This document provides an overview of palliative radiation therapy for cancer patients. It discusses the fundamentals of how radiation works and advances that have allowed it to more effectively treat cancer. It then focuses on how palliative radiation can effectively relieve symptoms from bone metastases, lung cancer, bleeding, and other cancers in 1-3 fractions rather than longer courses of treatment. Studies show short fractionation schedules provide pain relief comparable to longer schedules with fewer side effects and greater convenience. The document provides guidance on discussing palliative radiation options with radiation oncologists to help simplify the process for hospice patients.

1. Christian Sinclair, MD, FAAHPM
Gentiva Health Systems
Spring 2012

2. 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
work
 to Remix — to adapt the work
 to make commercial use of the work

3. Objectives
 Understand the fundamentals of radiation
therapy
 Manage commonly expected side effects from
radiation therapy
 Identify three situations where palliative
radiation may be effective in hospice patients

4. Questions
 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?

5. Outline
 Conventional Radiation Therapy
 Psychology of A Radiation Oncologist
 Palliative Radiation Therapy
 Hospice collaboration

6. Fundamentals
 Curie’s discover Radium 1898
 Biologic effects of ionizing radiation
 1st ‘cure from radiation therapy 1899
 1st radiation oncologists
 Dermatologists
 Low-energy, low-output machines

7. Tissue Absorption
 At any energy, x-rays are attenuated by tissue
 Absorbed dose decreases with depth
 Early treatments for deep tumors overdosed
superficial tissues

8. Advances in WWII
 Higher energy tools
 Cobalt-60
 Linear accelerators
 Penetrating radiation
 Skin-sparing effect
 Without advanced imaging treatment focused
on tumors easily seen

9. Volume-dose relationship
Greater tumor volume
requires
greater radiation dose

10. Dose-Damage Relationship
Higher radiation dose
increases risk for
damage to normal tissues

11. Finding Balance
Benefit of tumor control
versus
Risk of normal tissue injury

12. 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

13. Fractionation
 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

14. 3000 cGy in 15 fractions
(200 cGy/fraction)
≠
3000 cGy in 10 fractions
(300 cGy/fraction)

16. Late Effects - Hypofractionation
 Years
 Brain and spinal cord
 Fibrosis
 Bowel
 Months-years
 Lung tissue
 lymphedema

17. Benefits - Hypofractionation
 Radiation dose given quickly
 Faster tumor response
 Avoid multiple trips

18. Cancer Symptoms for XRT
 Bleeding
 Pain
 Obstruction – Airway/Visceral
 Spinal cord compression
 Impending fractures
 Wounds
 Skin metastases

19. Bone Metastases
 65-75% of advanced breast/prostate CA
 30-40% of advanced lung cancer
 Skeletal-related events: pain, fracture,
compression, hypercalcemia
 SRE’s impact on QOL
 Mobility and functional wellbeing
 Decrease ADL’s
 Increase depression/anxiety
 Increase opioid needs
Costa L et al. Support Care Cancer 2008;16:879‐889

20. Bone Metastases
 Historically
 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.

21. 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.

22. RTOG 97-14 – Painful Bone
 Breast or Prostate cancer
 Painful bone mets
 Confirmed met by imaging
 Prognosis > 3 mos, KPS ≥ 40

23. 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)
p=NS
 ASTRO plenary: “800 cGy x 1 fraction is the new standard of
care for palliation of painful bony metastases”

24. Cancer Care Ontario 2004
 Practice guidelines
 “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
bone metastases.”
 Survey (Ontario practitioners)
 83% agreed with evidence interpretation
 75% agreed approved of guideline
Wu JS-Y et al. BMC Cancer 2004;4:71-78

25. Intl Survey of Practice Patterns
 Rad Onc in ASTRO, CARO, RANZCR
 5 scenarios
 101 schedules recommended
 Median dose 3000 cGy/10 fractions
 US Rad Onc 3x the number of fractions for same
indication
Fairchild A et al. IJROBP 2009;75:1501‐1510

26. RVU for XRT
 3D Conformal XRT - $6,000-10,000
 IMRT $12,000-20,000

27. 10 vs. 1 Fraction

28. 10 vs. 1 Fraction

29. Spinal Cord Compression
 Previous concern with large doses per fraction in
this setting (‘double injury’ of radiation and
physical injury to cord)
 Cochrane Review
 Ambulatory patient, stable spine: palliative radiotherapy
(short course suffices in patients with predicted survival
<6 months)
 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

30. Pathologic/Impending Fracture
 Very little published data
 Case‐by‐case decision making for palliative
radiotherapy
 Pain is better relieved with
surgery/stabilization in some cases

31. 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
2008;71:1208‐1212]
 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]

32. Lung Cancer
 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

33. 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%
 Cervix/vagina/vulvar/endometrial cancers
 Bladder/prostate/urethral cancers
 Colorectal cancer
Onsrud 2001; Pereira 2004; Tinger 2001

34. Gastrointestinal Cancers
 Retrospective studies suggest
hypofractionated radiotherapy is effective in:
 improving pain (86%)
 bleeding (70%)
 dysphagia (81%)
 Acute nausea when treating upper abdomen
may limit short courses
 MDACC: 14 fractions (3500 cGy) used most
commonly
Kim 2008; Murakami 2008; Hashimoto 2009

35. Head/Neck Cancers
 Prospective and retrospective studies suggest
hypofractionated radiotherapy is effective in
improving pain, bleeding, airway obstruction,
 wound progression, hoarseness, otalgia,
dysphagia/odynophagia
 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

36. Brain Metastases
 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

37. Medical Director Strategies
 Meet in advance of need with your local radiation
oncologist
 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

39. Rapid Access Palliative XRT
 Canadian approach:
 combining separate clinic visits
 hypofractionated radiotherapy
 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

40. Conclusions
 Hospices and palliative care programs are
providing care for patients with symptomatic
advanced cancers
 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

41. Bibliography
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
PMID: 18392862.
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.

42. 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
PMID: 18685358.

43. 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.

44. 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
PMID: 20890143.

45. 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
PMID: 21963448.
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.

46. 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.

47. 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.

48. 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.