Comparison of pain response and functional interference outcomes between spinal and non-spinal bone metastases treated with palliative radiotherapy.

PURPOSE: The purpose of this study was to compare functional interference and pain response outcomes using the Brief Pain Inventory (BPI) for patients treated with palliative radiotherapy to spine versus non-spine bones and determine if dose fractionation was associated with each group's respective response. MATERIALS AND METHODS: Patients treated for painful bone metastases with palliative radiotherapy during May 2003 to June 2007 were analyzed. The BPI was utilized at baseline and monthly for 6 months post-radiation. Pain response was determined using International Bone Metastases Consensus response definitions. Wilcoxon rank-sum test (for continuous variable), Fisher exact test (for categorical value), and two-way analysis of variance were used for comparisons, and a p value of ≤ 0.05 was considered statistically significant. RESULTS: Three hundred eighty-six patients were analyzed, 62% were treated with a single fraction, 38% with multiple fractions. Pain and functional interference scores significantly improved over time in both spine and non-spine sites. At 3 months, 42% of all patients had a partial response, and 25% had a complete response. Location of bone metastases and radiotherapy dose were not predictive factors for pain response nor functional interference following radiation treatment. CONCLUSION: Spine and non-spine bone metastases exhibited similar pain and functional interference improvements over a period of 6 months post-radiotherapy. There were, however, high attrition rates as expected with palliative studies, with approximately half the patients remaining in this study by 3 months and a fifth by 6 months. A single 8 Gy resulted in equal benefits in terms of both pain response and improvement in function.

Symptom clusters in patients with bone metastases--a reanalysis comparing different statistical methods.

PURPOSE: The aims of this study were to determine whether symptom clusters in patients with bone metastases varied when derived using three different statistical methods and to compare the presentation of symptom clusters over time in responders and nonresponders to palliative radiation treatment (RT). METHODS: Secondary analysis of a previously reported data set compiled using the brief pain inventory from 348 patients with bone metastases. Hierarchical cluster analysis (HCA) and exploratory factor analysis (EFA) were performed to identify symptom clusters at baseline, 1, 2, and 3 months following radiation treatment. Clusters derived were compared with the findings obtained using principal component analysis (PCA) in our previous study. The total patient sample was further separated into two subgroups: responders and nonresponders to RT. PCA, HCA, and EFA identified symptom clusters experienced by each subgroup at the same time points as before. RESULTS: Little correlation was observed in the symptom cluster findings of PCA, EFA, and HCA in the total patient sample. Absolute consensus among all three statistical methods was never reached at any assessment time point in the present study. Varying patterns of symptom cluster presentation over time were observed in the responders versus nonresponders subgroups regardless of the analytical method employed. A core cluster of symptoms composed of worst pain, general activity, walking ability, normal work, and enjoyment of life frequently presented in the same cluster. CONCLUSION: The presence and composition of symptom clusters derived varied depending on which statistical analysis method was employed. A key step in attaining consistency in symptom cluster research necessitates the utilization of a common method.

Comparing baseline symptom severity and demographics over two time periods in an outpatient palliative radiotherapy clinic.

PURPOSE: The primary objective of this study was to compare the symptom severity in two different patient populations assessed in an outpatient palliative radiotherapy clinic over two time periods spanning 10 years. The secondary objective was to assess any changes in the baseline demographics of these patients. METHODS: Data were collected from 1999 to 2009. Upon initial presentation to the clinic, the Edmonton Symptom Assessment Scale (ESAS) was administered to patients to capture symptom severity. This validated assessment tool asks patients to score their level of pain, tiredness, nausea, depression, anxiety, drowsiness, loss of appetite, well-being, and dyspnea on an 11-point Likert scale. Differences between the two patient groups were assessed using chi-squared analysis and Wilcoxon rank-sum tests. A p value of <0.05 was considered significant. RESULTS: A total of 1,439 patients completed the ESAS from 1999 to 2009. Patients were divided into two time periods 1999-2002 (n = 689) and 2006-2009 (n = 750). Pain, depression, nausea, fatigue, anxiety, drowsiness, and dyspnea were significantly better in 2006-2009 (p < 0.0001). Loss of appetite was not statistically different between the two time periods (p = 0.236). Significantly more patients with genitourinary cancers (p = 0.03) or a referral for a mass (p < 0.0001) were seen in 2006-2009. More patients with breast cancer (p = 0.04) and bone pain (p = 0.0002) were seen in 1999-2002. The median age was significantly higher (70 years vs. 68 years, p = 0.03) for patients seen in 2006-2009. No significant differences were seen in performance status or gender between the two groups. CONCLUSION: There have been statistically significant lower scores in the severity of the majority of symptoms as scored by the latter patient cohort; however, whether this difference in magnitude is clinically significant is debatable. The reason for referral and demographics in patients sent for palliative radiotherapy has changed over a 10-year period. This may be a reflection of the changes in systemic therapies and improvements in supportive care for patients with advanced cancer.

EORTC QLQ-C15-PAL quality of life scores in patients with advanced cancer referred for palliative radiotherapy.

PURPOSE: Symptom control and improved quality of life (QOL) are primary goals of treatment in palliative oncology. The present study assessed and compared patient demographics, baseline Karnofsky Performance Status (KPS) and QOL using the QLQ-C15-PAL questionnaire prior to palliative radiotherapy (RT) for bone, brain, or lung disease. Few studies have used this questionnaire, an abbreviated version that was developed by the European Organization for Research and Treatment of Cancer specifically for patients with advanced cancer to decrease the burden of completing the longer, more time-consuming QLQ-C30. METHODS: Patients referred to an outpatient palliative RT clinic completed QLQ-C15-PAL questionnaires prior to palliative RT for bone, brain, or lung cancer sites. The associations between baseline QLQ-C15-PAL functional/symptom scales, patient demographics, and clinical variables including KPS were explored. RESULTS: When data from all 369 patients were analyzed, higher KPS scores correlated significantly with better overall QOL and higher physical and emotional functioning. The QLQ-C15-PAL provided more detailed information regarding how symptom burden varied depending on disease site. Patients with bone metastases had worse QLQ-C15-PAL scores for pain, while those with brain and lung disease had worse scores for fatigue. Other health-related QOL scores measured by the QLQ-C15-PAL varied as a function of age and gender. CONCLUSION: As the QLQ-C15-PAL provides detailed and often critical information regarding symptom burden, it may eventually be recognized as a universal core questionnaire to assess QOL in this patient population with advanced cancer while relieving the survey burden.

Do elderly patients with metastatic cancer have worse quality of life scores?

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.

The palliative performance scale: examining its inter-rater reliability in an outpatient palliative radiation oncology clinic.

INTRODUCTION: The Palliative Performance Scale (PPS) was developed by the Victoria Hospice Society in 1996 to modernize the Karnofsky Performance Scale. Currently, it is being used to measure palliative patient performance status in a variety of settings. Despite its widespread use, only one study has examined the inter-rater reliability of the PPS. PURPOSE: To examine the inter-rater reliability of the PPS in measuring performance status in patients seen in an outpatient palliative radiation oncology clinic METHODS: Performance status for 102 consecutive patients was assessed by an oncologist (MD), a radiation therapist (RT), and a research assistant (RA) in the Rapid Response Radiotherapy Program at the Odette Cancer Centre in Toronto, Ontario, Canada. Raters' scores were analyzed for correlation and compared to evaluate the inter-rater reliability of the PPS tool. RESULTS: Excellent correlation was found between the scores rated by the MD and RA (r = 0.86); good correlation was observed between scores rated by the MD and RT (r = 0.69) and the RT and RA (r = 0.77). Scores between all three raters, as well as between rater pairs, were also found to have good reliability as measured by the Chronbach's alpha coefficient. Significant results were obtained for the range of PPS scores in which the majority of our patients fell: 40-80%. CONCLUSION: PPS was shown to have good overall inter-rater reliability in an outpatient palliative setting, but more research is needed to establish the validity and reliability of the tool in a variety of different palliative settings.

Outcomes following definitive stereotactic body radiotherapy for patients with Child-Pugh B or C hepatocellular carcinoma.

PURPOSE: To report outcomes in patients with Child-Pugh B or C (CP B/C) hepatocellular carcinoma (HCC) treated with stereotactic body radiotherapy (SBRT). METHODS AND MATERIALS: A prospective study of SBRT was developed for patients with CP B7 or B8 unresectable HCC, <10 cm. Selected ineligible patients (e.g. CP>B8, >10 cm) treated off-study from 2004 to July 2012 were also reviewed. Patients were excluded if they were treated as a bridge-to-liver-transplant. RESULTS: 29 patients with CP B/C HCC were treated with SBRT (median dose 30 Gy in 6 fractions) from 2004 to December 2012. The majority had CP B7 liver function (69%) and portal vein tumor thrombosis (76%). The median survival was 7.9 months (95% CI: 2.8-15.1). Survival was significantly better in patients with CP=B7 and AFP≤4491 ng/mL. Of 16 evaluable patients, 63% had a decline in CP score by ≥2 points at 3 months. CONCLUSION: SBRT is a treatment option for selected HCC patients with small HCCs and modestly impaired (CP B7) liver function.

Projected referral to other healthcare services in an outpatient palliative radiotherapy clinic.

AIMS: To investigate the projected referral to other healthcare services in an outpatient palliative radiotherapy clinic. METHODS: Patients referred for palliative radiotherapy from 1999 to 2002 inclusive and 2007 to 2009 inclusive were evaluated. The Edmonton Symptom Assessment System, which assesses nine symptoms, was completed by 1439 patients prior to radiotherapy consultation. The numeric scale was converted into a categorical scale of none, mild, moderate and severe. Patients with moderate-to-severe symptoms were identified as potential referrals to other healthcare services. RESULTS: Tiredness (66%), poor sense of wellbeing (64%), pain (57%) and poor appetite (52%) had the most patients scoring in the moderate-to-severe range. Moderate-to-severe anxiety and depression occurred in 39 and 30% of patients, respectively, reflecting the percentage of projected referrals for symptom and/or psychosocial management. CONCLUSION: Cancer symptoms are complex, and a multidisciplinary and collaborative approach should be taken to provide timely management and maintain patients' quality of life.

Symptom Clusters Using the Edmonton Symptom Assessment System in Patients With Bone Metastases: A Reanalysis Comparing Different Statistical Methods.

BACKGROUND: To determine whether symptom clusters in patients with bone metastases vary when extracted using three different statistical methods. To compare the temporal composition of symptom clusters in responders versus non-responders to palliative radiation treatment. METHODS: A previous dataset of 518 bone metastases patients who completed the Edmonton Symptom Assessment System (ESAS) was used in this study. Clusters derived using Principal Component Analysis (PCA) in our previous study were compared to symptom clusters extracted using Hierarchical Cluster Analysis (HCA) and Exploratory Factor Analysis (EFA). Clusters were derived at baseline, and 1, 2, 4, 8 and 12 weeks after radiation treatment. The patient sample was further divided into responders versus non-responders to radiotherapy. The three statistical methods were performed to identify clusters in the subgroups at each time point. RESULTS: A complete consensus between HCA, EFA and PCA for the number and composition of symptom clusters was not reached at any time point. Furthermore, little correlation in clusters was found between the three statistical methods despite the use of an identical data set. As expected, different symptom clusters were observed in the responders and non-responders with all three statistical methods. In addition, clusters varied at each time point within each subgroup. Depression and anxiety were consistently found in the same cluster. CONCLUSION: The quantity, composition, and occurrence of symptom clusters varied based on which statistical method was employed. The use of a common analytical method is necessary for consistency and comparison purposes in future symptom cluster research.

The EORTC QLQ-BN20 for assessment of quality of life in patients receiving treatment or prophylaxis for brain metastases: a literature review.

INTRODUCTION: Brain metastases occur in approximately 20-40% of cancer patients during the course of disease. As treatment for brain metastases is palliative over curative, quality of life (QoL) is emphasized over prolonged survival. The European Organization for Research and Treatment of Cancer (EORTC) QLQ-BN20 is a QoL assessment specific to brain neoplasms. We aim to provide a review of the current use of the EORTC QLQ-BN20 for patients with brain metastases. MATERIALS & METHODS: All studies utilizing the QLQ-BN20 for QoL assessment in patients receiving treatments related to brain metastases were included. Study information including treatment type, assessment periods, patient enrolment and all information pertaining to the QLQ-BN20 were extracted. RESULTS: A total of 13 studies were identified, five of which were randomized trials assessing prophylactic whole brain radiation for patients with small-cell lung cancer. The QLQ-BN20 was used in conjunction with the core QLQ-C30 questionnaire in all but one of the studies and together these comprised the entire QoL assessments for 11 of the 13 studies. Neurocognitive function assessments supplemented QoL in four studies and accompanying performance status indices used with the QLQ-BN20 varied. Compliance issues were commonly cited. QoL changes during study periods varied as improvements, deteriorations and stabilizations were all observed. CONCLUSION: QoL assessments should be conducted using disease-specific tools. Future studies should minimize patient burden in order to maximize data collection and accrual. A common set of QoL end points for patients with brain metastases should be created.

Comparison of the EORTC QLQ-C15-PAL and the FACIT-Pal for assessment of quality of life in patients with advanced cancer.

Shorter quality-of-life (QoL) assessments are beneficial for palliative patients as they reduce burden associated with completing personal, and at times stressful, questionnaires. The European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire Core 15 Palliative (QLQ-C15-PAL) and the Functional Assessment of Chronic Illness Therapy - Palliative Care (FACIT-Pal) are two palliative QoL tools that have been validated for use in this population. The purpose of this article was to conduct a review of studies utilizing these two palliative-specific QoL instruments, their development and their relative strengths for use in advanced cancer patients. Studies detailing the development process for the QLQ-C15-PAL and the FACIT-Pal were identified. A comparison between both questionnaires in terms of development, characteristics, validation and use was conducted. The QLQ-C15-PAL was developed via structured shortening of the longer core instrument, the Quality of Life Questionnaire Core 30 (QLQ-C30), whereas the FACIT-Pal includes the Functional Assessment of Cancer Therapy - General tool plus a new 19-item palliative scale created through interviews with patients and healthcare professionals. Although significant overlap exists between both tools, there is a marked difference in the aspects of QoL assessed. Scoring, organization and item format are different; however, response options and recall period are the same. Both tools cover the core items relevant to patients with advanced cancers and can be supplemented with disease-specific tools. Both QLQ-C15-PAL and FACIT-Pal allow for assessment of QoL issues specific to patients with advanced diseases. Each instrument has unique strengths and weaknesses and choice between these tools is dependent on the investigator and study needs. Future studies should directly compare these two tools and validate their use through a number of administration modes.

5-year review of a unique multidisciplinary nonmelanoma skin cancer clinic.

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.

FACT-Br for assessment of quality of life in patients receiving treatment for brain metastases: a literature review.

INTRODUCTION: Brain metastases are a significant cause of morbidity and mortality for patients with advanced cancers, and quality-of-life (QoL) end points are most appropriate for this population. The Functional Assessment of Cancer Therapy (FACT) questionnaires are commonly used to assess cancer-related QoL issues. The FACT-Brain (FACT-Br) provides an additional set of disease-specific questions pertaining to brain neoplasms. We aim to provide a comprehensive review to examine the use of the FACT-Br as a QoL assessment for patients with brain metastases. MATERIALS & METHODS: A review of the literature was conducted and all studies utilizing the FACT-Br for QoL assessment of patients with brain metastases were included. Study information and relevant information regarding the FACT-Br were extracted. RESULTS: A total of 14 studies were identified representing various treatment options (radiation, chemotherapy and surgery) for patients with brain metastases. All studies utilized at least part of the FACT-Br as the main QoL assessment. In addition, neurocognitive and performance status assessments were performed in nine and 12 out of 14 studies, respectively. Issues of poor accrual, compliance and attrition were common and posed problems in reaching statistically significant changes in QoL despite changes in raw QoL scores. CONCLUSION: Studies involving patients with brain metastases should continue to utilize QoL tools such as the FACT-Br; however, this tool still requires validation for use in this patient population. Additional studies should observe the relationship between neurocognitive function and QoL, and attempt to minimize poor accrual and compliance issues through modifications of trial design and reduction of patient burden.

Poor Accrual in Palliative Research Studies: An Update From the Rapid Response Radiotherapy Program.

BACKGROUND: In June 2003, the Rapid Response Radiotherapy Program (RRRP) implemented changes to recruitment strategies in attempts to increase patient accrual to research studies. Such modifications included the use of a dedicated research assistant to screen for and identify eligible study patients, the introduction of more appropriate inclusion criteria, and the switch towards telephone interviews to minimize patient burden. The purpose of this study is to provide an update on patient accrual in the RRRP. METHODS: All patients seen in the RRRP from January 2002 to December 2009 were recorded in a prospective database. Reasons for referral, eligibility for clinical trials, reasons for non-accrual, and various demographics information were recorded. Descriptive statistics summarized findings. RESULTS: A total of 4726 patient visits were recorded from January 1st, 2002 to December 31st, 2009. Prior to changes, the overall rate of accrual into research studies was 14.9% versus 48.1% after changes were implemented. Patients were not accrued onto studies mainly to due ineligibility according to study protocol. Other reasons such as language barrier (12.1%), physician objection (3.5%), patient declining participation (11.3%) and lack of a research assistant (9.3%) were cited. CONCLUSIONS: Changes in clinical structure and study design can significantly impact accrual patterns in palliative radiotherapy studies. Despite these changes however, the majority of patients are still not enrolled in studies. Therefore additional efforts need to be made to maximize patient accrual and minimize attrition.

Gender Difference in Symptom Presentations Among Patients With Bone Metastases in Gender-Specific and Gender-Neutral Primary Cancers.

BACKGROUND: Studies have assessed gender differences on symptoms commonly experienced by cancer patients at various stages in their disease trajectory using heterogeneous cancer populations with different tumor types. The purpose of our study was to evaluate the effect of gender on symptoms among patients with bone metastases while controlling for gender-specific malignancies. METHODS: A retrospective review of patients receiving palliative radiotherapy for bone metastases was conducted on patients that completed the Brief Pain Inventory (BPI) or Edmonton Symptom Assessment System (ESAS) questionnaires from 1999 - 2004. Baseline and follow-up BPI and ESAS symptom scores were compared between males and females, with and without controlling for gender-specific tumors. RESULTS: A total of 900 patients completed baseline questionnaires: ESAS (n = 508) or BPI (n = 392). The most common tumor types were lung (26%), breast (25%) and prostate (24%). In all ESAS patients, females had significantly greater severity of tiredness, nausea, depression, anxiety and breathlessness. In the subgroup analysis when gender-specific primary cancers were removed (i.e., breast, prostate and gynecological), no significant differences in ESAS symptoms were found between genders. The BPI functional item of walking ability was significantly worse for females in both the overall and subgroup analyses. Females had worse symptoms at follow-up prior to the removal of gender-specific primaries in both ESAS and BPI. CONCLUSIONS: Gender-specific cancers may significantly bias gender studies of cancer-related symptoms when primary tumor type is not taken into account. Gender differences are best assessed in gender-neutral primaries.

Analysis of Pain and Interference Patterns With Brief Pain Inventory in Patients With Bone Metastases: A Confirmatory Study.

BACKGROUND: This study investigates the validity of the psychometric properties of the Brief Pain Inventory (BPI) in patients with bone metastases and determines if patients with lower body pain exhibit higher levels of activity interference than those with upper body pain. METHODS: Three hundred and eighty-six patients treated, between May 2003 and June 2007, for painful bone metastases were included in this analysis, 336 patients with complete data were included in further analyses. Cronbach's Alpha, confirmatory factor analysis (CFA), and discriminant validity tests were performed to analyze the psychometric properties of the BPI. One-way analysis of variance was used to compare mean scores of BPI subscales (pain, activity, and affect) in patients with upper or lower bone metastases. RESULTS: Internal consistency of two- and three-factor BPI analysis was high. In both cases, consistency was further improved when the sleep item was removed. CFA confirmed these results and showed that three-factor analysis was recommended. Patients with lower body metastases reporting moderate to severe pain exhibited greater levels of functional interference. A single fraction radiotherapy dose of 8 Gy was as effective as multi-fraction therapy where the predominant fractionation was 20 Gy in 5 fractions. CONCLUSIONS: Our data confirms the psychometric validation of the BPI and the recommendations to use three-factor analysis in patients with bone metastases. Patients exhibiting lower extremity pain should receive prompt pain interventions and functional aid.

Edmonton symptom assessment scale as a prognosticative indicator in patients with advanced cancer.

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.

Correlation of computed tomography imaging features with pain response in patients with spine metastases after radiation therapy.

PURPOSE: To correlate computed tomography (CT) imaging features of spinal metastases with pain relief after radiotherapy (RT). METHODS AND MATERIALS: Thirty-three patients receiving computed tomography (CT)-simulated RT for spinal metastases in an outpatient palliative RT clinic from January 2007 to October 2008 were retrospectively reviewed. Forty spinal metastases were evaluated. Pain response was rated using the International Bone Metastases Consensus Working Party endpoints. Three musculoskeletal radiologists and two orthopaedic surgeons evaluated CT features, including osseous and soft tissue tumor extent, presence of a pathologic fracture, severity of vertebral height loss, and presence of kyphosis. RESULTS: The mean patient age was 69 years; 24 were men and 9 were women. The mean worst pain score was 7/10, and the mean total daily oral morphine equivalent was 77.3 mg. Treatment doses included 8 Gy in one fraction (22/33), 20 Gy in five fractions (10/33), and 20 Gy in eight fractions (1/33). The CT imaging appearance of spinal metastases included vertebral body involvement (40/40), pedicle involvement (23/40), and lamina involvement (18/40). Soft tissue component (10/40) and nerve root compression (9/40) were less common. Pathologic fractures existed in 11/40 lesions, with resultant vertebral body height loss in 10/40 and kyphosis in 2/40 lesions. At months 1, 2, and 3 after RT, 18%, 69%, and 70% of patients experienced pain relief. Pain response was observed with various CT imaging features. CONCLUSIONS: Pain response after RT did not differ in patients with and without pathologic fracture, kyphosis, or any other CT features related to extent of tumor involvement. All patients with painful spinal metastases may benefit from palliative RT.

What QLQ-C15-PAL Symptoms Matter Most for Overall Quality of Life in Patients With Advanced Cancer?

BACKGROUND: Few studies have evaluated the QLQ-C15-PAL health-related quality of life (QOL) questionnaire, an abbreviated version of the QLQ-C30 questionnaire that was designed specifically for patients with advanced cancer. The present study assessed whether certain symptoms or functional domains from the QLQ-C15-PAL predicted overall QOL when rated prior to palliative radiation treatment (RT). PATIENTS AND METHODS: Patients attending an outpatient palliative radiotherapy clinic completed QLQ-C15-PAL questionnaires prior to palliative RT for bone, brain or lung disease. Pearson correlations were computed between the QLQ-C15-PAL functional/symptom scores and overall QOL scores. Multiple linear regressions were used to evaluate the relative importance of functional/symptom scales in association with overall QOL. RESULTS: Data from 369 patients were analyzed. The QLQ-C15-PAL domains of physical and emotional functioning, pain, and appetite loss were significant predictors of overall QOL in these patients with advanced cancer. Appetite loss was the only significant independent predictor of overall QOL in the subgroup of patients with advanced lung cancer (n = 29). Both appetite loss and emotional functioning were independently predictive of overall QOL in patients with bone metastases (n = 190). In patients with brain metastases (n = 150), independent predictors of overall QOL included physical and emotional functioning as well as fatigue. CONCLUSION: The QLQ-C15-PAL domains of physical and emotional functioning, pain and appetite loss were significant predictors of overall QOL in this cohort of patients with advanced cancer. Different functional and symptom scales predicted overall QOL in patients with bone metastases, brain metastases or advanced lung cancer.

Self-reported rates of sleep disturbance in patients with symptomatic bone metastases attending an outpatient radiotherapy clinic.

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.