Radiation Oncology in Palliative Cancer Care

Stephen Lutz is one of only a small number of Radiation Oncologists who is also board certified in Hospice and Palliative Medicine.?He has served as the liaison between the US radiotherapy and palliative care communities for the past several years. His main research interests have included the formation of palliative radiotherapy treatment guidelines as well as the collaboration between the two specialties with regard to research, education, and patient advocacy. Edward Chow is a Professor in the Department of Radiation Oncology at the University of Toronto?and is a senior scientist in the Sunnybrook Research Institute. He is Chair of the Rapid Response Radiotherapy Program and Bone Metastases Site Group in the Odette Cancer Center at?Sunnybrook Health Sciences Centre. Peter Hoskin is a UK clinical oncologist with long standing research interests in palliative radiotherapy, in particular the management of bone metastases and spinal cord compression. He was a clinical research fellow in Palliative Medicine working in opioid pharmacology before focusing his interests in clinical oncology and was Chair of the International Consensus in Palliative Radiotherapy in 2000 and ESTRO Co-chair in 2010. He has written extensively on the role of radiotherapy in palliative care in original publications and major book chapters.

• Contributor list xvForeword xixPart 1: General principles of radiation oncology 11 A brief history of palliative radiation oncology 3Joshua JonesIntroduction 3The early years 3Fractionation 6Advances in radiotherapy technique: the 1950s and 1960s 7Fractionation revisited: explicit palliation 10Stereotactic radiotherapy 11Prognostication and tailoring palliative radiotherapy to anticipated survival 11Conclusion 12References 132 The radiobiology of palliative radiation oncology 15Candice A. JohnstoneIntroduction 15Radiation effect on cells 15Cell cycle characteristics 18Interaction of cell cycle and radiotherapy fractionation 18Radiotherapy fractionation characteristics 19Conclusion 20References 203 The physics of radiation oncology 22Shaun Baggarley Jiade J. LuIntroduction 22The development of radiation therapy technology 24Process of radiation therapy 27Special considerations in developing countries 28Conclusion 29References 294 Curative intent versus palliative intent radiation oncology 31Vassilios Vassiliou Haris CharalambousIntroduction 31The determination of cure plus palliation intent versus pure palliative intent 33Clinical diagnoses 35Special considerations in developing countries 38Conclusion 39References 395 Side effects of palliative radiotherapy 43Alysa FairchildIntroduction 43Issues with interpreting palliative radiotherapy toxicity data 44Acute side effects 45Late side effects 50Additive toxicity 53Clinical advice 53New technologies 55Challenges in developing countries 55Conclusion 56References 56Part 2: General principles of palliation and symptom control 616 A history of hospice and palliative medicine 63Michelle Winslow Marcia MeldrumIntroduction 63Before the modern movement 63St. Christopher’s and the modern hospice 64Palliative care in the United States 66Global development of hospice and palliative care 68Continuing challenges 69References 697 Radiation therapy and hospice care 72Charles F. von Gunten Frank D. Ferris and Arno J. Mundt Introduction 72Hospice care around the world 72Hospice care in the United States 73Palliative radiation and hospice 77Conclusion 79References 798 The current status of palliative care and radiotherapy 81Thomas Smith Susannah Batko-YovinoWhat is palliative care? 81Who can benefit from palliative care? 81What are the goals of palliative care and what features of a palliative care program help to accomplish these goals? 83What is the evidence regarding the benefi ts and risks of palliative care? When should palliative care be introduced to a patient? 84Are there standards for palliative care? If so what are the defining measures? 88How does palliative care fi t in with radiation oncology? 90References 929 Palliative care in low and middle income countries: A focus on sub-Saharan Africa 95Henry Ddungu Elizabeth A. BarnesIntroduction 95The need for palliative care 95Radiotherapy 96Specific clinical indications for palliative radiotherapy in Africa 97Challenges of palliative care delivery 98Addressing challenges to adequate palliative care 98Palliative care research 100Delivery of palliative care 101Conclusion 102References 10210 Pain management 105Erin McMenaminIntroduction 105Pain assessment 105Analgesia ladder 106Primary pharmacologic interventions 107Adjuvant medications 108End-of-life considerations 109Conclusion 109References 110Part 3: Locally advanced or locally recurrent diseases 11311 Primary tumors of the central nervous system 115Caroline Chung Eric L. ChangIntroduction 115Radiotherapy 116Side-effect risks 120Radiotherapy limitations 120Adjuvant treatment modalities 121Promise of newer technologies 121Special considerations in developing countries 122Conclusion 122References 12212 The role of palliative care in head and neck cancer 126Albert Tiong June CorryIntroduction 126Current management of head and neck squamous cell carcinomas 126Patient selection for palliative treatment 127Use of palliative radiotherapy in head and neck squamous cell carcinomas 130Recurrent disease 134The promise of emerging technologies 135Chemotherapy in palliative head and neck squamous cell carcinomas 135Non-squamous cell carcinomas histologies 136Specific issues in palliation of head and neck squamous cell carcinomas 137Special considerations in developing countries 138Conclusion 138References 13913 The role of palliative radiotherapy in breast cancer 145Ian H. KunklerIntroduction 145Rates of palliative loco-regional radiotherapy 148Biologic considerations 148Definitions clinical features and multi-disciplinary approach 148Clinical scenarios 150Symptom control 153Palliative loco-regional radiotherapy for oligometastatic disease 154Radiotherapy dosing schedules 154Radiotherapy technique and the promise of newer technology 156Special considerations in developing countries 158Follow up 158Conclusion 159References 15914 Palliative radiotherapy in advanced lung cancer 163George Rodrigues Benjamin MovsasIntroduction 163Radiotherapy treatment 165The impact of emerging technologies 169Important circumstances 171Special considerations in developing countries 173Conclusion 173References 17415 Palliative radiotherapy for gastrointestinal and colorectal cancer 177Robert Glynne-Jones Mark HarrisonIntroduction 177Treatment of dysphagia 178Gastric cancer 180Palliation of biliary obstruction 181Nodes at origin of the superior mesenteric artery 181High dose rate brachytherapy 182Locally advanced/recurrent rectal cancer 182Re-irradiation 184Anal cancer 184The promise of highly conformal therapy 184Special considerations in developing countries 184Conclusion 185References 18516 Genitourinary malignancies 188Gillian M. DuchesneIntroduction 188Incidence and etiology 188Clinical behavior 190Bladder cancer 190Prostate cancer 190Renal cancer 190Palliative radiotherapy and other approaches for management of primary disease 192Specific management of metastatic disease in urologic malignancies 194The promise of highly conformal therapy 196Special considerations in developing countries 197Conclusion 197References 19717 Palliative radiotherapy in locally advanced and locally recurrent gynecologic cancer 199Firuza PatelIntroduction 199Patterns of loco-regional failures for gynecologic cancers 200Management 201Treatment of recurrent carcinoma of the cervix 206Recurrence after defi nitive radiation 206Recurrence after defi nitive surgery 207The promise of newer technologies 207Special considerations in developing countries 207Conclusion 208References 20918 Hematologic malignancies and associated conditions 210David D. HowellIntroduction 210Diagnoses 210Specific clinical circumstances 213Locally advanced and recurrent disease 216Future directions 216Special considerations in developing countries 217Conclusion 217References 21719 Pediatric palliative radiation oncology 220Tamara Vern-GrossIntroduction 220Delivery of radiation treatment 221Differences between pediatric and adult populations 222Background 222Clinical indications for palliative radiotherapy 224Caring for the pediatric patient 232Barriers to the use of palliative radiotherapy 233Special considerations in developing countries 233Conclusion 234References 234Part 4: Metastatic disease 23920 Bone metastases 241Yvette van der Linden Dirk RadesIntroduction 241Clinical implications and treatment modalities 241Clinical symptoms 242Technical considerations 250Prognosis and choice for treatment 250Proactive approach 251Special considerations in developing countries 251Conclusion 251References 25321 Spinal cord compression 257Ernesto Maranzano Fabio TrippaIntroduction 257Treatment 259Promise of newer technologies 264Re-irradiation 265Special considerations in developing countries 265Conclusion 266References 26722 Brain metastases 270May TsaoIntroduction 270Radiotherapy treatment 271Radiotherapy limitations 277Promise of newer technologies and areas of ongoing research 277International patterns of care and special considerations in developing countries 278Conclusion 278References 27923 Liver metastases 283Sean BydderIntroduction 283Radiotherapy treatment 284Whole-liver radiation therapy 286Conformal radiation therapy 288Brachytherapy 289Selective internal radiation therapy 289Surgery for liver metastases 290Radiofrequency ablation 290Promising new radiotherapy techniques 290Practice variation among different countries 293Conclusion 294Acknowledgments 294References 29424 Palliative radiotherapy for malignant neuropathic pain adrenal choroidal and skin metastases 299Daniel E. Roos Aaron H. WolfsonMalignant neuropathic pain 299Adrenal metastases 302Choroidal metastases 308Skin metastases (A.H. Wolfson) 312Conclusion 314References 314Part 5: Integration of radiation oncology and palliative care 31725 Design challenges in palliative radiation oncology clinical trials 319Deborah Watkins Bruner Lawrence B. BerkIntroduction 319Challenges with the validation of palliative metrics 319Evolution of palliative care clinical trials: the Radiation TherapyOncology Group experience 320International research efforts 325Conclusion 326References 32626 Radiation oncology cost-effectiveness 329Andre KonskiIntroduction 329Cost-effectiveness 330Newer technologies 332Conclusion 333References 33327 Quality measures and palliative radiotherapy 335James A. Hayman Rinaa S. Punglia and Anushree M. VichareIntroduction 335Quality measures: characteristics 336Developing quality measures 338Desirable attributes of quality measures 340Uses of quality measures 340Current uses of quality measures in radiation oncology 341International quality measures in radiation oncology 342Conclusion 343References 34428 Use of technologically advanced radiation oncology techniques for palliative patients 347Simon S. Lo Bin S. Teh Samuel T. Chao Arjun Sahgal Nina A. Mayr and Eric L. ChangIntroduction 347Overview of technologically advanced radiotherapy techniques 347Clinical applications reported in the literature 349Brain metastasis 349Stereotactic radiosurgery 349Scalp-sparing whole brain radiation therapy 351Hippocampus-sparing whole brain radiation therapy 351Stereotactic radiation therapy 351Spinal metastasis 352Spinal cord compression 352Bone metastasis 355Adrenal metastasis 355Toxicities associated with palliative radiotherapy using advanced technologies 356Conclusion 357References 357Index 361

“This is an excellent book that addresses a crucial aspect of radiotherapy in a way that I have not seen before. It is concise and easy to digest, but also packed with information that will help guide healthcare professionals in their practice. It would be useful for palliative care clinicians and medical oncologists, but is of particular use as a reference text to radiation oncologists and their trainees.”  (European Journal of Palliative Care, 21 April 2014)