Head and Neck Cancer
Appropriate Radiation Therapy Not Given To Terminal Cancer Patients
A considerable proportion of patients with end-stage or terminal cancer do not benefit from palliative radiation therapy despite spending most of their remaining life undergoing treatments, according to a new analysis.
Published early online in CANCER, a peer-reviewed journal of the American Cancer Society, the study indicates that greater efforts are needed to tailor appropriately palliative radiotherapy to patients with end-stage cancer. Palliative radiotherapy for end-stage cancer patients is intended to control cancer-related pain and other symptoms and to help patients maintain a good quality of life when long-term cancer control is not possible. By reducing the number of cancer cells, palliative radiotherapy can ease pain, stop bleeding, and relieve pressure, even when the cancer cannot be controlled. However, for many patients, the treatments are not effective. In addition, if patients are close to death, they may wish to stop treatments if they would like to die at home.To investigate the adequacy of palliative radiotherapy in end-stage cancer patients, Stephan Gripp, MD, of the University Hospital Duesseldorf in Germany and colleagues evaluated the treatment of patients who were referred for palliative radiotherapy at their hospital from December 2003 to July 2004 and who died within 30 days. The investigators identified 33 such patients.
Radiotherapy was delivered to 91 percent of patients. Half of the patients spent more than 60 percent of their remaining lifespan on radiotherapy, and in only 58 percent of patients was radiotherapy completed. Many physicians overestimated the length of time their patients would survive. Among this group who died within one month, about one in five physicians predicted more than six months survival. In addition, progressive complaints were noted in 52 percent of patients, and palliation or pain reduction was reported by only 26 percent of patients.
The authors concluded that radiotherapy was not appropriately customized to these cancer patients, many of whom did not benefit despite spending most of their remaining life on therapy. Excessive radiotherapy in end-stage cancer patients may reflect overoptimistic prognoses and unrealistic concerns about radiation damage."Radiation oncologists have fallen short in accurately determining the life span of terminally ill cancer patients. This has resulted in unduly prolonged radiation therapy regimens that often go uncompleted due to death or withdrawal from treatment," said Dr. Gripp. He added that physicians need better methods for estimating how long their end-stage cancer patients will live. He also recommended that they use shorter-duration radiation schedules for palliative radiotherapy.
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For Your Patients: Understanding Palliative Care For Breast Cancer
Key Points
Your healthcare partners are committed to providing you with the most up-to-date and timely therapies and interventions to treat breast cancer. One of these interventions is palliative care, also known as supportive care. Palliative care aims to help you maintain the best quality of life possible as you undergo treatment.
Palliative care is not the same as hospice care. While there is overlap, hospice care provides support and care for people who are nearing -- usually within 6 months -- the end of life.
Although palliative care and hospice care both focus on improving quality of life, you can remain on active treatment while receiving palliative care.
Palliative care can be an important part of your treatment plan, regardless of disease stage or treatment.
People who have received palliative and supportive care alongside treatment for breast cancer have reported less severe symptoms, better quality of life, and greater satisfaction with treatment.
What Is Palliative Care?
Managing the physical pain associated with breast cancer treatment is an important component of palliative care. Palliative care providers also put an equal emphasis on helping you control the natural and normal stress and anxiety that accompany a diagnosis of breast cancer.
Nutrition, exercise, rest, meditation, mental health, and overall well-being are all part of palliative care.
Disease Progression
Every person with breast cancer experiences the disease in ways that are unique to them, and not everyone responds in the exact same way to treatment.
There are four general types of progression of metastatic breast cancer:
Smoldering: Very slow progression, patients are often asymptomatic, and survival is generally considered in terms of years and in some cases, over 10 years
Rapid: Rapid progression, with severe symptoms, and survival is typically characterized by a prognosis of several months
Palliative Drug Therapy for Bone Metastases
Bone is one of the most common sites for distant metastases in metastatic breast cancer. More than half of patients with metastatic breast cancer will develop metastases to bone. Patients with breast cancer and bone metastases should be treated with bone-modifying agents and options include zoledronic acid, pamidronate, or denosumab. These medications can reduce bone complications and bone pain caused by bone metastases.
These medications can sometimes have rare but serious side effects, such as osteonecrosis of the jaw. It is important to keep track of your symptoms and alert your healthcare providers if you experience any changes.
Palliative Radiation Therapy
Palliative radiation therapy may be used to alleviate pain caused by breast cancer. The treatment can target specific areas where the cancer has spread, such as bones or soft tissues, to reduce tumor size and relieve pain. This is especially beneficial when there are bone metastases.
Palliative Surgery
Palliative surgery for breast cancer can help alleviate pain and improve mobility, via procedures known as vertebroplasty or kyphoplasty, for people whose cancer has spread to their bones.
For other people, surgical removal of tumors may be necessary when an obstruction or bleeding is caused by the tumor.
Nerve block procedures can be performed to manage pain caused by nerve compression or invasion by cancer.
If the breast cancer has caused fluid to collect in the abdomen (known as ascites) or led to the buildup of too much fluid around the lungs (known as pleural effusion), surgical procedures such as paracentesis or thoracentesis, respectively, can be performed to drain excess fluid and provide relief. (6)
Pain Management
Over-the-counter pain medications such as aspirin, ibuprofen, acetaminophen, and naproxen are typically used to treat mild to moderate pain associated with breast cancer.
Opioid medicines, either in long-acting forms or immediate-release forms, can be used to treat moderate-to-severe pain.
Careful routine pain assessments will be conducted by your healthcare providers to ensure you are receiving the pain relief you require.
Complementary or integrative medicine approaches such as acupuncture, massage, or hypnosis, are options for pain management and can be combined with standard medical treatment.
Fatigue Management
Fatigue, or extreme tiredness, is a normal response to breast cancer treatment. Prioritizing your daily rest, nutrition, and exercise can help ease the symptoms of fatigue. Treating other side effects, such as pain, can help ease cancer fatigue. Complementary or integrative medicine approaches may also help with the management of fatigue.
Shortness of Breath Management
The management of shortness of breath (also called dyspnea) includes treatment of conditions that may contribute to it, including but not limited to the presence of lung metastases, pleural effusion, infections, anemia, drug toxicities, blood clots in the lungs (pulmonary embolus), or airway obstruction.
If you are experiencing shortness of breath on a regular basis, you need to alert your healthcare providers as soon as you can. A work-up can be done to evaluate the cause of the dyspnea and interventions considered. In addition to potential treatment of the underlying cause, certain breathing techniques can help, along with supplemental oxygen and morphine, in some situations.
Mental Health Management
Coping with breast cancer, and its associated treatments, is a challenging and sometimes daunting experience – both physically and emotionally.
It is also an experience that you should not, and do not, have to go through on your own.
The emotional and social effects of a breast cancer diagnosis and treatment are areas in which palliative care can help.
This can include working with an oncology social worker, counselor, or clergy on an ongoing or as-needed basis.
You can expect that your healthcare providers will be assessing your levels of distress and anxiety as part of your treatment.
Advance Care Planning, End-of-Life Care
Advance care planning is a process of communication between the person with metastatic breast cancer, their family and loved ones, and their healthcare team.
Research has shown that people with metastatic breast cancer -- and patients with advanced disease in general, along with family members and providers -- consider these five factors to be most important to end-of-life care:
Advance care planning should be regarded as a standard of care to improve the quality of life of people with metastatic breast cancer. Physicians will discuss end-of-life care options, including hospice and emotional support specialists, to help patients and family members make informed decisions.
Read previous installments in this series:
For Your Patients: Breast Cancer Basics
For Your Patients: The Crucial Role of the Biopsy in Breast Cancer
For Your Patients: Understanding Early-Stage Breast Cancer
For Your Patients: New Therapies, New Hope in Later-Stage Breast Cancer
For Your Patients: The Importance of Genes in Breast Cancer
"Medical Journeys" is a set of clinical resources reviewed by physicians, meant for the medical team as well as the patients they serve. Each episode of this journey through a disease state contains both a physician guide and a downloadable/printable patient resource. "Medical Journeys" chart a path each step of the way for physicians and patients and provide continual resources and support, as the caregiver team navigates the course of a disease.
Shalmali Pal is a medical editor and writer based in Tucson, Arizona. She serves as the weekend editor at MedPage Today, and contributes to the ASCO and IDSA Reading Rooms.
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Program Details
The UAB Department of Radiation Oncology's Residency Program is proud to offer a comprehensive residency program that produces experts in clinical radiation oncology, radiation physics, and radiobiology. Our graduates regularly rank in the top quartile on board examinations, and our program is recognized to be among the nation's best.
The UAB Department of Radiation Oncology's Resident Education Program is accredited through the ACGME. Residents' training incorporates rotations with experts in all ACGME radiation oncology subsites, regular didactic lectures, and departmental conferences. In addition, residents participate in multidisciplinary clinics and tumor boards interacting with medical and surgical oncology colleagues, pathologists, radiologists, and geneticists to emphasize a holistic approach to the management of cancer.
OrientationResidents are welcomed to Orientation the first week in July, and participate in the national standardized Introductory Radiation Oncology Curriculum (IROC) to learn essential radiation oncology concepts and skills. In addition, residents receive an introduction to the daily routines of the department and learn essential "hands-on" skills like contouring and beam placement. Following the completion of orientation, incoming residents are mentored by the chief residents and assisted by senior residents during their first clinical rotations.
Clinical EducationResidents work on-on-one with our attending physicians, spending at least 36 months in clinical rotations. Our department faculty specialize in treatment of particular organ sites, such that each rotation focuses on a select number of organ/disease sites. All faculty offer palliative treatment and staff inpatient consultations, allowing residents to learn management of palliative care and radiation oncology emergencies.
UAB serves a diverse patient population, including the urban, suburban, and rural communities around Birmingham and throughout the state. We are honored to treat many veterans from the VA hospital, and many patients referred from the Southeast for our expertise. With this large catchment area, our residents see a wide variety of common and rare cancers throughout their four year training.
Residents most frequently meet patients in our outpatient clinics for initial consultation and routine follow-up visits. If radiation therapy is recommended, residents assist with simulation, treatment planning, and undertreatment patient visits for their assigned patients. Residents also participate in chart rounds and other patient safety conferences to learn the importance of quality assurance programs to ensure safe treatment delivery.
During each rotation, residents present cases and participate in specialty tumor boards and conferences relating to the disease sub-site(s) of the attending physician. Multidisciplinary interaction with medical oncology, pathology, diagnostic radiology, and surgical oncology satisfies all ACGME requirements for graduation. Site-specific conferences include: gynecologic, head and neck, pediatric, neuro-oncology, breast, thoracic, hepatobiliary, lymphoma, genitourinary and molecular oncology conferences.
Didactic CurriculumResidents' education is a top priority for our department, as evidenced by our robust didactic curriculum. Weekly didactics are grouped by disease site, and include presentations by department faculty, local experts, residents and visiting professors. Didactics include site-specific anatomy and contouring, radiographic anatomy, surgical principles, review of high-yield publications, and dosimetry and treatment planning concepts. At the end of each didactic block, we host a socratic session to review key topics.
The department hosts a monthly journal club, correlating with the disease site discussed in our didactic lectures. Residents also take the lead in presenting cases during our morbidity and mortality rounds.
Each spring, the department invites all program graduates preparing for oral boards and senior level residents to participate in our Annual Mock Oral Examination. The disease-site specific faculty lead participants through a series of cases and provide feedback to help prepare for the ABR Certification (Oral) Exam.
Resident ResearchThe UAB Department of Radiation Oncology maintains a robust presence in cancer research. Our residents are strongly encouraged to participate in research projects tailored to their specific interests. The collaborative university atmosphere and diverse patient population at UAB provide residents with a wealth of resources to ask, investigate, and publish their innovative research ideas.
Learn more about research at UAB in the Department of Radiation Oncology.
Physics & Radiation Biology
Residents participate in physics and radiation biology instruction taught by seasoned instructors, offered on an annual basis. The aim of the physics and radiation biology programs is not simply to prepare residents for board examinations but also to teach them basic concepts applicable to radiation therapy treatments. Our residents regularly score above the 90th percentile on the annual in-service exam and in the top quartile on the ABR Initial Qualifying board exams. In fact, current and former residents have achieved the nation's highest score in the physics and clinical sections of the in-service exam. Our program is considered by many to be among the very best in the nation.
PhysicsThe Physics teaching program begins during orientation, when new residents are made familiar with radiation therapy machines, immobilization devices and radioisotopes. Our weekly physics lectures follow the ASTRO Core Physics Curriculum for Radiation Oncology Residents, consisting of basic and clinical radiotherapy physics including external beam and brachytherapy. The curriculum is repeated on an annual basis and offered to all residents.
Radiation BiologyThe Radiation Biology teaching program is led by Dr. Lewis Shi, who brings specific expertise in cancer biology and immunology. Radiation biology instruction begins during orientation, when new residents learn about the concepts of BED, fractionation, and the 4 "R's" of radiobiology. Lectures then cover high-yield radiation and cancer biology concepts to prepare residents for the annual inservice exam and board exam. Some select topics include: DNA damage and repair, mechanisms of cell death, hypoxia and angiogenesis, tumor microenvironment and immunotherapy. The curriculum is repeated on an annual basis and offered to all residents.
SRS & SBRTThe UAB Department of Radiation Oncology has a long history of excellence in radiosurgery, treating over 1500 SRS/SBRT cases annually. As the first institution in the U.S. To use Varian Edge Virtual Cone, HyperArc™, and RapidArc™ technologies, residents are exposed to state of the art technology for these precision procedures. Residents actively participate in radiosurgery planning and treatment delivery procedures, and present cases for discussion weekly at our specialized Multidisciplinary Radiosurgery Conference.
Of note, UAB's Department of Radiation Oncology has partnered with Varian to develop a three-day conference that discusses and demonstrates stereotactic radiation (SRS) and stereotactic body radiation (SBRT) delivery with Eclipse™ and TrueBeam™. Learn more about the SRS/SBRT Training Course.
ProceduresUAB has a large brachytherapy program, owing to the wide catchment area of the hospital system. Residents receive didactic lectures and hands-on demonstrations in brachytherapy techniques and treatment, including intracavitary and interstitial high dose rate (HDR) treatment. While on the brachytherapy service, residents directly participate in all brachytherapy procedures, including applicator placement, treatment planning, and treatment.
ElectivesThe O'Neal Comprehensive Cancer Center at UAB provides the environment and experience for all ACGME requirements to be satisfied without external or off-site rotations. However, residents with particular interests may wish to design individualized electives or enrichment activities with the permission of the program director.
Prior residents' enrichment activities have included: pursuit of an Masters in Public Health, LDR prostate brachytherapy elective, and a particle therapy international elective to the Heidelberg Ion Therapy Center (HIT) in Heidelberg, Germany.
BenefitsThe UAB Department of Radiation Oncology is proud to offer residents a competitive benefits package.
Learn more about Residency at UAB.
Learn more about UAB employee benefits.
For all other questions, please contact Tracey Cotton-Bickham at tcotton@uabmc.Edu or (205) 975-0222.
Resident RetreatEach fall our residents participate in a one-day residency retreat, which combines leadership training, wellness and professionalism education, and team building. Residents enjoy time away from the clinic to set personal and career goals, and get to know one another. Our collegial and collaborative environment is one of the primary reasons many residents enjoy training at UAB.
Learn more about why our residents chose to train at UAB.
Sample Rotation ScheduleResidents are assigned to approximately eight-week rotations working on-on-one with our attending physicians, spending at least 36 months in clinical rotations. Research/elective may be scheduled consecutively or nonconsecutively, based on resident interest and preference. Below is a sample rotation schedule.
Sample Schedule:
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