RADIOTHERAPY FOR PALLIATION Bhadrasain Vikram, MD International Atomic Energy Agency of the United Nations
RADIOTHERAPY • Effectiveness • Cost-effectiveness
RADIOTHERAPYEFFECTIVE FOR PREVENTION/RELIEF OF • Pain: Localized or Widespread bone mets. • Fractures: Localized or Widespread bone mets. • Paralysis: Spinal cord compression, Cranial nerves compression, Brain mets. • Blindness: Choroid or Optic chiasm mets. • Bleeding: Cervix, Bladder, Hemoptysis. • Esophageal obstruction. • Airway obstruction. • Intestinal obstruction:CONTRAINDICATED.
RADIOTHERAPY PAIN RELIEF PARADIGM • Localized bone mets: • Single dose RT can decrease/eliminate need for opioids for several months. • Widespread bone mets: • Hemi-body RT over 2 days is effective, with very few side effects. • Single dose OK, if pre-medicated with IV Ondansetron and Dexamethasone.
LOCALIZED METS(Hartsell et al. J Natl Cancer Inst. 2005;97:798-804) • Prospective randomised trial of single-dose vs long-course RT. • 3 mos after RT, 33% of patients no longer required narcotic meds. • Longer treatment course caused toxicity but no added benefit.
HEMI-BODY RADIOTHERAPY(Salazar et al. Int J Radiat Oncol Biol Phys. 2001;50:765-75) • Prospective, randomised trial. • Pain relief in 91% within 1 week. • Median pain-relief duration 4 mos. • Pain relief for remaining life in 71%. • Four doses over 2 days least toxic. • Single dose requires pre-medication.
INTRAVENOUS RADIOTHERAPY • Similar effectiveness as external radiotherapy but far more expensive*. • No good evidence that external plus IV radiotherapy better than either one alone. *IAEA is researching cheaper radionuclides.
A cobalt-60 source (“The Medicine”) costs ~ 80000 USD. During its half life (~5 yr) it can deliver ~200000 doses of RT*. Cost: 40 cents/dose. *If adequately staffed. Pain relief : Single dose. Curative treatment: 20-40 doses. Priorities: Replace old sources. Repair broken machines. Hire enough staff. COST EFFECTIVENESS
Building the infrastructure. Acquiring appropriate technology. Improving QA. Preventing accidents. Training doctors, physicists, etc.(Fellowships, Expert visits, CME). Developing and evaluating ‘resource-sparing protocols’. IAEA ASSISTS MEMBER STATES IN