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

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

  • 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. 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. SO IS THERE STILL A ROLE FOR RADIOTHERAPY IN MBC? UNDOUBTEDLY! AND, WHAT’S MORE, THERE’S EVIDENCE TO SUPPORT IT
  • 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. 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. RADIATION MODALITY• LOCALISED BONE PAIN – EXTERNAL BEAM RADIOTHERAPY (EBRT)• GENERALISED BONE PAIN ► RADIO-ISOTOPES ► HEMIBODY RT
  • 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. 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. 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. 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. COMPRESSIVE SPINAL METASTASES• SURGERY – decompression and stabilisation• RADIOTHERAPY – sole treatment• RADIOTHERAPY - postoperative• RADIOTHERAPY - EBRT• RADIOTHERAPY – SBRT/SBRS• LEVEL OF EVIDENCE III/IV
  • 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. 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. 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. 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. 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. 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. 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. 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. 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. BRAIN METASTASES QUESTIONS FOR FURTHER RESEARCH• SURGERY v. SBRS/SBRT• PLACE of whole brain EBRT – in combination or alone• DOSE/FRACTIONATION of SBRT
  • 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. 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. 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