'Sufficient Pain relief ' as a Practical Benchmark in Cancer Pain Management: A Prospective Study of Serial Pain Scores, Patient-rated Pain Relief and Perceived Sufficiency of Analgesics.

Objectives: Serial pain scores are used to guide pain management but there can be variability in what constitutes 'adequate' pain relief for an individual patient. We aimed to evaluate how patient-rated sufficiency of pain relief corresponded to pain scores, pain relief scores, and the felt need for increasing analgesics. Material and Methods: Baseline and follow-up scores on the 11-point numerical rating scale (11-NRS) and verbal rating scale were obtained for116 patients with cancer pain. Patients used the pain relief sufficiency rating (PRSR) to rate pain relief as 'no reduction,' 'some reduction, but not enough,' 'sufficient reduction,' and 'very good reduction.' They also rated analgesics as 'sufficient' or 'insufficient.' Receiver-operating characteristic (ROC) curve analysis was used to compare PRSR responses with follow-up pain scores, patient rated percentage pain relief, and the perceived need for an increase in analgesics. Results: The 11-NRS had an area under the ROC curve of 94.2% against the PRSR. A pain score of three provided the best cutoff to identify adequate pain relief (88.2% sensitivity and 85.7% specificity). Follow-up verbal pain scores corresponded to PRSR categories (severe pain: no reduction; moderate pain: some reduction; mild pain: sufficient reduction and no pain: very good reduction). The PRSR identified 97.3% of patients who wanted analgesics increased and 85% of those who said pain medications were sufficient. Conclusion: The PRSR is a brief, simple and intuitive measure to elicit patient perceptions on the sufficiency of pain relief. Our findings suggest that it might be a useful tool in pain and symptom management.

Practical aspects of palliative care & palliative radiotherapy in incurable cervical cancer.

Cervical cancer is the most common cause of cancer-related deaths among economically disadvantaged women. The symptoms of pain, discharge, constipation, foul smell, insomnia and depression can be controlled with inexpensive medicines such as oral morphine, maintenance oral metronidazole, antidepressants and laxatives. These medications should be prescribed according to the palliative care guidelines and titrated to the individual patient's clinical response, pathophysiology, and metabolic parameters. A hypothetical clinical scenario illustrates some aspects of pain and symptom management, inter-disciplinary palliative care, medical ethics and communication needs in low-resource settings. Palliative radiotherapy is a cost-effective intervention to reduce vaginal discharge, bleeding, pressure effects and nociceptive or neuropathic pain caused by pelvic and para-aortic disease. The role of palliative radiotherapy in patients with malignant fistulae is discussed and the literature on hypo-fractionated pelvic radiotherapy is briefly reviewed.

Prognostic Factors of Malignant Pleural Effusion among Palliative Care Outpatients: A Retrospective Study.

BACKGROUND: Malignant pleural effusion (MPE) has varied survival and indicates advanced disease. LENT prognostic score is the first validated score used for MPE. This study assessed the role of LENT among palliative care cancer patients and assessed different patient, tumor, and treatment related factors that may affect survival. METHODS: A retrospective study of advanced cancer patients with MPE, seen in palliative care outpatient clinic (2013-2015) until death, was done. LENT prognostic score could be calculated in 15 patients. Patient, tumor, and treatment related factors that affect survival were assessed. RESULTS: The study included 48 patients (70.8% female; 29.2% male) with a median age of 53 years. Lung (41.7%) was the most common primary, and adenocarcinoma (44.7%) was the most common histology. The median overall survival (OS) was 14.5 months (interquartile range [IQR]: 5.25-32.75) and median survival time (ST) was 3 months (IQR: 1-7.75). ST was significantly low with poor Eastern Cooperative Oncology Group (ECOG) performance status (P = 0.002), bilateral effusion (P < 0.001), and with no oncological treatment after MPE diagnosis (P < 0.001). OS and ST were significantly low with lung primary (P = 0.006 and 0.02, respectively). Age, gender, breathlessness, tumor histology, lung metastasis, and interventions for MPE did not significantly affect survival. The median ST in the moderate and high risk LENT groups was 6 and 3 months, respectively (P = 0.16). CONCLUSION: ECOG performance status, bilateral effusion, and no oncological treatment after diagnosis of MPE were associated with poor ST. Lung primary was associated with shorter OS and ST. Small numbers precluded any definitive conclusion on the prognostic value of LENT in our group of patients, and hence larger studies are recommended.

Beyond Competence: Perspectives From Two Centuries.

A sense of failure and guilt can often be associated with the death of a patient. Using the Serenity Prayer as a framework, we present autobiographical narratives describing encounters that happened in Vellore, India over a hundred years apart. Powerlessness in the face of death, we suggest, is not the same as ignorance or incompetence. It could well be the breakthrough to a deeper wisdom and lasting empowerment.

The patient who 'must not be told': demographic factors associated with collusion in a retrospective study in South India.

BACKGROUND: Patients with cancer need adequate information about diagnosis, treatment options, and possible outcomes and prognosis to make therapeutic decisions. In cultures where the family plays the dominant role in healthcare decisions, doctors are often requested to collude in withholding distressing information from the patient. This challenging situation has not been well studied and there is limited knowledge on the different factors that may contribute to collusion. OBJECTIVE: To study the prevalence of collusion among adult cancer patients attending a palliative care outpatient clinic and the contributing factors. METHODS: The healthcare records of 306 adult cancer patients who had visited the palliative care outpatient clinic at least three times with follow-up until death were retrospectively reviewed. Details on information shared and why it was not shared were retrieved from the documentation in the communication sheet in the patient chart. The prevalence, sociodemographic and clinical factors that could contribute to collusion in doctor-patient communication were studied. RESULTS: Collusion was present in 40% of cases at the time of referral to the palliative care outpatient clinic (collusion regarding diagnosis in 18%; collusion regarding prognosis in 40%). Collusion was later addressed in 35%. Collusion was significantly higher among female patients (p=0.005), manual workers (p=0.035), those not accompanied by a spouse (p=0.000) and with no oncological treatment (p=0.001). CONCLUSIONS: Collusion regarding diagnosis or prognosis is common among cancer patients referred for palliative care. It was more prevalent among female patients, manual workers, patients who had not received oncological treatment, and patients not accompanied by a spouse.

Interventions for the treatment of metastatic extradural spinal cord compression in adults.

BACKGROUND: Metastatic extradural spinal cord compression (MESCC) is treated with radiotherapy, corticosteroids, and surgery, but there is uncertainty regarding their comparative effects. This is an updated version of the original Cochrane review published in theCochrane Database of Systematic Reviews (Issue 4, 2008). OBJECTIVES: To determine the efficacy and safety of radiotherapy, surgery and corticosteroids in MESCC. SEARCH METHODS: In March 2015, we updated previous searches (July 2008 and December 2013) of the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, CINAHL, LILACS, CANCERLIT, clinical trials registries, conference proceedings, and references, without language restrictions. We also contacted experts for relevant published, unpublished and ongoing trials. SELECTION CRITERIA: Randomised controlled trials (RCTs) of radiotherapy, surgery and corticosteroids in adults with MESCC. DATA COLLECTION AND ANALYSIS: Three authors independently screened and selected trials, assessed risk of bias, and extracted data. We sought clarifications from trial authors. Where possible, we pooled relative risks with their 95% confidence intervals, using a random effects model if heterogeneity was significant. We assessed overall evidence-quality using the GRADE approach. MAIN RESULTS: This update includes seven trials involving 876 (723 evaluable) adult participants (19 to 87 years) in high-income countries. Most were free of the risk of bias. Different radiotherapy doses and schedulesTwo equivalence trials in people with MESCC and a poor prognosis evaluated different radiotherapy doses and schedules. In one, a single dose (8 Gray (Gy)) of radiotherapy (RT) was as effective as short-course RT (16 Gy in two fractions over one week) in enhancing ambulation in the short term (65% versus 69%; risk ratio (RR) was 0.93, (95% confidence interval (CI) 0.82 to 1.04); 303 participants; moderate quality evidence). The regimens were also equally effective in reducing analgesic and narcotic use (34% versus 40%; RR 0.85, 95% CI 0.62 to 1.16; 271 participants), and in maintaining urinary continence (90% versus 87%; RR 1.03, 95% CI 0.96 to 1.1; 303 participants) in the short term (moderate quality evidence). In the other trial, split-course RT (30 Gy in eight fractions over two weeks) was no different from short-course RT in enhancing ambulation (70% versus 68%; RR 1.02, 95% CI 0.9 to 1.15; 276 participants); reducing analgesic and narcotic use (49% versus 38%; RR 1.27, 95% CI 0.96 to 1.67; 262 participants); and in maintaining urinary continence (87% versus 90%; RR 0.97, 0.93 to 1.02; 275 participants) in the short term (moderate quality evidence). Median survival was similar with the three RT regimens (four months). Local tumour recurrence may be more common with single-dose compared to short-course RT (6% versus 3%; RR 2.21, 95% CI 0.69 to 7.01; 303 participants) and with short-course compared to split-course RT (4% versus 0%; RR 0.1, 95% CI 0.01 to 1.72; 276 participants), but these differences were not statistically significant (low quality evidence). Gastrointestinal adverse effects were infrequent with the three RT regimens (moderate quality evidence), and serious adverse events or post-radiotherapy myelopathy were not noted.We did not find trials comparing radiotherapy schedules in people with MESCC and a good prognosis. Surgery plus radiotherapy compared to radiotherapyLaminectomy plus RT offered no advantage over RT in one small trial with 29 participants (very low quality evidence). In another trial that was stopped early for apparent benefit, decompressive surgery plus RT resulted in better ambulatory rates (84% versus 57%; RR 1.48, 95% CI 1.16 to 1.90; 101 participants, low quality evidence). Narcotic use may also be lower, and bladder control may also be maintained longer than with than RT in selected patients (low quality evidence). Median survival was longer after surgery (126 days versus 100 days), but the proportions surviving at one month (94% versus 86%; RR 1.09, 95% CI 0.96 to 1.24; 101 participants) did not differ significantly (low quality evidence). Serious adverse events were not noted. Significant benefits with surgery occurred only in people younger than 65 years. High dose corticosteroids compared to moderate dose or no corticosteroidsData from three small trials suggest that high-dose steroids may not differ from moderate-dose or no corticosteroids in enhancing ambulation (60% versus 55%; RR 1.08, 95% CI 0.81 to 1.45; 3 RCTs, 105 participants); survival over two years (11% versus 10%; RR 1.11, 95% CI 0.24 to 5.05; 1 RCT, 57 participants); pain reduction (78% versus 91%; RR 0.86, 95% CI 0.62 to 1.20; 1 RCT, 25 participants); or urinary continence (63% versus 53%; RR 1.18, 95% CI 0.66 to 2.13; 1 RCT, 34 participants; low quality evidence). Serious adverse effects were more frequent with high-dose corticosteroids (17% versus 0%; RR 8.02, 95% CI 1.03 to 62.37; 2 RCTs, 77 participants; moderate quality evidence).None of the trials reported satisfaction with care or quality of life in participants. AUTHORS' CONCLUSIONS: Based on current evidence, ambulant adults with MESCC with stable spines and predicted survival of less than six months will probably benefit as much from one dose of radiation (8 Gy) as from two doses (16 Gy) or eight doses (30 Gy). We are unsure if a single dose is as effective as two or more doses in preventing local tumour recurrence. Laminectomy preceding radiotherapy may offer no benefits over radiotherapy alone. Decompressive surgery followed by radiotherapy may benefit ambulant and non-ambulant adults younger than 65 years of age, with poor prognostic factors for radiotherapy, a single area of compression, paraplegia for less than 48 hours, and a predicted survival of more than six months. We are uncertain whether high doses of corticosteroids offer any benefits over moderate doses or indeed no corticosteroids; but high-dose steroids probably significantly increases the risk of serious adverse effects. Early detection; and treatment based on neurological status, age and estimated survival, are crucial with all treatment modalities. Most of the evidence was of low quality. High-quality evidence from more trials is needed to clarify current uncertainties, and some studies are in progress.

Creation of Minimum Standard Tool for Palliative Care in India and Self-evaluation of Palliative Care Programs Using It.

BACKGROUND: It is important to ensure that minimum standards for palliative care based on available resources are clearly defined and achieved. AIMS: (1) Creation of minimum National Standards for Palliative Care for India. (2) Development of a tool for self-evaluation of palliative care organizations. (3) Evaluation of the tool in India. In 2006, Pallium India assembled a working group at the national level to develop minimum standards. The standards were to be evaluated by palliative care services in the country. MATERIALS AND METHODS: The working group prepared a "standards" document, which had two parts - the first composed of eight "essential" components and the second, 22 "desirable" components. The working group sent the document to 86 hospice and palliative care providers nationwide, requesting them to self-evaluate their palliative care services based on the standards document, on a modified Likert scale. RESULTS: Forty-nine (57%) palliative care organizations responded, and their self-evaluation of services based on the standards tool was analyzed. The majority of the palliative care providers met most of the standards identified as essential by the working group. A variable percentage of organizations had satisfied the desirable components of the standards. CONCLUSIONS: We demonstrated that the "standards tool" could be applied effectively in practice for self-evaluation of quality of palliative care services.

Choosing wisely: protocols, priorities and a postcard.

Can a young doctor without training in communication skills use empathy as a compass for making ethical decisions? This narrative reflects on a young boy left alone with a paralyzed dying father after six months of 'free' but futile treatment. Protocols should be weighed against prognosis and priorities when the disease is incurable.

Impact of the Lockdown on Patients Receiving Maintenance Hemodialysis at a Tertiary Care Facility in Southern India - A Mixed-methods Approach.

Aims: The mass quarantine measures adopted to control the COVID-19 pandemic greatly impacted the lives of patients on haemodialysis in India. We used a mixed methods approach to study its effect on dialysis outcomes and the lived experience of haemodialysis patients during the lockdown. Methods: Quantitative data was collected from 141 subjects using a structured proforma to determine the impact of the lockdown on dialysis outcomes and travel expenses. Qualitative data collected through in-depth interviews with 9 patients by purposive sampling were recorded and transcribed to explore the lived experience of haemodialysis patients during lockdown. The cohort was followed up till October 31st 2020 for incidence of COVID-19, deaths, and dropouts. Results: The median increase in per day travel expense was 25%. Due to decrease in dialysis frequency, patients previously on thrice weekly haemodialysis experienced significant increase in pre-dialysis systolic blood pressure (P = 0.005) compared to those on twice weekly haemodialysis. Between March 25th and July 15th 2020, 12 patients (8.5%) required emergency dialysis sessions, and 4 patients (2.8%) required admissions for hypertensive emergencies. Four main themes emerged from thematic analysis of transcribed interviews: Travel inconveniences, uncertainty resulting in anxiety, financial burden and frequency change in dialysis leading to worsening of symptoms. Twenty-two patients (15.6%) were diagnosed with COVID-19, the first case diagnosed 33 days after the first 'unlock' phase. Conclusion: The lockdown was successful in delaying infection transmission but had unintended physical and psychosocial effects on haemodialysis patients.

Comparing three-dimensional volume-rendered CT images with fibreoptic tracheobronchoscopy in the evaluation of airway compression caused by tuberculous lymphadenopathy in children.

BACKGROUND: Lymphobronchial tuberculosis (TB) causes airway compression in 38% of patients. The airway obstruction is conventionally assessed with fibreoptic tracheobronchoscopy (FTB). Multidetector-row spiral computed tomography (MDCT) with three-dimensional volume rendering (3-D VR) has significantly improved the imaging of the airways. No previous studies have assessed the accuracy of 3-D VR in determining the degree of airway compression in children due to TB lymphadenopathy. OBJECTIVE: To compare 3-D VR CT to FTB for the assessment of airway compression due to TB lymphadenopathy in children. MATERIALS AND METHODS: Included in the study were 26 children presenting with symptoms of airway compression caused by pulmonary TB. MDCT of the chest and FTB were performed in all patients. Retrospective 3-D VR reconstruction of the major airways was performed from the original CT raw data and used to evaluate the tracheobronchial tree for site and degree of airway compression and then compared to the FTB findings. FTB was used as the reference standard RESULTS: By FTB 87 sites of airway compression were identified. Using the 3-D VR technique, 138 sites of airway compression were identified, of which 78 (90%) matched with the sites identified by FTB. The sensitivity and specificity of 3-D VR when compared with that of FTB was 92% and 85%, respectively. In four patients (15%), severe narrowing of the bronchus intermedius made FTB evaluation of the right middle and right lower lobe bronchi impossible. VR demonstrated significant distal obstruction in three of these four patients CONCLUSION: 3-D VR demonstrates a very good correlation with FTB in determining airway compression caused by TB lymphadenopathy in children. In combination with FTB, 3-D VR adds confidence to the bronchoscopy findings and complements FTB by adding additional information on the status of the airway distal to severe obstructions unreachable by FTB.

Pulmonary infections in HIV-positive children.

Infection of the lungs and airways by viral, bacterial, fungal and protozoal agents, often producing atypical radiographic features, is common in children with human immunodeficiency virus (HIV) infection. Conventional chest radiography and chest CT remain the most useful imaging modalities for evaluation of the immunocompromised patient presenting with a suspected pulmonary infection. In this review the radiological features of acute lung infections in this population are discussed.

Non-infective pulmonary disease in HIV-positive children.

It is estimated that over 90% of children infected with human immunodeficiency virus (HIV) live in the developing world and particularly in sub-Saharan Africa. Pulmonary disease is the most common clinical feature of acquired immunodeficiency syndrome (AIDS) in infants and children causing the most morbidity and mortality, and is the primary cause of death in 50% of cases. Children with lung disease are surviving progressively longer because of earlier diagnosis and antiretroviral treatment and, therefore, thoracic manifestations have continued to change and unexpected complications are being encountered. It has been reported that 33% of HIV-positive children have chronic changes on chest radiographs by the age of 4 years. Lymphocytic interstitial pneumonitis is common in the paediatric HIV population and is responsible for 30-40% of pulmonary disease. HIV-positive children also have a higher incidence of pulmonary malignancies, including lymphoma and pulmonary Kaposi sarcoma. Immune reconstitution inflammatory syndrome is seen after highly active antiretroviral treatment. Complications of pulmonary infections, aspiration and rarely interstitial pneumonitis are also seen. This review focuses on the imaging findings of non-infective chronic pulmonary disease.

Central nervous system manifestations of HIV infection in children.

Vertically transmitted HIV infection is a major problem in the developing world due to the poor availability of antiretroviral agents to pregnant women. HIV is a neurotrophic virus and causes devastating neurological insults to the immature brain. The effects of the virus are further compounded by the opportunistic infections and neoplasms that occur as a result of the associated immune suppression. This review focuses on the imaging features of HIV infection and its complications in the central nervous system.

Pain assessment and analgesic prescription for cancer patients in a medical ward: the influence of an educational intervention.

BACKGROUND: Pain is present in more than 75% of patients with advanced cancer and is often under-treated. Adequate pain control is an essential component of patient care. By correctly following the WHO analgesic ladder, pain can be controlled in nearly 90% of patients with cancer. Clinical audits help to improve patient care. Hence, an audit was done on documentation of pain and prescription of analgesics in patients with cancer admitted to a medical ward. METHODS: We conducted a retrospective audit of inpatient charts to assess the adequacy of documentation of pain and prescription of analgesics. Following this, we introduced an educational intervention in the form of teaching, provision of pocket guidelines and displaying a poster with the WHO analgesic guidelines. Subsequently, we conducted a prospective audit of documentation of pain and prescribing practices against the followingstandards: documentation of pain, intensity and response, prescription of analgesics based on WHO guidelines, prescribing breakthrough analgesics and prescribing stimulant laxatives with strong opioids. RESULTS: The retrospective audit included 39 patients and the prospective audit had 34 patients. Pain was documented in 89.7% and 82.4%, pain intensity in 12.8% and 8.8%, and pain response in 12.8% and 11.8%, in the retrospective and prospective audits, respectively. WHO principles were correctly followed in 74.3% and 88.2%, and breakthrough analgesics prescribed in 38.4% and 61.8%, respectively. CONCLUSION: There was improvement in correctly following the WHO analgesic guidelines and prescribing breakthrough analgesics but not in documentation of pain. Clinical audits and interventions such as teaching, pocket guidelines and posters can result in better patient care.

Caregiver Burden-Within and Without.

This essay describes the experience of an oncologist in India and palliative care involving grieving families and coconuts.

Regular Low-Dose Oral Metronidazole Is Associated With Fewer Vesicovaginal and Rectovaginal Fistulae in Recurrent Cervical Cancer: Results From a 10-Year Retrospective Cohort.

PURPOSE: Anaerobic necrosis in cervical cancer can lead to malodor, fistulae, and treatment abandonment. In this retrospective cohort study, we examined the association between maintenance metronidazole and the incidence of malignant fistulae in recurrent cervical cancer. METHODS: We screened all cervical cancer records registered between 2007 and 2016 in the local palliative care database at Christian Medical College, Vellore, India. There were 208 eligible patients with post-treatment residual/recurrent pelvic disease. Among them, 76 had received oral maintenance metronidazole 200 mg once per day for 2 to 86 weeks (interquartile range, 4-16 weeks). RESULTS: Seventy-two patients developed at least one fistula. Forty-nine had vesicovaginal fistulae, 10 had rectovaginal fistuale, and 13 developed both types of fistulae. Patients on maintenance metronidazole had fewer fistulae (22.4% v 41.7%; P = .005), a longer median fistula-free survival (42.9 months v 14.1 months; P < .001), and a postrecurrence survival of 11.5 months versus 8.7 months (P = .112). We performed Cox multivariable proportional hazards regression analysis on the data from the subset of 146 patients observed until death. Bladder/rectal infiltration had a higher risk of fistula (HR, 5.24; P = .011), whereas distant metastases (HR, 2.46; P = .012) and Eastern Cooperative Oncology Group performance status greater than 1 (HR, 1.64; P = .008) were associated with a higher risk of death. Maintenance metronidazole was associated with a lower risk of fistula (hazard ratio [HR], 0.33; 95% CI, 0.16 to 0.67; P = .002) and a lower risk of death (HR, 0.56; 95% CI, 0.39 to 0.81; P = .002). CONCLUSION: Our data indicate that there is a significant inverse association between oral maintenance metronidazole and malignant fistulae in locally recurrent cervical cancer. The impact of this simple intervention on pelvic symptoms, fistulae, and survival should be evaluated in prospective studies.

Interventions for the treatment of metastatic extradural spinal cord compression in adults.

BACKGROUND: Metastatic epidural spinal cord compression (MESCC) is often treated with radiotherapy and corticosteroids. Recent reports suggest benefit from decompressive surgery. OBJECTIVES: To determine effectiveness and adverse effects of radiotherapy, surgery and corticosteroids in MESCC. SEARCH STRATEGY: CENTRAL, MEDLINE, EMBASE, CINAHL, LILACS and CANCERLIT were searched; last search ran July 2008 SELECTION CRITERIA: We selected randomized controlled trials (RCTs) of radiotherapy, surgery and corticosteroids in adults with MESCC. DATA COLLECTION AND ANALYSIS: Three review authors independently assessed quality of included studies and extracted data. We calculated risk ratios (RR) and numbers needed to treat to benefit (NNT) with 95% confidence intervals (CI) and assessed heterogeneity. MAIN RESULTS: We identified six trials (n = 544). One trial (n = 276) compared radiotherapy 30 Gray in eight fractions with 16 Gray in two fractions and showed no difference. Overall ambulatory rates were 71% versus 68%, (RR 1.02, CI 0.90 to 1.15); 91% versus 89% of ambulant patients maintained ambulation (RR 1.02, CI 0.93 to 1.12); 28% versus 29% of non-ambulant patients regained ambulation (RR 0.98, CI 0.51 to 1.88). In one trial (n = 101) decompressive surgery had significantly better outcomes than radiotherapy in selected patients. Overall ambulatory rates were 84% versus 57% (RR 0.67, CI 0.53 to 0.86, NNT 3.70 CI 2.38 to 7.69); 94% versus 74% maintained ambulation (RR 0.79, CI 0.64 to 0.98, NNT 5.00 CI 2.78 to 33.33); 63% versus 19% regained ambulation (RR 0.30, CI 0.10 to 0.89; NNT 2.27 CI 1.35 to 7.69). Median survival was 126 days versus 100 days. Laminectomy offered no advantage (n = 29, 1 trial). Three trials provided insufficient evidence about the role of corticosteroids (n = 105, Overall ambulation RR 0.91, CI 0.68 to 1.23). Serious adverse effects were significantly higher in high dose corticosteroid arms (n = 77, two RCTs, RR 0.12, CI 0.02 to 0.97). AUTHORS' CONCLUSIONS: Patients with stable spines retaining the ability to walk may be treated with radiotherapy. One trial indicates that short course radiotherapy suffices in patients with unfavourable histologies or predicted survival of less than six months. There is some evidence of benefit from decompressive surgery in ambulant patients with poor prognostic factors for radiotherapy; and in non-ambulant patients with a single area of compression, paraplegia < 48 hours, non-radiosensitive tumours and a predicted survival of more than three months. High dose corticosteroids carry a significant risk of serious adverse effects.