE PAIN•   SPINAL CORD CO...
PALLIATION OF BONE PAIN WITH RADIOTHERAPY• COMPLETE PAIN RELIEF IN 25% @ 1 MONTH  (395/1580)• > 50% PAIN RELIEF IN 41% AT ...
RADIATION MODALITY• LOCALISED BONE PAIN – EXTERNAL BEAM RADIOTHERAPY (EBRT)• GENERALISED BONE PAIN ► RADIO-ISOTOPES       ...
RADIATION FRACTIONATION for EBRT• SINGLE FRACTION IS EQUIVALENT TO  MULTIPLE FRACTIONS• LEVEL OF EVIDENCE I – Cochrane  Re...
SINGLE FRACTION EBRT for PAIN               RELIEF• PAIN CONTROL EQUIVALENT• TOXICITY SIMILAR (though poor assessment)• RE...
NON-COMPRESSIVE SPINAL             METASTASES• INTERVENTIONAL RADIOLOGY –  vertebroplasty, kyphoplasty (see Gerszten et al...
SPINAL SBRS/SBRT• NO RCTs• SMALL SERIES• RETREATMENTS/SOLE TREATMENT/POST-  INTERVENTIONAL PROCEDURE – mixes in studies• E...
COMPRESSIVE SPINAL METASTASES•   SURGERY – decompression and stabilisation•   RADIOTHERAPY – sole treatment•   RADIOTHERAP...
COMPRESSIVE SPINAL CORD METASTASES• EBRT and PROGNOSIS on MULTIVARIATE  ANALYSIS - Rades et al JCO 2006 (n = 1852) LoE  II...
COMPRESSIVE SPINAL METASTASES• EMERGENCY• MRI – of not just area of neurological interest  but also adjacent areas superio...
IMPENDING LONG BONE FRACTURES• PROPHYLACTIC SURGERY and POST-  OPERATIVE EBRT – when compared with  fracture followed by s...
PATHOLOGICAL LONG BONE FRACTURES• POST-OPERATIVE EBRT – more likely to regain  normal use of the extremity• POST-OP EBRT –...
CRANIAL METASTASES            BASE of SKULL• BONE METASTASES• COMPRESSIVE NEUROLOGICAL SYMPTOMS  and SIGNS• RESPOND TO CON...
CRANIAL METASTASES              ORBITAL• SOFT TISSUE MASS MAY BE PRESENT• COMPRESSIVE SYMPTOMS• CHOROIDAL METASTASES – spe...
INTRACRANIAL (BRAIN) METASTASES• PROGNOSIS – depends on age, PS and extent  of disease (LoE II – RTOG trials)• PROGNOSIS i...
INTRACRANIAL (BRAIN) METASTASES        Treatment Options• MULTIPLE METASTASES – EBRT 20 Gray/5  fractions as no other frac...
SOLITARY OR FEW (1-3?) BRAIN             METASTASES          Treatment options• SURGERY – with post-op whole brain EBRT• S...
BRAIN METASTASES         QUESTIONS FOR FURTHER RESEARCH• SURGERY v. SBRS/SBRT• PLACE of whole brain EBRT – in combination ...
SOFT TISSUE and SOLID VISCERAL            METASTASES• LOCAL SYMPTOM CONTROL – from skin  lesions, nodal masses, uncontroll...
AREA for URGENT RESEARCH   SBRS and SBRT IN OLIGO-METASTATIC DISEASE• NATURAL HISTORY of OLIGO-METASTATIC DISEASE in  MBC ...
RADIOTHERAPY IN MBC              LET US NOT FORGET• IT IS PALLIATIVE – reduce symptoms that are  there; cause no distress;...
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ABC1 - A. Rodger - Is there still a role for radiotherapy in advanced breast cancer?

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Transcript of "ABC1 - A. Rodger - Is there still a role for radiotherapy in advanced breast cancer?"

  1. 1. IS THERE STILL A ROLE FOR RADIOTHERAPY IN METASTATIC BREAST CANCER? ALAN RODGER SPECIALTY EDITOR (RADIATION ONCOLOGY), THE BREAST. RETIRED CLINICAL ONCOLOGIST. ABC1, Lisbon, November 2011.
  2. 2. ALTERNATIVE QUESTIONS?• HAVE BISPHOSPHONATES, CYTOTOXICS, TARGETED THERAPIES AND AROMATASE INHIBITORS CURED METASTATIC BREAST CANCER (MBC)?• CAN THEY PALLIATE EVERY SYMPTOM AND PREVENT EVERY COMPLICATION OF MBC?
  3. 3. SO IS THERE STILL A ROLE FOR RADIOTHERAPY IN MBC? UNDOUBTEDLY! AND, WHAT’S MORE, THERE’S EVIDENCE TO SUPPORT IT
  4. 4. • KEY MESSAGES.RADIOTHERAPY HAS AN IMPORTANT ROLE IN MBC IN THEPALLIATION AND TREATMENT OF:• BONE PAIN• SPINAL CORD COMPRESSION• PATHOLOGICAL FRACTURES• INTRACRANIAL METASTASES• CRANIAL METASTASES – BASE OF SKULL AND ORBITAL• SOFT TISSUE DISEASE• SOLID VISCERAL METASTASES
  5. 5. PALLIATION OF BONE PAIN WITH RADIOTHERAPY• COMPLETE PAIN RELIEF IN 25% @ 1 MONTH (395/1580)• > 50% PAIN RELIEF IN 41% AT SOME TIME (788/1933)• WHEN COMPLETE PAIN RELIEF, 52% ACHIEVE THIS IN 4 WEEKS WITH MEDIAN DURATION 12 WEEKS• LEVEL OF EVIDENCE I - Cochrane Review, McQuay et al, 1999.
  6. 6. RADIATION MODALITY• LOCALISED BONE PAIN – EXTERNAL BEAM RADIOTHERAPY (EBRT)• GENERALISED BONE PAIN ► RADIO-ISOTOPES ► HEMIBODY RT
  7. 7. RADIATION FRACTIONATION for EBRT• SINGLE FRACTION IS EQUIVALENT TO MULTIPLE FRACTIONS• LEVEL OF EVIDENCE I – Cochrane Review, ASTRO 2011 Guidelines, other guidelines, numerous RCTs.
  8. 8. SINGLE FRACTION EBRT for PAIN RELIEF• PAIN CONTROL EQUIVALENT• TOXICITY SIMILAR (though poor assessment)• RETREATMENT RATES HIGHER – 20% v. 8% (Kachnic et al, 2011)• MORE COST-EFFECTIVE – it costs less (ASTRO, 2011)• BISPHOSPHONATES DO NOT ELIMINATE THE NEED FOR RADIOTHERAPY• LEVEL OF EVIDENCE I
  9. 9. NON-COMPRESSIVE SPINAL METASTASES• INTERVENTIONAL RADIOLOGY – vertebroplasty, kyphoplasty (see Gerszten et al in Neurosurg. Focus, 2005) with Stereotactic Body Radiosurgery (SBRS)• EXTERNAL BEAM RT• STEREOTACTIC RADIOSURGERY (SBRS) – single fraction• STEREOTACTIC RADIOTHERAPY (SBRT) - multiple fractions (often a few)• LEVEL OF EVIDENCE III/IV
  10. 10. SPINAL SBRS/SBRT• NO RCTs• SMALL SERIES• RETREATMENTS/SOLE TREATMENT/POST- INTERVENTIONAL PROCEDURE – mixes in studies• EQUIPMENT CAN BE EXPENSIVE – so cost per treatment high• COMPLEX, TIME CONSUMING RADIOTHERAPY PLANNING• NEED FOR MORE HIGH QUALITY STUDIES AND RCTs• LEVEL OF EVIDENCE – need for more research (III/IV)
  11. 11. COMPRESSIVE SPINAL METASTASES• SURGERY – decompression and stabilisation• RADIOTHERAPY – sole treatment• RADIOTHERAPY - postoperative• RADIOTHERAPY - EBRT• RADIOTHERAPY – SBRT/SBRS• LEVEL OF EVIDENCE III/IV
  12. 12. COMPRESSIVE SPINAL CORD METASTASES• EBRT and PROGNOSIS on MULTIVARIATE ANALYSIS - Rades et al JCO 2006 (n = 1852) LoE III• BETTER LOCAL CONTROL – histology (breast, prostate, lymphoma); no visceral mets; no/few other bone mets; good ambulatory status; longer interval from first diagnosis; slow loss of motor function• RADIOTHERAPY COURSE – longer course (10, 15 or 20 fractions) better than shorter (1 or 5 fractions) – only a trend on univariate analysis
  13. 13. COMPRESSIVE SPINAL METASTASES• EMERGENCY• MRI – of not just area of neurological interest but also adjacent areas superior and inferior• MUTLIDISCIPLINARY OPINIONS – surgery and radiation oncology• CONSIDER FAST-TRACKING SYSTEM• MORE RESEARCH REQUIRED – radiation dose/fractionation; indications for SBRS/SBRT
  14. 14. IMPENDING LONG BONE FRACTURES• PROPHYLACTIC SURGERY and POST- OPERATIVE EBRT – when compared with fracture followed by surgery and EBRT: more likely to maintain or improve pre-diagnosis level of mobility and self-care Hardman et al Clin. Oncol.1992 LEVEL OF EVIDENCE IV
  15. 15. PATHOLOGICAL LONG BONE FRACTURES• POST-OPERATIVE EBRT – more likely to regain normal use of the extremity• POST-OP EBRT – fewer re-operations• MEDIAN SURVIVAL – 12-14 months after EBRT v.3.3 months when no RT - ns ?? selection bias• LEVEL OF EVIDENCE III – Townsend et al JCO, 1994
  16. 16. CRANIAL METASTASES BASE of SKULL• BONE METASTASES• COMPRESSIVE NEUROLOGICAL SYMPTOMS and SIGNS• RESPOND TO CONVENTIONAL PALLIATIVE EBRT – five fractions/20 Gray• RESPONSE MAY BE SEEN AFTER PROLONGED SIGNS/SYMPTOMS (unlike cord compression)• LEVEL OF EVIDENCE IV
  17. 17. CRANIAL METASTASES ORBITAL• SOFT TISSUE MASS MAY BE PRESENT• COMPRESSIVE SYMPTOMS• CHOROIDAL METASTASES – special case and rare• CONVENTIONAL PALLIATIVE EBRT (dose/fractionation/technique) – can be beneficial• SBRS/SBRT may be considered• LEVEL OF EVIDENCE III/IV
  18. 18. INTRACRANIAL (BRAIN) METASTASES• PROGNOSIS – depends on age, PS and extent of disease (LoE II – RTOG trials)• PROGNOSIS in MBC – influenced also by ER status, availability of therapy for extra-cranial disease ( LoE III/IV)• SINGLE/FEW BRAIN METS – generally respond better. (LoE III/IV)
  19. 19. INTRACRANIAL (BRAIN) METASTASES Treatment Options• MULTIPLE METASTASES – EBRT 20 Gray/5 fractions as no other fractionation is superior in terms of overall survival, symptom control, neurological function, toxicity• LEVEL OF EVIDENCE I – Cochrane Review 2007
  20. 20. SOLITARY OR FEW (1-3?) BRAIN METASTASES Treatment options• SURGERY – with post-op whole brain EBRT• SURGERY – alone• EBRT – alone to whole brain• EBRT (whole brain) – with SBRS/SBRT “boost”• COMBINATION SBRS/SBRT and EBRT seems ‘equivalent’ to surgery and EBRT• LEVEL OF EVIDENCE III/IV
  21. 21. BRAIN METASTASES QUESTIONS FOR FURTHER RESEARCH• SURGERY v. SBRS/SBRT• PLACE of whole brain EBRT – in combination or alone• DOSE/FRACTIONATION of SBRT
  22. 22. SOFT TISSUE and SOLID VISCERAL METASTASES• LOCAL SYMPTOM CONTROL – from skin lesions, nodal masses, uncontrolled local recurrence• RADIOTHERAPY DOSE/FRACTIONATION/TECHNIQUE – will depend on site, lesion, previous EBRT, PS, symptoms• LEVEL OF EVIDENCE IV
  23. 23. AREA for URGENT RESEARCH SBRS and SBRT IN OLIGO-METASTATIC DISEASE• NATURAL HISTORY of OLIGO-METASTATIC DISEASE in MBC - what is it?• The EFFICACY (RESPONSE and IMPACT ON SURVIVAL) of IMRT and SBRS and SBRT against solid visceral metastases• OPTIMAL TECHNIQUES, DOSES and FRACTIONATION – if any• COST-EFFECTIVENESS• TOXICITY
  24. 24. RADIOTHERAPY IN MBC LET US NOT FORGET• IT IS PALLIATIVE – reduce symptoms that are there; cause no distress; do not treat the asymptomatic (Ralston Patterson)• TO BE EFFECTIVE IT MUST BE PART OF GOOD MULTI-DISCIPLINARY CARE• TODAY IT MUST BE COST-EFFECTIVE• IT MUST CONSIDER THE PATIENT FOREMOST – as sadly MBC is still incurable

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