Current Issues

INTERNATIONAL CONSENSUS CONFERENCE
ON PALLIATIVE RADIATION THERAPY

3rd ESTRO Forum 2015
Centre de Convencions International de Barcelona (CCIB), Barcelona, Spain
1445h-1745h Friday 24th April 2015, Room 130

MINUTES

Chair

Peter Hoskin

Attendees (alphabetical)

Andrea Bezjak andrea.bezjak@rmp.uhn.ca
Antonio J Conde antoniojconde@gmail.com
Kristopher Dennis krdennis@toh.on.ca
Alysa Fairchild alysa@ualberta.ca
Matthias Guckenberger matthias.guckenberger@usz.ch
Carol Hahn carol.hahn@duke.edu
Tanya Holt tanyaholt@me.com
Peter Hoskin peterhoskin@nhs.net
Morten Høyer hoyer@aarhus.rm.dk
Mary Job mary.job@health.qld.gov.au
Isabel Linares ilg686@hotmail.com
Simon Lo simonsmlo@gmail.com
Stephen Lutz slutz@bvha.org
Dirk Rades rades.dirk@gmx.net
Daniel Roos daniel.roos@health.sa.gov.au
May Tsao may.tsao@sunnybrook.ca
Joel Yasney kodwoahen@gmail.com

Welcome

• Peter Hoskin welcomed attendees to the conference

Introductions

• Attendees introduced themselves and shared contact information

Summary of previous conferences and plans for future conference

• Peter Hoskin reminded attendees of the history behind the previous conferences and the agenda for the present conference.
• The first conference was in Washington in 1990, the second in London in 2000, the 3rd in San Diego in 2010.
• The goals of the conferences have been to generate consensus statements for the management of advanced and metastatic disease with RT after reviewing the published literature. The statements have been influenced by RT efficacy, effectiveness, toxicity and quality of life impact, international patterns of practice and treatment philosophies, and economic factors.
• The present conference will allow for discussion and updates on the management with RT of thoracic lung cancer, bone metastases, liver metastases and brain metastases.
• Kristopher Dennis confirmed that CARO leadership support hosting the next conference in 2020. A location for that meeting will likely be set in the next month. The hope is that a major centre will be chosen as this will make travel easier for international attendees. Kristopher Dennis and May Tsao would work to organise this conference

Update on the Society for Palliative Radiation Oncology (SPRO)

• Stephen Lutz provided an update on the newly formed SPRO.
• SPRO was founded in 2014 and has brought together dozens of individuals from a multidisciplinary background in order to advance the practice of palliative RT.
• SPRO has an overall leadership structure with a single representative from each of the ASTRO, ESTRO, CARO, RANZCR organisations. The three main SPRO committees: Research, Education, Advocacy, are likewise led by a leadership structure with a single representative from each of the same organisations.
• The overall immediate operational goals are to create a website (under construction: www.spro.org), obtain administrative support and solicit memberships
• The committees are presently exploring specific goals, member interests, research opportunities and models of cooperation.
• Topics of discussion included:
• Encouraging communication between SPRO and other organisations such as ASTRO, ESTRO, CARO, RANZCR, MASCC, ASCO, or smaller colleges and groups within these organisations, perhaps through formal memorandums of understanding
• Exploring how goals of SPRO might interdigitate with other organisation priorities
• Expanding membership to include more radiation therapists, nurses, palliative care- and other specialists with shared interests
• The potential for a membership fee to support administration

Thoracic

• Andrea Bezjak led the update and discussion on palliative thoracic RT for lung cancer
• The 2010 conference and related work were reviewed, including the consensus statement, international practice survey and the ASTRO clinical practice guideline.
• A Norwegian trial published since the last consensus statement was reviewed. It involved patients with lower performance status and Stage III disease undergoing non-curative treatment. Results suggested a benefit to combining RT and chemotherapy in terms of survival and HRQoL. Discussion ensued about design elements and limitations to the study, RT contamination in the chemotherapy alone arm, whether to incorporate this data into the consensus statements, the role of concurrent vs. sequential RT and chemotherapy, other studies examining the combination of these therapies and the heterogeneity of patients falling under the umbrella of Stage III disease.
• The recent Cochrane analysis on palliative RT for non-small cell lung cancer was reviewed.
• Discussion ensued about how large data sources could help to describe the patterns of practice for patients undergoing palliative thoracic RT for lung cancer, and aid in the design and data capture for prospective cohort studies using pragmatic designs to capture important symptom and QoL outcomes. Efforts to make data capture more uniform across centres in the US is currently ongoing and was cited as an example of relevant cooperation. Potential patient groups for study in such studies were suggested to be those with early vs. late Stage III disease, patients with poor estimated survival, oligometastatic disease.
• Superior vena cava compression was discussed and the general feeling was that the window for studying this entity has likely passed as it is less of an urgent priority for radiation oncologists in the day to day management of patients.
• An ongoing study of external beam RT +/- brachytherapy in Hamilton, Canada was discussed.
• It was acknowledged that future studies in palliative RT for thoracic lung cancer will need to incorporate designs that allow for highly-conformal RT, reflecting changes in practice. The role of SBRT/SABR is likely to be defined more in the coming years but data does not support any specific mention otherwise for the present consensus statements.
• Andrea Bezjak was to prepare her presentation for the following day’s meeting. It was agreed upon that the consensus statements would not vary much from those from 2010.

Brain

• Dirk Rades and May Tsao led the update and discussion on palliative RT for brain metastases
• The 2010 conference and related work were reviewed.
• A lot of new data has come forth since the last meeting, perhaps creating more new questions than answers
• Studies employing the use of hippocampal sparing were discussed.
• Studies employing the use of memantine and other systemic agents were discussed.
• It was thought that the use of both hippocampal sparing and memantine may indeed be useful in the future but that at present it is not possible to describe them as standard of care
• One of the challenges moving forward with new trials will be creating appropriate control arms when evaluating new therapies
• It was suggested that the present NCCN guidelines are vague about when SBRT alone is ‘appropriate’
• The recent meta-analysis by Sahgal was discussed
• It was discussed how future trials attempting to define the role of SBRT would be helped by a tool that could better predict the risk of distant in-brain failure following localized treatment. Exploring neurosurgical registries was thought to be a possible source of data looking in to this.
• Other themes that require future study in coming years are integrated boosts with whole brain RT, post-operative cavity RT
• Dirk Rades was to prepare his presentation for the following day’s meeting. It was generally agreed upon that since the last meeting there are many new questions and options for patient management (ideally within the confines of clinical trials), but that it is difficult to state that any treatment recommendations considered standard of care have convincingly changed.

Liver

• Morten Høyer led the update and discussion on palliative RT for liver metastases
• The 2010 conference work was reviewed.
• After the 2010 conference a review paper and practice patterns survey were conducted.
• There are many single institution studies and phase II trials, but no randomized data.
• Many ongoing trials now are found on clinicaltrials.gov – a lot of these are attempting to better define the role of SBRT
• One of the challenges identified in conducting these trials is reluctance from surgical and interventional radiology departments to cooperate
• The upcoming phase III trial of whole liver RT vs. best supportive care for patients with liver metastases and advanced HCC from the NCIC CTG was discussed.
• Qualitative work to define clinically-meaningful symptom relief levels among patients with liver metastases was suggested to be a useful avenue for study prior to the next meeting.
• Cooperation and use of multi-institutional registries was encouraged.
• Morten Høyer was to prepare his presentation for the following day’s meeting.

Bone

• Stephen Lutz led the update and discussion on palliative RT for bone metastases
• The 2010 conference work was reviewed.
• The ASTRO practice guideline became the most downloaded article from IJROBP in 2011, and the work has also been incorporated as a US National Quality Forum measure and into the Consumer Reports Choosing Wisely campaign.
• Since the last meeting a number of important studies have been published
• The NCIC CTG SC20 study demonstrated that reirradiation for bone metastases can be effective
• The re-analysis of RTOG 97-14 demonstrated no significant long-term consequences of vertebral irradiation
• A definition of what constitutes an ‘uncomplicated’ bone metastasis based on eligibility criteria from previous randomized studies
• The term ‘complicated’ bone metastasis requires clarification. Some practitioners consider any amount of soft tissue component extending beyond the normal confines of the bone as evidence of a complicated metastasis that should not be treated with single fraction RT. The fact that many of these lesions were included within prior randomised studies and responded well to single fraction therapy was discussed, as well as the marked heterogeneity in soft tissue components from lesion to lesion.
• The use of SBRT for vertebral metastases is increasing but there is still no randomized data supporting its use outside of a clinical trial. The progress of the ongoing RTOG trial was discussed.
• A number of new systemic agents are in greater use now compared to the time of the last meeting. Neither their use, nor the use of previous systemic agents, nor local surgical/interventional procedures obviate the need for external beam RT to palliate painful bone metastases.
• The use of highly conformal RT beyond SBRT needs to be evaluated. Work towards defining an acceptable CTV for bone metastases is an avenue for further consensus and validation work.
• An update to the ASTRO practice guideline is expected in the coming year
• Stephen Lutz was to prepare his presentation for the following day’s meeting.

Thank you to Kris Dennis for collecting the minutes for this meeting.