The current landscape of oncologic emergencies: the role of radiotherapy

We are pleased to present this collection of papers for the special series of the Annals of Palliative Medicine on how radiation therapy (RT) has shaped the landscape in the management of oncologic emergencies. Oncologic emergencies can occur at any point during a patient’s cancer journey, from initial diagnosis to a patient at the end-of-life. They mandate urgent recognition to maximize therapeutic benefit and avoid significant morbidity. The treatment of these emergencies can often improve the quality of life and, in some cases, prolong survival. Multi-disciplinary involvement is paramount to ensuring the needs of the situation are being addressed with the most effective tools available using the best available data. Given RT is a cornerstone in the management of oncologic emergencies, our compendium of papers provides a site-specific evidence based holistic approach to share with the community to elevate the quality and comprehensive nature of care that we provide for our patients and their families and support system in this critical time of need for shared decision-making to support a patient’s goals.

A common thread emerged regarding the paucity of randomized or high-quality prospective data to inform decision-making, and there is an urgent need for prospective RT data to inform efficiency, optimal fractionation to maximize durability of response while minimizing side effects and number of days of treatment, and time to response of treatment. Advancements in novel systemic therapies have resulted in patients living longer with an increasing need for local disease-directed therapy in the metastatic and/or palliative setting. RT treatment in the emergent setting is typically administered using more basic radiation techniques (e.g., 3D-conformal RT) given the ability to generate a plan in hours to 1–2 days. Anticipatory use of advanced techniques such as stereotactic body radiation therapy (SBRT) to the spine or other potential parenchymal locations (e.g., liver, bone, lung), and/or radiosurgery to brain metastases may potentially decrease the risk of further progression and need for emergent treatment. The papers of this special series provide a guide for the clinician regarding the best approach to take given the patient presentation, extent of disease, and performance status.

Furthermore, these works sought to shine light on barriers to treatment, such as the logistical, financial, and spiritual considerations that need to be assessed to inform next steps. A thorough assessment, including spiritual history taking sometimes teaches us that no cancer-directed treatment may be the most appropriate in some cases, as it may be detrimental to the critical hours of need for preparation and saying goodbye.

We express our gratitude to the multi-disciplinary team of authors for their contributions to educating us on the current state of RT for oncologic emergencies.

Acknowledgments

Funding: None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Annals of Palliative Medicine for the series “Radiotherapy for Oncologic Emergencies”. 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-24-159/coif). The series “Radiotherapy for Oncologic Emergencies” was commissioned by the editorial office without any funding or sponsorship. C.B.S. serves as an Editor-in-Chief of Annals of Palliative Medicine from April 2014 to April 2027. S.S.L. serves as an unpaid Associate Editor-in-Chief of Annals of Palliative Medicine from February 2024 to January 2026. All authors served as unpaid Guest Editors of the series. S.S.L. received research funding (he was co-PI) from Kuni Foundation, and funding from Hutchinson Center as Lead Academic Participating Site (UG1 CA 233328). He is an Assistant Councilor and the Chair of CARROS Nominating Committee for American College of Radiology (ACR) and also serves as a member of the Board of Directors and the Director of the Distinction in Practice in Stereotactic Radiotherapy Program of the Radiosurgery Society. S.S.L. was invited as a guest speaker in the Japanese Society for Radiation Oncology (JASTRO) annual meeting in 2022 and was invited as a speaker in the Freiburg Prostate Cancer Symposium at the University of Freiburg, Germany in 2024. S.K.S. received the single-time honoraria for a speaking engagement from CarboFix LLC. The authors have no other conflicts of interest to declare.

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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/.

Stephanie K. Schaub

Charles B. Simone II

Simon S. Lo

J. Isabelle Choi