,nr. J Radiation
0
Onrology
Bid.
Phys., 1977, Vol. 2. pp. 1223-1224.
Pergamon Press
Printed in the U.S.A
Editorial
PALLIATION
Chairman,
OF CEREBRAL
METASTASES
FRANK R. HENDRICKSON, M.D. IDepartment of Therapeutic Radiology, Rush-Presbyterian-St. Luke’s Medical Center 1753 West Congress Parkway, Chicago, IL 60612, U.S.A. Cerebral. Metastases. Palliation, Irradiation.
The article by Doctors Harwood and Simpson4 entitled, “Radiation Therapy of Cerebral .Metastases: A Randomized Prospective Clinical Trial”, in this issue develops several provocative general points concerning palliation of metastatic sites in general, and of brain metastases in particular. In a well designed prospective study involving just over 100 patients they have compared single increment treatment of 1000 rad with the more standard palliative course of 3000 rad delivered in 2 weeks. They conclude that both treatment programs are highly effective for between half and two-thirds of the patients. The major covariants that predict for survival have related to the primary site of the tumor, (lung cancer is less favorable than the others) and the degree of neurologic deficit present at the time of treatment. Other factors in that have historically been considered important radiation response or prognosis are apparently not of high predictive value. S,ome 21 patients with “slowly responding” tumors lik;e melanomas and adenocarcinemas other than breast both responded and survived as well as the lung cancer and breast cancer patients; this suggests that the specific histology is an unimportant factor in predicting palliative responses. The general survival averaged 14 weeks, which is consistent with numerous other studies.‘.‘” Patients with breast cancer survived about 50% longer than those with lung cancer. The lung cancer patients frequently had brain metastases only, even at the time of death. Patients with breast cancer and cancer from other primary sites frequently had widely disseminated disease in adldition to the brain metastases. The major disquieting aspect of the study was the high frequency with which regrowth of the brain metastases were consid’ered a significant factor in the patients death. This frequency of regrowth and life threatening aspect of brain metastases also was found in the Radiation Therapy Oncology Group (RTOG) studies.233 Unfortunately, there is no evidence that
doses even to the 4000 rad range modify this probability of regrowth significantly, or the significance of brain metastases in the patients longevity. Survival is significantly better when patients are treated with minimal symptoms, but possibly this can be the result of just earlier identification of the problem and not related to a more favorable therapeutic response. Clearly there is need for recognition of the critical life threatening aspects of brain metastases in patients with cancer. Improved control of this site of metastases is needed; it could be forthcoming from either combinations of chemotherapy and radiation therapy, or more serious consideration of prophylactic radiation of the brain in high risk patients such as those with oat cell lung cancer. It is preferable to replace the term, “no statistical difference”, with “the difference is significant to a In this reported study the median certain level”. survival was longer in the single fraction as opposed to the 10 fraction group, with the difference occurring by chance alone only 8 times in 100. The presence of treatment related symptoms of headache, nausea and vomiting occurred more frequently in the single treatment group, and this increase in frequency would occur by chance alone only 1 time in 4. The difference in the survival between the treatment schedules of the (neurologic) functional level I patients was small, and would be expected to occur by chance 19 times out of 20. Clearly none of these differences reach the significance level of having a chance occurrence of only 1 in 20; however, equally clearly differences were observed the significance of which should be judged by the user of the data. In some circumstances highly significant differences (occurring by chance only rarely) may have little clinical value. Conversely, differences that may occur by chance 1 in 5, or 1 in 10 times may have clinical usefulness if the various treatments have logistic or economic benefits. 1223
,.
1224
Radiation
Oncology
0 Biology
0 Physics
November-December
1977, Volume
2, No.
1I and No. 12
REFERENCES I. Chu, F.C.H., Hilaris, B.S.: Value of radiation therapy in the management of intracranial metastases. Cancer 14: 557-581, 1961. therapy of metastatic 2. Hendrickson, F.R.: Radiation tumors. Semin. Oncol. 2: 43-46, 1975. 3. Hendrickson, F.R.: The optimum schedule for palliative radiotherapy of metastatic brain cancer. Znt. J. Radiat. Oncol. Biol. Phys. 2: 165-168, 1977. 4. Harwood, A.R., Simpson, W.J.: Radiation therapy of
cerebral metastases. A randomized prospective clinical trial. Znt. J. Radiat. Oncol. Biol. Phys. 2: 1091-1094. 1977. 5. Hindo, W.A., DeTrana, III, F.A., Lee, M.S., Hendrickson, F.R.: Large dose increment irradiation in treatment of cerebral metastases. Cancer 26: 138-141, 1970. 6. Shehata, W.M., Hendrickson, F.R., Hindo, W.A.: Rapid fractionation technique and retreatment of cerebral metastases by irradiation. Cancer 34: 257-261, 1974.
0
Onrology
Bid.
Phys., 1977, Vol. 2. pp. 1223-1224.
Pergamon Press
Printed in the U.S.A
Editorial
PALLIATION
Chairman,
OF CEREBRAL
METASTASES
FRANK R. HENDRICKSON, M.D. IDepartment of Therapeutic Radiology, Rush-Presbyterian-St. Luke’s Medical Center 1753 West Congress Parkway, Chicago, IL 60612, U.S.A. Cerebral. Metastases. Palliation, Irradiation.
The article by Doctors Harwood and Simpson4 entitled, “Radiation Therapy of Cerebral .Metastases: A Randomized Prospective Clinical Trial”, in this issue develops several provocative general points concerning palliation of metastatic sites in general, and of brain metastases in particular. In a well designed prospective study involving just over 100 patients they have compared single increment treatment of 1000 rad with the more standard palliative course of 3000 rad delivered in 2 weeks. They conclude that both treatment programs are highly effective for between half and two-thirds of the patients. The major covariants that predict for survival have related to the primary site of the tumor, (lung cancer is less favorable than the others) and the degree of neurologic deficit present at the time of treatment. Other factors in that have historically been considered important radiation response or prognosis are apparently not of high predictive value. S,ome 21 patients with “slowly responding” tumors lik;e melanomas and adenocarcinemas other than breast both responded and survived as well as the lung cancer and breast cancer patients; this suggests that the specific histology is an unimportant factor in predicting palliative responses. The general survival averaged 14 weeks, which is consistent with numerous other studies.‘.‘” Patients with breast cancer survived about 50% longer than those with lung cancer. The lung cancer patients frequently had brain metastases only, even at the time of death. Patients with breast cancer and cancer from other primary sites frequently had widely disseminated disease in adldition to the brain metastases. The major disquieting aspect of the study was the high frequency with which regrowth of the brain metastases were consid’ered a significant factor in the patients death. This frequency of regrowth and life threatening aspect of brain metastases also was found in the Radiation Therapy Oncology Group (RTOG) studies.233 Unfortunately, there is no evidence that
doses even to the 4000 rad range modify this probability of regrowth significantly, or the significance of brain metastases in the patients longevity. Survival is significantly better when patients are treated with minimal symptoms, but possibly this can be the result of just earlier identification of the problem and not related to a more favorable therapeutic response. Clearly there is need for recognition of the critical life threatening aspects of brain metastases in patients with cancer. Improved control of this site of metastases is needed; it could be forthcoming from either combinations of chemotherapy and radiation therapy, or more serious consideration of prophylactic radiation of the brain in high risk patients such as those with oat cell lung cancer. It is preferable to replace the term, “no statistical difference”, with “the difference is significant to a In this reported study the median certain level”. survival was longer in the single fraction as opposed to the 10 fraction group, with the difference occurring by chance alone only 8 times in 100. The presence of treatment related symptoms of headache, nausea and vomiting occurred more frequently in the single treatment group, and this increase in frequency would occur by chance alone only 1 time in 4. The difference in the survival between the treatment schedules of the (neurologic) functional level I patients was small, and would be expected to occur by chance 19 times out of 20. Clearly none of these differences reach the significance level of having a chance occurrence of only 1 in 20; however, equally clearly differences were observed the significance of which should be judged by the user of the data. In some circumstances highly significant differences (occurring by chance only rarely) may have little clinical value. Conversely, differences that may occur by chance 1 in 5, or 1 in 10 times may have clinical usefulness if the various treatments have logistic or economic benefits. 1223
,.
1224
Radiation
Oncology
0 Biology
0 Physics
November-December
1977, Volume
2, No.
1I and No. 12
REFERENCES I. Chu, F.C.H., Hilaris, B.S.: Value of radiation therapy in the management of intracranial metastases. Cancer 14: 557-581, 1961. therapy of metastatic 2. Hendrickson, F.R.: Radiation tumors. Semin. Oncol. 2: 43-46, 1975. 3. Hendrickson, F.R.: The optimum schedule for palliative radiotherapy of metastatic brain cancer. Znt. J. Radiat. Oncol. Biol. Phys. 2: 165-168, 1977. 4. Harwood, A.R., Simpson, W.J.: Radiation therapy of
cerebral metastases. A randomized prospective clinical trial. Znt. J. Radiat. Oncol. Biol. Phys. 2: 1091-1094. 1977. 5. Hindo, W.A., DeTrana, III, F.A., Lee, M.S., Hendrickson, F.R.: Large dose increment irradiation in treatment of cerebral metastases. Cancer 26: 138-141, 1970. 6. Shehata, W.M., Hendrickson, F.R., Hindo, W.A.: Rapid fractionation technique and retreatment of cerebral metastases by irradiation. Cancer 34: 257-261, 1974.
