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 1–23%. 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

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 ≤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 ≤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

Independent validation of a risk stratification model predicting survival in elderly patients irradiated for bone metastases

Background/Aim: Many patients with bone metastases receive palliative radiotherapy. However, treatment personalization tools are needed, due to heterogeneous survival. The aim of this study was to analyze the validity of the prognostic survival model, originally developed by Rades et al., because international variations in clinical practice and survival outcomes may impact on the performance of predictive tools. Patients and Methods: Data from a single institution were retrospectively analyzed. The study included 305 patients managed with palliative radiotherapy for bone metastases. The Rades et al. score was assigned and the resulting 3 prognostic strata were compared. Results: The median overall survival for the 3 strata was 48, 248, and 1065 days, respectively (p25 points) was not in accordance with the overlapping survival curves in some of the subgroups, leading us to propose slight adjustments. The modified model also performed satisfactorily in older patients (age ≥80 years; median survival 26, 192 and 489 days, respectively, p<0.001). Conclusion: The original Rades et al. survival score was a valid prognostic model in our Norwegian validation database. However, inclusion of patients with 18 points into the poor prognosis group is suggested as a modification to enhance the score’s performance.acceptedVersio

Patterns of Care and Survival in Cancer Patients with Brain Metastases Receiving Immune Checkpoint Inhibitors

Introduction: Immune checkpoint inhibitors (ICIs) have become a mainstay of treatment for different cancer types. The purpose of this study was to evaluate patterns of care and overall survival (OS) after diagnosis of brain metastases in patients managed with ICI as component of care. Methods: This was a retrospective cohort study. Fifty patients were included (34 with brain metastases at first cancer diagnosis, 16 with metachronous spread). Results: Depending on symptoms, lesion number and size, and other individualized criteria, multidisciplinary tumor (MDT) board discussion resulted in highly individualized treatment sequences. Selected patients received systemic treatment alone. Twenty-four patients (48%) had any stereotactic radiosurgery or neurosurgical resection at some point in time (upfront/salvage). Only 7 patients (14%) were never treated with brain irradiation or neurosurgery. Median OS was 13.0 months. Better Karnofsky performance status, absence of extracranial metastases, and time interval between cancer diagnosis and brain metastases of 0–18 months predicted for improved survival. Treatment sequence was not associated with survival. Patients without extracranial metastases had median OS of 52.2 months. Conclusion: Long-term survival is possible in patients managed with ICI ± brain-directed treatment. This study did not identify a clear treatment sequence of choice. MDT assessment at diagnosis and each progression is recommended to ensure favorable outcomes.acceptedVersio

The LabPS score: Inexpensive, Fast, and Site-agnostic Survival Prediction

Objectives: To provide a widely applicable, blood-biomarker-based and performance-status-based prognostic model, which predicts the survival of patients undergoing palliative non-brain radiotherapy. This model has already been examined in a cohort of patients treated for brain metastases and performed well. Methods: This was a retrospective single-institution analysis of 375 patients, managed with non-ablative radiotherapy to extracranial targets, such as bone, lung, or lymph nodes. Survival was stratified by LabPS score, a model including serum hemoglobin, platelets, albumin, C-reactive protein, lactate dehydrogenase, and performance status. Zero, 0.5, or 1 point was assigned and the final point sum calculated. A higher point sum indicates shorter survival. Results: The LabPS score predicted overall survival very well (median 0.6 to 26.5 mo, 3-month rate 0% to 100%, 1-year rate 0% to 89%), P=0.0001. However, the group with the poorest prognosis (4.5 points) was very small. Most patients with comparably short survival or radiotherapy administered in the last month of life had a lower point sum. Additional prognostic factors, such as liver metastases, opioid analgesic use, and/or corticosteroid medication, were identified. Conclusions: If busy clinicians prefer a general prognostic model rather than a panel of separate diagnosis-specific/target-specific scores, they may consider validating the LabPS score in their own practice. In resource-constrained settings, inexpensive standard blood tests may be preferable over imaging-derived prognostic information. Just like other available scores, the LabPS cannot identify all patients with very short survival

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 (&lt; 5% vs. ≥ 5%). The retrospective study included 219 patients (287 courses of palliative radiotherapy). After univariate analyses, multi-nominal logistic regression was employed.   Results: PRL on treatment ranged from 1–23%. Single-fraction radiotherapy resulted in &lt; 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 &lt; 0.001). If analyzed without fractionation, none-bone target volume (p &lt; 0.001), hemoglobin (p &lt; 0.001), KPS (p = 0.01), lack of additional systemic treatment (p = 0.01), and hypercalcemia (p = 0.04) were significant.      Conclusions: Fractionation is an easily modifiable factor with high impact on PRL. Patients with KPS &lt; 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.   

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 (2011–2021) 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 3–6 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 model’s 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

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