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Palliative, Benign, Constraints > Palliative > Flashcards

Palliative Flashcards

1
Q

What were the pt population, randomization, and endpoint of the Patchell 2005 study for metastatic epidural spinal cord compression?

A
  • Pts: spinal cord compression caused by metastatic cancer
    – ≥ 1 Neurologic sx, including pain
    – Paraplegia ≤ 48 hrs
    – Radiosensitive tumors (lymphomas, leukemias, MM, GCT) excluded
    – Most pts had anteriorly located tumors tx w/ anterior or lateral approach corpectomy if randomized to the surgical arm.
  • Randomization:
    – Surgical decompression f/b RT (30/10)
    – RT alone (30/10)
    — many unstable pts ended up in this arm, as this study was conducted before the SINS score was in use
  • Primary Endpoint: ability to walk
    – “A patient was deemed ambulatory if he or she could take at least two steps with each foot unassisted (4 steps total), even if a cane or walker was needed”
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2
Q

What were the pt results and the conclusion of the Patchell 2005 study for metastatic epidural spinal cord compression?

A
  • Results: Surgery f/b RT vs. RT alone
    – Post-treatment ambulatory rate: 84% vs. 57% (p=0.001)
    – Retained ability to walk: 122 days vs. 13 days (p=0.003)
    – Regained the ability to walk: 62% vs. 19% (p=0.012)
    – Dexamethasone required: 1.5 mg vs. 4.5 mg (p=0.0093)
    – Daily morphine equivalent: 0.7 mg vs. 4.8 mg (p=0.002)
  • Conclusion: Direct decompressive surgery f/b PORT is superior to RT alone for patients with spinal cord compression caused by metastatic cancer with respect to ability to ambulate and requirements for steroids and narcotics
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3
Q

How was walking defined in the Patchell 2005 study for metastatic epidural spinal cord compression?

A

“A patient was deemed ambulatory if he or she could take at least two steps with each foot unassisted (4 steps total), even if a cane or walker was needed”

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4
Q

What were the pt population, randomization, and endpoint of the first Patchell 1990 study for brain metastases?

A
  • Pt: 48 patients with a single brain metastasis
    – 11% were excluded as their surgical path did not show cancer
  • Randomization:
    • S-WBRT: Surgical removal of metastatic lesion f/b WBRT (36 Gy in 12 fx w/ Co-60)
    • Bx f/b WBRT (36 Gy in 12 fx w/ Co-60)
  • Primary EP: OS

1st Patchell: Everyone gets RT
2nd Patchall: Everyone gets Surgery

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5
Q

What were the results of the first Patchell 1990 study for brain metastases?

A
  • S-WBRT vs. bx-WBRT only
    • OS: 40 weeks vs. 15 weeks (p<0.001)
    • Recurrence rate at the original site: 20% vs. 52% (p<0.02)
    • Time to recurrence at original site: >59 weeks vs. 21 weeks (p<0.0001)
    • Median time to death from neurological causes: 62 weeks vs. 26 weeks (p<0.0009)
    • Median length of functional independence: 38 weeks vs. 8 weeks (p<0.005)
  • Conclusion: Surgery f/b WBRT improves OS, local control, and QoL compared to WBRT alone in patients with one brain metastasis
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6
Q

What were the pt population, randomization, and endpoint of the second Patchell 1998 study for brain metastases?

A
  • Goal: to determine if surgical resection f/b PORT for patients with a single metastasis improved neurological control and increased survival.
  • Randomization following surgery:
    – WBRT (50.4 Gy in 28 fx)
    – Observation
  • Primary EP: Recurrence within the brain
  • Secondary EP: OS, cause of death, preservation of the ability to function independently.

1st Patchell: Everyone gets RT
2nd Patchall: Everyone gets Surgery

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7
Q

What were the results and conclusions of the second Patchell 1998 study for brain metastases?

A
  • WBRT vs. Obs:
    – In-brain tumor recurrence: 18% vs. 70% (p<0.001)
    – Recurrence at the original site: 10% vs. 46% (p<0.001)
    – Recurrence not at original site: 14% vs. 37% (p<0.01)
    – Time to recurrence: 50 wks vs. 27 wks (p<0.001)
    – Death 2/2 neurological causes: 14% vs. 44% (p=0.003)
    – OS: 48 wks vs. 43 wks (p=0.39)
    – 60% of obs pts eventually received RT
  • Conclusion: Patients with 1 brain metastasis who receive surgery f/b PORT experience fewer in-brain tumor recurrences and are less likely to die of neurological causes versus those treated with surgery alone.
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8
Q

Do pts receiving 5 fx RT for spinal cord compression do better if they receive it over five days (M-F) than if they do it over 7 days (RT interrupted by a 2 day weekend?

A

No

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9
Q

Which ABX can be used for PJP prophylaxis in high-risk pts?

A
  • TMP-SMX DS thrice weekly
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10
Q

What was the pt population, randomization, and endpoint of the Phase II SABR-COMET trial (Lancet, 2019)?

A
  • Phase II study of pts w/ oligomet recurrence (1-5 metastases) and controlled primary.
    – All histologies enrolled, but the most common were colorectal breast, lung, prostate
    – Most common metastatic sites were adrenal, bone, lung, liver
  • Randomization: SoC palliative therapy ± SABR to all sites
    – Most common RT regimens were 35/5, 60/8, and 54/3
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11
Q

What were the results of the Phase II SABR-COMET trial (Lancet, 2019)?

A
  • SoC vs. SoC w/ SABR to all sites:
    – Median PFS: 6 vs. 12 mos (SS)
    – 8-yr PFS: 0 vs. 21.3% (SS)
    – Median OS: 28 vs. 48 mos (SS)
    – 8-yr OS: 13.6 vs 27.2% (SS)
    – ≥ Gr 2 tox: 9.1 vs. 30.3% (SS)
    – NS grade 3-5 toxicities or differences in QOL
  • Conclusion: The addition of ablative radiotherapy may provide PFS and OS benefits for patients w/ 1-5 metastases
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12
Q

What is the first step in managing a pt w/ metastatic cord compression a/w neurologic deficits?

A

Initiate steroids!

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13
Q

What is the general steroid admin protocol for pts w/ metastatic cord compression a/w neurologic deficits?

A
  • 8-10 mg IV dexamethasone bolus (or equivalent) f/
    -16 mg/day (usually in twice-daily to four-time daily)
    – 4 mg q6h
  • Patients with dense paraparesis (Grade 3 or worse) should be considered for higher bolus (100 mg) and maintenance doses (up to 96 mg/day), but the risk of serious adverse events should be considered.
  • *Patients with radiographic spinal cord compression but no neurologic deficits do not require steroids
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14
Q

Should you initiate steroids in pts w/ spinal cord compression w/o neurologic deficits?

A

Not always

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15
Q

What is the general recommendation regarding the use of steroids in the management of metastatic extramedullary spinal cord compression (MESCC)?

A
  1. Initiate steroids for any patient w/ neurologic deficits suspected or confirmed to have MESCC, particularly if they are being treated w/ ≤ 5 fx RT
  2. Patients being treated with surgery will need PORT and should receive maintenance steroids.
  3. Those treated w/ ≥ 6 fx RT w/ no neurologic deficits or those prescribed high-dose steroids can have the steroids weaned over ≥ 2 weeks once treatment is started
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16
Q

What were the findings of the Rades et al. IJROBP 2011 paper examining short (8/1 and 20/5) vs long course (30/10 or 50/20) radiation therapy for the treatment of spinal cord compression?

A
  • Short (8/1 and 20/5) vs long course (30/10 or 50/20) RT:
    – 1-year LC: 61% vs. 81% (p=0.005)
    – 1-year OS: 23% vs. 30% (p= 0.28)
    – Motor function improvement: 37% vs. 39% (p=0.95)
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17
Q

What did the SCORAD III trial examining short vs. long course RT for malignant spinal cord compression show?

A

1 fx was not non-inferior to multi-fx RT in the treatment of malignant spinal cord compression w/ regard to ambulatory status at 8 weeks

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18
Q

How was RT prescribed in the Mahajan et al 2017 trial looking at post-op SRS vs. observation in pts w/ resected brain mets?

A
  • Dose depends on cavity size:
  • ≤ 10 cc → 16 Gy
  • 10.1-15 cc → 14 Gy
  • > 15 cc → 12 Gy
  • Used 1 mm margins around the resection cavity
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19
Q

What is the LC benefit of using a 0 mm vs. 2 mm margin for brain met SRS?

A
  • 2 mm vs. 0 mm
    – 1 yr LF rate: 3% vs. 8%, p=0.042 (Choi et al IJORBP 2012)
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20
Q

What were the results of the Mahajan et al 2017 trial looking at post-op SRS vs. observation in pts w/ resected brain mets?

A
  • Obs. vs. SRS
    – Median OS: 18 mos vs. 17 mos; P=0.24
    – 1-yr freedom from local recurrence: 43% vs. 72%; p=0.015
    — 1-yr LC: 57% vs. 28%
    – 1-yr freedom from local recurrence a/w # of resected mets:
    — 1 Resected Met: 53%
    — 2-3 Resected Mets: 62%
    – In the MVA, the significant predictors of local recurrence were SRS and met size
    – There were no treatment-related deaths in either group, and there was no radiographic evidence of necrosis in the SRS group.
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21
Q

Per the post hoc analysis of the Mahajan et al. 2017 trial, which looked at post-op SRS vs. observation, how is resection cavity diameter size related to LC?

A
  • 1-yr freedom from LR w/ respect to cavity diameter
    – ≤ 2.5 cm: 91%
    – 2.5-3.5 cm: 40%
    – > 3.5 cm: 36%
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22
Q

For targets > 3-4 cm, is SRS or SRT preferred?

A
  • SRT (30/5, 24/3, etc.)
    – Risk of radionecrosis is increased
    – LC w/ SRS for targets > 3-4 cm is suboptimal
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23
Q

Which liver met histologies are the most radiosensitive?

A
24
Q

Following SRS to the brainstem, what is the rate of severe (Gr ≥ 3) tox

A
  • 7.4%
  • Grade 3 tox includes:
    – Local edema
    – Hemorrhage
    – Radionecrosis requiring medical intervention
    – Encephalopathy
    – Seizure
    – Syncope
    – Memory loss
    – Ataxia impairing activities of daily living.
25
Q

When combining WBRT w/ SRS for brain mets, by how much is it reasonable to decrease the SRS dose?

A

~30%

26
Q

What were the overall results and the main conclusion of the FIRE-SCLC study looking at SRS vs. SBRT for brain mets from SCLC?

A
  • For all pts:
    – Median OS = 8.5 months
    – Median TTCP = 8.1 months
    – Rare leptomeningeal progression (10.8%) and neurologic mortality (12.4%)
  • Propensity score-matched analysis of SRS vs. WBRT
    – WBRT a/w improved TTCP (HR=0.38, p<0.001)
    – No change in OS (6.5 mos vs 5.2 mos)
  • Conclusion: The results for SRS for brain metastases in SCLC are similar to those in other malignancies versus those of WBRT, namely decreased TTCP with similar OS
27
Q

What were the results of the FIRE-SCLC study looking at SRS vs. SBRT for brain mets from SCLC when stratified by the number of brain mets?

A
  • Median OS:
    –1 lesion: 11.0 months
    – 2-4 lesions: 8.7 months
    – 5-10 lesions: 8.0 months
    – ≥ 11 lesions: 5.5 months
28
Q

What are the components of the TEACHH prognostic model for pts referred for palliative RT?

A
  1. Type of Cancer (lung and other vs. breast and prostate)
  2. ECOG performance status (2-4 vs. 0-1)
  3. Older Age (>60 years vs. ≤ 60 years)
  4. Chemotherapy, prior palliative courses (≥2 vs.<2)
  5. Hepatic metastases
  6. Hospitalizations within 3 months before palliative RT (0 vs. ≥1)
29
Q

How are the TEACHH prognostic model scores related to OS for metastatic pts referred for palliative RT?

A
30
Q

For a pt w/ continued pain after RT for bone mets, when can re-irradiation be considered?

A

> 4 wks

31
Q

How many pts will experience pain relief upon re-irradiation if they did not respond do a prior round of palliative RT for their bone met?

A

~ 50%

32
Q

What doses of RT can be used to treat spinal metastases from radioresistant histologies, like RCC?

A

SBRT is more useful than conventional palliative RT for radioresistant histologies:
- 24 Gy in 2 fx
- 27-30 Gy in 3 fx

33
Q

What is the rate of a flare reaction for pts undergoing conventional palliative RT for bone mets w/o steroids?

A

30-40%

34
Q

What is the rate of a flare reaction for pts undergoing palliative SBRT for bone mets w/o steroids?

A

~60%

35
Q

What is the rate of a flare reaction for pts undergoing single-fx palliative RT for bone mets w/o steroids?

A

15%

36
Q

How can flare reaction in pts undergoing palliative bone met RT be managed?

A
  • Steroids (dex 8 mg 1 hr prior to tx and 4 days after)
  • May reduce the incidence of a flare reaction by ~10%
  • May improve the time to flare reaction occurrence
37
Q

What are the SINS criteria?

A
  • CAPLET for SINS criteria:
    – Collapse of the vertebral body
    – Alignment of spine radiographically
    – Pain
    – Location (junctional, mobile, semi-rigid, or rigid spine)
    – Extension unilaterally or bilaterally to posterolateral spinal elements
    – Type of lesion (blastic, mixed, or lytic)
  • Scores:
    – 0-6 Stable
    – 7-12 indeterminate
    – 13-18 is unstable
    – Surgical consult required ≥ 7
  • HOOK: Capitol (CAPLET) Sin
38
Q

In RTOG 9508, what were the outcomes in the WBRT vs. WBRT + SRS arm?

A
  • 1-3 brain mets → WBRT (37.5/15) vs. WBRT+SRS (RTOG 9005 doses)
    – Median OS: 5.7 vs. 6.5 mos (NS)
    – Median OS (multiple mets): 6.7 vs. 5.8 months (NS)
    – Median OS (single met): 4.9 vs 6.5 mos (SS)
    – Stable or improved KPS at 6 mos: 27% vs. 43% (SS)
    – 1-yr LC: 71% vs. 82% (SS)
39
Q

What is the OS survival benefit a/w using a PRO questionnaire vs. usual care for pts undergoing palliative CHT?

A
  • 5 mos (31.2 mos vs. 26 mos)
  • Anytime a patient reported new or worsening symptoms on PRO, a nurse was alerted to follow-up.
40
Q

What are the benefits of using mindfulness-based cognitive therapy, art therapy, and stress therapy for cancer pts?

A

Reduces anxiety and depression

41
Q

What are the barriers to palliative and goals of care discussions in the medical setting for the ROs?

A
  • Not wanting to upset the medical oncologist (31%)
  • Inability to schedule clinic time to hold these conversations (31%)
  • Poor insurance reimbursement (12%)
  • Lack of interest in this clinical area (9%)
  • Other causes (17%)
42
Q

How much can you save costs by calling an inpatient palliative care consult within 2 or 6 days of hospitalization per Project ENABLE Il, Bakitas et al. JAMA 2009?

A
  • 2 days: 24%
  • 6 days: 16%
43
Q

What were the main findings of Project ENABLE Il, Bakitas et al. JAMA 2009?

A
  • Advanced cancer pt → Nursing-led palliative intervention vs. usual care
  • Improved QoL in the intervention group (SS)
  • Resource use (days in hospital/ICU, visits to ED, etc) NS
44
Q

What were the main findings of Project ENABLE IlI, May et al. JCO 2015?

A
  • Advanced care → early vs. delayed supportive oncology intervention
  • No change in QOL
  • Improved OS at 1 yr
    – ↑15%: 48% → 63%
45
Q

What is the rate of skeletal-related events (SRE) in high-risk asymptomatic bone mets treated w/ RT vs. observation per the recent MSKCC Phase II clinical trial?

A

SREs in RT vs. Obs arms:
- 1.6% vs. 29% (p=0.001)

46
Q

What characterizes a high-risk bone lesion per the recent MSKCC Phase II clinical trial?

A
  • High-risk
    – Diameter ≥ 2 cm
    – Location in the junctional spine
    – Involving the hip or sacroiliac joint
    – Involving one of the long bones of the body, such as those found in arms and legs.
47
Q

What skeletal-related events were improved w/ the tx of a a high-risk bone lesion per the recent MSKCC Phase II clinical trial?

A
  • Skeletal-related events (SREs)
    – Pain
    – Spine fractures
    – Spinal cord compression requiring surgery or radiation
48
Q

What was the pt population, randomization, and primary EP of the SCORAD trial for malignant epidural spinal cord compression (MESCC)?

A
  • Pt: proved dx of MSECC or cauda equina syndrome
  • Randomization:
    – 8 Gy / 1 fx
    – 20 Gy / 5 fx
  • Primary EP: Ambulatory status at 8 weeks
  • Secondary EPs: Ambulatory status at weeks 1, 4, and 12, and OS
49
Q

What were the results of the SCORAD trial for malignant epidural spinal cord compression (MESCC)?

A
  • 8 Gy vs. 20 Gy:
    – Week 8 ambulatory status: 69.3% in the 8Gy vs. 72.7%; p=0.06 (non-inferiority not demonstrated)
    – Non-inferiority was demonstrated for all other secondary time points at 1, 4, and 12 weeks
    – 12 weeks OS: 50% vs. 55% (NS)
  • Conclusion: While the SCORAD trial failed to meet its primary endpoint of non-inferiority of ambulatory status at 8 weeks with single-fraction RT, the clinical difference between arms was overall negligible
50
Q

Which malignant histology demonstrates on OS benefit w/ WBRT f/b SRS boost for brain metastases per RTOG 9508?

A
  • SqCC
  • NCLC
51
Q

What are the RPA classes for pts w/ brain metastases, and what are their respective effects on OS?

A
52
Q

What is the median OS of pts w/ 1-4 brain mets (<3 cm each) that receive WBRT + SRS vs. WBRT alone per Aoyama et al, JAMA 2006?

A
  • 7.5 mos vs. 8 mos (NS)
53
Q

What were the findings of the Temel et al study, NEJM 2010 re: standard oncologic care w/wo early palliative care in pts w/ mNSCLC?

A
  • At 12 weeks, the early palliative care group had
    – better QOL
    – less depressive sx
    – longer median OS (11.6 vs. 8.9 mos) despite receiving less aggressive EOL care
54
Q

What were the findings of the RTOG 0631 trial re: SBRT (16-18Gy/1fx) vs. standard 1-fx EBRT (8/1)?

A

SBRT (16-18/1) vs. EBRT (8/1)
- Pain response at 3 mos: 41.3% vs. 60.5% (SS)
- Pain response at 12 mos: NS
- Rate of adverse events: NS

MNEMONIC: 6x3 in 1 fx (631)

55
Q

What were the findings of the SC.24 trial (Sahgal et al, Lancet Onc 2021) re: SBRT (24Gy/2fx) vs. standard EBRT (20/5)?

A

SBRT (24/2) vs. EBRT (20/5)
- Pain response at 3 mos: 35% vs. 14% (SS)
- Pain response at 6 mos: 32% vs. 16% (SS)
- ≥ Gr 3 pain: 5% vs. 4% (SS)

56
Q

What is the Bilsky scoring system for spinal cord compression?

A
  • Grade 0: Bone involvement only
  • Grade 1: Epidural impingement
  • Grade 2: Spinal cord compression but CSF visible
  • Grade 3: Spinal cord compression and no CS seen
57
Q

What is Mirels criteria for pathologic fx?

A

Palliative, Benign, Constraints (3 decks)

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