|Year : 2016 | Volume
| Issue : 1 | Page : 24-26
Comparison between two different fractionation radiation dose schedules for palliation of advanced solid tumours
Cindy Laltanpui, Yengkhom Indibor Singh, Yongba Waulong Phom
Department of Radiotherapy, Regional Institute of Medical Sciences, Imphal, Manipur, India
|Date of Web Publication||5-Feb-2016|
Yengkhom Indibor Singh
Department of Radiotherapy, Regional Institute of Medical Sciences, Imphal - 795 004, Manipur
Source of Support: Department of Radiotherapy, RIMS,, Conflict of Interest: None
Context: Palliative radiotherapy (RT) is radiation treatment administered with the intent to improve symptoms and relieve suffering. Aims: The aim of this study is to compare between two different fractionation radiation Dose schedules for palliation of advanced solid tumours. Setting and design: An interventional study carried out in the Department of Radiotherapy, RIMS. Materials and Methods: The study population comprised of 60 patients who were histopathologically confirmed patients with dyspnea in lung cancer, bleeding in cervical cancer and pain in rectal cancers. The eligible patients were randomized into two arms, Arm A and Arm B with a 1:1 randomization, consisting of 30 patients in each arm. Patients in Arm A were prescribed tumor dose of 20 Gray (Gy) over 5 fractions (that is 400 cGy per fractions) and the patients in Arm B were prescribed tumor dose of 10 Gy as weekly dose for 2 fraction. Theratron 780-C Cobalt 60 unit (80 cm SSD) was used. Statistical analysis used: statistical packages for the social sciences (SPSS) version 11.5. Result: In both treatment arms, mean symptoms grade of dyspnoea, mean pain scores and mean bleeding grade scores, improved from week 0-12 with better grades in Arm B group which indicated adequate palliation. Conclusion: 10 Gy into 2 fractions once a week (Arm B) gives better symptom palliation than 20 Gy over 5 fractions (Arm A) in advanced solid tumors like lung, rectal and cervix cancers with more toxicities in Arm B.
Keywords: Palliative radiotherapy, Radiation toxicities, Solid tumour
|How to cite this article:|
Laltanpui C, Singh YI, Phom YW. Comparison between two different fractionation radiation dose schedules for palliation of advanced solid tumours. J Med Soc 2016;30:24-6
|How to cite this URL:|
Laltanpui C, Singh YI, Phom YW. Comparison between two different fractionation radiation dose schedules for palliation of advanced solid tumours. J Med Soc [serial online] 2016 [cited 2020 May 24];30:24-6. Available from: http://www.jmedsoc.org/text.asp?2016/30/1/24/175796
| Introduction|| |
Palliative radiotherapy (RT) is radiation treatment administered with the intent to palliate, that is, improve symptoms and relieve suffering. It is estimated that 40-50% of all radiotherapy courses are given with palliative intent.  Pain associated with direct tumor involvement is the most common cause of cancer pain, occurring in as many as 85% of patients as reported in a pain service study, to 65% as demonstrated by an outpatient cancer center pain clinic survey. In advanced bronchogenic carcinoma, more than 70% of patients have dyspnoea, chest pain and hemoptysis. Palliative radiotherapy can effectively reduce chest pain and haemoptysis as well as dysphagia and dyspnoea.  Some patients with locally advanced cervical cancer are suitable only for palliative treatment aimed primarily at symptom control of bleeding. Colorectal carcinoma represents 15% of all malignant tumors, about 40% occurring in the rectal area. One palliative treatment method is external radiotherapy for control of pain. In a palliative setting, The schedule of 20 Gray (Gy) over five fractions has been proven to give a good palliative effect.  However, the new schedule of 10 Gy as weekly doses for two fractions has not been tried.  Most of the RT centres are busy with long waiting list. Hence once a week will be more convenient and economical if proven to be effective as prolong RT course of 10 to 15 days. As most patients are terminally ill and expected to survive a few months only, the weekly schedule will be more convenient and effective.  The present study compares 10 Gy as weekly dose for two fractions with 20 Gy over five fractions, five treatment days a week.
| Materials and Methods|| |
The study is an experimental/interventional study. It is randomized into two armed clinical trial conducted in the department of Radiotherapy, RIMS, Imphal, Manipur for one and half years from 1st September 2010 to 29th February 2012. The study population comprised of 60 patients who were histopathologically confirmed lung, cervix and rectal cancers. Only those patients with dyspnea in lung cancer, with bleeding in cervical cancer, with pain in rectal cancers, having a Karnofski's performance status  of ≥50%, with adequate hematological functions and age more than 12 years but less than 80 years were included in the study. The eligible patients were randomized into two arms, Arm A and Arm B with a 1:1 randomization, consisting of 30 patients in each arm; 10 patients for lung cancer, 10 for cervical cancer and another 10 for rectal cancer for each arm. Patients in Arm A were prescribed tumor dose of 20 Gy over five fractions (that is 400 cGy per fractions) and the patients in Arm B were prescribed tumor dose of 10 Gy as weekly dose for two fractions to the affected site. Assessment of pain was done by subjective and objective measures, using Verbal Rating Scale.  Bleeding was assessed clinically by using World Health Organization (WHO) standardized Bleeding Scale.  Dyspnoea was assessed and graded by American Thoracic Society Scale Statistical analysis was done to know if any significance exists between the two different fractionation radiation dose schedules.
| Results|| |
Mean symptom scores are depicted in [Table 1]a-d for both arms P-values for mean dyspnea grade of Ca. Lung is highly significant in study arm at with Ps < .0003 at 95% confidential limit. Both the reduction of the pain score and analgesic score of Ca. Rectum is also significant at 95% confidential limit. However for Ca. Cervix control of bleeding is not significant. Acute radiation toxicities were found to be uniformly increased but of mild nature grade 1 in arm B and were managed with simple medication of antibiotics and nutritional support [Table 2]a-c. The observation data are not shown as the toxicities are mild and of little consequence in the treatment protocol. Late radiation Toxicity are not included in the study as the patients survival period was short.
| Discussion|| |
For lung cancer the mean dyspnea grade in both treatment arms showed improvement from week 0-12, indicating adequate palliation. There was a significant difference in the mean dyspnea grade, with better grades in Arm B [Table 1]a. For rectal cancer the mean pain scores in both treatment arms showed improvement from week 0-12, indicating adequate palliation. There was a significant difference in the mean pain score, with better scores in Arm B (10 Gy weekly into two fractions) [Table 1]b. There was a significant difference in the mean analgesic score, with better scores in Arm B [Table 1]c. For cervix cancer the mean bleeding grade in both treatment arms showed improvement from week 0-12, indicating adequate palliation. There was a significant difference in the mean bleeding grade, with better grade in Arm B [Table 1]d. The onset of dyspnoea relief and pain relief for both lung and rectal cancers were found to occur within a week in both arms indicating adequate palliation as defined for the purpose of this study. For cervix cancer the onset of bleeding relief occurred within 2 weeks for both arms. 90% in Arm A were relieved in the first week whereas 80% were relieved in Arm B. The difference in onset is not statistically significant [Table 1]d. The duration of dyspnoea relief for lung cancer were more than 12 weeks in Arm A (40%) whereas in Arm B, 80% were relieved for more than 12 weeks, indicating adequate palliation. For rectal and cervix cancer the duration of symptom relief in both arms were more than 12 weeks, indicating adequate palliation. Our finding agrees with similar studies ,, using large dose fraction size which yields adequate symptom relief without increasing toxicity significantly. The duration of the relief of symptom is also adequate as the patients survival period is short.
| Conclusion|| |
Thus, our conclusion is that 10 Gy into two fractions once a week gives better symptom palliation than 20 Gy over five fractions in advanced solid tumours like lung, rectal and cervix cancers, for a follow-up period of 12 weeks. However, it also gives more acute toxicity but this is not significant and of low grade which can be managed with simple medication.
| References|| |
Kirkbride P, Bezjak A. Palliative Radiation Therapy. In: Berger AM, Portenoy RK, Weisman D, editors. Principles and practice of Palliative Care and Supportive Oncology. 2 nd
ed. Philadelphia Walnut Street: Lippincott Williams and Wilkins; 2002. p. 685-7.
Abernathy A, Foley KM. Management of Cancer Pain. In: DeVita VT, Lawrence TS, Rosenberg SA, editors. Cancer Principles & Practice of Oncology. 9 th
ed. Philadelphia: Lippincott Williams and Wilkins; 2011. p. 2426.
Mohanti BK, Sharma DN, Lal P, Biswal. Palliative Therapy. In: Rath GK, Mohanti BK, editors. Textbook of Radiation Oncology, Principles and Practice. 1 st
ed. New Delhi: Elsevier; 2007. p. 748.
van Den Hout WB, Kramer GW, Noordijk EM, Leer JW. Cost-utility analysis of short-versus long-course palliative radiotherapy in patients with non-small-cell lung cancer. J Natl Cancer Inst 2006;98:1786-94.
Halle JS, Rosenman JG, Varia MA, Fowler WC, Walton LA, Curie JL. 1000 cGy single dose palliation for advanced carcinoma of the cervix or endrometrium. Int J Radiat Oncol Biol Phys 1986;12:1947-50.
Mishra SK, Laskar S, Muckaden MA, Mohindra P, Shrivastava SK, Dinshaw KA. Monthly palliative pelvic radiotherapy in advanced carcinoma of uterine cervix. J Cancer Res Ther 2005;1:208-12.
Lutz ST, Chow EL, Hartsell WF, Konski AA. A review of hypofractionated palliative radiotherapy. Cancer 2007;109:1462-70.
[Table 1], [Table 2]