Page 317 Guide to Pain Management in Low-Resource Settings

Cytoreductive Radiation Th erapy 305

may be noted if the bowels or the stomach are involved. breast cancer) and if the life expectancy due to
Supportive treatment with antiemetics or antidiarrheal the whole tumor situation could be some months
agents might be indicated symptomatically. Th e side ef- or longer.
fects tend to come on gradually through the treatment • Tumor-related pain combined with a short life
course and may last for a week or two after the treat- expectancy should be treated with analgesics
ment has fi nished. only. Th e time and eff ort in terms of travel and
accommodation for the radiotherapy treatment,

What about radiotherapy for locally the costs, the technical complexity of the radio-
advanced tumors and metastases in therapy must be balanced against the benefi t (e.g.,
osteoblastic metastases of a prostate carcinoma
soft tissues and organs? or presacral recurrent rectal carcinoma).

• Radiotherapy has been a mainstay in the pallia-
As in the case of pain due to bone metastases, radio-
tion of symptomatic metastatic prostate cancer
therapy is eff ective in tumor-related pain due to visceral
and is most often used for palliation of painful
recurrences and metastases. Besides all direct tumor-
metastatic bone lesions, resulting in a relief of
associated pain from locally extended and nerve-infi l-
pain in about 80–90% of patients and therefore
trating situations, indications include pelvic pain due
reduced dependence on analgesics.
to recurrent non-operable rectal cancer or cancer of
• Palliative radiotherapy of bone metastases is
the cervix. In this palliative situations, marked pain re-
very eff ective and should be applied with a single
lief may be achieved with only minor shrinkage of the
dose of 8 Gy in most patients as multifraction
pelvic mass. In patients with pelvic pain, 70% had relief
regimens do not off er relevant better pain relief.
after irradiation.
More protracted schedules should be used in pal-
Th e prescribed dose of palliative radiotherapy has to
liative situations with a life expectancy of more
be adjusted to the individual situation and the organs at
than 6 months as the rates of retreatment and
risk. Schedules mostly used are single-dose treatments
pathological fractures are reduced.
of 8 Gy, or hypofractionated regimens with total doses
from 20 to 30 Gy.
For pelvic masses, equal responses are obtained References
from 30 Gy in 10 fractions and from 20 Gy in fi ve
[1] Bese NS, Kiel K, El-Gueddari Bel-K, Campbell OB, Awuah B, Vikram
fractions, given at four fractions per week. Opposed B; International Atomic Energy Agency. Radiotherapy for breast cancer
portals are used most often; multiple portals should in countries with limited resources: program implementation and evi-
dence-based recommendations. Breast J 2006;12:S96–102.
be considered if the anteroposterior diameter is great- [2] Bodei L, Lam M, Chiesa C, Flux G, Brans B, Chiti A, Giammarile F; Eu-
er than 22 cm and photons of higher energy (10 MV) ropean Association of Nuclear Medicine (EANM). EANM procedure
guideline for treatment of refractory metastatic bone pain. Eur J Nucl
are unavailable. Med Mol Imaging 2008;35:1934–40.
[3] Fine PG. Palliative radiation therapy in end-of-life care: evidence-based
utilization. Am J Hospice Pall Care 2002;19:166–70.
[4] Souchon R, Wenz F, Sedlmayer F, Budach W, Dunst J, Feyer P, Haase W,
Pearls of wisdom Harms W, Sautter-Bihl ML, Sauer R; German Society of Radiation On-
cology (DEGRO). DEGRO practice guidelines for palliative radiothera-
py of metastatic breast cancer: bone metastases and metastatic spinal
• Painful complications of cancer, such as bone cord compression (MSCC). Strahlenther Onkol 2009;185:417–24.
pain, should be amenable to radiotherapy, if the [5] Wu JS, Wong RK, Lloyd NS, Johnston M, Bezjak A, Whelan T; Sup-
portive Care Guidelines Group of Cancer Care Ontario. Radiotherapy
pain is anatomically localized and not diff use, fractionation for the palliation of uncomplicated painful bone metasta-
so that a target for radiotherapy can be defi ned ses—an evidence-based practice guideline. BMC Cancer 2004;4:71.
(e.g., single painful osteolytic metastasis following