Publications by authors named "Adam Pawinski"

46 Publications

Management of Patients With Metastatic Renal Cell Cancer and Bone Metastases.

In Vivo 2020 Mar-Apr;34(2):675-678

Department of Oncology and Palliative Medicine, Nordland Hospital, Bodø, Norway.

Background/aim: Previous research has suggested that patients with metastatic renal cell cancer (mRCC) and bone metastases have a poorer prognosis compared to their counterparts with no skeletal involvement. Therefore, we analyzed the management and outcomes of such patients in our center.

Patients And Methods: We performed a retrospective study of 35 consecutive patients who received systemic treatment, largely targeted therapy, for mRCC with bone metastases.

Results: The median overall survival was 25 months from the time of diagnosis of mRCC. The 5-year survival rate was 16%. Survival from diagnosis of mRCC was significantly worse in patients with bone metastases present at the start of first-line systemic therapy (median 13 months) compared to delayed metastases diagnosed later during the course of disease (46 months, p=0.01). Few patients (29%) were able to receive more than two lines of systemic therapy. Bone-only metastases were uncommon (11%).

Conclusion: Most patients with mRCC and bone metastases have limited overall survival.
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http://dx.doi.org/10.21873/invivo.11822DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7157836PMC
November 2020

Confirmatory Analysis of QUARTZ Study Results: Survival Prolongation After Whole-brain Radiotherapy.

Anticancer Res 2020 Feb;40(2):977-981

Department of Oncology and Palliative Medicine, Nordland Hospital, Bodø, Norway.

Background/aim: The aim of this study was to analyze the survival of patients with brain metastases treated with best supportive care or additional whole-brain radiotherapy (WBRT), in order to confirm results from the prospective randomized QUARTZ study, which suggested prolonged survival after WBRT (5 fractions of 4 Gy) if favorable prognostic factors were present (age younger than 60 years, graded prognostic assessment score 2.5-3 points).

Patients And Methods: We performed a retrospective single institution analysis of 76 patients with favorable prognosis. In contrast to the QUARTZ trial, inclusion was not limited to patients with non-small cell lung cancer (NSCLC). Furthermore, a cohort treated with higher total doses of WBRT was included (10 fractions of 3 Gy).

Results: All patients were younger than 60 years or had a graded prognostic assessment score of 2.5-3. The median survival was significantly shorter after best supportive care (1.2 months; 3.2 months after WBRT with 5 fractions of 4 Gy and 3.9 months after 10 fractions of 3 Gy). Also, in multivariate analyses, survival was significantly better after WBRT. Further favorable prognostic factors included better performance status, no or limited extracranial metastases and primary tumor other than gastrointestinal.

Conclusion: In line with the QUARTZ trial results, WBRT prolonged survival in patients with favorable prognostic features.
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http://dx.doi.org/10.21873/anticanres.14031DOI Listing
February 2020

Presence of Brain Metastases at Initial Diagnosis of Cancer: Patient Characteristics and Outcome.

Cureus 2019 Feb 21;11(2):e4113. Epub 2019 Feb 21.

Oncology, Nordland Hospital Trust, Bodø, NOR.

Objective To describe the characteristics of patients who present with brain metastases already at first diagnosis of cancer and to evaluate overall survival (OS) and long-term survival. Methods Retrospective uni- and multivariate analyses in a group of 84 patients treated with different approaches. Results With respect to primary cancer type, the largest entities were adenocarcinoma non-small cell lung cancer (NSCLC) and small cell lung cancer (SCLC) (34.5 and 21.4%, respectively). The most common diagnostic setting was symptomatic brain metastases (64 patients, 76.2%). Median OS was 7.2 months (one-year survival rate 31%). Four patients survived for at least three years, all had solitary metastases. The best survival was observed in the group managed with neurosurgical resection, median 17.7 months. Systemic treatment was also associated with better survival (median 9.7 vs. 2.8 months, p = 0.0001). Multivariate analysis revealed two prognostic baseline factors for OS, Karnofsky performance status (KPS) and number of brain metastases. Neurologic cause of death was uncommon (n = 14, 17%). Conclusion Long-term survival was limited and observed exclusively in the setting of a solitary brain metastasis. In patients with good KPS and limited number of brain metastases, systemic treatment as well as effective local treatment, such as resection and/or radiotherapy with sufficiently high equivalent dose, is warranted.
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http://dx.doi.org/10.7759/cureus.4113DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6476608PMC
February 2019

External Validation of the LabBM Score in Patients With Brain Metastases.

J Clin Med Res 2019 May 14;11(5):321-325. Epub 2019 Apr 14.

Department of Oncology and Palliative Medicine, Nordland Hospital, Bodo, Norway.

Background: The aim of this study was to validate the prognostic impact of the recently introduced three-tiered LabBM score in patients with brain metastases. In contrast to the previous development and validation cohorts, the present cohort did not include patients treated with primary surgery and/or radiosurgery. The score is based on hemoglobin, platelet counts, albumin, C-reactive protein and lactate dehydrogenase.

Methods: This was a retrospective single institution analysis. Overall, 167 patients managed with first-line whole-brain radiotherapy (WBRT) were identified from a prospectively maintained database.

Results: The LabBM score significantly predicted overall survival (median 4.0, 2.9 and 1.5 months, respectively).

Conclusions: The LabBM score is also valid in a patient population that differs from the previously studied cohorts, that is patients who were judged to be better candidates for WBRT than surgery or radiosurgery. As these patients in general represent a less favorable subset, their median survival was shorter than reported in the development cohort (11, 7 and 3 months, respectively). Future studies should examine whether or not combinations of the LabBM and other scores, for example, lung-molGPA and melanoma-molGPA, improve the clinical value of single scores.
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http://dx.doi.org/10.14740/jocmr3746DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6469893PMC
May 2019

Contribution of Serum Biomarkers to Prognostic Assessment in Patients With Oligometastatic Prostate Cancer.

In Vivo 2019 Mar-Apr;33(2):465-468

Department of Oncology and Palliative Medicine, Nordland Hospital, Bodø, Norway.

Background/aim: The aim of this study was to analyze the prognostic impact of biomarkers, such as serum lactate dehydrogenase (LDH), in patients with oligometastatic castration-resistant prostate cancer, arbitrarily defined as a maximum of five metastatic lesions.

Patients And Methods: This was a retrospective single-institution analysis. Overall 34 patients were included, all of whom received first-line docetaxel without ablative local treatment.

Results: Twelve patients (35%) had elevated LDH (≥255 U/l). Their median survival was significantly shorter than that of patients with normal LDH. Due to an interaction with other biomarkers, multivariate Cox regression analysis was performed. The latter showed that serum hemoglobin was the only significant predictor of survival.

Conclusion: Correct diagnosis of oligometastatic disease is not trivial, because all radiological modalities are limited by certain thresholds for detection of small metastases. Serum biomarkers may reflect the total burden of malignant disease. However, this relatively small study did not clearly demonstrate that elevation of LDH may be useful for clinical decision-making, e.g. in terms of adding local treatment for all sites of metastatic spread.
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http://dx.doi.org/10.21873/invivo.11495DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6506299PMC
June 2019

Initiation of Systemic Therapy During the Last 30 Days of Life in Patients With Metastatic Castration-resistant Prostate Cancer.

Anticancer Res 2019 Jan;39(1):335-340

Department of Clinical Medicine, Faculty of Health Sciences, UiT - The Arctic University of Norway, Tromsø, Norway.

Background/aim: Compared to intravenous taxane chemotherapy, newer orally-available and/or less toxic agents for metastatic castration-resistant prostate cancer (MCRPC) may be associated with higher likelihood of starting treatment in patients with adverse prognostic features and limited life expectancy. To test this hypothesis, we analyzed the rates of treatment initiation during the last 30 days of life in a real-world cohort of men with MCRPC.

Patients And Methods: This was a retrospective analysis of 146 patients.

Results: Seven patients (5%) who started any systemic treatment during the last 30 days of life were identified. The likelihood of treatment initiation in the last 30 days of life correlated significantly with the number of lines of systemic treatment (higher risk for previously treated patients) and non-use of bone-targeted agents.

Conclusion: Initiation of systemic therapy in the last 30 days of life was uncommon. This endpoint might complement other quality-of-care indicators.
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http://dx.doi.org/10.21873/anticanres.13116DOI Listing
January 2019

Serum Lactate Dehydrogenase Contributes to Prognostic Assessment in Patients With Oligometastatic Cancer and Brain Involvement.

In Vivo 2019 Jan-Feb;33(1):229-232

Department of Oncology and Palliative Medicine, Nordland Hospital, Bodø, Norway.

Background/aim: The aim of this study was to analyze the prognostic impact of serum lactate dehydrogenase (LDH) in patients with oligometastatic brain metastases, arbitrarily defined as max. Four brain lesions and 5 metastatic lesions overall.

Patients And Methods: This was a retrospective single institution analysis. Overall, 42 patients were identified from a prospectively maintained database.

Results: Seventeen patients (40%) had extracranial metastases. Twelve patients (29%) had elevated LDH (≥255 U/l). Their median survival was significantly shorter than that of patients with normal LDH. Due to an interaction with performance status, this result was separately confirmed in patients with performance status ≥70.

Conclusion: Oligometastatic disease is not always correctly diagnosed, because all radiological modalities are limited by certain thresholds for detection of small metastases. We hypothesize that LDH is associated with survival, because this biomarker may reflect the total burden of malignant disease. Future studies should examine whether or not ablative local treatment of oligometastases is warranted in patients with elevated LDH.
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http://dx.doi.org/10.21873/invivo.11464DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6364069PMC
April 2019

Seven-month prostate-specific antigen (PSA) is prognostic in patients with prostate cancer initially diagnosed with distant metastases.

Med Oncol 2018 Mar 5;35(4):46. Epub 2018 Mar 5.

Department of Clinical Medicine, Faculty of Health Sciences, UiT - The Arctic University of Norway, 9037, Tromsö, Norway.

Recent research suggests that prostate-specific antigen (PSA) ≤ 0.2 ng/dl at 7 months is prognostic for better survival with androgen deprivation therapy for metastatic hormone-sensitive prostate cancer regardless of chemotherapy with docetaxel. These results were derived from a group of clinical trial participants. Therefore, we performed a confirmatory analysis in patients treated outside of trials. Furthermore, we limited inclusion to those who presented with metastases at the initial diagnosis of prostate cancer (synchronous metastases). A retrospective analysis of a comprehensive regional database was performed. The oncology care in this region (Nordland County, Northern Norway) was provided by one center. Patients who were diagnosed between January 01, 2004 and December 31, 2016 were included. Of 101 patients, 90 were alive at 7 months and had their PSA value measured. Their median age was 68.5 years. Only six patients (7%) achieved PSA ≤ 0.2 ng/dl at 7 months. The median value was 4.05 ng/dl. Median overall survival was shortest in patients with PSA > 4.0 ng/dl (22 months). For patients with PSA between 0.3 and 4.0 ng/dl, median survival was 54 months (p = 0.0001). No further increase was seen in the small group with lower PSA. Statistical significance was also found for a cutoff of ≤ 1.0 ng/dl (55 vs. 32 months). PSA at 7 months predicts overall survival. Given that only 7% of patients achieved PSA ≤ 0.2 ng/dl, confirmation of this particular cutoff requires additional studies in other populations.
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http://dx.doi.org/10.1007/s12032-018-1110-yDOI Listing
March 2018

Patient-reported symptoms before palliative radiotherapy predict survival differences.

Strahlenther Onkol 2018 06 17;194(6):533-538. Epub 2018 Jan 17.

Department of Oncology and Palliative Medicine, Nordland Hospital Trust, 8092, Bodø, Norway.

Background: Widely used prognostic scores, e. g., for brain or bone metastases, are based on disease- and patient-related factors such as extent of metastases, age and performance status, which were available in the databases used to develop the scores. Few groups were able to include patient-reported symptoms. In our department, all patients were assessed with the Edmonton Symptom Assessment System (ESAS, a one-sheet questionnaire addressing 11 major symptoms and wellbeing on a numeric scale of 0-10) at the time of treatment planning since 2012. Therefore, we analyzed the prognostic impact of baseline ESAS symptom severity.

Methods: Retrospective review of 102 patients treated with palliative radiotherapy (PRT) between 2012 and 2015. All ESAS items were dichotomized (below/above median). Uni- and multivariate analyses were performed to identify prognostic factors for survival.

Results: The most common tumor types were prostate, breast and non-small cell lung cancer, predominantly with distant metastases. Median survival was 6 months. Multivariate analysis resulted in six significant prognostic factors. These were ESAS pain while not moving (median 3), ESAS appetite (median 5), Eastern Cooperative Oncology Group (ECOG) performance status, pleural effusion/metastases, intravenous antibiotics at start or within 2 weeks before PRT and no systemic cancer treatment.

Conclusions: Stronger pain while not moving and reduced appetite (below/above median) predicted significantly shorter survival. Development of new prognostic scores should include patient-reported symptoms and other innovative parameters because they were more important than primary tumor type, age and other traditional baseline parameters.
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http://dx.doi.org/10.1007/s00066-018-1259-5DOI Listing
June 2018

Eligibility for phase 3 clinical trials of systemic therapy in real-world patients with metastatic renal cell cancer managed in a rural region.

Med Oncol 2017 Sep 26;34(9):149. Epub 2017 Jul 26.

Department of Clinical Medicine, Faculty of Health Sciences, University of Tromsø, 9037, Tromsö, Norway.

Previous research has identified disparities between urban and rural cancer care, including clinical trial access. Therefore, we addressed three different questions in patients with metastatic renal cell cancer managed according to national guidelines in a rural Norwegian standard practice setting. (1) How many patients would have been eligible for three recent landmark randomized clinical trials? (2) Is survival different between eligible and non-eligible patients receiving first-line systemic therapy? (3) Is survival different between eligible patients and published trial results? We performed a retrospective analysis of 101 consecutive patients (2006-2016). Only 52% of the patients were eligible for the first-line study of pazopanib versus sunitinib. The main reasons for violating inclusion or exclusion criteria were presence of brain metastases, absence of clear cell histology, and poor performance status. Even fewer patients were eligible for trials of nivolumab and cabozantinib in pre-treated patients. Eligible patients had significantly better survival than non-eligible patients, median 29.2 versus 8.5 months (p = 0.0001). These results confirm that many patients from rural practices do not fulfill all mandatory trial eligibility criteria. However, eligible patients managed according to national guidelines had survival outcomes in line with published first-line trial results.
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http://dx.doi.org/10.1007/s12032-017-1002-6DOI Listing
September 2017

The Glasgow prognostic score: Useful information when prescribing palliative radiotherapy.

Mol Clin Oncol 2017 Jun 26;6(6):811-816. Epub 2017 Apr 26.

Department of Clinical Medicine, Faculty of Health Sciences, UiT - The Arctic University of Norway, N-9037 Tromsø, Norway.

The purpose of the present retrospective study was to investigate whether a score reflecting systemic inflammatory processes [the Glasgow Prognostic Score (GPS)] provides relevant information for radiation oncologists. GPS is a three-tiered score [0: normal C-reactive protein (CRP) and albumin; 1: one abnormal result; 2: increased CRP and low albumin]. Correlations between disease type and extent, resource utilization, survival and GPS were analyzed in 703 patients. In the subgroup with GPS 2, significantly higher rates of lung, adrenal gland and liver metastases were observed. An increasing GPS score was associated with a higher likelihood of anemia, leukocytosis and thrombocytosis. Comparable findings were made regarding utilization of palliative care resources, need for blood transfusion and intravenous administration of antibiotics. Compared with GPS 0 or 1, more patients with GPS 2 did not complete their prescribed course of radiotherapy. One-third of patients with GPS 2 received treatment during the final month of life. Multivariate analysis demonstrated that GPS was a significant prognostic factor for overall survival (median, 479, 136, and 61 days, for GPS 0, 1 and 2, respectively). In patients with GPS 2 and additional leukocytosis, the median survival was 38 days. In conclusion, GPS provides important prognostic information. This biomarker-based score may be considered for deciding fractionation, and should be validated further.
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http://dx.doi.org/10.3892/mco.2017.1228DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5451880PMC
June 2017

Palliative Thoracic Radiotherapy for Lung Cancer: What Is the Impact of Total Radiation Dose on Survival?

J Clin Med Res 2017 Jun 26;9(6):482-487. Epub 2017 Apr 26.

Department of Oncology and Palliative Medicine, Nordland Hospital Trust, Bodo, Norway.

Background: Effective symptom palliation can be achieved with low-dose palliative thoracic radiotherapy. In several studies, median survival was not improved with higher doses of radiation. More controversy exists regarding the impact of higher doses on 1- and 2-year survival rates. Therefore, a comparison of survival outcomes after radiotherapy with different biologically equivalent doses (equivalent dose in 2-Gy fractions, EQD2) was performed.

Methods: This was a retrospective single-institution study of 232 patients with small or non-small cell lung cancer. Most commonly 2 fractions of 8.5 Gy were prescribed (34%), followed by 10 fractions of 3 Gy or equivalent regimens (30%, EQD2 circa 33 Gy). The highest EQD2 consisted of 45 Gy. Intention-to-treat analyses were performed.

Results: Survival was significantly shorter with regimens of intended EQD2 < 33 Gy, e.g., 2 fractions of 8.5 Gy (median 2.5 months compared to 5.0 and 7.5 months with EQD2 of circa 33 and 45 Gy, respectively). The 2-year survival rates were 0%, 7% and 11%, respectively. In 128 prognostically favorable patients, median survival was comparable for the three different dose levels (6 - 8.3 months). The 2-year survival rates were 0%, 10%, and 13%, respectively (not statistically significant).

Conclusion: Although most of the observed survival differences diminished after exclusion of poor prognosis patients with reduced performance status and/or progressive extrathoracic disease, a slight increase in 2-year survival rates with higher EQD2 cannot be excluded. Because of relatively small improvements, a confirmatory randomized trial in this subgroup would have to include a large number of patients.
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http://dx.doi.org/10.14740/jocmr2980wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5412521PMC
June 2017

Contemporary radiooncological management of bone metastases from breast cancer: factors associated with prescription of different fractionation regimens (short or long course) in a rural part of North Norway with long travel distance.

Int J Circumpolar Health 2017 ;76(1):1270080

a Department of Oncology and Palliative Medicine , Nordland Hospital , Bodø , Norway.

The aim of this study was to reduce barriers that prevent implementation of evidence-based recommendations about single-fraction palliative radiotherapy (PRT) and to demonstrate that single-fraction PRT yields similar outcomes as long-course treatment (≥10 fractions) in patients with bone metastases from breast cancer. This retrospective study (2007-2014) included 118 Norwegian female patients. All patients received guideline-conform systemic therapy including bone-targeting agents. Median survival was 12.7 months. Long-course PRT was prescribed in 60% of patients, while 21% had PRT with a single fraction of 8 Gy to at least one target. Reirradiation rate was not significantly higher after 8 Gy (9%, compared to 5% after long-course PRT and 6% after 4 Gy x5). Patients with favorable baseline characteristics such as younger age and good performance status (PS) were significantly more likely to receive long-course PRT. Biological subtype and comorbidity did not correlate with fractionation. Prognosis was influenced by biological subtype, extra-skeletal disease extent, severe anemia and abnormal CRP. The limited need for reirradiation after single fraction PRT might encourage physicians to prescribe this convenient regimen, which would improve resource utilization. Even patients with PS3 had a median survival of 3 months, which indicates that they could experience worthwhile clinical benefit.
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http://dx.doi.org/10.1080/22423982.2016.1270080DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5328357PMC
March 2018

Prognostic Impact of the Tumor Marker CA 15-3 in Patients With Breast Cancer and Bone Metastases Treated With Palliative Radiotherapy.

J Clin Med Res 2017 Mar 25;9(3):183-187. Epub 2017 Jan 25.

Department of Oncology and Palliative Medicine, Nordland Hospital, 8092 Bodo, Norway.

Background: The aim of the study was to explore the prognostic impact of different abnormal blood tests and the tumor marker CA 15-3 as well as established parameters such as disease extent and receptor status in patients with bone metastases from breast cancer who received palliative radiotherapy in addition to contemporary systemic treatment.

Methods: This was a retrospective uni- and multivariate analysis of 118 female patients treated in the time period from 2007 to 2014 (median follow-up 28 months).

Results: The median age was 61 years and the median time interval from the initial diagnosis of breast cancer was 57 months (median time interval from metastatic disease to radiotherapy was 7 months). Only 16% of patients had normal serum CA 15-3. HER2 receptor status correlated with CA 15-3. The median survival was 17.6 months (lowest CA 15-3 quartile), 14.7 months (intermediate), and 6.9 months (highest quartile) (P = 0.002). However, multivariate analysis showed that survival was influenced by extent of extra-skeletal metastases, pleural metastases/effusion, lung metastases, estrogen receptor status, serum C-reactive protein, and anemia with need for blood transfusion (all P < 0.05) rather than CA 15-3.

Conclusions: Survival was highly variable. The tumor marker CA 15-3 did not provide independent prognostic information. Nevertheless, the results of simple blood tests contributed to the multivariate prognostic model.
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http://dx.doi.org/10.14740/jocmr2653wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5289136PMC
March 2017

Polypharmacy in Older Patients ≥70 Years Receiving Palliative Radiotherapy.

Anticancer Res 2017 02;37(2):795-799

Department of Oncology and Palliative Medicine, Nordland Hospital Trust, Bodø, Norway.

Background/aim: Many older cancer patients receive five or more daily medications (polypharmacy). The purpose of this study was to assess the prevalence of polypharmacy in older patients undergoing palliative radiotherapy and its influence on the risk of being unable to complete the prescribed number of fractions, as well as the 30-day mortality and overall survival.

Patients And Methods: Retrospective review of 289 patients aged 70 years or older.

Results: The median and mean Charlson comorbidity index (11) was 2, ranging between 0-7 (presently treated cancer not included). The median and mean number of daily medications was 7, ranging between 0-18. Only 27% of patients used less than 5 daily medications. Corticosteroids were used by 59% of the patients and opioid analgesics by 55%. Comorbidity, but also symptom severity, as indexed by pain medication, correlated significantly with the prevalence of polypharmacy. In multivariate analysis, neither polypharmacy nor use of corticosteroids or opioid analgesics influenced overall survival. No trends were seen for 30-day mortality or failure to complete radiotherapy.

Conclusion: Polypharmacy is a common phenomenon in older patients receiving palliative radiotherapy and it does not predict adverse radiotherapy outcomes.
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http://dx.doi.org/10.21873/anticanres.11379DOI Listing
February 2017

Survival After Palliative Radiotherapy in Patients with Breast Cancer and Bone-only Metastases.

In Vivo 2016 11-12;30(6):879-883

Department of Oncology and Palliative Medicine, Nordland Hospital, Bodø, Norway.

Background/aim: Patients with bone-only metastases survive longer than patients with widespread visceral disease. We analyzed the prognostic impact of different baseline parameters, such as abnormal blood tests and receptor status in patients who received local radiotherapy, in addition to contemporary systemic treatment, according to national guidelines.

Patients And Methods: Retrospective uni- and multivariate analyses of 57 consecutive female patients treated in the time period 2007-2014 (median follow-up=29 months).

Results: The median age was 59 years and the median time interval from the initial diagnosis of breast cancer was 57 months. The median survival was 23 months from radiotherapy and 32 months from initial diagnosis of metastatic disease. Five-year survival rates were 13 and 21%, respectively. Survival after radiotherapy was significantly longer in patients who were prescribed higher radiation doses; 29 months after ≥30 Gy and 10 months after <30 Gy, p=0.02. Multivariate analysis confirmed 4 independent prognostic factors for shorter survival: triple-negative histology (p=0.0001), high serum lactate dehydrogenase (LDH) (p=0.001), high serum alkaline phosphatase (ALP) (p=0.015) and intended radiation dose <30 Gy (p=0.028). A 3-tiered prognostic score with median survival of 48, 21 and 12 months was developed.

Conclusion: Prognosis varied widely with many patients surviving for several years. The results of simple blood tests provided important prognostic information. Prospective studies are necessary to confirm that more aggressive radiotherapy improves survival in patients with bone-only disease suitable for local therapy.
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http://dx.doi.org/10.21873/invivo.11008DOI Listing
January 2018

Palliative Radiotherapy in Cancer Patients with Increased Serum C-Reactive Protein Level.

In Vivo 2016 09-10;30(5):581-6

Department of Oncology and Palliative Medicine, Nordland Hospital, Bodø, Norway.

Background/aim: Connections exist between inflammation and cancer, for example with regard to disease progression and prognosis. Therefore, we investigated whether systemic inflammatory processes indicated by increased serum C-reactive protein (CRP) provide prognostic information for physicians prescribing palliative radiotherapy.

Patients And Methods: We analyzed data from 781 patients and evaluated prognostic factors for survival.

Results: Only 277 patients (35%) had CRP <8 mg/l before radiotherapy. No significant association was observed between CRP level and steroid treatment. In patients with the highest CRP level (>60 mg/l, 20% of patients), intravenous therapy with antibiotics was more common. CRP significantly influenced survival and contributed prognostic information together with established parameters, such as performance status (PS). In the multivariate model, white blood cell count did not provide relevant additional information. A simple four-tiered prognostic score solely based on CRP showed promising results.

Conclusion: Most patients treated with palliative radiotherapy had increased CRP. This widely available biomarker might improve decision-making and should be further validated.
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March 2017

Palliative radiotherapy during the last month of life: Predictability for referring physicians and radiation oncologists.

Oncol Lett 2015 Nov 2;10(5):3043-3049. Epub 2015 Sep 2.

Institute of Clinical Medicine, Faculty of Health Sciences, University of Tromsø - The Arctic University of Norway, Tromsø, Troms 9037, Norway ; Department of Radiology, University Hospital of North Norway, Tromsø, Troms 9038, Norway.

Oncologists commonly overestimate the survival time of patients receiving palliative therapy, which may result in the administration of treatments that are too aggressive for patients near the end of their lives. Previous studies have discussed the negative implications of palliative radiotherapy if administered during the last month of life. Models predicting a limited survival time may improve the ability of the oncologists to tailor the treatment according to the needs of each individual patient. In the present study, prognostic factors for survival time, and the use of palliative radiotherapy during the last month of life, were analyzed in 873 patients. Models predicting the likelihood of administering such therapy were examined, and the risk of receiving radiotherapy during the last month of life was observed to be lower in patients with non-metastatic cancer than in those with metastatic cancer (7 vs. 13%, respectively; P=0.12). On multivariate analysis, 11 factors that significantly influenced the survival time were identified. These findings emphasize the complexity of potential prediction models. The most important risk factor regarding the prediction of extremely short survival times was observed to be an Eastern Cooperative Oncology Group performance status (ECOG PS) of 4, followed by an ECOG PS of 3 (median survival times, 14 and 64 days, respectively). A limited number of patients who received palliative radiotherapy during their last month of life died unexpectedly. Disease-specific prediction models were developed; however, the small number of events available for analysis limited their immediate clinical impact. Furthermore, these prediction models identified a minority of patients who received radiotherapy during the last month of life. In conclusion, the majority of the palliative radiotherapy courses administered to patients with advanced cancer during their last month of life may be preventable if accurate decision models for the clinic are developed. However, due to the complexity associated with the prediction of survival times in patients receiving palliative radiotherapy, large databases are required to allow accurate models to be established. The present study also discusses the recommendations of the Department of Oncology and Palliative Medicine of Nordland Hospital (Bodø, Nordland, Norway) with regard to the use of palliative radiotherapy during the last month of life of patients with terminal cancer.
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http://dx.doi.org/10.3892/ol.2015.3656DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4665322PMC
November 2015

Palliative radiotherapy with or without additional care by a multidisciplinary palliative care team in patients with newly diagnosed cancer: a retrospective matched pairs comparison.

Radiat Oncol 2015 Mar 7;10:61. Epub 2015 Mar 7.

Department of Oncology and Palliative Medicine, Nordland Hospital, Bodø, 8092, Norway.

Purpose: To analyze survival after early palliative radiotherapy (RT) in patients managed exclusively by regular oncology staff or a multidisciplinary palliative care team (MPCT) in addition.

Methods: Retrospective matched pairs analysis. Comparison of two groups of 29 patients each: MPCT versus none. Early RT started within three months after cancer diagnosis.

Results: Bone and brain metastases were common RT targets. No significant differences in baseline characteristics were observed between both groups. Twelve patients in each group had non-small cell lung cancer. Median performance status was 2 in each group. Twenty-seven patients in each group had distant metastases. Median survival was not significantly different. In multivariate analysis, MPCT care was not associated with survival, while performance status and liver metastases were. Rate of radiotherapy during the last month of life was comparable. Only one patient in each group failed to complete radiotherapy.

Conclusions: MPCT care was not associated with survival in these two matched groups of patients. The impact of MPCT care on other relevant endpoints such as symptom control, side effects and quality of life should be investigated prospectively.
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http://dx.doi.org/10.1186/s13014-015-0365-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4355455PMC
March 2015

Early palliative radiation therapy in patients with newly diagnosed cancer: Reasons, clinical practice, and survival.

Pract Radiat Oncol 2015 Sep-Oct;5(5):e537-e542. Epub 2015 Mar 29.

Department of Oncology and Palliative Medicine, Nordland Hospital, Bodø, Norway; Institute of Clinical Medicine, Faculty of Health Sciences, University of Tromsø, Tromsø, Norway.

Purpose: To analyze indications for early palliative radiation therapy (RT) (ie, start within 1 month from cancer diagnosis), regimens used in clinical practice, rate of treatment completion and treatment in the last 30 days of life, and overall survival.

Methods And Materials: Retrospective uni- and multivariate analyses covering a 4.5-year inclusion period.

Results: Seventeen percent of all palliative RT courses were administered in the specified time frame (n = 100 patients, 30 Gy in 10 fractions in 49%). Common indications were bone and brain metastases, whereas metastatic spinal cord compression or other emergencies comprised a minority. Only 14% of patients had no distant metastases. Most patients had non-small cell lung cancer (51%), whereas other high-incidence primary tumors such as breast, prostate, and colorectal cancer combined comprised 10%. Failure to complete RT occurred in 6%. Median survival was 3.6 months. A startling high rate of RT in the last 30 days of life was observed (19%). Risk correlated significantly with performance status and extent of metastatic disease.

Conclusions: The study population of patients who received early palliative RT is not identical to the general population described in previous studies, which covered the entire disease trajectory. Median survival was relatively short and rate of RT in the last 30 days of life higher than expected. Need for early palliative RT might be caused by large symptom burden and/or contraindication(s) for other management options, and might in many cases also be associated with adverse prognostic features and aggressive disease.
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http://dx.doi.org/10.1016/j.prro.2015.02.008DOI Listing
June 2016

Tumor marker analyses in patients with brain metastases: patterns of practice and implications for survival prediction research.

Tumour Biol 2015 Aug 24;36(8):6471-6. Epub 2015 Mar 24.

Department of Oncology and Palliative Medicine, Nordland Hospital, 8092, Bodø, Norway,

This study aims to explore patterns of practice of tumor marker analyses and potential prognostic impact of abnormal markers in patients with brain metastases from solid tumors. Previously, lactate dehydrogenase (LDH) and albumin were identified as relevant biomarkers. We performed a retrospective analysis of 120 patients with known LDH and albumin treated with whole-brain radiotherapy (WBRT) in two different situations: (1) brain metastases detected at initial cancer diagnosis (n = 46) and (2) brain metastases at later time points (n = 74, median interval 13 months). Twenty-six patients (57 %) from group 1 had at least one tumor marker analyzed, and 11 patients (24 %) had abnormal results. Twenty-two patients (30 %) from group 2 had at least one tumor marker analyzed, and 16 patients (22 %) had abnormal results. When assuming that LDH and albumin would be standard tests before WBRT, additional potential biomarkers were found in 36 % of patients with normal LDH and albumin. Marker positivity rates were for example 80 % for carcinoembryonic antigen (CEA) in colorectal cancer and 79 % for CA 15-3 in breast cancer. Abnormal markers were associated with presence of liver metastases. CA 15-3 values above median predicted shorter survival in patients with breast cancer (median 1.9 vs. 13.8 months, p = 0.1). Comparable trends were not observed for various markers in other tumor types. In conclusion, only a minority of patients had undergone tumor marker analyses. Final group sizes were too small to perform multivariate analyses or draw definitive conclusions. We hypothesize that CA 15-3 could be a promising biomarker that should be studied further.
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http://dx.doi.org/10.1007/s13277-015-3337-yDOI Listing
August 2015

Survival after palliative radiotherapy in geriatric cancer patients.

Anticancer Res 2014 Nov;34(11):6641-5

Department of Oncology and Palliative Medicine, Nordland Hospital, Bodø, Norway.

Background/aim: Older cancer patients might experience inferior survival outcomes. However, no standard age cut-off is currently being used for commonly administered treatments such as radiotherapy. We evaluated survival outcomes and prognostic factors for survival after palliative radiotherapy (PRT) in our oldest patients (age≥80 years).

Patients And Methods: This retrospective study covered the time period between 2007 and 2012, and included 94 patients in this age group who were treated with PRT. Comparisons to a group of younger patients (31-79 years of age, N=445) treated during the same time period were made. Uni- and multivariate analyses were also performed. Most patients received PRT for bone and brain metastases or in order to improve thoracic symptoms from lung cancer.

Results: Median age was 83 years. Survival outcomes and rates of PRT completion were not significantly different. Short median survival of less than 2 months was observed in two sub-groups of geriatric patients; those with brain metastases and those with Eastern Cooperative Oncology Group (ECOG) performance status (PS) 4. Multivariate analysis confirmed the prognostic impact of PS, adrenal gland metastases, progressive disease outside PRT target volume(s), need for opioid analgetics and steroids (all p<0.05). Brain metastasis was associated with a borderline increase in risk of mortality (p=0.051).

Conclusion: Our data support utilization of PRT irrespective of age for most patients with PS 0-3 but care should be taken in selecting the right fractionation regimen in order to avoid lengthy PRT courses when survival is limited.
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November 2014

Oligometastatic non-small cell lung cancer: a significant entity outside of specialized cancer centers?

Med Princ Pract 2014 3;23(6):526-31. Epub 2014 Sep 3.

Department of Oncology and Palliative Medicine, Nordland Hospital, Bodø, Norway.

Objective: To report the incidence, patterns of care, and outcomes of oligometastatic non-small cell lung cancer (NSCLC) in a rural practice setting in Norway.

Materials And Methods: A retrospective analysis was conducted of all patients with stage IV NSCLC at the initial diagnosis who received active treatment in the central part of Nordland, a rural county in northern Norway, during the period of 2006-2012. We analyzed overall survival and prognostic factors.

Results: The initial study population included 113 patients with stage IV disease who received active therapy; of these, 23 (20%) had oligometastatic spread (a maximum of 3 metastases to 1 organ). The median age was 71 years. Of the 23 patients, 16 (70%) did not receive radical or at least moderately aggressive local treatment for their thoracic disease. Of the remaining 7 patients, 4 (17.4%) did not receive systemic therapy. The median actuarial survival was 5.6 months in patients with more advanced metastases and 11.7 months in those with oligometastases (p = 0.03). Significant differences were also seen between the 2 oligometastatic patient groups with and without more intense thoracic treatment (median 19.7 vs. 7.6 months, p = 0.004). Further significant predictors of survival in patients with oligometastases were nodal stage (p = 0.028) and weight loss (p = 0.045). Trends were seen for T stage (p = 0.058) and performance status (p = 0.07).

Conclusion: Oligometastatic NSCLC was diagnosed in a relevant proportion of patients; therefore, warranting prospective studies are recommended. Such studies are also needed to confirm the treatment-dependent survival differences observed in our patient population.
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http://dx.doi.org/10.1159/000365634DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5586936PMC
July 2015

Survival prediction score: a simple but age-dependent method predicting prognosis in patients undergoing palliative radiotherapy.

ISRN Oncol 2014 19;2014:912865. Epub 2014 Mar 19.

Department of Oncology and Palliative Medicine, Nordland Hospital, 8092 Bodø, Norway ; Institute of Clinical Medicine, Faculty of Health Sciences, University of Tromsø, Tromsø, Norway.

Purpose. Validation of a Canadian three-tiered prognostic model (survival prediction score, SPS) in Norwegian cancer patients referred for palliative radiotherapy (PRT), and evaluation of age-dependent performance of the model. Patients and Methods. We analyzed all 579 PRT courses administered at a dedicated PRT facility between 20.06.07 and 31.12.2009. SPS was assigned as originally described, That is, by taking into consideration three variables: primary cancer type, site of metastases, and performance status. Results. Patients with poor prognosis (non-breast cancer, metastases other than bone, and Karnofsky performance status (KPS) ≤ 60) had median survival of 13 weeks. Those with intermediate prognosis (two of these parameters) survived for a median of 29 weeks, and patients with good prognosis for a median of 114 weeks, P < 0.001. While this model performed well in patients who were 60 years or older, it was less satisfactory in younger patients (no significant difference between the good and intermediate prognosis groups). Conclusion. SPS should mainly be used to predict survival of elderly cancer patients. However, even in this group accuracy is limited because the good prognosis group contained patients with short survival, while the poor prognosis group contained long-term survivors. Thus, improved models should be developed.
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http://dx.doi.org/10.1155/2014/912865DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3977506PMC
July 2014

Palliative Radiotherapy with or without Additional Care by a Multidisciplinary Palliative Care Team: A Retrospective Comparison.

ISRN Oncol 2014 30;2014:715396. Epub 2014 Mar 30.

Department of Oncology and Palliative Medicine, Nordland Hospital, 8092 Bodø, Norway.

Purpose. To analyze pattern of care and survival after palliative radiotherapy (RT) in patients managed exclusively by regular oncology staff or a multidisciplinary palliative care team (MPCT) in addition. Methods. Retrospective analysis of 522 RT courses. Comparison of Two Groups: MPCT versus none. Results. We analyzed 140 RT courses (27%) with MPCT care and 382 without it. The following statistically significant differences were observed: 33% of female patients had MPCT care versus only 23% of male patients and 37% of patients <65 years had MPCT care versus only 22% of older patients. MPCT patients were more likely to have poor performance status and liver metastases. In the MPCT group steroid and opioid use was significantly more common. Dose-fractionation regimens were similar. Median survival was significantly shorter in the MPCT group, 3.9 versus 6.9 months. In multivariate analysis, MPCT care was not associated with survival. Adjusted for confounders, MPCT care reduced the likelihood of incomplete RT by 33%, P > 0.05. Conclusions. Patterns of referral and care differed, for example, regarding age and medication use. It seems possible that MPCT care reduces likelihood of incomplete RT. Therefore, the impact of MPCT care on symptom control should be investigated and objective referral criteria should be developed.
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http://dx.doi.org/10.1155/2014/715396DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4004167PMC
July 2014

A case of recurrent breast cancer with solitary metastasis to the urinary bladder.

Case Rep Oncol Med 2014 4;2014:931546. Epub 2014 Mar 4.

Department of Oncology and Palliative Medicine, Nordland Hospital, P.O. Box 1480, 8092 Bodø, Norway.

Elderly patients with breast cancer often present with symptomatic, locoregionally advanced rather than screening-detected disease, thereby increasing the risk of metastatic recurrence during their remaining life time. Typical sites of metastases include lungs, bones, liver, and brain. Here we present a patient who developed a solitary urinary bladder metastasis five years after primary diagnosis of stage T4 N0 estrogen receptor-positive lobular carcinoma, while on continued adjuvant endocrine treatment (91 years of age). Anemia and increased serum creatinine resulting from hydronephrosis led to diagnosis of metastatic disease, which was confirmed by transurethral resection. The patient responded clinically to palliative radiotherapy and a different type of endocrine therapy. One year after diagnosis of metastatic disease, she died without signs of cancer progression.
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http://dx.doi.org/10.1155/2014/931546DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3970251PMC
April 2014

Impact of systemic treatment on survival after whole brain radiotherapy in patients with brain metastases.

Med Oncol 2014 Apr 20;31(4):927. Epub 2014 Mar 20.

Department of Oncology and Palliative Medicine, Nordland Hospital, 8092, Bodø, Norway,

Most patients with brain metastases have active extracranial disease, which limits survival unless effective systemic therapy can be administered. Available options have increased over the last 5 years. Therefore, we analyzed patient cohorts treated with or without systemic treatment after completion of whole brain radiotherapy (WBRT). This study included retrospective uni- and multivariate analyses of 189 patients. Two landmark analyses requiring minimum survival of 1 or 2 months from start of WBRT were performed. Age and Karnofsky performance status (KPS) requirements were also applied in order to resemble a prospective trial that would limit inclusion to patients with defined baseline characteristics such as adequate KPS. Irrespective of these different statistical scenarios, systemic treatment significantly improved survival. For example, the 2-month landmark analysis with upper age limit and inclusion of patients with KPS > 60 only showed median survival of 9.0 versus 3.7 months, p = 0.001. All patients alive after more than 2 years had received systemic treatment (chemotherapy, endocrine therapy, tyrosine kinase inhibitors or other drugs). After WBRT, systemic treatment is a prerequisite for long-term survival. The exact magnitude of improvement can only be assessed in randomized trials because retrospective cohort studies, even if carefully designed, are not able to correct for all potential imbalances.
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http://dx.doi.org/10.1007/s12032-014-0927-2DOI Listing
April 2014

Active anticancer treatment during the final month of life in patients with non-small cell lung cancer.

Anticancer Res 2014 Feb;34(2):1015-20

Department of Oncology and Palliative Medicine, Nordland Hospital, P.O. Box 1480, 8092 Bodø, Norway.

Non-small cell lung cancer (NSCLC) is a major cause of cancer-related death and consumption of healthcare resources worldwide. Significant costs are generated shortly before death, partly because of continued oncological treatment during the terminal stage of disease. We analyzed factors predicting for the likelihood of active anticancer therapy during the final month of life. Patients who died from NSCLC (any stage and treatment) during the years 2006-2013 within a defined geographical region of northern Norway were included (n=266). Out of these, 28.6% received oncological treatment during the final month of life. Hospital death occurred in 70% of patients who received active treatment during their last month of life, compared to 41% of other patients (p=0.0001). Multivariate analysis showed that lack of documented resuscitation preference (p=0.001) and the presence of superior vena cava compression (p=0.039) were the most important predictors of active therapy during the last month of life. Trends were observed with regard to use of steroids for symptom palliation (p=0.067) and advanced T stage (p=0.071). Given that patients with documented resuscitation preference before their last month of life (typically a do not resuscitate order) were unlikely to receive active treatment during the final month (2% versus 35% in patients without documented preference), early discussion of prognosis, options for symptom control and resuscitation preference are crucial components in strategies for improving terminal care.
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February 2014

Development and validation of a model predicting short survival (death within 30 days) after palliative radiotherapy.

Anticancer Res 2014 Feb;34(2):877-85

Department of Oncology and Palliative Medicine, Nordland Hospital, 8092 Bodø, Norway.

The present study aimed to develop a predictive model that would allow for reduced utilization of palliative radiotherapy (PRT) during the final 30 days of life in patients with incurable cancer. We performed uni- and multivariate analyses of factors predicting PRT during the final 30 days of life for all PRT courses administered at a dedicated PRT facility between 20.06.2007 and 31.12.2009. We also developed a predictive model by recursive partitioning analysis (RPA), followed by independent validation of its performance in patients treated during 2010 and 2011. We analyzed 579 PRT courses. Median survival was 6.3 months. In 53 cases (9%) PRT was administered during the final 30 days of life. RPA resulted in a model consisting of six parameters (lung or bladder cancer, Eastern Cooperative Oncology Group performance status of 3-4, low hemoglobin, opioid analgesic use, steroid use, known progressive disease outside PRT volume), which correctly identified 75% of PRT courses administered during the final 30 days of life. Maximum survival of patients fulfilling all criteria was 69 days. Death within 40 days occurred in 83% of patients. In the independent validation data set, similar results were obtained: 74% (30 days), 84% (40 days), while maximum survival was 92 days. As demonstrated here and in other recent studies, assigning the right patient to the right palliative approach is challenging. We suggest that patients with lung or bladder cancer and the adverse features mentioned above are at high risk of dying shortly after initiation of PRT. Our model might support decision-making (best supportive care versus PRT) and is the first decision aid specifically addressing PRT near end of life.
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February 2014

Combined radio- and chemotherapy for non-small cell lung cancer: systematic review of landmark studies based on acquired citations.

Front Oncol 2013 9;3:176. Epub 2013 Jul 9.

Department of Oncology and Palliative Medicine, Nordland Hospital , Bodø , Norway ; Institute of Clinical Medicine, Faculty of Health Sciences, University of Tromsø , Tromsø , Norway.

The important role of combined chemoradiation for several groups of patients with non-small cell lung cancer (NSCLC) is reflected by the large number of scientific articles published during the last 30 years. Different measures of impact and clinical relevance of published research are available, each with its own pros and cons. For this review, article citation rate was chosen. Highly cited articles were identified through systematic search of the citation database Scopus. Among the 100 most often cited articles, meta-analyses (n = 5) achieved a median of 203 citations, guidelines (n = 7) 97, phase III trials (n = 29) 168, phase II trials (n = 21) 135, phase I trials (n = 7) 88, and others combined 115.5 (p = 0.001). Numerous national and international cooperative groups and several single institutions were actively involved in performing often cited, high-impact trials, reflecting the fact that NSCLC is a world-wide challenge that requires research collaboration. Platinum-containing combinations have evolved into a standard of care, typically administered concurrently. The issue of radiotherapy fractionation and total dose has also been studied extensively, yet with less conclusive results. Differences in target volume definition have been addressed. However, it was not possible to test all theoretically possible combinations of radiotherapy regimens, drugs, and drug doses (lower radiosensitizing doses compared to higher systemically active doses). That is why current guidelines offer physicians a choice of different, presumably equivalent treatment alternatives. This review identifies open questions and strategies for further research.
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http://dx.doi.org/10.3389/fonc.2013.00176DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3705186PMC
July 2013
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