Elizabeth A. Barnes

Palliative Thoracic Radiotherapy for Lung Cancer: A Systematic Review

PURPOSEnThe optimal dose of radiotherapy (RT) to palliate symptomatic advanced lung cancer is unclear. We systematically reviewed randomized controlled trials (RCTs) of palliative thoracic RT.nnnMETHODSnRCTs comparing two or more dose fractionation schedules were reviewed using the random-effects model of a freely available information management system. The relative risk and 95% CI for each outcome were presented in Forrest plots. Exploratory analysis comparing dose schedules after conversion to the time-adjusted biologically equivalent dose (BED) was performed to investigate for a dose-response relationship.nnnRESULTSnA total of 13 RCTs involving 3,473 randomly assigned patients were identified. Outcomes included symptom palliation, overall survival, toxicity, and reirradiation rate. For symptom control in assessable patients, lower-dose (LD) RT was comparable with higher-dose (HD), except for the total symptom score (TSS): 65.4% of LD and 77.1% of HD patients had improved TSS (P = .003). Greater likelihood of symptom improvement was seen with schedules of 35 Gy(10) versus lower BED. At 1 year after HD and LD RT, 26.5% versus 21.7% of patients were alive, respectively (P = .002). Sensitivity analysis suggests this survival improvement was seen with 35 Gy(10) BED schedules compared with LDs. Physician-assessed dysphagia was significantly greater in the HD arm (20.5% v 14.9%; P = .01), and the likelihood of reirradiation was 1.2-fold higher after LD RT.nnnCONCLUSIONnNo significant differences were observed for specific symptom-control end points, although improvement in survival favored HD RT. Consideration of palliative thoracic RT of at least 35 Gy(10) BED may therefore be warranted, but must be weighed against increased toxicity and greater time investment.

Patient-Controlled Methylphenidate for the Management of Fatigue in Patients With Advanced Cancer: A Preliminary Report

PURPOSEnTo assess the effects of patient-controlled methylphenidate for cancer-related fatigue.nnnPATIENTS AND METHODSnIn this prospective open study, 31 patients with advanced cancer and fatigue who scored >/= 4 on a scale of 0 to 10 received methylphenidate 5 mg by mouth every 2 hours as needed for 7 days (maximum, 20 mg/d). Multiple symptoms were assessed daily; the primary end point, fatigue, was measured using the 0 to 10 scale, and the Functional Assessment for Chronic Illness Therapy-Fatigue (FACIT-F) was performed at baseline, day 7, and day 28.nnnRESULTSnThe following mean (+/- standard deviation) scores for 30 assessable patients improved significantly between baseline and day 7: fatigue (0 to 10 scale), 7.2 +/- 1.6 v 3.0 +/- 1.9 (P <.001); overall well-being (0 to 10 scale), 4.5 +/- 2.2 v 2.8 +/- 2.1 (P <.001); fatigue (FACIT-F) subscore, 17.5 +/- 11.3 v 34.7 +/- 10.0 (P <.001); functional well-being, 14.4 +/- 5.9 v 18.3 +/- 6.6 (P <.001); and physical well-being, 13.5 +/- 6.4 v 21.4 +/- 5.0 (P <.001). Anxiety, appetite, pain, nausea, depression, and drowsiness all improved significantly (P <.05). All patients took afternoon or evening doses, and 28 patients (93%) took three or more doses daily. All patients chose to continue taking methylphenidate after 7 days of treatment. No serious side effects were reported.nnnCONCLUSIONnThese preliminary results suggest that patient-controlled methylphenidate administration rapidly improved fatigue and other symptoms. Randomized controlled trials are justified.

Patient outcome study of concurrent chemoradiation, external beam radiotherapy, and high-dose rate brachytherapy in locally advanced carcinoma of the cervix.

Introduction: A regimen of concurrent chemoradiation for definitive treatment of cervical cancer is widely used. This retrospective review has been conducted to determine the outcomes and late toxic effect associated with the specific regimen of whole-pelvic external beam radiotherapy of 45 Gy in 25 fractions with parametrial boosts of 5.4 or 9 Gy and HDR brachytherapy (BT) of 30 Gy in 5 fractions to point A delivered by tandem and ring. This protocol is accepted by the Gynecological Oncology Group and endorsed by the American Brachytherapy Society, but no late toxic effect data have been reported. Materials and Methods: The electronic records of sequential patients treated definitively at the Sunnybrook Odette Cancer Centre between January 2006 and December 2008 were reviewed. Patient-, tumor-, and treatment-related details (including external beam radiotherapy, BT, and chemotherapy) were obtained. Outcome measures included disease-free status, dates and sites of first recurrence, survival, and grade 3/4 late toxic effect results (Common Terminology Criteria Adverse Events 3.0 criteria). Exclusion criteria were no follow-up or a planned alternative regimen. Results: One hundred twenty-two patients (+11 excluded) were treated with a median follow-up of 18 months from diagnosis. The actuarial 2-year disease-free survival rate was 70%. The median time to recurrence was 8 months (range, 2-22 months). The median time to toxic effect was 10 months (range 4-27 months). Grade 3/4 toxic effect was observed in 13 patients (11%). The actuarial grade 3/4 toxic effect rate at 2 years was 14%. Conclusions: Despite a relatively short follow-up, the toxicity of this regimen seems high compared with other retrospective series, although pelvic control is good. Consideration should be given to a reduction in BT dose alternatively when feasible image-guided BT may allow maintenance of tumor dose with reduced dose to organs at risk.

Prevalence of symptom control and palliative care abstracts presented at the Annual Meeting of the American Society for Therapeutic Radiology and Oncology.

PURPOSEnForty percent of all patients referred for radiotherapy are treated with palliative intent. The American Society for Therapeutic Radiology and Oncology (ASTRO) has recently emphasized the importance of radiation oncologists being skilled in the field of symptom control and palliative care (SCPC). The purpose of this study was to determine the number of abstracts relating to SCPC presented at the annual ASTRO meetings.nnnMETHODS AND MATERIALSnThe number of SCPC abstracts presented at ASTRO meetings between 1993 and 2000 was counted. Abstracts were included if they described populations with advanced or metastatic cancer for whom the goal of treatment was symptom palliation. The treatment sites and symptoms palliated were recorded.nnnRESULTSnOf 3511 abstracts presented at ASTRO between 1993 and 2000, an average of 47 (1.3%, range 0.9-2.2%/y) were related to SCPC. The most common treatment sites were bone, brain, and lung. Pain, bleeding, and neurologic and pulmonary symptoms were the ones most commonly palliated. Thirty-two percent of the SCPC abstracts involved randomized controlled trials, 47% had palliation of symptoms as a secondary treatment outcome, and in 21%, the symptomatic treatment outcome was not specifically stated.nnnCONCLUSIONnSCPC research has been poorly represented at the annual ASTRO meetings. Education and research in this field needs to be actively encouraged, because SCPC is an important component of a radiation oncologists role in comprehensive patient care.

Involvement of Family Physicians in the Care of Cancer Patients Seen in the Palliative Rapid Response Radiotherapy Program

PURPOSEnIt is important for cancer patients to maintain continuity of care with their family physician (FP) while being followed at the cancer center. The primary objective of this study was to determine the perception of patients seen in the palliative Rapid Response Radiotherapy Program (RRRP) on FP involvement in their cancer care. Secondary objectives were to identify factors predicting for perceived FP involvement in patient cancer care.nnnPATIENTS AND METHODSnConsecutive patients were approached for study enrollment at the time of RRRP visit and asked to complete a 15-item survey.nnnRESULTSnThree hundred sixty-five patients were accrued over 15 months. Ninety-eight percent had an FP, and 43% felt their FP was involved in their cancer care. Eighty percent of patients were satisfied with the overall medical care provided by their FP, and 71% had been with their FP for > or = 5 years. The most common reason patients gave for perceiving limited FP involvement was the medical oncologist looking after all of their cancer needs. Multivariate analysis found that satisfaction with overall medical care provided by the FP, shorter time since last FP visit, seeing the FP since cancer diagnosis, and FP providing on-call service for after-hour emergencies all significantly predicted for patients perceiving FP involvement in their cancer care.nnnCONCLUSIONnLess than half of patients surveyed perceived their FP as involved in their cancer care. Encouraging continuity of care between patients and FPs may allow for easier transition of care back to the FP once palliative treatment at the cancer center has finished and help facilitate end-of-life planning.

An interdisciplinary and collaborative initiative in palliative care research.

The scale and complexity of palliative care increasingly demands that researchers move beyond their own discipline and explore interdisciplinary collaboration. At a Palliative Care Research Retreat held in January 2006 at the Toronto Sunnybrook Regional Cancer Centre, researchers from multiple care settings with the center and from other Toronto hospitals came together with the vision of becoming Canadian leaders in palliative care research. As a result of this retreat, five interdisciplinary groups were formed to pursue research in the areas of pain and symptom management, access to services, translational research, education, and communication. An overview of the retreat and direction of research for each group is provided.

A prospective analysis of catheter complications for gynecological cancers treated with interstitial brachytherapy in the 3D era

PURPOSEnPerineal interstitial brachytherapy (P-ISBT) is an important component in the treatment of locally advanced gynecological cancers. However, there are concerns about potential acute complications from catheter needles. The goal is to evaluate the safety of P-ISBT by studying acute complications and radiological organ needle intrusions.nnnMATERIALS AND METHODSnForty-eight patients with gynecological cancers treated with P-ISBT at a single institution from September 2014 to April 2016 were included in a prospective registry trial. Postoperative adverse events were recorded during inpatient stay and at 6-week followup. Postprocedure CT and MRI images were reviewed by two physicians to record the number of needles intruded into organs. Discrepancies were resolved by a radiologist.nnnRESULTSnMedian followup time was at least 3xa0months. Forty-two patients were initially treated with external beam radiation therapy, median dose of 45xa0Gy. A total of 73 insertions were performed. The median number of needles for first and second insertions was 17 and 19, respectively. Twenty-eight patients had radiological evidence of needle intrusion(s) into at least one pelvic organ. The most commonly intruded organs were large bowel (18 cases) and bladder (18), followed by rectum (12). A total of nine acute toxicities from needle intrusions were found: four hematuria (1 G1, 3 G2); four perineal infections (3 G2, 1 G3); and one vaginal bleeding (G3). No gastrointestinal complications were found.nnnCONCLUSIONSnPerineal ISBT is an effective treatment for gynecological cancers. Despite occasional radiological catheter intrusions, there are low rates of organ complications. Concern of needle complications from P-ISBT should not be a barrier to adopting this technique for effective treatment.