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Palliative Radiation Therapy in the Last 30 Days of Life: A Systematic Review
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Volume 99 Number 2S Supplement 2017 ment, were included in the study. BPE intensity was evaluated by Visual Analog Scale (VAS) after the procedure that triggered them, and after the administration of FPNC. All pts described a very high VAS value (mean: 8.8; range: 7-10) related with the specific procedure. The administration of FPNC was performed according our department protocol. 87.9% of the pts were already receiving an opioid basal treatment equivalent to 40-160 mg morphine. For every FPNC administration, data related to response, degree of pain relief, onset of the relief, need of new FPNC administration and fulfilment of the procedure were collected. Results: Age: Mean 62.5 years (range: 42-89). Gender: 36 males and 22 females. Primary tumor: lung 24 pts, prostate 12, breast 11, gynecological 4, digestive 2 and others 5. 53 pts (91.3%) suffered from bone metastases. Procedure that triggered the BPE: Simulation 46 pts and treatment administration 12. In 49 pts (84.5%) VAS score was reduced to 4.8 (range 2-6) after 4.5 minutes (range: 2-10) of first FPNC administration. 9 pts (15.5%) dis not responded after 15 minutes and required a second dose of FPNC. All of them responded and the VAS score was reduced to 4.6 (range 4-6) after 3 minutes of second administration. No side effects related to the FPNC administration were reported. In 84.5% of the patients the procedure was performed after 4.5 minutes. Conclusion: Some procedures in the radiotherapy process may trigger BPE episodes which impede its accomplishment. In our study, FPNC has proven to be very effective in the BPE management, allowing the accomplishment of these procedures in a short time, avoiding delays and unnecessary suffering to patients. Author Disclosure: J. Pardo: None. A. Mena: None. E. Jimenez-Jimenez: None. N. Aymar: None. I. Ortiz: None. M. Vidal: None. R. Roncero: None.
3247 Palliative Radiation Therapy in the Last 30 Days of Life: A Systematic Review K.R. Park,1 C.G. Lee, Jr,2 S. Reddy,3 E. Bruera,4 and S. Yennu3; 1 University of Washington, Seattle, WA, 2Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University Health System, Seoul, Korea, Republic of (South), 3MD Anderson Cancer Center, Houston, TX, 4 MD Anderson Cancer Center, Houston, TX, United States Purpose/Objective(s): To investigate the utilization of palliative radiation therapy (RT), risk factors related to the use of RT, and symptom response of palliative RT during the last 30 days of life through systemic review of literature. Materials/Methods: A systematic electronic literature search of available medical literature databases was performed for these categories: radiation therapy, terminally ill patients, and end-of-life. Only studies on patients receiving palliative RT in the last 30 days of life were included. A formal meta-analysis was not feasible because of the heterogeneity of published studies and the lack of minimal standards in reporting results. Results: A total of 18 studies were evaluated: 9 were population based studies and 9 were from single institutions. RT utilization rate was variable according to study cohort. For all cancer types, 5-10% of patients who died of cancer received palliative RT in the last 30 days of life. Of patients who received any palliative RT, 9-15.3% received this in the last 30 days of life. The most common indications for RT were metastatic bone, lung/mediastinal, brain, or spinal disease. The most commonly used RT fractionation was 30 Gy in 10 fractions (36-90%). Single fraction RT utilization ranged from 0-59%, with reported rates of 8-9.4% in the US and 19-59% in Canada. The proportions of patients receiving >10 fractions during the last 30 days of life was 17-17.8%, 11-12%, and 11% in studies from the US, Canada and Norway, respectively. In 2 studies that reported time spent on RT relative to remaining life span, 52% of patients who survived less than 1 month died during their treatment courses, and half spent greater than 60% of their remaining lifespan
on therapy. ECOG performance status 3-4 was significantly associated with receiving RT in the last 30 days of life and shorter survival. Only 26% of patients who survived less than 1 month were reported to show symptom response following RT. Conclusion: Palliative RT is utilized in about 10% of patients near the end of life. Dose fractionation regimens are variable, as is utilization of single fraction regimens. Many patients spend a large proportion of their end of life actively receiving treatment, with a high rate of mortality during treatment. Careful consideration of the benefits of palliative RT in this patient population should be weighed and greater use of shorter or single fraction regimens rather than more protracted regimens may be beneficial, especially in patients with poor performance status. Author Disclosure: K. Park: None. C. Lee: None. S. Reddy: None. E. Bruera: None. S. Yennu: None.
3248 External Validity of a Nomogram Predicting Risk of 6-Month and 9-Month Distant Brain Failure After Initial Stereotactic Radiosurgery Alone for Brain Metastases in an Independent Multi-institutional Patient Cohort R.S. Prabhu,1 R.H. Press,2 D.M. Boselli,3 K. Patel,4 J.T. Symanowski,3 S.P. Lankford,1 R.J. McCammon,5 B.J. Moeller,5 J.H. Heinzerling,5 C. Fasola,5 A. Asher,6 A.L. Sumrall,7 W.J. Curran, Jr,8 H.K.G. Shu,8 I.R. Crocker,2 and S.H. Burri5; 1Southeast Radiation Oncology Group, Levine Cancer Institute, Carolinas HealthCare System, Charlotte, NC, 2 Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta, GA, 3Department of Biostatistics, Levine Cancer Institute, Carolinas Healthcare System, Charlotte, NC, 4Winship Cancer Institute, Emory University, Atlanta, GA, 5Levine Cancer Institute: Carolinas HealthCare System, Charlotte, NC, 6Carolina Neurosurgery and Spine Associates, Charlotte, NC, 7Department of Oncology, Levine Cancer Institute, Carolinas Healthcare System, Charlotte, NC, 8Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, GA Purpose/Objective(s): Patients (pts) treated with stereotactic radiosurgery (SRS) alone for brain metastases (BM) are at increased risk of distant brain failure (DBF). A nomogram for predicting individualized 6 and 9-month freedom from DBF after SRS was recently published based on a single institution database (Ayala-Peacock et al., Neuro Oncol 2014). This nomogram has not undergone external validation in an independent patient population. The goal of this study was to assess the external validity of this nomogram in a multi-institutional independent patient cohort. Materials/Methods: The records of consecutive pts with BM treated with SRS alone at 2 tertiary care cancer institutes between 2005-2013 were reviewed. Inclusion criteria was the same as the Ayala-Peacock study and included patients with BM treated with initial SRS alone, no previous cranial radiotherapy, up to 13 synchronous BM, and either non-small cell lung (NSCLC), breast, renal cell (RCC), or melanoma primary cancer. Additionally, our validation cohort excluded pts with less than 3 months MRI follow-up. The nomogram variables included age, sex, race, primary histology, systemic disease status, and number of BM to calculate 6 and 9-month freedom from DBF using the Kaplan-Meier method. Discrimination was assessed using the Harrell’s c-index and calibration was evaluated using calibration plots and correlation between expected and observed freedom from DBF. Results: After exclusions, 281 patients with 416 BM were eligible and made up the validation cohort. The median patient age was 61 years old, 48% were male, and 78% were white. Primary site was NSCLC for 49%, melanoma - 25%, breast - 19%, RCC - 8%, and 63% had active systemic disease at the time of SRS. The median imaging
Volume 99 Number 2S Supplement 2017 ment, were included in the study. BPE intensity was evaluated by Visual Analog Scale (VAS) after the procedure that triggered them, and after the administration of FPNC. All pts described a very high VAS value (mean: 8.8; range: 7-10) related with the specific procedure. The administration of FPNC was performed according our department protocol. 87.9% of the pts were already receiving an opioid basal treatment equivalent to 40-160 mg morphine. For every FPNC administration, data related to response, degree of pain relief, onset of the relief, need of new FPNC administration and fulfilment of the procedure were collected. Results: Age: Mean 62.5 years (range: 42-89). Gender: 36 males and 22 females. Primary tumor: lung 24 pts, prostate 12, breast 11, gynecological 4, digestive 2 and others 5. 53 pts (91.3%) suffered from bone metastases. Procedure that triggered the BPE: Simulation 46 pts and treatment administration 12. In 49 pts (84.5%) VAS score was reduced to 4.8 (range 2-6) after 4.5 minutes (range: 2-10) of first FPNC administration. 9 pts (15.5%) dis not responded after 15 minutes and required a second dose of FPNC. All of them responded and the VAS score was reduced to 4.6 (range 4-6) after 3 minutes of second administration. No side effects related to the FPNC administration were reported. In 84.5% of the patients the procedure was performed after 4.5 minutes. Conclusion: Some procedures in the radiotherapy process may trigger BPE episodes which impede its accomplishment. In our study, FPNC has proven to be very effective in the BPE management, allowing the accomplishment of these procedures in a short time, avoiding delays and unnecessary suffering to patients. Author Disclosure: J. Pardo: None. A. Mena: None. E. Jimenez-Jimenez: None. N. Aymar: None. I. Ortiz: None. M. Vidal: None. R. Roncero: None.
3247 Palliative Radiation Therapy in the Last 30 Days of Life: A Systematic Review K.R. Park,1 C.G. Lee, Jr,2 S. Reddy,3 E. Bruera,4 and S. Yennu3; 1 University of Washington, Seattle, WA, 2Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University Health System, Seoul, Korea, Republic of (South), 3MD Anderson Cancer Center, Houston, TX, 4 MD Anderson Cancer Center, Houston, TX, United States Purpose/Objective(s): To investigate the utilization of palliative radiation therapy (RT), risk factors related to the use of RT, and symptom response of palliative RT during the last 30 days of life through systemic review of literature. Materials/Methods: A systematic electronic literature search of available medical literature databases was performed for these categories: radiation therapy, terminally ill patients, and end-of-life. Only studies on patients receiving palliative RT in the last 30 days of life were included. A formal meta-analysis was not feasible because of the heterogeneity of published studies and the lack of minimal standards in reporting results. Results: A total of 18 studies were evaluated: 9 were population based studies and 9 were from single institutions. RT utilization rate was variable according to study cohort. For all cancer types, 5-10% of patients who died of cancer received palliative RT in the last 30 days of life. Of patients who received any palliative RT, 9-15.3% received this in the last 30 days of life. The most common indications for RT were metastatic bone, lung/mediastinal, brain, or spinal disease. The most commonly used RT fractionation was 30 Gy in 10 fractions (36-90%). Single fraction RT utilization ranged from 0-59%, with reported rates of 8-9.4% in the US and 19-59% in Canada. The proportions of patients receiving >10 fractions during the last 30 days of life was 17-17.8%, 11-12%, and 11% in studies from the US, Canada and Norway, respectively. In 2 studies that reported time spent on RT relative to remaining life span, 52% of patients who survived less than 1 month died during their treatment courses, and half spent greater than 60% of their remaining lifespan
on therapy. ECOG performance status 3-4 was significantly associated with receiving RT in the last 30 days of life and shorter survival. Only 26% of patients who survived less than 1 month were reported to show symptom response following RT. Conclusion: Palliative RT is utilized in about 10% of patients near the end of life. Dose fractionation regimens are variable, as is utilization of single fraction regimens. Many patients spend a large proportion of their end of life actively receiving treatment, with a high rate of mortality during treatment. Careful consideration of the benefits of palliative RT in this patient population should be weighed and greater use of shorter or single fraction regimens rather than more protracted regimens may be beneficial, especially in patients with poor performance status. Author Disclosure: K. Park: None. C. Lee: None. S. Reddy: None. E. Bruera: None. S. Yennu: None.
3248 External Validity of a Nomogram Predicting Risk of 6-Month and 9-Month Distant Brain Failure After Initial Stereotactic Radiosurgery Alone for Brain Metastases in an Independent Multi-institutional Patient Cohort R.S. Prabhu,1 R.H. Press,2 D.M. Boselli,3 K. Patel,4 J.T. Symanowski,3 S.P. Lankford,1 R.J. McCammon,5 B.J. Moeller,5 J.H. Heinzerling,5 C. Fasola,5 A. Asher,6 A.L. Sumrall,7 W.J. Curran, Jr,8 H.K.G. Shu,8 I.R. Crocker,2 and S.H. Burri5; 1Southeast Radiation Oncology Group, Levine Cancer Institute, Carolinas HealthCare System, Charlotte, NC, 2 Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta, GA, 3Department of Biostatistics, Levine Cancer Institute, Carolinas Healthcare System, Charlotte, NC, 4Winship Cancer Institute, Emory University, Atlanta, GA, 5Levine Cancer Institute: Carolinas HealthCare System, Charlotte, NC, 6Carolina Neurosurgery and Spine Associates, Charlotte, NC, 7Department of Oncology, Levine Cancer Institute, Carolinas Healthcare System, Charlotte, NC, 8Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, GA Purpose/Objective(s): Patients (pts) treated with stereotactic radiosurgery (SRS) alone for brain metastases (BM) are at increased risk of distant brain failure (DBF). A nomogram for predicting individualized 6 and 9-month freedom from DBF after SRS was recently published based on a single institution database (Ayala-Peacock et al., Neuro Oncol 2014). This nomogram has not undergone external validation in an independent patient population. The goal of this study was to assess the external validity of this nomogram in a multi-institutional independent patient cohort. Materials/Methods: The records of consecutive pts with BM treated with SRS alone at 2 tertiary care cancer institutes between 2005-2013 were reviewed. Inclusion criteria was the same as the Ayala-Peacock study and included patients with BM treated with initial SRS alone, no previous cranial radiotherapy, up to 13 synchronous BM, and either non-small cell lung (NSCLC), breast, renal cell (RCC), or melanoma primary cancer. Additionally, our validation cohort excluded pts with less than 3 months MRI follow-up. The nomogram variables included age, sex, race, primary histology, systemic disease status, and number of BM to calculate 6 and 9-month freedom from DBF using the Kaplan-Meier method. Discrimination was assessed using the Harrell’s c-index and calibration was evaluated using calibration plots and correlation between expected and observed freedom from DBF. Results: After exclusions, 281 patients with 416 BM were eligible and made up the validation cohort. The median patient age was 61 years old, 48% were male, and 78% were white. Primary site was NSCLC for 49%, melanoma - 25%, breast - 19%, RCC - 8%, and 63% had active systemic disease at the time of SRS. The median imaging