Metastatic Prostate Cancer: An Update on Treatments and a Review of Patient Symptom Management.

BACKGROUND: Available treatment options have improved overall survival and contributed to delayed progression, but metastatic prostate cancer remains incurable. Treatment strategies are based on disease progression assessed by a combination of biochemical, radiographic, and symptomatic changes. OBJECTIVES: The aim of this article is to review metastatic prostate cancer, symptoms representing disease progression, disease treatments, and symptom management. METHODS: A PubMed® search restricted to English-language articles published since 1990 was conducted in August 2018 with combinations of the keywords "metastatic prostate cancer," "symptom assessment," and "treatment." Review articles were excluded, but their reference lists were reviewed to identify additional articles. Information from relevant articles published after August 2018 was added as appropriate based on author consensus. FINDINGS: Nursing professionals play vital roles in symptom recognition and reporting, identification of disease progression, patient education, and implementation of individualized treatment strategies.

The role of plain radiographs in management of bone metastases.

Approximately 50% of patients with cancer will develop skeletal metastases, which often lead to significant pain. When a patient complains of pain, a bone scan and/or plain x-rays are ordered as investigations. X-rays necessitate a 1-cm diameter mass and 50% bone mineral loss at minimum for detection. Up to 40% of lesions will be unidentified by x-rays, presenting false-negative results. Computed tomography (CT) scans can recognize a bony metastatic lesion up to 6 months earlier than an x-ray. However, plain x-rays can also lead to rare false-positive results. We present a case with a false-positive result in a patient with lung cancer.

The palliative performance scale: examining its inter-rater reliability in an outpatient palliative radiation oncology clinic.

INTRODUCTION: The Palliative Performance Scale (PPS) was developed by the Victoria Hospice Society in 1996 to modernize the Karnofsky Performance Scale. Currently, it is being used to measure palliative patient performance status in a variety of settings. Despite its widespread use, only one study has examined the inter-rater reliability of the PPS. PURPOSE: To examine the inter-rater reliability of the PPS in measuring performance status in patients seen in an outpatient palliative radiation oncology clinic METHODS: Performance status for 102 consecutive patients was assessed by an oncologist (MD), a radiation therapist (RT), and a research assistant (RA) in the Rapid Response Radiotherapy Program at the Odette Cancer Centre in Toronto, Ontario, Canada. Raters' scores were analyzed for correlation and compared to evaluate the inter-rater reliability of the PPS tool. RESULTS: Excellent correlation was found between the scores rated by the MD and RA (r = 0.86); good correlation was observed between scores rated by the MD and RT (r = 0.69) and the RT and RA (r = 0.77). Scores between all three raters, as well as between rater pairs, were also found to have good reliability as measured by the Chronbach's alpha coefficient. Significant results were obtained for the range of PPS scores in which the majority of our patients fell: 40-80%. CONCLUSION: PPS was shown to have good overall inter-rater reliability in an outpatient palliative setting, but more research is needed to establish the validity and reliability of the tool in a variety of different palliative settings.

Rare bone metastases of the olecranon.

Abstract Bone metastases are prevalent in patients with cancer, especially with primary lung, breast, renal cell, thyroid, and prostate carcinomas. When looking specifically at primary renal cell carcinoma, approximately 40% of patients will develop bone metastases during the course of their disease. However, distal bony involvement to the appendicular skeleton occurs less frequently, developing below the elbow and knee in approximately 7% of metastatic renal cell carcinoma patients. The incidence of olecranon metastasis is extremely rare in all cancers and so far only two cases have been reported in literature. We report the third case of an olecranon metastasis in a patient with renal cell carcinoma.

Has the pattern of practice in the prescription of radiotherapy for the palliation of thoracic symptoms changed between 1999 and 2006 at the rapid response radiotherapy program?

PURPOSE: Eleven randomized controlled trials (RCT) comparing various radiotherapy (RT) schedules for locally advanced lung cancer published since 1991 found no difference in palliation of intrathoracic symptoms. The most commonly prescribed schedule by Canadian Radiation Oncologists (RO) (20 Gy in five fractions [20 Gy/5]), when first evaluated versus 10 Gy/1 in a 2002 RCT, showed a significant survival benefit. A subsequent RCT assessing 20 Gy/5 found worse survival versus 16 Gy/2. This study examines whether the RT prescription for lung cancer palliation in the Rapid Response Radiotherapy Program (RRRP) has changed over time. METHODS AND MATERIALS: Chart review was conducted for patients treated with palliative thoracic RT across three periods (1999-2006). Patient demographics, tumor, treatment, and organizational factors were analyzed descriptively. Chi-square test was used to detect differences in proportions between unordered categorical variables. Continuous variables were tested using analysis of variance. Multivariate logistic regression was used to identify independent predictors of RT schedule prescribed. RESULTS: A total of 117 patients received 121 courses of palliative thoracic RT. The most common dose (20 Gy/5) comprised 65% of courses in 1999, 68% in 2003, and 60% in 2005-2006 (p = 0.76). The next most common dose was 30 Gy/10 (13%). Overall, the median survival was 14.9 months, independent of RT schedule (p = 0.68). Multivariate analysis indicated palliative chemotherapy and certification year of RO were significant predictors of prescription of 20 Gy/5. CONCLUSION: RT schedule for palliation of intrathoracic symptoms did not mirror the results of sequential, conflicting RCTs, suggesting that factors other than the literature influenced practice patterns in palliative thoracic RT.

Dexamethasone for the prophylaxis of radiation-induced pain flare after palliative radiotherapy for bone metastases: a pilot study.

PURPOSE: To investigate the efficacy of dexamethasone as a prophylactic adjuvant analgesic to decrease pain flare and to assess its safety and tolerance of dexamethasone. MATERIALS AND METHODS: Patients treated with a single 8 Gy for bone metastases took 8 mg dexamethasone before the radiation treatment. The Brief Pain Inventory was administered at baseline and then daily for 10 days after radiation. Pain flare was defined as a two-point increase in the worst pain or a 25% increase in the analgesic intake when compared with the baseline. RESULTS: Thirty-three patients (23 males, 10 females) had complete follow-up data. Their median age was 73 years old. Ten patients had progressive worsening pain during the entire 10-day follow-up. A total of eight patients (24%; 95% CI, 10-39%) experienced pain flare during the 10-day follow-up. Two patients had a 1-day pain flare on day 3. Three patients had a 1-day pain flare on day 7. Three other patients had a prolonged pain flare: one had a 3-day pain flare on days 2-4, one had a 3-day pain flare on days 4-6, and the other, a 6-day pain flare on days 3-8. The half-life of dexamethasone is 36-54 h. Only one patient (3%) experienced pain flare in the first 2 days of follow-up with the action of dexamethasone. Dexamethasone was well tolerated. CONCLUSION: Dexamethasone might be effective in the prophylaxis of radiation-induced pain flare after palliative radiotherapy for bone metastases. Randomized trials are required to confirm the finding.