Palliative Radiotherapy Regimens Research Articles

Are oral cancers effectively palliated with radiotherapy? Outcomes of treatment with a modified QUAD SHOT regimen.

This study assessed a palliative radiotherapy regimen using daily radiation over 4 days for three courses in inoperable head and neck cancers, emphasizing oral primary cancers. Retrospective data of 116 patients treated with a daily dose of 3.6-3.7 Gy in four fractions over 4 days to a total of three courses, with a 2-week gap after every course, were analyzed for survival outcomes. A subgroup analysis was done for oral cancer. Ninety-nine (85%) completed three courses. Overall subjective response rate was 77%. Median overall survival and progression-free survival were 12 months (95% confidence interval [CI]: 8-20) and 8 months (95% CI: 6-10), with numerically higher overall survival in oral cancer. The treatment was well tolerated, with no on-treatment hospitalization or grade 3-4 toxicities. The modified QUAD SHOT regimen is practical for palliation in head and neck cancers.

Palliative Quad Shot Radiation Therapy with or without Concurrent Immune Checkpoint Inhibition for Head and Neck Cancer.

Patients with recurrent and metastatic head and neck cancer (HNC) have limited treatment options. 'QuadShot' (QS), a hypofractionated palliative radiotherapy regimen, can provide symptomatic relief and local control and may potentiate the effects of immune checkpoint inhibitors (ICIs). We compared outcomes of QS ± concurrent ICIs in the palliative treatment of HNC. We identified patients who received ≥three cycles of QS from 2017 to 2022 and excluded patients without post-treatment clinical evaluation or imaging. Outcomes for patients who received QS alone were compared to those treated with ICI concurrent with QS, defined as receipt of ICI within 4 weeks of QS. Seventy patients were included, of whom 57% received concurrent ICI. Median age was 65.5 years (interquartile range [IQR]: 57.9-77.8), and 50% patients had received prior radiation to a median dose of 66 Gy (IQR: 60-70). Median follow-up was 8.8 months. Local control was significantly higher with concurrent ICIs (12-month: 85% vs. 63%, p = 0.038). Distant control (12-month: 56% vs. 63%, p = 0.629) and median overall survival (9.0 vs. 10.0 months, p = 0.850) were similar between the two groups. On multivariable analysis, concurrent ICI was a significant predictor of local control (HR for local failure: 0.238; 95% CI: 0.073-0.778; p = 0.018). Overall, 23% patients experienced grade 3 toxicities, which was similar between the two groups. The combination of QS with concurrent ICIs was well tolerated and significantly improved local control compared to QS alone. The median OS of 9.4 months compares favorably to historical controls for patients with HNC treated with QS. This approach represents a promising treatment option for patients with HNC unsuited for curative-intent treatment and warrants prospective evaluation.

Outcome of Hypofractionated Palliative Radiotherapy Regimens for Patients With Advanced Head and Neck Cancer in Tikur Anbessa Hospital, Ethiopia: A Prospective Cohort Study.

Head and neck cancers (HNCs) are the third most commonly treated cancer with radiation in Ethiopia. Most patients present with advanced stage and are not candidates for curative treatment. The objective of our study is to assess the outcome of hypofractionated palliative radiotherapy (RT) for advanced HNCs in a resource-limited setting. Patients with histology-proven advanced HNC candidates for hypofractionated palliative RT were enrolled. Three regimens were allowed: 44.4 Gy in 12 fractions, 30 Gy in 10 fractions, and 20 Gy in five fractions. Response to treatment was assessed at baseline and at 4 weeks after treatment completion. The Kaplan-Meier curve was used to measure the survival. Between January 2022 and January 2023, 52 patients were enrolled and 25 patients were eligible for outcome assessment. Index symptoms include pain, bleeding, dysphagia, respiratory distress, and others in 25, 13, 10, 6, and 17 patients, respectively. Complete relief of the top three symptoms include pain in 52% of patients, hemostasis in 84% of patients, and dysphagia in 30% of patients. Objectively, 64% of patients attained partial response. For 48% of patients, their quality of life (QoL) improved in one parameter of the physical scores. Moreover, 64% of patients showed improvement in three parameters. The global functional score improved in 80% of patients. One patient had grade 3 xerostomia. At the end of the study period, 44% of patients died. The median survival after radiation was 9 months (95% CI, 7.2 to 10.8). All palliative hypofractionated regimens used were effective in terms of symptom control, tumor response rate, and QoL, and were well tolerated. This makes it appropriate for our setup because the majority of patients require palliation.

Hypo-Fractionated Palliative QUADSHOT Radiotherapy and Concurrent CDDP in Patients with LAHNSCC: Toxicities and Clinical Outcomes

Shorter palliative hypo-fractionated radiotherapy regimens given concurrently with chemotherapy, preferably cisplatin (radiosensitizer), increase response rates with acceptable toxicity, leading to better compliance of patients with locally advanced squamous cell carcinoma of the head and neck (LAHNSCC) in whom late toxicities due to chemoradiotherapy are less relevant. This single institution prospective interventional phase II study was conducted with the goal of achieving high rates of locoregional control with acceptable treatment-related toxicity. In this prospective interventional phase- II study, 60 patients with LAHNSCC (treatment naive), the majority in stage IVB and ECOG PS ≤ 3, were treated with QUAD SHOT RT using the conventional 2D technique (14Gy in 4 fractions on 2 consecutive days twice daily with a 6-hour interval between the two fractions) and concurrent cisplatin (CDDP) at a dose of 6 mg/m2. This treatment was repeated at 4-week intervals for 2 additional cycles if tumor progression did not occur. The Kaplan-Meier method was used to determine survival probability for progression-free survival (PFS) and overall survival (OS). Descriptive statistics with number and percentage were used for each toxicity and tumor response at different time points. A P value of less than 0.05 was considered significant. In our study, all patients received at least one cycle of QUADSHOT chemoradiotherapy (CTRT), while 35 and 18 patients received the 2nd and 3rd QUADSHOT CTRT, respectively. Of the patients who completed the first cycle of QUADSHOT CTRT, 27 (45%) patients had a partial response (PR) and 22 (36.7%) had stable disease (SD). Of the patients who completed the second cycle QUADSHOT CTRT, 77.2% had SD, while 11.4% had PR and 11.4% had PD. After the 3rd QUADSHOT CTRT, 72.2% had SD, while 11.1% had PR and 16.7% had PD. The overall response rate (SD +PR) in our study was 81%, 88.6%, and 83% after the 1st, 2nd, and 3rd QUADSHOT CTRT, respectively. After the 3rd QUADSHOT CTRT, no patient showed grade 4 toxicity. Most patients had grade I/ II toxicities e.g., skin (grade I -83%), mucositis (grade II -50%), salivary gland toxicity (grade II -50%), grade I laryngitis (83.3%). Grade- III oral mucositis and pharyngitis were seen in 27% and 6.7% of patients, respectively. Median OS and PFS were 7.9 months and 6.2 months, respectively. Concurrent chemotherapy acts as a radiosensitizer and provides a synergistic effect when coupled with hypo-fractionated radiation, resulting in more effective control of locoregional disease in locally advanced head and neck tumors with acceptable toxicities. This study is hypothesis-generating and may serve as a basis for developing optimal CTRT regimens for patients with LAHNSCC who are not suitable for curative treatment.

Phase II Multi-Institutional Study of a Low-Dose (4 Gy) Palliative Response-Adapted Radiotherapy Regimen for Symptomatic Bone Metastases from Multiple Myeloma: Planned Interim Analysis of First 40 Patients

Painful bone lesions are common in patients with multiple myeloma (MM). Radiotherapy (RT) is effective in providing pain relief from MM bone lesions in over 80% of patients. There is no consensus as to the most effective dose or fractionation for palliation. Shorter courses of therapy are not only more convenient for patients, but they also have less impact on timing of systemic therapies. There is precedent for using 4 Gy in the palliation of lymphomas, which have similar radiosensitivity to myeloma. The primary objective of this trial is to determine whether treatment with a total dose of 4 Gy to a painful myeloma bone lesion achieves patient-reported pain reduction comparable to historical controls at 4 weeks. Patients with a known diagnosis of MM and a painful bone lesion that was not at the base of skull, in need of stabilization, or causing cord compression were treated with 4 Gy (2 Gy x 2 or 4 Gy x 1). Patients' pain was measured using the brief pain index (BPI) prior to treatment and at 2, 4, 8 weeks and 6 months following treatment. Pain response was determined by the international consensus on palliative radiotherapy and considered change in BPI and oral morphine equivalent dose (OMED). A planned interim analysis for futility was completed after 40 patients. Reirradiation with clinician choice regimens could be considered at ≥4 weeks following initial treatment for indeterminate pain response or pain progression. Forty patients were treated at 6 institutions between 2019 and 2022. Median age was 65 years with 40% women and 88% with an ECOG of 0-1. A complete response (CR) was defined as a BPI score of 0 with no concomitant increase in OMED. A partial response (PR) was defined as BPI reduction in 2 or more without analgesic increase, or an OMED reduction of 25% or more without an increase in pain. An indeterminate response (IR) was any response that is not captured by a CR, PR or pain progression. A CR was achieved in 48%, a PR in 38% of patients, an IR in 13% with 1 patient who refused participation. Pain response was achieved in 86% of patients. Seven patients (18%) requested reirradiation at ≥4 weeks. Median BPI at baseline and 4 weeks after RT for patients with CR, PR, and IR were 3.75 and 0, 4.00 and 1, and 5.25 and 4.75, respectively. Median change of BPI between baseline and 4 weeks after RT for all responders (CR and PR) was -3.25. The median PTV volume (cc) for patients with CR, PR and IR were 81, 140 and 226, respectively. Based on these results, the futility threshold was not met, and the recommendation by the DSMC is to continue the trial. In the first 40 patients who received 4 Gy palliation for painful bone lesions from multiple myeloma, there were 86% that had a pain response (48% CR, 38% PR). This low dose, response-adapted treatment, led to reirradiation in less than 20% of patients.

A Comparison of the Subjective Responses to Two Hypofractionated Palliative Radiotherapy Regimens in Patients with Locally Advanced Inoperable Head and Neck Cancer

Background: Patients with advanced head and neck cancers typically succumb to uncontrolled local disease. Even with aggressive therapy, median survival is about 12 months, and the five-year overall survival <20%. Radiation treatment used in palliative setting is an option for some patients who are not eligible for curative therapy. Palliative treatment aims to reduce cancer-related symptoms while causing the fewest side effects and toxicities as possible. Materials and Methods: After approval from the institutional ethical committee, a prospective randomised study was conducted on squamous cell carcinomas of locally advanced head and neck cancer patients treated with palliative radiotherapy. A total of 62 patients were chosen and randomly assigned (1:1) to one of two treatment groups. Patients in Arm-A received 40 Gy in 16 fractions of radiation therapy, while those in Arm-B received 30 Gy in 10 fractions. The primary goal was to evaluate the subjective responses in both arms, including pain, dysphagia, and bleeding. Results: Mean pain score after completion of radiotherapy was 4.69 and 3.65 in Arm-A and Arm-B respectively, with significant p-value of <0.001. The mean pain score 3 months after completion of treatment was 2.39 and 3.61 in Arm-A and Arm-B respectively, with significant p-value of <0.001. Comparing both the arms dysphagia relief at completion of treatment was higher in Arm-B compared to Arm- A with mean scores of 1.95 and 2.03 which was not significant. After 3 months, it was higher in Arm-A compared to Arm-B, which was also insignificant, while Arm A patients received significant relieve from dysphagia at completion of treatment and during follow-ups. Bleeding was not a significant factor in both the arms. Conclusion: Our study found for immediate pain relief, 30Gy/10 fractions was better, but for long-term relief, 40Gy/16 fractions was better. Alleviation of swallowing difficulties was seen in both regimens.

Locoregional control and toxicity following high-dose hypofractionated and accelerated palliative radiotherapy regimens in breast cancer

AimsFor patients with locally advanced primary/recurrent breast cancer, radiotherapy is an effective treatment for locoregional control. 36 Gy in 6 Gy once-weekly fractions is a commonly used schedule, but there are no data comparing local control and toxicity between 36 Gy delivered once-weekly versus accelerated schedules of multiple 6 Gy fractions per week. This retrospective study compared local control rates and acute and late toxicity in patients undergoing 30–36 Gy in 6 Gy fractions over 6 weeks versus more accelerated schedules over 2–3 weeks for an unresected breast cancer. Materials and methodsPatients who received 30–36 Gy in 6 Gy fractions to an unresected breast cancer ± involved lymph nodes between December 2011 and August 2020 were identified. Patients were grouped into once-weekly versus accelerated fractionation schedules. Response rates, local control and toxicity data were analysed. ResultsIn total, 109 patients were identified. The median follow-up duration was 46 months. Forty-seven patients (43%) received once-weekly fractions and 62 patients (57%) received accelerated fractionation schedules. There were no significant differences in baseline tumour characteristics between the groups. Eighty-seven per cent of patients had an objective (complete or partial) response (81% in the once-weekly group; 91% in the accelerated group). The median time to local progression was 23.5 months overall (95% confidence interval 17.8–29.2); 23.5 months (95% confidence interval 18.8–28.1) in the once-weekly group and 19.0 months (95% confidence interval 7.0–31.1) in the accelerated group (P = 0.99). Acute toxicity of any grade occurred in 75% of patients (76% in the once-weekly group; 74% in the accelerated group) and grade 3 toxicity occurred in 7% of patients (7% in the once-weekly group; 8% in the accelerated group). There were no associations between the groups and acute or late toxicity grade (P = 0.78 and P = 0.26, respectively), although one grade 4 late toxicity (skin radionecrosis) occurred in a patient who received five fractions a week and therefore this regimen is not recommended. Study limitations included a lack of statistical power analysis, the necessary grouping of all accelerated patients for analysis and a high rate of censored data. ConclusionThere were no apparent differences in response rate, time to local progression or toxicity between patients who received 30–36 Gy in 6 Gy fractions once-weekly compared with twice-weekly as palliative treatment for locally advanced breast cancer. This regimen appears to be a safe alternative and may be preferred by patients.

Use of split-course hypofractionated radiotherapy in palliative treatment of head and neck cancers: how does our regimen compare with others?

Abstract Introduction: Head and neck cancers (HNCs) are some of the commonest cases requiring palliative radiotherapy (PRT) in an Indian radiotherapy practice. A variety of PRT protocols have been explored with varying success. Methods: The study objective was to evaluate the efficacy and tolerability of a short-course hypofractionated PRT schedule in HNC patients in terms of symptom relief, tumour response, acute side effects and survival and to compare results with other PRT regimens. All patients received 30 Gy in 10 fractions over 2 weeks followed by another 20 Gy in 5 fractions after a 4 weeks gap. Results: Seventy-five percent of patients completed both phases of treatment. Symptom relief was seen in 71% (pain) to 76% (dysphagia) of patients. Tumour response was recorded in 73% of patients. At 12 months, the mean overall survival was 10·29 months for patients who responded to PRT compared to 7·87 months for those who did not. Results were comparable to other regimens reported in the literature, but no radiobiological advantage of a higher dose was discernible. Conclusions: Short-course hypofractionated PRT is effective in reducing tumour burden and relieving symptoms in HNC patients and possibly in lengthening survival. Selection of any schedule should be decided by treating oncologists based on clinical, logistic and socio-economic factors.

Short course palliative radiotherapy in advanced solid tumors: a pooled analysis (the SHARON project)

Previous trials showed the tolerability and efficacy of a palliative radiotherapy (RT) regimen (SHARON) based on the 4 fractions delivered in 2 days in different oncological settings. In order to identify possible predictors of symptomatic response, the purpose of this study is to perform a pooled analysis of previous trials. We analyzed the impact on symptomatic response of the following parameters: tumor site, histological type, performance status (ECOG), dominant symptom, and RT dose using the Chi-square test and Fisher’s exact test. One-hundred-eighty patients were analyzed. Median RT dose was 20 Gy (range: 14–20 Gy). The overall response rate was 88.8% (95% CI 83.3–92.7%) while pre- and post-treatment mean VAS was 5.3 (± 7.7) and 2.2 (± 2.2), respectively (p < 0.001). The overall response rate of pain, dyspnea, bleeding, dysphagia, and other symptoms was 86.2%, 90.9%, 100%, 87.5%, and 100%, respectively. Comparing the symptomatic effect based on the analyzed parameters no significant differences were recorded. However, patients with locally advanced disease showed a higher rate of symptomatic responses than metastatic ones (97.3% vs 83.0%; p = 0.021). Finally, the complete pain response rate was more than double in patients with mild to moderate (VAS: 4–7) compared to those with severe (VAS > 7) pain (36.0% vs 14.3%; p = 0.028). This pooled analysis showed high efficacy of the SHARON regimen in the relief of several cancer-related symptoms. The markedly and significantly higher complete pain response rate, in patients with mild-moderate pain, suggests early referral to palliative RT for patients with cancer-related pain.

Palliative Appropriateness Criteria: A Pragmatic Method to Evaluate the Suitability of Palliative Radiotherapy Fractionation.

Purpose: To describe a novel metric to aid clinical decision making between shorter versus longer palliative radiotherapy (PRT) regimens using objective patient factors. Materials and Methods: Patients receiving PRT at a single institution between 2014 and 2018 were reviewed. The time between PRT start and finish was calculated and divided by overall survival (in days from start of PRT) to generate the percent of remaining life (PRL). This value was compared across various clinical factors using the Kruskal-Wallis test. Factors identified with a significance level p < 0.01 were included in a novel Palliative Appropriateness Criteria Score (PACS) and were included in an online risk assessment tool to assist clinicians in patient-specific fractionation decisions. Results: Totally 1027 courses of PRT were analyzed. Median age was 64 years; Eastern Cooperative Oncology Group (ECOG) performance status was 3-4 in 22%. Primary malignancies included were lung (38%), breast (13.8%), prostate (9.3%), and other (39%). The indication for PRT was pain (61%), neurological (21%), or other (18%). Palliative regimens included 199 (19.4%) receiving single fraction, 176 (17.1%) receiving 2-5 fractions, and 652 (63.5%) receiving 10 fractions. Median follow-up was 83 days overall and 437 days for patients alive at last follow-up. Factors significantly associated with increased PRL (and included in the PACS) were male gender, ECOG 3-4, lung or "other" primary diagnosis (vs. breast or prostate), PRT indication (neurological dysfunction vs. pain/other), inpatient status, and extraosseous sites treatment. Death within 30 days was significantly associated with high-risk PACS categorization, regardless of fractionation scheme (p < 0.001). Conclusions: The PACS is a novel metric for evaluating the utility of PRT regimens to improve clinical decision making. Single fraction is associated with low PRL. When considering multifraction PRT regimens, the PACS identifies patients who may benefit from shorter courses of PRT and alternatively, low-risk patients for whom a more protracted course is reasonable. Prospective external validation is warranted.

Improving providers' survival estimates and selection of prognosis- and guidelines-appropriate treatment for patients with symptomatic bone metastases: Development of the Bone Metastases Ensemble Trees for Survival Decision Support Platform.

In the management of symptomatic bone metastases, current practice guidelines do not provide clear methodology for selecting palliative radiotherapy (RT) regimens based on specific patient and disease features. Decision support aids may offer an effective means for translating the complex data needed to render individualised treatment decisions, yet no such tools are available for use in this setting. Thus, we describe the development of the Bone Metastases Ensemble Trees for Survival-Decision Support Platform (BMETS-DSP), which aims to optimise selection of evidence-based, individualised palliative RT regimens. The Ottawa Decision Support Framework was used as the theoretical basis for development of BMETS-DSP. First, we utilised stakeholder input and review of the literature to assess determinants underlying the provider decision. Based on this assessment and iterative stakeholder feedback, we developed the web-based, provider-facing BMETS-DSP. Consistent with the underlying theoretical framework, our design also included assessment of decision quality using the International Patient Decision Aids Standards (IPDAS) certification checklist. Stakeholder input and review of 54 evidence-based publications identified the following determinants of the provider decision: estimated prognosis, characteristics of the target symptomatic lesion and the primary cancer type, consideration of alternative interventions, access to patient-specific recommendations, and patient preferences. Based on these determinants, we developed the BMETS-DSP that (1) collects patient-specific data, (2) displays an individualised predicted survival curve, and (3) provides case-specific, evidence-based recommendations regarding RT, open surgery, systemic therapy, and hospice referral to aid in the decision-making process. The finalised tool met IPDAS quality requirements. Preliminary results of a pilot assessment suggest impact of clinical outcomes. We describe the successful development of a provider-facing decision support platform to aid in the provision of palliative RT in better alignment with patient and disease features. Impact of the BMETS-DSP on decision outcomes will be further assessed in a randomised, controlled study.

What Did the Pandemic Teach Us About Palliative Radiation in Head and Neck Cancer?

Objective: To assess the feasibility and efficacy of palliative radiotherapy dose regimens for patients with locally advanced head and neck cancer. Methods: Fifty patients of previously untreated, inoperable, stage IVA and IVB squamous cell carcinoma of the head and neck, deemed unfit for radical treatment, were included in the study from May 2020 to June 2020. Two palliative radiotherapy regimens were used. First was a single fraction radiation with 8 Gy for patients with limited life expectancy and poor performance status, which was repeated after 4 weeks in case of good symptom relief. The second regimen was used for patients with good performance status and consisted of fractionated radiation with 30 Gy in 10 fractions over 2 weeks, which was followed by supplementary radiation with 25 Gy in 10 fractions over 2 weeks in patients with good symptomatic response at 2 weeks. Symptoms were assessed at baseline and at the end of 4 weeks after treatment completion using the numerical rating score. Patients were followed up for a median of 4.5 months and assessed for symptom control and overall survival. Results: Forty-eight patients completed treatment and were included for analysis. Of the 24 patients who received single fraction radiation, 13 (54.2%) were given the second dose. Improvement in pain and dysphagia were reported in 57.9% and 60% patients, respectively. A total of 55.5% noted decrease in size of the neck node. Twenty-four patients received fractionated radiation and 15 (62.5%) were given the second course after 2 weeks. Relief in pain and dysphagia was reported in 68.2% and 63.6% patients, respectively. There were no grade 3/4 toxicities. Symptom control lasted for at least 3 months in 30% of the patients who received single fraction radiation and 54.2% of the patients who received fractionated radiation. The estimated 6-month overall survival of the entire cohort was 51.4%. Conclusion: Judicious use of palliative radiation in advanced incurable head and neck cancers provides effective and durable symptom relief and should be used after careful consideration of patient prognosis, logistics of treatment, and goals of care.

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.

Effectiveness of two Palliative Radiotherapy Regimens (20 Gy in five fractions versus 8 Gy in one fraction) for Thoracic Spine Bone metastases. Experience of Saudi Arabia

Effectiveness of two Palliative Radiotherapy Regimens (20 Gy in five fractions versus 8 Gy in one fraction) for Thoracic Spine Bone metastases. Experience of Saudi Arabia

Palliative Radiotherapy During the Last Month of Life: Have COVID-19 Recommendations Led to Reduced Utilization?

The study aimed to evaluate practice changes in the time period of the early wave of the COVID-19 pandemic. This was a retrospective single institution study. We defined palliative radiotherapy (PRT) initiated before Saturday, March 14th as pre-COVID and PRT initiated later as during-COVID (through June 30th). National COVID-19 recommendations led to a significant decrease in PRT with 10 or more fractions, while re-irradiation and radiotherapy during the final 30 days of life were equally common before and after these recommendations had been issued in March 2020. Rapid adoption of modified PRT regimens was feasible. However, the challenge of overtreatment in the final phase of the disease, due to inaccurate survival prediction, persisted.

"Christie Regimen" palliative radiotherapy in advanced head-and-neck cancer: A single-center experience.

Relevance of aggressive treatment in advanced head neck squamous cell cancers(HNSCC) is debatable in view of expected poor outcome. Long treatment duration only adds up to the cost of treatment without any improvements in outcomes. To assess the outcomes of hypofractionated "Christie" palliative radiotherapy regimen in advanced HNSCC. Patients of advanced HNSCC registered from June 2015 to June 2019 were treated by parallel pair field technique on Cobalt60 machine (Theatron 780E) to total dose of 50 Gray/16 fractions over 3.2 weeks. Toxicity was scored using Radiation Therapy Oncology Group (RTOG) criteria and response was evaluated as per WHO criteria. Records of 110 patients of HNSCC with mean age of 56.19 years were analysed. Evaluation at 4-8 weeks after radiotherapy resulted in a complete response (CR) in 19.1%, partial response (PR) in 32.7%, stable disease (SD) in 29.1% and progressive disease (PD) in 3.6%, while 15.5% patients did not report for post treatment evaluation. Median progression free survival was 9.52 months (95% CI 5.9 - 13.1 months). The median overall survival was 12.7 ± 2.2 months (95% CI 8.2 - 17.2). Median time to progression after completion of radiotherapy was 84 days. Grade IV dermatitis and mucositis was encountered in 2.7% and 1.8% cases respectively, requiring hospitalization. Christie regimen for advanced HNSCC is a clinically viable option with acceptable outcomes in a resource constrained setting.

Palliation of advanced pelvic malignancies via quad shot regimen: A single institution experience

Objective: RTOG 8502 outlines a palliative external beam radiotherapy (EBRT) regimen commonly known as the Quad Shot, wherein cycles of 4 twice-daily treatments are delivered; here our goal is to review techniques used for Quad Shot delivery at our institution and outcomes.

Palliative Lung Radiotherapy: Higher Dose Leads to Improved Survival?

AimsChoosing the optimal palliative lung radiotherapy regimen is challenging. Guidance from The Royal College of Radiologists recommends treatment stratification based on performance status, but evidence suggests that higher radiotherapy doses may be associated with survival benefits. The aim of this study was to investigate the effects of fractionation regimen and additional factors on the survival of palliative lung cancer radiotherapy patients. Materials and methodsA retrospective univariable (n = 925) and multivariable (n = 422) survival analysis of the prognostic significance of baseline patient characteristics and treatment prescription was carried out on patients with non-small cell and small cell lung cancer treated with palliative lung radiotherapy. The covariates investigated included: gender, age, performance status, histology, comorbidities, stage, tumour location, tumour side, smoking status, pack year history, primary radiotherapy technique and fractionation scheme. The overall mortality rate at 30 and 90 days of treatment was calculated. ResultsUnivariable analysis revealed that performance status (P < 0.001), fractionation scheme (P < 0.001), comorbidities (P = 0.02), small cell histology (P = 0.02), ‘lifelong never’ smoking status (P = 0.01) and gender (P = 0.06) were associated with survival. Upon multivariable analysis, only better performance status (P = 0.01) and increased dose/fractionation regimens of up to 30 Gy/10 fractions (P < 0.001) were associated with increased survival. Eighty-five (9.2%) and 316 patients (34%) died within 30 and 90 days of treatment, respectively. ConclusionIn this retrospective single-centre analysis of palliative lung radiotherapy, increased total dose (up to and including 30 Gy/10 fractions) was associated with better survival regardless of performance status.

Effect of Hypofractionated, Palliative Radiotherapy on Quality of Life in Late-Stage Oral Cavity Cancer: A Prospective Clinical Trial.

Context:The study was designed to evaluate the effect of a hypofractionated, palliative conformal radiotherapy regimen of 5250 cGy in 15 fractions in inoperable/incurable oral cavity carcinoma.Aims:The primary objective was to assess the change in the quality of life (QOL) with respect to pain and mouth opening pre- and post-radiotherapy using standardized questionnaires. The secondary objective was to assess overall QOL using the same questionnaires and also to assess response rates, survival, compliance, early and late toxicity.Settings and Design:This was a single-arm, prospective trial. Patients with incurable oral cavity cancer referred for palliative intent radiotherapy to the Department of Radiotherapy, RCC, JIPMER were recruited into the study.Subjects and Methods:Forty-eight patients were recruited and twenty-five patients were given conformal radiotherapy to a dose of 52.5 Gy in 15 fractions. QOL was assessed using the European Organization of Research and Treatment of Cancer (EORTC) questionnaires before and 2 months after the completion of radiotherapy. The response assessment was made using the Response Evaluation Criteria in Solid Tumors (RECIST) criteria 2 months after radiotherapy. The early and late toxicities were assessed at 2 months and 6 months after radiotherapy completion, respectively.Statistical Analysis Used:Sample size was calculated to be 53. The Wilcoxon signed-rank test was used to compare QOL scores pre- and post-radiotherapy. Median survival was assessed using the Kaplan–Meier method.Results:There was a significant improvement in the pain, mouth opening, speech, social contact, social eating, felt ill items of the EORTC QLQ-H and N35 questionnaire and role functioning, emotional functioning, social functioning, fatigue, pain, insomnia, appetite loss, financial difficulties, and Global QOL subscales of the QLQ-C30 questionnaire. 72% of the patients had grade 3 acute radiation oral mucositis and 36% had grade 3 acute radiation dermatitis. There were no significant treatment breaks due to toxicity. There were no grade 3 late toxicities observed. Overall median survival was 5.1 months. The overall response rate was 47%. The median time to treatment completion was 24 days.Conclusions:The improvement in QOL parameters suggests that the regimen of 52.5 Gy in 15 fractions is suitable for palliative intent radiotherapy in late-stage oral cavity cancer for effective palliation for short periods.

Palliative head-and-neck radiotherapy with cyclical hypofractionated radiotherapy (Quad Shot): A single-institutional experience

Background: This study aims to report on our institutional experience of palliative radiotherapy (RT) in the locally advanced head and neck by cyclical hypofractionated RT (Quad Shot) which is a short-course palliative regimen with good patient compliance, low rates of acute toxicity, and good response rates. Objectives: The objectives of the study were to review the use of the Quad Shot technique at our institution to quantify the palliative response in locally advanced head-and-neck cancer. Materials and Methods: Between April 2017 and July 2019, 45 patients with biopsy-proven squamous cell carcinoma of the head-and-neck region at the Department of Radiotherapy, Nil Ratan Sircar Medical College, Kolkata, which were deemed to be fit for palliative RT by departmental tumor board were given cyclical hypofractionated palliative RT as 14 Gy in four fractions over 2 days, twice daily, repeated every 4 weeks for a maximum of 3 cycles. Retrospective assessment was done for improvement in pain and dysphagia and also response to treatment. Results: Pain response occurred in 66.7% of the patients. The mean pain scores decreased significantly from pre- to post-treatment, 47.4 to 21.5 (P < 0.0001). The mean initial dysphagia score improved from 21.9 to 38.2 (P = 0.0002). About 60% of patients developed mucositis (≤ Grade 2), while no Grade 3 mucositis was reported. A total of 30 patients had partial response (66.67%) and 6 patients had stable disease. However, a total of nine patients had progressive disease which included those patients that were given fewer courses of Quad Shot. Conclusion: In locally advanced head-and-neck cancer patients particularly with poor performance status or elderly patients who are in dire need of some form of local therapy for symptom control and palliation, the hypofractionated palliative RT regimen (Quad Shot) offers an effective and quick treatment option which is beneficial both clinically and in logistics issue.