Helen Fosmire, MD

The VHA is the primary care provider for 20.4% of the more than 21.9 million military veterans.¹ Surveys report that over a lifetime, an estimated 28.4% of U.S. veterans will receive some measure of their health care from the VHA.² An estimated 40,000 new cancer cases are diagnosed each year from these veterans, resulting in a minimum of 175,000 veterans receiving cancer care in VHA facilities.³ The 39 VHA facilities currently with onsite radiation oncology practices annually provide radiation therapy to about 20,000 veterans (Figure 1).

Nationally, tumor control and toxicity outcomes have each improved over recent decades as advances have occurred in imaging, radiation treatment planning, and equipment for the delivery of radiotherapy.⁴ The VHA has kept pace with these technological advancements to the point where image-guided radiotherapy (IGRT), intensity-modulated radiotherapy (IMRT), and stereotactic body radiotherapy (SBRT) are widely available at VHA centers. Additionally, all active VHA radiation oncology centers have earned accreditation from the American College of Radiology, while 3 new centers are in the process of gaining accreditation.

When technologies deemed to be medically necessary are not available onsite, these treatments are made available to veterans through referral to other VHA or non-VHA centers. Here, the authors present the results of a survey of VHA-based radiation oncologists to evaluate onsite availability of various radiation technologies.

Methods

The VHA Palliative Radiotherapy Task Force constructed an online survey and sent it to the 82 radiation oncologists practicing at the 38 VHA radiation oncology centers that were active at the time. After emailing the survey,follow-up phone calls were made to maximize response rates. The survey was conducted during the months of May and June of 2014.

In this survey, all 82 VHA radiation oncologists were queried on the availability of advanced radiation delivery technologies including IGRT, IMRT, and SBRT at their facilities. The authors also surveyed for presence of brachytherapy (BT) programs, stereotactic radiosurgery (SRS), and cone-beam computed tomography (CBCT). Information was collected regarding the extent to which physicians can treat cases requiring SRS and/or SBRT onsite vs through referral to another facility for treatment. These data were gathered from a survey conducted in conjunction with a larger survey on the practice and patterns of care in the treatment of patients with brain metastases within the VHA.5,6 The data presented here apply to radiation therapy in general and are not limited to the treatment of brain metastases.

Results

The overall response rate was 76% (62 of 82 radiation oncologists). At the time of the survey, 90% (34 of 38) of active VHA radiation oncology treatment facilities were represented. However as of May 2016, there are 40 active VHA radiation oncology centers. Figure 2 describes the availability of various treatment delivery systems. The data demonstrated 100% availability of IMRT. Respondents reported onsite availability of IGRT at 91%, CBCT at 74%, and SBRT at 53%. Treatment technologies that were not as widely available at VHA facilities with inherent radiation oncology practices included SRS at 29% and BT at 21%. For cases requiring SRS, 69% (40 of 58) of respondents who answered this question indicated that they refer patients to other VHA radiation oncology centers or VHA contracted private entities. This report is limited by the following factors:

• A narrow scope of practices was surveyed. The survey was solely sent to VHA physicians at 38 active VHA radiation oncology centers out of 144 VHA hospitals. Therefore the practices at VHA medical centers without active VHA radiation was not acquired with this survey.
• This survey only addresses availability of these newer treatment technologies, not their actual use, in treating cancers predominant within the VHA.
• Literature comparison in this report is based on current use of these technologies for some of the reports cited, rather than availability as this report reflects. As such, direct comparisons could be misleading.
  

Discussion

Although the total number of veterans has been decreasing in recent years, the number of veterans enrolling into VHA-related programs has been increasing and is expected to expand increase further in years to come.^1,2 It is important for radiation oncologists to keep pace with new technologies to ensure their patients have access to the best possible treatments.

Advances in radiation oncology have allowed radiotherapy to evolve from the 2-dimensional treatments of the 1950s to the 1980s, to more targeted treatments that employ advanced imaging and complex planning. Modern techniques for delivery of radiotherapy are better at confining radiation dose to the tumor volume while minimizing the irradiation of normal structures. The use of cumbersome blocks, wedges, and tissue compensators has given way to treatment with internal collimation techniques such as IMRT, SBRT, and SRS. These techniques rely heavily on image guidance for tumor targeting. Four-dimensional planning and treatment allow radiation oncologists to track tumor and normal tissue motion, thereby increasing the accuracy and precision of radiation treatments.

As is true in the community, IMRT and IGRT are widely available within the VHA. According to a survey by Simpson and colleagues evaluating the use of IGRT in the U.S., 93% of radiation oncologists use IGRT.⁷ Similarly, the survey presented here demonstrates that 91% of VHA radiation oncologists report availability of IGRT at their centers. All VHA radiation oncologists surveyed report access to IMRT.

Shen’s recent report evaluating radiotherapy patterns of practice from 2002 to 2010 examined volume of payments for treatment delivery by codes for office-based IMRT.⁸ These authors noted an increase in the usage of IMRT as a percentage of external beam radiotherapy from 2002 to 2010 of 0% to 70%, respectively. They further noted during this period that IGRT use, based on total payments for treatment delivery, increased from 2.1% to 11.1%.

The reported use of onsite SBRT among VHA physicians is slightly less than that of community physicians. A survey study by Pan and colleagues demonstrated that 63.9% of U.S. radiation oncologists use SBRT, while in the survey study presented here, 53% of VHA radiation oncologists reported availability of onsite SBRT.⁹ Of note, the lack of availability of onsite SBRT at VHA centers does not preclude treatment with SBRT when medically necessary. These cases can be referred to other VHA or community centers with the requisite accreditation credentials. Because of the increasing use of SBRT and related technologies in the treatment of some cancers, an improved availability of SBRT in the future within the VHA will allow for some centers to participate in the Veterans Affairs Lung Cancer Surgery or Stereotactic Radiotherapy (VALOR) trial, which was approved for open recruitment in 2015.

Although BT and SRS are not as widely available within the VHA as other evaluated technologies such as IGRT and IMRT, their availability mirrors a similar limited availability in the community.^10-12 When necessary these services also can be provided for veterans through referral to other VHA or non-VHA centers.

The benefit of charged particle radiotherapy, such as proton beam radiotherapy, is limited to specific cancers.¹³ This technology is not widely available in the community or within the VHA. Because of a VHA policy currently in place permitting non-VHA care when needed, veterans who require treatment with charged particle radiotherapy are referred to accredited non-VHA radiation oncology centers when indicated.

Conclusion

In this survey, 92% of the VHA radiation oncology centers are accredited by the American College of Radiology. Further, VHA radiation oncologists respondents reported availability of treatment technologies in line with responses of physicians from community based surveys. The majority of VHA radiation oncologists report access to IMRT, IGRT, CBCT, and SBRT. While BT and SRS are not available onsite at the majority of the 40 VHA radiation oncology centers, this mirrors limited availability and use of these technologies in the community as well.

Acknowledgments
This article was based on a presentation at the ASCO Quality Care Symposium (October 17-18, 2014) in Boston, Massachusetts. Dawson GA, Cheuk AV, Jolly S, et al. Advanced radiation oncology technology within the Veterans Health Administration (VHA). J Clin Oncol. 214;32(suppl 30):52.

Author disclosures
The authors report no actual or potential conflicts of interest with regard to this article.

Disclaimer
The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, or any of its agencies.

Click here to read the digital edition.

The VHA is the primary care provider for 20.4% of the more than 21.9 million military veterans.¹ Surveys report that over a lifetime, an estimated 28.4% of U.S. veterans will receive some measure of their health care from the VHA.² An estimated 40,000 new cancer cases are diagnosed each year from these veterans, resulting in a minimum of 175,000 veterans receiving cancer care in VHA facilities.³ The 39 VHA facilities currently with onsite radiation oncology practices annually provide radiation therapy to about 20,000 veterans (Figure 1).

Nationally, tumor control and toxicity outcomes have each improved over recent decades as advances have occurred in imaging, radiation treatment planning, and equipment for the delivery of radiotherapy.⁴ The VHA has kept pace with these technological advancements to the point where image-guided radiotherapy (IGRT), intensity-modulated radiotherapy (IMRT), and stereotactic body radiotherapy (SBRT) are widely available at VHA centers. Additionally, all active VHA radiation oncology centers have earned accreditation from the American College of Radiology, while 3 new centers are in the process of gaining accreditation.

When technologies deemed to be medically necessary are not available onsite, these treatments are made available to veterans through referral to other VHA or non-VHA centers. Here, the authors present the results of a survey of VHA-based radiation oncologists to evaluate onsite availability of various radiation technologies.

Methods

The VHA Palliative Radiotherapy Task Force constructed an online survey and sent it to the 82 radiation oncologists practicing at the 38 VHA radiation oncology centers that were active at the time. After emailing the survey,follow-up phone calls were made to maximize response rates. The survey was conducted during the months of May and June of 2014.

In this survey, all 82 VHA radiation oncologists were queried on the availability of advanced radiation delivery technologies including IGRT, IMRT, and SBRT at their facilities. The authors also surveyed for presence of brachytherapy (BT) programs, stereotactic radiosurgery (SRS), and cone-beam computed tomography (CBCT). Information was collected regarding the extent to which physicians can treat cases requiring SRS and/or SBRT onsite vs through referral to another facility for treatment. These data were gathered from a survey conducted in conjunction with a larger survey on the practice and patterns of care in the treatment of patients with brain metastases within the VHA.5,6 The data presented here apply to radiation therapy in general and are not limited to the treatment of brain metastases.

Results

The overall response rate was 76% (62 of 82 radiation oncologists). At the time of the survey, 90% (34 of 38) of active VHA radiation oncology treatment facilities were represented. However as of May 2016, there are 40 active VHA radiation oncology centers. Figure 2 describes the availability of various treatment delivery systems. The data demonstrated 100% availability of IMRT. Respondents reported onsite availability of IGRT at 91%, CBCT at 74%, and SBRT at 53%. Treatment technologies that were not as widely available at VHA facilities with inherent radiation oncology practices included SRS at 29% and BT at 21%. For cases requiring SRS, 69% (40 of 58) of respondents who answered this question indicated that they refer patients to other VHA radiation oncology centers or VHA contracted private entities. This report is limited by the following factors:

• A narrow scope of practices was surveyed. The survey was solely sent to VHA physicians at 38 active VHA radiation oncology centers out of 144 VHA hospitals. Therefore the practices at VHA medical centers without active VHA radiation was not acquired with this survey.
• This survey only addresses availability of these newer treatment technologies, not their actual use, in treating cancers predominant within the VHA.
• Literature comparison in this report is based on current use of these technologies for some of the reports cited, rather than availability as this report reflects. As such, direct comparisons could be misleading.
  

Discussion

Although the total number of veterans has been decreasing in recent years, the number of veterans enrolling into VHA-related programs has been increasing and is expected to expand increase further in years to come.^1,2 It is important for radiation oncologists to keep pace with new technologies to ensure their patients have access to the best possible treatments.

Advances in radiation oncology have allowed radiotherapy to evolve from the 2-dimensional treatments of the 1950s to the 1980s, to more targeted treatments that employ advanced imaging and complex planning. Modern techniques for delivery of radiotherapy are better at confining radiation dose to the tumor volume while minimizing the irradiation of normal structures. The use of cumbersome blocks, wedges, and tissue compensators has given way to treatment with internal collimation techniques such as IMRT, SBRT, and SRS. These techniques rely heavily on image guidance for tumor targeting. Four-dimensional planning and treatment allow radiation oncologists to track tumor and normal tissue motion, thereby increasing the accuracy and precision of radiation treatments.

As is true in the community, IMRT and IGRT are widely available within the VHA. According to a survey by Simpson and colleagues evaluating the use of IGRT in the U.S., 93% of radiation oncologists use IGRT.⁷ Similarly, the survey presented here demonstrates that 91% of VHA radiation oncologists report availability of IGRT at their centers. All VHA radiation oncologists surveyed report access to IMRT.

Shen’s recent report evaluating radiotherapy patterns of practice from 2002 to 2010 examined volume of payments for treatment delivery by codes for office-based IMRT.⁸ These authors noted an increase in the usage of IMRT as a percentage of external beam radiotherapy from 2002 to 2010 of 0% to 70%, respectively. They further noted during this period that IGRT use, based on total payments for treatment delivery, increased from 2.1% to 11.1%.

The reported use of onsite SBRT among VHA physicians is slightly less than that of community physicians. A survey study by Pan and colleagues demonstrated that 63.9% of U.S. radiation oncologists use SBRT, while in the survey study presented here, 53% of VHA radiation oncologists reported availability of onsite SBRT.⁹ Of note, the lack of availability of onsite SBRT at VHA centers does not preclude treatment with SBRT when medically necessary. These cases can be referred to other VHA or community centers with the requisite accreditation credentials. Because of the increasing use of SBRT and related technologies in the treatment of some cancers, an improved availability of SBRT in the future within the VHA will allow for some centers to participate in the Veterans Affairs Lung Cancer Surgery or Stereotactic Radiotherapy (VALOR) trial, which was approved for open recruitment in 2015.

Although BT and SRS are not as widely available within the VHA as other evaluated technologies such as IGRT and IMRT, their availability mirrors a similar limited availability in the community.^10-12 When necessary these services also can be provided for veterans through referral to other VHA or non-VHA centers.

The benefit of charged particle radiotherapy, such as proton beam radiotherapy, is limited to specific cancers.¹³ This technology is not widely available in the community or within the VHA. Because of a VHA policy currently in place permitting non-VHA care when needed, veterans who require treatment with charged particle radiotherapy are referred to accredited non-VHA radiation oncology centers when indicated.

Conclusion

In this survey, 92% of the VHA radiation oncology centers are accredited by the American College of Radiology. Further, VHA radiation oncologists respondents reported availability of treatment technologies in line with responses of physicians from community based surveys. The majority of VHA radiation oncologists report access to IMRT, IGRT, CBCT, and SBRT. While BT and SRS are not available onsite at the majority of the 40 VHA radiation oncology centers, this mirrors limited availability and use of these technologies in the community as well.

Acknowledgments
This article was based on a presentation at the ASCO Quality Care Symposium (October 17-18, 2014) in Boston, Massachusetts. Dawson GA, Cheuk AV, Jolly S, et al. Advanced radiation oncology technology within the Veterans Health Administration (VHA). J Clin Oncol. 214;32(suppl 30):52.

Author disclosures
The authors report no actual or potential conflicts of interest with regard to this article.

Disclaimer
The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, or any of its agencies.

Click here to read the digital edition.

The VHA is the primary care provider for 20.4% of the more than 21.9 million military veterans.¹ Surveys report that over a lifetime, an estimated 28.4% of U.S. veterans will receive some measure of their health care from the VHA.² An estimated 40,000 new cancer cases are diagnosed each year from these veterans, resulting in a minimum of 175,000 veterans receiving cancer care in VHA facilities.³ The 39 VHA facilities currently with onsite radiation oncology practices annually provide radiation therapy to about 20,000 veterans (Figure 1).

Nationally, tumor control and toxicity outcomes have each improved over recent decades as advances have occurred in imaging, radiation treatment planning, and equipment for the delivery of radiotherapy.⁴ The VHA has kept pace with these technological advancements to the point where image-guided radiotherapy (IGRT), intensity-modulated radiotherapy (IMRT), and stereotactic body radiotherapy (SBRT) are widely available at VHA centers. Additionally, all active VHA radiation oncology centers have earned accreditation from the American College of Radiology, while 3 new centers are in the process of gaining accreditation.

When technologies deemed to be medically necessary are not available onsite, these treatments are made available to veterans through referral to other VHA or non-VHA centers. Here, the authors present the results of a survey of VHA-based radiation oncologists to evaluate onsite availability of various radiation technologies.

Methods

The VHA Palliative Radiotherapy Task Force constructed an online survey and sent it to the 82 radiation oncologists practicing at the 38 VHA radiation oncology centers that were active at the time. After emailing the survey,follow-up phone calls were made to maximize response rates. The survey was conducted during the months of May and June of 2014.

In this survey, all 82 VHA radiation oncologists were queried on the availability of advanced radiation delivery technologies including IGRT, IMRT, and SBRT at their facilities. The authors also surveyed for presence of brachytherapy (BT) programs, stereotactic radiosurgery (SRS), and cone-beam computed tomography (CBCT). Information was collected regarding the extent to which physicians can treat cases requiring SRS and/or SBRT onsite vs through referral to another facility for treatment. These data were gathered from a survey conducted in conjunction with a larger survey on the practice and patterns of care in the treatment of patients with brain metastases within the VHA.5,6 The data presented here apply to radiation therapy in general and are not limited to the treatment of brain metastases.

Results

The overall response rate was 76% (62 of 82 radiation oncologists). At the time of the survey, 90% (34 of 38) of active VHA radiation oncology treatment facilities were represented. However as of May 2016, there are 40 active VHA radiation oncology centers. Figure 2 describes the availability of various treatment delivery systems. The data demonstrated 100% availability of IMRT. Respondents reported onsite availability of IGRT at 91%, CBCT at 74%, and SBRT at 53%. Treatment technologies that were not as widely available at VHA facilities with inherent radiation oncology practices included SRS at 29% and BT at 21%. For cases requiring SRS, 69% (40 of 58) of respondents who answered this question indicated that they refer patients to other VHA radiation oncology centers or VHA contracted private entities. This report is limited by the following factors:

• A narrow scope of practices was surveyed. The survey was solely sent to VHA physicians at 38 active VHA radiation oncology centers out of 144 VHA hospitals. Therefore the practices at VHA medical centers without active VHA radiation was not acquired with this survey.
• This survey only addresses availability of these newer treatment technologies, not their actual use, in treating cancers predominant within the VHA.
• Literature comparison in this report is based on current use of these technologies for some of the reports cited, rather than availability as this report reflects. As such, direct comparisons could be misleading.
  

Discussion

Although the total number of veterans has been decreasing in recent years, the number of veterans enrolling into VHA-related programs has been increasing and is expected to expand increase further in years to come.^1,2 It is important for radiation oncologists to keep pace with new technologies to ensure their patients have access to the best possible treatments.

Advances in radiation oncology have allowed radiotherapy to evolve from the 2-dimensional treatments of the 1950s to the 1980s, to more targeted treatments that employ advanced imaging and complex planning. Modern techniques for delivery of radiotherapy are better at confining radiation dose to the tumor volume while minimizing the irradiation of normal structures. The use of cumbersome blocks, wedges, and tissue compensators has given way to treatment with internal collimation techniques such as IMRT, SBRT, and SRS. These techniques rely heavily on image guidance for tumor targeting. Four-dimensional planning and treatment allow radiation oncologists to track tumor and normal tissue motion, thereby increasing the accuracy and precision of radiation treatments.

As is true in the community, IMRT and IGRT are widely available within the VHA. According to a survey by Simpson and colleagues evaluating the use of IGRT in the U.S., 93% of radiation oncologists use IGRT.⁷ Similarly, the survey presented here demonstrates that 91% of VHA radiation oncologists report availability of IGRT at their centers. All VHA radiation oncologists surveyed report access to IMRT.

Shen’s recent report evaluating radiotherapy patterns of practice from 2002 to 2010 examined volume of payments for treatment delivery by codes for office-based IMRT.⁸ These authors noted an increase in the usage of IMRT as a percentage of external beam radiotherapy from 2002 to 2010 of 0% to 70%, respectively. They further noted during this period that IGRT use, based on total payments for treatment delivery, increased from 2.1% to 11.1%.

The reported use of onsite SBRT among VHA physicians is slightly less than that of community physicians. A survey study by Pan and colleagues demonstrated that 63.9% of U.S. radiation oncologists use SBRT, while in the survey study presented here, 53% of VHA radiation oncologists reported availability of onsite SBRT.⁹ Of note, the lack of availability of onsite SBRT at VHA centers does not preclude treatment with SBRT when medically necessary. These cases can be referred to other VHA or community centers with the requisite accreditation credentials. Because of the increasing use of SBRT and related technologies in the treatment of some cancers, an improved availability of SBRT in the future within the VHA will allow for some centers to participate in the Veterans Affairs Lung Cancer Surgery or Stereotactic Radiotherapy (VALOR) trial, which was approved for open recruitment in 2015.

Although BT and SRS are not as widely available within the VHA as other evaluated technologies such as IGRT and IMRT, their availability mirrors a similar limited availability in the community.^10-12 When necessary these services also can be provided for veterans through referral to other VHA or non-VHA centers.

The benefit of charged particle radiotherapy, such as proton beam radiotherapy, is limited to specific cancers.¹³ This technology is not widely available in the community or within the VHA. Because of a VHA policy currently in place permitting non-VHA care when needed, veterans who require treatment with charged particle radiotherapy are referred to accredited non-VHA radiation oncology centers when indicated.

Conclusion

In this survey, 92% of the VHA radiation oncology centers are accredited by the American College of Radiology. Further, VHA radiation oncologists respondents reported availability of treatment technologies in line with responses of physicians from community based surveys. The majority of VHA radiation oncologists report access to IMRT, IGRT, CBCT, and SBRT. While BT and SRS are not available onsite at the majority of the 40 VHA radiation oncology centers, this mirrors limited availability and use of these technologies in the community as well.

Acknowledgments
This article was based on a presentation at the ASCO Quality Care Symposium (October 17-18, 2014) in Boston, Massachusetts. Dawson GA, Cheuk AV, Jolly S, et al. Advanced radiation oncology technology within the Veterans Health Administration (VHA). J Clin Oncol. 214;32(suppl 30):52.

Author disclosures
The authors report no actual or potential conflicts of interest with regard to this article.

Disclaimer
The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, or any of its agencies.

Click here to read the digital edition.

The authors would like to acknowledge Tony Quang, MD, JD, for the advice given on this project.

Palliative radiotherapy for bone metastases is typically delivered either as a short course of 1 to 5 fractions or protracted over longer courses of up to 20 treatments. These longer courses can be burdensome and discourage its utilization, despite a 50% to 80% likelihood of meaningful pain relief from only a single fraction of radiation therapy. Meanwhile, there are multiple randomized studies that have demonstrated that shorter course(s) are equivalent for pain control.

Although the VHA currently has 143 medical facilities that have cancer diagnostic and treatment capabilities, only 40 have radiation oncology services on-site.¹ Thus, access to palliative radiotherapy may be limited for veterans who do not live close by, and many may seek care outside the VHA. At VHA radiation oncology centers, single-fraction radiation therapy (SFRT) is routinely offered by the majority of radiation oncologists.^2,3 However, the longer course is commonly preferred outside the VA, and a recent SEER-Medicare analysis of more than 3,000 patients demonstrated that the majority of patients treated outside the VA actually receive more than 10 treatments.⁴ For this reason, the VA National Palliative Radiotherapy Task Force prepared this document to provide guidance for clinicians within and outside the VA to increase awareness of the appropriateness, effectiveness, and convenience of SFRT as opposed to longer courses of treatment that increase the burden of care at the end of life and often are unnecessary.

Veterans, Cancer, and Metastases

Within the VA, an estimated 40,000 new cancer cases are diagnosed each year, and 175,000 veterans undergo cancer care within the VHA annually.¹ Unfortunately, the majority will develop bone metastases with postmortem examinations, suggesting that the rate can be as high as 90% at the end of life.^5-7 For many, including veterans with cancer, pain control can be difficult, and access to palliative radiotherapy is critical.⁸

Single-Fraction Palliatiev Radiation Therapy

Historically, patients with painful bone metastases have been treated with courses of palliative radiotherapy ranging between 2 and 4 weeks of daily treatments. However, several large randomized clinical trials comparing a single treatment with multiple treatments have established that SFRT provides equivalent rates of pain relief even when it may be required for a second time.^9-12 Recommendations based on these trials have been incorporated into various treatment guidelines that widely acknowledge the efficacy of SFRT.^13-15

For this reason, SFRT is often preferred at many centers because it is substantially more convenient for patients with cancer. It reduces travel time for daily radiation clinic visits, which allows for more time with loved ones outside the medical establishment. Furthermore, SFRT improves patient access to radiotherapy and reduces costs. The benefits can be direct as well as indirect to those who have to take time for numerous visits.

Longer courses of palliative radiotherapy can be burdensome for patients and primary care providers. Unnecessarily protracted courses of palliative radiotherapy also delay the receipt of systemic therapies because they are typically considered unsafe to administer concurrently. Moreover, when SFRT is unavailable, the burden of long-course palliation is known to discourage health care providers from referring patients since opioid therapy is more convenient, even though it exchanges lucidity for analgesia.^16,17

For this reason, the authors believe that it is in the best interest for veterans with terminal cancers and their providers to be aware of the shorter SFRT for effective, convenient pain relief. This treatment option is particularly relevant for patients with a poor performance status, patients already in hospice care, or patient who travel long distances.

Author disclosures
The authors report no actual or potential conflicts of interest with regard to this article.

Disclaimer
The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, or any of its agencies. This article may discuss unlabeled or investigational use of certain drugs. Please review complete prescribing information for specific drugs or drug combinations—including indications, contraindications, warnings, and adverse effects—before administering pharmacologic therapy to patients.

Click here to read the digital edition.

The authors would like to acknowledge Tony Quang, MD, JD, for the advice given on this project.

Palliative radiotherapy for bone metastases is typically delivered either as a short course of 1 to 5 fractions or protracted over longer courses of up to 20 treatments. These longer courses can be burdensome and discourage its utilization, despite a 50% to 80% likelihood of meaningful pain relief from only a single fraction of radiation therapy. Meanwhile, there are multiple randomized studies that have demonstrated that shorter course(s) are equivalent for pain control.

Although the VHA currently has 143 medical facilities that have cancer diagnostic and treatment capabilities, only 40 have radiation oncology services on-site.¹ Thus, access to palliative radiotherapy may be limited for veterans who do not live close by, and many may seek care outside the VHA. At VHA radiation oncology centers, single-fraction radiation therapy (SFRT) is routinely offered by the majority of radiation oncologists.^2,3 However, the longer course is commonly preferred outside the VA, and a recent SEER-Medicare analysis of more than 3,000 patients demonstrated that the majority of patients treated outside the VA actually receive more than 10 treatments.⁴ For this reason, the VA National Palliative Radiotherapy Task Force prepared this document to provide guidance for clinicians within and outside the VA to increase awareness of the appropriateness, effectiveness, and convenience of SFRT as opposed to longer courses of treatment that increase the burden of care at the end of life and often are unnecessary.

Veterans, Cancer, and Metastases

Within the VA, an estimated 40,000 new cancer cases are diagnosed each year, and 175,000 veterans undergo cancer care within the VHA annually.¹ Unfortunately, the majority will develop bone metastases with postmortem examinations, suggesting that the rate can be as high as 90% at the end of life.^5-7 For many, including veterans with cancer, pain control can be difficult, and access to palliative radiotherapy is critical.⁸

Single-Fraction Palliatiev Radiation Therapy

Historically, patients with painful bone metastases have been treated with courses of palliative radiotherapy ranging between 2 and 4 weeks of daily treatments. However, several large randomized clinical trials comparing a single treatment with multiple treatments have established that SFRT provides equivalent rates of pain relief even when it may be required for a second time.^9-12 Recommendations based on these trials have been incorporated into various treatment guidelines that widely acknowledge the efficacy of SFRT.^13-15

For this reason, SFRT is often preferred at many centers because it is substantially more convenient for patients with cancer. It reduces travel time for daily radiation clinic visits, which allows for more time with loved ones outside the medical establishment. Furthermore, SFRT improves patient access to radiotherapy and reduces costs. The benefits can be direct as well as indirect to those who have to take time for numerous visits.

Longer courses of palliative radiotherapy can be burdensome for patients and primary care providers. Unnecessarily protracted courses of palliative radiotherapy also delay the receipt of systemic therapies because they are typically considered unsafe to administer concurrently. Moreover, when SFRT is unavailable, the burden of long-course palliation is known to discourage health care providers from referring patients since opioid therapy is more convenient, even though it exchanges lucidity for analgesia.^16,17

For this reason, the authors believe that it is in the best interest for veterans with terminal cancers and their providers to be aware of the shorter SFRT for effective, convenient pain relief. This treatment option is particularly relevant for patients with a poor performance status, patients already in hospice care, or patient who travel long distances.

Author disclosures
The authors report no actual or potential conflicts of interest with regard to this article.

Disclaimer
The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, or any of its agencies. This article may discuss unlabeled or investigational use of certain drugs. Please review complete prescribing information for specific drugs or drug combinations—including indications, contraindications, warnings, and adverse effects—before administering pharmacologic therapy to patients.

Click here to read the digital edition.

The authors would like to acknowledge Tony Quang, MD, JD, for the advice given on this project.

Palliative radiotherapy for bone metastases is typically delivered either as a short course of 1 to 5 fractions or protracted over longer courses of up to 20 treatments. These longer courses can be burdensome and discourage its utilization, despite a 50% to 80% likelihood of meaningful pain relief from only a single fraction of radiation therapy. Meanwhile, there are multiple randomized studies that have demonstrated that shorter course(s) are equivalent for pain control.

Although the VHA currently has 143 medical facilities that have cancer diagnostic and treatment capabilities, only 40 have radiation oncology services on-site.¹ Thus, access to palliative radiotherapy may be limited for veterans who do not live close by, and many may seek care outside the VHA. At VHA radiation oncology centers, single-fraction radiation therapy (SFRT) is routinely offered by the majority of radiation oncologists.^2,3 However, the longer course is commonly preferred outside the VA, and a recent SEER-Medicare analysis of more than 3,000 patients demonstrated that the majority of patients treated outside the VA actually receive more than 10 treatments.⁴ For this reason, the VA National Palliative Radiotherapy Task Force prepared this document to provide guidance for clinicians within and outside the VA to increase awareness of the appropriateness, effectiveness, and convenience of SFRT as opposed to longer courses of treatment that increase the burden of care at the end of life and often are unnecessary.

Veterans, Cancer, and Metastases

Within the VA, an estimated 40,000 new cancer cases are diagnosed each year, and 175,000 veterans undergo cancer care within the VHA annually.¹ Unfortunately, the majority will develop bone metastases with postmortem examinations, suggesting that the rate can be as high as 90% at the end of life.^5-7 For many, including veterans with cancer, pain control can be difficult, and access to palliative radiotherapy is critical.⁸

Single-Fraction Palliatiev Radiation Therapy

Historically, patients with painful bone metastases have been treated with courses of palliative radiotherapy ranging between 2 and 4 weeks of daily treatments. However, several large randomized clinical trials comparing a single treatment with multiple treatments have established that SFRT provides equivalent rates of pain relief even when it may be required for a second time.^9-12 Recommendations based on these trials have been incorporated into various treatment guidelines that widely acknowledge the efficacy of SFRT.^13-15

For this reason, SFRT is often preferred at many centers because it is substantially more convenient for patients with cancer. It reduces travel time for daily radiation clinic visits, which allows for more time with loved ones outside the medical establishment. Furthermore, SFRT improves patient access to radiotherapy and reduces costs. The benefits can be direct as well as indirect to those who have to take time for numerous visits.

Longer courses of palliative radiotherapy can be burdensome for patients and primary care providers. Unnecessarily protracted courses of palliative radiotherapy also delay the receipt of systemic therapies because they are typically considered unsafe to administer concurrently. Moreover, when SFRT is unavailable, the burden of long-course palliation is known to discourage health care providers from referring patients since opioid therapy is more convenient, even though it exchanges lucidity for analgesia.^16,17

For this reason, the authors believe that it is in the best interest for veterans with terminal cancers and their providers to be aware of the shorter SFRT for effective, convenient pain relief. This treatment option is particularly relevant for patients with a poor performance status, patients already in hospice care, or patient who travel long distances.

Author disclosures
The authors report no actual or potential conflicts of interest with regard to this article.

Disclaimer
The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, or any of its agencies. This article may discuss unlabeled or investigational use of certain drugs. Please review complete prescribing information for specific drugs or drug combinations—including indications, contraindications, warnings, and adverse effects—before administering pharmacologic therapy to patients.

Click here to read the digital edition.

In recent years, there has been increasing interest in palliative care for patients with cancer at the end of life. Up to 23% of patients have metastatic disease at presentation, and symptoms from metastatic lesions can cause significant anxiety and impair patients’ quality of life (QOL).¹

Palliative radiotherapy (RT) plays a valuable role in the management of metastatic disease to relieve tumor-related symptoms. Although palliative RT does not provide a chance for a cure, it improves QOL and may prolong survival time.^2-4 An estimated 20% to 50% of radiation courses are prescribed with palliative intent, because RT is highly effective in providing symptom relief, and the toxicity associated with palliative doses is typically mild.^5,6 Palliative RT can be used to manage bone and brain metastases, prevent or treat spinal cord compression, and manage numerous tumor-related symptoms, such as pain and bleeding in patients with terminal cancer.

Palliative RT for bone and brain metastases is supported by high-quality evidence and is considered one of the most effective and cost-effective options available.^7,8 This article aims to review the role of RT in treating 3 conditions commonly encountered in patients with metastatic disease—bone metastases, spinal cord compression, and brain metastases—and to emphasize the importance of timely integration of RT for optimal results.

Bone Metastases

About 80% of patients with metastatic solid tumors develop bone metastases, and about 350,000 deaths are linked to bone metastases in the U.S. each year.⁹ Osseous
metastases can lead to pain, fracture, hypercalcemia, and spinal cord compression. The primary modality for treatment of pain and prevention of morbidity from bone metastases is external beam RT.¹⁰

The likelihood of bone pain relief with palliative RT is 60% to 80%, and 30% to 40% of patients achieving complete pain relief. Randomized studies have shown multiple-dose and fractionation regimens provided effective symptom relief for bone metastases. Most commonly used regimens include a single fraction of 8 gray (Gy) delivered in 1 treatment, 20 Gy in 5 fractions delivered daily over 1 week, and 30 Gy in 10 fractions delivered over 2 weeks. Treatment with a single fraction improves access to treatment and patient convenience, whereas more prolonged courses have been associated with lower rates of retreatment.^11,12 Regarding the higher rate of retreatment with single-fraction RT, no clear evidence exists that this is due to a less durable pain response or lower level of pain relief.¹³

There has been recent interest in using predictive models to estimate life expectancy to avoid long courses of RT at the end of life.^14,15 Shorter treatment courses of 8 Gyonce or 20 Gy in 5 fractions are particularly valuable for patients with a life expectancy < 3 months to avoid long courses of treatment, and thereby improve QOL as patients transition into hospice. A recent survey demonstrated that 93% of radiation oncologists within the VHA are willing to prescribe short courses of RT consisting of ≤ 6 fractions, and 76% have experience with single-fraction RT.¹⁶ These findings are in contradiction to the findings in the non-VA radiation oncology community, in which < 10% of patients with uncomplicated bone metastases are treated with a single fraction.^17,18 

In addition to providing pain relief, RT is used in the treatment of impending fractures either, adjuvant after surgical stabilization or alone for lower risk lesions.¹⁹ Factors that impact fracture risk include location of the metastasis (weight-bearing bones, such as femurs, which are at particularly high risk), length of bone involved, and extent of cortical involvement. Mirels’ scoring system was developed to predict fracture risk in patients with bone metastasis, based on 4 criteria: the
extent of cortical involvement, the location of the metastasis, the osteolytic vs osteoblastic appearance of the lesion, and the degree of pain.²⁰ Surgical fixation can be considered, based on the total score and corresponding fracture risk. When appropriate, surgical stabilization should be considered by an orthopedic surgeon prior to initiating RT.

Postoperative RT after surgical stabilization has been associated with a reduced rate of secondary surgical procedures as well as with improved functional status.²¹ Radiotherapy promotes remineralization and bone healing and prevents the loss of surgical fixation by treating any residual tumor. A retrospective review of 60 patients with metastatic disease in weight-bearing bones with pathologic fracture or impending pathologic fracture demonstrated that surgery followed by RT was associated with improved functional status as well as with improved overall survival (OS).^22,23 For patients in whom surgery is not indicated, the consulting radiation oncologist should consider factors such as the location of the metastasis in weight-bearing vs nonweight bearing bones, the size and extent of the metastasis, and associated symptoms when making a treatment recommendation. In patients at fracture risk from bone metastases, bisphosphonates should also be considered as part of the treatment regimen.²⁴

Spinal Cord Compression

About 5% to 10% of patients diagnosed with cancer will develop spinal cord compression during the course of their disease.²⁵ Spinal cord compression is considered a medical emergency that can result in significant pain and neurologic symptoms, including weakness, paralysis, parasthesias, and incontinence. Early treatment of spinal cord compression can prevent onset or progression of these symptoms; furthermore, early treatment prior to loss of ambulation is associated with improved long-term ambulatory function.^26,27

Treatment decisions for spinal metastases with an associated concern for cord compression should be made after a consultation with both a neurosurgeon and a radiation oncologist. Early initiation of steroids is recommended to aid in tumor shrinkage for potential symptom relief.²⁸ A standard way to administer dexamethasone is with a 10-mg loading dose followed by 16 mg per day, divided into 4 doses of 4 mg. Higher steroid doses showed no benefit in a prospective randomized trial comparing 96 mg with 16 mg of dexamethasone daily.²⁹

Surgical decompression should be considered initial management of spinal cord compression. For patients treated surgically, local RT is indicated postoperatively as well. Randomized data show that surgery followed by RT provides better ambulatory function than does RT alone in patients with paralysis of < 2 days’ duration.³⁰ Some patients with metastatic disease are not good candidates for surgery due to comorbidities, poor performance status, life expectancy < 3 months, or multilevel spinal involvement.

In patients who are not operative candidates, radiation alone is an appropriate alternative. However, several factors need consideration in deciding whether to manage cord compression with surgery followed by RT vs RT alone. These factors include life expectancy, tumor type (myeloma and lymphoma are more radiosensitive), interval since tumor diagnosis, and the presence of visceral metastases.³¹ Factors favoring surgical decompression plus postoperative RT over RT alone include spinal instability, KPS (Karnofsky Performance Status) > 70, radio-resistant tumor histology, minimal metastatic disease, and projected survival > 3 months.¹⁰

For patients managed with RT alone, early diagnosis and treatment is associated with improved outcomes. A prospective study of patients treated with RT without surgery for spinal cord compression demonstrated that 82% of patients experienced back pain relief, 76% achieved improvement in or preservation of ambulation, and 44% of patients with sphincter dysfunction experienced improvement with treatment.³² Patients with certain tumor histologies, such as myeloma, breast cancer, and prostate cancer, had better responses to RT.³²

In the setting of spinal cord compression, longer courses of RT may provide better local control than do shorter courses.³³ Therefore, longer courses of RT, such as 30 Gy in 10 fractions delivered over 2 weeks, are often preferred in cases of spinal cord compression treated with definitive RT as well as after surgical decompression. However, overall life expectancy is an important factor considered by the treating radiation oncologist when selecting a short course vs a longer course of RT.

In the instance of painful vertebral body metastases without spinal cord compression, a new subset analysis of the Radiation Therapy Oncology Group (RTOG) 9714 randomized trial indicated that single fraction RT (8 Gy) is just as effective as multiple fractions (30 Gy in 10 fractions), with this study demonstrating comparable rates of pain relief and narcotic use in both groups 3 months after RT.³⁴ Advantages to the single-fraction plan compared with those of multiple fractions include mitigation of logistic concerns for patients and family at the end of life and less acute adverse effects.

Brain Metastases

An estimated 20% to 40% of patients with cancer develop brain metastases.³⁵ The incidence of brain metastases has been rising most likely due to improved detection rates with magnetic resonance imaging (MRI) and improved cancer survival, because treatment regimens have improved with targeted chemotherapy and radiation techniques. Currently, the annual incidence of brain metastases is 170,000 to 200,000 in the U.S.³⁶ Prognosis for these patients is poor, with median survival of 1 month without treatment and about 4 months with whole brain RT (WBRT) (Table).^25,37-39

The goal of management for patients with brain metastases is to prevent or treat neurologic symptoms and to prolong survival. Treatment options include corticosteroids, WBRT, surgery, and stereotactic radiosurgery (SRS). Recommendations for treatment should involve both a radiation oncologist and neurosurgeon to determine the best treatment for an individual based on patient age, performance status, extent of systemic disease, and number of brain metastases. These prognostic factors that may predict life expectancy and impact treatment recommendations.⁴⁰

Factors that have been correlated with improved survival include younger age, better performance status, fewer brain metastases, and lower burden of systemic disease.^41,42 Prognostic assessment tools such as the Graded Prognostic Assessment and RTOG-Recursive Partitioning Analysis can be used to predict life expectancy in patients with brain metastases.^41,43 However, routine use of these tools is lagging, as evidenced by a recent survey of VHA radiation oncologists. Use of these tools in the clinic will enhance the quality of end of life care and decision making.

Corticosteroids have classically been used in the treatment of brain metastases either alone for supportive care or in combination with RT. Steroids are recommended to provide symptom relief in patients with symptoms related to cerebral edema or mass effect.⁴⁴ Steroids have been shown to mitigate edema and improve neurologic deficits in about two-thirds of patients with brain metastases.^36,45 The effect of corticosteroids is thought to be mediated through inhibition of prostaglandin synthesis, reduction in vascular permeability, and anti-inflammatory properties.⁴⁶ A common corticosteroid regimen is a 10-mg loading dose of dexamethasone, followed by 16 mg daily in divided doses. For patients without neurologic deficits or cerebral edema, it is reasonable to defer corticosteroid use only when patients are symptomatic.

In general, WBRT is considered an appropriate treatment option for patients with multiple brain metastases based on data suggesting an improvement in OS compared with the use of corticosteroids alone.⁴⁷ Whole brain radiation has been shown to result in the improvement of baseline neurologic deficits or the prevention of further symptom progression.⁴⁸ The partial or complete metastasis response rates are on the order of 60%.38 Tumor regression after WBRT has been associated with preservation of neurocognitive function as well as prolonged survival.⁴⁹

For good prognosis patients with a single brain metastasis and good performance status, the use of surgery or radiosurgery added to WBRT has been associated with improved OS (Table). The RTOG 9508 randomized trial of WBRT with or without SRS demonstrated a survival advantage with SRS, with median survival times of 6.5 months with WBRT + SRS vs 4.9 months with WBRT alone.⁵⁰ Similarly, a randomized trial evaluating WBRT alone compared with surgery followed by WBRT in patients
with good prognosis demonstrated significantly improved OS in the surgery group (median 40 weeks vs 15 weeks).51 In general, WBRT or postoperative RT to the tumor bed is still indicated after surgical resection, based on randomized data showing a reduction in tumor bed recurrence with postoperative RT.⁵²

For patients with only 1 to 3 brain metastases and a favorable prognosis, surgery and SRS can be considered treatment options, oftentimes with WBRT. The EORTC randomized trial of patients with 1 to 3 brain metastases was designed to determine the benefit of WBRT after treatment with surgery or SRS. In this study, 119 patients underwent SRS and 160 patients underwent surgical resection.⁵³ Both groups of patients were randomized to observation vs adjuvant WBRT. This study demonstrated reduced rates of intracranial relapse with WBRT, however, without any change in OS. Although there is concern that WBRT may impair cognitive function with no clear survival benefit after surgery or SRS, WBRT does reduce recurrence rates in the brain and the need for further treatment.⁵⁴ Therefore, decisions regarding WBRT in such a setting should be made only after a detailed discussion with a radiation oncologist regarding risks vs benefits of treatment as part of the informed decision-making process.

Conclusions

Palliative RT plays an important role in the management of metastatic cancer to provide symptom relief and is a cost-effective treatment option for bone and brain metastases. Life expectancy and tumor characteristics should be considered when making treatment recommendations to ensure selection of regimens that complement patients’ unique situations. Timely referrals for treatment are important to optimize treatment results.

Author disclosures
The authors report no actual or potential conflicts of interest with regard to this article.

Disclaimer
The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, or any of its agencies. This article may discuss unlabeled or investigational use of certain drugs. Please review complete prescribing information for specific drugs or drug combinations—including indications, contraindications, warnings, and adverse effects—before administering pharmacologic therapy to patients.

Click here to read the digital edition.

In recent years, there has been increasing interest in palliative care for patients with cancer at the end of life. Up to 23% of patients have metastatic disease at presentation, and symptoms from metastatic lesions can cause significant anxiety and impair patients’ quality of life (QOL).¹

Palliative radiotherapy (RT) plays a valuable role in the management of metastatic disease to relieve tumor-related symptoms. Although palliative RT does not provide a chance for a cure, it improves QOL and may prolong survival time.^2-4 An estimated 20% to 50% of radiation courses are prescribed with palliative intent, because RT is highly effective in providing symptom relief, and the toxicity associated with palliative doses is typically mild.^5,6 Palliative RT can be used to manage bone and brain metastases, prevent or treat spinal cord compression, and manage numerous tumor-related symptoms, such as pain and bleeding in patients with terminal cancer.

Palliative RT for bone and brain metastases is supported by high-quality evidence and is considered one of the most effective and cost-effective options available.^7,8 This article aims to review the role of RT in treating 3 conditions commonly encountered in patients with metastatic disease—bone metastases, spinal cord compression, and brain metastases—and to emphasize the importance of timely integration of RT for optimal results.

Bone Metastases

About 80% of patients with metastatic solid tumors develop bone metastases, and about 350,000 deaths are linked to bone metastases in the U.S. each year.⁹ Osseous
metastases can lead to pain, fracture, hypercalcemia, and spinal cord compression. The primary modality for treatment of pain and prevention of morbidity from bone metastases is external beam RT.¹⁰

The likelihood of bone pain relief with palliative RT is 60% to 80%, and 30% to 40% of patients achieving complete pain relief. Randomized studies have shown multiple-dose and fractionation regimens provided effective symptom relief for bone metastases. Most commonly used regimens include a single fraction of 8 gray (Gy) delivered in 1 treatment, 20 Gy in 5 fractions delivered daily over 1 week, and 30 Gy in 10 fractions delivered over 2 weeks. Treatment with a single fraction improves access to treatment and patient convenience, whereas more prolonged courses have been associated with lower rates of retreatment.^11,12 Regarding the higher rate of retreatment with single-fraction RT, no clear evidence exists that this is due to a less durable pain response or lower level of pain relief.¹³

There has been recent interest in using predictive models to estimate life expectancy to avoid long courses of RT at the end of life.^14,15 Shorter treatment courses of 8 Gyonce or 20 Gy in 5 fractions are particularly valuable for patients with a life expectancy < 3 months to avoid long courses of treatment, and thereby improve QOL as patients transition into hospice. A recent survey demonstrated that 93% of radiation oncologists within the VHA are willing to prescribe short courses of RT consisting of ≤ 6 fractions, and 76% have experience with single-fraction RT.¹⁶ These findings are in contradiction to the findings in the non-VA radiation oncology community, in which < 10% of patients with uncomplicated bone metastases are treated with a single fraction.^17,18 

In addition to providing pain relief, RT is used in the treatment of impending fractures either, adjuvant after surgical stabilization or alone for lower risk lesions.¹⁹ Factors that impact fracture risk include location of the metastasis (weight-bearing bones, such as femurs, which are at particularly high risk), length of bone involved, and extent of cortical involvement. Mirels’ scoring system was developed to predict fracture risk in patients with bone metastasis, based on 4 criteria: the
extent of cortical involvement, the location of the metastasis, the osteolytic vs osteoblastic appearance of the lesion, and the degree of pain.²⁰ Surgical fixation can be considered, based on the total score and corresponding fracture risk. When appropriate, surgical stabilization should be considered by an orthopedic surgeon prior to initiating RT.

Postoperative RT after surgical stabilization has been associated with a reduced rate of secondary surgical procedures as well as with improved functional status.²¹ Radiotherapy promotes remineralization and bone healing and prevents the loss of surgical fixation by treating any residual tumor. A retrospective review of 60 patients with metastatic disease in weight-bearing bones with pathologic fracture or impending pathologic fracture demonstrated that surgery followed by RT was associated with improved functional status as well as with improved overall survival (OS).^22,23 For patients in whom surgery is not indicated, the consulting radiation oncologist should consider factors such as the location of the metastasis in weight-bearing vs nonweight bearing bones, the size and extent of the metastasis, and associated symptoms when making a treatment recommendation. In patients at fracture risk from bone metastases, bisphosphonates should also be considered as part of the treatment regimen.²⁴

Spinal Cord Compression

About 5% to 10% of patients diagnosed with cancer will develop spinal cord compression during the course of their disease.²⁵ Spinal cord compression is considered a medical emergency that can result in significant pain and neurologic symptoms, including weakness, paralysis, parasthesias, and incontinence. Early treatment of spinal cord compression can prevent onset or progression of these symptoms; furthermore, early treatment prior to loss of ambulation is associated with improved long-term ambulatory function.^26,27

Treatment decisions for spinal metastases with an associated concern for cord compression should be made after a consultation with both a neurosurgeon and a radiation oncologist. Early initiation of steroids is recommended to aid in tumor shrinkage for potential symptom relief.²⁸ A standard way to administer dexamethasone is with a 10-mg loading dose followed by 16 mg per day, divided into 4 doses of 4 mg. Higher steroid doses showed no benefit in a prospective randomized trial comparing 96 mg with 16 mg of dexamethasone daily.²⁹

Surgical decompression should be considered initial management of spinal cord compression. For patients treated surgically, local RT is indicated postoperatively as well. Randomized data show that surgery followed by RT provides better ambulatory function than does RT alone in patients with paralysis of < 2 days’ duration.³⁰ Some patients with metastatic disease are not good candidates for surgery due to comorbidities, poor performance status, life expectancy < 3 months, or multilevel spinal involvement.

In patients who are not operative candidates, radiation alone is an appropriate alternative. However, several factors need consideration in deciding whether to manage cord compression with surgery followed by RT vs RT alone. These factors include life expectancy, tumor type (myeloma and lymphoma are more radiosensitive), interval since tumor diagnosis, and the presence of visceral metastases.³¹ Factors favoring surgical decompression plus postoperative RT over RT alone include spinal instability, KPS (Karnofsky Performance Status) > 70, radio-resistant tumor histology, minimal metastatic disease, and projected survival > 3 months.¹⁰

For patients managed with RT alone, early diagnosis and treatment is associated with improved outcomes. A prospective study of patients treated with RT without surgery for spinal cord compression demonstrated that 82% of patients experienced back pain relief, 76% achieved improvement in or preservation of ambulation, and 44% of patients with sphincter dysfunction experienced improvement with treatment.³² Patients with certain tumor histologies, such as myeloma, breast cancer, and prostate cancer, had better responses to RT.³²

In the setting of spinal cord compression, longer courses of RT may provide better local control than do shorter courses.³³ Therefore, longer courses of RT, such as 30 Gy in 10 fractions delivered over 2 weeks, are often preferred in cases of spinal cord compression treated with definitive RT as well as after surgical decompression. However, overall life expectancy is an important factor considered by the treating radiation oncologist when selecting a short course vs a longer course of RT.

In the instance of painful vertebral body metastases without spinal cord compression, a new subset analysis of the Radiation Therapy Oncology Group (RTOG) 9714 randomized trial indicated that single fraction RT (8 Gy) is just as effective as multiple fractions (30 Gy in 10 fractions), with this study demonstrating comparable rates of pain relief and narcotic use in both groups 3 months after RT.³⁴ Advantages to the single-fraction plan compared with those of multiple fractions include mitigation of logistic concerns for patients and family at the end of life and less acute adverse effects.

Brain Metastases

An estimated 20% to 40% of patients with cancer develop brain metastases.³⁵ The incidence of brain metastases has been rising most likely due to improved detection rates with magnetic resonance imaging (MRI) and improved cancer survival, because treatment regimens have improved with targeted chemotherapy and radiation techniques. Currently, the annual incidence of brain metastases is 170,000 to 200,000 in the U.S.³⁶ Prognosis for these patients is poor, with median survival of 1 month without treatment and about 4 months with whole brain RT (WBRT) (Table).^25,37-39

The goal of management for patients with brain metastases is to prevent or treat neurologic symptoms and to prolong survival. Treatment options include corticosteroids, WBRT, surgery, and stereotactic radiosurgery (SRS). Recommendations for treatment should involve both a radiation oncologist and neurosurgeon to determine the best treatment for an individual based on patient age, performance status, extent of systemic disease, and number of brain metastases. These prognostic factors that may predict life expectancy and impact treatment recommendations.⁴⁰

Factors that have been correlated with improved survival include younger age, better performance status, fewer brain metastases, and lower burden of systemic disease.^41,42 Prognostic assessment tools such as the Graded Prognostic Assessment and RTOG-Recursive Partitioning Analysis can be used to predict life expectancy in patients with brain metastases.^41,43 However, routine use of these tools is lagging, as evidenced by a recent survey of VHA radiation oncologists. Use of these tools in the clinic will enhance the quality of end of life care and decision making.

Corticosteroids have classically been used in the treatment of brain metastases either alone for supportive care or in combination with RT. Steroids are recommended to provide symptom relief in patients with symptoms related to cerebral edema or mass effect.⁴⁴ Steroids have been shown to mitigate edema and improve neurologic deficits in about two-thirds of patients with brain metastases.^36,45 The effect of corticosteroids is thought to be mediated through inhibition of prostaglandin synthesis, reduction in vascular permeability, and anti-inflammatory properties.⁴⁶ A common corticosteroid regimen is a 10-mg loading dose of dexamethasone, followed by 16 mg daily in divided doses. For patients without neurologic deficits or cerebral edema, it is reasonable to defer corticosteroid use only when patients are symptomatic.

In general, WBRT is considered an appropriate treatment option for patients with multiple brain metastases based on data suggesting an improvement in OS compared with the use of corticosteroids alone.⁴⁷ Whole brain radiation has been shown to result in the improvement of baseline neurologic deficits or the prevention of further symptom progression.⁴⁸ The partial or complete metastasis response rates are on the order of 60%.38 Tumor regression after WBRT has been associated with preservation of neurocognitive function as well as prolonged survival.⁴⁹

For good prognosis patients with a single brain metastasis and good performance status, the use of surgery or radiosurgery added to WBRT has been associated with improved OS (Table). The RTOG 9508 randomized trial of WBRT with or without SRS demonstrated a survival advantage with SRS, with median survival times of 6.5 months with WBRT + SRS vs 4.9 months with WBRT alone.⁵⁰ Similarly, a randomized trial evaluating WBRT alone compared with surgery followed by WBRT in patients
with good prognosis demonstrated significantly improved OS in the surgery group (median 40 weeks vs 15 weeks).51 In general, WBRT or postoperative RT to the tumor bed is still indicated after surgical resection, based on randomized data showing a reduction in tumor bed recurrence with postoperative RT.⁵²

For patients with only 1 to 3 brain metastases and a favorable prognosis, surgery and SRS can be considered treatment options, oftentimes with WBRT. The EORTC randomized trial of patients with 1 to 3 brain metastases was designed to determine the benefit of WBRT after treatment with surgery or SRS. In this study, 119 patients underwent SRS and 160 patients underwent surgical resection.⁵³ Both groups of patients were randomized to observation vs adjuvant WBRT. This study demonstrated reduced rates of intracranial relapse with WBRT, however, without any change in OS. Although there is concern that WBRT may impair cognitive function with no clear survival benefit after surgery or SRS, WBRT does reduce recurrence rates in the brain and the need for further treatment.⁵⁴ Therefore, decisions regarding WBRT in such a setting should be made only after a detailed discussion with a radiation oncologist regarding risks vs benefits of treatment as part of the informed decision-making process.

Conclusions

Palliative RT plays an important role in the management of metastatic cancer to provide symptom relief and is a cost-effective treatment option for bone and brain metastases. Life expectancy and tumor characteristics should be considered when making treatment recommendations to ensure selection of regimens that complement patients’ unique situations. Timely referrals for treatment are important to optimize treatment results.

Author disclosures
The authors report no actual or potential conflicts of interest with regard to this article.

Disclaimer
The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, or any of its agencies. This article may discuss unlabeled or investigational use of certain drugs. Please review complete prescribing information for specific drugs or drug combinations—including indications, contraindications, warnings, and adverse effects—before administering pharmacologic therapy to patients.

Click here to read the digital edition.

In recent years, there has been increasing interest in palliative care for patients with cancer at the end of life. Up to 23% of patients have metastatic disease at presentation, and symptoms from metastatic lesions can cause significant anxiety and impair patients’ quality of life (QOL).¹

Palliative radiotherapy (RT) plays a valuable role in the management of metastatic disease to relieve tumor-related symptoms. Although palliative RT does not provide a chance for a cure, it improves QOL and may prolong survival time.^2-4 An estimated 20% to 50% of radiation courses are prescribed with palliative intent, because RT is highly effective in providing symptom relief, and the toxicity associated with palliative doses is typically mild.^5,6 Palliative RT can be used to manage bone and brain metastases, prevent or treat spinal cord compression, and manage numerous tumor-related symptoms, such as pain and bleeding in patients with terminal cancer.

Palliative RT for bone and brain metastases is supported by high-quality evidence and is considered one of the most effective and cost-effective options available.^7,8 This article aims to review the role of RT in treating 3 conditions commonly encountered in patients with metastatic disease—bone metastases, spinal cord compression, and brain metastases—and to emphasize the importance of timely integration of RT for optimal results.

Bone Metastases

About 80% of patients with metastatic solid tumors develop bone metastases, and about 350,000 deaths are linked to bone metastases in the U.S. each year.⁹ Osseous
metastases can lead to pain, fracture, hypercalcemia, and spinal cord compression. The primary modality for treatment of pain and prevention of morbidity from bone metastases is external beam RT.¹⁰

The likelihood of bone pain relief with palliative RT is 60% to 80%, and 30% to 40% of patients achieving complete pain relief. Randomized studies have shown multiple-dose and fractionation regimens provided effective symptom relief for bone metastases. Most commonly used regimens include a single fraction of 8 gray (Gy) delivered in 1 treatment, 20 Gy in 5 fractions delivered daily over 1 week, and 30 Gy in 10 fractions delivered over 2 weeks. Treatment with a single fraction improves access to treatment and patient convenience, whereas more prolonged courses have been associated with lower rates of retreatment.^11,12 Regarding the higher rate of retreatment with single-fraction RT, no clear evidence exists that this is due to a less durable pain response or lower level of pain relief.¹³

There has been recent interest in using predictive models to estimate life expectancy to avoid long courses of RT at the end of life.^14,15 Shorter treatment courses of 8 Gyonce or 20 Gy in 5 fractions are particularly valuable for patients with a life expectancy < 3 months to avoid long courses of treatment, and thereby improve QOL as patients transition into hospice. A recent survey demonstrated that 93% of radiation oncologists within the VHA are willing to prescribe short courses of RT consisting of ≤ 6 fractions, and 76% have experience with single-fraction RT.¹⁶ These findings are in contradiction to the findings in the non-VA radiation oncology community, in which < 10% of patients with uncomplicated bone metastases are treated with a single fraction.^17,18 

In addition to providing pain relief, RT is used in the treatment of impending fractures either, adjuvant after surgical stabilization or alone for lower risk lesions.¹⁹ Factors that impact fracture risk include location of the metastasis (weight-bearing bones, such as femurs, which are at particularly high risk), length of bone involved, and extent of cortical involvement. Mirels’ scoring system was developed to predict fracture risk in patients with bone metastasis, based on 4 criteria: the
extent of cortical involvement, the location of the metastasis, the osteolytic vs osteoblastic appearance of the lesion, and the degree of pain.²⁰ Surgical fixation can be considered, based on the total score and corresponding fracture risk. When appropriate, surgical stabilization should be considered by an orthopedic surgeon prior to initiating RT.

Postoperative RT after surgical stabilization has been associated with a reduced rate of secondary surgical procedures as well as with improved functional status.²¹ Radiotherapy promotes remineralization and bone healing and prevents the loss of surgical fixation by treating any residual tumor. A retrospective review of 60 patients with metastatic disease in weight-bearing bones with pathologic fracture or impending pathologic fracture demonstrated that surgery followed by RT was associated with improved functional status as well as with improved overall survival (OS).^22,23 For patients in whom surgery is not indicated, the consulting radiation oncologist should consider factors such as the location of the metastasis in weight-bearing vs nonweight bearing bones, the size and extent of the metastasis, and associated symptoms when making a treatment recommendation. In patients at fracture risk from bone metastases, bisphosphonates should also be considered as part of the treatment regimen.²⁴

Spinal Cord Compression

About 5% to 10% of patients diagnosed with cancer will develop spinal cord compression during the course of their disease.²⁵ Spinal cord compression is considered a medical emergency that can result in significant pain and neurologic symptoms, including weakness, paralysis, parasthesias, and incontinence. Early treatment of spinal cord compression can prevent onset or progression of these symptoms; furthermore, early treatment prior to loss of ambulation is associated with improved long-term ambulatory function.^26,27

Treatment decisions for spinal metastases with an associated concern for cord compression should be made after a consultation with both a neurosurgeon and a radiation oncologist. Early initiation of steroids is recommended to aid in tumor shrinkage for potential symptom relief.²⁸ A standard way to administer dexamethasone is with a 10-mg loading dose followed by 16 mg per day, divided into 4 doses of 4 mg. Higher steroid doses showed no benefit in a prospective randomized trial comparing 96 mg with 16 mg of dexamethasone daily.²⁹

Surgical decompression should be considered initial management of spinal cord compression. For patients treated surgically, local RT is indicated postoperatively as well. Randomized data show that surgery followed by RT provides better ambulatory function than does RT alone in patients with paralysis of < 2 days’ duration.³⁰ Some patients with metastatic disease are not good candidates for surgery due to comorbidities, poor performance status, life expectancy < 3 months, or multilevel spinal involvement.

In patients who are not operative candidates, radiation alone is an appropriate alternative. However, several factors need consideration in deciding whether to manage cord compression with surgery followed by RT vs RT alone. These factors include life expectancy, tumor type (myeloma and lymphoma are more radiosensitive), interval since tumor diagnosis, and the presence of visceral metastases.³¹ Factors favoring surgical decompression plus postoperative RT over RT alone include spinal instability, KPS (Karnofsky Performance Status) > 70, radio-resistant tumor histology, minimal metastatic disease, and projected survival > 3 months.¹⁰

For patients managed with RT alone, early diagnosis and treatment is associated with improved outcomes. A prospective study of patients treated with RT without surgery for spinal cord compression demonstrated that 82% of patients experienced back pain relief, 76% achieved improvement in or preservation of ambulation, and 44% of patients with sphincter dysfunction experienced improvement with treatment.³² Patients with certain tumor histologies, such as myeloma, breast cancer, and prostate cancer, had better responses to RT.³²

In the setting of spinal cord compression, longer courses of RT may provide better local control than do shorter courses.³³ Therefore, longer courses of RT, such as 30 Gy in 10 fractions delivered over 2 weeks, are often preferred in cases of spinal cord compression treated with definitive RT as well as after surgical decompression. However, overall life expectancy is an important factor considered by the treating radiation oncologist when selecting a short course vs a longer course of RT.

In the instance of painful vertebral body metastases without spinal cord compression, a new subset analysis of the Radiation Therapy Oncology Group (RTOG) 9714 randomized trial indicated that single fraction RT (8 Gy) is just as effective as multiple fractions (30 Gy in 10 fractions), with this study demonstrating comparable rates of pain relief and narcotic use in both groups 3 months after RT.³⁴ Advantages to the single-fraction plan compared with those of multiple fractions include mitigation of logistic concerns for patients and family at the end of life and less acute adverse effects.

Brain Metastases

An estimated 20% to 40% of patients with cancer develop brain metastases.³⁵ The incidence of brain metastases has been rising most likely due to improved detection rates with magnetic resonance imaging (MRI) and improved cancer survival, because treatment regimens have improved with targeted chemotherapy and radiation techniques. Currently, the annual incidence of brain metastases is 170,000 to 200,000 in the U.S.³⁶ Prognosis for these patients is poor, with median survival of 1 month without treatment and about 4 months with whole brain RT (WBRT) (Table).^25,37-39

The goal of management for patients with brain metastases is to prevent or treat neurologic symptoms and to prolong survival. Treatment options include corticosteroids, WBRT, surgery, and stereotactic radiosurgery (SRS). Recommendations for treatment should involve both a radiation oncologist and neurosurgeon to determine the best treatment for an individual based on patient age, performance status, extent of systemic disease, and number of brain metastases. These prognostic factors that may predict life expectancy and impact treatment recommendations.⁴⁰

Factors that have been correlated with improved survival include younger age, better performance status, fewer brain metastases, and lower burden of systemic disease.^41,42 Prognostic assessment tools such as the Graded Prognostic Assessment and RTOG-Recursive Partitioning Analysis can be used to predict life expectancy in patients with brain metastases.^41,43 However, routine use of these tools is lagging, as evidenced by a recent survey of VHA radiation oncologists. Use of these tools in the clinic will enhance the quality of end of life care and decision making.

Corticosteroids have classically been used in the treatment of brain metastases either alone for supportive care or in combination with RT. Steroids are recommended to provide symptom relief in patients with symptoms related to cerebral edema or mass effect.⁴⁴ Steroids have been shown to mitigate edema and improve neurologic deficits in about two-thirds of patients with brain metastases.^36,45 The effect of corticosteroids is thought to be mediated through inhibition of prostaglandin synthesis, reduction in vascular permeability, and anti-inflammatory properties.⁴⁶ A common corticosteroid regimen is a 10-mg loading dose of dexamethasone, followed by 16 mg daily in divided doses. For patients without neurologic deficits or cerebral edema, it is reasonable to defer corticosteroid use only when patients are symptomatic.

In general, WBRT is considered an appropriate treatment option for patients with multiple brain metastases based on data suggesting an improvement in OS compared with the use of corticosteroids alone.⁴⁷ Whole brain radiation has been shown to result in the improvement of baseline neurologic deficits or the prevention of further symptom progression.⁴⁸ The partial or complete metastasis response rates are on the order of 60%.38 Tumor regression after WBRT has been associated with preservation of neurocognitive function as well as prolonged survival.⁴⁹

For good prognosis patients with a single brain metastasis and good performance status, the use of surgery or radiosurgery added to WBRT has been associated with improved OS (Table). The RTOG 9508 randomized trial of WBRT with or without SRS demonstrated a survival advantage with SRS, with median survival times of 6.5 months with WBRT + SRS vs 4.9 months with WBRT alone.⁵⁰ Similarly, a randomized trial evaluating WBRT alone compared with surgery followed by WBRT in patients
with good prognosis demonstrated significantly improved OS in the surgery group (median 40 weeks vs 15 weeks).51 In general, WBRT or postoperative RT to the tumor bed is still indicated after surgical resection, based on randomized data showing a reduction in tumor bed recurrence with postoperative RT.⁵²

For patients with only 1 to 3 brain metastases and a favorable prognosis, surgery and SRS can be considered treatment options, oftentimes with WBRT. The EORTC randomized trial of patients with 1 to 3 brain metastases was designed to determine the benefit of WBRT after treatment with surgery or SRS. In this study, 119 patients underwent SRS and 160 patients underwent surgical resection.⁵³ Both groups of patients were randomized to observation vs adjuvant WBRT. This study demonstrated reduced rates of intracranial relapse with WBRT, however, without any change in OS. Although there is concern that WBRT may impair cognitive function with no clear survival benefit after surgery or SRS, WBRT does reduce recurrence rates in the brain and the need for further treatment.⁵⁴ Therefore, decisions regarding WBRT in such a setting should be made only after a detailed discussion with a radiation oncologist regarding risks vs benefits of treatment as part of the informed decision-making process.

Conclusions

Palliative RT plays an important role in the management of metastatic cancer to provide symptom relief and is a cost-effective treatment option for bone and brain metastases. Life expectancy and tumor characteristics should be considered when making treatment recommendations to ensure selection of regimens that complement patients’ unique situations. Timely referrals for treatment are important to optimize treatment results.

Author disclosures
The authors report no actual or potential conflicts of interest with regard to this article.

Disclaimer
The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, or any of its agencies. This article may discuss unlabeled or investigational use of certain drugs. Please review complete prescribing information for specific drugs or drug combinations—including indications, contraindications, warnings, and adverse effects—before administering pharmacologic therapy to patients.

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