Palliative pelvic radiotherapy of symptomatic incurable rectal cancer – a systematic review

Abstract

Background.Locally advanced and recurrent rectal cancers frequently cause pelvic morbidity including pain, bleeding and mass effect. Palliative pelvic radiotherapy is used to relieve these symptoms and delay local progression. There is no established optimal radiotherapy regimen and clinical practices vary. Our aim was to review the efficacy and toxicity of palliative pelvic radiotherapy of symptomatic rectal cancer and to evaluate different fractionation schedules, based on published literature.Material and methods.Systematic literature searches of Medline, Embase and Cochrane databases were performed through 2011. Studies reporting symptomatic response or quality of life (QOL) after palliative radiotherapy for rectal or rectosigmoid cancer were eligible.Results.Twenty-seven studies were included, of which 23 were retrospective reviews. There were no patient-reported outcomes or QOL assessments. There were large variations in applied radiotherapy regimens. Pooled overall symptom response rate was 75% and positive responses were reported for pain (78%), bleeding and discharge (81%), mass effect (71%) and other pelvic symptoms (72%). Toxicity results were not evaluable.Conclusion.Palliative pelvic radiotherapy for symptomatic rectal cancer appears to provide relief of a variety of pelvic symptoms, although there is no documented optimal radiotherapy regimen in this context. There is inadequate evidence regarding onset, duration and degree of symptom palliation, QOL and associated toxicity with this treatment and prospective studies are therefore needed.

Palliative radiotherapy during the last month of life: Predictability for referring physicians and radiation oncologists

“…Considering that short-course regimens with no or low-grade side effects exist, which often improve symptoms such as pain, dyspnea and hemoptysis, clinicians are wary of withholding a meaningful therapeutic measure for patients with terminal cancer (15)(16)(17)(18). Therefore, prediction tools must not predict short survival times in patients who survive long enough to experience a reduced burden of symptoms, and must also identify the majority of patients will succumb to the disease too early to benefit from the treatment.…”

Palliative pelvic radiotherapy for symptomatic rectal cancer – a prospective multicenter study

“…However, patients with locally recurrent or primarily inoperable RC may still experience a growing pelvic tumor, potentially leading to symptoms, such as pain, obstruction, and hematochezia [2].…”

“…Tumor shrinkage in response to radiotherapy is often not apparent radiologically until several weeks after treatment completion [5]. The radiation dose and degree of tumor response required to palliate different pelvic symptoms is unknown, but a recent systematic review of palliative pelvic radiotherapy (PPRT) of RC found symptomatic improvement across a wide range of treatment schedules [2]. Conventional curative fractionation regimens intended to downstage tumors may not be appropriate in the context of symptom palliation, and there is a need for studies evaluating the effects of palliative radiotherapy [6].…”

“…Studies of PPRT of RC to date are largely outdated and retrospective, and their validity for today's clinical decision making is limited [2]. Questions of optimal application of PPRT with regard to indication, dose and timing within the greater context of palliative oncologic treatment, remain unanswered [2].…”

What is most relevant in preoperative rectal cancer chemoradiotherapy – the chemotherapy, the radiation dose or the timing to surgery?

“…In a systematic review of the literature, the group of authors behind a prospective study exploring the palliative value of external radiation to 30-39 Gy in 3 Gy fractions, could not find an optimal radiation dose or fractionation useful for palliation [44]. In the prospective study, most patients had major symptomatic relief of the treatment [42].…”