Radiation Oncology in Palliative Cancer Care

Contributor list xv
Foreword xix
Part 1: General principles of radiation oncology 1
1 A brief history of palliative radiation oncology 3 Joshua Jones
Introduction 3
The early years 3
Fractionation 6
Advances in radiotherapy technique: the 1950s and 1960s 7
Fractionation revisited: explicit palliation 10
Stereotactic radiotherapy 11
Prognostication and tailoring palliative radiotherapy to anticipated survival 11
Conclusion 12
References 13
2 The radiobiology of palliative radiation oncology 15 Candice A. Johnstone
Introduction 15
Radiation effect on cells 15
Cell cycle characteristics 18
Interaction of cell cycle and radiotherapy fractionation 18
Radiotherapy fractionation characteristics 19
Conclusion 20
References 20
3 The physics of radiation oncology 22 Shaun Baggarley Jiade J. Lu
Introduction 22
The development of radiation therapy technology 24
Process of radiation therapy 27
Special considerations in developing countries 28
Conclusion 29
References 29
4 Curative intent versus palliative intent radiation oncology 31 Vassilios Vassiliou Haris Charalambous
Introduction 31
The determination of cure plus palliation intent versus pure palliative intent 33
Clinical diagnoses 35
Special considerations in developing countries 38
Conclusion 39
References 39
5 Side effects of palliative radiotherapy 43 Alysa Fairchild
Introduction 43
Issues with interpreting palliative radiotherapy toxicity data 44
Acute side effects 45
Late side effects 50
Additive toxicity 53
Clinical advice 53
New technologies 55
Challenges in developing countries 55
Conclusion 56
References 56
Part 2: General principles of palliation and symptom control 61
6 A history of hospice and palliative medicine 63 Michelle Winslow Marcia Meldrum
Introduction 63
Before the modern movement 63
St. Christopher s and the modern hospice 64
Palliative care in the United States 66
Global development of hospice and palliative care 68
Continuing challenges 69
References 69
7 Radiation therapy and hospice care 72 Charles F. von Gunten Frank D. Ferris and Arno J. Mundt Introduction 72
Hospice care around the world 72
Hospice care in the United States 73
Palliative radiation and hospice 77
Conclusion 79
References 79
8 The current status of palliative care and radiotherapy 81 Thomas Smith Susannah Batko–Yovino
What is palliative care? 81
Who can benefit from palliative care? 81
What are the goals of palliative care and what features of a palliative care program help to accomplish these goals? 83
What is the evidence regarding the benefi ts and risks of palliative care? When should palliative care be introduced to a patient? 84
Are there standards for palliative care? If so what are the defining measures? 88
How does palliative care fi t in with radiation oncology? 90
References 92
9 Palliative care in low and middle income countries: A focus on sub–Saharan Africa 95 Henry Ddungu Elizabeth A. Barnes
Introduction 95
The need for palliative care 95
Radiotherapy 96
Specific clinical indications for palliative radiotherapy in Africa 97
Challenges of palliative care delivery 98
Addressing challenges to adequate palliative care 98
Palliative care research 100
Delivery of palliative care 101
Conclusion 102
References 102
10 Pain management 105 Erin McMenamin
Introduction 105
Pain assessment 105
Analgesia ladder 106
Primary pharmacologic interventions 107
Adjuvant medications 108
End–of–life considerations 109
Conclusion 109
References 110
Part 3: Locally advanced or locally recurrent diseases 113
11 Primary tumors of the central nervous system 115 Caroline Chung Eric L. Chang
Introduction 115
Radiotherapy 116
Side–effect risks 120
Radiotherapy limitations 120
Adjuvant treatment modalities 121
Promise of newer technologies 121
Special considerations in developing countries 122
Conclusion 122
References 122
12 The role of palliative care in head and neck cancer 126 Albert Tiong June Corry
Introduction 126
Current management of head and neck squamous cell carcinomas 126
Patient selection for palliative treatment 127
Use of palliative radiotherapy in head and neck squamous cell carcinomas 130
Recurrent disease 134
The promise of emerging technologies 135
Chemotherapy in palliative head and neck squamous cell carcinomas 135
Non–squamous cell carcinomas histologies 136
Specific issues in palliation of head and neck squamous cell carcinomas 137
Special considerations in developing countries 138
Conclusion 138
References 139
13 The role of palliative radiotherapy in breast cancer 145 Ian H. Kunkler
Introduction 145
Rates of palliative loco–regional radiotherapy 148
Biologic considerations 148
Definitions clinical features and multi–disciplinary approach 148
Clinical scenarios 150
Symptom control 153
Palliative loco–regional radiotherapy for oligometastatic disease 154
Radiotherapy dosing schedules 154
Radiotherapy technique and the promise of newer technology 156
Special considerations in developing countries 158
Follow up 158
Conclusion 159
References 159
14 Palliative radiotherapy in advanced lung cancer 163 George Rodrigues Benjamin Movsas
Introduction 163
Radiotherapy treatment 165
The impact of emerging technologies 169
Important circumstances 171
Special considerations in developing countries 173
Conclusion 173
References 174
15 Palliative radiotherapy for gastrointestinal and colorectal cancer 177 Robert Glynne–Jones Mark Harrison
Introduction 177
Treatment of dysphagia 178
Gastric cancer 180
Palliation of biliary obstruction 181
Nodes at origin of the superior mesenteric artery 181
High dose rate brachytherapy 182
Locally advanced/recurrent rectal cancer 182
Re–irradiation 184
Anal cancer 184
The promise of highly conformal therapy 184
Special considerations in developing countries 184
Conclusion 185
References 185
16 Genitourinary malignancies 188 Gillian M. Duchesne
Introduction 188
Incidence and etiology 188
Clinical behavior 190
Bladder cancer 190
Prostate cancer 190
Renal cancer 190
Palliative radiotherapy and other approaches for management of primary disease 192
Specific management of metastatic disease in urologic malignancies 194
The promise of highly conformal therapy 196
Special considerations in developing countries 197
Conclusion 197
References 197
17 Palliative radiotherapy in locally advanced and locally recurrent gynecologic cancer 199 Firuza Patel
Introduction 199
Patterns of loco–regional failures for gynecologic cancers 200
Management 201
Treatment of recurrent carcinoma of the cervix 206
Recurrence after defi nitive radiation 206
Recurrence after defi nitive surgery 207
The promise of newer technologies 207
Special considerations in developing countries 207
Conclusion 208
References 209
18 Hematologic malignancies and associated conditions 210 David D. Howell
Introduction 210
Diagnoses 210
Specific clinical circumstances 213
Locally advanced and recurrent disease 216
Future directions 216
Special considerations in developing countries 217
Conclusion 217
References 217
19 Pediatric palliative radiation oncology 220 Tamara Vern–Gross
Introduction 220
Delivery of radiation treatment 221
Differences between pediatric and adult populations 222
Background 222
Clinical indications for palliative radiotherapy 224
Caring for the pediatric patient 232
Barriers to the use of palliative radiotherapy 233
Special considerations in developing countries 233
Conclusion 234
References 234
Part 4: Metastatic disease 239
20 Bone metastases 241 Yvette van der Linden Dirk Rades
Introduction 241
Clinical implications and treatment modalities 241
Clinical symptoms 242
Technical considerations 250
Prognosis and choice for treatment 250
Proactive approach 251
Special considerations in developing countries 251
Conclusion 251
References 253
21 Spinal cord compression 257 Ernesto Maranzano Fabio Trippa
Introduction 257
Treatment 259
Promise of newer technologies 264
Re–irradiation 265
Special considerations in developing countries 265
Conclusion 266
References 267
22 Brain metastases 270 May Tsao
Introduction 270
Radiotherapy treatment 271
Radiotherapy limitations 277
Promise of newer technologies and areas of ongoing research 277
International patterns of care and special considerations in developing countries 278
Conclusion 278
References 279
23 Liver metastases 283 Sean Bydder
Introduction 283
Radiotherapy treatment 284
Whole–liver radiation therapy 286
Conformal radiation therapy 288
Brachytherapy 289
Selective internal radiation therapy 289
Surgery for liver metastases 290
Radiofrequency ablation 290
Promising new radiotherapy techniques 290
Practice variation among different countries 293
Conclusion 294
Acknowledgments 294
References 294
24 Palliative radiotherapy for malignant neuropathic pain adrenal choroidal and skin metastases 299 Daniel E. Roos Aaron H. Wolfson
Malignant neuropathic pain 299
Adrenal metastases 302
Choroidal metastases 308
Skin metastases (A.H. Wolfson) 312
Conclusion 314
References 314
Part 5: Integration of radiation oncology and palliative care 317
25 Design challenges in palliative radiation oncology clinical trials 319 Deborah Watkins Bruner Lawrence B. Berk
Introduction 319
Challenges with the validation of palliative metrics 319
Evolution of palliative care clinical trials: the Radiation Therapy
Oncology Group experience 320
International research efforts 325
Conclusion 326
References 326
26 Radiation oncology cost–effectiveness 329 Andre Konski
Introduction 329
Cost–effectiveness 330
Newer technologies 332
Conclusion 333
References 333
27 Quality measures and palliative radiotherapy 335 James A. Hayman Rinaa S. Punglia and Anushree M. Vichare
Introduction 335
Quality measures: characteristics 336
Developing quality measures 338
Desirable attributes of quality measures 340
Uses of quality measures 340
Current uses of quality measures in radiation oncology 341
International quality measures in radiation oncology 342
Conclusion 343
References 344
28 Use of technologically advanced radiation oncology techniques for palliative patients 347 Simon S. Lo Bin S. Teh Samuel T. Chao Arjun Sahgal Nina A. Mayr and Eric L. Chang
Introduction 347
Overview of technologically advanced radiotherapy techniques 347
Clinical applications reported in the literature 349
Brain metastasis 349
Stereotactic radiosurgery 349
Scalp–sparing whole brain radiation therapy 351
Hippocampus–sparing whole brain radiation therapy 351
Stereotactic radiation therapy 351
Spinal metastasis 352
Spinal cord compression 352
Bone metastasis 355
Adrenal metastasis 355
Toxicities associated with palliative radiotherapy using advanced technologies 356
Conclusion 357
References 357
Index 361