role of radiotherapy · role of radiotherapy • approximately 50% of all cancer patients ... p.r....
TRANSCRIPT
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Role of Radiotherapy
• Approximately 50% of all cancer patients
require radiotherapy as part of their disease
management
• An attractive treatment option for older
patients, especially where surgery or
chemotherapy pose too great a risk
• Radical versus Palliative versus Prophylactic
versus Abscopal
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Questions to Ask for Older Patients
• Will this patient be able to tolerate a course of
radiotherapy and associated toxicity?
• Or is a more palliative approach suitable?
• Are there alternative treatment schedules that might be
more suitable for an older patient?
• Is every possible attempt being made to reduce toxicity?
• Will the patient be able to attend radiotherapy every day?
• Does the patient have adequate support?
• Does the patient have capacity to consent to treatment?
• What are the patient’s wishes if treatment will result in
functional decline?
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The Importance of Patient Wishes
Fried, T.R., et al., Understanding the Treatment Preferences of Seriously Ill Patients. New England Journal of
Medicine, 2002. 346(14): p. 1061-1066.
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Case Study: Rectal Cancer
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Why use Radiotherapy?
• Reduce the risk of local recurrence
– Involvement of the circumferential margin
– Lymph node status
– Extramural venous invasion
• Neoadjuvant
– Induce tumour response prior to Surgery (Sx)
– Increase the chances of sphincter sparing Sx: *not supported by evidence
– Potentially less small bowel toxicity as bowel adhesions more common
after Sx
– Surgically naïve tissue is better oxygenated…..therefore more responsive
to radiotherapy
� But not proven to increase survival*Bujko, Krzysztof, et al. Does rectal cancer shrinkage induced by preoperative radio (chemo) therapy increase the
likelihood of anterior resection? A systematic review of randomised trials. Radiotherapy and oncology 2006; 80: 4-12
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Long Course vs Short Course RT
Long Course
• 45-50.4Gy in 25-28 fractions
delivered in 5 days/week, one
fraction/day
• 1.8 Gy/#
• Trend toward increased pCR with
higher doses. A statistically
significant increase in LRFS, DFS,
and OS was seen with radiation
doses of 46 and greater, but there
was no difference between 46 Gy
and 50 Gy. 2Gy/#
Short Course
25Gy in 5 fractions delivered in 1
week
• 5 Gy/#
Wiltshire et al. Preoperative radiation with concurrent chemotherapy for resectable rectal cancer: Effect of dose escalation on pathologic
complete response, local recurrence-free survival, disease-free survival, and overall survival
International Journal of Radiation Oncology*Biology*Physics, 2006; 64 (3):709-716
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Case Study: Prostate Cancer
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Hypofractionation: Less is More
• CHHiP (Conventional or Hypofractionated High-dose Intensity Modulated Radiotherapy in Prostate Cancer) (Lancet Oncol 2016;17[8]:1047-1060, PMID: 27339115),
• NRG Oncology 0415 trial (J ClinOncol 2016;34[20]:2325-2330, PMID: 27044935)
• Ontario Clinical Oncology Group/Trans-Tasman Radiation Oncology Group trial, PROFIT (PROstateFractionated Irradiation Trial) (J Clin Oncol 2017 Mar 15. [Epub ahead of print], PMID: 28296582).
4/5 weeks versus 7/8 weeks
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Case Study: Head and Neck Cancer
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CGA in Older H&N RT Patients
• Deterioration during
treatment supports
continuous assessment
• Screening tools are no
substitute for full CGA
• CGA deficits closely
associated with HRQOL
Pottel, L., Lycke, M., Boterberg, T., Pottel, H., Goethals, L., Duprez, F., Van Den Noortgate, N., De Neve, W., Rottey, S., Geldhof, K., Buyse, V.,
Kargar-Samani, K., Ghekiere, V. and Debruyne, P.R. (2014), Serial comprehensive geriatric assessment in elderly head and neck cancer patients
undergoing curative radiotherapy identifies evolution of multidimensional health problems and is indicative of quality of life. European Journal of
Cancer Care, 23: 401–412. doi: 10.1111/ecc.12179
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Key Questions to Ask the RO
• Is this the only radiotherapeutic option for this patient?
• Is a different fractionation schedule possible/feasible/effective?
• What is the anticipated toxicity of treatment?
• What efforts can be made to reduce toxicity and manage pre-existing concerns?
• What supportive care options will the patient have access to during radiotherapy and during follow-up?
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Role of CGA
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An Integrated Approach
“broader than a restricted definition of technical
maintenance and quality control of equipment and
treatment delivery ….should encompass a comprehensive
approach to all activities in the radiotherapy department
from the moment a patient enters it until the moment they
leave, and also continuing into the follow-up period”(ESTRO,
1998)
“Quality geriatric care has been defined as aging-sensitive, evidence-based, individualised care that
promotes informed decision-making and is continuous across settings” (Barba, 2012)