Palliative Radiotherapy
“the active total care of
patients whose
disease is not responsive to
curative treatment ….” WHO
About 30-45 % of patients
receiving radiotherapy are
palliative
GOALS OF PALLIATIVE RT
control symptoms
 enhance quality of life
 optimize the patient’s limited
remaining time
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guided by basic ethical principles
and clinical based evidence
EMERGENCY
INDICATIONS:
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Spinal cord compression
Haemorrhage/bleeding
Superior Vena caval obstruction
Seizures/ Fitting
INDICATIONS
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Pain relief from bone mets.
Prevention of pathological #
Spinal cord compression.
Impending or actual obstruction hollow
viscera.
Brain mets.
Control of Haemorrhage.
Control of ulceration/ fungation.
Fraction
A single treatment session
Conventionally 1.8 – 2.0 Gy
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Hypofractionation
Fewer
fractions than conventional
Higher dose per fraction
Shorter treatment time
Increased probability of late effects
Decreased radiotherapy waiting times
Hypofractionation
clinical evidence suggests that shorter
fractionation schedules compared to
more protracted schedules have the
same effectiveness in symptom control
of incurable cancer patients,
particularly, for metastatic bone pain
and multiple brain metastases.
Bony Metastases
Bony mets can cause:
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Pain
Pathological fracture
Spinal cord compression
Hypercalcemia
Leading to debilitation and impaired
quality of life
External beam radiation provides
significant relief in 50-80% of patients
and complete pain relief in 30 % of
patients (ASTRO)
Factors affecting choice
of fractionation regimen
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Performance status
Prognosis
Risk for fracture or cord compression
Site to be treated
A literature review confirms similar rates of
pain control using a single fraction versus a
multiple fractions (50-85%). There are
however higher retreatment rates for single
fraction regimens.
Fractionation regimens
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8 Gy in 1 fraction
20 Gy in 5 fractions
30 Gy in 10 fractions
24 Gy in 6 fractions
Endpoints using pain relief, narcotic relief
and quality of life measures show consistent
similarity in the regimens
The frequency and severity of side
effects especially mucosal are a more
of a function of radiation planning than
radiotherapy dose
BRAIN METASTASES
Comparison of median survival in 7 studies using the recursive partitioning analyses
(RPA) classes (treatment was WBRT with or without local measures, none of the studies
is limited to one particular cancer type).
Clinical Recommendations of
DEGRO
Breast Care (Basel). 2010; 5(6): 401–407.
Published online 2010 December 8. doi: 10.1159/000322661
“Analysis of all included patients, SRS plus WBRT, did not
show a survival benefit over WBRT alone. However,
performance status and local control were significantly better
in the SRS plus WBRT group. Furthermore, significantly
longer OS was reported in the combined treatment group for
RPA Class I patients as well as patients with single
metastasis.”
Cochrane Database Syst Rev. 2010 Jun 16;(6):CD006121.
Whole brain radiation therapy (WBRT) alone versus WBRT and radiosurgery for the treatment of brain metastases
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conventional fractionation can be used
to avoid late neurotoxicity
dexamethasone is the corticosteroid of
choice for cerebral edema
anticonvulsants should not be
prescribed prophylactically
Spinal cord compression
Inform patients at high risk of
developing bone metastases, patients
with diagnosed bone metastases, or
patients with cancer who present with
spinal pain about the symptoms of
MSCC
(NICE)
Patients with cancer and any of the
following symptoms suggestive of spinal
metastases should seek medical attention
immediately for assessment:
• pain in the middle (thoracic) or upper
(cervical) spine
• progressive lower (lumbar) spinal pain
• severe unremitting lower spinal pain
• spinal pain aggravated by straining (for
example, at stool, or when coughing or
sneezing)
• localized spinal tenderness
• nocturnal spinal pain preventing sleep
Patient should be nursed flat with
neutral spine alignment (including ‘log
rolling’ with use of a bed pan for
toilet) until bony and neurological
stability are ensured and cautious
remobilisation may begin
For patients with MSCC, once any spinal
shock has settled and neurology is
stable, carry out close monitoring and
interval assessment during gradual
sitting from supine to 60 degrees over
a period of 3–4 hours
Offer conventional analgesia (including
NSAIDs, non-opiate and opiate
medication) as required to patients
with painful spinal metastases in
escalating doses as described by the
WHO three-step pain relief ladder
Offer patients with vertebral
involvement from myeloma or breast
cancer bisphosphonates to reduce pain
and the risk of vertebral
fracture/collapse
Unless contraindicated (including a significant
suspicion of lymphoma) offer all patients
with MSCC a loading dose of at least 16 mg
of dexamethasone as soon as possible after
assessment, followed by a short course of
16 mg dexamethasone daily while treatment
is being planned
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If surgery is appropriate in patients with
MSCC, attempt to achieve both spinal cord
decompression and durable spinal column
stability
Patients with MSCC who have been
completely paraplegic or tetraplegic for
more than 24 hours should only be offered
surgery if spinal stabilisation is required for
pain relief
There should be urgent (within 24
hours) access to and availability of
radiotherapy and simulator facilities in
daytime sessions, 7 days a week for
patients with MSCC requiring definitive
treatment or who are unsuitable for
surgery
Fractionation regimens
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8 Gy in 1 fraction
20 Gy in 5 fractions
30 Gy in 10 fractions
24 Gy in 6 fractions
Palliative radiotherapy a
slice of the palliative pie
Palliative radiotherapy
should be aimed as a “one
stop approach”
Factors affecting utilization
of palliative radiotherapy
services
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Poor performance status
Short predicted life expectancy
Access to radiotherapy centres
Limited oncology training of attending
physicians
Waiting time for radiotherapy