FAST FACTS AND CONCEPT #67: Radiation for
Palliation – Part 2

2nd Edition

Authors: Carolyn Rutter, MD and David E. Weissman, MD

This Fast Fact reviews the common indications for palliative radiation. The most important decision when considering palliative XRT is to assess the balance between anticipated functional/symptomatic benefit versus time spent receiving therapy and acute toxicities. It is vital to review

1) The estimated prognosis

2) Current and anticipated best functional status outcome

3) Expected toxicities

4) Treatment burden—time spent coming to XRT site, time off work for family, and cost

Bone Metastases -- External beam therapy achieves pain relief in >75% of patients with healing and reosification occurring in 65-85% of lytic lesions in non-fractured bone. Pain relief may begin within the first few treatments and peaks by 4 weeks following XRT completion. A standard radiation prescription in the US is 300 cGy x 10 fractions; however, data exists to support a single large fraction (800 cGy x 1) for extremity lesions, especially in patients with expected survival < 3 months. Note: surgical fixation prior to XRT is indicated for large lesions, when >50% of the cortex is replaced by tumor, or when fracture has occurred in a weight-bearing bone.

Radionuclide therapy with Strontium 89 or Samarium 153 is indicated for multiple sites of painful bone metastases, typically breast or prostate cancer. Peak analgesic effect occurs 3-6 weeks following treatment. Side effects are hematological with decreased blood counts in 10-30% of patients. Worsening of pain, “pain flare”, may occur following administration and prior to pain relief. Radionuclide therapy can be combined with external beam radiation and can be given more than once.

Epidural Metastases and Spinal Cord Compression -- External Beam Radiation is the primary definitive treatment in conjunction with a short-course of steroids. The standard U.S. prescription is 300 cGy x 10 fractions; although shorter courses can be used if needed (e.g. 400 cGy x 5). Results of treatment are directly related to the neurological status at the time treatment starts. Ambulatory patients at the start of treatment generally remain ambulatory, while non-ambulatory patients are unlikely to have return of weight-bearing function. Indications for surgery include no tissue diagnosis, spinal instability, bone fragments causing cord damage and progression during/after XRT.

Brain Metastases -- Palliative Radiation, either whole-brain external beam radiation or, for small lesions, stereotactic radiosurgery (AKA Gamma Knife), can relieve symptoms and prolong survival. The standard US prescription is 300 cGy x 10 fractions ; although s horter courses can be used ( e.g. 400 cGy x 5) . Surgery is indicated for good prognosis patients with a single accessible lesion or for refractory neurological symptoms (e.g. seizures).

Other Indications: The following are all appropriate for consideration of palliative radiation:

1. Obstruction: vascular (SVC syndrome), esophagus, airway, rectum, biliary tract
2. Pain: adrenal metastases—flank pain, nerve impingement
3. Bleeding: stomach, esophagus, head/neck cancer, bladder, cervix
4. Ulceration/fungation

References:

1. Ciezki JP. Palliative Radiotherapy. Seminars in Oncology. 01-Feb-2000; 27(1):90-3
2. Kirkbride, P. The Role of Radiation Therapy in Palliative Care. Journal of Palliative Care. 1995; 11(1):19-26
3. Labow DA, Laperriere NJ. Emergency Treatment of Malignant Extradural Spinal Cord Compression: An Evidence-Based Guideline. Journal of Clinical Oncology. 1998;16(4):1613-24
4. Perez C, Brady L., Chao KSC, eds. Radiation Oncology: Management Decisions. 3 rd ed. Philadelphia: Lippincott-Raven 1999
5. Tisdale BA. When to Consider Radiation Therapy for Your Patient. American Family Physician 1999;59(5)
6. Kirkbride P and Bezjak. Palliative Radiation Therapy. In Principles and Practice of Palliative Care and Supportive Oncology. Berger A, Portenoy R and Weissman DE (eds.) Lippincott, 2002.

Fast Facts were edited by David Weissman MD, Palliative Care Center, Medical College of Wisconsin until January 2007.  For comments/questions write to the current editor, Drew Rosielle MD: drosiell@mcw.edu. The complete set of Fast Facts is available at EPERC: www.eperc.mcw.edu

Copyright/Referencing Information: Users are free to download and distribute Fast Facts for educational purposes only. Citation for referencing: Ritter C and Weissman DE. Fast Facts and Concepts #67: Radiation for palliation Part 2; 2 nd Edition. September 2006. End-of-Life / Palliative Education Resource Center: www.eperc.mcw.edu.

Disclaimer: Fast Facts provide educational information. This information is not medical advice. Health care providers should exercise their own independent clinical judgment. Some Fast Fact information cites the use of a product in dosage, for an indication, or in a manner other than that recommended in the product labeling. Accordingly, the official prescribing information should be consulted before any such product is used.

Creation Date: 5/2002

Purpose: Instructional Aid, Self-Study Guide, Teaching

Audience(s)

ACGME Competencies: Medical Knowledge, Patient Care

Keyword(s): Pain>non-opioids; cancer

Specific Disease and Organ System Category(s): Cancer