Radiation Oncology in Palliative Cancer Care E-Book

• Herausgeber: John Wiley & Sons
• Kategorie: Fachliteratur
• Sprache: Englisch

Veröffentlichungsjahr: 2013

Beschreibung

“This textbook, Radiation Oncology in Palliative Cancer Care, represents the full evolution of radiation therapy, and of oncology in general. ( … ) [It] is an acknowledgment that palliative radiotherapy is now a sub-specialty of radiation oncology. This formally makes palliative radiotherapy a priority within patient care, academic research, quality assurance, and medical education.” – From the Foreword by Nora Janjan, MD, MPSA, MBA, National Center for Policy Analysis, Dallas, TX, USA

Palliative Medicine is the professional medical practice of prevention and relief of suffering and the support of the best possible quality of life for patients and their families, regardless of the stage of the disease or the need for other therapies. The most common cause for palliative care referral is terminal cancer, and a large proportion of those referrals include patients who will need palliative radiotherapy during the course of their disease. Still, there are barriers to coordinated care between radiation oncologists and palliative care physicians that differ from one country to another. Until now, one overarching limitation to appropriate concurrent care between the specialties across all countries has been the lack of a comprehensive yet concise reference resource that educates each of the specialties about the potential synergistic effects of their cooperation. This book fills that void.

Radiation Oncology in Palliative Cancer Care:

• Is the first book-length treatment of this important topic available on the market
• Is authored by world-renowned experts in radiation oncology and palliative medicine
• Uses a multidisciplinary approach to content and patient treatment
• Features decision trees for palliative radiotherapy based upon factors such as patient performance status and prognosis
• Pays careful attention to current best practices and controversies in the delivery of end-of-life cancer care

This book is an important resource for practicing radiation oncologists and radiation oncologists in training, as well as hospice and palliative medicine physicians and nurses, medical oncologists, and geriatricians.

Leseprobe

Table of Contents

Title page

Copyright page

Contributor list

Foreword

PART 1: General principles of radiation oncology

CHAPTER 1 A brief history of palliative radiation oncology

Introduction

The early years

Fractionation

Advances in radiotherapy technique: the 1950s and 1960s

Fractionation revisited: explicit palliation

Stereotactic radiotherapy

Prognostication and tailoring palliative radiotherapy to anticipated survival

Conclusion

CHAPTER 2 The radiobiology of palliative radiation oncology

Introduction

Radiation effect on cells

Cell cycle characteristics

Interaction of cell cycle and radiotherapy fractionation

Radiotherapy fractionation characteristics

Conclusion

CHAPTER 3 The physics of radiation oncology

Introduction

The development of radiation therapy technology

Process of radiation therapy

Special considerations in developing countries

Conclusion

CHAPTER 4 Curative intent versus palliative intent radiation oncology

Introduction

The determination of cure plus palliation intent versus pure palliative intent

Clinical diagnoses

Special considerations in developing countries

Conclusion

CHAPTER 5 Side effects of palliative radiotherapy

Introduction

Issues with interpreting palliative radiotherapy toxicity data

Acute side effects

Late side effects

Additive toxicity

Clinical advice

New technologies

Challenges in developing countries

Conclusion

PART 2: General principles of palliation and symptom control

CHAPTER 6 A history of hospice and palliative medicine

Introduction

Before the modern movement

St. Christopher’s and the modern hospice

Palliative care in the United States

Global development of hospice and palliative care

Continuing challenges

CHAPTER 7 Radiation therapy and hospice care

Introduction

Hospice care around the world

Hospice care in the United States

Palliative radiation and hospice

Conclusion

CHAPTER 8 The current status of palliative care and radiotherapy

What is palliative care?

Who can benefit from palliative care?

What are the goals of palliative care and what features of a palliative care program help to accomplish these goals?

What is the evidence regarding the benefits and risks of palliative care? When should palliative care be introduced to a patient?

Are there standards for palliative care? If so, what are the defining measures?

How does palliative care fit in with radiation oncology?

CHAPTER 9 Palliative care in low and middle income countries: A focus on sub-Saharan Africa

Introduction

The need for palliative care

Radiotherapy

Specific clinical indications for palliative radiotherapy in Africa

Challenges of palliative care delivery

Addressing challenges to adequate palliative care

Palliative care research

Delivery of palliative care

Conclusion

CHAPTER 10 Pain management

Introduction

Pain assessment

Analgesia ladder

Primary pharmacologic interventions

Adjuvant medications

End-of-life considerations

Conclusion

PART 3: Locally advanced or locally recurrent diseases

CHAPTER 11 Primary tumors of the central nervous system

Introduction

Radiotherapy

Side-effect risks

Radiotherapy limitations

Adjuvant treatment modalities

Promise of newer technologies

Special considerations in developing countries

Conclusion

CHAPTER 12 The role of palliative care in head and neck cancer

Introduction

Current management of head and neck squamous cell carcinomas

Patient selection for palliative treatment

Use of palliative radiotherapy in head and neck squamous cell carcinomas

Recurrent disease

The promise of emerging technologies

Chemotherapy in palliative head and neck squamous cell carcinomas

Non-squamous cell carcinomas histologies

Specific issues in palliation of head and neck squamous cell carcinomas

Special considerations in developing countries

Conclusion

CHAPTER 13 The role of palliative radiotherapy in breast cancer

Introduction

Rates of palliative loco-regional radiotherapy

Biologic considerations

Definitions, clinical features, and multi-disciplinary approach

Clinical scenarios

Symptom control

Palliative loco-regional radiotherapy for oligometastatic disease

Radiotherapy dosing schedules

Radiotherapy technique and the promise of newer technology

Special considerations in developing countries

Follow up

Conclusion

CHAPTER 14 Palliative radiotherapy in advanced lung cancer

Introduction

Radiotherapy treatment

The impact of emerging technologies

Important circumstances

Special considerations in developing countries

Conclusion

CHAPTER 15 Palliative radiotherapy for gastrointestinal and colorectal cancer

Introduction

Treatment of dysphagia

Gastric cancer

Palliation of biliary obstruction

Nodes at origin of the superior mesenteric artery

High dose rate brachytherapy

Locally advanced/recurrent rectal cancer

Re-irradiation

Anal cancer

The promise of highly conformal therapy

Special considerations in developing countries

Conclusion

CHAPTER 16 Genitourinary malignancies

Introduction

Incidence and etiology

Clinical behavior

Bladder cancer

Prostate cancer

Renal cancer

Palliative radiotherapy and other approaches for management of primary disease

Specific management of metastatic disease in urologic malignancies

The promise of highly conformal therapy

Special considerations in developing countries

Conclusion

CHAPTER 17 Palliative radiotherapy in locally advanced and locally recurrent gynecologic cancer

Introduction

Patterns of loco-regional failures for gynecologic cancers

Management

Treatment of recurrent carcinoma of the cervix

Recurrence after definitive radiation

Recurrence after definitive surgery

The promise of newer technologies

Special considerations in developing countries

Conclusion

CHAPTER 18 Hematologic malignancies and associated conditions

Introduction

Diagnoses

Specific clinical circumstances

Locally advanced and recurrent disease

Future directions

Special considerations in developing countries

Conclusion

CHAPTER 19 Pediatric palliative radiation oncology

Introduction

Delivery of radiation treatment

Differences between pediatric and adult populations

Background

Clinical indications for palliative radiotherapy

Caring for the pediatric patient

Barriers to the use of palliative radiotherapy

Special considerations in developing countries

Conclusion

PART 4: Metastatic disease

CHAPTER 20 Bone metastases

Introduction

Clinical implications and treatment modalities

Clinical symptoms

Technical considerations

Prognosis and choice for treatment

Proactive approach

Special considerations in developing countries

Conclusion

CHAPTER 21 Spinal cord compression

Introduction

Treatment

Promise of newer technologies

Re-irradiation

Special considerations in developing countries

Conclusion

CHAPTER 22 Brain metastases

Introduction

Radiotherapy treatment

Radiotherapy limitations

Promise of newer technologies and areas of ongoing research

International patterns of care and special considerations in developing countries

Conclusion

CHAPTER 23 Liver metastases

Introduction

Radiotherapy treatment

Whole-liver radiation therapy

Conformal radiation therapy

Brachytherapy

Selective internal radiation therapy

Surgery for liver metastases

Radiofrequency ablation

Promising new radiotherapy techniques

Practice variation among different countries

Conclusion

Acknowledgments

CHAPTER 24 Palliative radiotherapy for malignant neuropathic pain, adrenal, choroidal, and skin metastases

Malignant neuropathic pain

Adrenal metastases

Choroidal metastases

Skin metastases (A.H. Wolfson)

Conclusion

PART 5: Integration of radiation oncology and palliative care

CHAPTER 25 Design challenges in palliative radiation oncology clinical trials

Introduction

Challenges with the validation of palliative metrics

Evolution of palliative care clinical trials: the Radiation Therapy Oncology Group experience

International research efforts

Conclusion

CHAPTER 26 Radiation oncology cost-effectiveness

Introduction

Cost-effectiveness

Newer technologies

Conclusion

CHAPTER 27 Quality measures and palliative radiotherapy

Introduction

Quality measures: characteristics

Developing quality measures

Desirable attributes of quality measures

Uses of quality measures

Current uses of quality measures in radiation oncology

International quality measures in radiation oncology

Conclusion

CHAPTER 28 Use of technologically advanced radiation oncology techniques for palliative patients

Introduction

Overview of technologically advanced radiotherapy techniques

Clinical applications reported in the literature

Brain metastasis

Stereotactic radiosurgery

Scalp-sparing whole brain radiation therapy

Hippocampus-sparing whole brain radiation therapy

Stereotactic radiation therapy

Spinal metastasis

Spinal cord compression

Bone metastasis

Adrenal metastasis

Toxicities associated with palliative radiotherapy using advanced technologies

Conclusion

Index

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Library of Congress Cataloging-in-Publication Data

Radiation oncology in palliative cancer care / edited by Stephen Lutz, Edward Chow, Peter Hoskin.

p. ; cm.

 Includes bibliographical references and index.

 ISBN 978-1-118-48415-9 (hardback : alk. paper)

 I. Lutz, Stephen. II. Chow, Edward. III. Hoskin, Peter J.

 [DNLM: 1. Neoplasms–radiotherapy. 2. Palliative Care–methods. 3. Radiation Oncology–methods. 4. Radiotherapy–methods. QZ 269]

 616.99’407572–dc23

2012044508

ISBN: 9781118484159

A catalogue record for this book is available from the British Library.

Wiley also publishes its books in a variety of electronic formats. Some content that appears in print may not be available in electronic books.

Cover image: (Top) iStockphoto.com Courtesy of Simon Lo

Cover design by Modern Alchemy LLC

Contributor List

Shaun Baggarley, MScChief Radiation PhysicistDepartment of Radiation OncologyNational University Cancer InstituteNational University Health SystemRepublic of Singapore

Elizabeth A. Barnes, MD FRCP(C)Assistant ProfessorDepartment of Radiation OncologyUniversity of TorontoOdette Cancer CentreToronto, ON, Canada

Susannah Batko-Yovino, MDAssistant ProfessorDepartment of Radiation Oncology, and Program of Palliative MedicineJohn Hopkins UniversityBaltimore, MD, USA

Lawrence B. Berk, MD PhDChair, Radiation OncologyDirector, Radiation Oncology at Tampa General HospitalUniversity of South FloridaTampa, FL, USA

Sean Bydder, BHB MBChB MBA FRANZCRConsultant Radiation OncologistDepartment of Radiation OncologySir Charles Gairdner Hospital;ProfessorSchool of SurgeryThe University of Western AustraliaPerth, Australia

Eric L. Chang, MDProfessor and ChairDepartment of Radiation OncologyKeck School of Medicine atUniversity of Southern CaliforniaLos Angeles, CA, USA

Samuel T. Chao, MDAssistant ProfessorCleveland Clinic Lerner College of MedicineCleveland, OH, USA

Haris Charalambous, BM MRCP FRCRConsultant in Clinical OncologyDepartment of Radiation OncologyBank of Cyprus Oncology CentreNicosia, Cyprus

Caroline Chung, MD MSc FRCPC CIPRadiation Oncologist and Clinician-ScientistUniversity Health Network-Princess MargaretAssistant ProfessorDepartment of Radiation OncologyUniversity of TorontoToronto, ON, Canada

June Corry, FRANZCR FRACP MDConsultant Radiation OncologistChair Head and Neck ServicePeter MacCallum Cancer CentreMelbourne, Victoria, Australia

Henry Ddungu, MDUCI Hutchinson Center Cancer AllianceUpper Mulago Hill RoadP O Box 3935 KampalaKampala, Uganda

Gillian M. Duchesne, MB MD FRCR FRANZCR Gr Ct Health EconProfessor of Radiation OncologyPeter MacCallum Cancer CentreUniversity of Melbourne and Monash UniversityMelbourne, Victoria, Australia

Alysa Fairchild, BSc MD FRCPCAssociate ProfessorDepartment of Radiation OncologyCross Cancer InstituteUniversity of AlbertaEdmonton, AB, Canada

Frank D. Ferris, MD FAAHPMExecutive DirectorPalliative Medicine Research and EducationOhioHealthColumbus, OH, USA

Robert Glynne-Jones, MB BS FRCP FRCRMacmillan Lead Clinician in Gastrointestinal CancerMount Vernon Cancer CentreNorthwood, London, UK

Charles F. von Gunten, MD PhD FAAHPMVice PresidentMedical AffairsHospice and Palliative MedicineOhioHealthColumbus, OH, USA

Mark Harrison, MB.BC PhDConsultant OncologistMount Vernon Cancer CentreNorthwood, London, UK

James A. Hayman, MD MBAProfessorDepartment of Radiation OncologyUniversity of MichiganAnn Arbor, MI, USA

David D. Howell, MD FACR FAAHPMAssistant ProfessorDepartment of Radiation OncologyUniversity of Toledo College of MedicineToledo, OH, USA

Candice A. Johnstone, MD MPHAssistant ProfessorMedical Director of the Froedtert and Medical College of Wisconsin Cancer NetworkDepartment of Radiation OncologyMedical College of WisconsinMilwaukee, WI, USA

Joshua Jones, MD MAFellowPalliative Care ServiceMassachusetts General HospitalBoston, MA, USA

Andre Konski, MD MBA MA FACRProfessor and ChairDepartment of Radiation OncologyWayne State University School of MedicineBarbara Ann Karmanos Cancer CenterDetroit, MI, USA

Ian H. Kunkler, MA MB BCHIR FRCPE CRCRHonorary Professor of Clinical OncologyUniversity of EdinburghEdinburgh Cancer CentreEdinburgh, Scotland, UK

Yvette van der Linden, MD PhDRadiation oncologistDepartment of Clinical OncologyUniversity Medical CentreLeiden, The Netherlands

Simon S. Lo, MDDirectorRadiosurgery Services and Neurologic Radiation Oncology;Associate ProfessorUniversity Hospitals Seidman Cancer CenterCase Comprehensive Cancer CenterCase Western Reserve UniversityCleveland, OH, USA

Jiade J. Lu, MD MBAHead and Associate ProfessorDepartment of Radiation OncologyNational University Cancer InstituteNational University Health SystemRepublic of Singapore

Ernesto Maranzano, MDDirectorRadiation Oncology CentreSanta Maria HospitalTerni, Italy

Nina A. Mayr, MDProfessorRadiation OncologyArthur G. James Cancer HospitalThe Ohio State UniversityColumbus, OH, USA

Erin McMenamin, MSN CRNP AOCN ACHPNOncology Nurse PractitionerDepartment of Radiation OncologyHospital of the University of PennsylvaniaPhiladelphia, PA, USA

Marcia Meldrum, PhDAssociate ResearcherCenter for Health Services and SocietySemel Institute for Neuroscience and Human BehaviorUniversity of California, Los AngelesLos Angeles, CA, USA

Benjamin Movsas, MDChairmanDepartment of Radiation OncologyHenry Ford Health SystemDetroit, MI, USA

Arno J. Mundt, MDProfessor and ChairCenter for Advanced Radiotherapy Technologies (CART)Department of Radiation Medicine and Applied SciencesUniversity of California, San DiegoSan Diego, CA, USA

Firuza Patel, MDProfessorDepartment of Radiotherapy and OncologyPost Graduate Institute of Medical Education and ResearchChandigarh, India

Rinaa S. Punglia, MD MPHAssistant ProfessorDepartment of Radiation OncologyDana-Farber Cancer Institute and the Brigham and Women’s HospitalHarvard Medical SchoolBoston, MA, USA

Dirk Rades, MD PhDProfessorHead of DepartmentDepartment of RadiotherapyUniversity Hospital LübeckLübeck, Germany

George Rodrigues, MD MSc FRCPCClinician Scientist and Radiation OncologistDepartments of Radiation Oncology and Epidemiology/BiostatisticsLondon Health Sciences Centre and University of Western OntarioLondon, ON, Canada

Daniel E. Roos, BSc(Hons) DipEd MBBS MD FRANZCRSenior Radiation OncologistDepartment of Radiation OncologyRoyal Adelaide Hospital;ProfessorUniversity of Adelaide School of MedicineAdelaide, South Australia, Australia

Arjun Sahgal, MDAssociate ProfessorRadiation OncologyPrincess Margaret Hospital and the Sunnybrook Health Sciences CenterUniversity of Toronto,Toronto, ON, Canada

Thomas Smith, MD FACPHarry J. Duffey Family Professor of Palliative Medicine;Professor of OncologyDepartment of Oncology and Program of Palliative MedicineJohn Hopkins UniversityBaltimore, MD, USA

Bin S. Teh, MDProfessor, Vice Chair and Senior MemberThe Methodist Hospital, Cancer Center and Research InstituteWeill Cornell Medical CollegeHouston, TX, USA

Albert Tiong, MB BS M.App.Epi. FRANZCRConsultant Radiation OncologistPeter MacCallum Cancer CentreMelbourne, Victoria, Australia

Fabio Trippa, MDVice ChairRadiation Oncology CentreSanta Maria HospitalTerni, Italy

May Tsao, MD FRCPCAssistant ProfessorDepartment of Radiation Oncology, University of Toronto;Sunnybrook Odette Cancer CentreToronto, ON, Canada

Vassilios Vassiliou, MD PhDConsultant in Radiation OncologyDepartment of Radiation OncologyBank of Cyprus Oncology CentreNicosia, Cyprus

Tamara Vern-Gross, DO FAAPDepartment of Radiation OncologyWake Forest Baptist HealthComprehensive Cancer CenterWinston-Salem, NC, USA

Anushree M. Vichare, MBBS MPHMeasures Development ManagerAmerican Society for Radiation OncologyFairfax, VA, USA

Deborah Watkins Bruner, RN PhD FAANRobert W. Woodruff Professor of NursingNell Hodgson Woodruff School of NursingProfessor of Radiation OncologyAssociate Director for Outcomes ResearchWinship Cancer InstituteEmory UniversityAtlanta, GA, USA

Michelle Winslow, BA PhDResearch FellowAcademic Unit of Supportive CareUniversity of SheffieldSheffield, South Yorkshire, UK

Aaron H. Wolfson, MDProfessor and Vice ChairDepartment of Radiation OncologyUniversity of Miami Miller School of MedicineMiami, FL, USA

Foreword

“The final causes, then, of compassion are to prevent and to relieve misery.”

Joseph Butler [1692–1752]

This textbook, Radiation Oncology in Palliative Cancer Care, represents the full evolution of radiation therapy, and of oncology in general. This evolution in radiation oncology is in response to the changing priorities of cancer care.

More than a century ago, radiotherapy was the only treatment available for cancer, palliating the suffering from large masses and open wounds from the disease. The priority was to relieve the suffering from the disease, as the cure of cancer was rare. As medical science evolved, especially in anesthesia and surgery, the principles of cancer resection were developed. Cure of cancer became the priority, often at the accepted price of disfigurement. In the latter half of the 20th century, the development of chemotherapeutic agents dominated. Cure of cancer remained the priority, but now at the price of toxicity. Acute toxicity often limited the patient’s ability to receive chemotherapy on schedule or complete the prescribed number of courses of chemotherapy. Late chemotherapeutic toxicity risked significant end-organ damage. Despite the “War on Cancer,” the sacrifice of cure at any human cost was beginning to be questioned.

Quality of life, during and after cancer therapy, became a priority commensurate with cancer cure. Although often not fully recognized as such, palliative care principles were applied to improve the cancer patient’s quality of life. In its broadest definition, palliative care relieves the symptoms of cancer and its treatment at any stage of disease, and maintains or restores the dignity of function. For every patient, spanning all age groups from young children to elderly adults, the palliative principles of comfort in positioning, reassurance, and beneficence, and the avoidance of treatment-related symptoms are paramount.

These principles of palliative care invoked the priority of delivering effective cancer treatment with the fewest side effects. Most notably, acute chemotherapy toxicity was significantly reduced with the development of more effective anti-emetic agents. The development of sophisticated linear accelerators, including electron beam and intensity modulated radiation, allowed improved outcomes due to the targeted delivery of higher radiation doses with fewer side effects. Previously unthinkable, advancements in radiation therapy technology also allowed multi-modality therapy, the combination of chemotherapy and radiation with function-sparing surgery for virtually every anatomic region. This exciting period both expanded the potential for cancer cure and improved the cancer patient’s quality of life because side effects of cancer therapy were more effectively controlled.

While most of the focus in cancer treatment over the latter half of the 20th century was, very understandably, on these multi-modality developments, a smaller, but concerted, effort was formally launched for patients with incurable disease. Hospice care was exported from the groundbreaking work of Dame Cicely Saunders in Great Britain. Meanwhile, the contributing role and significant impact of radiotherapy in palliative care was often relegated to “service work” within academic centers. Palliative radiotherapy was neither the topic of scientific research, nor acknowledged as a valuable sub-specialty within the field.

Palliative radiotherapy finally began to be recognized as an integral aspect of radiation oncology through the convergence of multiple factors. First and foremost were advocacy efforts to improve cancer patients’ quality of life. The expanding role of medical ethics within health-care systems also reinforced the responsibility to relieve suffering. Meanwhile, clinical research documented improved rates of survival among incurable cancer patients with effective symptom control.

The second factor was the continued development of systemic agents used for palliation. Expanding beyond supportive care that reduced the side effects of cancer treatment, drug development then prioritized the treatment of metastatic disease. This was exemplified most prominently by the clinical trials of bisphosphonates for bone metastases. Radiation oncology recognized the scope of palliative care within its practices as the number of patients who received bisphosphonates, instead of palliative radiation, increased. It was then determined that palliative care, even at tertiary care cancer centers, accounted for more than one-third of the requests for radiotherapeutic consultation, and represented an untapped research potential.

The third factor involved both the economics of health care, and the limited health-care resources faced in all nations. In the United States, last-year-of-life expenditures constituted 26% of the entire Medicare budget [1]. Many governments have dealt with spiraling health-care costs by developing guidelines for care that incorporate comparative effectiveness research. The potential impact and main priority for comparative effectiveness research is based on prevalence, disease burden, variability in outcomes, and costs of care. The most efficient means of delivering effective cancer treatment is an economic priority for all nations. Additionally, access to care with limited health-care resources is especially prevalent in middle and low-income nations. These economic and resource issues in health care prompted international clinical trials that evaluated the most efficient radiotherapeutic fractionation for the treatment of bone metastases. Clinical trials that address economics as well as outcomes, like that of the international palliative bone metastases trial, will not only influence palliative treatment approaches, but every aspect of cancer therapy in the future.

This textbook is an acknowledgment that palliative radiotherapy is now a sub-specialty of radiation oncology. This formally makes palliative radiotherapy a priority within patient care, academic research, quality assurance, and medical education. However, the principles of palliation were the first precepts of cancer treatment, and were first applied by radiation oncologists. The priorities of the past have now evolved to the priorities of the future.

Nora Janjan, MD MPSA MBA National Center for Policy Analysis, Dallas, TX, USA

Reference

1. Hoover DR, Crystal S, Kumar R, et al. Medical expenditures during the last year of life: findings from the 1992-1996 Medicare current beneficiary survey. Health Serv Res 2002; 37: 1625–1642.

PART 1

General Principles of Radiation Oncology

CHAPTER 1

A Brief History of Palliative Radiation Oncology

Joshua Jones

Palliative Care Service, Massachusetts General Hospital, Boston, MA, USA

Introduction

A simple chronology of scientific and technologic developments belies the complexity of the history of palliative radiotherapy. The diversity of palliative radiation treatments utilized today reflects a dichotomy evident in the earliest days of therapeutic radiation, namely that radiation can be utilized to extend survival or to address anticipated or current symptoms. However, the line between “curative” and “palliative” treatments is not always obvious. Furthermore, even “palliative” radiotherapy has an impact on local tumor control, potentially improving survival and complicating the balance between effective and durable palliation with possible short- or long-term side effects of therapy. This introduction provides a basic overview of developments in the history of radiation therapy that continue to inform the complex thinking on how best to palliate symptoms of advanced cancer with radiation therapy.

The Early Years

Within a few short months of Wilhelm Roentgen’s publication of his monumental discovery in January 1896, several early pioneers around the world began treating patients with the newly discovered X-rays [1]. Early reports detailed treatments of various conditions of the hair, skin (lupus and “rodent ulcers”) and “epitheliomata,” primarily cancers of the skin, breast, and head and neck [2] (Figure 1.1). Other early reports, as championed by Emile Grubbe in a 1902 review, touted both the cure of malignancy as well as “remarkable results” in “incurable cases” including relief of pain, cessation of hemorrhage or discharge and prolongation of life without suffering [3]. Optimism was high that X-rays would soon be able to transform many of the “incurable cases” to curable.

Figure 1.1 An early radiotherapy machine delivering low energy X-rays with shielding of the face by a thin layer of lead.

Reproduced from Williams [4].

In his 1902 textbook, Francis Williams, one of the early pioneers from Boston, described his optimism that radiation therapy would eliminate growths on the skin: “The best way of avoiding the larger forms of external growths is by prevention; that is, by submitting all early new growths, whether they seem of a dangerous nature or not, to the X-rays. No harm can follow their use in proper hands and much good will result from this course [4].” He went on to state that, while “internal new growths” could not yet be treated with X-ray therapy, he was optimistic that such treatments would be possible in the future. In this setting, he put forward an early treatment algorithm for cancer that divided tumors into those treatable with X-ray therapy, those treatable with surgery and X-ray therapy post-operatively, and those amenable to palliation with X-ray therapy. He further described that the specific treatment varied from patient to patient but could be standardized between patients based on exposure time and skin erythema.

Other early radiology textbooks took a more measured approach to X-ray therapy. Leopold Freund’s 1904 textbook described in great detail the physics of X-rays and again summarized the early clinical outcomes. In his description of X-ray therapy, he highlighted the risks of side effects, including ulceration, with prolonged exposures to X-rays without sufficient breaks. He noted that the mechanism of action of radiation was still not understood, with theories at the time focusing on the electrical effects of radiation, the production of ozone, or perhaps direct effects of the X-rays themselves. Freund highlighted early attempts at measuring the dose of radiation delivered, emphasizing the necessity of future standardization of dosing and research into the physiologic effects of X-ray therapy [2]. As foreshadowed in the textbooks of Williams and Freund, early research in radiation therapy focused on clinical descriptions of the effectiveness of X-rays contrasted with side effects of X-rays, the determination of what disease could be effectively treated with radiotherapy, the standardization of equipment and measurement of dose, and attempts to understand the physiologic effects of X-ray therapy.