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Abstract: Aims: To assess health-related quality of life (HRQOL) after palliative radiotherapy for painful bone metastases using a palliative questionnaire (European Organization for Research and Treatment of Cancer QLQ-C15-PAL). Materials and methods: Patients scheduled to receive palliative radiotherapy for painful bone metastases (n =178) completed the QLQ-C15-PAL questionnaire before treatment and at week 1, week 2, month 1 and month 2 after the first day of radiotherapy. A partial response (PR) or a complete response (CR) to radiotherapy was defined according to the International Consensus criteria. General linear regression was used to analyse changes in QOL in the entire cohort and within responders and non-responders to radiotherapy at all follow-up periods. Results: The overall radiotherapy response was 45% at week 1 (n =21) (41% PR, 4% CR), 62% at week 2 (n =28) (58% PR, 4% CR), 62% at month 1 (n =58) (60% PR, 2% CR) and 65% at month 2 (n =38) (60% PR, 5% CR). In general, a significant decrease in pain (P <0.0001), insomnia (P <0.0001) and constipation (P =0.004) was seen by month 1 after radiotherapy. In patients who responded to radiotherapy, overall QOL significantly improved by month 2 after radiotherapy (P =0.002). Radiotherapy responders also reported an improvement in emotional functioning together with a decrease in symptoms such as insomnia and constipation at month 1. No improvements were seen in any of the QLQ-C15-PAL scores for patients whose pain did not respond to radiotherapy. Conclusion: Radiotherapy responders showed not only an improvement in pain, but also in HRQOL as assessed by QLQ-C15-PAL. As early as 1 week after radiotherapy for bone metastases, a pain relief response was reported by patients. [Copyright &y& Elsevier]

Abstract: Aims: : To assess patients’ understanding of their illness and expectations of palliative radiotherapy for symptomatic metastases before and after consultation and to explore the relationship between response and demographics/Edmonton Symptom Assessment Scale (ESAS) scores. Materials and methods: In total, 100 participants completed a survey before and after consultation from March to October 2009. Descriptive statistics and statistical analyses were conducted to compare responses and to determine any relationship between responses and demographics or ESAS variables. Results: Up to 25% believed their cancer was curable; there was no change in belief that radiotherapy would cure their cancer (17% before and 15% after) or prolong their life (40% before and 45% after). There were significant differences in radiotherapy expectation for symptom relief (P =0.0094) and for patients who did not know the role of radiotherapy (P =0.0025). Patient anxiety was reduced after consultation on questions about radiotherapy (P <0.001), concerns on effectiveness (P <0.0001) and side-effects of treatment (P <0.0001); 96, 24 and 46% said after consultation that they were satisfied with information from the team, better understood their diagnosis of cancer and the role of radiotherapy, respectively. Conclusion: A significant proportion of patients with advanced disease believe their cancer is curable, expect that radiotherapy will cure their cancer and prolong their life despite understanding the intent of radiotherapy is for symptom relief. After consultation, patients say they have a better understanding of their cancer and feel more confident about treatment. More work is needed to improve patients’ understanding of their illness and expectations of the role of palliative radiotherapy. [Copyright &y& Elsevier]

Abstract: Aims: To determine the efficacy of radiotherapy for the palliation of pain from bone metastases among patients in their last 3 months of life. Materials and methods: Mutually exclusive, prospectively gathered Edmonton Symptom Assessment System and Brief Pain Inventory databases compiled from patients with bone metastases receiving palliative radiotherapy were reviewed. Demographic information and response rates from patients dying within 3 months of beginning radiotherapy were analysed. Results: From a total of 918 patients, 232 dying within 3 months of beginning treatment were identified. There were 148 men and 84 women. Their median age was 69 years and their median Karnofsky Performance Status was 60. The three most common primary cancers were lung (34%), prostate (18%) and gastrointestinal (14%). Fifty-eight percent of patients received single fraction treatment. A pain response was evaluable for the 109 (47%) patients with available follow-up information. The overall response rates were 70% at 1 month and 63% at 2 months, which included complete and partial responses in accordance with the International Bone Metastases Consensus definitions. Conclusions: Despite their limited lifespan, patients reported pain relief after palliative radiotherapy. Patients suffering from painful bone metastases with an estimated survival of 3 months should still be considered for palliative radiotherapy. [Copyright &y& Elsevier]

Abstract: Aims: To report pain and functional interference responses in patients radiated for painful spinal metastases, and to determine if location within the vertebral column or dose fractionation are associated with response. Materials and methods: Patients treated with palliative radiotherapy for symptomatic spinal metastases from May 2003 to June 2005 were analysed. All patients completed the Brief Pain Inventory (BPI) assessment tool at 1, 2 and 3 months after radiotherapy. The pain response was determined using the International Bone Metastases Consensus response definitions. Given seven BPI functional interference items, a Bonferroni adjusted P value of less than 0.007 was considered significant. Results: One hundred and nine treated patients were assessed. About 50% of patients were treated with a single fraction of 8Gy. All pain scores and functional interference scores significantly decreased over time after radiotherapy. At 3 months, 64% of patients achieved a response. Mood was significantly improved for responders (P =0.003) and a trend in improvement was observed for general activity (P =0.01) and normal work (P =0.04). Breast and prostate primaries were more likely to achieve an early response as compared with a lung primary. Neither location within the vertebral column or radiotherapy dose fractionation independently predicted for pain or functional interference responses. Conclusion: Conventional radiotherapy with 8Gy in a single fraction for spine metastases resulted in effective palliation of pain at 3 months and had a positive effect on a patient’s mood. Location within the spine was not a predictive factor. [Copyright &y& Elsevier]

Importance: Adjuvant radiation plays an important role in reducing locoregional recurrence in patients with uterine cancer. Although hypofractionated radiotherapy may benefit health care systems and the global community while decreasing treatment burden for patients traveling for daily radiotherapy, it has not been studied prospectively nor in randomized trials for treatment of uterine cancers, and the associated toxic effects and patient quality of life are unknown., Objective: To evaluate acute genitourinary and bowel toxic effects and patient-reported outcomes following stereotactic hypofractionated adjuvant radiation to the pelvis for treatment of uterine cancer., Design, Setting, and Participants: The Stereotactic Pelvic Adjuvant Radiation Therapy in Cancers of the Uterus (SPARTACUS) phase 1/2 nonrandomized controlled trial of patients accrued between May 2019 and August 2021 was conducted as a multicenter trial at 2 cancer centers in Ontario, Canada. In total, 61 patients with uterine cancer stages I through III after surgery entered the study., Interventions: Stereotactic adjuvant pelvic radiation to a dose of 30 Gy in 5 fractions administered every other day or once weekly., Main Outcomes and Measures: Assessments of toxic effects and patient-reported quality of life (European Organisation for Research and Treatment of Cancer Quality of Life Questionnaires C30 and endometrial EN24) were collected at baseline, fractions 3 and 5, and at 6 weeks and 3 months of follow-up. Descriptive analysis was conducted, calculating means, SDs, medians, IQRs, and ranges for continuous variables and proportions for categorical variables. Univariate generalized linear mixed models were generated for repeated measurements on the quality-of-life scales., Results: A total of 61 patients were enrolled (median age, 66 years; range, 51-88 years). Tumor histologic results included 39 endometrioid adenocarcinoma, 15 serous or clear cell, 3 carcinosarcoma, and 4 dedifferentiated. Sixteen patients received sequential chemotherapy, and 9 received additional vault brachytherapy. Median follow-up was 9 months (IQR, 3-15 months). Of 61 patients, worst acute gastrointestinal tract toxic effects of grade 1 were observed in 33 patients (54%) and of grade 2 in 8 patients (13%). For genitourinary worst toxic effects, grade 1 was observed in 25 patients (41%) and grade 2 in 2 patients (3%). One patient (1.6%) had an acute grade 3 gastrointestinal tract toxic effect of diarrhea at fraction 5 that resolved at follow-up. Only patient-reported diarrhea scores were both clinically (scores ≥10) and statistically significantly worse at fraction 5 (mean [SD] score, 35.76 [26.34]) compared with baseline (mean [SD] score, 6.56 [13.36]; P < .001), but this symptom improved at follow-up., Conclusions and Relevance: Results of this phase 1/2 nonrandomized controlled trial suggest that stereotactic hypofractionated radiation was well tolerated at short-term follow-up for treatment of uterine cancer. Longer follow-up and future randomized studies are needed to further evaluate this treatment., Trial Registration: ClinicalTrials.gov Identifier: NCT04866394.

Background: Clinician predicted survival (CPS) plays a crucial role in palliative care, informing physicians of appropriate treatment best suited to the patient. The primary objective of this study was to assess the accuracy of CPS of cancer patients referred for palliative radiotherapy. Secondary objectives included an analysis of factors predictive of accurate CPS, comparisons of the accuracy of survival predictions over subsequent clinic visits, and comparisons to the previous study in the Rapid Response Radiotherapy Program (RRRP) in 2005., Methods: CPS was provided by one of four radiation oncologists from August 2014 to March 2017. Karnofsky Performance Status (KPS), primary cancer site, and sites of metastases were recorded. Date of death was retrieved from the Patient Care System (PCS) and Excelicare. Mean difference between actual survival (AS) and CPS was used to determine the accuracy of survival predictions., Results: One-hundred seventy-two patients were included in the final analysis. Survival was largely overestimated (n=135, 78.5%), with CPS being overestimated by 19.0 weeks on average. KPS (P=0.2), primary cancer site (P=0.08), and various sites of metastases were not significantly related to CPS accuracy. Gender was significantly related to CPS accuracy after multivariable analysis (P=0.04), but was no longer significant after excluding prostate and breast cancer patients in multivariable analysis (P=0.2). The mean difference between AS and CPS did not significantly change over subsequent visits (P=0.5) and CPS accuracy decreased significantly compared to the previous RRRP study (P=0.04)., Conclusions: The survival estimates provided by radiation oncologists are inaccurately overestimated. Further research should aim to increase the accuracy of CPS in order to improve patient outcomes.

Context: Longitudinal symptom monitoring is important in the setting of patients with advanced cancer. Scores over time may naturally fluctuate, although a patient may feel the same., Objectives: The purpose of this study was to determine the minimal levels of change required to be clinically relevant (minimal clinically important difference [MCID]) using the Edmonton Symptom Assessment System (ESAS)., Methods: Between 1999 and 2009, patients completed the ESAS before palliative radiotherapy and at follow-up. MCIDs were calculated using both the anchor- and distribution-based methods for improvement and deterioration; 95% confidence intervals for the differences in mean change scores between adjacent categories also were calculated., Results: A total of 276 patients completed the ESAS at baseline and during at least one follow-up visit. At the four-week follow-up, decrease of 1.2 and 1.1 units in pain and depression scales, respectively, constituted clinically relevant improvement, whereas increase of at least 1.4, 1.8, 1.1, 1.1, and 1.4 units, respectively, in pain, tiredness, depression, anxiety, and appetite loss items were required for deterioration. At the subsequent follow-ups, these values were similar. Overall, the MCID for improvement tended to be smaller than that for deterioration. The distribution-based method estimates tended to be larger than the 0.3 SD estimates, but closer to the 0.5 SD estimates., Conclusion: MCIDs allow health care professionals to determine the success of treatment in improving the patient's quality of life. MCIDs may prompt health care professionals to intervene with new treatment. Future studies should confirm our findings with a variety of anchors., (Copyright © 2013 U.S. Cancer Pain Relief Committee. Published by Elsevier Inc. All rights reserved.)

Purpose: The purpose of this study is to compare self-reported quality of life (QOL) scores in old and young patients with metastatic cancer using the European Organization for Research and Treatment of Cancer (EORTC) QLQ-C15-PAL questionnaire., Materials and Methods: Patients receiving palliative radiotherapy (RT) for bone metastases and brain metastases completed the QLQ-C15-PAL questionnaire prior to treatment. Using multiple linear regression analysis, a parametric test, the QLQ-C15-PAL scores were compared using 65 and 70 years as cutoff ages., Results: A total of 340 patients were referred for palliative RT for bone metastases (n = 190) or brain metastases (n = 150). Physical functioning and appetite were worse in the older group using either 65 or 70 years as the cutoff age. Age-related differences in the QLQ-C15-PAL scores varied as a function of age cutoff used and location of metastatic site irradiated., Conclusion: Based on the (EORTC) QLQ-C15-PAL, elderly advanced cancer patients have a different QOL profile. Similar observations have been reported with the (EORTC) QLQ-C30 questionnaire.

Background: A multidisciplinary nonmelanoma skin cancer (NMSC) clinic is held weekly at our center, where all new patients are jointly assessed by dermatology/dermatopathology, radiation oncology, and plastic surgery. A new patient database was established in 2004. The purpose of this study was to provide a preliminary report on the patients seen in the NMSC clinic and the treatment recommendations rendered., Methods: The new patient database was reviewed from January 2004 to December 2008, and patient demographics, tumor characteristics, and treatment recommendations were extracted. Cochran-Mantel-Harnszel (CMH) testing and chi-square analysis were used to detect any associations or relationships between variables within the database. A p value of less than .05 was considered significant., Results: During the 5-year study period, 2,146 new patients were seen in the NMSC clinic. The majority of patients presented with basal cell carcinoma (64%) or squamous cell carcinoma (22%), with a median tumor size of 1 to 2 cm (range 0 to > 9 cm). Tumors were located in the head and neck region (80%), extremities (14%), and torso (6%). Previous treatment included biopsy only (62%), surgery (20%), electrodesiccation and curettage (11%), topical imiquimod (3%), and radiotherapy (1%). Treatment recommendations included surgery (55%) (with either simple excision [31%] or excision with margin control under frozen-section guidance [24%]), radiotherapy (19%), topical imiquimod (10%), observation (7%), and electrodesiccation and curettage (4%)., Conclusions: The NMSC clinic at our center sees a high volume of patients who benefit from the multidisciplinary assessment provided. Treatment recommendations were based on patient and disease characteristics as well as patient preference.

Purpose: To examine the reported rates and predictive factors for sleep disturbance in patients with bone metastases., Methods: Patients with symptomatic bone metastases treated with palliative radiotherapy (RT) were eligible. At initial consultation, demographic information, baseline Brief Pain Inventory (BPI) questionnaire, and analgesic consumption were recorded. The BPI functional interference sleep item was categorized into none (0), mild (1-3), moderate (4-6), and severe (7-10). Follow-up BPI was collected in person or via telephone post-RT at week 4, 8, and 12. Subgroup analysis for BPI between responders and nonresponders was performed. Ordinal logistic regression analysis was used to search for the relationship between sleep disturbance and other covariates., Results: Four hundred patients were enrolled between May 2003 and June 2007. Two hundred thirty-five males (59%) were accrued. The median age was 68 years old (range, 30-91). Within the study population, primary cancer sites included breast (25%), lung (25%), prostate (24%), bladder (4%), pancreas/gastric (3%), and other primaries (18%). In the BPI functional interference items, the mean baseline score for sleep disturbance was 4.8. When categorized in terms of severity, 99 (25%) patients had moderate sleep disturbance and 144 (36%) patients had severe sleep disturbance, respectively. There was an improvement in sleep scores for both responders and nonresponders at week 4 and 8, but scores worsened for nonresponders at week 12., Conclusion: Age, Karnofsky Performance Scale (KPS), pain score, and lung primary were the significant variables associated with sleep disturbance. The scores for sleep disturbance improved significantly post-RT in responders at week 4 and 12.

Background: Few studies incorporate patient self-assessment scales in prognostic models of survival prediction. The Edmonton Symptom Assessment Scale (ESAS) is commonly used as a symptom screening tool in cancer patients., Objective: The goal of this study was to evaluate the prognostic value of the ESAS for survival prediction in the advanced cancer population., Materials and Methods: Patients completed the ESAS and demographic information prior to palliative radiotherapy consultation and at follow-up at the Odette Cancer Centre between 1999 and 2009. Generalized estimating equation (GEE) methodology was applied to analyze ESAS trends within the last months of life. One-way analysis of variance (ANOVA) with repeated measurements was used to characterize trends between time periods., Results: ESAS records (2377) from 808 patients (433 male and 375 female) were included in this cohort. Median age was 68 years (range 32-95) with median Karnofsky performance status (KPS) of 60 (range 10-100). Primary cancer sites were of the lung (36%), breast (20%), and prostate (19%). All nine ESAS symptoms significantly deteriorated in the last 4 weeks immediately before death when compared with those scores in the preceding months. At one week prior to death, the worst ESAS symptoms experienced by patients were fatigue, appetite, and well-being with mean scores of 7.4, 6.9, and 6.1, respectively., Conclusions: All ESAS scores significantly worsened in the last 4 weeks prior to death compared with those in the previous months. Sudden deterioration of the global ESAS symptoms may predict impending death. Future studies on a prognostic model should incorporate both ESAS symptom severity and trends.

Purpose: To determine the incidence of pain flare following radiotherapy (RT) for painful bone metastases., Materials and Methods: Patients with bone metastases treated with RT were eligible. Worst pain scores and analgesic consumption were collected before, daily during, and for 10 days after treatment. Pain flare was defined as a 2-point increase in the worst pain score (0-10) compared to baseline with no decrease in analgesic intake, or a 25% increase in analgesic intake with no decrease in worst pain score. Pain flare was distinguished from progression of pain by requiring the worst pain score and analgesic intake return to baseline levels after the increase/flare (within the 10-day follow-up period)., Results: A total of 111 patients from three cancer centers were evaluable. There were 50 male and 61 female patients with a median age of 62 years (range, 40-89 years). The primary cancers were mainly breast, lung, and prostate. Most patients received a single 8 Gy (64%) or 20 Gy in five fractions (25%). The overall pain flare incidence was 44/111 (40%) during RT and within 10 days following the completion of RT. Patients treated with a single 8 Gy reported a pain flare incidence of 39% (27/70) and, with multiple fractions, 41% (17/41)., Conclusion: More than one third of the enrolled patients experienced a pain flare. Identifying at-risk individuals and managing potential pain flares is crucial to achieve an optimal level of care.

Background: Basal cell carcinoma (BCC) is the most common human malignancy and accounts for over 60,000 new cases of cancer in Canada annually. Although expensive to the health care system, no Canadian studies have reported the costs involved in management. This study calculated the costs of managing high-risk BCCs using radiotherapy (RT) and Mohs micrographic surgery (MMS)., Methods: Forty-nine consecutive complex BCC cases presenting to a skin cancer referral center were collected prospectively. All were located on the head and neck and were either recurrent disease or located in "at risk" sites such as the eye, ear, lip, or nose. All patients underwent MMS. A radiation oncologist reviewed each case retrospectively. The costs of MMS were the actual costs of the procedure, with an additional amount added to account for the technical costs of the surgery. The costs of RT included physician fees and technical fees. A sensitivity analysis was performed using known recurrence rates from the medical literature., Results: Five patients were excluded from the comparative analysis because radiation was not recommended (age < 50 years or radiation would overlap with a previous radiation field). The direct cost of treating a patient with a single BCC was $871 (range $630-1,159) using MMS and $3,625 (range $3,430-3,971) using RT. The costs were significantly higher for patients with multiple tumors with both modalities (p = .02 for both). The direct costs of a "5-year cure" were $952 (range $644-1,647) for MMS and $3,758 (range $3,564-4,675) for RT., Conclusions: This study attempted to document the costs associated with two well-recognized and effective methods of treating complex BCC in Ontario. Subgroup analysis revealed independent associations between aggressive histology, larger size, and complexity of surgical closure with higher costs. Although we did notice a trend toward greater costs in patients with recurrent disease, in males, younger patients, and tumors present for > 1 year, these did not reach significance within our sample size. Despite the limitation that treatment costs may be center and provincially dependent, we hope this preliminary report will initiate further study into comparing Canadian costs of managing skin cancer.