22 research outputs found
Shortened Palliative Radiotherapy Results in a Lower Rate of Treatment During the Last Month of Life
Introduction
Palliative radiotherapy (PRT) during the last month of life (PRT30) should be avoided because relevant
clinical benefits are unlikely to occur. While traditional short-course fractionation regimens are suitable for
most patients, a minority may derive gains from higher doses of PRT. Compared to older regimens such as 13
fractions of 3 Gy, more hypofractionated, non-ablative concepts with reduced overall treatment time are not
well studied.
Methods
Retrospective analysis (2017-2020) of 107 patients treated to metastatic lesions (one or two target volumes
per patient) with traditional >2 weeks regimens or newer â€2 weeks regimens, e.g. seven fractions of 5 Gy or
five fractions of 6 Gy.
Results
Failure to complete radiotherapy was registered in 8% of patients (traditional fractionation) and 1%,
respectively (p=0.12). Moderate rates of PRT30 were observed (11% and 6%, respectively, p=0.44). PRT30 was
more likely in patients irradiated for brain or lymph node metastases. Utilization of newer â€2 weeks
regimens was highest in 2020, presumably as a result of the coronavirus disease 2019 (COVID-19) pandemic.
Conclusion
The implementation of newer fractionation regimens for selected patients has resulted in acceptable rates of
non-completion and PRT30. Optimal selection criteria remain to be determined. Established, guidelineendorsed short-course regimens such as five fractions of 4 Gy and 8-Gy single fractions continue to
represent important PRT approaches
Percent of remaining life on palliative radiation treatment: solely a function of fractionation?
Background: This study analyzed the percent of remaining life (PRL) on treatment in patients irradiated for bone metastases. Bone metastases were treated together with other target volumes, if indicated, e.g. a 10-fraction treatment course that included brain and bone metastases. PRL was determined by calculating the time between start and finish of palliative radiotherapy (minimum 1 day in case of a single-fraction regimen) and dividing it by overall survival in days from start of radiotherapy.
Materials and methods: Different baseline parameters were assessed for association with dichotomized PRL (
Results: PRL on treatment ranged from 1â23%. Single-fraction radiotherapy resulted in
Conclusions: Fractionation is an easily modifiable factor with high impact on PRL. Patients with KPS < 70 and those treated for additional target types during the same course are at high risk of spending a larger proportion of their remaining life on treatment
Percent of remaining life on palliative radiation treatment: solely a function of fractionation?
Background: This study analyzed the percent of remaining life (PRL) on treatment in patients irradiated for bone metastases. Bone metastases were treated together with other target volumes, if indicated, e.g. a 10-fraction treatment course that included brain and bone metastases. PRL was determined by calculating the time between start and finish of palliative radiotherapy (minimum 1 day in case of a single-fraction regimen) and dividing it by overall survival in days from start of radiotherapy. Â
Materials and methods: Different baseline parameters were assessed for association with dichotomized PRL (< 5% vs. â„ 5%). The retrospective study included 219 patients (287 courses of palliative radiotherapy). After univariate analyses, multi-nominal logistic regression was employed. Â
Results: PRL on treatment ranged from 1â23%. Single-fraction radiotherapy resulted in < 5% PRL on treatment in all cases. All courses with 10 fractions resulted in at least 5% PRL on treatment. Significant associations were found between various baseline parameters and PRL category. With fractionation included in the regression model, 3 parameters retained significant p-values: Karnofsky performance status (KPS), none-bone target volume and fractionation (all with p < 0.001). If analyzed without fractionation, none-bone target volume (p < 0.001), hemoglobin (p < 0.001), KPS (p = 0.01), lack of additional systemic treatment (p = 0.01), and hypercalcemia (p = 0.04) were significant.    Â
Conclusions: Fractionation is an easily modifiable factor with high impact on PRL. Patients with KPS < 70 and those treated for additional target types during the same course are at high risk of spending a larger proportion of their remaining life on treatment. Â
Palliative appropriateness criteria: external validation of a new method to evaluate the suitability of palliative radiotherapy fractionation
Background Recently, the palliative appropriateness criteria (PAC) score, a novel metric to aid clinical decision-making
between different palliative radiotherapy fractionation regimens, has been developed. It includes baseline parameters
including but not limited to performance status. The researchers behind the PAC score analyzed the percent of remaining life
(PRL) on treatment. The latter was accomplished by calculating the time between start and finish of palliative radiotherapy
(minimum 1 day in case of a single-fraction regimen) and dividing it by overall survival in days from start of radiotherapy.
The purpose of the present study was to validate this novel metric.
Patients and methods The retrospective validation study included 219 patients (287 courses of palliative radiotherapy). The
methods were identical to those employed in the score development study. The score was calculated by assigning 1 point
each to several factors identified in the original study and using the online calculator provided by the PAC developers.
Results Median survival was 6 months and death within 30 days from start of radiotherapy was recorded in 13% of courses.
PRL on treatment ranged from 1 to 23%, median 8%. Significant associations were confirmed between online-calculated
PAC score, observed survival, and risk of death within 30 days from the start of radiotherapy. Patients with score 0 had
distinctly better survival than all other groups. The score-predicted median risk of death within 30 days from start of
radiotherapy was 22% in our cohort. A statistically significant correlation was found between predicted and observed risk
(p< 0.001). The original and present study were not perfectly concordant regarding number and type of baseline parameters
that should be included when calculating the PAC score.
Conclusion This study supports the dual strategy of PRL and risk of early death calculation, with results stratified for
fractionation regimen, in line with the original PAC score study. When considering multifraction regimens, the PAC score
identifies patients who may benefit from shorter courses. Additional work is needed to answer open questions surrounding
the underlying components of the score, because the original and validation study were only partially aligned
30-day mortality in patients treated for brain metastases: extracranial causes dominate
Background: Established prognostic models, such as the diagnosis-specific graded prognostic assessment, were
not designed to specifically address very short survival. Therefore, a brain metastases-specific 30-day mortality model
may be relevant. We hypothesized that in-depth evaluation of a carefully defined cohort with short survival, arbitrarily
defined as a maximum of 3 months, may provide signals and insights, which facilitate the development of a 30-day
mortality model.
Methods: Retrospective analysis (2011â2021) of patients treated for brain metastases with different approaches. Risk
factors for 30-day mortality from radiosurgery or other primary treatment were evaluated.
Results: The cause of death was unrelated to brain metastases in 61%. Treatment-related death (grade 5 toxicity) did
not occur. Completely unexpected death was not observed, e.g. accident, suicide or sudden cardiac death. Logistic
regression analysis showed 9 factors associated with 30-day mortality (each assigned 3â6 points) and a point sum
was calculated for each patient. The point sum ranged from 0 (no risk factors for death within 30 days present) to
30. The results can be grouped into 3 or 4 risk categories. Eighty-three percent of patients in the highest risk group
(>16 points) died within 30 days, and none survived for more than 2 months. However, many cases of 30-day mortality (more than half ) occurred in intermediate risk categories.
Conclusion: Extracranial tumor progression was the prevailing cause of 30-day mortality and few, if any deaths could
be considered relatively unexpected when looking at the complete oncological picture. We were able to develop a
multifactorial prediction model. However, the modelâs performance was not fully satisfactory and it is not routinely
applicable at this point in time, because external validation is needed to confirm our hypothesis-generating findings
Palliative radiotherapy with or without additional care by a multidisciplinary palliative care team in patients with newly diagnosed cancer: A retrospective matched pairs comparison
License: Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0)Purpose: To analyze survival after early palliative radiotherapy (RT) in patients managed exclusively by regular
oncology staff or a multidisciplinary palliative care team (MPCT) in addition.
Methods: Retrospective matched pairs analysis. Comparison of two groups of 29 patients each: MPCT versus none.
Early RT started within three months after cancer diagnosis.
Results: Bone and brain metastases were common RT targets. No significant differences in baseline characteristics
were observed between both groups. Twelve patients in each group had non-small cell lung cancer. Median
performance status was 2 in each group. Twenty-seven patients in each group had distant metastases. Median
survival was not significantly different. In multivariate analysis, MPCT care was not associated with survival, while
performance status and liver metastases were. Rate of radiotherapy during the last month of life was comparable.
Only one patient in each group failed to complete radiotherapy.
Conclusions: MPCT care was not associated with survival in these two matched groups of patients. The impact
of MPCT care on other relevant endpoints such as symptom control, side effects and quality of life should be
investigated prospectively
Validation of a graded prognostic model in patients with brain metastases treated with whole-brain radiotherapy instead of radiosurgery
Background/Aim: The aim of this study was to analyze the survival predictions obtained from a recent graded prognostic model developed and validated in Japan. Patients and Methods: This was a retrospective single-institution analysis of 249 patients, managed with whole-brain radiotherapy for brain metastases. The sum of scores was calculated as in the Japanese study. The following parameters were included: number of brain metastases, volume of the largest lesion, sex, Karnofsky performance status, primary cancer type, control of primary cancer, and presence of extra-cerebral metastases. Results: Median overall survival was 3.0 months (95% CI= 2.6-3.4 months). The median sum of scores was 12, range=0-29. Statistically significant differences were observed between all prognostic strata. Conclusion: The graded prognostic model is also applicable to patients treated with whole-brain rather than stereotactic radiotherapy
Patterns of treatment and outcome in patients with 20 or more brain metastases
Background/Aim - The aim of this study was to analyze the patterns of treatment and outcomes in patients with a large number of brain metastases, arbitrarily defined as 20 or more lesions. These patients are typically excluded from studies of focal brain treatment, e.g., surgery or radiosurgery, and might have a limited prognosis.
Patients and Methods - This was a retrospective single-institution analysis. Overall, 11 patients were identified from a prospectively maintained database.
Results - Ten patients had received active treatment (9 whole-brain radiotherapy, 7 systemic therapy). Median survival was 5.0 months without long-term survival beyond 13 months. Patients with better performance status had numerically longer survival, however we did not identify baseline parameters with a significant impact on survival.
Conclusion - While long-term survival was not observed in this small study, most patients survived long enough to experience symptomatic improvement from whole-brain radiotherapy. Therefore, we recommend multidisciplinary assessment of the patients' prognosis and systemic treatment options, and initiation of whole-brain radiotherapy if survival is not limited to 1-2 months
Validation of a Graded Prognostic Model in Patients With Brain Metastases Treated With Whole-brain Radiotherapy Instead of Radiosurgery
Background/Aim: The aim of this study was to analyze the survival predictions obtained from a recent graded prognostic model developed and validated in Japan. Patients and Methods: This was a retrospective single-institution analysis of 249 patients, managed with whole-brain radiotherapy for brain metastases. The sum of scores was calculated as in the Japanese study. The following parameters were included: number of brain metastases, volume of the largest lesion, sex, Karnofsky performance status, primary cancer type, control of primary cancer, and presence of extra-cerebral metastases. Results: Median overall survival was 3.0 months (95% CI= 2.6-3.4 months). The median sum of scores was 12, range=0-29. Statistically significant differences were observed between all prognostic strata. Conclusion: The graded prognostic model is also applicable to patients treated with whole-brain rather than stereotactic radiotherapy
Independent External Validation of the METSSS Model Predicting Survival after Palliative Radiotherapy
Background/Aim: A validation of the recently published METSSS model (developed from a large US database) predicting survival after palliative radiotherapy was performed. METSSS includes age, sex, cancer type, localization of distant metastases, comorbidity, and radiotherapy site. Patients and Methods: Both 1- and 5-year survival was assessed in the validation cohort. Deviations between model-predicted and observed survival were analyzed. Results: The METSSS model predicted a 1-year survival of 29% (cohort median, predicted probability 0-74% in individual patients). The observed 1-year survival rate was 33% (median survival 5.3 months). The corresponding figures for predicted 5-year survival were 0% and 0-46% (observed rate 3%). Statistical comparison of the survival curves was possible for two of three strata (insufficient number of low-risk patients) and the resulting p-value was 0.045. Conclusion: A complete validation was hampered by imbalances in group size. More than 90% of our patients were classified as high risk. If this distribution is representative for other countries, the METSSS model might need adjustment. However, its general ability to predict survival appears promising