Birgitt van Oorschot

Effects of Radiotherapy for Brain Metastases on Quality of Life (QoL)

Background:Prospective data on quality-of-life (QoL) effects of radiotherapy for brain metastases are currently lacking, but would be of great interest to guide therapeutic decisions.Patients and Methods:From 01/2007 to 08/2007, 46 patients with previously untreated brain metastases were recruited at eight centers. QoL was measured at start of treatment (T0) and at 3 months (T3mo). In the pilot study, two combinations of QoL instruments could be used at the discretion of the centers (A: EORTC QLQ-C30 and B: EORTC QLQ-C15-PAL both with brain module BN20, assessment by proxies with A: Palliative Care Outcome Scale, B: self-constructed brain-specific instrument).Results:All patients received whole-brain radiotherapy, four with an additional boost irradiation. At T3mo, 26/46 patients (56.5%) had died. 17/20 survivors (85%) completed the questionnaires. In 3-month survivors, QoL deteriorated in most domains, significant in drowsiness, hair loss and weakness of legs. The scores for headaches and seizures were slightly better after 3 months. Assessment by proxies also suggested worsening of QoL. Initial QoL at T0 was better in those alive than in those deceased at T3mo, significant for physical function and for the symptom scales of fatigue and pain, motor dysfunction, communication deficit and weakness of legs.Conclusion:Practicability and compliance appeared better with the (shorter) version B. This version is now used in the ongoing main phase of the study with additional centers. First results indicate a moderate worsening of QoL during the first 3 months after start of palliative radiotherapy for brain metastases. QoL at initiation of radiotherapy may be prognostic for survival.Hintergrund:Prospektive Daten über die Auswirkung einer palliativen Strahlentherapie auf die Lebensqualität (LQ) von Patienten mit Hirnmetastasen existieren nur wenige, jedoch sind sie von großem Interesse für Therapieentscheidungen.Patienten und Methodik:Von 01/2007 bis 08/2007 wurden an acht Zentren 46 Patienten mit bisher unbehandelten Hirnmetastasen rekrutiert (Tabelle 1). Die LQ vor und 3 Monate nach palliativer Strahlentherapie wurde erhoben. In der Pilotphase konnten die Zentren zwischen zwei Kombinationen von Instrumenten wählen (A: EORTC QLQ-C30 und B: QLQ C15-PAL jeweils mit Hirnmodul BN20, Fremdeinschätzung durch Angehörige mittels A: Palliative Care Outcome Scale, B: eigenen Hirnmoduls).Ergebnisse:Alle Patienten erhielten eine Ganzhirnbestrahlung, vier Patienten zusätzlich eine Boostbestrahlung. 3 Monate nach Therapiebeginn waren 26/46 Patienten (56,5%) verstorben. Die Rücklaufquote der Fragebögen der Überlebenden betrug 17/20 (85%). Für dieses Kollektiv der 3-Monats-Überlebenden zeigte die Selbsteinschätzung eine Verschlechterung in den meisten Bereichen, signifikant für Schläfrigkeit, Alopezie und Beinschwäche. Die Scores für Kopfschmerzen und Krampfleiden waren nach 3 Monaten etwas besser (Abbildung 1). Die Fremdeinschätzungen zeigten ebenfalls eine zunehmende Beeinträchtigung der Patienten nach 3 Monaten (Abbildung 2). Die initiale LQ war bei den 3-Monats-Überlebenden (Abbildung 3a) im Vergleich zu den Verstorbenen besser, signifikant für die körperliche Funktion und für die Symptomskalen Fatigue, Schmerz (Abbildung 3b), motorische Dysfunktion, Kommunikationsdefizit und Beinschwäche (Abbildung 3c).Schlussfolgerung:Die kürzere Fragebogenvariante B schien bezüglich der Praktikabilität und Compliance besser zu sein. Demzufolge wird diese Variante in der aktuell laufenden Hauptphase mit zusätzlichen Zentren verwendet (Abbildung 4). Erste Ergebnisse deuten auf eine mäßige LQ-Verschlechterung bei 3-Monats-Überlebenden hin. Möglicherweise könnte die initiale objektivierte LQ als prädiktiver Faktor herangezogen werden.

Prospective evaluation of quality of life effects in patients undergoing palliative radiotherapy for brain metastases

BackgroundRecently published results of quality of life (QoL) studies indicated different outcomes of palliative radiotherapy for brain metastases. This prospective multi-center QoL study of patients with brain metastases was designed to investigate which QoL domains improve or worsen after palliative radiotherapy and which might provide prognostic information.MethodsFrom 01/2007-01/2009, n=151 patients with previously untreated brain metastases were recruited at 14 centers in Germany and Austria. Most patients (82 %) received whole-brain radiotherapy. QoL was measured with the EORTC-QLQ-C15-PAL and brain module BN20 before the start of radiotherapy and after 3 months.ResultsAt 3 months, 88/142 (62 %) survived. Nine patients were not able to be followed up. 62 patients (70.5 % of 3-month survivors) completed the second set of questionnaires. Three months after the start of radiotherapy QoL deteriorated significantly in the areas of global QoL, physical function, fatigue, nausea, pain, appetite loss, hair loss, drowsiness, motor dysfunction, communication deficit and weakness of legs. Although the use of corticosteroid at 3 months could be reduced compared to pre-treatment (63 % vs. 37 %), the score for headaches remained stable. Initial QoL at the start of treatment was better in those alive than in those deceased at 3 months, significantly for physical function, motor dysfunction and the symptom scales fatigue, pain, appetite loss and weakness of legs. In a multivariate model, lower Karnofsky performance score, higher age and higher pain ratings before radiotherapy were prognostic of 3-month survival.ConclusionsModerate deterioration in several QoL domains was predominantly observed three months after start of palliative radiotherapy for brain metastases. Future studies will need to address the individual subjective benefit or burden from such treatment. Baseline QoL scores before palliative radiotherapy for brain metastases may contain prognostic information.

Palliative radiotherapy--new approaches.

Most cancer patients will require radiation therapy some time during their disease. Thirty percent to 50% of all radiation treatments are palliative, either to alleviate symptoms or prophylactic to prevent deterioration of quality of life from local progressive disease. Radiotherapy is a locally effective tool. It typically causes no systemic and mostly mild acute side effects. We will provide an overview of principles, decision-making, and new developments in palliative radiation therapy.

Patterns of Care and Course of Symptoms in Palliative Radiotherapy

AbstractBackground and Purpose:To evaluate patterns of care as well as effectiveness and side effects of palliative treatment in four German radiation oncology departments.Patients and Methods:All referrals in four German radiation oncology departments (two university hospitals, one academic hospital, one private practice) were prospective documented for 1 month in 2008 (2 months at one of the university hospitals). In palliatively irradiated patients, treatment aims and indications as well as treated sites and fractionation schedules were recorded. In addition, symptoms and side effects were analyzed with standardized questionnaires before and at the end of radiotherapy.Results:During the observation period, 603 patients underwent radiation therapy in the four centers and 153 (24%, study popu-lation) were treated with palliative intent. Within the study, patients were most frequently treated for bone (34%) or brain (27%) metastases. 62 patients reported severe or very severe pain, 12 patients reported severe or very severe dyspnea, 27 patients reported neurological deficits or signs of cranial pressure, and 43 patients reported a poor or very poor sense of well-being. The most frequent goals were symptom relief (53%) or prevention of symptoms (46%). Life prolongation was intended in 37% of cases. A wide range of fractionation schedules was applied with total doses ranging from 3–61.2 Gy. Of the patients, 73% received a slightly hypofractionated treatment schedule with doses of > 2.0 Gy to ≤ 3.0 Gy per fraction and 12% received moderate to highly hypofractionated therapy with doses of > 3.0 Gy to 8.0 Gy. Radiation therapy led to a significant improvement of well-being (35% of patients) and reduction of symptoms, especially with regard to pain (66%), dyspnea (61%), and neurological deficits (60%). Therapy was very well tolerated with only 4.5% grade I or II acute toxicities being observed. Unscheduled termination was observed in 19 patients (12%).Conclusions:Palliative radiation therapy is effective in reducing symptoms, increases subjective well-being, and has minimal side effects. More studies are necessary for subgroup analyses and for clarifying the different goals in palliative radiotherapy.ZusammenfassungZiel:Evaluation der Alltagspraxis, des Symptomverlaufs und akuter Nebenwirkungen bei palliativer Strahlentherapie in vier strahlentherapeutischen Einrichtungen.Patienten und Methode:Alle Erstvorstellungen in den vier Einrichtungen (zwei Universitätskliniken, ein Lehrkrankenhaus und eine private Praxis) wurden einen Monat lang im Jahr 2008 prospektiv dokumentiert und ausgewertet (über 2 Monate in einer der Universitätskliniken). Bei den palliativ bestrahlten Patienten wurden die Indikationen, Behandlungsziele, die bestrahlten Regionen, die Therapiekonzepte und der Behandlungsverlauf dokumentiert. Klinische Symptome und akute Nebenwirkungen wurden zu Beginn und bei Abschluss der Strahlentherapie standardisiert erfasst.Ergebnisse:Im Beobachtungszeitraum erhielten 603 Patienten eine Strahlentherapie. 153 Patienten (24%) wurden unter palliativer Zielsetzung bestrahlt, zumeist wegen Knochenmetastasen (34%) oder Hirnmetastasen (27%). Die häufigsten Behandlungsziele waren Symptomlinderung (53%) oder die Prävention klinischer Beschwerden (46%). 66 Patienten berichteten über mittlere oder starke Schmerzen zu Beginn, 12 Patienten berichteten über mittlere oder starke Dyspnoe, 27 Patienten über mittlere oder starke neurologische Ausfälle bzw. Hirndrucksymptomatik, und 43 Patienten berichteten über weniger gutes oder schlechtes Wohlbefinden. In 37% zielte die Strahlentherapie auch auf Lebensverlängerung. Die applizierte Gesamtdosis betrug 3–61,2 Gy. 73% der Patienten wurden mäßig hypofraktioniert bestrahlt (Einzeldosen > 2,0 Gy bis ≤ 3,0 Gy), und 12% der Strahlentherapien wurden mit Einzeldosen > 3,0 Gy–8,0 Gy durchgeführt. Das Allgemeinbefinden war bei 34% der Patienten bei Abschluss der Strahlentherapie signifikant gebessert. 66% der Patienten berichteten eine signifikante Schmerzlinderung, bei 61% konnte Dys-pnoe signifikant gelindert werden, und bei 60% besserten sich neurologische Defizite oder Hirndrucksymptomatik. Die Behand-lung wurde mit 4,5% Grd-I- bis -II-Toxizitäten gut vertragen. 19 Behandlungen wurden vorzeitig abgebrochen (12%).Schlussfolgerungen:Die Alltagspraxis und der Symptomverlauf wurden erfolgreich in der Routine dokumentiert. Die palliative Strahlentherapie war gut verträglich, nebenwirkungsarm und wirksam in Bezug auf das Allgemeinbefinden und die Symptomlinderung. Für Subgruppenanalysen und zur Abgrenzung der verschiedenen Endpunkte palliativer Strahlentherapie sind weitere Untersuchungen mit größeren Fallzahlen erforderlich.

Radiotherapeutic Options for Symptom Control in Breast Cancer

The majority of breast cancer patients will require radiation therapy at some time during the course of their disease. An estimated 30–50% of all radiation treatments are of palliative nature, either to alleviate symptoms or prophylactic to prevent deterioration of quality of life due to locally progressive disease. Radiotherapy is a locally effective tool, and typically causes no systemic and mostly mild acute side effects. The following article provides an overview of options and decision-making in palliative radiotherapy for symptom control.

SOP – Akuter Verwirrtheitszustand

Onkologe 2017 · 23:213–217 DOI 10.1007/s00761-017-0195-9 Online publiziert: 13. Februar 2017

Symptoms and Needs of Head and Neck Cancer Patients at Diagnosis of Incurability - Prevalences, Clinical Implications, and Feasibility of a Prospective Longitudinal Multicenter Cohort Study.

Background: Little is known about the physical symptoms and psychosocial burden of patients at the time of diagnosis of an incurable situation, although cancer treatment guidelines demand early assessment and integration of palliative care concepts, beginning from the diagnosis of incurability. Methods: Therefore, we initiated a prospective longitudinal multicenter cohort study assessing the symptoms and needs of patients suffering from incurable cancer (various entities), from the time of diagnosing incurability (i.e., before palliative anticancer treatment was initiated) and in 3-monthly intervals thereafter, by using validated self-reporting tools. Here, we focus on patients with head and neck cancer and present preliminary results on symptoms and need prevalences, on clinical implications, and on the feasibility of a methodologically complex assessment procedure in a particularly vulnerable study population. Results: 22 patients completed the first visit. The Eastern Cooperative Oncology Group (ECOG) performance scores and most physical symptoms and psychosocial items varied between the extremes, from a virtually uncompromised condition to extremely perceived symptoms and needs. If intense face-to-face study support was provided, the study concept proved to be feasible, despite the complexity of assessment, problems in interdisciplinary and patient communication, comorbidities, and early death from complications. Conclusions: The striking variability in the perceived symptom and need intensities requires a highly individualized approach. For clinical purposes, a less complex screening procedure would be desirable, in order to enable a routine, early and comprehensive support, including palliative care services.

Connections are clearly more complexy.

CME articles on palliative medicine are to be welcomed, since they are very important. In the article of Bausewein and Simon (1), the sections regarding drug treatment of palliative symptoms are appropriate and reflect the current state of knowledge. Unfortunately, the authors did not stringently adhere to their stated objective of restricting the recommendations to patients with refractory dyspnea (for example, in the title, in the defined learning objectives on page 564, and in the algorithm on page 567). It is not stated clearly enough that the cited evidence is from studies that explicitly included only patients in whom tumor specific treatments (chemotherapy, radiotherapy, or surgery) was no longer indicated or not sufficiently effective. From an oncological perspective, this limitation likely leads to considerable deficits, particularly regarding the care for patients in a palliative setting. The systematic evaluation of possible causes of dyspnea and cough is a crucial step towards the best possible treatment in the palliative setting. tThis is, for example, stated in the current US guidelines on palliative medicine published by the National Comprehensive Cancer Network (2). A plain chest x-ray (as suggested by Bausewein and Simon) will, for example, not be sufficient to detect pulmonary embolism, which is quite common in cancer patients, or malignant pericardial effusion. Another important issue not covered by this article is the administration of local treatments such as radiotherapy. Radiotherapy is well recognized as a very effective local treatment generally associated with only minor adverse effects in the treatment of tumor or metastasis related dyspnea, cough, or hemoptysis. Furthermore, the aspect of communication with the patients was not appropriately mentioned. As described in the Canadian guidelines on the relief of dyspnea, preventive treatment of dyspnea should be initiated before a patient displays symptoms, This can be achieved by using structured education programs for patients and by discussing effective, symptom oriented treatment measures that can be applied when the malignant disease is progressing (3). The process of multidisciplinary treatment decision making is mandatory in order to provide the most appropriate treatment approach for each individual cancer patient being in a palliative situation .Such a process requires a great expertise (4), which has been emphasized by the authors of this CME article. However, the authors have not mentioned important disciplines that can contribute very effectively to the relief of dyspnea in palliative cancer patients. The S3 guideline on palliative medicine that is currently under development will likely provide a more comprehensive perspective.

Frühe Mitbetreuung nichtheilbarer Krebspatienten durch Palliativteams bessert die Lebensqualität und fördert Gespräche über Versorgungswünsche am Lebensende

Hintergrund Die Auswirkungen einer integrierten palliativmedizinischen Mitbetreuung wurde bei Patienten mit neu diagnostiziertem, nichtheilbarem Lungenkrebs und gastrointestinalen Tumoren evaluiert. Primärer Studienendpunkt war die Veränderung der Lebensqualität innerhalb von 12 Wochen (T1, FACT-G-Scale). Sekundäre Endpunkte waren Veränderungen der Lebensqualität innerhalb von 24 Wochen (T2) sowie Veränderungen in den Depressionswerten (PHQ9) und Unterschiede in der Häufigkeit von Gesprächen mit den behandelnden Onkologen über Versorgungspräferenzen am Lebensende.

Use of standardized client simulations in an interprofessional teaching concept for social work and medical students: first results of a pilot study

ABSTRACT Teaching concepts with standardized clients/patients (SC) had been successfully implemented in the education of health professionals. Benefits were also demonstrated for social work education. Based on former experiences with simulated clients in medical education, we developed an innovative teaching concept for social work and medical students. We focused on the training of consultations with clients suffering from a serious illness like cancer—with different learning goals for medical students (e.g. breaking bad news) and social work students (e.g. psychosocial exploration and counseling). Both groups should gain knowledge about the other professions tasks and learn to handle clients’ emotional reactions. In addition to role-plays with simulated clients in small groups, the concept includes an interprofessional lecture by physicians, psychologists, social workers, and lawyers as well as a visit on the palliative care ward (for social work students only) and a research colloquium. A formative evaluation shows high satisfaction with the teaching concept. The students underline the realistic setting, interprofessional contact, authentic talks and direct feedback. The SC method and its interprofessional application proved to be a practicable and motivating way to enhance conversational skills.