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Palliative Radiation

Palliative Radiation

Executive Summary:

Palliative radiation has provided the participation of most patients to undergo radiation therapy, whose understanding has evolved from palliative care interventions. Patients require radiation therapy treatments for weeks, allowing the radiation oncology team to evaluate and address palliative goals beyond those addressed by radiation therapy. The radiation therapy oncologist gains the opportunity to contribute as palliative care professionals, pain medicine providers, and hospice specialists in a patient’s life when they are most in need. Almost half of the patients treated with radiation therapy undergo palliative care. It involves pain palliation that helps improve neurological function and prevent neurological compromise in cancer patients.

The patients undergoing radiation therapy may show stable or improved symptoms but also suffer from side effects that may not improve the overall survival rate among the patients. Palliative treatments provide low doses that focus on symptom control while reducing the treatment burden. Hence, it integrates the standard delivery of palliative radiotherapy using concise courses with a large fraction known as hypo-fractionation. It is effective in treating painful bone metastasis, symptomatic brain metastases, spinal cord, nerve root compression, superior vena cava syndrome (SVCO), hematuria, hemoptysis, and hematemesis. It helps improve pain relief, neurologic functions, and quality of life among patients with metastatic cancers. The side effects of palliative radiation are represented by the tissues receiving a substantial dose. New approaches are involved in the advancement of palliative radiation therapy that is considered as a significant treatment approach for the future.

Introduction:

Radiation therapy is a practical approach to addressing cancer symptoms and reducing skin lesions in cancer treatment (Lutz et al., 2010). The integration of radiation therapy is known to be an efficient technique of cancer treatment which is successfully integrated, well-tolerated and proved to be cost-efficient which is essential for proper delivery of palliative oncology care. Palliative care is the new medical approach that has achieved great importance in the twenty-first century. The World Health Organization has provided a proper understanding of palliative care to be effective in improving the quality of life of patients and their families who have faced issues of life-threatening illness through the prevention and relief of suffering using early identification, assessment and treatment of pain and other problems, physical, psychosocial, and spiritual. 

The concept of palliative radiation has provided the participation of most patients to undergo radiation therapy, whose understanding has evolved from palliative care interventions. Patients require radiation therapy treatments for weeks, allowing the radiation oncology team to evaluate and address palliative goals beyond those addressed by radiation therapy. The radiation therapy oncologist gains the opportunity to contribute as palliative care professionals, pain medicine providers, and hospice specialists in a patient’s life when they are most in need.

Almost half of the patients treated with radiation therapy undergo palliative care. It involves pain palliation that helps improve neurological function and prevent neurological compromise in cancer patients. The patients undergoing radiation therapy may show stable or improved symptoms but also suffer from side effects that may not improve the overall survival rate among the patients. The patients undergoing radiation therapy at the end of life do not experience symptomatic benefits and may spend a significant proportion of their remaining life expectancy receiving treatment (Gripp et al., 2010). Hence, palliative radiation therapy provides a quick, inexpensive, and effective way of reducing focal symptoms of advanced, incurable cancer that integrates from the primary and metastatic tumor. It helps improve the quality of life, with little treatment burden in terms of hospital attendance and side effects (Lutz et al., 2014). The statistical reports of UK general practice have evolved the palliative care for almost 20 patients with terminal cancer every year, providing an increasing number in secondary care. In contrast, the Canadian survey of general practitioners has revealed the fact that almost 85% have given care to patients with advanced cancer within the previous month (Health and social care information centre, 2016; Samant et al., 2007).  

Delivery of radiation therapy:

The delivery of radiation therapy is integrated with linear accelerators in advanced cancer centres located within the urban regions. The energy x-rays of high intensity are given at the disease target site, damaging the DNA and later causing cell death. Curative radiotherapy is delivered at regular intervals with small doses that will eventually reduce the long-term risk and permanent side effects in adjacent normal tissues (Joiner & van der Kogel, 2009). Palliative treatments provide low doses that focus on symptom control while reducing the treatment burden. Hence, it integrates the standard delivery of palliative radiotherapy using concise courses with a large fraction known as hypo-fractionation.

Palliative radiation

Figure 1: Linear accelerator for delivery of radiotherapy

Aspects of palliative radiation

Palliative radiation is an anatomically targeted treatment requiring patients to lie on a hard-topped treatment couch for about 15 minutes. This procedure is not concerned with pain, but some patients find the treatment quite uncomfortable in terms of position. The increased pain relief before the treatment helps the patients to undergo appropriate treatment. Patients are provided with informed consent. During emergencies, the patients should make an immediate decision that they think will benefit their well-being in case they lack capabilities and have no available representative.

The patients can follow the verbal comments from radiographers outside the treatment room. Lack of capability to follow the verbal comments makes the treatment process difficult and unsafe for delivering the treatment. Sedation and anaesthesia are not used regularly in palliative radiation. Palliative radiation treatments are delivered as a single dose or a short course, usually over 1-3 weeks. The close-fitting mask is required to ensure consistent treatment position if the treatment is done for the head, neck or upper chest. It is well-tolerated even among anxious patients. The re-treatment of palliative radiation is made possible for recurrent symptoms but may cause more side effects. The local radiotherapy department can discuss the referrals and management of treatment-related side effects. Hence, advanced techniques provide precise treatment approaches for delivering palliative radiation. It provides an increased dose to the tumor while maintaining a limited dose to surrounding tissues, known as stereotactic radiotherapy.

Indications of integrating palliative radiation

Palliative radiation is capable of treating focal symptoms of advanced cancer. The patients are observed to undergo radiation therapy along with palliative systemic anticancer treatments. The radiation therapy addresses the focal disease; the palliative radiation treatment can supplement and not replace the holistic palliative care. The assessment and support for all physical, psychological, and social needs, with strong communication between services, is considered necessary. Palliative radiation therapy has been observed to rarely improve the overall survival rate of cancer patients (Williams et al., 2013). Patients with limited prognosis require integration of appropriate levels of intervention which is considered necessary. Expected side effects and treatment burden may outweigh the potential benefits of treatment.

Palliative radiation therapy treats painful bone metastasis, symptomatic brain metastases, spinal cord, nerve root compression, superior vena cava syndrome (SVCO), hematuria, hemoptysis, and hematemesis. It helps improve pain relief, neurologic functions, and quality of life among patients with metastatic cancers. 

Side-effects of palliative radiation

The side effects of palliative radiation are represented by the tissues receiving a substantial dose. The integration of conventional radiation therapy for lumbar spine vertebral metastasis involves the irradiation of the bowels, resulting in evolving side effects concerning bone metastasis and bowels. Also, such treatment is concerned with fatigue in at least two-thirds of patients, affecting their quality of life while limiting their participation in preferred activities (Radbruch et al., 2008). 

The acute side-effects of palliative radiation are mainly observed among the patients and are more often resolved within 4-6 weeks of the completion of the treatment. The palliative prescription of analgesia includes strong opiates and antiemetics, which is recommended as routine practice. The long-term side effects are uncommon in palliative radiation therapy, and managing these side effects is integrated by communicating with the treatment team (Andreyev et al., 2012). 

New approaches to palliative radiation

The dose of radiation therapy is delivered to the tumor site, which becomes limited within the surrounding tissues. The integration of advanced techniques provides treatments matching the tumor shape for delivery using computed tomography that targets high radiotherapy doses to small focal disease sites. These are known as stereotactic body radiotherapy, ablative body radiotherapy, and stereotactic radiosurgery. High-dose stereotactic treatments eliminate all macroscopic disease sites, resulting in a superior overall survival rate for the patients. Another advancement in palliative radiation involves the integration of high radiotherapy dose to a symptomatic metastasis which improves the symptom control while continuing to deliver treatment in a minimum number of fractions with limited toxicity to surrounding tissues (van der Velden et al., 2016). Significant advancement is made in palliative radiation by using radionuclides that integrate the delivery of radioactive isotopes to tumour tissue either by anatomically targeted delivery or by using radiolabeled molecules or monoclonal antibodies taken up by the tumour or its microenvironment (NCRI, 2016). Dose-fractionation and type of radiotherapy are integrated individually, considering the primary aim of the treatment, localization of the tumor manifestations, and the patient’s prognosis.  

The services of palliative radiation have shown quick response clinics by providing consultation, simulation, treatment planning, and initiation of radiation therapy on the same day to implicate palliative response and reduce the time investment and transportation on the part of patients and their caretakers (Pituskin et al., 2010). Some sites have evolved weekly or more frequent meetings between palliative care and radiation oncology teams, which provide comprehensive palliative care evaluations among patients receiving radiotherapy. Other sites have maintained effective communication between hospice teams and radiotherapy centres, resulting in quick integration and reduced-cost radiotherapy treatment among patients receiving hospice care. Other recommended approaches are discussed in below table:

Primary Site Clinical CircumstancesRecommendations
Bone metastasisUncomplicated, painful bone metastasisAcceptable fractionation schemes: 30 Gy in 10 fractions, 24 Gy in six fractions, 20 Gy in five fractions, 8 Gy in one fraction
Recurrent pain at sameRe-treatment may be attempted, taking into account normal tissue tolerance
Skeletal siteMultiple painful osteoblastic metastasisConsider radiopharmaceutical injection
Spinal cord compressionSurgical decompression plus postoperative radiotherapy.Radiotherapy alone in those who do not qualify for or desire surgery
Metastasis in bones of the spineStandard external beam radiotherapy.Stereotactic body radiation therapy may be used, although preferably on a trial
Brain metastasisPoor prognosis or performance status20 Gy in five fractions.Supportive care alone
Multiple lesions, all < 4 cm in sizeWhole-brain radiotherapy alone.Whole-brain plus radiosurgery.Radiosurgery alone.
Multiple lesions, any > 4 cm in sizeWhole-brain radiotherapy alone
Solitary lesionIf completely resectable, then surgery plus whole-brain or radiosurgery.If not completely resectable and < 4 cm in size, then radiosurgery alone or with whole-brain radiotherapy.If not completely resectable and > 4 cm in size, then whole-brain radiotherapy alone.

Table 1: Palliative radiation therapy for metastatic cancer

Future aspects of palliative radiation:

Technological advancements have provided opportunities for supporting and treating palliative care patients, mainly the ones undergoing stereotactic radiation surgery for brain metastases, stereotactic body radiation therapy for metastasis of the spine, liver, or lung, and ablative treatments for selected patients having oligometastatic. These advances in radiation therapy are integrated while keeping palliative care approaches in mind. The benefits of early palliative care intervention are considered an important approach in treating cancer patients. Patients have shown improved quality of life with low depression rates and prolonged survival rates. The guidelines are adopted that represent the significance of palliative care during the initial phase of illness among patients having symptoms of metastatic cancer (Smith et al., 2012). Also, the recommendation of hospice informational visits for cancer patients tends to have a survival of 3 to 6 months. The radiation oncology speciality is responsible for fulfilling the requirement of the patients by contributing to palliative care education, research, and advocacy.

References

  1. Lutz S, Korytko T, Nguyen J, et al. Palliative radiotherapy: When is it worth it and when is it not? Cancer J. 2010;16:473–482.
  2. Gripp S, Mjartan S, Boelke E, Willers R. Palliative radiotherapy tailored to life expectancy in end-stage cancer patients. Cancer. 2010;116(13):3251–3256. doi: 10.1002/cncr.25112.
  3.  Lutz ST, Jones J, Chow E. Role of radiation therapy in palliative care of the patient with cancer. J Clin Oncol 2014;32:2913-9. 10.1200/JCO.2014.55.114
  4. Health and social care information centre. General practice trends in the UK to 2015. 2016. http://content.digital.nhs.uk/media/21726/General-Practice-Trends-in-the-UK-to-2015/pdf/General_Practice_Trends_in_the_UK_to_2015.pdf
  5.  Samant RS, Fitzgibbon E, Meng J, Graham ID. Barriers to palliative radiotherapy referral: a Canadian perspective. Acta Oncol 2007;46:659-63. 10.1080/02841860600979005
  6. Joiner MC, van der Kogel A, eds. Basic clinical radiobiology 4th ed. CRC Press; 2009. www.crcpress.com/Basic-Clinical-Radiobiology-Fourth-Edition/Joiner-van-der-Kogel/p/book/9780340929667
  7. Williams M, Woolf D, Dickson J, Hughes R, Maher J, Mount Vernon Cancer Centre Routine clinical data predict survival after palliative radiotherapy: an opportunity to improve end of life care. Clin Oncol (R Coll Radiol) 2013;25:668-73. 10.1016/j.clon.2013.06.003 
  8. Radbruch L, Strasser F, Elsner F, et al.Research Steering Committee of the European Association for Palliative Care (EAPC) Fatigue in palliative care patients—an EAPC approach. Palliat Med 2008;22:13-32. 10.1177/0269216307085183
  9. Andreyev HJN, Davidson SE, Gillespie C, Allum WH, Swarbrick E, British Society of Gastroenterology. Association of Colo-Proctology of Great Britain and Ireland. Association of Upper Gastrointestinal Surgeons. Faculty of Clinical Oncology Section of the Royal College of Radiologists Practice guidance on the management of acute and chronic gastrointestinal problems arising as a result of treatment for cancer. Gut 2012;61:179-92. 10.1136/gutjnl-2011-300563 
  10. van der Velden JM, Verkooijen HM, Seravalli E, et al. Comparing conVEntional RadioTherapy with stereotactIC body radiotherapy in patients with spinAL metastases: study protocol for an randomized controlled trial following the cohort multiple randomized controlled trial design. BMC Cancer 2016;16:909. 10.1186/s12885-016-2947-0 
  11. NCRI. CTRad: identifying opportunities to promote progress in molecular radiotherapy research in the UK. 2016. www.ncri.org.uk/wp-content/uploads/2016/06/CTRad-promoting-research-in-MRT-UK-June-2016.pdf
  12. Pituskin E, Fairchild A, Dutka J, et al. Multidisciplinary team contributions within a dedicated outpatient palliative radiotherapy clinic: A prospective descriptive study. Int J Radiat Oncol Biol Phys. 2010;78:527–532.

Smith TJ, Temin S, Alesi ER, et al. American Society of Clinical Oncology provisional clinical opinion: The integration of palliative care into standard oncology care. J Clin Oncol. 2012;30:880–887.

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