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Purpose Our aim was to determine the efficacy and quality of life outcomes of head and neck (HN) stereotactic body radiotherapy (SBRT) in a palliative population with significant proportions of de novo HN tumors not amenable to surgery or protracted course of curative radiotherapy (RT). Methods A retrospective review of a prospective database identified 21 patients with 24 sites that were treated. Patients were treated with intensity modulated RT (IMRT), usually 7–9 static fields with a 2–3-mm margin from gross tumor volume to planning target volume only with no microscopic margin added. Electronic patient records and treatment plans were reviewed. Basic demographic information was collected. The EORTC QLQ-H&N35 questionnaire was the tool used to collect QOL data both pre- and on-treatment fraction 5. Univariate analysis was performed for predictors of local control (LC) and prognostic factors for overall survival (OS). Results A total of 21 patients had 24 sites that were treated. The median age was 87 (range 25–103) and median KPS was 70. The most common histology was squamous cell carcinoma (SCC) 19/24 (79 %), basal cell carcinoma (BCC) 3/24 (16 %), and melanoma (4 %). The median maximal diameter was 3.7 cm (range 1–10 cm). The most commonly treated site was lymph nodes in the neck 13/24 (54 %), skin 8/24 (33 %), 4/24 (16 %) other HN mucosal primary sites. Of the 24 lesions, 17 (71 %) were de novo, without prior treatment and 7/24 (29 %) were recurrent. The most commonly used dose/fraction (fx) was 40 Gy/5 (fx) (range 35/5fx−48/6fx). Of the 24 lesions, 6 (25 %) had complete response, 16/24 (67 %) had partial response, and 2/24 (8 %) had no response. Control was defined as no further progression after treatment. For the entire cohort, LC at 3, 6, and 9 months were 66, 50, and 33 %, respectively. In the de novo group, 2/16 (12.5 %) had local failures with the LC rate of 94, 94, and 87 % at 3 months, 6 months, and 1 year, respectively. In the recurrent group, 4/8 (50 %) had failure with LC rates of 87. 5, 62.5, and 50 % at 3 months, 6 months, and 1 year, respectively. Of the 21 patients, 10 died during follow up, with the OS rate at 3 months, 6 months, and 1 year of 90, 70, and 60 %, respectively. Being defined “de novo” showed a trend toward statistical significance p  = 0.046 for local failure. Overall survival did not show significant difference between de novo and recurrent with a p value of 0.267. No significant prognostic variables for OS were found. Pre-treatment QOL scores for the entire cohort were 53/130 versus 38/130 (lower scores indicating better QOL) scores with a trend toward statistical significance p  = 0.05. Conclusions SBRT is efficacious with improved quality of life within this elderly frail population in the treatment of de novo and recurrent tumors of the head and neck with promising quality of life scores.

Purpose Whole brain radiotherapy (WBRT) is a treatment strategy used commonly to relieve burdensome symptoms and improve quality of life (QOL) in patients with multiple brain metastases. The purpose of this study is to determine changes in fatigue score following WBRT as it is a common symptom experienced in this population. Methods Fatigue and overall QOL scores were collected prospectively in patients for up to 3 months post-WBRT by several questionnaires at different times including the following: Edmonton Symptom Assessment System (ESAS), Brain Symptom and Impact Questionnaire (BASIQ), Spitzer Questionnaire, European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30), EORTC brain module (EORTC QLQ-BN20 + 2), EORTC QLQ-C15-PAL, and Functional Assessment of Cancer Therapy—General (FACT-G). Questionnaires were grouped for analysis by Wilcoxon Signed Rank test according to the scale of ranking into 0–10, 1–4, and 0–4. Results Thirty-six patients were interviewed with the ESAS or BASIQ. The median age was 65 years old, and median Karnofsky Performance Status (KPS) was 70. There was a significant increase in fatigue score from baseline to month 1 ( p  = 0.02), and months 2 and 3 had no significant change. There was a significant correlation between fatigue and overall QOL score at baseline and month 1 ( p  = 0.01, p  < 0.0001), respectively. Two hundred and twenty-eight patients were surveyed with Spitzer, C15-PAL, BN20 + 2, QLQ-C30, or FACT-G. Median age was 64 years old and median KPS was 80. Compared to baseline, fatigue score was significantly higher at month 1 ( p  < 0.0001) and month 2 ( p  = 0.001), with no significant change at month 3. Significant correlation was found between fatigue and overall QOL at baseline, months 1, 2 ( p  < 0.0001), and 3 ( p  = 0.0009). For all groups, there was no significant change in fatigue score between patients with or without dexamethasone (Dx), except for the fatigue changed score of the group with scale 0–4. Conclusions Fatigue was significantly increased from baseline to month 1 in all patients, and most patients experienced no difference in fatigue if they were receiving Dx. Increased fatigue was significantly related with decreased overall QOL.

Purpose The purpose of this study was to determine the incidence of pain flare (PF) in patients receiving spine stereotactic body radiotherapy (SBRT) treated with prophylactic oral dexamethasone (DEX) 1 h before and for 4 days following SBRT. Methods Forty-seven patients were accrued on this prospective observational study. The first cohort of 24 patients was treated with 4 mg, while a second cohort of 23 patients treated with 8 mg of DEX. The Brief Pain Inventory (BPI) was used to score pain and functional interference each day during SBRT and for 10 days following. Comparisons between the 4 and 8 mg cohorts, in addition to our previously reported steroid naïve patients post SBRT ( n  = 41), were also performed. Results The total incidence of PF was 19 % (9/47). The incidence in the 4 and 8 mg cohorts was 25 % (6/24) and 13 % (3/23), respectively, and the difference was not statistically significant ( p  = 0.46). Comparing functional interference, the 4 mg cohort had better profile in walking ability ( p  < 0.005) and relationships with others ( p  < 0.035) compared to the 8 mg cohort. Compared to our previously reported steroid naïve cohort, prophylactic DEX significantly reduced the incidence of PF (68 vs. 19 %, p  < 0.0001, respectively), patients had lower worst pain scores, and improved general activity interference outcome. Conclusion We recommend prophylactic DEX for patients treated with spine SBRT. Our current practice is based on the 4 mg protocol primarily due to the improved functional interference outcomes. A randomized trial is required to finalize the optimal regimen and schedule.

Pain is one major symptom of cancer patients, and many patients receive inadequate management of their cancer pain. Various medications are used to manage cancer pain such as NSAIDs and opioids. For patients whose cancer symptoms are not relieved by commonly available medications, cannabis and cannabinoids emerged as alternative options. Many patients with terminal cancer considering the use of cannabis and cannabinoids to provide pain relief. It is important to objectively appraise cannabinoids efficacy and safety profile in relieving cancer pain before regularly prescribing them to patients. Based on current evidence, the use of cannabinoids in treating cancer pain may be limited to intractable pain which is not fully resolved by opioids. While cannabinoid monotherapy was shown to be efficacious in treating cancer pain, the effective dose is associated with significant adverse effects. Considering the safety profile of cannabis products and availability of effective alternatives, more evidence is needed to justify more widespread use of cannabinoids in treating chemotherapy induced emesis, and cancer-related anorexia and cachexia.

Purpose The purpose of this paper is to determine whether the use of three different statistical methods influences the composition of symptom clusters derived from patients with brain metastases. Materials and methods The dataset previously compiled from 129 brain metastases patients who completed the Spitzer Quality of Life Index (SQLI) and an additional study-designed 17-item symptom questionnaire was employed in this study. Symptom clusters extracted using principal component analysis in our previous study were compared to clusters determined using hierarchical cluster analysis and exploratory factor analysis. Clusters were identified using the three statistical methods at baseline, and at 1, 2, and 3 months following whole brain radiotherapy. Results The number and composition of symptom clusters at each time point varied based on the statistical method employed, despite the use of an identical dataset. However, some domains consistently clustered together, such as activity and daily living from the SQLI items. Of the 17 additional symptoms, memory loss, confusion, and trouble concentrating were always present in the same cluster. Nausea and vomiting also occurred in conjunction regardless of the analytical method employed. Conclusion Symptom clusters vary with respect to occurrence, quantity, and composition based on the statistical method utilized to extract them. Further studies should be conducted to determine an ideal statistical method in order to select the optimal method to employ. The use of a single analytical method is essential for consistency and comparison purposes in future symptom cluster research.

Purpose The purpose of this study was to compare functional interference and pain response outcomes using the Brief Pain Inventory (BPI) for patients treated with palliative radiotherapy to spine versus non-spine bones and determine if dose fractionation was associated with each group’s respective response. Materials and methods Patients treated for painful bone metastases with palliative radiotherapy during May 2003 to June 2007 were analyzed. The BPI was utilized at baseline and monthly for 6 months post-radiation. Pain response was determined using International Bone Metastases Consensus response definitions. Wilcoxon rank–sum test (for continuous variable), Fisher exact test (for categorical value), and two-way analysis of variance were used for comparisons, and a p value of ≤0.05 was considered statistically significant. Results Three hundred eighty-six patients were analyzed, 62% were treated with a single fraction, 38% with multiple fractions. Pain and functional interference scores significantly improved over time in both spine and non-spine sites. At 3 months, 42% of all patients had a partial response, and 25% had a complete response. Location of bone metastases and radiotherapy dose were not predictive factors for pain response nor functional interference following radiation treatment. Conclusion Spine and non-spine bone metastases exhibited similar pain and functional interference improvements over a period of 6 months post-radiotherapy. There were, however, high attrition rates as expected with palliative studies, with approximately half the patients remaining in this study by 3 months and a fifth by 6 months. A single 8 Gy resulted in equal benefits in terms of both pain response and improvement in function.

The aim of this article is to present a review reporting empirically determined symptom clusters in breast cancer patients. We conducted a literature search on symptom clusters in breast cancer patients using PubMed, MEDLINE, EMBASE and CINAHL. Studies examining the presence of predetermined clusters were excluded. The five relevant studies identified were published between 2005 and 2009. The five studies differed from each other by statistical methodology, by the number of symptom clusters produced and by the symptoms comprising the clusters. Symptom clusters extracted between the five studies varied from one to four, while the number of symptoms in a cluster ranged from two to five. One study examining symptom clusters between different patient groups and a second study examining clusters across a time trajectory had certain reproducible clusters comprising similar symptoms. There were no clusters across different studies that contained the same symptoms, although the single symptom of fatigue was present in a cluster in all five studies and depression/psychological distress was noted in four of the studies. Nausea and appetite were the only two symptoms that associated together across three of the five studies; however, they were not the only two symptoms in those clusters. Methodological disparities include different patient populations between and within studies, different statistical methods, varying assessment tools and time points, with the majority of studies employing more than one symptom tool. Although there were common symptoms assessed across the five studies, no common symptom clusters could be derived from these reports. This lack of commonality may result from the disparities in subpopulations of patients, assessment tools, and analytical and methodological approaches. As symptom cluster research continues to develop towards a clearer consensus on guidelines, the findings of symptom clusters may provide clinically valuable information regarding diagnosis, prognostication, prioritizing and managing symptoms in breast cancer patients.

Objective: To provide a review of literature reporting empirically determined symptom clusters in lung cancer patients. Method: We conducted a literature search on symptom clusters in lung cancer patients using MEDLINE, EMBASE and CINAHL. Studies examining the presence of predetermined clusters were excluded. The five relevant studies identified were published between 1997 and 2009. Results: Overall, the five studies reported significantly diverse findings with regards to symptom cluster quantity and composition in lung cancer patients. The number of symptom clusters extracted varied from one to four per study. The number of symptoms in a cluster ranged from two to 11. The only cluster that was consistently identified in two studies was composed of nausea and vomiting symptoms. Respiratory clusters identified in two studies were also comparable, containing both dyspnea and cough, among other symptoms. Methodological disparities, including differences in sample population characteristics, assessment tools and analytical methods, were evident in the five studies reviewed. Conclusion: Symptom cluster exploration is a developing area of research in the oncology field and is promising in providing insights into diagnosis, prognostication and symptom management. Disparities in methodology are significant barriers to producing comparable results. These inconsistencies result in a lack of consensus in symptom clusters in lung cancer populations, thus impeding the determination of clinically relevant findings.