Front Cover

Handbook of Supportive and Palliative Radiation Oncology

Copyright Page

Contents

List of Contributors

Preface

Acknowledgments

I. Issues in Supportive and Palliative Radiation Oncology

1 General Approach to Palliative Care and Palliative Radiation Oncology

Introduction

Life Expectancy and Prognostication

Religion and Spirituality

Relief of Pain and Suffering

Palliative Radiation Therapy

Efficacy of Palliative Radiation Therapy

Emerging Technologies

Radiation Therapy Planning and Delivery

Side Effects of Radiation Therapy

Guidelines and Quality Measures

Bone Metastasis

End-of-Life Radiation Therapy

Conclusion

List of Abbreviations

References

2 Communication

Introduction

ASK-TELL-ASK

Delivering Bad News: SPIKES

Responding With Empathy: NURSE

Discussing Prognosis: ADAPT

Conducting a Family Meeting/Goals of Care Discussion

FICA Spiritual History Tool

References

3 Prognostication in Patients Receiving Palliative Radiation Therapy

Introduction

Importance of Prognostication

Physician Accuracy

What Patients Want to Hear

Prognostic Factors

Prognostic Models

Future Directions

References

4 Palliative Care, Hospice Care, Advance Care Planning, and Advance Directives

Background

Palliative Care

Definitions

Guidelines

Palliative Care Services

Interdisciplinary Team

Setting

Barriers

Outcomes

Hospice

Criteria for Enrollment in the Medicare Hospice Benefit

Hospice Services

Interdisciplinary Care Team

Setting

Reasons for Discharge

Barriers to Enrollment

Outcomes

Resources

Advance Care Planning and Advance Directives

Definitions

Advance care planning

Advance Directives

Utilization

**Why It Matters**

Effectiveness

Documents

Resources

References

5 Palliative Care Assessment

Introduction

References

II. Symptom Management for Palliative Radiation Oncology Practitioners

6 Pain Management

Introduction

What Is Pain?

Common Pain Terminology

Pain Assessment

Patient Reported Outcomes

Management of Pain

Pharmacologic Management of Pain

Nonpharmacologic Management of Pain

Patient Case 1.1

Patient Case 1.2

Patient Case 1.3

Patient Case 1.4

Patient Case 1.5

Patient Case 1.6

Patient Case 1.7

Conclusion

Glossary

List of Abbreviations

References

7 GI Symptoms: Radiation-Induced Adverse Effects

Radiation-Induced Mucositis and Esophagitis

Definition/Diagnosis

Prevalence/Progression

Mucositis

Esophagitis

Treatment

Mucositis

Esophagitis

Radiation-Induced Diarrhea

Definition/Diagnosis

Presentation/Prevalence/Progression

Treatment

Radiation-Induced Constipation

Definition/Diagnosis

Presentation/Prevalence

Treatment

Radiation-Induced Nausea and Vomiting

Incidence

Risk Factors

Treatment

References

8 Management of Dyspnea and Central Airway Obstruction in Patients With Malignancy

Introduction

Pathophysiology of Dyspnea

Evaluation of Dyspnea

Visual Analog Scale

Management of Potentially Reversible Etiologies of Dyspnea

Symptom Management for Dyspnea

Opioids

Benzodiazepines

Oxygen Therapy

Nonpharmacologic Therapies

Summary

Palliative Management of Malignant Central Airway Obstruction (CAO)

Significance of CAO

Diagnosis

Management

Initial Stabilization

Bronchoscopy

Bronchoplasty or Balloon Dilation

Airway Stents

Argon Plasma Coagulation

Laser Therapy

Cryotherapy

Palliative Surgery

Palliative Chemotherapy

Palliative Radiation

Brachytherapy (Intraluminal)

Helium/Oxygen Therapy

Summary

References

9 Malignant Bleeding

Scope of the Problem

Goals of Care, Communication, and Assessment

Local Therapies

Dressings, Packing, and Topical Agents

Radiation Therapy

Endoscopic Procedures

Transcutaneous Embolization

Surgery

Treatment Options by Site of Hemorrhage

Skin Lesions

Hemoptysis

Vaginal Bleeding

Gastrointestinal Bleeding

Hematuria

Systemic Therapies and Considerations

Antifibrinolytics: Tranexamic Acid to Minimize the Risk of Bleeding

Discontinuation of Causative or Exacerbating Agents

Conclusion

References

10 Skin Toxicity in Palliative Radiation Therapy

Introduction

Acute Skin Toxicities From Radiation

Pathology and Timeline

Grading of Toxicity

Prevention

Treatment

Chronic Skin toxicities From Radiation

Pathology

Grading

Prevention

Treatment

Radiation Recall Dermatitis

Conclusion

References

III. Disease-Specific Management for Palliative Radiation Oncology Practitioners

11 Palliative Radiotherapy for Brain Metastasis

Introduction

Evaluation

Palliative Radiotherapy Regimens

Whole Brain Radiation Therapy

Partial Brain Radiation Therapy

Stereotactic Radiosurgery

Hypofractionated Stereotactic Radiotherapy

Evaluation and Management of Common Clinical Concerns

Headache

Nausea/Vomiting

Anorexia

Seizure

Fatigue/Lethargy/Somnolence

Tearing/Conjunctivitis

Otitis Externa

Functional Deficits

Conclusion

List of Abbreviations

References

12 Palliative Radiotherapy for Malignant Epidural Spinal Cord Compression

Introduction

Definition

Presentation

Pain

Myelopathy/Neurological Impairment

Prognostic Factors

Evaluation

History

Physical Examination

Imaging

Management

Dexamethasone

Radiotherapy

Radiotherapy Planning Technique

Side Effects

Dose/Fractionation

Data From Randomized Clinical Trials

Data From Prospective Studies

Retrospective Studies

Highly Conformal Radiotherapy: Stereotactic Radiosurgery/Stereotactic Body Radiation Therapy (SRS/SBRT)

Surgery

Surgical Decompression

Surgical Stabilization

Recurrence

Summary

References

13 Palliative Radiotherapy for Bone Metastasis

Introduction/Background

Pathophysiology

Presentation/Evaluation

Clinical Assessment

Imaging

Management Overview

External Beam Radiation Therapy

Randomized Controlled Trials

Recommendations

Exceptions

Side Effects

QOL Improvement and Palliative EBRT

Re-Irradiation

Intention to Treat

Per Protocol Population

Toxicity

Conclusions

Stereotactic body radiotherapy/Stereotactic radiosurgery

Prospective Trial

External Beam Radiation Therapy Techniques

Radiopharmaceuticals for Diffuse Painful Bone Metastases

Beta Emitters

Summary

Alpha Emitters

Radium-223

Bisphosphonates and Denosumab to Prevent SREs

Bisphosphonates in Combination With EBRT

Denosumab

Conclusion

References

14 Site-Specific Symptom Management: Palliative Radiotherapy for Advanced and Metastatic Lung Cancer

Introduction

Evaluation

General History and Physical Exam

Treatment Recommendations

General Pulmonary Symptoms

Hemoptysis

Postobstructive Pneumonia

Mesothelioma

Superior Vena Cava Syndrome

Asymptomatic Metastases

Expected Acute Side Effects

On-Treatment Management

References

15 Palliative Radiation Oncology for Gastrointestinal Tract Malignancies

Introduction/Background

Esophageal Cancer

Dysphagia

Radiation Therapy

Side Effects of Radiotherapy to the Esophagus

Gastric Cancer

Side Effects of Radiotherapy to the Stomach

Pancreatic Cancer

Local Disease

Symptom Palliation

Metastatic Disease

Hepatobiliary Cancer

Y-90 Radioembolization

Stereotactic Body Radiation Therapy

Biliary Obstruction

Palliative Radiation Therapy for Biliary Obstruction or Pain

Anorectal Cancer

Liver Metastases

Surgical Resection

Y-90 Radioembolization

Stereotactic Body Radiation Therapy

Central Biliary Obstruction

Whole Liver Irradiation

On Treatment Management

Conclusion

List of Abbreviations

References

16 Palliative Radiotherapy for Advanced and Metastatic Gynecologic and Genitourinary Malignancies

Introduction

Evaluation

Female Patients

Male Patients

All Patients

Treatment Recommendations

Primary Gynecologic Malignancies

10Gy × 1

Quad Shot

Other Palliative External Beam Regimens

Electron Cone and Brachytherapy

Recurrent Disease

Primary Genitourinary Malignancies

Renal Cell Carcinoma

Bladder Cancer

Prostate Cancer

Penile and Urethral Cancer

Treatment Planning

Conclusion

List of Abbreviations

References

17 Palliative Radiotherapy for Advanced and Metastatic Head and Neck Cancers and Skin Metastases

Evaluation

General History & Physical Examination (H&P)

Symptoms

Goals of Care, Performance Status

Treatment Recommendation

Supportive Care

Palliative Chemotherapy

Radiotherapy for Aggressive Local Control or Potential Cure

Head and Neck Primaries

Important Trials

Radiotherapy for Palliation

Palliative Radiotherapy Regimens for Head and Neck Cancer

Stereotactic Body Radiotherapy and Brachytherapy

Expected Acute Side Effects From Radiation

Dermatitis

Mucositis

Xerostomia

Edema

Dysgeusia

On Treatment Management

Multidisciplinary

Steroids

Skin Care

Oral Care

References

Index

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