Emily Sinclair

Determining the Incidence of Pain Flare Following Palliative Radiotherapy for Symptomatic Bone Metastases: Results From Three Canadian Cancer Centers

PURPOSEnTo determine the incidence of pain flare following radiotherapy (RT) for painful bone metastases.nnnMATERIALS AND METHODSnPatients with bone metastases treated with RT were eligible. Worst pain scores and analgesic consumption were collected before, daily during, and for 10 days after treatment. Pain flare was defined as a 2-point increase in the worst pain score (0-10) compared to baseline with no decrease in analgesic intake, or a 25% increase in analgesic intake with no decrease in worst pain score. Pain flare was distinguished from progression of pain by requiring the worst pain score and analgesic intake return to baseline levels after the increase/flare (within the 10-day follow-up period).nnnRESULTSnA total of 111 patients from three cancer centers were evaluable. There were 50 male and 61 female patients with a median age of 62 years (range, 40-89 years). The primary cancers were mainly breast, lung, and prostate. Most patients received a single 8 Gy (64%) or 20 Gy in five fractions (25%). The overall pain flare incidence was 44/111 (40%) during RT and within 10 days following the completion of RT. Patients treated with a single 8 Gy reported a pain flare incidence of 39% (27/70) and, with multiple fractions, 41% (17/41).nnnCONCLUSIONnMore than one third of the enrolled patients experienced a pain flare. Identifying at-risk individuals and managing potential pain flares is crucial to achieve an optimal level of care.

An innovative rapid response radiotherapy program to reduce waiting time for palliative radiotherapy

BackgroundWaiting for radiation therapy (RT) in Ontario has been a major problem for the past decade. In 1996, the Toronto–Sunnybrook Regional Cancer Centre (TSRCC) initiated a Rapid Response Radiotherapy Program (RRRP) to provide timely palliative RT for symptom relief of patients with terminal cancer.PurposeThis study reviews the clinical activity of the RRRP over the past 8 years to evaluate if we are meeting the objectives of the program.Materials and methodsFrom the TSRCC oncology patient information system (OPIS) database, we retrieved the number of patients referred to the RRRP, their demographics, diagnosis and treatment for the calendar years 1996 to 2003 inclusive. We calculated the time interval between referral to consultation, consultation to simulation and the percentage of cases who started RT on their initial consultation for all new cases referred to the RRRP.ResultsFrom 1996 to 2003, the number of cases seen in consultation increased from just over 200 cases annually in the first 2 years to about 500 cases per year in the last 4 years, for a total of 3,290. There were 1,792 (54%) men and 1,498 (46%) women; median age was 69 years (range, 21–95 years). Breast, lung, genitourinary and gastrointestinal primaries accounted for over 80% of all referrals. The majority was referred for palliative treatment of symptomatic bone (70%) or brain (14%) metastases. The dose fractionation for bone metastases was a single 8-Gy fraction in 45%, 20xa0Gy in five fractions in 42%, 30xa0Gy in ten fractions in 4% and other dose fractionations in 9%. Nearly 90% were seen within 2 weeks of referral (38% within 1 week). Eighty-five percent were simulated on the day of their initial consultation. Sixty percent started their RT treatment on the day of their consultation visit. The overall median interval from referral to treatment was 8 days.ConclusionOver the past 8 years, the annual number of new cases referred to the RRRP has doubled. The overall median interval from referral to consultation was 8 days. Sixty percent were simulated, planned and started treatment on the day of their initial consultation. We therefore are meeting our goal of providing rapid access to palliative RT for symptomatic cancer patients.

Symptoms and Quality of Life in Cancer Patients With Brain Metastases Following Palliative Radiotherapy

PURPOSEnTo examine prospectively patient self-rated symptoms and quality of life (QOL) indicators in patients with brain metastases following whole brain radiotherapy (WBRT).nnnMETHODS AND MATERIALSnConsecutive patients with brain metastases referred for WBRT were approached for this study. Patients were asked to rate their symptoms and QOL using the Spitzer Quality of Life Index questionnaire. Follow-up was at 1, 2, and 3 months following WBRT. Linear regression analysis was used to determine the change in symptom severity over time.nnnRESULTSnBetween August 2005 to October 2007, 129 patients with brain metastases were enrolled. The majority of patients (88%) received 20 Gy in five fractions. Median age was 64 years, and median Karnofsky Performance Status at baseline was 70. The most commonly experienced symptoms at baseline were headaches, weakness, balance problems, and fatigue. Thirty-five percent of patients rated neurological functional (NF) status as 1, indicating moderate neurological symptoms and need for assistance. Forty-three percent of patients had stable or decreased fatigue, and 47% had a stable or improved NF status over time (p = 0.0040). Although certain QOL domains improved over time, all other QOL domains and symptom items did not change significantly following WBRT.nnnCONCLUSIONnWBRT may have contributed to symptom stabilization in our study. An alternative goal of WBRT may be the prevention of symptom progression and QOL deterioration. Further research is required to select the most appropriate group of patients with brain metastases who would benefit most from WBRT.

Retrospective Assessment of Cancer Pain Management in an Outpatient Palliative Radiotherapy Clinic Using the Pain Management Index

CONTEXTnThe Pain Management Index (PMI) is a simple index linking the usual severity of cancer pain with the category of medication prescribed to treat it. Medication categories are derived from the World Health Organizations analgesic ladder approach to cancer pain, and the PMI is an indicator of the extent to which the medication prescribed corresponds to the recommended categories for mild, moderate, and severe pain.nnnOBJECTIVESnThe aim of this study was to assess prevalence of inadequate pain management in an outpatient palliative radiotherapy clinic using the PMI.nnnMETHODSnAll patients with bone metastases referred for palliative radiotherapy from 1999 to 2006 were retrospectively analyzed for patient-rated pain scores (0-10 scale) and analgesic consumption. Pain scores were assigned 0, 1, 2, and 3 when patients reported no pain (0), mild (1-4), moderate (5-6), or severe pain (7-10), respectively. Analgesic scores of 0, 1, 2, and 3 were assigned when patients were prescribed no pain medication, nonopioids, weak opioids, and strong opioids, respectively. The PMI score was calculated by subtracting the pain score from the analgesic score. A negative PMI score was considered an indicator of potentially inadequate pain management by the prescriber. Descriptive statistics, Pearsons r correlation, and univariate and multivariate logistic regression analysis were used to determine the relationship of PMI over time, and the relationship with predictive factors.nnnRESULTSnOne thousand patients were included from January 1999 to December 2006. A negative PMI was calculated for 25.8% of patients at initial consultation. Prevalence of negative PMI significantly increased over years (P<0.0001). Higher Karnofsky Performance Status (P<0.0001) and breast primary cancer site (P<0.0001) were significantly associated with negative PMI after adjusting for year variable.nnnCONCLUSIONnDespite publication of numerous cancer pain management guidelines, undermedication appears to be a persistent problem for patients with painful bone metastases referred for radiotherapy.

Has Pain Management in Cancer Patients with Bone Metastases Improved? A Seven-Year Review at An Outpatient Palliative Radiotherapy Clinic

The primary objective of this study was to determine the prevalence of underdosage of analgesics for pain associated with bone metastases in outpatients referred to the Rapid Response Radiotherapy Program at the Odette Cancer Centre from 1999 to 2006. A prospective database containing data for all patients with bone metastases who were referred to the Rapid Response Radiotherapy Program for palliative radiotherapy from 1999 to 2006 was analyzed. The database included patient demographic information, including age at referral for radiation to the bone, gender, primary cancer site, and Karnofsky Performance Status; information on treatment-related factors, such as worst pain ratings and analgesic consumption in the past 24 hours (recorded as oral morphine equivalent doses); pain intensity ratings (none [rating=0], mild [rating=1-4], moderate [rating=5-6] or severe [rating=7-10]; and analgesic consumption (rated as none, nonopioids, weak opioids [e.g., codeine] and strong opioids [e.g., morphine and hydromorphone]). Patients who experienced moderate or severe pain and were prescribed no pain medication, nonopioids, or weak opioids were considered to be undermedicated. Between January 1999 and December 2006, 1,038 patients were included in the study database. Approximately 56% of patients were male and 44% were female. The median age was 68 years (range 28-95) and the median Karnofsky Performance Status was 70 (range 10-100). The percentages of undermedicated patients were 40% in 1999, 34% in 2000, 29% in 2001, 37% in 2003, 39% in 2004, 36% in 2005, and 48% in 2006. No appreciable decline was noted in the proportion of patients with moderate-to-severe pain who received no pain medication, nonopioids, or weak opioids during the study period. Despite the publication of pain management guidelines and the dissemination of data regarding the proportion of patients with bone metastases who are being prescribed inadequate analgesics, our findings suggest that a significant proportion of patients continue to be undermedicated.

Elderly Patients With Painful Bone Metastases Should be Offered Palliative Radiotherapy

PURPOSEnTo investigate the efficacy of palliative radiotherapy (RT) in relieving metastatic bone pain in elderly patients.nnnMETHODS AND MATERIALSnThe response to RT for palliation of metastatic bone pain was evaluated from a prospective database of 558 patients between 1999 and 2008. The pain scores and analgesic intake were used to calculate the response according to the International Bone Metastases Consensus Working Party palliative RT endpoints. Subgroup analyses for age and other demographic information were performed.nnnRESULTSnNo significant difference was found in the response rate in patients aged >or=65, >or=70, and >or=75 years compared with younger patients at 1, 2, or 3 months after RT. The response was found to be significantly related to the performance status.nnnCONCLUSIONnAge alone did not affect the response to palliative RT for bone metastases. Elderly patients should be referred for palliative RT for their painful bone metastases, regardless of age, because they receive equal benefit from the treatment.

The palliative performance scale: examining its inter-rater reliability in an outpatient palliative radiation oncology clinic

IntroductionThe Palliative Performance Scale (PPS) was developed by the Victoria Hospice Society in 1996 to modernize the Karnofsky Performance Scale. Currently, it is being used to measure palliative patient performance status in a variety of settings. Despite its widespread use, only one study has examined the inter-rater reliability of the PPS.PurposeTo examine the inter-rater reliability of the PPS in measuring performance status in patients seen in an outpatient palliative radiation oncology clinicMethodsPerformance status for 102 consecutive patients was assessed by an oncologist (MD), a radiation therapist (RT), and a research assistant (RA) in the Rapid Response Radiotherapy Program at the Odette Cancer Centre in Toronto, Ontario, Canada. Raters’ scores were analyzed for correlation and compared to evaluate the inter-rater reliability of the PPS tool.ResultsExcellent correlation was found between the scores rated by the MD and RA (ru2009=u20090.86); good correlation was observed between scores rated by the MD and RT (ru2009=u20090.69) and the RT and RA (ru2009=u20090.77). Scores between all three raters, as well as between rater pairs, were also found to have good reliability as measured by the Chronbach’s alpha coefficient. Significant results were obtained for the range of PPS scores in which the majority of our patients fell: 40–80%.ConclusionPPS was shown to have good overall inter-rater reliability in an outpatient palliative setting, but more research is needed to establish the validity and reliability of the tool in a variety of different palliative settings.

Has the Pattern of Practice in the Prescription of Radiotherapy for the Palliation of Thoracic Symptoms Changed Between 1999 and 2006 at the Rapid Response Radiotherapy Program

PURPOSEnEleven randomized controlled trials (RCT) comparing various radiotherapy (RT) schedules for locally advanced lung cancer published since 1991 found no difference in palliation of intrathoracic symptoms. The most commonly prescribed schedule by Canadian Radiation Oncologists (RO) (20 Gy in five fractions [20 Gy/5]), when first evaluated versus 10 Gy/1 in a 2002 RCT, showed a significant survival benefit. A subsequent RCT assessing 20 Gy/5 found worse survival versus 16 Gy/2. This study examines whether the RT prescription for lung cancer palliation in the Rapid Response Radiotherapy Program (RRRP) has changed over time.nnnMETHODS AND MATERIALSnChart review was conducted for patients treated with palliative thoracic RT across three periods (1999-2006). Patient demographics, tumor, treatment, and organizational factors were analyzed descriptively. Chi-square test was used to detect differences in proportions between unordered categorical variables. Continuous variables were tested using analysis of variance. Multivariate logistic regression was used to identify independent predictors of RT schedule prescribed.nnnRESULTSnA total of 117 patients received 121 courses of palliative thoracic RT. The most common dose (20 Gy/5) comprised 65% of courses in 1999, 68% in 2003, and 60% in 2005-2006 (p = 0.76). The next most common dose was 30 Gy/10 (13%). Overall, the median survival was 14.9 months, independent of RT schedule (p = 0.68). Multivariate analysis indicated palliative chemotherapy and certification year of RO were significant predictors of prescription of 20 Gy/5.nnnCONCLUSIONnRT schedule for palliation of intrathoracic symptoms did not mirror the results of sequential, conflicting RCTs, suggesting that factors other than the literature influenced practice patterns in palliative thoracic RT.

Is Response to Radiotherapy in Patients Related to the Severity of Pretreatment Pain

PURPOSEnThe primary objective of this study was to determine whether there is a relationship between the severity of pretreatment pain and response to palliative radiotherapy (RT) for painful bone metastases.nnnMETHODS AND MATERIALSnThe database for patients with bone metastases seen at the Rapid Response Radiotherapy Program at the Odette Cancer Center from 1999 to 2006 was analyzed. The proportion of patients with mild (scores 1-4), moderate (scores 5-6), or severe (scores 7-10) pain at baseline who experienced a complete response, partial response, stable response, or progressive response after palliative RT was determined according to International Bone Metastases Consensus definitions.nnnRESULTSnDuring the 7-year study period 1,053 patients received palliative radiation for bone metastases. The median age was 68 years and the median Karnofsky performance status was 70. Of the patients, 53% had a complete or partial response at 1 month, 52% at 2 months, and 54% at 3 months post-RT.nnnCONCLUSIONSnThere was no significant difference in terms of the proportion of responders (patients with complete or partial response) and nonresponders in terms of painful bone metastases among patients presenting with mild, moderate, or severe pain. Patients with moderate pain should be referred for palliative RT.

Would Larger Radiation Fields Lead to a Faster Onset of Pain Relief in the Palliation of Bone Metastases

PURPOSEnHemibody irradiation has been shown to relieve bony metastatic pain within 24-48 hours of treatment, whereas for local external beam radiation, onset of pain relief is 1-4 weeks after radiation. The primary objective of this study is to examine whether there is a relationship between the areas of radiation treatment and onset of pain relief.nnnMETHODS AND MATERIALSnFrom Jan 1999 to Jan 2002, a total of 653 patients with symptomatic bone metastases were treated with external beam radiation. Pain scores and analgesic consumption were recorded at baseline and Weeks 1, 2, 4, 8, and 12. The areas of radiation treatment for all patients were calculated, then correlated with the response and analyzed in various ways. We first compared pain score alone with mean radiation field size. Second, we combined pain score and analgesic consumption. Last, we implemented the International Consensus end points for pain score and analgesic intake.nnnRESULTSnAssessment of 653 patients showed no significant correlation comparing pain scores alone with radiation field area, with the exception of Week 4 for partial responders. Again, no significant correlation was found when combining both analgesic intake and pain score against radiation field size. Even when implementing the International Consensus end point definitions for radiation response, the only significant correlation between radiation field size and response was observed in Week 2 for partial response.nnnCONCLUSIONnThere was no statistical significance between mean areas of radiation treatment with the onset of pain relief.