Palliative Radiotherapy for the Management of Metastatic Cancer
Life expectancy and tumor characteristics should be considered when making treatment recommendations for palliative radiotherapy, which can be cost-effective and provide symptom relief.
Dr. Gutt is a radiation oncologist at the Washington DC VAMC. Dr. Dawson and Dr. Cheuk are radiation oncologists at the James J. Peters VAMC in the Bronx, New York, and assistant professors at Mount Sinai School of Medicine in New York. Dr. Kelly and Dr. Dawson are radiation oncologists at the New Jersey VAHCS in East Orange, New Jersey. Dr. Fosmire is a radiation oncologist at the Richard L. Roudebush VAMC in Indianapolis, Indiana. Dr. Moghanaki is a radiation oncologist at the Hunter Holmes McGuire VAMC and an assistant professor at Virginia Commonwealth University Massey Cancer Center, both in Richmond, Virginia. Dr. Jolly is a radiation oncologist at the VA Ann Arbor HCS in and an associate professor at the University of Michigan, Ann Arbor.
References
In recent years, there has been increasing interest in palliative care for patients with cancer at the end of life. Up to 23% of patients have metastatic disease at presentation, and symptoms from metastatic lesions can cause significant anxiety and impair patients’ quality of life (QOL). 1
Palliative radiotherapy (RT) plays a valuable role in the management of metastatic disease to relieve tumor-related symptoms. Although palliative RT does not provide a chance for a cure, it improves QOL and may prolong survival time. 2-4 An estimated 20% to 50% of radiation courses are prescribed with palliative intent, because RT is highly effective in providing symptom relief, and the toxicity associated with palliative doses is typically mild. 5,6 Palliative RT can be used to manage bone and brain metastases, prevent or treat spinal cord compression, and manage numerous tumor-related symptoms, such as pain and bleeding in patients with terminal cancer.
Palliative RT for bone and brain metastases is supported by high-quality evidence and is considered one of the most effective and cost-effective options available. 7,8 This article aims to review the role of RT in treating 3 conditions commonly encountered in patients with metastatic disease—bone metastases, spinal cord compression, and brain metastases—and to emphasize the importance of timely integration of RT for optimal results.
Bone Metastases
About 80% of patients with metastatic solid tumors develop bone metastases, and about 350,000 deaths are linked to bone metastases in the U.S. each year. 9 Osseous metastases can lead to pain, fracture, hypercalcemia, and spinal cord compression. The primary modality for treatment of pain and prevention of morbidity from bone metastases is external beam RT. 10
The likelihood of bone pain relief with palliative RT is 60% to 80%, and 30% to 40% of patients achieving complete pain relief. Randomized studies have shown multiple-dose and fractionation regimens provided effective symptom relief for bone metastases. Most commonly used regimens include a single fraction of 8 gray (Gy) delivered in 1 treatment, 20 Gy in 5 fractions delivered daily over 1 week, and 30 Gy in 10 fractions delivered over 2 weeks. Treatment with a single fraction improves access to treatment and patient convenience, whereas more prolonged courses have been associated with lower rates of retreatment. 11,12 Regarding the higher rate of retreatment with single-fraction RT, no clear evidence exists that this is due to a less durable pain response or lower level of pain relief. 13
There has been recent interest in using predictive models to estimate life expectancy to avoid long courses of RT at the end of life. 14,15 Shorter treatment courses of 8 Gyonce or 20 Gy in 5 fractions are particularly valuable for patients with a life expectancy < 3 months to avoid long courses of treatment, and thereby improve QOL as patients transition into hospice. A recent survey demonstrated that 93% of radiation oncologists within the VHA are willing to prescribe short courses of RT consisting of ≤ 6 fractions, and 76% have experience with single-fraction RT. 16 These findings are in contradiction to the findings in the non-VA radiation oncology community, in which < 10% of patients with uncomplicated bone metastases are treated with a single fraction. 17,18
