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Palliative radiotherapy for gynecologic malignancies

Introduction The five primary gynecologic malignancies (vulvar, vaginal, cervical, uterine, and ovarian) accounted for 12.2% ( n = 109,000) of new cancer diagnoses and 11.6% ( n = 33,100) of cancer deaths in American women in 2019. Uterine cancers are most commonly diagnosed ( n = 61,880), followed by ovarian ( n = 22,530) and cervical cancers ( n = 13,170). Five-year relative survival rates in…

Palliative radiotherapy for gastrointestinal malignancies

Pancreatic cancer Indications for palliative radiotherapy A diagnosis of pancreatic cancer is devastating; the 5-year overall survival for patients with locally-advanced unresectable disease is less than 5%, and for patients with metastatic disease is worse. At least 50% of patients present initially with metastatic disease, with many carrying a heavy burden of local and systemic symptoms. Patients often present with epigastric or more diffuse abdominal pain;…

Palliative radiotherapy in the breast and chest wall

Introduction The definition of palliative care by the World Health Organization (WHO) is centered around “an approach that improves the quality of life of patients … through the prevention and relief of suffering ….” One of the most important and straightforward goals of palliation for locally advanced breast cancer is therefore to provide in their words “relief from pain and other distressing symptoms.” This approach to…

Palliative thoracic radiation

Introduction Patients with advanced lung cancer may experience a variety of symptoms that can cause suffering, including (but not limited to) anxiety, dyspnea, fatigue, nausea, and pain. Palliative radiation to the thorax can ameliorate these symptoms in an attempt to improve quality of life in patients with advanced disease. The benefits of early palliative care, however, extend beyond mere symptom management. In fact, early palliative care…

Palliative radiotherapy in the head and neck

Introduction Head and neck cancers represent the sixth most common cancer worldwide, with approximately 630,000 new patients diagnosed annually. While many advances within the field of head and neck cancer have focused on the improvement of curative-intent treatment, there remains a lack of universal guidelines for the palliative treatment of head and neck cancers. Disease and health-related factors associated with the delivery of palliative-intent treatment include…

Considerations involving reirradiation

Principles of reirradiation The guiding principle of “Do No Harm” lies at the heart of reirradiation, as the limits of radiation therapy are bounded by the potential for morbidity. Patients are commonly referred for reirradiation in two distinct clinical settings. The first of these situations is for locoregional progression after definitive intent treatment. Generally, these patients do not have competing risks from other sites of metastatic…

Combining radiation and systemic therapy

Introduction Historically, systemic therapy played the primary role in the management of metastatic disease, while radiation therapy (RT) was primarily reserved for palliation of symptoms and sequelae of metastatic disease including pain, bleeding, compression, risk of fracture, and neurological compromise. Emergence of data supporting the use of ablative RT in the oligometastatic setting and the potential for radiation to enhance antitumor immunity in combination with immunotherapy…

Alternate modalities for palliation

Introduction More than 16.9 million people are living with cancer in the United States, and approximately 1.8 million new cancer cases are expected to be diagnosed in 2020. The population of cancer survivors in the United States is predicted to reach 26 million by 2040. Cancer survivors—defined here as individuals with cancer from the time of diagnosis and for the balance of life, including post-treatment survivorship…

Treatment planning in palliative radiotherapy

Introduction It is estimated that up to 40% of patients with advanced cancers will receive palliative radiation therapy (RT) during the course of their disease. While specific details of patient, treatment modality, and dose selection are discussed elsewhere in this book, we will focus on (1) treatment simulation, planning, evaluation, and delivery techniques for conventional external beam and stereotactic radiotherapy and (2) additional innovative approaches for…

Selecting modalities

General considerations The choice of appropriate treatment modality in the curative setting is typically based on efficacy for cure and avoidance of severe adverse effects. Historical experience, theoretical considerations of radiobiology, and results of research studies (especially randomized controlled trials) comparing specific treatments are integrated into the recommendations for the best choice of modality and the best dose-fractionation regimen. In the curative situation, this information determines…

Palliative radiation

What is the approach to the patient referred for palliative radiotherapy? While most patients with advanced or metastatic cancer referred for consideration of palliative radiotherapy will undergo radiation treatment, deciding who is a candidate for palliative radiotherapy and if so, the appropriate radiotherapy treatment, is not always straightforward. This is, in part, due to multiple patient, clinical, pathologic, radiographic, and treatment factors that must be integrated.…

Models of multidisciplinary management

Background The World Health Organization’s definition of palliative care states that: Palliative care is an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial, and spiritual. While the goals of any medical…

Troubleshooting difficult conversation

Why is it important? Communication is an essential part of high-quality, person-centered care, especially in the context of a serious illness like cancer. The majority of people living with cancer want to have conversations with their clinicians about what to expect with their illness and what is most important. When people engage in these conversations, they tend to have treatments that match their goals and priorities…

Basic communication frameworks

Introduction Communication skills can be broadly defined as “the cognitive and emotional abilities used by clinicians to enable patients and their families to understand the nature of the illness, to partner with patients to make sound medical decisions, and to facilitate patient and family adjustment to the illness.” Over the past three decades there has been increasing appreciation of the importance of communication skills in medicine.…

Introduction to prognostication

I always avoid prophesying beforehand because it is much better to prophesy after the event has already taken place. Winston Churchill Prognostication is the act of foretelling or prophesying future events. Along with diagnosis and treatment, it has served as one of the three pillars of medicine for hundreds of years. Once central to the role of physicians, the skill of prognostication, however, has received less…

Definition of palliative care

What is palliative care? Palliative care is specialized medical care for people with serious illness that is focused on improving quality of life for patients and their families and caregivers. It is available to patients of any age and any stage of disease, starting at diagnosis, and can be offered alongside disease targeted treatments. Palliative care services are provided by an interdisciplinary team, including physicians, nurses,…

Ethical Considerations in Pediatric Oncology Clinical Trials

Ethical decision making is a fundamental goal common to both clinical medicine and clinical research trials of all types. Broad attempts have long been made to thoroughly explicate the elements of ethical decision making that are common to both settings. However this goal has been pursued with increased vigor since the exposure of human moral abuses in the United States Public Health Service–sponsored Tuskegee Syphilis Study…

Psychosocial Care of the Child and Family

The diagnosis and treatment of cancer represents a major challenge for the family and the individual child. For most families, coping with a child's cancer will be the most stressful and difficult experience they will face. Although the majority of families will make an adequate adjustment, coping with the diagnosis and the subsequent challenges of treatment is a difficult and demanding process. In this chapter we…

Childhood Cancer Survivorship

With ongoing advances in the diagnosis and treatment of childhood cancers, increasing numbers of children and adolescents diagnosed with cancer are becoming long-term survivors. However, even as higher cure rates are achieved, there is increasing recognition that the diagnosis and treatment of cancer during childhood and adolescence can have lifelong implications for health and well-being. Cancer therapy administered during critical periods of growth and development render…