Course Of Palliative Radiotherapy Research Articles

Outcomes for pediatric patients with osteosarcoma treated with palliative radiotherapy.

Few studies have addressed the efficacy of palliative radiotherapy (RT) for pediatric osteosarcoma (OS), a disease generally considered to be radioresistant. We describe symptom relief, local control, and toxicity associated with palliative RT among children with OS. Patients diagnosed with OS at age 18 and under and treated with RT for palliation of symptomatic metastases or local recurrence at the primary site from 1997 to 2017 were included. We retrospectively reviewed details of RT, symptom improvement, local control, survival, and toxicity. Thirty-two courses of palliative RT were given to 20 patients with symptomatic metastatic and/or locally recurrent primary disease. The median equivalent dose in 2Gy fractions (EQD2) was 40.0Gy (range, 20.0-60.4). The median number of fractions per course was 15 (range, 5-39). Symptom improvement occurred in 24 (75%) courses of RT at a median time of 15.5days (range, 3-43). In nine courses (37.5%), symptoms recurred after a median duration of symptom relief of 140days (range, 1-882). Higher EQD2 correlated with longer duration of response (r=0.39, P=0.0003). Imaging revealed local failure in 3 of 14courses followed with surveillance imaging studies (21.4%). The median time to progression was 12.9 months (range, 4.4-21.8). The median follow-up time following the first course of palliative RT was 17.5 months (range, 1.74-102.24), and median time to overall survival was 19.4 months. Toxicity was mild, with grade 2 toxicity occurring in one course (3.1%). RT is an effective method of symptom palliation for patients with recurrent or metastatic OS, with higher delivered dose correlating with longer symptom relief and with little associated toxicity.

Palliative radiation oncology programs: design, build, succeed!

The palliation of symptoms caused by advanced cancer is one of the most common indications for radiation therapy. Radiation therapy is an efficient and effective treatment for the palliation of pain, bleeding, obstruction, compression of nerves or the spinal cord and other local symptoms caused by tumors. The general principles of palliative radiation therapy are to use the shortest course of palliative radiation therapy needed to achieve the desired goal. It can typically be effective in a convenient single treatment (fraction) or over a small number of fractions. Given aging populations and the incidence of advanced cancer, there is increasing need for palliative radiation therapy. Many radiation oncology centers now recognize the unique needs of patients with advanced cancer and have developed palliative radiation oncology programs. This review will highlight key features of these palliative radiation oncology programs and their success in facilitating the treatment of these patients.

Persistent Use of Extended Fractionation Palliative Radiotherapy for Medicare Beneficiaries With Metastatic Breast Cancer, 2011 to 2014.

With no evidence to support extended radiation courses for the palliation of bone metastases, multiple guidelines were issued discouraging its use. We assessed contemporary use and cost of prolonged palliative radiotherapy in Medicare beneficiaries with bone metastases from breast cancer. We conducted a retrospective, longitudinal study of palliative radiotherapy use among fee-for-service Medicare beneficiaries with bone metastasis from breast cancer who underwent palliative radiotherapy during 2011 to 2014. Patients were categorized according to the number of days (fractions) on which they received palliative radiotherapy: 1, 2 to 10, 11 to 19, or 20 to 30. We examined the association of clinical, demographic, and provider characteristics with the use of extended (≥11 fractions) or very extended (≥20 fractions) fractionation with logistic regression models. We also compared the cost of different fractionation schemes from the payer perspective. Of the 7547 patients in the sample (mean age, 71 y), 3084 (40.8%) received extended fractionation. The proportion of patients receiving 11 to 19 (34.7% in 2011 and 28.1% in 2014, trend P<0.001) and 20 to 30 treatments (10.3% in 2011 to 9.0% in 2014, trend P=0.07) decreased modestly over time. Patients with comorbidities were less likely to undergo extended fractionation (34.4% for ≥3 comorbidities vs. 44.9% for 0 comorbidities; adjusted odds ratio 0.67 [95% confidence interval, 0.58-0.76]). Patients treated at free-standing practices were more likely to undergo extended fractionation (47.9%) compared with those treated at hospital-based practices (37.3%, P<0.001; adjusted odds ratio, 1.49 [95% confidence interval, 1.35-1.65]). The mean cost of treatment varied from $633 (SD $240) for single-fraction treatment, to $3566 (SD $1349) for 11 to 19 fractions, to $6597 (SD $2893) for 20 to 30 fractions. The use of prolonged courses of palliative radiotherapy among Medicare beneficiaries with breast cancer remained high in 2011 to 2014. The association between free-standing facility status and use of extended fractionation suggests that provider financial incentives may impact choice of treatment.

Short versus long course of palliative radiotherapy for symptom control irradiating chest in lung cancer patients

Short versus long course of palliative radiotherapy for symptom control irradiating chest in lung cancer patients

Palliative Radiation Therapy Near the End of Life in Lung Cancer Patients: A Population-Based Analysis

Palliative radiotherapy (PRT) can improve quality of life for patients with advanced lung cancer, but symptomatic relief may take up to a few weeks. PRT in the last 4 weeks of life is an emerging indicator of poor quality care. We sought to determine the patterns of PRT utilization in patients with advanced lung cancer in a population-based health care system. All patients with lung cancer in a Canadian province treated with PRT between 1st January 2014 and 31st December 2015 were identified. Patient and treatment characteristics were extracted from a provincial cancer database. Chart review was performed for patients receiving potentially radical dose fractionation schedules to confirm palliative intent. Site of PRT was classified as bone, brain or chest; all other sites were excluded. Patients who received more than one course of PRT were considered independently for each course. Associations between starting a course of PRT within 4 weeks of death and patient/treatment characteristics were assessed using chi-square and t-tests. Multi-variable logistic regression analysis was subsequently performed to assess associations. A total of 4,160 courses of PRT were delivered to 2571 patients. Median survival for the entire cohort was 17 weeks (95% CI 15.7-17.4) from start of PRT. Forty-one percent of PRT courses were delivered to chest, 39% to bone and 20% to brain. Fourteen percent of PRT courses were prescribed to patients in the last 4 weeks of their life, with significant differences by male vs female (17% vs 11%; p<0.001), performance status (ECOG 0, 1, 2, 3 and 4 were 8%, 9%, 11%, 19% and 39% respectively; p<0.001), histology (adenocarcinoma, squamous cell carcinoma, NSCLC NOS and small cell lung cancer were 11%, 15%, 19% and 16% respectively; p<0.001) and site of PRT (bone, chest and brain were 17%, 12% and 11%; p<0.001). These associations persisted on multi-variable analysis. Of PRT courses delivered in the last 4 weeks of life, the majority were planned using simple techniques (1-2 fields, 96%) and using short fractionation regimes (single fraction for bone, 71%; ≤5 fractions for brain, 92%; ≤5 fractions for chest, 91%). This population-based analysis found that 14% of PRT courses for lung cancer were delivered in the last 4 weeks of life. Males, those with poor performance status, non-adenocarcinoma histology and bone metastases were more likely to receive PRT near end of life. Appropriately, simple planning techniques and shorter fractionation regimes were used more commonly closer to death. Although there is no consensus of what constitutes poor quality care with regard to PRT near end of life, the limited number of published series report 10-20% death within 4 weeks of PRT. While further clarification in this domain occurs, clinicians should be cognizant of the prognosis of their patients when considering indications and fractionation schedules of PRT.

Efficacy of Palliative Radiation Therapy (RT) for Diffuse Large B-Cell Lymphoma: A Population-Based Retrospective Review

To investigate outcomes of palliative RT in patients with diffuse large B-cell lymphoma (DLBCL) and clinical factors that impact treatment efficacy. We hypothesize that factors can be identified which are associated with improved response. All patients with DLBCL who received palliative RT from 2001-2015 in the province were reviewed for patient characteristics, treatment details, and outcomes. Two hundred and seventeen patients who received 370 courses of palliative RT were identified. Median age at RT was 76 years, and 57% of courses were in male patients (n=211). Median equivalent dose in 2 Gy fractions (EQD2) was 19 Gy. Size of treated lesion was documented in 240 courses; median largest dimension was 5.8 cm. Irradiated sites were 22% skin, 18% head and neck, 14% spine, 13% abdomen, 10% pelvis, 7% bone, 6% thorax, 5% axilla, and 5% other. Indications for palliative RT were 42% pain, 22% enlarging mass, 20% obstruction or peripheral nerve compression, 9% spinal cord compression, 4% bleeding, 2% non-healing wound, and 1% pruritis. Clinical response assessment was available for 274 courses (74%), of which 42 courses had radiologic follow up; 2 courses had only radiologic response assessments. Symptom resolution was achieved in 42% of courses (114/274), symptom improvement in 40% (110/274), and stability in 13% (36/274); there was symptom progression in 5% (14/274). For courses given for pain relief, complete pain relief was achieved in 51% of courses (60/118) and partial pain relief in 36% (43/118). Using a logistic generalized estimating equation method, factors associated with symptomatic benefit and/or radiological response were initial stage I/II vs III/IV (94% vs 76%, p<0.0005), response vs no response to initial chemotherapy (84% vs 69%, p=0.03), concurrent vs no concurrent steroid use (71% vs 88%, p=0.001), skin vs non-skin disease (96% vs 79%, p<0.0005), and spinal vs non-spinal disease (61% vs 85%, p=0.008). Local control (LC) at 6 months was 65% (95% confidence interval [CI] 54-74%). Six month LC was 78% vs 50% when lesion size was <5.8 vs ≥5.8 (p=0.04); 74% vs 61% when initial stage was I/II vs III/IV (p=0.04); 51% vs 85% when the time from diagnosis to first relapse or progression was <1 year vs ≥1 year (p=0.02); and 75% vs 27% when initial response to chemotherapy was partial or complete vs none (p<0.0005). LC was not significantly associated with age, skin disease, spinal disease, EQD2, concurrent steroids use, or number of previous chemotherapy lines. On multivariable Cox regression analysis, response to initial chemotherapy (HR 4.3, 95% CI 2.1-8.5) was associated with improved LC. Palliative RT for DLBCL is effective for symptom improvement and local disease control. In deciding upon RT for incurable DLBCL, factors to consider include lesion size, response to initial chemotherapy, and anatomical site.

The Impact of Radiation Therapy on Lymphocyte Count and Survival in Metastatic Cancer Patients Receiving PD-1 Immune Checkpoint Inhibitors

Therapeutic radiation has conflicting immune effects: radiation therapy (RT)-induced immunogenic cell death can contribute to immune response, but lymphocytes are also sensitive to RT. It is unknown whether palliative RT leads to lymphopenia in patients treated with immune checkpoint inhibitors (ICIs) and whether this affects outcomes. As such, we sought to assess the impact of palliative RT on circulating lymphocyte count and neutrophil-to-lymphocyte ratio in patients being treated with PD-1-directed ICI and associations with survival. We identified patients from 5 radiation oncology centers, treated with palliative RT and either pembrolizumab or nivolumab with non-small cell lung cancer, metastatic melanoma, and renal cell carcinoma. Patients who received intervening cytotoxic chemotherapy were excluded. We recorded absolute lymphocyte count (ALC) and neutrophil-to-lymphocyte ratio before and after palliative RT and at the start of ICI. Survival was analyzed using the Kaplan-Meier method and Cox proportional hazard models. One hundred ten patients received 225 courses of palliative RT. Median change in ALC after RT was -161cells/mL. Decreases in ALC were greater with RT to the spine, lung/mediastinum, and chest wall compared with the brain, extremity, or abdomen/pelvis (P=.002) and after courses >5 fractions (P=.003). Extracranial and >5-fraction RT was associated with increased odds of severe lymphopenia (ALC <500) at the end of RT (odds ratio [OR], 3.7; P=.001; and OR, 3.9; P=.001, respectively). Patients who developed RT-induced severe lymphopenia were more likely to have severe lymphopenia when ICI was initiated (OR, 6.4; P=.0001), particularly when RT was administered in the previous 3months (OR, 189; P<.0001). Severe lymphopenia at onset of ICI therapy was associated with increased mortality on multivariable analysis (hazard ratio, 2.1; P=.03). Extracranial or prolonged courses of RT increase the risk of severe lymphopenia, which is associated with poorer survival in patients treated with ICI.

Short Hypofractionated Radiation Therapy in Palliation of Pediatric Malignancies: Outcomes and Toxicities

Treatment strategies in palliation of pediatric cancer remain a significant challenge. In this study, we aimed to assess the efficacy and safety of a short course of hypofractionated radiation therapy (RT) for metastatic or recurrent childhood tumors. A total of 104 lesions in 62 pediatric patients with metastatic or recurrent cancer were treated with a short hypofractionation schedule (>1 but ≤5 fractions; ≥3Gy per fraction) between 2007 and 2017 in our institution. The primary endpoint was local control (LC). Other endpoints included treatment response, overall survival, progression-free survival, and toxicity. Toxicities were assessed using the Common Terminology Criteria for Adverse Events v.4.0. The most common histologies were neuroblastoma, comprising 50 of the 104 lesions (48.1%); osteosarcoma, 17 lesions (16.4%); and Ewing sarcoma, 13 lesions (12.5%). A median total dose of 24Gy was delivered in a median of 5 fractions. Of 104 lesions, 26 (25.0%) were treated with stereotactic body radiation therapy, 24 (23.1%) with intensity modulated RT, and 48 (46.2%) with 2-dimensional RT or 3-dimensional conformal RT. A complete or partial response was observed in 63 (60.6%) of lesions, and stable disease was observed in 34 (32.7%). At a median follow-up of 8.7months, 21 local failures occurred (20.2%). The 1- and 2-year LC rateswere 74% and 68%, respectively. LC was better for tumors without previous irradiation (83% vs 57% with previous RT; P=.004). LC rates did not differ between RTtechniques or total biologically effective dose with α/β ratio of 10 (BED10) (≤30 vs>30Gy). At the time of analysis, 38 deaths in the cohort of 62 patients (61.3%) wererecorded. The 1-year progression-free survival and overall survival rates were 31% and 44%, respectively. Incidence of any grade ≥3 toxicity was 6.7% (7 of 104). No grade 5 events occurred. A short hypofractionation scheme yields effective disease control and treatment response with a favorable side effect profile. Select pediatric patients with symptomatic metastases or recurrent disease can be considered for a short course of palliative RT.

Choosing Wisely at the End of Life: Use of Shorter Courses of Palliative Radiation Therapy for Bone Metastasis

American Society for Radiation Choosing Wisely guidelines recommend ≤10 fractions of radiation therapy (RT) for bone metastasis, with consideration for 1 fraction in patients with a poor prognosis. The purpose of this analysis was to evaluate characteristic differences in guideline concordance to fractionation regimens in a modern cohort of older patients with a diagnosis of bone metastasis. Medicare beneficiaries aged ≥65 years treated with RT for bone metastasis from 2012 to 2015 were identified. Guideline-concordant RT fractionation was defined in the entire cohort as ≤10 fractions. Utilization of 1 fraction versus ≥2 fractions was analyzed in deceased patients. Patient demographic, disease, and facility characteristics associated with shorter fractionation were analyzed. In 569 patients treated with RT, the median age at diagnosis was 73 years. The most common cancer types were lung (37%), genitourinary (26%), breast (15%), and gastrointestinal (10%). Among all patients, 34%, 30%, and 36% received 1 fraction, 2 to 10 fractions, and ≥11 fractions, respectively. In comparison with receipt of 1 to 10 fractions, receipt of ≥11 fractions was associated with a $1467 increase in per-patient cost to Medicare during the calendar quarter of RT. Almost two-thirds of patients who died within 30 days of RT completion were treated with >1 fraction. Although guideline concordance was high overall, a large number of patients received longer courses of RT at the end of life. Strong consideration should be made for utilization of shorter courses, particularly in patients with a limited prognosis.

Levels of Anxiety and Depression Before Palliative Reirradiation Are Comparable to Those Before First Palliative Radiotherapy.

Introduction: The purpose of this study was to evaluate whether or not patients scheduled for the reirradiation of a previously treated target volume report reduced levels of anxiety and depression, compared to patients receiving their first course of palliative radiotherapy, e.g., because they are familiar with the process of treatment planning and delivery.Methods: A retrospective comparison of two groups of patients (37% reirradiated, overall 102 patients), which scored their symptoms before palliative radiotherapy with the Edmonton symptom assessment system (ESAS).Results: The two groups differed significantly with regard to the incidence of bone metastases, which was higher in the reirradiation group. Mean anxiety and depression scores were not significantly different between the two groups. The same was true for the proportion of patients with symptom scores ≥4. Analyses limited to patients treated for bone metastases revealed no significant differences either. Survival was similar, too.Conclusion: The facts that similar ESAS scores of anxiety and depression were observed and that prognosis was comparable suggest that the magnitude of these symptoms might be associated with the presence of incurable cancer itself (or the related somatic symptom burden) rather than the setting in which palliative radiotherapy is performed.

Factors associated with palliative radiotherapy in the last 30 days of life.

84 Background: A significant proportion of patients will undergo radiotherapy (RT) within their last 30 days of life. Identifying patients who may not benefit from RT is difficult and use of predictive models for life expectancy is not routine (Chow et al., JCO 2008; Krishnan et al., Cancer 2013). Methods: Patients treated with external beam RT to a site of metastatic disease between 2012-2016 at a single institution prior to death were included in this analysis. Mann-Whitney U and chi-squared tests were used to compare patients who received RT within 30 days of death (D30RT) and those who did not. Multivariate analysis was used to identify factors associated with D30RT. Results: 518 patients accounting for 922 palliative RT courses were included. Median age at treatment was 63 yrs (IQR 54-71 yrs), median survival time was 28 months (IQR 11-53 mos) and median time from RT to death was 74 days (IQR 33-174 days). 49% of patients were metastatic at diagnosis. The most common primary sites were lung (26%), breast (19%) and prostate (10%). The most common treatment sites were bone (56%) and brain (28%). 125 patients (24%) died within 30 days of RT. D30RT was associated with older median age at treatment (64 vs. 62 yrs, p = 0.04), shorter interval since diagnosis (14 vs. 31 months, p &lt; 0.001), liver but not brain or lung metastasis (p = 0.02, 0.43, and 0.06 respectively), lower median KPS scores (50 vs. 70, p &lt; 0.001), lower median BMI (22 vs. 24, p = 0.001), and inpatient status at consult (56% vs. 26%, p &lt; 0.001). Despite poor outcomes, patients who died within 30 days of RT were less likely to have hospice involved in their care (44% vs. 71%, p = 0.001). The only factor associated with hospice was longer time since diagnosis (28 months vs. 21 months, p = 0.04). D30RT was associated with higher Chow and TEACHH scores at the time of consult (p &lt; 0.001 for both). Conclusions: A high frequency of patients received palliative RT at the end of life in our cohort. Earlier integration of palliative care or hospice services may allow patients and physicians to optimally direct treatment at the end of life. Existing life-expectancy prediction models may allow physicians to identify patients who could benefit from short treatment courses or alternative interventions to maximize quality at the end of life.

Metastatic Colon Cancer: A Rare Presentation of Parotid Gland Metastasis

Colorectal cancer is the third most common type of cancer in the United States and has the potential of metastasizing to nearly any organ in the body. We present a rare case of metastatic colon cancer to the parotid gland. A 64-year-old male presented with a history of adnocarcinoma of the esophagus and colon. PET-CT showed no metastatic disease. The esophageal disease was reported T3N0 and the transverse colon disease T3N1. Ideally the patient would have pursued neoadjuvant chemoradiation followed by surgery, but he was not a candidate hence systemic chemoradiation was not performed. He underwent a right hemicolectomy followed by a short course of palliative radiation therapy to his chest. 6months later he developed a new left parotid mass. Biopsy of the left parotid gland, showed a poorly differentiated adenocarcinoma. Immunohistochemistry determined that this was likely from lower GI origin making metastatic disease from his colon cancer the most likely source. Unfortunately, he remains a poor candidate for systemic chemotherapy due to his advance age and poor performance status, hence arrangements were made to initiate radiation therapy in palliation. Colorectal cancer is a common and potentially lethal disease. Estimates range as high as 134,490 new cases of colon cancer are diagnosed annually in the US. Approximately 49,190 Americans are expected to die of colon cancer each year which has decreased significantly since 1990 at a rate of approximately 3% per year presumably due to better screening methods. Approximately 20% of patients in the US have distant metastatic disease at the time of presentation. The most common metastatic sites are the regional lymph nodes, liver, lungs, and peritoneum. Parotid gland involvement by adenocarcinoma of the colon is extremely rare. Metastatic involvement of the parotid gland may arise from lymphatic spread, hematogenous dissemination, or contiguous involvement. Contiguous extension is common with malignancies of the supporting tissues in the parotid region, whereas the parotid gland is unusual as the focus of a distant primary tumor. Most metastases to the parotid gland arise from primary tumors in the head and neck region, usually being either melanomas or squamous cell carcinomas. Colorectal carcinoma has the potential to metastasize to almost any organ of the body. Although rare, metastatic adenocarcinoma from the colon should be included in the differential diagnosis of lesions of the parotid gland.

Profile of patients undergoing palliative radiotherapy: A single-institute study from a tertiary care oncology center.

Background:Palliative radiotherapy (PRT) plays a significant role in the palliation of symptoms in patients with cancer and constitutes nearly 50% of the workload in different settings.Aims:The aim is to study patient-, disease-, and treatment-related characteristics in locoregionally advanced and metastatic malignancies meriting palliative management.Setting and Design:This was a retrospective observational study in a tertiary care government institute with academic and research potential.Methodology:The electronic medical records, medical documents, and radiotherapy (RT) treatment charts were retrieved and studied.Observations:A total of 460 patients were included in the study over 2 years, forming 30% of the total number of patients treated during the study period. Three hundred and ninety-six patients received PRT to the metastatic sites, while 64 patients received extremely hypofractionated PRT to the primary for symptomatic relief. Totally 442 patients showed good symptomatic response to PRT. One hundred and thirty-eight patients underwent re-irradiation. Lung was the most common primary site seen in 155 cases. The most common indication for PRT was palliation of pain from painful metastases as seen in 240 cases, and the next common indication was palliative whole-brain RT for brain metastases as seen in 159 cases.Conclusion:PRT forms an integral and important aspect of palliative care to the vast number of patients harboring metastatic disease that warrants some form of treatment for symptomatic relief. Short course of PRT in outdoor setting is a preferred mode of treatment to improve the quality of life of these distressed patients.

Patterns of Referral for Palliative Radiation Therapy

Palliative radiotherapy (PRT) is effective in alleviating the symptoms of many patients with advanced cancer, but there is evidence that it is underutilized, particularly in the elderly and in patients who live further from an RT center. Efforts to optimize access to PRT require an understanding of patterns of referral. The purpose of this study was to identify the sources of referral for PRT to a regional RT program. Our hypothesis is that the source of referral for PRT varies with the characteristics the patient. Medical and billing records were reviewed to identify the source of referral of patients who received PRT at a regional cancer center in Ontario between 2010 and 2015. Multivariate analysis was used to identify characteristics of the patient that are associated with the source of referral for PRT. Only the first course of PRT was considered. In total, 3,258 patients received PRT between 2010 and 2015. The patients’ median age was 70, 55% were male, and the median distance from patient residence to the radiotherapy center was 38.5 miles. The most common primary cancer sites were lung (37.2%), genitourinary (GU) (17.2%), gastrointestinal (GI) (12.8%), and breast (9.0%). PRT was given for locoregional disease in 36.0%, for distant metastases in 47.8%, and for indeterminate or multiple sites in 16.2%. Patients were referred by medical oncologists (MOs) (30.1%), other internists (26.4%), surgeons (24.2%), and family practitioners (FPs) (13.4%). In the remaining 5.9%, the need for PRT was identified by a radiation oncologist during follow-up after adjuvant or radical RT. The sources of PRT referrals varied significantly by primary cancer site (p<0.0001). Most lung cancer patients were referred by respirologists (34%), MOs (19%), or general internists (13%); most GU patients were referred by urologists (36%), FPs (20%), or MOs (19%); most GI patients were referred by MOs (47%), surgical oncologists (15%), or FPs (12%); and most breast patients were referred by MOs (61.2%), FPs (15%), or surgical oncologists (7%). The proportion of patents referred by their FP varied widely by disease site (range 7%-21%; p<0.0001). A multivariate analysis that controlled for primary site, showed that older patients were significantly more likely to be referred by their FP [>80 vs ≤60, OR 2.34 (1.67-3.27); 71-80 vs ≤60, OR 1.57 (1.15-2.14)], and that patients who lived further from the RT center were more likely be referred by their FP [>31 miles vs ≤31 miles, OR 1.37 (1.08-1.72)]. Diverse groups of doctors are involved in referring patients for PRT. Strategies for improving access to PRT should address the needs of specific patient groups by targeting the doctors who are most responsible for their care. FPs may be a key target for interventions aimed at enhancing access to PRT for older patients, and for those who reside further from an RT center.

Exploring the Usefulness of Concurrent Chemoradiation for Bulky Disease in the Setting of Advanced/Inoperable or Metastatic Breast Cancer

Improvements in systemic therapy (ST) have improved survival for breast cancer (BC) patients with locally advanced/inoperable and metastatic disease. Therefore, traditional palliative radiotherapy courses (e.g. 30 Gy/10 fractions) may not be sufficient treatment to secure durable control of bulky locoregional or symptomatic metastases and more aggressive approaches may be warranted. We sought to characterize the outcome of treating this population with concurrent chemoradiotherapy (CRT). We queried our institution's pharmacy database for BC patients treated with capecitabine (C) from 2012-2016 to identity patients that received CRT. Demographic, disease characteristics, treatment information and outcome was collected. Local failures (LF) were classified as progression documented within the irradiated field. All other failures were classified as distant failures (DF). Competing risks analysis was performed to estimate LF/DF. We used the linear quadratic formalism to calculate the biologically effective dose of the different RT regimens assuming α/β=3 (BED3). We chose to assess differences in LF using a cutoff value BED=80 Gy3 (equivalent to common whole breast RT regimens). Of 323 patients in the C database, 33 patients underwent 35 courses of CRT. 48% were ER+/PR+, 45% triple-negative, and 18% HER2+. For CRT, C (500 mg-1500 mg PO BID, was most commonly used (N=26); 7 patients received Carboplatin (AUC=2 IV weekly) or Cisplatinum (22.5-30 mg/m2 IV weekly); 1 patient received doxorubicin-liposomal 32mg/m2 IV q3 weeks; 1 patient received gemcitabine 300mg/m2 IV weekly. At the time of CRT, 4 pts had inoperable disease, 11 pts had local-regional recurrence (LRR), and 18 patients had distant metastatic disease (DM). The median number of prior lines of ST was 4 (range, 1-11) for DM patients and 1 (1-4) for inoperable/LRR patients. Median PTV was 886 cc (range, 180-2956 cc) for inoperable/LRR and 427 cc (34-3336 cc) for DM. 28% were treated with ≤2Gy/fraction to a median dose of 60 Gy (range, 36-66 Gy); 46% were treated at 2.5-3Gy/fraction to a median dose of 45 Gy (30-60 Gy); and 26% were treated at >3Gy/fraction to a median dose of 48 Gy (22.8-68 Gy). Median follow-up was 8 months. The 1-year LF was 23%, DF 71%, and OS rate 54%. Patients that received BED3≥80 Gy vs. <80 Gy had numerically lower rates of LF at 1 year (18% vs. 39%, p=0.09). Grade 3 acute toxicity was low (9% Grade dermatitis; 9% hematologic). Patients resumed standard dose ST at a median of 10.5 days after completion of CRT. We found that CRT for bulky disease in the breast, nodal or metastatic sites is well-tolerated in heavily pre-treated BC patients. Patients returned promptly to ST and at 1 year an overall local control of 77% was achieved, and 82% when an RT regimen with BED>80 Gy3 was used. The predominant failure pattern was at distant sites outside the RT field. We suggest that this approach warrants future prospective studies and hypofractionated regimens with a BED>80 Gy3 is recommended.

(P089) Comparison of Survival by Different Palliative Radiation Therapy Fractionation Schedules

Choice of palliative radiotherapy regimen has taken on greater importance in recent years with the 2013 ASTRO Choosing Wisely campaign recommending against protracted fractionation schemes for palliation of bone metastases and encouraging single-fraction treatment for appropriately selected patients. The aims of this project were to 1) determine survival based upon palliative fractionation scheme utilized and 2) determine additional factors which predict survival. We identified a cohort of 1292 patients (569 female, 723 male) treated with palliative intent from 2000-2014 who were treated according to one of four palliative treatment schedules: 37.5 Gy in 15 fractions (n= 318), 30 Gy in 10 fractions (n = 982), 20 Gy in 5 fractions (n = 262), 8 Gy in a single fraction (n = 139). Death dates were obtained from medical records, Social Security Death Index, and publicly-available obituaries. Performance status, marital status, burden of metastatic disease and insurance type were also noted. SAS was used to generate a multivariate model with time from treatment to death as a continuous dependent variable. We found that the length of treatment correlated directly with survival, with the exception of no significant difference between single-fraction and 5-fraction palliative regimens. Median survival was 13.4, 9.8, 7.0 and 6.9 months for 15, 10, 5 and single fraction treatments, respectively. Performance status and insurance status were also correlated with survival, with worse performance status and lack of insurance correlating with decreased survival. Given that patients receiving shorter courses of palliative radiotherapy have a shorter survival, this indicates we may be appropriately selecting shorter treatment for patients with limited survival. However, the lack of survival difference between patients treated with single-fraction and 5-fraction palliative regimens supports consideration of single-fraction treatment over 5-fraction treatment.

EP-1241: Successful pain relief after a short course of palliative radiotherapy in painful pancreatic cancer

EP-1241: Successful pain relief after a short course of palliative radiotherapy in painful pancreatic cancer

The role of radiation therapy in palliative care of children with advanced cancer: Clinical outcomes and patterns of care.

There are few published data to guide the use and timing of palliative radiation therapy (RT) in children. We aimed to determine the clinical outcomes of palliative RT in children and the relationship with palliative care and hospice referrals. A retrospective chart review was performed onall patients younger than 18 years who received palliative RT in our clinic from January 2005 to January 2015. In the specified time period, 50 children underwent 83 courses of palliative RT. Median survival after treatment was 124 days (range, 1-1141 days). Fifteen courses were delivered to children in the last 30 days of life (dol). Palliative RT was successful in 89% of courses delivered before the last 30 dol versus 28% of courses delivered in the last 30 dol (p < 0.0001, Fisher's exact test). At the time of data collection, 43 children were deceased. Altogether, 88% of children who received palliative RT were also referred to our institution's pediatric palliative care team or to hospice at some time in their course. Of the children who died, 74% were referred to hospice and 34% were on hospice while receiving palliative RT. For children not already on hospice, the median time to hospice referral was 96 days after the last fraction (range, 0-924 days). Palliative RT is effective in children with advanced cancer, although less so in the last 30 dol. With careful care coordination and multidisciplinary collaboration, RT can be successfully integrated into supportive and end-of-life care for children with advanced cancer.

Short-course radiation for palliation of squamous cell carcinoma of an unknown primary of the head and neck.

62 Background: The purpose of this study was to examine the treatment patterns used for palliative radiotherapy for squamous cell carcinoma of an unknown primary of the head and neck and to compare the acute toxicity and tumor response for these patients for the most common dose-fractionation regimens. Methods: Patients with biopsy-proven squamous cell carcinoma of an unknown primary with cervical lymphadenopathy were included who were treated with radiation therapy with palliative intent at a single institution between 1966 and 2015 (N = 45). Chart abstraction was performed on the radiation therapy records and follow-up visit notes. Results: Most patients presented with N3 disease (32/45, 71%), with symptoms of pain (19/45, 42%), or with difficulty swallowing (12/45, 27%). Patients were most commonly treated with 20 Gy in 2 fractions (13/45, 29%) or 30 Gy in 10 fractions (13/45, 29%). Toxicity was mild regardless of dose-fractionation, with only 6 patients experiencing dysphagia and 1 having a pulmonary embolus. Most patients had a partial nodal response during the radiation course (25/45, 56%), and partial symptom response by the first followup (17/33, 52%). Results were similar for 20 Gy and 30 Gy courses. Median survival was approximately 5 months and did not differ by radiation course. Conclusions: Patients treated with dose-fractionations of 20 Gy in 2 weekly treatments or 30 Gy in 10 fractions had minimal toxicity. Most patients had an excellent response in nodal size during radiation and nearly all had symptomatic response within the first month of follow. Patients with advanced disease of the head and neck may have a surprising durability of response with even a short course of palliative radiation therapy.

Impact of intense systemic therapy and improved survival on the use of palliative radiotherapy in patients with bone metastases from prostate cancer.

More effective drugs may reduce the requirement for palliative external beam radiotherapy for bony target volumes; however, living with metastases for prolonged periods of time may result in more frequent episodes of bone pain or serious skeletal-related events. The purpose of the present study was to evaluate how recent advances in systemic therapy impact radiotherapy utilization. A retrospective analysis of a comprehensive regional database was performed. All oncology care in this region was provided by only one center, assuring complete data. Patients that had succumbed between June 1, 2004 and June 1, 2015 were included. For all 236 patients, the median age at diagnosis of bone metastases was 75 years and median overall survival was 20 months. More intense systemic therapy was associated with a significantly longer survival time. Only 69 patients (29%) did not receive palliative radiotherapy for bony target volumes, whilst 1 course was given to 101 patients (43%), 2 courses to 34 patients (14%) and >2 courses to 32 patients (14%). Radiotherapy was used more frequently in younger patients, those with spinal cord compressions or pathological fractures, and those treated with intense and long-standing systemic therapy. Radiotherapy utilization increased with survival time. For 100 poor-prognosis patients that succumbed within 12 months, 57 courses of palliative radiotherapy were administered, whilst 100 patients that survived for 12-24 months were administered 114 courses (24-36 months, 148 courses). In conclusion, the use of palliative radiotherapy did not decrease when more effective systemic therapy was administered. However, provided that only 5% of patients received radionuclide treatment, additional studies in other populations are required.