Addressing concerns and uncertainties surrounding the application of palliative radiotherapy in cases with a 30-day expected mortality
Letter to the Editor | Palliative Medicine and Palliative Care for Incurable Cancer

Addressing concerns and uncertainties surrounding the application of palliative radiotherapy in cases with a 30-day expected mortality

Inmaculada Navarro-Domenech1, Tara Behroozian2, Peter Hoskin3,4, Candice Johnstone5, Abram Recht6, Johan Menten7, Eva Oldenburger7, Yvette M. van der Linden8,9, Joanne M. van der Velden8,9, Quynh-Nhu Nguyen10, Charles B. Simone II11, Peter Johnstone12,13, Stephen Lutz14, Lauren Milton2, Nicolaus Andratschke15, Jonas Willmann15, Joanna Kazmierska16,17, Mateusz Spałek18,19, Gustavo N. Marta20, Edward Chow2, Srinivas Raman1

1Department of Radiation Oncology, Princess Margaret Cancer Centre, University of Toronto, Toronto, Canada; 2Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada; 3Mount Vernon Cancer Centre, Northwood, UK; 4Division of Cancer Sciences, University of Manchester, Manchester, UK; 5Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, WI, USA; 6Department of Radiation Oncology, Beth Israel Deaconess Medical Center, Boston, MA, USA; 7Department of Radiation Oncology, University Hospital Leuven, Leuven, Belgium; 8Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, The Netherlands; 9Leiden University Medical Center, Leiden, The Netherlands; 10Department of Radiation Oncology, the University of Texas MD Anderson Cancer Center, Houston, TX, USA; 11Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA; 12Department of Health Outcomes and Behavior, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA; 13Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA; 14Eastern Woods Radiation Oncology, Blanchard Valley Health Organization, Findlay, OH, USA; 15Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Zurich, Switzerland; 16Radiotherapy Department II, Greater Poland Cancer Centre, Poznan, Poland; 17Department of Electroradiology, Poznań University of Medical Sciences, Poznań, Poland; 18Department of Soft Tissue/Bone Sarcoma and Melanoma, Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland; 19Department of Radiotherapy I, Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland; 20Department of Radiation Oncology, Hospital Sírio-Libanês, Sao Paulo, Brazil

Correspondence to: Srinivas Raman, MD, MASc, FRCPC. Department of Radiation Oncology, Princess Margaret Cancer Centre, University of Toronto, 610 University Avenue, Toronto, Ontario M5G 2M9, Canada. Email: srinivas.raman@rmp.uhn.ca.

Response to: Vargas A. 30-day expected mortality and hemostatic palliative radiotherapy: definitions, certainties and uncertainties. Ann Palliat Med 2023;12:1485-87.

Submitted Sep 05, 2023. Accepted for publication Oct 07, 2023. Published online Nov 06, 2023.

doi: 10.21037/apm-2023-03

We recently had the opportunity to read the letter to the editor entitled “30-day Expected Mortality and Hemostatic Palliative Radiotherapy: Definitions, Certainties and Uncertainties” by Vargas (1), which relates to our published narrative review about 30-day mortality (30-DM) metric and the use of palliative radiation treatment (RT) in a single fraction (2).

Several of the presented points align with our perspective. Undoubtedly, the 30-DM serves as a valuable quality metric. However, practical implementation often involves its utilization in determining the continued eligibility of patients for palliative RT (3). Given the established data for pain flares and delayed responses, many clinicians resort to this threshold, leading to scrutiny from our peers when treating less fortunate patients. While acknowledging the challenges in predicting the 30-DM (4), we find ourselves in need of a criterion to guide the decision-making process for administering palliative RT. Employing ‘an educated guess’ regarding prognosis, although not foolproof, proves superior to a lack of guidance.

Furthermore, we agree with the point that there are more data for single fraction radiotherapy (SFRT) for bone metastases and spine (5,6), and thus there are greater challenges when attempting to predict response in other scenarios, such as for the use of hemostatic RT.

As reported, the absence of sufficient data and high-quality studies poses a challenge. In the majority of trials, assessments of toxicity and response are predominantly provided by physicians, even in cases involving curative intent. Patient-reported outcome measures (PROMs) are rarely incorporated as a primary endpoint and are more commonly relegated to secondary endpoints when performed (resulting in underpowered studies for this aspect). Retrospective data inherently carry limitations. Furthermore, initiating a study for palliative patients that involves systematic follow-up, even in the absence of complaints, is intricate due to ethical considerations specific to this population, as well as the frequently compromised performance status often seen in these patients. However, hemostatic RT proves to be a valuable instrument, characterized by minimal invasiveness, low rate of side effects and relatively easy accessibility, rendering it an effective solution, although there is less evidence for the use of SFRT (7).

While lacking high quality studies, our clinical experience consistently yields favourable results, thereby prompting the suggestion of its consideration as a viable choice for patients with advanced disease and poor performance status; even within low-income countries, where patients often present with more advanced illnesses and palliative RT emerges as a potential avenue for treatment. Therefore, we agree that patient selection demands a careful consideration; however, we disagree with the outright exclusion of any form of treatment during the end of the life. Hemostatic RT should be contemplated as an integral component of optimal supportive care, similar to other minimally invasive interventions such as draining ascites or pleural effusion for symptomatic relief.

In conclusion, we agree that the need for good metrics system for patients at the end of life and prospective trials on hemostatic radiotherapy is evident but challenging to initiate. Furthermore, we advocate for personalized deliberation concerning the merits and drawbacks of palliative radiotherapy in individuals grappling with advanced disease and poor performance status. The application of a patient-centered, multidisciplinary approach should extend into palliative care, beyond the confines of definitive treatment scenarios. Furthermore, the feedback from patients through directed surveys would be useful in addressing these concerns; nonetheless, the unique nature of the palliative care patients presents challenges in this endeavour.

Acknowledgments

Funding: None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Annals of Palliative Medicine. The article did not undergo external peer review.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://apm.amegroups.com/article/view/10.21037/apm-2023-03/coif). CBS serves as the co-Editor-in-Chief of Annals of Palliative Medicine. EO reports that she received a Varian Research Grant. The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

  1. Vargas A. 30-day expected mortality and hemostatic palliative radiotherapy: definitions, certainties and uncertainties. Ann Palliat Med 2023;12:1485-87. [Crossref] [PubMed]
  2. Navarro-Domenech I, Behroozian T, Hoskin P, et al. Appropriateness of the 30-day expected mortality metric in palliative radiation treatment: a narrative review. Ann Palliat Med 2023;12:620-32. [Crossref] [PubMed]
  3. Kutzko JH, Dadwal P, Holt T, et al. Defining the expected 30-day mortality for patients undergoing palliative radiotherapy: A meta-analysis. Radiother Oncol 2022;168:147-210. [Crossref] [PubMed]
  4. Vázquez M, Altabas M, Moreno DC, et al. 30-Day Mortality Following Palliative Radiotherapy. Front Oncol 2021;11:668481. [Crossref] [PubMed]
  5. Chow R, Hoskin P, Hollenberg D, et al. Efficacy of single fraction conventional radiation therapy for painful uncomplicated bone metastases: a systematic review and meta-analysis. Ann Palliat Med 2017;6:125-42. [Crossref] [PubMed]
  6. Squires JE, Asad S, Varin MD, et al. Behavioral Determinants of Canadian Radiation Oncologists' Use of Single Fraction Palliative Radiation Therapy for Uncomplicated Bone Metastases. Int J Radiat Oncol Biol Phys 2021;109:374-86. [Crossref] [PubMed]
  7. Katano A, Yamashita H. The Efficacy of Hemostatic Radiotherapy for Advanced Malignancies Assessed by World Health Organization Bleeding Status. Cureus 2021;13:e19939. [Crossref] [PubMed]
Cite this article as: Navarro-Domenech I, Behroozian T, Hoskin P, Johnstone C, Recht A, Menten J, Oldenburger E, van der Linden YM, van der Velden JM, Nguyen QN, Simone CB 2nd, Johnstone P, Lutz S, Milton L, Andratschke N, Willmann J, Kazmierska J, Spałek M, Marta GN, Chow E, Raman S. Addressing concerns and uncertainties surrounding the application of palliative radiotherapy in cases with a 30-day expected mortality. Ann Palliat Med 2023;12(6):1488-1490. doi: 10.21037/apm-2023-03

Article Options

Download Citation

Share