Course Of Palliative Radiotherapy Research Articles

Predicting Time of Remaining Life on Treatment During Palliative Radiotherapy: A Stratified Analysis of a Novel Palliative Use Ratio

To investigate factors associated with high proportion of remaining life spent receiving palliative radiotherapy (PRT) for three commonly utilized PRT regimens using a novel metric, the Palliative Use Ratio (PUR).We identified consecutive patients receiving PRT with 8 Gy in a single fraction (n = 207), 20 Gy in 5 fractions (n = 152), and 30 Gy in 10 fractions (n = 651) at the discretion of the treating clinician between 2014-2018. The number of days between PRT start and finish was calculated. This value was then divided by overall survival (OS, in days from start of PRT) to generate the PUR, which is summarized using median (interquartile range, IQR) and compared across various clinical factors using the Kruskal-Wallis test. Factors identified with a significance level P < 0.01 were included in a novel PUR Score (PURS). Each factor, if present, equals 1 point. This score was used to categorize and predict for high PUR across each fractionation scheme.A total of 1010 PRT courses were delivered. Baseline factors associated with fractionation included ECOG, PRT indication, prior PRT, chemotherapy, and treated site. The fractionation scheme chosen was ultimately associated with OS. Factors associated with increased PUR were included in the scoring system and stratified across 1, 5, and 10 fraction regimens, as outlined in the table below. For patients treated with 8 Gy in 1 fraction, low (0-1) v. high (2-5) PUR Score was associated with a median PUR of 0.01 v. 0.03 (P < 0.001). For those treated with 20 Gy in 5 fractions, low (0-1) v. high (2) PUR Score was associated with a PUR 0.05 v. 0.15 (P < 0.001). A three-tiered PUR Score categorization (low, 0-2; medium, 3-4; high, 5-6) predicted increased PUR in patients treated with 10 fractions: 0.06 v. 0.13 v. 0.23, respectively (P < 0.001). A high PUR Score predicted for an increased ratio of time on treatment to remaining life: 3% for 1 fraction, 15% for 5 fractions, and 23% for 10 fraction regimens.We describe a novel metric for evaluating the utility of three common PRT regimens that may assist with clinical decision-making. Single-fraction regimens are associated with low PUR. When considering 5 or 10 fraction regimens, the PUR Score identifies patients who may benefit from shorter courses of PRT, as those with a high PUR score spent a substantial proportion of their remaining life on treatment. Prospective, external validation is warranted.

Quality Assurance of Radiotherapy During the Covid-19 Pandemic: Impact on Peer Review in 14 Regional Cancer Centers Across Ontario

Purpose/Objective(s)Quality Assurance (QA) is an integral part of the delivery of Radiotherapy (RT). Peer review (PR) is an essential component of the QA process mandated by Cancer Care Ontario (CCO). The COVID-19 pandemic has caused significant disruptions to cancer care worldwide. We aimed to investigate PR rates across all regional cancer centers in Ontario during the pandemic.Materials/MethodsUsing a provincial database maintained by CCO, PR data regarding completed curative and palliative RT courses were reviewed from December 2014 to November 2020. Peer reviews reported completed in March 2020 onward were considered to be completed during the pandemic. The monthly PR rates of 2019 were used as a baseline comparator. Wilcoxon signed-rank test (two-tailed) was used to determine significance in PR rates and courses of RT delivered. A P-value of < 0.05 was considered significant.ResultsA total of 24,936 radical courses and 18,759 palliative radiotherapy courses were completed in Ontario during the first 8 months of the pandemic. We found no difference in the average number of RT courses the year prior compared to during the pandemic for radical (3117/month vs 3382/month, P = 0.078) or palliative courses (2344/month vs 2227/month, P = 0.195). PR rates of radical RT were significantly decreased compared to the previous 12-month time period 86.1% vs 88.5% (95% CI: 0.6%-4.6% P = 0.014). Palliative RT also had a decrease in PR from 61.7% to 56.6% (95% CI:1.4%-7.2%, P = 0.016). In the 2 immediate months following March 2020, there was a decrease of PR rates with radical RT PR rates nadiring at 83% and palliative RT nadiring a 53% PR rate, the lowest since April 2016 and January 2018 respectively. This trend quickly reversed and PR rates increased in subsequent months. Analysis by disease site indicated a significant decrease compared to the prior year in disease site-specific PR rates for radical courses within breast (87.8% vs 90.3%, P = 0.16) and gynecologic (76.9% vs 84.1%, P = 0.049) disease sites respectively. Lung, Head and Neck, Gastrointestinal and CNS sites had no significant differences in PR rates when compared to the preceding year.ConclusionPeer review rates had an initial decrease across regional cancer in both radical and palliative intent radiation. Overall, peer review rates remain modestly lower than the period immediately preceding the pandemic. All centers still maintained a high rate of PR during the initial 8 months of the COVID 19 pandemic.

Patient-Provider Communication, Decision-Making, and Psychosocial Burdens in Palliative Radiotherapy: A Qualitative Study on Patients’ Perspectives

ContextPatient-provider communication impacts how patients with cancer make decisions about treatment. ObjectivesTo examine patient perceptions of discussions, decision-making, and psychosocial burdens related to receiving palliative radiotherapy (RT), in order to inform best practices for communication about palliative RT. MethodsWe conducted an exploratory qualitative study using oral questionnaires and semi-structured interviews. Seventeen patients receiving their first course of palliative RT for lung or bone metastases at a comprehensive cancer center were interviewed. Patient interviews were transcribed verbatim and thematically analyzed using NVivo software. ResultsThemes that impacted patients’ decisions to initiate RT included a desire to minimize pain, optimism about what RT could provide for the future, perception of having “no other choice,” disappointment about cancer progression, and unfamiliarity with RT. Most patients preferred shared decision-making regarding RT initiation and reported patient empowerment, effective communication, and team collaboration as contributing to shared decision-making. Most patients preferred their physicians to make decisions about RT treatment intensity and described trust in their physicians, institutional reputation, and RT expertise as motivators for this preference. Patients who possessed a proactive decisional mindset about initiating RT as opposed to having “no other choice” were less likely to report experiencing psychosocial burdens. ConclusionMost patients prefer shared decision-making regarding RT initiation but prefer their radiation oncologists to make decisions regarding treatment intensity. Communication that empowers patients in their desired level of engagement for RT decision-making may help patients make informed decisions, contribute toward a proactive decisional mindset, and reduce their perception of psychosocial burdens.

Review of Palliative Radiation Therapy Patterns of Practice for Adrenal Metastases in British Columbia

The adrenal gland is a common site of metastasis in patients with advanced cancer, but it is rarely symptomatic. A subset of patients develop a complex pain syndrome with anorexia, nausea, and poorly localized visceral pain in the back, flank, or epigastric region. These symptoms can affect quality of life and are occasionally challenging to palliate. The role of palliative radiation therapy (PRT) in these patients is unclear. This population-based retrospective study evaluates PRT practices for patients with adrenal metastases and aims to describe treatment response and acute toxicity. Patients who received PRT to an adrenal metastasis between the years of 1985 and 2015 were identified in a provincial database. Patient demographics, tumor factors, symptom burden, radiation therapy prescriptions, and response to treatment were collected. Variables were summarized using descriptive statistics. The Kaplan-Meier test was used to assess survival. Factors associated with clinical response were evaluated using univariate and logistic regression analysis. Factors associated with survival were evaluated using univariate and Cox proportional hazards model. One hundred patients who received 103 separate courses of PRT were identified. The majority had a lung primary (82%). The most common baseline symptoms were pain (90%) and gastrointestinal upset (13%). Prescriptions ranged from 600 cGy in a single fraction to 4500 cGy in 25 fractions. Seventy percent of patients experienced an improvement in pain (either a complete or partial response). Forty-three percent of patients developed acute toxicity from treatment. Median survival was 3 months. Compared with other anatomic sites, conventional PRT is uncommonly delivered to adrenal metastases. Despite heterogeneity in tumor histology and radiation therapy prescriptions, treatment was associated with an overall pain response of 70%. Prophylactic antiemetics to decrease radiation-induced nausea are required before treatment. Given the poor prognosis of this population, short fractionations are indicated.

Palliative Radiation Therapy for Metastatic, Persistent, or Recurrent Epithelial Ovarian Cancer: Efficacy in the Era of Modern Technology and Targeted Agents

PurposeMetastatic, persistent, or recurrent epithelial ovarian cancer (MPR-EOC) remains a significant threat to patient mortality despite advances in novel targeted agents. Radiation therapy (RT) is often used as a palliative option. We report outcomes of a large series of MPR-EOC patients treated with modern palliative RT (PRT) in an era of novel systemic therapies. Methods and MaterialsA retrospective review was conducted of women treated with PRT for MPR-EOC between 2007 and 2019 at an academic institution. Clinical response rates were recorded at <1 month, 1 to 3 months, and >3 months. Radiographic responses were categorized by RECIST 1.1 criteria. Overall response rate (ORR) was the sum of complete and partial response. Linear regression analyses of baseline characteristics were conducted for statistical testing. ResultsEighty-six patients with PMR-OC received 120 courses of palliative RT. Median follow-up was 8.6 months. Median age was 61 (range, 22-82). Thirty-six percent of women received central nervous system (CNS)-directed RT. In addition, 43% received targeted therapies before RT. Clinical ORR within 1 month and at last follow-up for non-CNS lesions was 79% and 61% (69% and 88% for CNS lesions, respectively). High-grade serous lesions were more likely to have clinical response (P = .04). Biologically effective doses (BED) >39 Gy were associated with improved clinical response in CNS lesions (P = .049). Bony sites were associated with worse clinical (P = .004) response in non-CNS lesions compared with soft tissue or nodal sites. Acute or late grade 3+ toxicities with bevacizumab were low (8.7%/4.3%). ConclusionsPRT offers excellent rates of response for symptomatic patients with MPR-EOC within 1 month of treatment, with durable responses beyond 3 months. High-grade serous lesions were associated with improved response in all patients. Higher BED and soft tissue or nodal sites were associated with improved response in CNS and non-CNS patients, respectively. Acute or late toxicities with bevacizumab and PRT were low. Prospective investigation is warranted to determine the optimal PRT regimen.

Patterns of use of palliative radiotherapy fractionation for bone metastases and 30-day mortality

Background and purposeAdoption of single-fraction radiation therapy (SFRT) has not been universal in the palliative treatment of bone metastases, despite evidence supporting its safety and efficacy. The aim of this study was to assess SFRT use for bone metastases in New South Wales (NSW), Australia, and the rate of 30-day mortality (30DM). Materials and methodsThis is a population-based cohort of patients who received palliative radiation therapy (RT) for bone metastases (2009–2014), as captured in the NSW Central Cancer Registry. A logistic regression model was used to identify factors associated with fractionation type. The proportion of patients dying within 30-days from treatment start date was calculated. ResultsOf the 14,602 courses of palliative RT delivered for bone metastases, 30% were SFRT. SFRT was more likely to be delivered to older patients: ≥80 years (34%) versus < 60 years (28%). Patients with lower socioeconomic status (SES) (35%) were more likely to receive SFRT compared with higher SES (25%). SFRT delivered to patients from outer regional area of residence (34%) were higher compared to those from the major city (29%). The proportion of SFRT delivered to patients with comorbidities ≥2 (34%) was higher than patients with no comorbidity (29%). SFRT was associated with higher 30DM of 21% compared with 11% for multi-fraction RT (MFRT). ConclusionSFRT is underused for the treatment of bone metastases in NSW. This is an impetus to develop tools making SFRT obligatory in this setting unless there is good justification not to.

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

PurposeThe study objective was to investigate the effectiveness of palliative radiation therapy (RT) for patients with diffuse large B-cell lymphoma (DLBCL) and to identify factors, such as chemotherapy relapsed/refractory (R/R) disease, that may influence RT outcomes. Methods and MaterialsPatients with DLBCL who received palliative RT from 2001 to 2015 in British Columbia were reviewed for patient characteristics, treatment details, and outcomes. Univariable and multivariable analyses for response and local progression were performed. ResultsThree-hundred and seventy courses of palliative RT in 217 patients were identified. Median equivalent dose in 2 Gy fractions was 19 Gy (range, 2-42 Gy). Clinical and/or radiologic response occurred in 230 (83%) of the 276 courses with response data available. Local control following palliative RT at 6 months was 66.7%. On univariable analysis, R/R disease was not associated with lower clinical response rates but had higher risk of progression (hazard ratio [HR], 0.5; P = .040). On multivariable analyses, patients with R/R disease who did not require concurrent steroids had greater response compared with those who received upfront palliative RT (odds ratio, 3.5; P = .011). Response to first-line chemotherapy and smaller lesion size were associated with improved local progression rates (HR, 0.2; P < .001 and HR, 0.5; P = .020, respectively). RT dose fractionation factors were not significant on any analyses. ConclusionsPalliative RT for DLBCL is effective for symptom improvement, including in the chemotherapy R/R setting. Not requiring concurrent steroids, response to first-line chemotherapy, and smaller lesion size predicted better RT outcomes. There was no association between dose fractionation and response rates or local control to suggest that higher RT doses are more effective for palliation.

The Impact of Provider-Driven Serious Illness Conversations on Length of Palliative Radiotherapy for Bone Metastases

Patients receiving palliative radiotherapy (PRT) are more likely to receive other active treatments at the end of life, including mechanical ventilation and resuscitation. Delayed or inadequate communication between patients and clinicians can further contribute to treatment that is inconsistent with patient goals and priorities. Prior randomized data has demonstrated that use of a serious illness conversation (SIC) guide by providers yields more frequent, earlier, and higher quality patient-centered discussions at the end of life. The use of this guide was implemented broadly by our cancer center in 2017 and 2018. Given the comparable outcomes of various fractionation schemes for bone metastases (BM), we hypothesized the presence of a documented SIC would be associated with a reduced number of prescribed fractions for patients receiving PRT for BM. We performed a retrospective analysis of patients receiving PRT for BM with or without a documented SIC within 90 days of PRT. We compared patient-specific factors and outcomes (demographic variables, radiation treatment parameters, SIC factors, and median survival) between the two groups. Fisher’s exact and Wilcoxon Rank Sum tests were performed to examine differences between categorical and continuous variables, respectively. We used Kaplan-Meier analysis to analyze survival. A total of 378 courses of PRT were delivered to 300 patients with BM from 9/2017 to 2/2020. SICs were documented for 140 (37.0%) PRT courses delivered to 110 (36.7%) patients (SIC+). No SICs were documented for 238 (63.0%) PRT courses delivered to 190 (63.3%) patients (SIC-). Median age was 62 in the SIC+ cohort and 65 in the SIC- cohort. Patients receiving SICs were significantly more likely to be <70 years old, (76% vs. 63%, p = .012), receive total dose ≤20 Gy (74% vs. 55%, p<.001), receive course 3 or higher of RT (56% vs. 37%, p<.001), and be prescribed 2 or fewer fractions per course (29% vs. 19%, p = .043). Median survival did not significantly differ between the two groups (2.8 versus 2.4 months, p = 0.26). Of the SIC+, 62.1% were documented by Medical Oncologists versus 13.6% by Radiation Oncologists (ROs). Documented SIC was associated with shorter length of prescribed PRT for BM in a population whose median survival was <3 months. Incorporating SICs into PRT workflows may thus help align treatment decisions with patient priorities, minimize travel burden, and reduce cost of care. Importantly, as a majority (>60%) of patients did not have documented SICs and <15% of conversations were documented by ROs, there are clear opportunities to improve the rate of provider (especially RO) participation in SICs. Our study also demonstrates that patients receiving SICs were more likely to be younger, highlighting an opportunity to improve patient-clinician communication in older patients with advanced cancer.

Factors Associated with Early Termination of Palliative Radiotherapy in a Hospitalized Patient Cohort

Patients receiving inpatient palliative radiotherapy (RT) for symptomatic metastases may not complete their treatment course, often due to declining functional status. Established tools estimating life expectancy have variable success in assessing whether patients are likely to complete a course of palliative RT, especially in a hospitalized setting where patients have other acute medical concerns. We report on a retrospective analysis of hospitalized patients initiated on palliative RT to determine predictive factors associated with early treatment termination. A retrospective analysis of 76 consecutive inpatient palliative RT treatments from August 2017 to September 2019 at a single academic institution was performed. Baseline characteristics including age, sex, Eastern Cooperative Oncology Group (ECOG) performance status, cancer diagnosis, and RT site were recorded. Treatment features reviewed included hospitalized days prior to consultation, time from consultation to treatment delivery, and delays (defined as 1+ hour from planned simulation/treatment). Univariable logistic regression was used to determine whether any variables were associated with incomplete treatment delivery. The Benjamini-Hochberg correction method was used to control for the false discovery rate (FDR) with an adjusted p-value threshold of 0.20 to address the multiple testing issue. Median age of the cohort was 61 years (interquartile range (IQR) 45-71). 74% and 26% of patients were ECOG 1-2 and 3-4, respectively. 80% completed treatment, while 20% did not complete palliative RT. Of those who terminated RT early, a median of 10 (IQR 10-12) fractions were planned, but a median of 4 (IQR 2-4) fractions were ultimately delivered. 9 of 15 (60%) patients who terminated RT early either rapidly declined in performance status or electively stopped to transition to hospice. Of the factors evaluated, only increased time from consultation to first treatment (odds ratio 1.01, unadjusted p = 0.02, adjusted p = 0.16) was significantly associated with early RT termination. Median time from consultation to first treatment was 2.9 (IQR 1.2 – 6.0) days. Patients who terminated RT early died after median of 23 (IQR 13–33) days from initial consultation. A fifth of hospitalized patients were unable to complete palliative RT, the majority of whom rapidly declined in ECOG status and/or transitioned to hospice. Increased time from consultation to initial treatment was related to early RT cessation, potentially due to ongoing deliberations about whether to initiate RT, or due to acute complications impacting medical stability for treatment. Implementing earlier goals-of-care discussions and prioritizing shorter fractionation schema would be helpful at reducing the number of initiated RT courses which are not completed, as these treatments have low therapeutic potential.

Can Breast Cancer Receptor Status Predict Pain Response in Palliative Radiation for Bone Metastases?

Breast cancer receptor status is predictive for local control following adjuvant radiotherapy (RT). The impact of receptor status on the clinical response to palliative RT for metastatic disease is not known. The purpose of this study was to investigate the significance of estrogen/progesterone receptor (ER/PR) and human epidermal growth factor receptor 2 (HER2) status on the subjective response of palliative RT for patients with breast cancer bone metastases. A retrospective analysis was conducted of prospectively collected patient reported outcomes (PRO) for breast cancer patients treated with palliative RT for bone metastases from 2015 to 2017. The PRO questionnaire scored pain severity, level of function, and symptom frustration at baseline and at 4 weeks following palliative RT. Patients were identified as having at least a partial improvement in PRO (≥1 improvement in score) or complete improvement (final score = 0) or no improvement. Patient demographics, tumor characteristics, systemic treatment information, and RT characteristics were collected. Patients were divided into 4 cohorts for analysis: Luminal A (ER+, HER2-, grade I-II), Luminal B (ER+, HER2-, grade III), HER2-enriched (HER2+), and triple negative breast cancer (ER/PR-, HER2-). There were 376 breast cancer patients who underwent 464 courses of palliative RT for bone metastases. Radiotherapy included 216 multifraction courses (median dose 20Gy) and 248 single fraction courses (median dose 8Gy). The cohort comprised of: 275 patients with Luminal A, 114 with Luminal B, 46 with HER2-enriched, and 29 with triple negative disease. On multivariate analysis, triple negative breast cancer was associated with a lower rate of partial improvement (OR: 0.37, p = 0.030) and complete improvement (OR: 0.27, p = 0.037). Lower baseline score (OR:1.19, p<0.001) and multiple bone sites treated concurrently (OR: 2.33, p = 0.021) were associated with a higher rate of partial improvement. Use of multifraction RT, chemotherapy, and hormone therapy were not associated with improvement in PRO in the cohort as a whole. In a subgroup analysis of patients with triple negative breast cancer (n = 29), multifraction RT was associated with a higher rate of partial improvement PRO (OR:15.8, p = 0.022) and higher rates of partial and complete improvement in PRO pain-specific scores (OR:19.7, p = 0.012 and OR:12.9, p = 0.035, respectively). Palliative radiotherapy for breast cancer bone metastases was less effective for patients with triple negative disease, even when controlling for the use of systemic therapy and hormone therapy. In this cohort, multifraction radiotherapy was associated with higher rates of symptom relief. There may be a role for dose escalation in this cohort. Otherwise, single fraction radiotherapy was associated with similar rates of symptom relief when compared to multifraction regimens.

The radiotherapy utilization rate in pediatric tumors: An analysis of 13,305 patients

PurposeAlthough the radiotherapy utilization rate (RUR) is determined for most adult cancers, it is seldom reported in childhood tumors, particularly in low- and middle-income countries (LMIC) where the majority of pediatric cancer patients reside. This study aims to investigate the real-life RUR for pediatric tumors in a large LMIC center. Materials and methodsThe electronic files of patients treated at a single institution during 2010–2017 were reviewed and the RUR was defined as the percentage of patients who received at least one radiotherapy (RT) course from the total number of patients. ResultsA total of 4390 out of 13,305 pediatric cancer patients received at least one RT course with a RUR of 33%. The curative, salvage, and palliative RURs were 27.8%, 2%, and 5.7%, respectively. There was a considerable variation in the RUR between various tumors, ranging from 0% in choroid plexus papilloma and other rare tumors to 100% in intracranial germinoma. Moreover, the RUR varied among different stages within each tumor type. Overall, 753 patients received 920 palliative RT courses (range 1–9) at a median dose of 30 Gy. The most commonly irradiated metastatic sites were the bone (34%) and the brain (9.8%). ConclusionThis is the first analysis to provide valuable insights into the RUR for childhood tumors. Together with population-based pediatric cancer registries, this will help decipher pediatric RT needs and deficits. Additionally, the underutilization of palliative RT calls for multidisciplinary palliative care provision for pediatric cancer patients.

Perceptions of Prognosis and Goals of Care in Patients Receiving Palliative Radiation Therapy

There is a gap in literature describing how much patients expect or want their radiation oncology team to discuss short-term or long-term goals of treatment and overall prognosis. This information could be helpful for clinicians to tailor how they share information with patients. We aimed to gain insight into the experiences and perceptions of patients with advanced metastatic cancer surrounding palliative radiation therapy (RT). After obtaining Institutional Review Board (IRB) approval, in-depth semistructured interviews were conducted from 9/2016 to 10/2018 with 17 patients receiving their first course of palliative radiation therapy (RT). Patients were asked about RT decision-making, patient-provider communication, goals of care, and disease prognosis. Interviews were recorded and transcribed verbatim. NVivo was used to facilitate coding and complement qualitative content analysis. The median survival from time of metastatic diagnosis was 17.6 months (range: 1-46). When asked about goals of RT, content analysis revealed that 53% (9/17) of patients linked receiving palliative RT to improving their quality of life, however, 35% (6/17) believed RT would completely get rid of their tumor. Words that were used commonly throughout patient answers included alleviating pain (41%), cure (29%), and reducing tumor growth (24%). All patients reported they received their information about the goals of care from their medical teams. When asked about prognosis, 53% (9/17) said prognosis had been discussed with them, whereas 76.5% (13/17) said they were interested in information about prognosis. Among the patients interested in learning more about their prognosis, there was a strong preference for this information to come from their medical teams. More than half of patients accurately identified the goal of RT as improving their quality of life; however some patients believed that the palliative RT would cure their tumor. This highlights the ongoing gap in patient provider communication and the need for improvement in this area. Inaccurate perceptions of goals of treatment and prognosis may motivate some patients to pursue unnecessarily aggressive treatments, which could affect quality of life without improving survival. Referrals to radiation oncologists present a potential opportunity to reopen discussions on goals of care and prognosis to adjust patient expectations.

Developing an Algorithm to Identify Palliative Radiation Treatments: A Single-Institution 10-year Experience

The definition of palliative radiotherapy (RT) has been changing over the past 20 years as patients live longer and radiotherapy for durable local control is delivered more frequently, even in the setting of metastatic disease. As such, the role of palliative RT continues to expand with changing and emerging treatment paradigms. The University of Pennsylvania established a dedicated palliative RT service in 2012 and has delivered several thousand courses of palliative RT over the last 11 years. In spite of a checkbox for “curative” or “palliative” intent, these courses are not always clearly defined in our treatment planning software. The development of a database of patients treated with palliative RT will allow us to study trends in approach and the algorithm may help other institutions to similarly study patients treated with palliative radiation. We sought to design a large, single-institution retrospective database of patients treated with palliative RT using an algorithmic approach to define and capture such patients based on clinical and electronic medical record data. All non-pediatric RT courses delivered at the University of Pennsylvania from 2008-2019 were eligible for review. Clinical details available for each course from the Varian Aria database (Varian Medical Systems, Palo Alto, CA) were course number, course name, provider name, treatment modality (proton vs. photon), treatment intent (provider specified as palliative vs. curative, and often left blank), associated ICD diagnosis code, prescribed dose, number of initial fractions, and number of cone down fractions. We pre-specified a target 95% sensitivity for identifying non-curative courses to include in the database. We defined palliative RT as any course delivered with non-curative intent including any ablative courses for oligometastatic disease, treatment for recurrent disease, or dose-escalated courses for durable local control. Investigators initially reviewed 214 courses delivered in January 2017 and based on chart review identified which courses were administered with curative versus palliative intent. This was repeated for courses delivered in March and April 2017. In total 634 courses were initially classified. We developed initial rules to reflect treatment parameters indicating an RT course was definitely curative (18 rules), definitely palliative (21), likely curative (12), or likely palliative (6). These rules were run on additional months as test data sets and adjusted to yield a higher sensitivity in identifying non-curative courses. Crude analyses were then iteratively run to determine which order and combination of rules led to best sensitivity in identifying palliative courses compared to gold standard of manual review of each treatment course. Our algorithm parses treatment courses in the following stepwise fashion: 1) Exclude courses delivered for benign conditions indicated by diagnosis code 2) Isolate all courses indicated by physician as “palliative” intent and add to database. Based on chart review “curative” was not a reliable indicator of curative intent as we have defined it. 3) From remaining courses isolate all courses with course names including “liver” and “SBRT” (stereotactic body radiotherapy) lung for manual review. The intent of these courses could not be reliably determined from available clinical details. 4) From remaining, exclude all courses with 1 or more “definitely curative” indicators and 0 “definitely palliative” indicators. 5) From remaining, isolate all courses with 1 or more “definitely palliative” and 0 or 1 “definitely curative” indicators and include in database. 6) From remaining, compare sum of “likely palliative” indicators and if greater than sum of “likely curative” indicators, include in database. With this basic approach we screened 23,782 courses and according to the stepwise process above found 1) 5,301 palliative courses, 2) 2,415 requiring manual review, 3) 13,467 excluded as definitely curative, 4) 2,195 definitely palliative, and 5) 404 likely palliative. In sum 7,900 palliative courses would be included in the database, with potentially more after manual review of 2,415 courses of liver-directed RT or lung SBRT. We were able to use a small number of relevant clinical details to reliably classify a majority of RT courses as curative or non-curative in intent. In the evolving setting of oligometastatic/oligorecurrent/oligoprogressive disease, identification of which RT courses are “curative” is highly variable between providers. Manual review of RT courses and rule generation results in >95% identification of palliative RT courses, but we have yet to show if machine learning techniques can improve on our manually generated algorithm.

Abscopal effect of unirradiated lung nodules following radiotherapy alone in recurrent non-small cell lung cancer: a case report

: Abscopal effect is an intriguing phenomenon when tumor regression is observed at non-irradiated region distant from the primary irradiation site. Despite its popularity as a research topic (especially in combination with immunotherapy), seldom was the phenomenon observed when radiotherapy (RT) was the only treatment modality. Here we reported the case of a 67-year-old man with abscopal effect observed in the right lung lesions after RT to the recurrent left lung tumor. The patient was a case of metachronous early-stage squamous cell carcinoma (SqCC) of the head and neck and lung. He was otherwise healthy without any other underlying systemic disease, and had never received any medication or systemic treatment. The patient was diagnosed with early-stage left lower lobe SqCC and received postoperative adjuvant RT alone to the tumor bed. Bilateral lung tumor recurrence was observed after 6 months, and the patient completed RT alone to the left lung lesion. However, tumor regression was observed in the non-targeted right lung lesions. Interestingly, we noticed fluctuation in white blood cell (WBC) count around the course of palliative RT. We hope that this case can help secure physicians’ attention to the systemic effect RT alone can contribute.

Does a radiographer-led palliative radiotherapy pathway provide an efficient service for patients with symptoms of advanced cancer? The Northampton experience

AbstractAim:To investigate whether a radiographer-led radiotherapy pathway can provide an efficient service for patients requiring treatment for symptomatic skeletal metastases.Materials and Methods:A retrospective review of 425 courses of palliative radiotherapy was conducted. Data was analysed assessing diagnosis, dose/fractionation, time from referral to treatment, gender, age, inpatient/outpatient status and referring clinic location for radiographer- and clinical oncologist-led cohorts.Results:Patients aged ≥70 years were more likely to be planned by radiographers (n = 162/57, p &lt; 0·001). Patients were more likely to be treated with 8 Gy in single fraction than with 20 Gy in five fractions (n = 279/136, p = 0·012). The median referral to treatment time in 8-Gy single-fraction prescriptions was 3 days for radiographer-led versus 7 days for clinical oncologist-led cohorts. In all patients and in 20 Gy in five-fraction prescriptions, it was 4 versus 8 days. A comparison of all prescriptions (p &lt; 0·001), 8 Gy in single-fraction (p &lt; 0·001) and 20 Gy in five-fraction prescriptions (p = 0·001) showed radiographer-led procedures as enabling faster access to treatment in each category.Findings:A radiographer-led service can facilitate faster access to treatment than a clinical oncologist-led pathway for an appropriately selected patient caseload.

Results of the ADRRAD Trial of pelvic IMRT plus radium-223 in men with mHSPC metastatic to bone.

136 Background: Radiotherapy to the Prostate in mHSPC improves overall survival (OS) and Progression free survival (PFS) for patients with low-volume-disease[1]. Radium-223 in metastatic castration resistant prostate cancer (mCRPC) improves OS [2]. We conducted a prospective phase 1/2 clinical trial in mHSPC, testing the combination of with LHRHa, concurrent pelvic radiotherapy and radium-223. Methods: Thirty patients were recruited with mHSPC; they had a minimum of 3 bone metastases (majority had &gt; 20 bone mets), nil visceral metastases, PS0-1. Patients were encouraged to receive up front docetaxel. They were treated with ongoing LHRHa, pelvic radiotherapy aiming for 74Gy in 37 fractions to prostate PTV with 60Gy concomitantly delivered to pelvic nodal PTV. Concurrently, patients received radium-223, 55kBq/kg for 6 cycles q28 days; fraction 1 radiotherapy was synchronous with cycle 1 day 1 radium-223. Results: Median age was 63 years and 28 (93%) received at least 4 cycles of docetaxel. One patient received prostate only radiotherapy due to bowel constraints. Three patients had cycle 6 radium-223 omitted. At a median follow-up of 28 months, there have been 415 Adverse events, (3% Grade &gt;3), and 6 serious adverse events (SAEs) ( 2 episodes of UTI, 1 each of cystitis non-infective, cardiac chest pain, pyrexia and AKI). Commonest AEs by number were: leucopenia, neutropenia, and diarrhoea. Ten SSE’s have occurred including 8 courses of palliative radiotherapy for bone pain, 1 course of radiotherapy for impending MSCC and 1 pathological fracture. At median follow up 28.0 months, median biochemical PFS is 17.9 months, median OS not yet reached. Conclusions: This trial shows clear tolerability and promising early efficacy data requiring further exploration in a randomised phase 3 trial. Clinical trial information: 2014-000273-39.

Set-up variation in palliative radiotherapy: one versus three skin localisation marks

AbstractBackground:Accuracy and reproducibility of the patient’s position is crucial for successful delivery of radiotherapy (RT). Data on palliative patients’ set-up uncertainties are sparse. The aim of this study was to calculate set-up errors observed for palliative patients positioned using one skin mark (Group 1) versus three skin marks (Group 2) and to assess the accuracy of both approaches.Methods:Displacements in the left–right (L–R) and superior–inferior (S–I) directions were retrospectively analysed for 175 sites treated with a course of fractionated palliative RT. Population mean, systematic and random errors were calculated in both directions for patients positioned with one and three skin marks. Frequency of deviations was also examined for both groups.Results:The population mean, systematic and random errors for Group 1 and 2 for the L–R direction were 0·0, 4·4, 4·8 and 0·4, 3·1 and 3·3 mm, respectively, and in the S–I direction: 0·1, 3·4, 4·2 and 1·2, 2·7 and 3·3 mm, respectively. Frequency of images within the clinical tolerance of 5 mm was 47·1% for Group 1 and 65·9% for Group 2.Conclusion:Three skin marks are recommended for patients receiving a fractionated course of palliative RT, as it reduces set-up error, reduces the number of gross displacements (&gt;10 mm) and increases the number of displacements within the clinically acceptable tolerance of 5 mm.

Factors associated with time to palliative radiotherapy in an academic radiation oncology clinic.

56 Background: Palliative radiotherapy (PRT) is a common and effective modality for the relief of symptoms due to malignancy. Members of the supportive care team may be hesitant to refer for PRT due to concerns regarding timeliness of treatment and patient/caregiver time burden. The current structure of most radiation oncology clinics is not conducive to the delivery of timely PRT and few metrics aimed at quality improvement have been reported. Methods: We reviewed all courses of PRT delivered at our institution between January 2017 and December 2018. Hematologic/myeloma primary and postoperative cases were excluded. The dates of referral, consultation, PRT planning simulation, PRT start and end were recorded. An inherent delay was noted if PRT was purposefully delayed (workup, imaging). Time to PRT (TTPRT) was defined as the number of days between referral and start of PRT. A remaining life ratio (RLR) representing TTPRT as a proportion of survival from the time of referral, was developed as a practical metric to represent timeliness of PRT with respect to prognosis. Results: 338 courses of PRT were included from 67% outpatient and 33% inpatient referrals. Indications included pain (55%), neurologic deficits/brain metastases (23%), respiratory symptoms (10%), bleeding (6%) and other (7%). Median TTPRT was 13 d (IQR 4-19), comprised of: referral to consult (3 d), consult to simulation (4 d), and simulation to PRT (6 d). Factors associated with TTPRT included ECOG, PRT indication, site (non-spine bone, chest, or brain), outpatient referral and delay. TTPRT was not associated with age, gender, rural residence, distance to hospital, race, median household income, insurance or marital status. Of 229 patients who died, factors associated with increased RLR were outpatient referral (13% v. 5%), abdomen/pelvis treatment site (16% v. 9%) and delay (17% v. 8%). Conclusions: TTPRT is associated with patient, treatment, and systematic factors, some of which are associated with increased RLR, elucidating several opportunities for improvement. Based on these results, our group has established a dedicated Palliative Radiation Oncology Clinic focused on timely, quality PRT, the outcomes of which will be assessed prospectively.

Perceptions of prognosis and goals of care in patients receiving radiation therapy.

30 Background: We aimed to gain insight into the experiences and perceptions of patients with advanced metastatic cancer surrounding palliative radiation therapy (RT). Methods: In-depth structured interviews were conducted from 9/2016 to 10/2018 with 17 patients with bone or lung metastases receiving their first course of palliative RT. Patient answers about understandings of goals of care and disease prognosis were recorded and analyzed through qualitative content analysis. Medical records were reviewed to obtain demographic and clinical data. Results: The median age of patients was 64 years (range: 21-82). The median survival from time of metastatic diagnosis was 17.6 months (range: 1-46). When asked about goals of RT, qualitative analysis revealed that half (53%) linked receiving palliative RT to improving their quality of life, however 35% believed RT would completely get rid of their tumor. Words that were used commonly throughout patient answers included alleviating pain (41%), cure (29%), and reducing tumor growth (24%). All patients reported they received their information about goals of care from their medical teams. When asked about prognosis, 53% said prognosis had been discussed with them, whereas 76.5% said they were interested in information about prognosis. When asked “What do you believe lies ahead?,” about half (47%) expressed uncertainty about the future, while others (41%) were focused on the next steps in treatment. In the patients interested in learning more about their prognosis, there was a strong preference for this information to come from their medical teams. Conclusions: More than half of patients accurately identified the goal of RT as improving their quality of life, however some patients believed that the palliative RT would cure their tumor. This highlights the ongoing gap in patient provider communication and the need for improvement in this area. Inaccurate perceptions of goals of treatment and prognosis may motivate some patients to pursue unnecessarily aggressive treatments, which could affect quality of life without improving survival. Referrals to radiation oncologists present a potential opportunity to reopen discussions on goals of care and prognosis to adjust patient expectations.

Radiotherapy and Cardiovascular Implantable Electronic Devices – A Single-Institution Evidence-Based Guideline

Patients with cardiovascular implantable electronic devices (CIEDs) requiring radiation therapy (RT) are becoming increasingly common. Existing guidelines are based on recommendations from over two decades ago and focus on limiting the total dose to CIEDs to below a threshold. Since then, CIED and RT technologies have evolved. Thus, there is a need to revisit the monitoring and management policies of patients with CIEDs undergoing RT. A single institution retrospective review of patients with CIEDs who were treated with RT between February 2008 and July 2017 was conducted. Oncologic and cardiovascular data were collected from each patient’s medical record. Dosimetry data from each plan were reviewed. The incidence of CIED malfunction was recorded. We identified 362 treatment plans in 223 patients, 169 (75.8%) and 54 (24.2%) of whom had pacemaker and defibrillators, respectively. Most patients were treated with 6MV beams (79.3%). The most common treatment site was the thorax (43.6%). The most common treatment technique was intensity-modulated RT (IMRT; 32.9%). For 10 plans, the device was either directly in the beam path or immediately adjacent to the field edge, resulting in an average mean dose of 6.34 Gy (SD 7.98) and maximum dose of 20.47 Gy (SD 13.78) to the CIEDs. For another 20 plans, the device was <2.5 cm from the beam path, and the average mean and maximum dose to the device was 0.58 Gy (SD 0.36) and 2.22 Gy (SD 1.07), respectively. In total, only 2 (0.9%) patients with device events were identified. Both patients had pacemakers and were non-dependent. One patient developed atrial high rate during the beginning of the first treatment session. Another patient’s device was reset to backup mode after completing a course of palliative radiotherapy to the pelvis. Both were malfunctions that occurred at estimated doses that were below the historical 2 Gy threshold. Our findings highlight the rarity and stochastic nature of CIED malfunction during RT. The rare events were seen at doses below historical thresholds, while some devices tolerated a much greater dose without incident. Given these findings and following review of the literature, we propose an algorithm for risk stratification that is based on risk factors other than dose threshold. We stratify patients as high risk if any of the following criteria are met: beam energy ≥10 MV, device located ≤2.5cm to treatment field, device capable of defibrillation, and device-dependent. All high-risk patients are monitored with an electrocardiogram during each treatment and their device is interrogated weekly. All patients are assessed prior to and at completion of RT by a cardiologist trained in electrophysiology, at which time, their devices are interrogated. This simpler algorithm can guide clinicians in the management and monitoring of CIED patients undergoing RT.