Luca Tontini

Background and Objectives: Effective palliative care relies on accurate identification and management of symptoms, especially in patients referred for palliative radiotherapy (PRT). This study aimed to identify symptom clusters (SCs)—defined as ≥2 interrelated symptoms—in patients evaluated at a multidisciplinary Radiotherapy and Palliative Care (RaP) outpatient clinic, using the Edmonton Symptom Assessment System (ESAS). Materials and Methods: We retrospectively analyzed data from patients referred to the RaP clinic between February 2017 and April 2020. Demographic and clinical characteristics, including ESAS scores at first visit, were collected. SCs were identified with principal component analysis (PCA) and unsupervised k-means clustering (KMC), determining the number of SCs based on the maximum gap statistic and interpretability. Associations with ECOG performance status (PS), primary tumor and metastases site, and PRT administration were analyzed. Exploratory survival analyses were performed. Results: Among 215 patients (median age = 71 years; 53% male), the mean total ESAS score was 24.03 (SD = 15.28). PCA identified four SCs: SC_PCA1 (tiredness, drowsiness, dyspnea, malaise), SC_PCA2 (depression, anxiety), SC_PCA3 (nausea, loss of appetite) and SC_PCA4 (pain). KMC revealed three SCs: SC_KMC1 (pain, tiredness, drowsiness, malaise), SC_KMC2 (nausea, loss of appetite, dyspnea), and SC_KMC3 (depression, anxiety). Worse ECOG PS correlated with physical SCs (p < 0.05). Psychological SCs were associated with lower likelihood of receiving PRT (OR_PCA2 = 0.26, CI: 0.07–0.80, OR_kmc3 = 0.19, CI: 0.02–0.85, p < 0.05), but when associated with pain/systemic clusters correlated with greater PRT use. A trend toward shorter survival was seen in SC_KMC2. Conclusions: SC analysis could improve personalized symptom management and clinical decision-making in the PRT setting.

Background/Objectives: Effective palliative care relies on accurate identification and management of symptoms, especially in patients referred for palliative radiotherapy (PRT). This study aimed to identify symptom clusters (SCs)—defined as ≥2 interrelated symptoms—in patients evaluated at a multidisciplinary Radiotherapy and Palliative Care (RaP) outpatient clinic, using the Edmonton Symptom Assessment System (ESAS). Methods: We retrospectively analyzed data from patients referred to the RaP clinic between February 2017 and April 2020. Demographic and clinical characteristics, including ESAS scores at first visit, were collected. Principal component analysis (PCA) and unsupervised K-means clustering (KMC) were used to identify SCs. Associations with ECOG performance status (PS), primary tumor site, metastases site and PRT administration were analyzed. Exploratory survival analyses were performed.Results: Among 215 patients (median age 71 years; 53% male), the mean total ESAS score was 24.03 ± 15.28. PCA identified four SCs: SCPCA1 (tiredness, drowsiness, dyspnea, malaise), SCPCA2 (depression, anxiety), SCPCA3 (nausea, loss of appetite) and SCPCA4 (pain). KMC revealed three SCs: SCKMC1 (pain, tiredness, drowsiness, malaise), SCKMC2 (nausea, loss of appetite, dyspnea), SCKMC3 (depression, anxiety). Worse ECOG PS correlated significantly with physical SCs (p < 0.05). A trend linked SCKMC1 with greater PRT use. Psychological SCs (SCPCA2, SCKMC3) were significantly associated with a lower likelihood of receiving PRT. A trend toward shorter survival was observed among patients belonging to SCKMC2. Conclusions: SC analysis could improve clinical decision-making in the PRT setting. SC profiles reflect patient complexity and may guide personalized symptom management and treatment selection in advanced cancer.

Background On the basis of substantial evidence demonstrate that palliative care combined with standard care improves patient, caregiver, and society outcomes, we have developed a new healthcare model called radiotherapy and palliative care (RaP) outpatient clinic were a radiation oncologist and a palliative care physician make a joint evaluation of advanced cancer patients. Methods We performed a monocentric observational cohort study on advanced cancer patients referred for evaluation at the RaP outpatient clinic. Measures of quality of care were carried out. Results Between April 2016 and April 2018, 287 joint evaluations were performed and 260 patients were evaluated. The primary tumor was lung in 31.9% of cases. One hundred fifty (52.3%) evaluations resulted in an indication for palliative radiotherapy treatment. In 57.6% of cases was used a single dose fraction of radiotherapy (8 Gy). All the irradiated cohort completed the palliative radiotherapy treatment. An 8% of irradiated patients received the palliative radiotherapy treatment in the last 30 days of life. A total of 80% of RaP patients received palliative care assistance until the end of life. Conclusion At the first descriptive analysis, the radiotherapy and palliative care model seem to respond to the need of multidisciplinary approach in order to obtain an improvement on quality of care for advanced cancer patients.

Malignant Pleural Mesothelioma (MPM) is a rare malignancy with an overall poor prognosis. The standard therapeutic strategy in early-stage disease is trimodality therapy. In this publication, we report the preliminary toxicity results of the first 20 patients treated with accelerated hypofractionated radiotherapy. Between July 2017 to June 2019, 20 MPM patients were enrolled and treated with accelerated hypofractionated radiotherapy using helical tomotherapy and intensity-modulated arc therapy. The prescription dose was 30 Gy in five daily fractions, while an inhomogeneous dose escalation to 40 Gy was prescribed based solely upon the presence of gross residual tumor. Only one case of G3 toxicity was reported, which was a bilateral pneumonitis that occurred two years after treatment probably due to superinfection. Median Time to Progression reached 18.2 months while one- and three-year Overall Survival rates were 85% (95% CI:60.4–94.9) and 49.5% (95% CI:26.5–68.9), respectively. Treatment of the intact lung with pleural intensity-modulated arc irradiation is a novel treatment strategy that appears to be safe, feasible, and without a high grade of lung toxicity. Survival rates and Time to Progression are encouraging.

In locally advanced pancreatic cancer (LAPC), the combination of chemotherapy and radiotherapy is a widely used treatment option. We performed a pooled analysis, including an exploratory analysis for prognostic and predictive factors, of two phase 2 trials including 73 patients with LAPC, treated with gemcitabine and oxaliplatin (GEMOX) and hypofractionated tomotherapy. With a median follow-up of 36 months (range 1–65), median progression-free (PFS) and overall survival (OS) were 10.2 (95% confidence interval [CI] 7.8–13.2) and 14.3 (95% CI 12.0–18.1) months, respectively. The overall resectability rate was 23.3% (95% CI 13.6–33.0), and the R0 resection rate was 13.7% (95% CI 5.8–21.6). In the multivariate analysis, ECOG performance status (PS) 0 and low levels of CA 19–9 were associated with improved OS and PFS. Concerning OS, log(CA19–9) resulted in a hazard ratio (HR) of 1.20 (95% CI 1.02–1.42), p = 0.027. For ECOG PS 0, HR was 1.00; for PS 1, HR was 2.69 (95% CI 1.46–4.96); for PS 2, HR was 4.18 (95% CI 0.90–19.46); p = 0.003. Low CA19–9 levels were also predictive for resection, with an odds ratio of 0.71 (95% CI 0.52–0.97), p = 0.034. In conclusion, GEMOX and hypofractionated radiotherapy is a treatment option in LAPC. Further studies are needed to identify differences in tumor biology, which may help to predict resectability and prognosis.