One stop shop. Natalie D. Klass, MD

Transcription

1 One stop shop Natalie D. Klass, MD AERO Academy Conference Innovation & Safety Lisbon 26th and 27th January 2018

2 Disclosure & Disclaimer An honorarium is provided by Accuray for this presentation The views expressed in this presentation are those of the presenters and do not necessarily reflect the views or policies of Accuray Incorporated or its subsidiaries. No official endorsement by Accuray Incorporated or any of its subsidiaries of any vendor, products or services contained in this presentation is intended or should be inferred.

3 Background I Majority of cancer patients receive one or several radiotherapy treatments throughout their disease. 30% to 50% of all radiation treatments are palliative: to alleviate symptoms or prophylactic to prevent deterioration of quality of life from local progressive disease. Local radiotherapy is efficient and safe, has few side effects, and is cost-effective. Furthermore, radiotherapy is important for oncological emergencies like symptoms due to obstruction/ compression, tumor bleeding, and spinal cord compression.

4 Background II Palliative patients are a very fragile group and need a special setup Dose-fractionation and type of radiotherapy must be tailored individually taking into account the goal of treatment, localization of the tumor manifestations, and the patient s prognosis. In limited life expectancy, irradiation should be performed with higher doses per fraction and a short overall treatment time. Selection of the individual palliative treatment concept (including radiotherapy) should be performed by a multidisciplinary and multiprofessional team.

5 Palliative Radiotherapy Clinic Unique program in the Netherlands since September 7 th, 2015 Offers palliative patients a quick and efficient treatment adapted to their complaints and general condition See-Scan-Plan-Treat in one day (80% of patients) Team: 8 radiation oncologists, 8 RTTs and 3 nurses 4 patients per day, about 70 patients per month Collecting data for research

6 A day at the Palliative Radiotherapy Clinic 09:00 Patient1 consult Radiation oncologist 09:30 Patient 1 consult RTT CT between 10:30-12:30 Delineate and planning Plan check Radiotherapist QA check and enter patient data in Mosaiq Irradiation between 15:00-17:00

7 Prospective database Forms at day 0 Patient fills in forms on day of first fraction. FU day 1 RTT calls patient the first day after last fraction. NRS score and side effects are noted FU 2 weeks RTT calls patient 2 weeks after last fraction. NRS score and side effects are noted FU 4 weeks Radiotherapist calls patient. Asks about side affects Notes NRS score and medication QoL forms at 4 weeks FU 8 weeks Nurse calls patient Asks about current situation and medication Notes NRS QoL forms at 8 weeks NRS = numeric rating scale; QoL = Quality of life

8 Reason for treatment Bone metastases (71%): Including spinal compression, epidural infiltration, soft tissue/ bone lesions Brain metastases (17%): including leptomeningeal metastases Bleeding (5%) Others (7%): Dyspnea, dysphagia, VCSS, skin ulceration

9 Project: prognostic factors in palliative patients with bone metastases Patients with bone metastases who were treated with palliative radiotherapy between 09/2015 and 12/2016 First consultation: evaluation of relevant patient and disease facttors, medicaments and also quality of life (EORTC-C15-PAL and BM 22) Prospective collection of clinical factors to assess relevant prognostic factors on patients overall survival.

10 Results 358 patients Sort primary tumor 27% lung cancer 17% prostate cancer 13% breast cancer 6% myeloma 37% others Median age 67 years (range years) 221 (62%) male, 137 (38%) female 56% adenocarcinoma Karnofsky Score 70: 60%

11 Median overall survival (OS) and follow up Median OS: 4.53 months (95% CI months) Median follow up 5.26 months (95% CI months)

12 Factors 19 factors were taken into analysis Gender Lung metastases Curative intent in beginning Time to metastases Age Liver metastases Metastasized at first diagnosis Morphine equivalent dose Sort primary tumor Brain metastases Systemic therapy 8 week before RT Residence during RT Histology Number of organs with metastases Sort systemic therapy before RT NRS Score Karnofsky performance score (KPS) Total number metastases Systemic therapy option after RT NRS = numeric rating scale

13 Univariate analysis Variable Univariate analysis Hazard ratio p value (95% CI) Primary tumor <.001 Lung - Prostate 0.48 ( ) Breast 0.41 ( ) <.001 Myeloma 0.17 ( ) <.001 Others 0.68 ( ) KPS < < ( ) Time to metastases >6 months - 6 months 1.57 ( ) Systemic therapy before RT Yes - No 1.50 ( ) Liver metasases No - Yes 1.68 ( ) Out of 19 factors 9 showed significant in the univariate analysis

14 Univariate analysis Variable Hazard ratio (95% CI) Morphine equivalent dose No morphine - Univariate analysis mg/d 1.30 ( ) >100 mg/d 2.20 ( ) p value <.001 Residence during RT <.001 At home - Institution 1.79 ( ) Systemic therapy after RT Yes - No 2.59 ( ) <.001 Number of organs < organ - 2 organs 1.80 ( )

15 Multivariable analyse In the multivariable analysis 5 could be assessed which have a significant influence on overall survival Sort primary tumor Karnofsky performance score: 70 vs <70 Liver metastases Time to metastases: >6 months vs 6 months Systemic therapy option after end of RT

16 Primary tumor 1 year overall survival: Myeloma 67% Prostate 40% Breast 37% Lung 20% Others 23% Hazard ratio (95% CI) p value Primary tumor <.001 Lung - Prostate 0.59 ( ) Breat 0.37 ( ) Myeloma 0.16 ( ) Others 0.72 ( ) 0.094

17 Karnofsky performance score Median OS in months: KPS 70: 7.55 ( ) KPS <70: 2.33 ( ) p<.001 Variable Multivariable analysis Hazard ratio p value (95% CI) KPS < < ( )

18 Liver metastases Median OS in months No: 6.30 ( ) Yes: 3.05 ( ) p<.001 Variable Multivariable analysis Hazard ratio (95% p value CI) Liver <.001 metastases No - Yes 1.96 ( )

19 Time to metastases Median OS in months 6 months: 3.77 ( ) >6 months: 7.26 ( ) p= Variable Multivariable analysis Hazard ratio p value (95% CI) Time to metastases >6 months - 6 months 1.54 ( )

20 Systemic therapy after the end of radiotherapy Median OS in months Yes: 6.83 ( ) No: 2.33 ( ) p<.001 Variable Multivariable analysis Hazard ratio (95% CI) Systemic therapy after RT Yes - No 1.52 ( ) p value 0.034

21 Summary Negative influence factors on overall survival: Primary tumor other than breast cancer or prostate cancer 1 Karnofsky score <70 1 Presence of liver metastases Time to metastases < 6 months after first diagnosis No other systemic treatment options after the end of radiotherapy Easy to evaluate clinical factors which can help to identify patients with a short overall survival and to avoid an overtreatment towards end of life 1: Glare PA et al. J Palliat Med. 2008

22 Conclusions By offering the specialized concept of a palliative radiotherapy clinic a tailored and optimal treatment can be offered. Patient s needs are in the focus. With 80% of patients treated within one day, patients don t have to spend too much of their remaining life time in hospital. Multidisciplinary approach optimizes whole treatment. Patients feel well supported and appreciate follow up via telephone. Simple technique, hypofractionated schedules -> good effect: 70% responders to treatment. Palliative teams should be regularly implemented in radiotherapy departments.

23 Thanks to the team! Radiation oncologists: Ilse de Pree Huda Abusaris Cecile Janus Manouk Olofsen Caroline van Rij Cleo Slagter Annemarie Swaak Marieke van Zwienen en alle AIOS! RTTs: Theresia van Battum Nikky van Blitterwijk Marcella Cramer Marja de Hon Lijanne Otto Illona Steinvoort Christa Timmermans Olijn Tims Nurses: Karin Dupree Hanneke Larooij Claudia Mangelaars Supervisor and research coordinator: Joost Nuyttens

24 Thank you for your attention!