Palliative Radiotherapy Treatment and when should it be used?

Palliative treatment is designed to relieve symptoms and improve your quality of life. It can be used at any stage of an illness if there are troubling symptoms, such as pain or sickness. Palliative treatment can also mean using medicines to reduce or control the side effects of cancer treatments. In advanced cancer, palliative treatment may help someone to live longer and to live comfortably, even if they cannot be cured.

Cancer can spread to the bones. This can cause pain and may cause weakness in the affected bone increasing the risk of a fracture. Palliative radiation is a simple and effective treatment for cancer-related bone pain. Often a single treatment can be used.

 Palliative treatment means treatment to shrink a cancer, slow down its growth, or control symptoms caused by the cancer.It does not aim to cure the cancer so lower doses of radiation can be safely used without much in the way of side effects for the patient. The aim of delivering palliative radiation therapy is to control symptoms of cancer or prevent symptoms from occurring and so give the patient a better quality of life.

Palliative radiation is not suitable for all types of cancers – it depends on the particular type and the area that the cancer has spread to. Sometimes other treatments such as surgery, chemotherapy, or hormone therapy may be more helpful.

Goals of Palliative Radiotherapy

Symptom Control: Primary goal is to relieve pain, reduce bleeding, alleviate obstruction, and control other symptoms caused by tumors.

Quality of Life: Improve overall well-being and maintain functionality as much as possible.

Minimal Side Effects: Aim to achieve benefits with the least possible side effects to avoid additional burdens on the patient.

Palliative radiation therapy is used for many different reasons including:

Pain Relief:

Bone Metastases: Often used to alleviate pain from bone metastases, which are common in cancers such as breast, prostate, and lung cancer.

 Spinal Cord Compression: To reduce pain and prevent neurological damage in cases where a tumor compresses the spinal cord.

 Control of Symptoms from Tumor Growth:

   Bleeding: Tumors that cause bleeding, such as in the lungs, cervix, or bladder, can be treated to reduce or stop bleeding.

   Obstruction: Tumors obstructing organs like the oesophagus, bronchus, or intestines can be treated to relieve the obstruction.

   Neurological Symptoms: Brain metastases causing headaches, seizures, or neurological deficits can be managed with palliative radiotherapy.

Improving Functional Outcomes:

 Skin Lesions: For ulcerating skin tumors or metastatic lesions causing pain or discharge.

  Soft Tissue Masses: To shrink tumors that cause significant discomfort or functional impairment.

The main indications are summarized in. A radiation oncologist must be consulted, to prevent inappropriate a priori decisions. Unfortunately, patients are not referred when it is considered that a tumor is not “radiosensitive.” Radiownsitivily is a radiobiological term referring to the intrinsic response of a given cell line to radiation. Radioresponsiveness is the clinical counterpart.

Most tumours “respond” to radiotherapy, although there is a quite marked variation in this response. For palliative endpoints, even the so-called “radioresistant” tumours will respond favourably, often without measurable tumor regression.

The role of radiotherapy in the management of pain due to malignant bone metastases is unquestioned, and this indicatic~n (mainly for patients with lung, breast, and prostate primaries) constitutes approximately 20% of the total numbers referred to most national oncology departments. The pathogenesis of metastatic hone pain and the mechanism of action of radiotherapy is not understood.

Delivery of a course of radiation with the intent of imposing growth: restraint on a tumour, or reduction or abolition of symptoms caused by the tumour (or both). Where the former is the intent, a high dose may be required, however, in many palliative situations. a short course or high-dose single-fraction treatment may be sufficient to achieve the favourable end point de- sired. A lower level of morbidity should be set for such situations.

The highly-dense irradiation of tumours that are deemed incurable at presentation for local control is often justified, and may be compatible with the preservation of function and body image.’ Important examples occur in head and neck, gynaecological, breast, urological, lung, skin, and colorectal cancers.Palliative treatment is not limited to painkillers and anti-sickness drugs. Cancer treatments can help to reduce pain by shrinking a tumour and reducing pressure on nerves or surrounding tissues. They can reduce or get rid of symptoms. Treatment used in this way include

• Chemotherapy

• Radiotherapy

• Hormone Therapy

• Biological Therapy

• Cryotherapy 

Palliative Radiotherapy offers a quick, inexpensive, and effective way of reducing many of the focal symptoms of advanced, incurable cancer, whether these arise from the primary tumour or metastatic deposits.

Side effects of Palliative Radiotherapy: In general, the side effects after palliative radiation are minimal because the doses used are lower than those used when curative radiation is given. Before radiation is planned and delivered the radiation oncologist sits with the patient and explains all the potential side effects of the treatment.

These vary depending on exactly what area of the body is being treated and the number of treatments and doses being given. General side effects include tiredness and minor skin redness in the area being treated. Nausea/sickness can occur with some treatments such as brain radiation and areas around the stomach/abdomen. If your radiation oncologist thinks that nausea/sickness may occur you will be given an anti-sickness tablet (antiemetic) half an hour before each treatment.

When to Use Palliative Radiotherapy

 Patient Condition: Typically used when the patient's overall condition suggests that a cure is unlikely, and the focus is on quality of life. It is often part of a broader palliative care strategy.

Life Expectancy: Considered when patients have a reasonable life expectancy (e.g., months to a year) where symptom relief can significantly impact their quality of life.

Response to Treatment: When other treatments, such as medications, have not adequately controlled symptoms.

Side Effects and Benefits: The decision balances potential side effects with expected benefits, aiming for minimal disruption to the patient’s life.

Multidisciplinary Approach: Involves coordination with oncologists, palliative care specialists, Radiation Therapists and other healthcare providers to ensure comprehensive care.

Palliative treatment Dose Fractionation:

No good-quality trials are evaluating different dose fractionation schedules for palliative treatment. An appropriate regime should be chosen after considering the patient’s likely prognosis, disease burden, symptoms and performance status.

Recommendation For the palliative treatment of anal cancer:

Single Fraction: 8 Gy in 1 Fraction: Commonly used for bone metastases to relieve rapid pain with minimal hospital visits.

 Short Courses: 20 Gy in 5 Fractions: Delivered over one week, suitable for bone metastases, brain metastases, and other symptomatic metastases.

 30 Gy in 10 Fractions: Delivered over two weeks, often used for symptomatic relief in various metastatic sites.

Palliative radiotherapy often employs different dosing and fractionation schedules compared to curative radiotherapy. The choice of dose and fractionation depends on the specific clinical scenario, the patient's overall health, and the goals of treatment. Here are some common dose fractionation schedules used in palliative radiotherapy:

 Prognostic factors and life expectancyOther Section

Optimal palliative oncology care requires both an accurate estimation of life expectancy as well as a determination of whether palliative treatments are to be delivered concurrently with curative-intent therapy or with palliative intent, only. Several factors complicate the survival prognostication of cancer patients, including patient factors such as co-morbid illnesses, disease-related factors such as tumour stage and histology, and psychological factors such as the desire of caregivers to maintain a hopeful outlook.  

 Palliative radiotherapy is a safe, effective, and time-efficient method of palliating symptoms of advanced cancer. Patients who develop symptoms, including pain, neurologic deficits, bleeding or obstruction, related to the local progression of cancer could benefit from early referral for palliative radiotherapy within the context of a palliative oncology model.

 Palliative radiation therapy (PRT) radiation therapy directed to improve patient quality of life and not at cure–is a substantial proportion of the care provided by radiation oncologists.  Approximately 40%-50% of radiation therapy delivered in radiation oncology departments is with palliative intent.1 Notably, delivery of PRT occurs at critical time points in a patient's advanced cancer diagnosis-including at the initial diagnosis of an incurable disease, at tumor progression in an established diagnosis, and/or at the end of life.

 Radiation Therapist's Role: Radiation Therapists have a crucial role in the delivery of palliative radiotherapy. Their responsibilities encompass patient care, treatment planning, and technical execution.

Patient Care and Support 

a. Patient Education:

- Explain the treatment process, potential side effects, and expected outcomes to patients and their families.

- Provide information on how to manage side effects and when to seek medical help. 

b. Emotional Support:

- Offer emotional and psychological support, addressing any concerns or fears the patient may have.

- Act as a liaison between the patient and the broader healthcare team to ensure comprehensive care.

 c. Treatment Delivery:

- Accurately deliver the prescribed dose of radiation to the target area, ensuring precision and safety.

- Monitor the patient during treatment for any immediate reactions or side effects.

 d.Side Effect Management:

- Observe and document any side effects or changes in the patient’s condition throughout the treatment course.

- Provide recommendations and support for managing side effects, such as skin irritation or fatigue.

 e. Communication:

- Regularly communicate with the radiation oncologist and other members of the healthcare team to discuss the patient’s progress and any issues that arise.

- Update the patient’s treatment records and ensure accurate documentation of each session.

 f.Advocacy:

- Advocate for the patient’s needs and preferences within the healthcare team.

- Ensure that the patient’s dignity and comfort are prioritized throughout the treatment process.

 Palliative radiotherapy is an important component of cancer care for patients with advanced disease, focusing on comfort and quality of life. It requires careful assessment and planning to tailor the treatment to the patient's needs and circumstances. In summary, radiation therapists are integral to the successful delivery of palliative radiotherapy, ensuring that patients receive safe, effective, and compassionate care. Radiation Therapist's technical expertise, combined with their supportive role, helps improve the quality of life for patients undergoing palliative treatment.

 References :

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