Clinical Oncology (1992) 4:272 © 1992 The Royal College of Radiologists
Clinical Oncology
Correspondence Letters are publbhed at the d&cretion of the Editor. Opinions expressed by correspondents are not necessarily those of the Editor. Unduly long letters may be returned to the authors for shortening. Letters in response to a paper may be sent to the author of the paper so that the reply can be published in the same issue. Letters should be typed double spaced and should be signed by all authors personally. References should be given in the style specified in the Instruction to Authors at the front of the Journal.
Ondansetron and Radiotherapy SIR I read with interest the letter from Dr Roberts [1] describing the effective use of oral ondansetron to control the side effects of abdominal irradiation. Three of the patients he describes were having prophylactic radiation for Stage I seminoma, all apparently receiving a 200 cGy mid-point dose daily. He records severe side effects in each case, refractory to conventional antiemetics, but does not mention the simple expedient of reducing the daily dose rate. A reduction of daily dose rate of 10%-25% is often effective unless the patients are in the therapeutic straight jacket of a clinical trial or rigid departmental policy. In the past 6 months, I have seen three patients with seminoma who had strong personal or social reasons why they must not experience side effects. Each was treated with a modified regime using a daily fraction size of 150 cGy mid-plane dose. -
throughout treatment and experienced only tiredness during the last week.
-
Patient 1. A 25-year-old single man had Stage I seminoma and was booked to have prophylactic radiotherapy to para-aortic and right iliac nodes. He was a civil engineer involved with complex site management of several major projects. He was also due to give his sister away at her wedding the week after completing radiotherapy. He requested that he should not have any major side effects. He received 3000 cGy TD in 20 fractions over 4 weeks on a 6MV linear accelerator. He worked throughout most of his treatment course, had no nausea and vomiting at any stage and required no antiemetics. In the final week he had an acute stress reaction and took a day off work. He made an uneventful recovery and completed his various duties. Patient 2. A 34-year-old married man who was a self-employed computer consultant had Stage I seminoma of the right testis. He had declined to enter a clinical trial comparing radiotherapy and chemotherapy. He again requested minimal disruption to his life and business during radiotherapy. He received 3000 cGy in 20 fractions over 4 weeks, which he tolerated well with no sickness, an almost normal appetite and required no antiemetics. He worked
Patient 3. A 50-year-old married man with a Stage I seminoma of the right testis was a self-employed design engineer, He was so concerned about the threat of losing his job during the recession that he was prepared to decline prophylactic radiotherapy if he had severe side effects. He was treated in a similar fashion at 150 cGy TD per day. He was given a supply of prophylactic metoclopramide but did not take them. He had no nausea or vomiting. He had colicky abdominal pains and also mild looseness of the bowels in the last week which was controlled with a low roughage diet. He worked throughout treatment.
None of these patients suffered any significant side-effects of radiation therapy. I accept that the total NSD was slightly lower and the total number of fractions increased by five. I may have been able to achieve the same with only a 10% dose reduction per fraction. A single dose of oral ondansetron 8 mg taken before each treatment may have been effective. The point I am making is that in the UK the trend towards fewer fractions, and the problems of limited machine capacity and standardizing treatment regimens should not alter good clinical practice. A highly effective antiemetic should not excuse a policy of inflexible fractionation. D. TONG
Guy's Hospital London
References
1. Roberts JT. Ondansetron in the control of refractory emesis following radiotherapy. Clin Oncol 1992;4:67-68. Dr Tong's letter was shown to Dr Roberts, who replied as follows: Ondansetron and Radiotherapy
S~R - The three patients referred to in my letter [1] were indeed receiving radiotherapy in the current MRC clinical trial, comparing prophylactic para-aortic irradiation
with conventional 'dog leg' fields. In accordance with the trial protocol they were prescribed a mid-point dose of 200 cGy daily. I would agree with Dr Tong that the incidence of nausea and vomiting following abdominal irradiation is related to daily dose, among other factors. It is my experience that a lower daily dose, for example the 150 cGy daily that he suggests, is associated with a lower incidence of nausea and vomiting. Nevertheless, as the following case illustrates, the 10%-25% dose reduction suggested by Dr Tong by no means guarantees an absence of these side-effects. A 53-year-old man with Stage I seminoma of the right testis was prescribed 30 Gy in 20 fractions over 4 weeks to paraaortic and right iliac lymph nodes. Despite three different antiemetics (metoclopramide, prochlorperazine and domperidone) prescribed sequentially, he suffered profound nausea and vomiting, was unable to work and refused to continue radiotherapy beyond seven fractions (total dose 1050 cGy). He has been followed closely in the 67 months since his radiotherapy and has shown no sign of recurrence. Had a 5-HT3 receptor antagonist been available at the time of this man's treatment, it may have been possible to continue to the intended treatment dose. For patients, such as those described by Dr Tong, with 'strong personal or social reasons why they must not experience side effects', even the low dose of radiation suggested may not offer this guarantee. Surveillance, as suggested by the Royal Marsden group [2] is an alternative which should be offered to such patients. J. T. ROBERTS Newcastle General Hospital Newcastle References
1. Roberts JT. Ondansetron in the control of refractory emesis following radiotherapy. Clin Oncol 1992;4:6%68. 2. Duchesne GM, Horwich A, Dearnaley D, et al. Orchiectomy alone for Stage I seminoma of the testis. Cancer 1990;65:1115-8.
Clinical Oncology
Correspondence Letters are publbhed at the d&cretion of the Editor. Opinions expressed by correspondents are not necessarily those of the Editor. Unduly long letters may be returned to the authors for shortening. Letters in response to a paper may be sent to the author of the paper so that the reply can be published in the same issue. Letters should be typed double spaced and should be signed by all authors personally. References should be given in the style specified in the Instruction to Authors at the front of the Journal.
Ondansetron and Radiotherapy SIR I read with interest the letter from Dr Roberts [1] describing the effective use of oral ondansetron to control the side effects of abdominal irradiation. Three of the patients he describes were having prophylactic radiation for Stage I seminoma, all apparently receiving a 200 cGy mid-point dose daily. He records severe side effects in each case, refractory to conventional antiemetics, but does not mention the simple expedient of reducing the daily dose rate. A reduction of daily dose rate of 10%-25% is often effective unless the patients are in the therapeutic straight jacket of a clinical trial or rigid departmental policy. In the past 6 months, I have seen three patients with seminoma who had strong personal or social reasons why they must not experience side effects. Each was treated with a modified regime using a daily fraction size of 150 cGy mid-plane dose. -
throughout treatment and experienced only tiredness during the last week.
-
Patient 1. A 25-year-old single man had Stage I seminoma and was booked to have prophylactic radiotherapy to para-aortic and right iliac nodes. He was a civil engineer involved with complex site management of several major projects. He was also due to give his sister away at her wedding the week after completing radiotherapy. He requested that he should not have any major side effects. He received 3000 cGy TD in 20 fractions over 4 weeks on a 6MV linear accelerator. He worked throughout most of his treatment course, had no nausea and vomiting at any stage and required no antiemetics. In the final week he had an acute stress reaction and took a day off work. He made an uneventful recovery and completed his various duties. Patient 2. A 34-year-old married man who was a self-employed computer consultant had Stage I seminoma of the right testis. He had declined to enter a clinical trial comparing radiotherapy and chemotherapy. He again requested minimal disruption to his life and business during radiotherapy. He received 3000 cGy in 20 fractions over 4 weeks, which he tolerated well with no sickness, an almost normal appetite and required no antiemetics. He worked
Patient 3. A 50-year-old married man with a Stage I seminoma of the right testis was a self-employed design engineer, He was so concerned about the threat of losing his job during the recession that he was prepared to decline prophylactic radiotherapy if he had severe side effects. He was treated in a similar fashion at 150 cGy TD per day. He was given a supply of prophylactic metoclopramide but did not take them. He had no nausea or vomiting. He had colicky abdominal pains and also mild looseness of the bowels in the last week which was controlled with a low roughage diet. He worked throughout treatment.
None of these patients suffered any significant side-effects of radiation therapy. I accept that the total NSD was slightly lower and the total number of fractions increased by five. I may have been able to achieve the same with only a 10% dose reduction per fraction. A single dose of oral ondansetron 8 mg taken before each treatment may have been effective. The point I am making is that in the UK the trend towards fewer fractions, and the problems of limited machine capacity and standardizing treatment regimens should not alter good clinical practice. A highly effective antiemetic should not excuse a policy of inflexible fractionation. D. TONG
Guy's Hospital London
References
1. Roberts JT. Ondansetron in the control of refractory emesis following radiotherapy. Clin Oncol 1992;4:67-68. Dr Tong's letter was shown to Dr Roberts, who replied as follows: Ondansetron and Radiotherapy
S~R - The three patients referred to in my letter [1] were indeed receiving radiotherapy in the current MRC clinical trial, comparing prophylactic para-aortic irradiation
with conventional 'dog leg' fields. In accordance with the trial protocol they were prescribed a mid-point dose of 200 cGy daily. I would agree with Dr Tong that the incidence of nausea and vomiting following abdominal irradiation is related to daily dose, among other factors. It is my experience that a lower daily dose, for example the 150 cGy daily that he suggests, is associated with a lower incidence of nausea and vomiting. Nevertheless, as the following case illustrates, the 10%-25% dose reduction suggested by Dr Tong by no means guarantees an absence of these side-effects. A 53-year-old man with Stage I seminoma of the right testis was prescribed 30 Gy in 20 fractions over 4 weeks to paraaortic and right iliac lymph nodes. Despite three different antiemetics (metoclopramide, prochlorperazine and domperidone) prescribed sequentially, he suffered profound nausea and vomiting, was unable to work and refused to continue radiotherapy beyond seven fractions (total dose 1050 cGy). He has been followed closely in the 67 months since his radiotherapy and has shown no sign of recurrence. Had a 5-HT3 receptor antagonist been available at the time of this man's treatment, it may have been possible to continue to the intended treatment dose. For patients, such as those described by Dr Tong, with 'strong personal or social reasons why they must not experience side effects', even the low dose of radiation suggested may not offer this guarantee. Surveillance, as suggested by the Royal Marsden group [2] is an alternative which should be offered to such patients. J. T. ROBERTS Newcastle General Hospital Newcastle References
1. Roberts JT. Ondansetron in the control of refractory emesis following radiotherapy. Clin Oncol 1992;4:6%68. 2. Duchesne GM, Horwich A, Dearnaley D, et al. Orchiectomy alone for Stage I seminoma of the testis. Cancer 1990;65:1115-8.
