|Year : 2015 | Volume
| Issue : 7 | Page : 106-108
Palliative and Supportive Care
|Date of Web Publication||24-Nov-2015|
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
. Palliative and Supportive Care. J Can Res Ther 2015;11, Suppl S3:106-8
Quad shot with concurrent chemotherapy: Short and effective palliative radiotherapy schedule
thM. Dubey , R. Dhankhar, V. Kaushal, R. Atri, A. K. Dhull, A. Soni
Pt. B.D. Sharma Post Graduate Institute of Medical Sciences, Rohtak, Haryana, India, E-mail: email@example.com
Background: To evaluate a QUAD-shot schedule of palliative radiation with chemotherapy in patients diagnosed as locally advanced head and neck carcinoma. Aims and Objectives: While palliative radiation with various fractionation regimens has shown benefit in this setting, the additional benefit of radio-sensitizing chemotherapy needs investigation. We report our experience with hypofractionated palliative local radiation therapy utilizing the "QUAD-shot" regimen with concurrent systemic therapy to evaluate tumor response, palliation of symptoms and toxicity. Materials and Methods: This study was conducted on 40 previously untreated, histopathologically proven patients, of locally advanced (stage IVA/B/C) squamous cell carcinoma of head and neck region. In all these patients definitive treatment was decided as palliative, radiotherapy along with chemotherapy. Group I (n = 20) is study group received paclitaxel 60 mg/m2 one hour prior to the first day of each radiation cycle and group II (n = 20) control received only palliative radiotherapy. Radiation was delivered at 3.7 Gy per fraction twice a day for two days and repeated every three weeks for a total of three cycles. Tumor response was documented by radiologic imaging and physical examination. Toxicity was graded utilizing a standardized scale of the Common Terminology Criteria for Adverse Events (CTCAE) version 4.0. Results: In study group, complete response was seen in 12 (60%), partial response in 6 (30%), and no response in 2 (10%) patients. Palliation of the symptoms was achieved in all 12 patients that completed the three cycles. Median follow up was 6 months. Treatment was well tolerated with acceptable toxicity. 0% grade 3 acute toxicity, and 30% grade 2 acute toxicity. In control group, complete response was seen in 10 (50%), partial response in 4 (20%) patients, and no response in 6 (30%) patients. Palliation of symptoms was achieved in all 10 patients that completed the three cycles. Treatment was well tolerated without grade III acute toxicity, 40% grade II acute toxicity. Conclusion: QUAD-Shot palliative radiation therapy combined with radio sensitizing chemotherapy is efficacious, well tolerated and improves symptoms of patients with newly diagnosed head and neck cancer not amenable to curative therapy.
Assessment of severity of dysphagia in patients following chemo radiation and post-operative radiation and the risk of aspiration
Background: Dysphagia (swallowing dysfunction) is a debilitating, depressing and potentially life threatening complication in cancer patients, related to high mortality rate for aspiration pneumonia. Aim: The aims of this paper are: (1) To assess severity of dysphagia after chemo radiation and post-operative radiation. (2) To assess the risk of aspiration after chemo radiation and post-operative radiation. Materials and Methods: 40 head and neck cancer patients who had undergone radiation therapy and considered disease free at the time of swallowing study, in Department of Radiotherapy, MMC and RGGGH were selected. Out of these, 20 had undergone definitive chemo radiation and 20 had undergone post operative irradiation. Dysphagia severity was assessed on a scale of 1-7. Patients were grouped according to severity: Mild (1-3), moderate (4-5) and severe (6-7) dysphagia. Results: Mean and median dysphagia grades were 4/5.4 and 4.07/4 for chemoradiation and postoperative radiation respectively. The mean difference between the two groups was statistically significant. Mild dysphagia occurred in 13 patients (22%) of the chemoradiation group and 17 (32%) of the postoperative group. Corresponding number for the moderate group was 25 (43%) and 25 (48%), respectively. Severe dysphagia was significant in the chemoradiation group (34%) compared to the postoperative group (19%). However, the difference was not statistically significant. There was a higher proportion of patients with large tumor (T3-T4) in the chemoradiation group who developed severe dysphagia. 25% of the chemoradiation group and 15% of post operative group developed aspiration pneumonitis leading to complications. Conclusion: Dysphagia remains a significant morbidity of chemoradiation and postoperative radiation for head and neck cancer. Dysphagia may be more severe in the chemoradiation group because of the higher proportion of patients with large tumor, the high radiation dose, and a high number of oropharyngeal tumors. Aspiration occurred in both groups. Due to the high mortality rates due to aspiration, it is necessary to motivate the patient regarding palliative measures like Ryle's tube feeding and feeding jejunostomy.
Analysis of sociodemographic parameters of patients treated with radiotherapy for bone metastases in the Radiotherapy Department of a Medical College
thK. P. Bhat , S. Mutha, P. Gaur, A. Malavat
Dr. Sampurnanand Medical College, Jodhpur, Rajasthan, India, E-mail: firstname.lastname@example.org
Background: Bone metastasis is commonly seen in patients with cancer of breast, prostate, renal, lung and thyroid. It causes significant morbidity to the patients and form significant part of palliative patients in an oncology department. Aim: To study the sociodemographic profile of patients treated with radiotherapy for bone metastases, presenting symptoms, indication for palliative radiotherapy and fractionation of palliative radiotherapy. Materials and Methods: A retrospective analysis of all the patients treated in the department of radiotherapy in a medical college for bone metastases between 2004 and 2014 was analysed for the sociodemographic profile, indication for palliative radiotherapy and fractionation schedule. Standard statistical methods were used to analyse the data. Results: Majority of the patients treated with palliative radiotherapy for bone metastases were male, agricultural background with pain and spinal cord compression being two most common indications. Various fractionation schedules were used based on the need for symptom relief, location of metastases and expected survival most patients had good symptom relief. Conclusion: Palliative care is a challenge to the medical staff and as well as the patients and their relatives. Bone metastases forms a significant percentage of Patients requiring palliative care. Optimisation of treatment modality will help a long way in meeting the demands of the patients.
An audit of pain management in patients referred to the outpatient department of cancer palliative medicine of malabar cancer centre
thM. S. Biji , T. Bhattacharyya, A. Bhattacharjee, S. Dessai, N. R. Sindhu, B. Satheesan
Malabar Cancer Centre, Thalassery, Kerala, India, E-mail: email@example.com
Introduction: Pain is one of the most common symptom in patients with advanced cancer. Pain occurs in two-third of patients with advanced cancer. Cancer pain can be managed effectively through relatively simple means in up to 90% of the patients who have cancer or a history of cancer. Unfortunately, pain associated with cancer is frequently undertreated. Failure to assess pain is a critical factor leading to under treatment. This prompted us to conduct a retrospective analysis to assess the intensity of pain with which patients reach the Cancer Palliative Medicine out-patient department. Aims: (1) To find out the intensity of pain with which patients reach the Cancer Palliative OPD on their first visit. (2) To compare the pain score of patients in first visit and on follow up visits. (3) To assess the impact of number of visits on pain scoring. Materials and Methods: This is a retrospective analysis of 125 patients who had visited cancer palliative medicine department from September 2014 to February 2015 for pain management. Apart from the demographic details, stage of disease, treatment details and pain score recorded using Numeric pain rating scale (NRS) during each visit was extracted from the case records. NRS was shown to each patient and the respondent was asked to indicate the numeric value on the segmented scale that best described their pain intensity. The number that the respondent indicated on the scale to rate their pain intensity was recorded. Scores ranged from 0-10. Higher scores indicate greater pain intensity. Pain score changes pattern were observed through trend analysis. Results: Sample size was 125. Among them 53.6% of the patients were males. Median age of the patients was 73 years (range 23-90 years). Most of the patients had a diagnosis of genitourinary malignancies (27.2%) followed by carcinoma lung (19.2%) and carcinoma head and neck (15.2%). Most of the patients belonged to stage III (52%) followed by stage IV (29.6%). The median pain score on first visit was 2 (range 0-8). A total of 61 patients (48.8%) could come for minimum 4 visits. There was no change in median pain score till fourth visit. There was no significant impact of number of visits on change in pain score pattern. Conclusion: There was no incline or decline trend observed on median pain score during different visits. Probably this could be due to upstaging of disease despite good palliative care.
Demographic and clinicopathological profile of patients receiving palliative radiotherapy to bone and their response to radiotherapy-An institutional review
thS. Mishra , A. Tripathy, L. Pattanayak, S. Padhi, N. Panda, S. Senapati
Acharya Harihara Regional Cancer Center, Cuttack, Odisha, India, E-mail: firstname.lastname@example.org
Background: Bone is a common site of metastases in many malignancies and role of radiotherapy in managing symptomatic bone metastases is well established. Aim: To correlate demographic and clinicopathological variables of bone metastases with mode of presentation & response to treatment with literature review. Materials and Methods: A retrospective study on 273 patients who have received palliative radiotherapy to bone metastases from January 2014 to June 2015 (18 months) at AHRCC, Cuttack has been analysed with respect to gender, age, site of primary, site of bone metastases and response to radiotherapy. Results: Among 273 patients receiving palliative radiotherapy to bone, 154 (56.4%) were males and 119 (43.6%) were females. Age distribution was 18 patients (6%) in ≤30 yrs, 33 patients (12%) in 31-40 yrs, 66 patients (25%) in 41-50 yrs, 76 patients (27%) in 51-60 yrs and 80 patients (30%) in >60 yrs age group. Most common site of primary was breast (22%) followed by lung (17.5%), prostate (12%), head and neck (9%), cervix (4%). Most of the patients (91%) presented with axial skeleton metastases among which vertebrae is the most common site (Most common subsite-lumbar vertebrae) followed by pelvis. Only 9% patients presented with appendicular bone mets (most common subsite-femur). 49 patients (18%) presented with upfront bone metastases. Average time period of developing bone metastases after treatment to primary site was 9 months. 113 patients (41.3%) had single whereas 160 patients (58.7%) had multiple bone lesions. 24 patients (8.8%) had multiple metastatic sites including bone. 86% of patients had a positive response to RT in pain management documented by 10 point pain scoring system, in which pain score decreased by average 5 points in patients receiving palliative RT in 30 Gy/10#s and 4 points in patients receiving 8 Gy/1#. Patients receiving 30 Gy/10# had a more durable pain relief compared to 8 Gy/1# patients. Conclusion: From this study we can conclude that carcinoma breast is the most common site of primary developing bone metastases followed by carcinoma lung and carcinoma prostate. Mostly axial skeleton is involved with lumbar vertebrae being the most common site. Metastatic bone show a very good response to palliative RT in decreasing pain and reduction in dose of analgesics used.
Palliation of pain with external beam radiotherapy and zoledronic acid versus external beam radiotherapy alone in the treatment of painful bone metastesis
Institute of Postgraduate Medical Education and Research, Kolkata, West Bengal, India, E-mail: email@example.com
Background: Bone is the common organ to be affected by metastatic cancer. Metastatic bone diseases are most frequent on breast, lung and prostate cancer. Besides these thyroid and renal carcinoma also metastises to bone. Other primary sites with propensity for bone metastasis include G.I. tract, melanoma, urinary bladder. The morbidity associated with bone metastasis referred as skeletal related events (SRE) which includes pain, hypercalcemia, pathological fracture, spinal cord compression. But the most common symptom in bone metastasis is pain. Radiotherapy is the most effective palliative treatment of bone metastasis. Over the past 10 years the bisphosphonates have become established as a valuable additional approach to the range of current treatment. Recent studies suggest that concomitant zoledronic acid with external beam radiotherapy (EBRT) is more effective than either treatment alone. Aim: Primary end point: To assess & compare the pain relief and the time to onset of pain relief obtained. Secondary end points: Skeletal Related Event free survival. Materials and Methods: Study was conducted between January 2014-July 2015. A total of 41 Patients with histopathologically proven painful bone metastatic disease were randomly assigned to two arms, A & B. Arm A received palliative EBRT only and arm B received palliative EBRT along with 3 weekly zoledronic acid 4 mg. Patients were received External beam radiotherapy with a total dose of 30 gray in 10 fractions @ 2 Gy/fraction over two weeks. Out of 41 patient 4 patient lost to follow-up and 2 patient died due to non -cancer causes and ultimately total 35 patient analysed. Pain relief assessed using 0-10 Numeric Pain Rating Scale and analgesic score based on WHO analgesic ladder. Statistical analysis was made by SPSS version 20. Results: Mean pain score and analgesic score analysed weekwise in the both arms and pain relief is better& statistically significant (p < 0.05) in arm B from second week following EBRT and starting of zoledronic acidwhich is. Onset of pain relief in arm A is earlier than arm B, but not statistically significant. SRE free survival is prolonged in arm B and statistically significant (p < 0.05). Conclusion: Addition of Zoledronic acid along with EBRT showed better pain relief and prolonged SRE free survival in painful bone metastatic disease.
Palliative cancer care services for head and neck cancer patients: An initial audit
thM. Verma , R. Shrivastava, S. Kumar, P. Lal
Sanjay Gandhi Postgraduate Institute of Medical Science, Lucknow, Uttar Pradesh, India, E-mail: firstname.lastname@example.org
Background: HNC is one of the most common malignancies especially in India. Poor socio-economic status and illiteracy attribute towards advanced presentation. Decision of radical or palliative treatment rests on stage, age, co-morbidity and general condition of the patient. 40% of the HNC patients are candidates for palliation in our set up. In general, in palliation the focus is on tumor growth restraint by cancer directed therapy, symptom control and address psychosocial issues. An independent cancer care clinic, that allowed clinicians more time to focus on the patients' holistic needs, was set up in January 2013 and an audit of initial 153 HNC patients is presented. Aim: To assess the impact of cancer directed therapy, pain management and other supportive measures on the general well-being, response and outcome of these patients. Materials and Methods: Data was collected from case records and telephonically, to document demography, symptomatology, cancer treatment offered, and analgesics (especially morphine). Pain relief and response at the primary were studied. Survival was computed from the date of first visit in palliative cancer care clinic (PCCC) till death or last visit. Data was analyzed as of August 15. Results: 153 patients were seen between January 13 to March 15, in the PCCC. 53% of cases that were referred to PCCC were due to advanced presentation. Median follow up was 5.2 months with median age - 52 yrs. 91% were males. 70% of them needed some degree of assistance for their normal activities. Oral cancers comprised 43% of cases, and 91% had stage IV disease (5% metastasis). Pain was the most common presenting symptom (87%) followed by difficulty in swallowing (40%) and fungation (31%). Nearly Ύ cases had adequate pain relief with morphine. Overall median duration of symptoms was 4 months. Cancer directed therapy, offering local control before the inevitable progression set in. At the time of analysis, 11% were alive, 65% dead and 24% were lost to follow up. Conclusion: Pain relief (with morphine) was seen in 67% cases. Patients responded well to cancer directed treatment. PCCC seems to be an effective working model in our set up.
Assessment of protein, calorie and weight changes in head and neck cancer patients before and during radiation treatment
thN. Singh , Z. Habeeb, M. Verma, S. Kumar, P. Lal
Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India, E-mail: email@example.com
Background : Head and neck cancer patients are often malnourished at the time of presentation. This is due to physical obstruction in the passage by the growth. The nutritional status worsens during treatment radiation mucositis. This state of malnutrition may directly or indirectly impact upon treatment outcome. We report our experience of nutrient dietary pattern, weight changes at baseline and during treatment, in patients who attended the diet clinic regularly. Materials and Methods: Sixty Head neck cancer patients, presented between May-August 15 in diet clinic from Radiotherapy OPD. Following thorough physical examination and staging work up, all these patients were subjected to radical/postoperative radiotherapy for 6 to 7 weeks, with or without chemotherapy. A dedicated team of nutritionists attended to patients' dietary needs by providing individualized diet charts as per their diet habits, taste and ability to eat. The family/patient were trained to make a diet diary for nutritional assessment and based on that dietary modifications were made. Nutritional status, protein, calorie and weight changes due to the cancer was documented at presented & weekly intervals during treatment. The statistical analysis of all nutritional parameters was done as of September, 2015. Results: In the present study 60 patients were included. 52 (87%) were males with median age 51 yrs. 56 (93%) were in regular follow up in which 36 (60%) were oral cavity patients. At the time of analysis, 49 (82%) patients have completed RT while 4 await treatment. 29 (50%) were non vegetarian and 15 (25%) needed naso-gastric tube. 42% cases were underweight at baseline. 17/52 (35%) patients continued to loose weight while 31% gained weight during RT. 29% (15) patients lost <5% weight & 1 lost >10%. 9 (17%) decreased their calorie intake by within 1000 kcal/day while 38 (73%) increased their calorie intake 500-1500 kcal/day. 3 (6%) patients had decreased protein intake- of which 2 had reduction of > 15 gm/day of their pre treatment protein intake. Conclusion : Head and neck cancer patients are underweight at the time of presentation. One-third may continue to loose weight during RT and an equal proportion may gain weight due to nutritional support. Protein & calorie intake decreased in 6 and 17% cases respectively, despite nutritional counseling.
Palliative Radiotherapy- 400 cGy/1#/week for 4 weeks in locally advanced oral cavity cancer after methotrexate weekly shots
thM. Korde , S. Prasad, S. Singh, P. Shukla, J. Verma, P. Singh,
R. Srivaastav, S. Kumar
J.K.Cancer Institute, Kanpur, Uttar Pradesh, India. E-mail: firstname.lastname@example.org
Background: The locally advanced oral cavity cancers with fungating mass or fistula formation are incurable. The number of cases with such advance stage getting registered in our institute is high may be due to late diagnosis or negligence. Also these patients have limited life expectancy. Aim: The study aims to evaluate the symptomatic response, improvement in Quality of life and acute toxicity after Injection MTX followed by Palliative Radiotherapy. Materials and Methods: Patients registered in J.K. Cancer Institute between December 2014 and July 2015 and who were histopathologically proved squamous cell carcinoma of oral cavity with stage IV and KPS >70 were chosen for study. All patients received 6 shots of weekly Injection MTX followed by Palliative RT (400 cGy/1#/week for 4 consecutive weeks). Patients were evaluated after 4 weeks of completion of RT for disease response, symptomatic response and acute toxicities. Results: Symptom relief for pain, dyspagia, otalgia, food intake, and discharge from fungating mass was obtained in 60% of patients following RT. None of these patients experienced radiation toxicity that required hospitalization. All Patients had up to grade I skin and mucosal toxicity. Main complain of patients before Paliative RT was Pain and after RT >70% patients got Pain relief. Conclusion: Palliative dose of 400 cGy/1#/Week for 4 continuous week proved good for symptomatic response and relief and improved Quality of Life and also helpful in decreasing burden of machine.
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