Brita Danielson

Quality of Life in Patients With Brain Metastases Using the EORTC QLQ-BN20+2 and QLQ-C15-PAL

PURPOSEnThe 20-item European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire-Brain Neoplasm (QLQ-BN20) is a validated quality-of-life (QOL) questionnaire for patients with primary brain tumors. The European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire-Core 15 Palliative (QLQ-C15-PAL) core palliative questionnaire is a 15-item version of the core 30-item QLQ-C30 and was developed to decrease the burden on patients with advanced cancer. The combination of the QLQ-BN20 and QLQ-C30 to assess QOL may be too burdensome for patients. The primary aim of this study was to assess QOL in patients before and after treatment for brain metastases using the QLQ-BN20+2 and QLQ-C15-PAL, a version of the QLQ-BN20 questionnaire with 2 additional questions assessing cognitive functioning that were not addressed in the QLQ-C15-PAL.nnnMETHODS AND MATERIALSnPatients with brain metastases completed the QLQ-C15-PAL and QLQ-BN20+2 questionnaires to assess QOL before and 1 month after radiation. Linear regression analysis was used to assess changes in QOL scores over time, as well as to explore associations between the QLQ-BN20+2 and QLQ-C15-PAL scales, patient demographics, and clinical variables. Spearman correlation assessed associations between the QLQ-BN20+2 and QLQ-C15-PAL scales.nnnRESULTSnAmong 108 patients, the majority (55%) received whole-brain radiotherapy only, with 65% of patients completing follow-up at 1 month after treatment. The most prominent symptoms at baseline were future uncertainty (QLQ-BN20+2) and fatigue (QLQ-C15-PAL). After treatment, significant improvement was seen for the QLQ-C15-PAL insomnia scale, as well as the QLQ-BN20+2 scales of future uncertainty, visual disorder, and concentration difficulty. Baseline Karnofsky Performance Status was negatively correlated to QLQ-BN20+2 motor dysfunction but positively related to QLQ-C15-PAL physical functioning and QLQ-BN20+2 cognitive functioning at baseline and follow-up. QLQ-BN20+2 scales of future uncertainty and motor dysfunction correlated with the most QLQ-C15-PAL scales, including overall QOL (negative association) at baseline and follow-up.nnnCONCLUSIONnAfter radiation, the questionnaires showed maintenance of QOL and improvement of QOL scores such as future uncertainty, which featured prominently in this patient population. It is proposed that the 37-item QLQ-BN20+2 and QLQ-C15-PAL, as opposed to the 50-item QLQ-BN20 and QLQ-C30, may be used together as a universal QOL assessment tool in this setting.

Beyond palliative radiotherapy: a pilot multidisciplinary brain metastases clinic

PurposeThe purpose of this study is to determine the feasibility of a multidisciplinary palliative radiotherapy clinic for patients with brain metastases.MethodsWe designed a 6-month pilot Rapid Access Palliative Radiotherapy Program (RAPRP) brain metastases clinic. The main goals of the clinic were: (1) to provide timely consultation and treatment, (2) to provide multidisciplinary assessment and care, (3) to facilitate accrual of patients to research studies, and (4) to be a positive experience for patients. Team members included a radiation oncologist, radiation therapist, nurse practitioner, social worker (SW), occupational therapist (OT), and registered dietitian (RD). Patients underwent multidimensional assessment with patient-reported questionnaires and completed a patient satisfaction survey. Data were collected in a prospective database and collated in a standardized fashion with descriptive statistics recorded as percentages, medians, and ranges.ResultsThe pilot brain metastases clinic ran weekly from August 5, 2009 to January 27, 2010. In total, 33 patients were seen. The median time from referral date to clinic date was 6xa0days, with 76% of patients seen within 1xa0week. Most patients (94%) started their radiotherapy on clinic day. Fifteen patients (45%) required assessment by a SW, 36% by an OT, and 33% by a RD. Ninety-one percent of patients participated in a research study. Eighty-six percent of patients reported being very satisfied with the clinic experience, and 97% would recommend the clinic to a patient in a similar situation.ConclusionsThe pilot RAPRP Brain Metastases Clinic was successful in providing patients with timely and multidisciplinary care and will continue beyond the pilot phase.

Comparative multidisciplinary prediction of survival in patients with advanced cancer

PurposeThe expected survival of patients with metastatic cancer can significantly impact decisions regarding treatment, care setting, and future planning. We evaluated the prognostication ability of a multidisciplinary team (MDT) experienced in providing supportive care and palliative radiotherapy.MethodsAfter clinical assessment of consecutive patients, survival predictions were independently made by each MDT member. Patient demographics, factors influencing predictions, and dates of death were collected. Clinical predictions of survival (CPS) were considered correct if within 30xa0days of actual survival (AS). Summary statistics and Kaplan–Meier estimates of overall survival were obtained. Correlations between actual and CPS were calculated using Spearmans correlation coefficient. Multivariate logistic regression analysis identified factors associated with prognostication accuracy.ResultsA total of 395 predictions (06/2010–07/2012) were made by eight disciplines. Average age was 68xa0years, 68.3xa0% of patients were male, and 48.4xa0% had lung cancer. Median AS was 87xa0days (95xa0% CI 66–102xa0days). Survival was over-estimated 72.4xa0% (286/395) of the time with ru2009=u20090.54 (pu2009<u20090.0001) for all predictions across all disciplines. In addition, 30.3xa0% (36/119) of radiation therapist (RTT) predictions were correct compared to 30.1xa0% (22/73) of nurses, 28.7xa0% (43/150) of physicians, and 15.1xa0% (8/53) of allied health (AH) providers. There were no differences in accuracy by discipline except for the RTT versus AH groups (pu2009=u20090.04). Factors most frequently cited as influencing correct predictions were Karnofsky performance status (KPS), extent of disease, and histology. KPS was the only significant variable on multivariate analysis (pu2009≤u20090.04).ConclusionMDT members providing collaborative care for advanced cancer patients utilize similar factors in predicting survival with comparable accuracy.

Physical activity interests and preferences of cancer patients with brain metastases: a cross-sectional survey

BackgroundPhysical activity has been shown to positively impact cancer-related fatigue, physical functioning and quality of life outcomes in early stage cancer patients, however its role at the end stage of cancer has yet to be determined. Brain metastases are amongst the most common neurological complications of advanced cancer, with significant deterioration in fatigue and quality of life. The purpose of the present study was to examine the physical activity interests and preferences of cancer patients with brain metastases initiating palliative whole brain radiotherapy.MethodsThirty-one patients aged 18xa0years or older, cognitively intact, diagnosed with brain metastases, and with Palliative Performance Scale scores of greater than 30xa0%, were recruited from a multidisciplinary outpatient brain metastases clinic. An interviewer-administered survey was used to assess physical activity interests and preferences of participants who were embarking upon palliative whole brain radiotherapy.Results87xa0% (nu2009=u200927) of participants felt that physical activity was important, however there was limited interest in participating in a structured program at the onset of palliative whole brain radiotherapy. Lung cancer diagnosis was associated with being less interested in participating in a physical activity program, and feeling less able to participate in a physical activity program at the onset of palliative whole brain radiotherapy.ConclusionsCancer patients with brain metastases demonstrate limited interest and varied preferences for physical activity during palliative whole brain radiotherapy. Additional pilot work with this patient population is needed before physical activity interventions can be tested in clinical research.

Minimal clinically important differences in the EORTC QLQ-BN20 in patients with brain metastases

IntroductionQuality of life (QOL) is an important treatment endpoint in advanced cancer patients with brain metastases. In clinical trials, statistically significant changes can be reached in a large enough population; however, these changes may not be clinically relevant.ObjectiveThe objective of this study was to determine the minimal clinically important difference (MCID) for the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire brain module (EORTC QLQ-BN20) in patients with brain metastases.MethodsPatients undergoing radiotherapy for brain metastases completed the EORTC QLQ-BN20 and QLQ-C30/C15-PAL at baseline and 1-month follow-up. MCIDs were calculated for both improvement and deterioration using anchor- and distribution-based approaches. The anchor of overall QOL (as assessed by question 30 or question 15 on the QLQ-C30 and QLQ-C15-PAL, respectively) was used to determine meaningful change.ResultsA total of 99 patients were included. The average age was 61xa0years, and the most common primary cancer sites were the lung and breast. Statistically significant meaningful differences were seen on two scales. A decrease of 6.1 (95xa0% confidence interval (CI) 0.8 to 11.4) units and 13.8 (0.2 to 27.4) units was required to represent clinically relevant deterioration of seizures and weakness of legs, respectively. Distribution-based MCID estimates tended to be closer to 0.5 SD on the EORTC QLQ-BN20.ConclusionUnderstanding MCIDs allows physicians to determine the impact of treatment on patients’ QOL and allows for determination of sample sizes for clinical trials. Future studies should be conducted to validate our findings in a larger population of patients with brain metastases.

Content validation of the EORTC QLQ-BN20+2 with patients and health care professionals to assess quality of life in brain metastases

ObjectiveThe validated EORTC quality of life (QOL) questionnaire QLQ-BN20 is a cancer subtype-specific supplement to the QLQ-C30 general QOL questionnaire for patients with primary brain neoplasms. The QLQ-C15-PAL core palliative questionnaire is an abbreviated version of the QLQ-C30 designed to decrease patient burden. We conducted content validation of the QLQ-BN20+2 for patients with brain metastases.Methods and materialsPatients undergoing treatment for brain metastases, along with health care professionals (HCPs) completed the QLQ-C15-PAL and QLQ-BN20+2 questionnaires. A structured interview followed to assess for any difficulties with the QLQ-BN20+2, irrelevant items, and whether additional pertinent items should be included.ResultsSeventy-four patients and 71 HCPs participated. The majority of patients (84xa0%) were treated with whole-brain radiotherapy only. Over 50xa0% of patients felt that seizures, hair loss and trouble controlling bladder were not related to brain metastases. Questions regarding uncertainty about the future were the most difficult, although still a small proportion (12–16xa0%). All items were endorsed by over 50xa0% of HCPs as ‘quite’ or ‘very’ relevant to brain metastases patients, with two exceptions: 15 and 12xa0% of HCPs rated pruritis and future uncertainty as irrelevant, respectively.ConclusionWe report the first content validation of the QLQ-BN20+2 and QLQ-C15-PAL QOL questionnaires for patients undergoing treatment for brain metastases, demonstrating feasibility and relevance. These questionnaires should be used together as universal QOL assessment tools in this setting.

[11C]-Choline PET/CT-guided simultaneous integrated boost to dominant intraprostatic lesions using intensity-modulated radiation therapy with helical tomotherapy technique for dose escalation

ObjectiveThe objective of the study is to demonstrate the feasibility of using [11C]-choline positron-emission tomography (PET)/CT to deliver helical tomotherapy (HT) to the prostate with a simultaneous integrated boost to dominant intraprostatic lesions as a biological target volume for dose escalation.MethodsEleven patients with intermediate-risk prostate cancer were included in this virtual planning study. Pretreatment baseline [11C]-choline PET/CT scans were acquired with a PET/CT scanner dynamically in 2-min frames from injection to 40xa0min post injection. PET data was reconstructed using the RAMLA 3D algorithm and analyzed to identify dominant intraprostatic lesion(s). Dominant lesions were defined as biological target volume(s) (BTV) including all voxels with a standardized uptake value of 75xa0% or above relative to the maximum standard uptake value (SUV) within the prostate gland. Three target volumes for optimization included the following: PTV78 (BTVu2009+u20095xa0mm margin), PTV68 (prostateu2009+u20095xa0mm posteriorly and 10xa0mm in all other dimensions), and PTV50 (prostate gland and proximal seminal vesiclesu2009+u20097xa0mm margin posteriorly and 10xa0mm in all other dimensions). Dose constraints on organs at risk were implemented based on a published data using hypofractionated IMRT with long-term follow-up. Helical tomotherapy plans were generated to deliver hypofractionated radiation therapy to these volumes using simultaneous integrated boost in 25 fractions.ResultsEight patients had one identifiable contiguous BTV, and the other three patients had two noncontiguous BTVs. The mean BTV ratio to prostate volume ratio was 6.03xa0% (minimum 0.80xa0%, maximum 13.44xa0%). Target volume and normal tissue constraints were met in seven of the 11 patients enrolled in the study. Targets and structures in the four patients that did not meet constraints were the bladder (3 patients), peritoneal cavity (2 patients), rectum (1 patient), PTV68 (1 patient), and PTV50 (1 patient).ConclusionIt is feasible in selected patients to use [11C]-choline PET/CT to deliver hypofractionated dose-escalated helical tomotherapy to dominant intraprostatic lesions with simultaneous integrated boost using clinically established normal tissue constraints.