Radiotherapy and Oncology 115 (2015) 284
Contents lists available at ScienceDirect
Radiotherapy and Oncology journal homepage: www.thegreenjournal.com
Letter to the Editor Palliative radiotherapy (PRT) during the last month of life: A constant sorrow even in a dedicated PRT facility with research focus on this endpoint To the Editor Spencer et al. have recently reported a population based study of 14,972 PRT episodes (2004–2011), which were performed in a large cancer center in Leeds, UK [1]. Treatment was prescribed by approximately 20–30 different oncologists. Survival was calculated from the start of PRT. The commonest irradiation site was bone and most patients had lung, breast or prostate cancer. Only 12% of patients received P10 fractions (50% single fraction PRT). Median survival was 169 days and 12% of patients died within 30 days of the initiation of PRT. Thirty day mortality (30DM) was highest in patients with lung or bladder cancer and after single fraction PRT. The latter fact illustrates that decision making and choice of fractionation reflected most patients’ prognosis. In other words, patients with short survival expectation were spared the burden and inconvenience of lengthy PRT. Over time, 30DM did not change significantly. Ideally, 30DM would be as low as possible and patients who die shortly after PRT would at least experience some clinical benefit. In our institution with dedicated PRT program, which serves a smaller population of less than 200,000, comparable survival and 30DM were seen during the time period 2007–2009 [2]. We were able to develop and validate a predictive model (presence of 6 parameters: lung or bladder cancer, Eastern Cooperative Oncology Group (ECOG) performance status (PS) of 3–4, low hemoglobin, opioid analgesic use, steroid use, progressive disease outside PRT volume), which correctly identified 75% of PRT courses administered during the final 30 days of life, and provide a recommendation for management of brain metastases [3]. External validation by other institutions is awaited. Given that our research focused on PRT and survival prediction, and only 3 clinical oncologists assessed patients and prescribed PRT, we hypothesized that increased awareness and knowledge about factors predicting 30DM might have led to decreased 30DM in the time period after completion of our analyses. Therefore, we evaluated our most recent data (01.09.2013–31.08.2014). As shown in Table 1, 30 DM was highest in patients with metastatic cancer (17%). Disappointingly, even in our small, dedicated PRT facility with considerable research activity, including publication of a comprehensive institutional audit, 30DM did not improve compared to previous years. As discussed by Spencer et al. [1], oncologists tend to overestimate survival of patients receiving palliative therapy. Given that short-course PRT regimens with no or minimal side effects exist, which nevertheless often improve symptoms, clinicians are afraid of withholding a meaningful therapeutic measure. In agreement with our findings [2], Anshushaug et al. also reported that ECOG PS 3–4 was strongly associated with PRT during the last month of life [4], but other factors also play a role. Given consistent reports from different countries, should we regard 30DM of 615% as unavoidable and acceptable? If not, we need to develop http://dx.doi.org/10.1016/j.radonc.2015.04.017 0167-8140/Ó 2015 Elsevier Ireland Ltd. All rights reserved.
Table 1 Rate of adult palliative radiotherapy during the last month of life stratified by cancer types (stereotactic radiotherapy not included). Primary cancer type
Metastatic (n = 174)
Non-metastatic (n = 38)
All combined Prostate cancer Breast cancer Thyroid cancer Non-small cell lung cancer Small cell lung cancer Colorectal cancer Gastric cancer Esophageal cancer Bladder cancer Kidney cancer Head and neck cancer Sarcoma Hepatocellular cancer Malignant melanoma Gynecological cancers Unknown primary tumor Multiple myeloma Lymphoma Others
30 out of 174 (17%) 2 out of 28 1 out of 28 0 out of 2 8 out of 39 2 out of 9 5 out of 18 1 out of 1 0 out of 1
2 out of 38 (5%) 0 out of 2 0 out of 3 0 out of 12 0 out of 1 0 out of 3 1 out of 5 1 out of 5
3 out of 12 0 out of 2 0 0 1 2 0 2 1 2
out out out out out out out out
of of of of of of of of
1 3 5 5 2 13 4 3
0 out of 5
more advanced, disease- and site-specific prediction tools, which must not predict short survival in patients actually surviving long enough to experience reduced symptoms. Ideally, they would also identify the vast majority of patients who die too soon to benefit. References [1] Spencer K, Morris E, Dugdale E. 30 day mortality in adult palliative radiotherapy – a retrospective population based study of 14,972 treatment episodes. Radiother Oncol 2015;115:264–71. [2] Angelo K, Norum J, Dalhaug A, et al. Development and validation of a model predicting short survival (death within 30 days) after palliative radiotherapy. Anticancer Res 2014;34:877–85. [3] Nieder C, Marienhagen K, Dalhaug A, et al. Prognostic models predicting survival of patients with brain metastases: integration of lactate dehydrogenase, albumin and extracranial organ involvement. Clin Oncol (R Coll Radiol) 2014;26:447–52. [4] Anshushaug M, Gynnild MA, Kaasa S, et al. Characterization of patients receiving palliative chemo- and radiotherapy during end of life at a regional cancer center in Norway. Acta Oncol 2014;27:1–8.
Carsten Nieder Institute of Clinical Medicine, Faculty of Health Sciences, UiT – The Arctic University of Norway, Tromsø Department of Oncology and Palliative Medicine, Nordland Hospital, 8092 Bodø, Norway E-mail address: [email protected]
Available online 14 May 2015
Contents lists available at ScienceDirect
Radiotherapy and Oncology journal homepage: www.thegreenjournal.com
Letter to the Editor Palliative radiotherapy (PRT) during the last month of life: A constant sorrow even in a dedicated PRT facility with research focus on this endpoint To the Editor Spencer et al. have recently reported a population based study of 14,972 PRT episodes (2004–2011), which were performed in a large cancer center in Leeds, UK [1]. Treatment was prescribed by approximately 20–30 different oncologists. Survival was calculated from the start of PRT. The commonest irradiation site was bone and most patients had lung, breast or prostate cancer. Only 12% of patients received P10 fractions (50% single fraction PRT). Median survival was 169 days and 12% of patients died within 30 days of the initiation of PRT. Thirty day mortality (30DM) was highest in patients with lung or bladder cancer and after single fraction PRT. The latter fact illustrates that decision making and choice of fractionation reflected most patients’ prognosis. In other words, patients with short survival expectation were spared the burden and inconvenience of lengthy PRT. Over time, 30DM did not change significantly. Ideally, 30DM would be as low as possible and patients who die shortly after PRT would at least experience some clinical benefit. In our institution with dedicated PRT program, which serves a smaller population of less than 200,000, comparable survival and 30DM were seen during the time period 2007–2009 [2]. We were able to develop and validate a predictive model (presence of 6 parameters: lung or bladder cancer, Eastern Cooperative Oncology Group (ECOG) performance status (PS) of 3–4, low hemoglobin, opioid analgesic use, steroid use, progressive disease outside PRT volume), which correctly identified 75% of PRT courses administered during the final 30 days of life, and provide a recommendation for management of brain metastases [3]. External validation by other institutions is awaited. Given that our research focused on PRT and survival prediction, and only 3 clinical oncologists assessed patients and prescribed PRT, we hypothesized that increased awareness and knowledge about factors predicting 30DM might have led to decreased 30DM in the time period after completion of our analyses. Therefore, we evaluated our most recent data (01.09.2013–31.08.2014). As shown in Table 1, 30 DM was highest in patients with metastatic cancer (17%). Disappointingly, even in our small, dedicated PRT facility with considerable research activity, including publication of a comprehensive institutional audit, 30DM did not improve compared to previous years. As discussed by Spencer et al. [1], oncologists tend to overestimate survival of patients receiving palliative therapy. Given that short-course PRT regimens with no or minimal side effects exist, which nevertheless often improve symptoms, clinicians are afraid of withholding a meaningful therapeutic measure. In agreement with our findings [2], Anshushaug et al. also reported that ECOG PS 3–4 was strongly associated with PRT during the last month of life [4], but other factors also play a role. Given consistent reports from different countries, should we regard 30DM of 615% as unavoidable and acceptable? If not, we need to develop http://dx.doi.org/10.1016/j.radonc.2015.04.017 0167-8140/Ó 2015 Elsevier Ireland Ltd. All rights reserved.
Table 1 Rate of adult palliative radiotherapy during the last month of life stratified by cancer types (stereotactic radiotherapy not included). Primary cancer type
Metastatic (n = 174)
Non-metastatic (n = 38)
All combined Prostate cancer Breast cancer Thyroid cancer Non-small cell lung cancer Small cell lung cancer Colorectal cancer Gastric cancer Esophageal cancer Bladder cancer Kidney cancer Head and neck cancer Sarcoma Hepatocellular cancer Malignant melanoma Gynecological cancers Unknown primary tumor Multiple myeloma Lymphoma Others
30 out of 174 (17%) 2 out of 28 1 out of 28 0 out of 2 8 out of 39 2 out of 9 5 out of 18 1 out of 1 0 out of 1
2 out of 38 (5%) 0 out of 2 0 out of 3 0 out of 12 0 out of 1 0 out of 3 1 out of 5 1 out of 5
3 out of 12 0 out of 2 0 0 1 2 0 2 1 2
out out out out out out out out
of of of of of of of of
1 3 5 5 2 13 4 3
0 out of 5
more advanced, disease- and site-specific prediction tools, which must not predict short survival in patients actually surviving long enough to experience reduced symptoms. Ideally, they would also identify the vast majority of patients who die too soon to benefit. References [1] Spencer K, Morris E, Dugdale E. 30 day mortality in adult palliative radiotherapy – a retrospective population based study of 14,972 treatment episodes. Radiother Oncol 2015;115:264–71. [2] Angelo K, Norum J, Dalhaug A, et al. Development and validation of a model predicting short survival (death within 30 days) after palliative radiotherapy. Anticancer Res 2014;34:877–85. [3] Nieder C, Marienhagen K, Dalhaug A, et al. Prognostic models predicting survival of patients with brain metastases: integration of lactate dehydrogenase, albumin and extracranial organ involvement. Clin Oncol (R Coll Radiol) 2014;26:447–52. [4] Anshushaug M, Gynnild MA, Kaasa S, et al. Characterization of patients receiving palliative chemo- and radiotherapy during end of life at a regional cancer center in Norway. Acta Oncol 2014;27:1–8.
Carsten Nieder Institute of Clinical Medicine, Faculty of Health Sciences, UiT – The Arctic University of Norway, Tromsø Department of Oncology and Palliative Medicine, Nordland Hospital, 8092 Bodø, Norway E-mail address: [email protected]
Available online 14 May 2015
