Patient-reported symptoms before palliative radiotherapy predict survival differences.

BACKGROUND: Widely used prognostic scores, e. g., for brain or bone metastases, are based on disease- and patient-related factors such as extent of metastases, age and performance status, which were available in the databases used to develop the scores. Few groups were able to include patient-reported symptoms. In our department, all patients were assessed with the Edmonton Symptom Assessment System (ESAS, a one-sheet questionnaire addressing 11 major symptoms and wellbeing on a numeric scale of 0-10) at the time of treatment planning since 2012. Therefore, we analyzed the prognostic impact of baseline ESAS symptom severity. METHODS: Retrospective review of 102 patients treated with palliative radiotherapy (PRT) between 2012 and 2015. All ESAS items were dichotomized (below/above median). Uni- and multivariate analyses were performed to identify prognostic factors for survival. RESULTS: The most common tumor types were prostate, breast and non-small cell lung cancer, predominantly with distant metastases. Median survival was 6 months. Multivariate analysis resulted in six significant prognostic factors. These were ESAS pain while not moving (median 3), ESAS appetite (median 5), Eastern Cooperative Oncology Group (ECOG) performance status, pleural effusion/metastases, intravenous antibiotics at start or within 2 weeks before PRT and no systemic cancer treatment. CONCLUSIONS: Stronger pain while not moving and reduced appetite (below/above median) predicted significantly shorter survival. Development of new prognostic scores should include patient-reported symptoms and other innovative parameters because they were more important than primary tumor type, age and other traditional baseline parameters.

Symptom Burden in Patients With Oligometastases at the Start of Palliative Radiotherapy.

BACKGROUND/AIM: Recent studies suggested that patients with oligometastases have a better prognosis compared with those who have widespread dissemination. In both groups, radiotherapy is a commonly applied treatment. Patient-reported symptoms might depend on the burden of disease. Possibly, oligometastatic patients report lower scores for symptoms, such as fatigue or reduced appetite, which tend to worsen as the disease progresses to a later stage. Therefore, we analyzed the symptom scores in two groups of patients with or without oligometastatic disease. PATIENTS AND METHODS: A retrospective study was performed in 83 patients who received palliative, non-ablative radiotherapy for distant metastases. The Edmonton Symptom Assessment Scale (ESAS) was employed to assess the pre-radiotherapy symptoms. RESULTS: The oligometastatic group was smaller than anticipated (n=11). The ESAS score differences were not statistically significant. However, oligometastatic patients reported less fatigue, pain and dry mouth (p<0.2). They also had a better performance status. The median survival of oligometastatic patients was longer (8.1 vs. 5.5 months, p=0.17), in the absence of ablative metastases-directed treatment. CONCLUSION: The oligometastatic state is not a major contributor to the variable patient-reported symptom scores.

Symptom Burden in Patients With Reduced Performance Status at the Start of Palliative Radiotherapy.

BACKGROUND/AIM: Previous research has suggested that palliative radiotherapy is a useful measure, unless short survival reduces the time spent without active treatment, and in the case of a low likelihood of experiencing a net benefit in quality of life. Patients with reduced performance status (PS) may be especially at risk of futile treatment, despite having a relatively high symptom burden and thus a potential benefit. Therefore, we analyzed the symptom burden of patients with Eastern Cooperative Oncology Group (ECOG) PS 3-4 in our center. PATIENTS AND METHODS: A retrospective study was performed of 102 consecutive patients who received palliative radiotherapy for different indications. The Edmonton Symptom Assessment Scale (ESAS) was employed to assess the pre-radiotherapy symptoms. RESULTS: When applying the lowest threshold (ESAS ≥1), up to 97% of patients with PS 3-4 reported symptoms, such as fatigue and dry mouth. When focusing on moderate/severe symptoms (ESAS ≥4), still up to 77% of patients with PS 3-4 reported such a burden. The largest differences between patients with PS 3-4 and those with 0-1 were seen with regard to nausea, fatigue, dry mouth and reduced appetite. The median survival of patients with PS 3-4 was 2 months. CONCLUSION: Given that many of the symptoms reported by patients with PS 3-4 tend to worsen temporarily after radiotherapy, patients with short survival may not experience a net benefit during the few weeks before death. However, if other symptoms such as dyspnea or pain prevail, short-course radiotherapy may result in worthwhile palliation and should, therefore, be considered on a case-by-case basis and after estimation of the remaining lifespan.

Frequency and Prognostic Impact of Consistently Low Edmonton Symptom Assessment System Score in the Patients Treated with Palliative Radiotherapy.

Introduction Our department's standard work-flow includes assessment of all the patients with the Edmonton Symptom Assessment System (ESAS), a one-sheet questionnaire addressing 11 major symptoms and wellbeing on a numeric scale of zero-10, before the palliative radiotherapy (PRT). Based on previous research, we hypothesized that the patients with minimal or moderate total symptom burden might have better overall survival after the PRT than those with at least one higher symptom score. Methods We performed a retrospective analysis of 94 patients and calculated actuarial survival from the first day of the PRT (Kaplan-Meier method). We identified the patients with the score zero for all ESAS items (no symptoms), at least one item with score one-two (minimal symptoms), and at least one item with the score three (moderate symptoms). Results High proportions of the patients had ESAS scores zero- two for nausea (80%), sadness/depression (65%) and constipation (64%). The mean values were often in the range of two-four. Only one patient reported scores of zero throughout the questionnaire. He was treated for hematuria, a symptom that is not part of the ESAS. Three patients reported scores of zero-two throughout the questionnaire. Except for the performance status zero-one, their baseline characteristics were heterogeneous. Two patients reported scores not exceeding three for all items. These patients had excellent performance status, too. None of the six patients (6%) with relatively low ESAS scores of zero-three received care by the hospital's multidisciplinary palliative team. Only one was using opioid analgesics. The median survival for this small subset of six patients was six months, identical to the result for all the patients with higher symptom burden (p = 0.62). Conclusion The proportion of the patients with ESAS scores zero-three throughout the questionnaire was 6%, which resulted in the limited statistical power for the survival comparisons. The survival outcomes were similar. Before PRT, 94% of the patients reported at least one ESAS item of severity four-10. The symptoms not included in the questionnaire, e.g., hematuria might result in erroneous assignment to the low-symptom-burden group and obscure the prognostic impact of low ESAS symptom burden.

Contribution of Patient-reported Symptoms Before Palliative Radiotherapy to Development of Multivariable Prognostic Models.

BACKGROUND/AIM: Typically, prognostic scores predicting survival in patients with metastatic cancer are based on disease- and patient-related factors, such as extent of metastases, age and performance status. Patient-reported symptoms have been included less often. Our group has assessed all patients with the Edmonton Symptom Assessment System (ESAS, a one-sheet questionnaire addressing 11 major symptoms and wellbeing on a numeric scale of 0-10) before palliative radiotherapy (PRT) since 2012. Therefore, we were able to analyze the prognostic impact of baseline ESAS symptom severity. PATIENTS AND METHODS: We performed a retrospective review of 102 patients treated with PRT between 2012 and 2015. All ESAS items were analyzed by two different methods, dichotomized by median score and by score <4 vs. ≥4. Uni- and multivariable analyses were performed to identify prognostic factors for survival, and from these a 4-tiered score was developed. RESULTS: The most common tumor types were prostate, breast and non-small cell lung cancer, predominantly with distant metastases. Despite differences between the two methods of ESAS data handling, the final multivariable models were strikingly similar. Therefore, the better reproducible cut-off was chosen, i.e. a score ≥4. Multivariable analyses resulted in 4 significant prognostic factors, which contributed equally to the 4-tiered survival score (performance status, more than one cancer diagnosis, progressive disease outside the PRT target volume(s), ESAS appetite). Estimated median survival for different point sums was 24.5 months (0), 8.4 months (1), 4.7 months (2) and 3.0 months (3), p=0.0001. CONCLUSION: This score identified patients with different survival outcomes, including a good prognostic group with median survival of approximately 2 years. The results may be useful to inform PRT fractionation.

Does Patient-reported Dyspnea Reflect Thoracic Disease Characteristics in Patients with Incurable Cancer?

BACKGROUND/AIM: A considerable proportion of patients with incurable cancer experience dyspnea. This study evaluates associations between the feeling of dyspnea, as quantified by radiotherapy patients scoring their symptoms before palliative treatment with the Edmonton symptom assessment system (ESAS), and potential underlying causes. PATIENTS AND METHODS: Retrospective comparison of the incidence of different parameters that could cause a feeling of dyspnea in two groups, patients with no or minimal dyspnea (ESAS score 0-2) and those with dyspnea scores >2. RESULTS: The mean dyspnea score of all 102 patients was 2.6. Dyspnea scores >2 were present in 68% of patients with lung cancer, 50% of those with breast cancer, 39% of those with prostate cancer and 26% of those with other tumors (p=0.025). Dyspnea scores >2 were also present in 69% of patients with pleural effusion (vs. 40% in patients without pleural effusion), p=0.031. Among patients treated with palliative thoracic radiotherapy, 71% had dyspnea scores >2 (40% if other targets were irradiated), p=0.041. In 13% of patients, anemia and pulmonary comorbidity were the most likely explanation for dyspnea. In 29% the feeling of dyspnea could not be related to objective findings. CONCLUSION: In the majority of patients, the feeling of dyspnea was associated with the presence of thoracic metastases with or without pleural effusion from extrathoracic primary tumors or with a lung cancer diagnosis. A substantial proportion of patients reported dyspnea that could be related neither to cancer burden nor comorbidity.

Levels of Anxiety and Depression Before Palliative Reirradiation Are Comparable to Those Before First Palliative Radiotherapy.

INTRODUCTION: The purpose of this study was to evaluate whether or not patients scheduled for the reirradiation of a previously treated target volume report reduced levels of anxiety and depression, compared to patients receiving their first course of palliative radiotherapy, e.g., because they are familiar with the process of treatment planning and delivery. METHODS: A retrospective comparison of two groups of patients (37% reirradiated, overall 102 patients), which scored their symptoms before palliative radiotherapy with the Edmonton symptom assessment system (ESAS). RESULTS: The two groups differed significantly with regard to the incidence of bone metastases, which was higher in the reirradiation group. Mean anxiety and depression scores were not significantly different between the two groups. The same was true for the proportion of patients with symptom scores ≥4. Analyses limited to patients treated for bone metastases revealed no significant differences either. Survival was similar, too. CONCLUSION: The facts that similar ESAS scores of anxiety and depression were observed and that prognosis was comparable suggest that the magnitude of these symptoms might be associated with the presence of incurable cancer itself (or the related somatic symptom burden) rather than the setting in which palliative radiotherapy is performed.

Does Marital Status Influence Levels of Anxiety and Depression Before Palliative Radiotherapy?

BACKGROUND/AIM: To evaluate whether or not single patients report increased levels of anxiety and depression, compared to married or partnered patients scheduled to receive palliative radiotherapy. In principle, different levels of social support might cause such disparities. PATIENTS AND METHODS: Retrospective comparison of two groups of patients (28% single, overall 100 patients), who scored their symptoms before palliative radiotherapy with the Edmonton symptom assessment system (ESAS). RESULTS: The two groups differed significantly with regard to irradiated target sites (more brain irradiation in the married/partnered group), receipt of systemic therapy, which was more common in the married/partnered group, and mean age (single patients were older). Mean anxiety and depression scores were not significantly different between the two groups. Survival was similar, too (median 6 months, p=0.77). CONCLUSION: Similar ESAS scores of anxiety and depression were observed in the two groups (single vs. married/partnered patients).

Patient-reported symptoms and performance status before palliative radiotherapy in geriatric cancer patients (octogenarians).

PURPOSE: To evaluate differences in baseline parameters including performance status and self-reported symptom burden between geriatric and non-geriatric cancer patients, and to assess the hypothesis that these factors might predispose older patients to incomplete radiotherapy and short survival. PATIENTS AND METHODS: Retrospective comparison of geriatric and non-geriatric patients treated with palliative radiotherapy (age ⩾80 years and <80 years, respectively). Between 2013 and 2015, 26 geriatric and 76 non-geriatric patients were treated. The Edmonton symptom assessment system (ESAS) was employed to document baseline symptoms. RESULTS: Most patients received radiotherapy for bone metastases, commonly 5-10 fractions. Geriatric patients had significantly less pain at rest and depression. No strong trends towards higher symptom burden in older patients emerged for any of the items. Overall survival was similar in the two subgroups with different age and also in a separate age-stratified analysis of patients with performance status >2. Relatively few patients were irradiated in the terminal stage of disease, defined as final 30 days of life (8% in geriatric and 12% in other patients, p = 0.73). A higher number of geriatric patients failed to complete their prescribed course of radiotherapy (14 vs. 3%, p = 0.08), despite lower rates of prescription of more than 10 fractions in this group (15 vs. 23%, p > 0.2). CONCLUSIONS: These data support utilization of palliative radiotherapy irrespective of age. However, care should be taken in assigning the right fractionation regimen in order to avoid lengthy treatment courses when survival is limited, such as in patients with performance status >2.