Please see the Creative Commons License on the second slide. This slide deck is for medical education uses only and does not constitute medical advice. Please consult with your own health care provider.
If printing a hand out you can exclude slides 41-48 This
• At ANY energy, x-rays are attenuated by tissue so that absorbed dose decreases with depth
↑ dose/fraction = ↑ risk late toxicity ↓ dose/fraction = ↓ risk late toxicity
Longer courses of treatment to higher total doses remain the most commonly used schedules in the United States. In a survey of 268 radiation oncologists in the United States, the physicians were asked about the management of a patient with bone metastases from breast cancer. The respondents recommended a median dose of 30 Gy given in 10 fractions, none recommended fewer than 7 treatments.
Inclusion Criteria Breast or prostate cancer Painful bone metastasis (>5/10 on brief pain index) Radiographic evidence of bone met at painful site RTOG 97-14 painful bone metastases Life expectancy > 3 months, KPS ≥ 40 No prior surgery or XRT to that site No change in systemic therapy for 30 days Bisphosphonates OK; no radioisotopes for 30 days No spinal cord compression; no fracture/impending fx Skull, hands, feet excluded from study
ASTRO plenary presentation RTOG 97-14: Optimal patient population V lid t d i RTOG 97-14 painful bone metastases Validated pain measures Statistical power Response definition clear “800 cGy x 1 fraction is the new standard of care for palliation of painful bony metastases”
Hartsell WF et al. J Natl Cancer Inst 2005;97:798-804
Deleted Wagoner 2008
Deleted Sanjob 2005, Deleted Spanos 1993
No differences in response rates among various schedules; quicker response seen with shorter courses
Radiation Therapy in Palliative Care Spring 2012
Christian Sinclair, MD, FAAHPM
Gentiva Health Systems
Credits and Creative Commons
Adopted with permission from
Jerry Baker, MD, Texas Oncology, Fort Worth, TX
Originally presented at the 2010 AAHPM Assembly
This talk is licensed under a Creative Commons
Attribution-ShareAlike 3.0 Unported License.
With attribution and sharing alike, you are free:
to Share — to copy, distribute and transmit the
to Remix — to adapt the work
to make commercial use of the work
Understand the fundamentals of radiation
Manage commonly expected side effects from
Identify three situations where palliative
radiation may be effective in hospice patients
I don’t understand how radiation works to treat
cancer. Can you explain it to me?
In which clinical situations is palliative
radiation truly effective?
How do you decide how many treatments?
Does radiation have to be so expensive?
Any tips for working with a radiation
oncologist, or for simplifying the radiation
process for patients?
Conventional Radiation Therapy
Psychology of A Radiation Oncologist
Palliative Radiation Therapy
Higher radiation dose
increases risk for
damage to normal tissues
Benefit of tumor control
Risk of normal tissue injury
Selectivity of radiation effect:
Radiation damages DNA
Leads to cell death
Radiation not selective
Variable DNA damage repair
Normal tissues repair damage
Malignant cells do not repair well
Small does of radiation over time
Most cancers sensitive to fractionated XRT
Normal tissues protected by fractionation
↑ dose/fraction = ↑ risk late toxicity
↓ dose/fraction = ↓ risk late toxicity
3000 cGy in 15 fractions
3000 cGy in 10 fractions
Late Effects - Hypofractionation
Brain and spinal cord
65-75% of advanced breast/prostate CA
30-40% of advanced lung cancer
Skeletal-related events: pain, fracture,
SRE’s impact on QOL
Mobility and functional wellbeing
Increase opioid needs
Costa L et al. Support Care Cancer 2008;16:879‐889
Palliative XRT fractionated daily over 2-3 weeks
Over past 20 years
9 large RCT (>4000 patients) all demonstrate
effectiveness of single fraction courses
Lutz ST et al. Cancer 2007;109:1462‐1470;
Coia LR et al. IJROBP 1988;14:1261‐1269.
Longer courses of treatment to higher total doses remain the
most commonly use schedules in the United States. In a
survey of 268 radiation oncologists in the United States
the physicians were asked about the management of a
patient with bone metastases from breast cancer. The
respondents recommended a median dose of 30 Gy given in
10 fractions, none recommended fewer than 7 treatments.
RTOG 97-14 – Painful Bone
Breast or Prostate cancer
Painful bone mets
Confirmed met by imaging
Prognosis > 3 mos, KPS ≥ 40
RTOG 97-14 Results
1998-2002; 897 eligible patients
56% weight-bearing site, 72% pain score 7-10 ( severe),
27% receiving bisphosphonates, 57% solitary site
Grade 2-4 toxicity: 17% (30 Gy) vs. 10% (8 Gy), p<.0001
Late toxicity: 4% overall, p=NS. Same path fx rates.
Median survival 9 months, 41% 1y-OS
Pain relief: (e.g., pain inventory, narcotic use, ambulation)
CR+PR 65% (1 fraction) vs. CR+PR 66% (10 fractions)
ASTRO plenary: “800 cGy x 1 fraction is the new standard of
care for palliation of painful bony metastases”
Cancer Care Ontario 2004
“Where the treatment objective is pain relief, a
single 8 Gy treatment, prescribed to the
appropriate target volume, is recommended as
the standard dose-fractionation schedule for the
treatment of symptomatic and uncomplicated
Survey (Ontario practitioners)
83% agreed with evidence interpretation
75% agreed approved of guideline
Wu JS-Y et al. BMC Cancer 2004;4:71-78
Intl Survey of Practice Patterns
Rad Onc in ASTRO, CARO, RANZCR
101 schedules recommended
Median dose 3000 cGy/10 fractions
US Rad Onc 3x the number of fractions for same
Fairchild A et al. IJROBP 2009;75:1501‐1510
RVU for XRT
3D Conformal XRT - $6,000-10,000
Spinal Cord Compression
Previous concern with large doses per fraction in
this setting (‘double injury’ of radiation and
physical injury to cord)
Ambulatory patient, stable spine: palliative radiotherapy
(short course suffices in patients with predicted survival
Non-ambulatory patient, paraplegia <48 hrs, survival >
3 mos, 1 area of spine involved: consider surgery
All others: palliative radiotherapy
George R et al. Cochrane Database Syst Rev 2008;4:CD006716
Very little published data
Case‐by‐case decision making for palliative
Pain is better relieved with
surgery/stabilization in some cases
Trivia: Bone Mets
Response to radiotherapy is not related to
severity of pretreatment pain
[Kirou‐Mauro A et al. Int J Radiat Oncol Biol Phys
Pain flare occurs in 10‐25% of patients treated
with radiotherapy (1‐2 days post‐treatment);
readily controlled/prophylaxed with steroids
[Hird A et al. Clin Oncol 2009;21:329‐335. Hird A et al. Int J Radiat
Oncol Biol Phys 2009]
QOL improves after radiotherapy for bone mets
(pain, anxiety, sense of well‐being)
[Chow E et al. Support Cancer Ther 2004;1:179‐184]
Second to bone metastases in available
published data for hypofractionated
radiotherapy: 13 RCTs
Short courses [800 cGy x 1; 800 cGy x2) and long
courses of radiotherapy are comparable in relieving
symptoms from advanced lung cancer (dyspnea,
pain, hemoptysis, cough, SVC syndrome)
Total symptom score improved more with long
courses (65.4% v. 77.1% at 1yr), and with a slight
survival advantage (26.5% v. 21.7%)
Fairchild 2008; Lester 2006; Salvo 2009
Pelvic (and other) Bleeding
Single or hypofractionated regimens reported
effective in prospective and retrospective reviews
(RTOG: 1000 cGy x 1‐3 monthly; RTOG: 370 cGy
BID x 2 days repeated q3 wks x2‐3; 800 cGy
weekly x 3)
Hemoptysis improved in ~ 80% pts
Pelvic bleeding improved in ~ 90‐100%
Onsrud 2001; Pereira 2004; Tinger 2001
Retrospective studies suggest
hypofractionated radiotherapy is effective in:
improving pain (86%)
Acute nausea when treating upper abdomen
may limit short courses
MDACC: 14 fractions (3500 cGy) used most
Kim 2008; Murakami 2008; Hashimoto 2009
Prospective and retrospective studies suggest
hypofractionated radiotherapy is effective in
improving pain, bleeding, airway obstruction,
wound progression, hoarseness, otalgia,
RTOG regimen: 370 cGy BID x 2 days, repeated
q3 weeks up to 3 cycles
‘Christie scheme’: 312 cGy x 12
AIIMS regimen: 400 cGy x 5
Agarwal 2008; Al-mamgani 2009; Chen 2008; Mohanti 2004
Radiotherapy prolongs survival
Steroids: 1-2 months median OS
XRT: 4-6 months median OS (RTOG)
Prevents death from neurologic progression
Reduces/resolves neurologic symptoms
200 cGy x 20
300 cGy x 10 (most common, ‘standard’)
400 cGy x 5
850 cGy x 2
Medical Director Strategies
Meet in advance of need with your local radiation
Conditional referrals: your group will refer patients when
patient convenience is maximized and cost is controlled
Review cases with radiation oncologist prior to a formal
consult (prevents unnecessary patient transfers)
Description of problem
Any available imaging
Records of previous cancer treatment
ESPECIALLY PRIOR RADIATION RECORDS
Rapid Access Palliative XRT
combining separate clinic visits
2004‐2008, >3200 pts treated
52% pts bone mets
Pain rapidly improved for >75% pts
100% patient satisfaction
Fairchild A et al. Support Care Cancer 2009;17:163‐70
Hospices and palliative care programs are
providing care for patients with symptomatic
Palliative radiotherapy is effective, with limited
side effects, and benefits some of these
patients, when . . .
. . . it is convenient
. . . it is reasonably priced
. . . it is available
Caissie A et al. Assessment of health-related quality of life with the European Organization
for Research and Treatment of Cancer QLQ-C15-PAL after palliative radiotherapy of
bone metastases. Clin Oncol (R Coll Radiol). 2012 Mar;24(2):125-33. Epub 2011 Sep
13. PubMed PMID: 21917431.
Chow E et al. Update on the systematic review of palliative radiotherapy trials for bone
metastases. Clin Oncol (R Coll Radiol). 2012 Mar;24(2):112-24. Epub 2011 Nov 29.
PubMed PMID: 22130630.
Coia LR et al. Practice patterns of palliative care for the United States 1984-1985. Int J
Radiat Oncol Biol Phys. 1988 Jun;14(6):1261-9. PubMed PMID: 2454905.
Costa L etal. Impact of skeletal complications on patients' quality of life, mobility, and
functional independence. Support Care Cancer. 2008 Aug;16(8):879-89. Epub 2008
Apr 8. Review. Erratum in: Support Care Cancer. 2008 Oct;16(10):1201. PubMed
Dennis K et al. Palliative radiotherapy for bone metastases in the last 3 months of life:
worthwhile or futile? Clin Oncol (R Coll Radiol). 2011 Dec;23(10):709-15. Epub 2011
Jun 12. PubMed PMID: 21665446.
Bibliography - continued
Fairchild A et al. The rapid access palliative radiotherapy program: blueprint for initiation of
a one-stop multidisciplinary bone metastases clinic. Support Care Cancer. 2009
Feb;17(2):163-70. Epub 2008 Jun 20. PubMed PMID: 18566840.
Fairchild A et al. Has the pattern of practice in the prescription of radiotherapy for the
palliation of thoracic symptoms changed between 1999 and 2006 at the rapid response
radiotherapy program? Int J Radiat Oncol Biol Phys. 2008 Mar 1;70(3):693-700.
PubMed PMID: 18262087.
Fairchild A et al. Palliative thoracic radiotherapy for lung cancer: a systematic review. J Clin
Oncol. 2008 Aug 20;26(24):4001-11. Review. PubMed PMID: 18711191.
Fairchild A, Chow E. Role of radiation therapy and radiopharmaceuticals in bone
metastases. Curr Opin Support Palliat Care. 2007 Oct;1(3):169-73. Review. PubMed
Bibliography - continued
George R et al. Interventions for the treatment of metastatic extradural spinal cord
compression in adults. Cochrane Database Syst Rev. 2008 Oct 8;(4):CD006716.
Review. PubMed PMID: 18843728.
Hashimoto K et al. Palliative radiation therapy for hemorrhage of unresectable gastric
cancer: a single institute experience. J Cancer Res Clin Oncol. 2009 Aug;135(8):1117-
23. Epub 2009 Feb 10. PubMed PMID: 19205735.
Higginson DS et al.Predicting the need for palliative thoracic radiation after first-line
chemotherapy for advanced nonsmall cell lung carcinoma. Cancer. 2011 Sep 20.
doi:10.1002/cncr.26495. [Epub ahead of print] PubMed PMID: 21935913.
Kim MM et al. Clinical benefit of palliative radiation therapy in advanced gastric cancer.
Acta Oncol. 2008;47(3):421-7. PubMed PMID: 17899453.
Bibliography - Continued
Lester JF, Macbeth FR, Toy E, Coles B. Palliative radiotherapy regimens for non-small cell
lung cancer. Cochrane Database Syst Rev. 2006 Oct 18;(4):CD002143. Review.
PubMed PMID: 17054152.
Lester JF, Macbeth FR, Brewster AE, Court JB, Iqbal N. CT-planned accelerated
hypofractionated radiotherapy in the radical treatment of non-small cell lung cancer.
Lung Cancer. 2004 Aug;45(2):237-42. PubMed PMID: 15246196.
Loblaw DA, Mitera G, Ford M, Laperriere NJ. A 2011 Updated Systematic Review and
Clinical Practice Guideline for the Management of Malignant Extradural Spinal Cord
Compression. Int J Radiat Oncol Biol Phys. 2012 Mar 13. [Epub ahead of print]
PubMed PMID: 22420969.
Lutz S, Korytko T, Nguyen J, Khan L, Chow E, Corn B. Palliative radiotherapy: when is it
worth it and when is it not? Cancer J. 2010 Sep-Oct;16(5):473-82. Review. PubMed
Bibliography - continued
Lutz ST, Chow EL, Hartsell WF, Konski AA. A review of hypofractionated palliative
radiotherapy. Cancer. 2007 Apr 15;109(8):1462-70. Review. PubMed PMID: 17330854.
Mehta RS, Arnold RM. Management of spinal cord compression #238. J Palliat Med. 2011
Mar;14(3):362-3. PubMed PMID: 21361838.
Mitera G, Zhang L, Sahgal A, Barnes E, Tsao M, Danjoux C, Holden L, Chow E. A survey of
expectations and understanding of palliative radiotherapy from patients with advanced
cancer. Clin Oncol (R Coll Radiol). 2012 Mar;24(2):134-8. Epub 2011 Oct 2. PubMed
Murakami N, Nakagawa K, Yamashita H, Nagawa H. Palliative radiation therapy for
advanced gastrointestinal cancer. Digestion. 2008;77 Suppl 1:29-35. Epub 2008 Jan
18. Review. PubMed PMID: 18204259.
Bibliography - continued
Onsrud M, Hagen B, Strickert T. 10-Gy single-fraction pelvic irradiation for palliation and
life prolongation in patients with cancer of the cervix and corpus uteri. Gynecol Oncol.
2001 Jul;82(1):167-71. PubMed PMID: 11426980.
Paes FM, Ernani V, Hosein P, Serafini AN. Radiopharmaceuticals: when and how to use
them to treat metastatic bone pain. J Support Oncol. 2011 Nov-Dec;9(6):197-205.
Review. PubMed PMID: 22055888.
Pereira J, Phan T. Management of bleeding in patients with advanced cancer. Oncologist.
2004;9(5):561-70. Review. PubMed PMID: 15477642.
Reinfuss M, Mucha-Małecka A, Walasek T, Blecharz P, Jakubowicz J, Skotnicki P,
Kowalska T. Palliative thoracic radiotherapy in non-small cell lung cancer. An analysis
of 1250 patients. Palliation of symptoms, tolerance and toxicity. Lung Cancer. 2011
Mar;71(3):344-9. Epub 2010 Jul 31. PubMed PMID: 20674068.
Bibliography - continued
Rodrigues G et al. Consensus statement on palliative lung radiotherapy: third international
consensus workshop on palliative radiotherapy and symptom control. Clin Lung
Cancer. 2012 Jan;13(1):1-5. doi: 10.1016/j.cllc.2011.04.004. Epub 2011 Jun 12.
PubMed PMID: 21729656.
Salvo N, et al. Quality of life measurement in cancer patients receiving palliative
radiotherapy for symptomatic lung cancer: a literature review. Curr Oncol. 2009
Mar;16(2):16-28. PubMed PMID: 19370175; PubMed Central PMCID: PMC2669235.
Salvo N et al. The role of plain radiographs in management of bone metastases. J Palliat
Med. 2009 Feb;12(2):195-8. PubMed PMID: 19207068.
Sundstrøm S et al. Hypofractionated palliative radiotherapy (17 Gy per two fractions) in
advanced non-small-cell lung carcinoma is comparable to standard fractionation for
symptom control and survival: a national phase III trial. J Clin Oncol. 2004 Mar
1;22(5):801-10. PubMed PMID: 14990635.
Bibliography – the end
Tanner C. Palliative radiation therapy for cancer. J Palliat Med. 2011 May;14(5):672-3. Epub
2011 Apr 12. PubMed PMID: 21486147.
Tinger A, Waldron T, Peluso N, Katin MJ, Dosoretz DE, Blitzer PH, Rubenstein JH, Garton
GR, Nakfoor BA, Patrice SJ, Chuang L, Orr JW Jr. Effective palliative radiation therapy
in advanced and recurrent ovarian carcinoma. Int J Radiat Oncol Biol Phys. 2001 Dec
1;51(5):1256-63. PubMed PMID: 11728685.