Palliative radiotherapyBMJ 2018; 360 doi: https://doi.org/10.1136/bmj.k821 (Published 23 March 2018) Cite this as: BMJ 2018;360:k821
All rapid responses
We were delighted to read this excellent review of palliative radiotherapy targeted at GPs (1).
However, its last learning point read “For patients in the final weeks of life… holistic palliative care may be more appropriate”.
This may mislead your readers as it is not one or the other. It is well established that patients should be offered both holistic palliative care and disease modifying treatments such a palliative radiotherapy integrated from diagnosis of life-threatening illness (2, 3). We know few patients request generalist palliative care while they are receiving palliative radiotherapy. As GPs we may find raising palliative care challenging due to the current stigma of palliative care, even when the patients know they are getting “palliative radiotherapy”.
A major side effect or opportunity-loss of specific palliative treatments is failure to embrace palliative care early when support for all dimensions of need may be timely and prevent distress. We identified this as an important issue in in-depth studies with patients and their carers with lung, brain and bowel cancer (4-6). We are currently embarking on a Macmillan funded study of early generalist palliative care by GPs triggered by starting palliative chemotherapy or radiotherapy to assess if this is feasible and how this might be best started.
Surely all patients receiving specific palliative treatments should also be offered holistic palliative care early on by their primary care team or relevant hospital specialist. So if you are thinking of referring for palliative radiotherapy, think also of holistic palliative care to embrace all dimensions.
Scott A. Murray, Debbie Cavers, Emma Carduff and Sebastien Moine
1. Spencer K, Parrish R, Barton R, Henry A. Palliative radiotherapy. BMJ. 2018;360:k821.
2. Murray SA, Kendall M, Boyd K, Sheikh A. Illness trajectories and palliative care. BMJ. 2005;330(7498):1007-11.
3. (WHO) WHA. Strengthening of palliative care as a component of integrated treatment within the continuum of care: WHO; 2014 May 2014.
4. Murray SA, Boyd K, Kendall M, Worth A, Benton TF, Clausen H. Dying of lung cancer or cardiac failure: prospective qualitative interview study of patients and their carers in the community. BMJ. 2002;325(7370):929.
5. Cavers D, Hacking B, Erridge S, Kendall M, Morris P, Murray S. Social, psychological and existential well-being in patients with glioma and their caregivers: a qualitative study. Canadian Medical Association Journal. 2012;184:373-82.
6. Carduff E, Kendall M, Murray SA. Living and dying with metastatic bowel cancer: Serial in-depth interviews with patients. European Journal of Cancer Care (Engl). 2017.
Competing interests: No competing interests
Palliative radiotherapy remains the gold standard treatment for painful bone metastases in all cancers including prostate cancer.1 Evidence supporting the analgesic effect of bisphosphonates is limited, of low quality and mostly supported by trials involving patients with breast cancer and myeloma.2-5
The authors state that, “[intravenous bisphosphonates] may be an alternative for patients with prostate cancer naïve to bisphosphonates.”6 However, the evidence suggests that intravenous bisphosphonates should be reserved for patients with painful bone metastases from any cancer who are unable to receive palliative radiotherapy or whose pain has not responded to (retreatment with) radiotherapy, and are naïve to bisphosphonates or denosumab.7-9
1. Chow E, Zeng L, Salvo N, Dennis K, Tsao M, Lutz S. Update on the systematic review of palliative radiotherapy trials for bone metastases. Clin Oncol (R Coll Radiol) 2012;24:112-24. doi:10.1016/j.clon.2011.11.004 pmid:22130630
2. Wong R and Wiffen PJ. Bisphosphonates for the relief of pain secondary to bone metastases. Cochrane Database Systematic Reviews 2002; 2: CD002068.
3. Groff L et al. The role of disodium pamidronate in the management of bone pain due to malignancy. Palliative Medicine 2001; 15: 297–307.
4. Kretzschmar A et al. Rapid and sustained influence of intravenous zoledronic Acid on course of pain and analgesics consumption in patients with cancer with bone metastases: a multicenter open-label study over 1 year. Supportive Cancer Therapy; 2007. 4: 203–210.
5. O’Carrigan et al. Bisphosphonates and other bone agents for breast cancer. Cochrane Database of Systematic Reviews; 2017. 10: CD003474.
6. Spence K, Parrish R, Barton R and Henry A. Palliative Radiotherapy. BMJ 2018;360:k821
7. Chow E, van der Linden Y, Roos D, et al. Single versus multiple fractions of repeat radiation for painful bone metastases: a randomized, controlled, noninferiority trial. Lancet Oncol. 2014;15:164–171.
8. Hoskin P, Sundar S, Reczko K, et al. A multicenter randomized trial of ibandronate compared with single-dose radiotherapy for localized metastatic bone pain in prostate cancer. J Natl Cancer Inst 2015;107:djv197. doi:10.1093/jnci/djv197 pmid:26242893
9. Van Poznak C et al. Role of bone-modifying agents in metastatic breast cancer: An American society of clinical oncology-cancer care Ontario Focused Guideline Update. Journal of Clinical Oncology 2017; 35: 3978-3986.
Competing interests: No competing interests