Many of us reveled at the sight of our brilliant sun disappearing behind a dark orb of moon last month as an historic solar eclipse traveled across our entire country. My son, Will, sent me the accompanying photograph from Nashville, TN where the eclipse was total. The radiation and light from our Solar System’s star are essential for life on this planet we call home. While we’re still marveling at the power of the sun’s radiation and buzzing about the spectacle we witnessed, let’s consider the power and benefit of a very different radiant energy, therapeutic ionizing radiation, and how it might enhance quality of life in the final months of one’s life.
Most people have heard of radiation treatments as a part of the curative therapy for a variety of cancers. Usually, these treatments occur 5 days/week for 6 to 8 weeks, depending on the dosing and the type of cancer being treated. However, radiation therapy might also be effective for symptom management in some advanced, incurable cancers as well. Especially patients with symptoms of pain, bleeding, and pressure or obstruction created by incurable cancers might be candidates for this therapy.
In contrast to the standard courses of radiation therapy, palliative radiation schedules are often shorter and deliver smaller overall doses of radiation. These abbreviated and consolidated courses are termed Rapid Radiation Therapy (RRT)
Especially for patients who already have poor functional status or have transportation difficulties getting to and from radiation treatment centers, the likelihood of better tolerance and shorter treatment courses offer significant advantages.
Palliative radiation for painful bone metastases (cancerous tumors that have spread into bone) may require only a single treatment. On average, palliative radiation treatments are completed within 3 weeks, saving patients many trips for the therapy and significant cost as well.
Bleeding is a frightening and debilitating complication of several advanced cancers, including head and neck cancer, urinary bladder cancer, stomach cancer, and cervical cancer. Targeted palliative radiation can be beneficial for these problems.
Because of their size and location, some incurable cancers create pressure and pain. At times, they even cause obstruction of adjacent organs and blood vessels. Again, targeted palliative radiation might shrink cancer size and treat these symptoms as a result. Shrinking cancers in the brain might relieve associated headaches. Cancers blocking bronchial tubes in the lungs might shrink enough to allow breathing to be restored. And cancers pressing against the spinal cord might shrink enough to relieve severe nerve pain or even restore some lost function.
Let’s review how radiation treatments work, since both the benefits and the side effects (toxicities) will make sense with this information. Ionizing radiation works by damaging a cell’s DNA, which is a primary building block of all cells. In radiation treatments, a calculated dose of radiation is directed at an area of the body where cancer is causing symptoms such as those mentioned above. Both normal and cancer cells within a treatment field are damaged by the radiation, but thankfully cancer cells are less likely to recover from the damage than normal tissue cells, and are therefore more likely to be killed by the treatments.
The injured/damaged normal tissues in a radiation field show remarkable resilience in repairing themselves. Consequently, after several weeks and appropriate support, these normal tissues exhibit amazing regenerative capacity and usually recover from the acute radiation injury. In designing radiation treatments, specialists strive to target cancer cells and avoid as much normal tissue as possible. Since long term complications from radiation therapy can take years to develop, such complications won’t likely occur in patients with life expectancies of 6 to 12 months and don’t have to be considered in the planning.
Though benefit of palliative radiation may occur in as short a time period as several days (e.g. relieving pain created by bone metastases), sometimes the benefit is not fully realized for a few weeks. During these same weeks, the short-term side effects of radiation damage to healthy tissues will also occur. Consequently, if a patient’s life expectancy is shorter than one month, the full benefit of treatment may not occur before their death. Additionally, as patients near the end of their lives, they often become progressively fatigued and fragile. Even one or two trips to a radiation treatment center might seem just too burdensome to consider.
As in all forms of palliative care, where symptom management and quality of life are the priorities, a patient’s goals of care should be clarified and drive subsequent decisions on medical treatment. There are risks and benefits to palliative radiation, so clear-eyed conversations are important. Physicians who suggest this form of treatment need to consider a patient’s overall health and symptom burden, the complications expected by the radiation therapy, and the expected time to benefit from the radiation.
If improved quality of life is likely for someone who now considers a single “good day” to be precious, palliative radiation may be worthwhile. In keeping with this sentiment, the Dalai Lama reminds, “Technology can greatly assist human capability, but it cannot produce compassion.” Especially in palliative medicine, the most beneficial outcomes depend on heart-felt communication just as much as scientific expertise.
Stephen L Hines, MD