Palliative radiotherapy is a centerpiece of supportive cancer care, offering an effective tool in the management of pain and other symptoms associated with primary or metastatic tumors. As the number of cancer patients climbs with the aging of the Baby Boom generation, and as survival times improve among cancer patients, palliative radiotherapy will represent an increasingly important component of radiation oncology procedures. With advances in diagnostic imaging and conformal radiotherapy, palliative radiotherapy is evolving; outcomes can be quickly predicted and tumors can now be targeted to prevent symptoms before they emerge. The increasing complexity of palliative planning will require more communication and coordination among members of the cancer care team, and with patients, including explicitly informing the patient that the goal of palliative radiotherapy is to reduce symptoms, rather than curing his or her cancer.
Palliative radiotherapy regimens afford patients rapid and potentially durable relief from pain and other neurologic symptoms, obstructions, and bleeding associated with incurable primary and metastatic tumors, with an emphasis on minimizing potential side effects.1-3 It is a cost-effective and relatively convenient treatment for relieving pain and other symptoms associated with metastatic tumors in bone, brain, and spinal tissues, for example. Palliative radiotherapy is a mainstay for palliation of bone metastases, which are the single most common cause of cancer pain and is frequently severe or intolerable.4
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Although outcomes vary for different patients, the overall benefits of palliative radiotherapy are clear, and include improved quality of life (including lower rates of clinical depression) and even prolonged survival but not cure.3,5,6 Palliative radiotherapy can help control or delay the growth of a tumor and thereby help manage or avoid quality-of-life-degrading symptoms, including pathologic bone fractures caused by metastatic tumor growth. Indications for palliative radiotherapy include pain associated with bone, brain, or visceral metastatic tumors, advanced primary tumor growth in any location, and tumor-associated spinal cord compression; brain tumor-associated neurologic symptoms such as memory and other cognitive impairments, seizures, headaches, motor-control deficits, and fatigue; symptoms of tumor-associated spinal cord compression; tumor-associated bleeding; or cough or shortness of breath associated with tumor obstruction of airways or esophagus.1,4 Biliary and pancreatic duct obstructions may also be treated with palliative radiotherapy.1
With advances in conformal irradiation modalities and improved diagnostic imaging techniques, palliative radiotherapy is evolving from regimens that offer short-term relief from pain and other symptoms, to prevention or delayed onset of incurable tumors’ impacts to quality of life.1 With increased numbers of cancer diagnoses among aging Baby Boomers and improved survival times, growing numbers of patients will undergo palliative radiotherapy in the coming years. Most radiotherapy centers do not operate dedicated palliative radiation oncology programs, but some cancer centers have developed palliative radiotherapy teams or rapid-palliation radiation clinics to address this facet of supportive cancer care.2,3 These models of care require coordinated multidisciplinary patient management, including communication between palliative and radiotherapy care teams. 1,2,7
PALLIATION MODELS
Shorter, more conformal radiotherapy regimens have emerged in the research literature as preferred palliative approaches because they minimize the potential toxicity, and travel and scheduling burdens, imposed on patients by longer regimens.2 Unfortunately, however, a recent retrospective study of the National Cancer Database found that single-fraction palliative radiotherapy is still significantly underutilized in current clinical practice.8
Intensity-modulated radiotherapy (IMRT) and stereotactic radiotherapy (SRT) allow delivery of higher doses of radiation to target tumors while minimizing irradiation of healthy, nontarget tissues, reducing side effects while improving the potential for local tumor control.2 Radiosurgery has also emerged as an important advance for palliating metastatic brain tumors, whereas body SRT is proving valuable for palliating metastatic tumors in the spine.3,9 Fractionated whole-brain radiotherapy is still in widespread use for brain metastases, but single-fraction stereotactic radiosurgery techniques such as Gamma Knife appear to offer lower neurocognitive impairment rates and good local tumor control rates (exceeding 80% and 90%, respectively, for lung and breast cancer metastases).9 Radiosurgery is highly conformal, irradiating very little nontarget tumor tissue in the brain and, unlike whole-brain radiotherapy, allows repeated treatments when tumors emerge elsewhere in the brain.9 For small metastatic brain tumors (those smaller than 8 cc), there is excellent evidence that Gamma Knife is as effective as traditional surgical removal of brain metastases.9
Imaging may also help with early assessments of palliative radiation’s efficacy, and subsequent treatment planning. For example, a recent study found that post-palliative radiotherapy maximal standardized uptake value (SUVmax) on FDG-positron emission tomography (FDG-PET) imaging of bone-metastatic lung cancer predicts both the severity of patient’s postintervention pain and local tumor control rates.10
CONCLUSION
Patients should be prepared ahead of treatment with clear descriptions of the radiotherapy modalities, fractionation schedule, goals, and potential complications or side effects involved in their treatment plans. Prior to, during, and following palliative radiotherapy, patients should be monitored for pain, breathing problems, nausea, and other symptoms.2 Importantly, patients and their families should be explicitly told that the intent of palliative radiotherapy is to reduce a patient’s symptom burden, not to cure cancer; while this may seem obvious to clinicians, patients frequently misunderstand any intervention to have a curative goal.2
Patients should also be prepared for the fact that there may come a point at which palliative radiotherapy will offer no additional benefits and may be stopped. A recently published study found that among patients with breast, colorectal, and prostate cancer, palliative radiotherapy correlates with palliative chemotherapy, even in the last 2 weeks of life, “when treatment may cause increased treatment burden without improved quality of life.”11
REFERENCES
1. Sharma S, Hertan L, Jones J. Palliative radiotherapy: current status and future directions. Semin Oncol. 2014;41(6):751-763. doi:10.1053/j.seminoncol.2014.09.021.
2. McMenamin E, Ross N, Jones J. Palliative radiotherapy and oncology nursing. Semin Oncol Nurs. 2014;30(4):242-252. doi:10.1016/j.soncn.2014.08.006.
3. Lutz S, Jones J, Chow E. Role of radiation therapy in palliative care of the patient with cancer. J Clin Oncol. 2014;32(26):2913-2919. doi:10.1200/jco.2014.55.1143.
4. Lutz S, Berk L, Chang E, et al; American Society for Radiation Oncology (ASTRO). Palliative radiotherapy for bone metastases: an ASTRO evidence-based guideline. Int J Radiat Oncol Biol Phys. 2011;79(4):965-976. doi:10.1016/j.ijrobp.2010.11.026.
5. Temel JS, Greer JA, Muzikansky A, et al. Early palliative care for patients with metastatic non-small-cell lung cancer. N Engl J Med. 2010;363(8):733-742. doi:10.1056/NEJMoa1000678.
6. Stavas MJ, Arneson KO, Ning MS, et al. The refusal of palliative radiation in metastatic non-small-cell lung cancer and its prognostic implications [published online ahead of print January 13, 2015]. J Pain Symptom Manage. doi:10.1016/j.jpainsymman.2014.11.298.
7. Economou D. Palliative care needs of cancer survivors. Semin Oncol Nurs. 2014;30(4):262-267. doi:10.1016/j.soncn.2014.08.008.
8. Rutter CE, Yu JB, Wilson LD, Park HS. Assessment of national practice for palliative radiation therapy for bone metastases suggests marked underutilization of single-fraction regimens in the United States. Int J Radiat Oncol Biol Phys. 2015;91(3):548-555. doi:10.1016/j.ijrobp.2014.10.045.
9. Lippitz B, Lindquist C, Paddick I, et al. Stereotactic radiosurgery in the treatment of brain metastases: the current evidence. Cancer Treat Rev. 2014;40(1):48-59. doi:10.1016/j.ctrv.2013.05.002.
10. Zhao F, Ding G, Huang W, et al. FDG-PET predicts pain response and local control in palliative radiotherapy with or without systemic treatment in patients with bone metastasis from non-small-cell lung cancer [published online ahead of print February 2, 2015]. Clin Lung Cancer. doi:10.1016/j.cllc.2015.01.005.
11. Kress MA, Jensen RE, Tsai HT, et al. Radiation therapy at the end of life: a population-based study examining palliative treatment intensity. Radiat Oncol. 2015;10(1):15. doi:10.1186/s13014-014-0305-4.
