"This textbook, Radiation Oncology in Palliative Cancer Care, represents the full evolution of radiation therapy, and of oncology in general. ( ... ) [It] is an acknowledgment that palliative radiotherapy is now a sub-specialty of radiation oncology. This formally makes palliative radiotherapy a priority within patient care, academic research, quality assurance, and medical education." - From the Foreword by Nora Janjan, MD, MPSA, MBA, National Center for Policy Analysis, Dallas, TX, USA

Palliative Medicine is the professional medical practice of prevention and relief of suffering and the support of the best possible quality of life for patients and their families, regardless of the stage of the disease or the need for other therapies. The most common cause for palliative care referral is terminal cancer, and a large proportion of those referrals include patients who will need palliative radiotherapy during the course of their disease. Still, there are barriers to coordinated care between radiation oncologists and palliative care physicians that differ from one country to another. Until now, one overarching limitation to appropriate concurrent care between the specialties across all countries has been the lack of a comprehensive yet concise reference resource that educates each of the specialties about the potential synergistic effects of their cooperation. This book fills that void.

Radiation Oncology in Palliative Cancer Care:

• Is the first book-length treatment of this important topic available on the market


• Is authored by world-renowned experts in radiation oncology and palliative medicine


• Uses a multidisciplinary approach to content and patient treatment


• Features decision trees for palliative radiotherapy based upon factors such as patient performance status and prognosis


• Pays careful attention to current best practices and controversies in the delivery of end-of-life cancer care

This book is an important resource for practicing radiation oncologists and radiation oncologists in training, as well as hospice and palliative medicine physicians and nurses, medical oncologists, and geriatricians.

Stephen Lutz is one of only a small number of Radiation Oncologists who is also board certified in Hospice and Palliative Medicine.?He has served as the liaison between the US radiotherapy and palliative care communities for the past several years. His main research interests have included the formation of palliative radiotherapy treatment guidelines as well as the collaboration between the two specialties with regard to research, education, and patient advocacy.

Edward Chow is a Professor in the Department of Radiation Oncology at the University of Toronto?and is a senior scientist in the Sunnybrook Research Institute. He is Chair of the Rapid Response Radiotherapy Program and Bone Metastases Site Group in the Odette Cancer Center at?Sunnybrook Health Sciences Centre.

Peter Hoskin is a UK clinical oncologist with long standing research interests in palliative radiotherapy, in particular the management of bone metastases and spinal cord compression. He was a clinical research fellow in Palliative Medicine working in opioid pharmacology before focusing his interests in clinical oncology and was Chair of the International Consensus in Palliative Radiotherapy in 2000 and ESTRO Co-chair in 2010. He has written extensively on the role of radiotherapy in palliative care in original publications and major book chapters.

Contributor list xv

Foreword xix

Part 1: General principles of radiation oncology 1

1 A brief history of palliative radiation oncology 3
Joshua Jones

Introduction 3

The early years 3

Fractionation 6

Advances in radiotherapy technique: the 1950s and 1960s 7

Fractionation revisited: explicit palliation 10

Stereotactic radiotherapy 11

Prognostication and tailoring palliative radiotherapy to anticipated survival 11

Conclusion 12

References 13

2 The radiobiology of palliative radiation oncology 15
Candice A. Johnstone

Introduction 15

Radiation effect on cells 15

Cell cycle characteristics 18

Interaction of cell cycle and radiotherapy fractionation 18

Radiotherapy fractionation characteristics 19

Conclusion 20

References 20

3 The physics of radiation oncology 22
Shaun Baggarley Jiade J. Lu

Introduction 22

The development of radiation therapy technology 24

Process of radiation therapy 27

Special considerations in developing countries 28

Conclusion 29

References 29

4 Curative intent versus palliative intent radiation oncology 31
Vassilios Vassiliou Haris Charalambous

Introduction 31

The determination of cure plus palliation intent versus pure palliative intent 33

Clinical diagnoses 35

Special considerations in developing countries 38

Conclusion 39

References 39

5 Side effects of palliative radiotherapy 43
Alysa Fairchild

Introduction 43

Issues with interpreting palliative radiotherapy toxicity data 44

Acute side effects 45

Late side effects 50

Additive toxicity 53

Clinical advice 53

New technologies 55

Challenges in developing countries 55

Conclusion 56

References 56

Part 2: General principles of palliation and symptom control 61

6 A history of hospice and palliative medicine 63
Michelle Winslow Marcia Meldrum

Introduction 63

Before the modern movement 63

St. Christopher's and the modern hospice 64

Palliative care in the United States 66

Global development of hospice and palliative care 68

Continuing challenges 69

References 69

7 Radiation therapy and hospice care 72
Charles F. von Gunten Frank D. Ferris and Arno J. Mundt

Introduction 72

Hospice care around the world 72

Hospice care in the United States 73

Palliative radiation and hospice 77

Conclusion 79

References 79

8 The current status of palliative care and radiotherapy 81
Thomas Smith Susannah Batko-Yovino

What is palliative care? 81

Who can benefit from palliative care? 81

What are the goals of palliative care and what features of a palliative care program help to accomplish these goals? 83

What is the evidence regarding the benefi ts and risks of palliative care? When should palliative care be introduced to a patient? 84

Are there standards for palliative care? If so what are the defining measures? 88

How does palliative care fi t in with radiation oncology? 90

References 92

9 Palliative care in low and middle income countries: A focus on sub-Saharan Africa 95
Henry Ddungu Elizabeth A. Barnes

Introduction 95

The need for palliative care 95

Radiotherapy 96

Specific clinical indications for palliative radiotherapy in Africa 97

Challenges of palliative care delivery 98

Addressing challenges to adequate palliative care 98

Palliative care research 100

Delivery of palliative care 101

Conclusion 102

References 102

10 Pain management 105
Erin McMenamin

Introduction 105

Pain assessment 105

Analgesia ladder 106

Primary pharmacologic interventions 107

Adjuvant medications 108

End-of-life considerations 109

Conclusion 109

References 110

Part 3: Locally advanced or locally recurrent diseases 113

11 Primary tumors of the central nervous system 115
Caroline Chung Eric L. Chang

Introduction 115

Radiotherapy 116

Side-effect risks 120

Radiotherapy limitations 120

Adjuvant treatment modalities 121

Promise of newer technologies 121

Special considerations in developing countries 122

Conclusion 122

References 122

12 The role of palliative care in head and neck cancer 126
Albert Tiong June Corry

Introduction 126

Current management of head and neck squamous cell carcinomas 126

Patient selection for palliative treatment 127

Use of palliative radiotherapy in head and neck squamous cell carcinomas 130

Recurrent disease 134

The promise of emerging technologies 135

Chemotherapy in palliative head and neck squamous cell carcinomas 135

Non-squamous cell carcinomas histologies 136

Specific issues in palliation of head and neck squamous cell carcinomas 137

Special considerations in developing countries 138

Conclusion 138

References 139

13 The role of palliative radiotherapy in breast cancer 145
Ian H. Kunkler

Introduction 145

Rates of palliative loco-regional radiotherapy 148

Biologic considerations 148

Definitions clinical features and multi-disciplinary approach 148

Clinical scenarios 150

Symptom control 153

Palliative loco-regional radiotherapy for oligometastatic disease 154

Radiotherapy dosing schedules 154

Radiotherapy technique and the promise of newer technology 156

Special considerations in developing countries 158

Follow up 158

Conclusion 159

References 159

14 Palliative radiotherapy in advanced lung cancer 163
George Rodrigues Benjamin Movsas

Introduction 163

Radiotherapy treatment 165

The impact of emerging technologies 169

Important circumstances 171

Special considerations in developing countries 173

Conclusion 173

References 174

15 Palliative radiotherapy for gastrointestinal and colorectal cancer 177
Robert Glynne-Jones Mark Harrison

Introduction 177

Treatment of dysphagia 178

Gastric cancer 180

Palliation of biliary obstruction 181

Nodes at origin of the superior mesenteric artery 181

High dose rate brachytherapy 182

Locally advanced/recurrent rectal cancer 182

Re-irradiation 184

Anal cancer 184

The promise of highly conformal therapy 184

Special considerations in developing countries 184

Conclusion 185

References 185

16 Genitourinary malignancies 188
Gillian M. Duchesne

Introduction 188

Incidence and etiology 188

Clinical behavior 190

Bladder cancer 190

Prostate cancer 190

Renal cancer 190

Palliative radiotherapy and other approaches for management of primary disease 192

Specific management of metastatic disease in urologic malignancies 194

The promise of highly conformal therapy 196

Special considerations in developing countries 197

Conclusion 197

References 197

17 Palliative radiotherapy in locally advanced and locally recurrent gynecologic cancer 199
Firuza Patel

Introduction 199

Patterns of loco-regional failures for gynecologic cancers 200

Management 201

Treatment of recurrent carcinoma of the cervix 206

Recurrence after defi nitive radiation 206

Recurrence after defi nitive surgery 207

The promise of newer technologies 207

Special considerations in developing countries 207

Conclusion 208

References 209

18 Hematologic malignancies and associated conditions 210
David D. Howell

Introduction 210

Diagnoses 210

Specific clinical circumstances 213

Locally advanced and recurrent disease 216

Future directions 216

Special considerations in developing countries 217

Conclusion 217

References 217

19 Pediatric palliative radiation oncology 220
Tamara Vern-Gross

Introduction 220

Delivery of radiation treatment 221

Differences between pediatric and adult populations 222

Background 222

Clinical indications for palliative radiotherapy 224

Caring for the pediatric patient 232

Barriers to the use of palliative radiotherapy 233

Special considerations in developing countries 233

Conclusion 234

References 234

Part 4: Metastatic disease 239

20 Bone metastases 241
Yvette van der Linden Dirk Rades

Introduction 241

Clinical implications and treatment modalities 241

Clinical symptoms 242

Technical considerations 250

Prognosis and choice for treatment 250

Proactive approach 251

Special considerations in developing countries 251

Conclusion 251

References 253

21 Spinal cord compression 257
Ernesto Maranzano Fabio Trippa

Introduction 257

Treatment 259

Promise of newer technologies 264

Re-irradiation 265

Special considerations in developing countries 265

Conclusion 266

References 267

22 Brain metastases 270
May Tsao

Introduction 270

Radiotherapy treatment 271

Radiotherapy limitations 277

Promise of newer technologies and areas of ongoing research 277

International patterns of care and special considerations in developing countries 278

Conclusion 278

References 279

23 Liver metastases 283
Sean Bydder

Introduction 283

Radiotherapy treatment 284

Whole-liver radiation therapy 286

Conformal radiation therapy 288

Brachytherapy 289

Selective internal radiation therapy 289

Surgery for liver metastases 290

Radiofrequency ablation 290

Promising new radiotherapy techniques 290

Practice variation among different countries 293

Conclusion 294

Acknowledgments 294

References 294

24 Palliative radiotherapy for malignant neuropathic pain adrenal choroidal and skin metastases 299
Daniel E. Roos Aaron H. Wolfson

Malignant neuropathic pain 299

Adrenal metastases 302

Choroidal metastases 308

Skin metastases (A.H. Wolfson) 312

Conclusion 314

References 314

Part 5: Integration of radiation oncology and palliative care 317

25 Design challenges in palliative radiation oncology clinical trials 319
Deborah Watkins Bruner Lawrence B. Berk

Introduction 319

Challenges with the validation of palliative metrics 319

Evolution of palliative care clinical trials: the Radiation Therapy

Oncology Group experience 320

International research efforts 325

Conclusion 326

References 326

26 Radiation oncology cost-effectiveness 329
Andre Konski

Introduction 329

Cost-effectiveness 330

Newer technologies 332

Conclusion 333

References 333

27 Quality measures and palliative radiotherapy 335
James A. Hayman Rinaa S. Punglia and Anushree M. Vichare

Introduction 335

Quality measures: characteristics 336

Developing quality measures 338

Desirable attributes of quality measures 340

Uses of quality measures 340

Current uses of quality measures in radiation oncology 341

International quality measures in radiation oncology 342

Conclusion 343

References 344

28 Use of technologically advanced radiation oncology techniques for palliative patients 347
Simon S. Lo Bin S. Teh Samuel T. Chao Arjun Sahgal Nina A. Mayr and Eric L. Chang

Introduction 347

Overview of technologically advanced radiotherapy techniques 347

Clinical applications reported in the literature 349

Brain metastasis 349

Stereotactic radiosurgery 349

Scalp-sparing whole brain radiation therapy 351

Hippocampus-sparing whole brain radiation therapy 351

Stereotactic radiation therapy 351

Spinal metastasis 352

Spinal cord compression 352

Bone metastasis 355

Adrenal metastasis 355

Toxicities associated with palliative radiotherapy using advanced technologies 356

Conclusion 357

References 357

Index 361