Fast Fact and Concept #67: Palliative Radiation - Part 2

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Title: Fast Fact and Concept #67: Palliative Radiation - Part 2

Author(s): Carolyn Rutter; David E Weissman

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 and 4) treatment burden-time spent coming to XRT site, time off work for family, cost, etc.

Bone Metastases-- External beam therapy achieves pain relief in >75% of patients with healing and reossification 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 shorter 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 neurology symptoms (e.g. seizures).

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

Also see:
Fast Fact #66, Radiation for Palliation - Part 1

References: Ciezki JP Palliative Radiotherapy Seminars in Oncology 01-Feb-2000; 27(1):90-3.

Kirkbride, P The Role of Radiation Therapy in Palliative Care Journal of Palliative Care1995; 11(1):19-26.

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.

Perez C, Brady L, Chao KSC, eds. Radiation Oncology: Management Decisions 3rd ed. Philadelphia: Lippincott-Raven. 1999.

Tisdale BA When to Consider Radiation Therapy for Your Patient American Family Physician 1999;59(5).

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.

Copyright and Referencing Information: Users are free to download and distribute Fast Facts for educational purposes only. Citation for referencing Fast Facts and Concepts #67 Radiation for palliation-Part 2. Rutter C and Weissman DE. April, 2002. End-of-Life Physician Education Resource Center www.eperc.mcw.edu.

Fast Facts and Concepts was originally developed as an end-of-life teaching tool by Eric Warm, MD, U. Cincinnati, Department of Medicine. See: Warm, E. Improving EOL care--internal medicine curriculum project. J Pall Med 1999; 2: 339-340.

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Creation Date: 5/2002

Format: Handouts

Purpose: Instructional Aid, Self-Study Guide, Teaching

Training: Fellows, 3rd/4th Year Medical Students, PGY1 (Interns), PGY2-6, Physicians in Practice
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Keyword(s): Neurologic, Neurologic diseases, Pain treatment, Radiation or chemotherapy

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