Time Stamps

  • 02:04 What is radiation?
  • 03:17 How does radiation therapy work?
  • 04:50 How is today’s radiation different from the past?
  • 05:40 What role does radiation play in cancer treatment?
  • 07:48 What are the different types of radiation?
  • 15:34 How do you write a rad onc one-liner as an internist?
  • 19:59 What is palliative radiation and how/when should we use it?

Video of Rad Onc Physiology

Whiteboard Animation Video

Show Notes

PEARL 1

What is radiation?

  • When we think of radiation therapy, for the most part, it’s made of the same stuff as X-rays – photons (only much stronger).
    • X-ray machines, CT scans and radiation all use photons. 
      • Therapeutic radiation also uses photons, but at much higher energies and doses.

How does radiation work?

How is today’s radiation different from the past?

What role does radiation play in cancer treatment?

  • Types of radiation:
    • Neoadjuvant: before surgery, to shrink the tumor size (make surgery easier)
    • Adjuvant: after chemo or surgery, to “mop up” residual cancer cells
    • Definitive: given to cure the cancer (most often used in head/neck cancer). 
    • Palliative: use to treat a symptom (pain, bleeding, or mass effect from a tumor) 
  • Over 50% of patients with cancer have been cited to receive radiation.

PEARL 2

What are the different types of radiation?

  • External beam therapy (most common): 
    • Beam of radiation fired at the tumor
    • Uses: brain, thoracic, and abdominopelvic tumors.
    • Challenge: can have collateral damage from the beam hitting nearby structures.
    • Types:
      • EBRT (External beam radiation therapy): 
        • Standard radiation therapy
          • IMRT, IGRT, 3D conformal – from the internist’s perspective, these modalities can be grouped together. 
        • SBRT (stereotactic body radiation therapy):
          • Highly-focused
          • Minimal toxicity 
          • Not everyone is a candidate
            •  Small tumor and the right anatomy is needed!
            • Occasionally used in oligometastatic disease
        • SRS (stereotactic radio-surgery): 
          • Extra-highly-focused subtype of SBRT
            •  Occurs in 1 session (or “fraction”)
              • Like “surgery”!
            • Intended to fully ablate a particular lesion (ex. brain) 
  • Brachytherapy: 
    • Radiation-emitting source placed inside the tumor or right next to it. 
    • Uses: prostate, cervix, breast (easily accessible tumors)
    • Benefit: Designed to deliver radiation to one spot, and only that spot.
      • Strategies: 
        • Intracavitary: 
          •  Source is placed near the tumor by inserting a probe into a body cavity (ex. cervical cancer)
        • Interstitial:
          •  Source is placed inside the tumor itself (ex. prostate cancer).

How do you create a rad onc one-liner as an internist?

  • Step 1:  The “what” 
    • External beam or brachytherapy?
      • If it is an external beam, is it EBRT, SBRT, or SRS?
        • Remember, IMRT, IGRT, and 3D-conformal are ALL types of EBRT!
        • Leave out “Cyberknife” and “gamma knife”
          • These are just brand names! 
  • Step 2: The “where”
    • What structures were targeted since you may need to think about what’s nearby for side effects (part 2)
  • Step 3: The “when”
    • Was this radiation weeks, months, or years ago?
  • These 3 properties help clinicians reason through the effects of radiation, both intended effects and adverse/side effects
  • Example of one-liner BEFORE and AFTER we cleaned it up with these tips:
    • BEFORE: Information overload!
      • 60 year-old male with borderline-resectable pancreatic cancer, s/p FOLFIRINOX for 4 cycles, followed by 4D-CT IMRT with respiratory gating at 1.8Gy/fraction (total 50.4 Gy) with concurrent capecitabine completed 10/31/2022
    • AFTER: Clear, concise, and informative!
      • 60 year-old male with borderline-resectable pancreatic cancer. He got chemotherapy, followed by an extended course of standard EBRT, alongside more chemotherapy. Treatment ended in October 2022. 

PEARL 3

What is palliative radiation?

  • Lower dose and fewer fractions of radiation
    • 5 or less fractions
  • Intent
    • Less burdensome 
      • Less appointments
      • Lower doses → less side effects
    • Manage and relieve symptoms:
      • Pain
        • Effect: 1-2 weeks after treatment, peak effect at 4-6 weeks
        • Pain flare can happen within 24-48 hours of treatment
      • Bleeding
        • Short-term: promotes clot formation
        • Long-term: blood vessel fibrosis
      • Cord compression
        • Note: this is a rad onc emergency!
        • Consult rad onc and neurosurgery
          • Steroids may be used to temporize

When should patients be referred for palliative radiation?

  • Early and often!
    • Associated with improved performance status and  extended life. 

Transcript

Dr. Matthew Abrams: A lot of patients and sometimes providers come in with misconceptions about how radiation works, what side effects patients may experience, whether patients are gonna be radioactive. I spend the majority actually of my time counseling patients in the first consultation to hopefully dispel any of these myths and misconceptions.

Dr. Shreya Trivedi: That’s Dr. Matthew Abrams, a radiation oncologist at BIDMC. We’ll aim to do some myth-busting for this episode – for ourselves and our patients. Welcome to “5 Pearls” podcast, bringing you high-yield, evidence based pearls. Today, we’ll dive deep into a topic that I think is a blind spot for many of us – radiation oncology.  This episode was largely inspired by Dr. Sam Kumarasena.

Dr. Sam Kumarasena: Hi everybody! I’m Sam, a second-year resident at Beth Israel Deaconess Medical Center.

Dr. Shreya Trivedi: And I guess since this topic is a whole field we did split this episode into two parts! So today, we are going cover the first 3 pearls today and really set the foundation with this episode.  

Dr. Sam Kumarasena: And next Wednesday, we’ll publish part 2, which will get into all things side effects-related.

Dr. Shreya Trivedi: And also look out for a short Youtube whiteboard animation that Sam created explains interesting physiology of radiation 

Dr. Sam Kumarasena: I’m gonna toot my own horn here, it’s worth a watch, for sure!

Dr. Shreya Trivedi: And with that, let’s get started! Quiz yourself on the following pearls. Remember, the more you test yourself, the deeper your learning gains.

Dr. Sam Kumarasena: Pearl 1 – Intro to Radiation.

Dr. Shreya Trivedi: What is radiation, and how does it work?

Dr. Sam Kumarasena: Pearl 2 – Types of Radiation.

Dr. Shreya Trivedi: What are the different types of radiation out there, and what should we and shouldn’t we put in our one-liners?

Dr. Sam Kumarasena: Pearl 3 – Palliative Radiation.

Dr. Shreya Trivedi: What makes palliative radiation different from curative radiation? And what are some of the most common scenarios to refer to for  palliative radiation?

Pearl 1

Dr. Shreya Trivedi: So, I think most of us have taken care of a patient who has had radiation therapy in the past, but let’s set the foundation with some big picture points on radiation and maybe the first and lowest hanging fruit, that comes to mind, to make sure we on the same page about is, what exactly is radiation? I mean I kind of know, but I’d love to hear how a rad onc describes it!

Dr. Sam Kumarasena: Me too! We sat down with Dr. Daphna Spiegel, an assistant professor in radiation oncology at Harvard Medical School. She specializes in breast and GYN malignancies at BIDMC. And she framed what exactly radiation is, in a really simple way.

Dr. Daphna Spiegel: So, when we deliver radiation to treat cancer, we’re using the exact same kind of radiation that patients get when they get an X-ray, like if they break their arm or a CAT scan. It’s exactly the same. The main difference that makes this therapeutic versus diagnostic is that the radiation is given in much higher doses, and is much more focused and targeted than what you get with an X-ray or a CAT scan. 

Dr. Sam Kumarasena: Okay, got it, so it’s the same stuff as X-rays, just at a higher energy level. If an X-ray machine is like a water gun, radiation therapy is like a firehose… So now, how does that actually work, do the photons physically destroy the cells, somehow? 

Dr. Matthew Abrams: The way that radiation works is, uh, it basically creates, uh, or ionizing radiation creates free radicals. Uh, these free radicals then go and, uh, damage the DNA through a series of double strand and, uh, single strand breaks, but it’s predominantly the double strand breaks that are catastrophic to the cell. And then when the cell goes to divide, the cell actually dies through something called mitotic catastrophe. Uh, and that’s actually how radiation kills cancer. 

Dr. Shreya Trivedi: Mitotic catastrophe ! I gotta save that one for my next dinner parties! So I guess with radiation causing all this mitotic catastrophe, I’m curious, how come the radiation doesn’t kill all the cells in the area, how come it doesn’t kill healthy cells?

Dr. Sam Kumarasena: That is a great question! I think the difference is, healthy cells still have their DNA repair pathways intact, so even if they get hit by radiation a little bit they’re able to recover from that kind of damage. But for cancer cells, they’re often missing that repair machinery they need to recover. So, it’s kind of a death sentence for them.

Dr. Shreya Trivedi: Womp-womp-womp!

Dr. Sam Kumarasena: The other thing to keep in mind, technology has come a long way. Rad oncs can really target the cancer carefully.

Dr. Matthew Abrams: For example, when I treat pancreas cancer, we actually use a machine that, uh, gates the treatment. So it will actually adjust the treatment based on the patient’s respiratory pattern based on implanted fiducials or little gold seeds that we put into the tumor. So if you actually watch the machine, it’ll actually move with the patient as they’re breathing to account for that motion. 

Dr. Shreya Trivedi: Wow today’s radiation therapy it sounds like is a completely different ball game. Yes, sure, I think we’ve all had that who received radiation 30-40 years ago, had significant complications because they radiation to large parts of their bodies. And, yeah, these cases come up on our board questions, stick in our memories, maybe more than they should. But today’s radiation is not the same radiation as we saw decades ago.

Dr. Matthew Abrams: And so the goal is that with more advanced technology, um, more accurate, more precise, better mobilization, better technology or machines, we’re able to once again, maximize the dose to the tumor, uh, and minimize the dose to the critical structures and hopefully minimizing toxicity and side effects down the road.

Dr. Sam Kumarasena: Got it! So, this isn’t your grandma’s radiation! 

Dr. Shreya Trivedi: That’s my favorite line of this whole episode! Hearing Sam say that! I guess, one last big-picture question to end this pearl is, how exactly does radiation fit into the larger cancer treatment plan? I think we often hear terms like neoadjuvant, adjuvant or definitive. Let’s kind of understand those terms a bit more and the role that radiation can play. 

Dr. Matthew Abrams: I think it’s important for internists to understand that for the vast majority of cancers, radiation does come into play, uh, through various ways. A lot of times it’s in conjunction with surgery. Uh, so, uh, we give radiation preoperatively before surgery, uh, that’s called neoadjuvant radiation. We can give radiation postoperatively after surgery, that’s called adjuvant radiation. The purpose, uh, of radiation when it’s given before surgery is often to, uh, help shrink the tumor down, make the surgery easier to do, and reduce the risk of the cancer coming back. When we give radiation after surgery, the purpose of it is to hopefully account for any microscopic disease that may have been left behind at the time of surgery, um, to reduce the risk of the cancer coming back. 

Dr. Sam Kumarasena: Yeah, I think we’re hearing that radiation really spans the whole breadth of cancer care. As a heads up we will also talk about another type of radiation, palliative radiation, in Pearl 3 of this episode.

Dr. Shreya Trivedi: Yeah, I can’t wait for that! So let me summarize some of the big concepts here. Radiation therapy works by using photons to kill cancer cells. These photons are the same stuff as visible light, X-rays, or CT scans, but these photons higher-energy, strong enough to disrupt DNA. And the hope is that radiation kills cancer cells, while sparing healthy tissue and this is especially possible with newer technology. And the role of the radiation can really differ based on if its neoadjuvant, in other words, pre-op to shrink the tumor, or adjuvant, which is post-op to try and reduce any residual disease, or given “definitively” to cure the cancer.

Dr. Shreya Trivedi: Alright, Sam! I think the other thing that is a blackbox for most of us is the different types of radiation. Sometimes I look at these ones liners of patients who have had radiation therapy in the past and it kind of feels like a big blob of hieroglyphics. I’m really curious, is there a better way to think about radiation or easier way to simplify it? 

Dr. Daphna Spiegel: Some of the ones that you might come across are things like EBRT, which stands for external beam radiation therapy. That’s really a big broad term that refers to most of the radiation that we do. Essentially saying that this is radiation that’s coming from the outside in. 

Dr. Shreya Trivedi: That makes sense. So the “EB” in EBRT means “External beam”, and that’s exactly what it sounds like, right? You point the beam at a cancer, often through a linear accelerator. 

Dr. Sam Kumarasena: Fun fact, a linear accelerator is called a “LINAC” in the biz. 

Dr. Shreya Trivedi: That’s a cool term to throw around, too. Thanks for that, Sam! So if “external beam” is the most common, right, that’s what she said, it’s the most common. Then, what’s the alternative to that?

Dr. Matthew Abrams: Another way to deliver radiation is not with a linear accelerator, but instead with a radioactive source that, uh, is called brachy therapy or brachy therapy. It comes from the, uh, Greek brachy meaning “close”. What it basically is, is when you take a radioactive source or, and you bring it into the tumor.

Dr. Sam Kumarasena: I think the teaching point here is, if we are using brachytherapy to physically implant radioactive sources, it kind of makes sense that brachytherapy is gonna be common in malignancies that are easy to access, such as prostate cancer.

Dr. Shreya Trivedi: Wait a minute, implanting radioactive sources? So does that mean brachytherapy patients are radioactive?

Dr. Matthew Abrams: Technically speaking, there are some patients that are radioactive. 

Dr. Sam Kamarasena: Oh geez, so we did talk to a few radiation oncologists about it, and the bottom line is, yeah, there are a rare few patients with brachytherapy who are radioactive, but most aren’t! And unless your patients are counseled differently by their rad oncs, they shouldn’t be worrying about it.

Dr. Shreya Trivedi: Okay, good to know! So I guess from what I am hearing, to simplify the different types of radiation, we can really divide it into two different buckets – “external beam versus brachytherapy.” But there are all these other acronyms I still see in one-liners. IMRT, SBRT, SRS, Cyberknife, gamma-knife. It’s all word salad to me!  

Dr. Daphna Spiegel: But then within external beam radiation, there’s all these other little acronyms and subtypes of radiation. So things that you might across are things like IMRT or Intensity Modulated Radiation Therapy or VMAT which is an ARC type of radiation therapy. And all of these are really kind of minutiae almost in terms of the big picture for your patients. What those terms refer to are really trying to say that we are trying to create this conformal radiation plan to really treat what we need to treat, and avoid the stuff that doesn’t need to get treated as best as possible.

Dr. Sam Kumarasena: Okay, okay. IMRT, other things like IGRT, 3D conformal radiation. These are all just garden-variety external-beam radiations. And as internists, we don’t really need to stress about the differences between them.

Dr. Shreya Trivedi: Ah, I’m so relieved to hear that! That it is minutiae and it’s okay if we don’t need think about this stuff so much!

Dr. Sam Kumarasena: Well, hold the phone! We do need to pull a couple things out of the alphabet soup. Two things, really, “SBRT” and “SRS.” Because these are special techniques, both under the external-beam radiation umbrella, and they’re pretty different from the rest of the soup. So we’ll focus on those for a minute. 

Dr. Shreya Trivedi: Alright, I’m getting a bit hungry, thinking about salad and soup! I am curious what is so special about SBRT and SRS? Maybe we can start with SBRT!

Dr. Daphna Spiegel: One thing that is a little bit different is when we do SBRT or stereotactic body radiation therapy, we’re giving high doses of radiation very quickly over a small number of treatments. And because there’s minimal normal tissue in the field, there’s not as much damage to normal stuff and your body doesn’t have to work as hard in order to repair that. So a lot of times those kinds of treatments are so well tolerated, patients have no side effects. They don’t even, they’re like, are you even turning the beam on? I feel great. And so, they might not experience much in the way of fatigue or any of the other side effects. 

Dr. Shreya Trivedi: Wow, so SBRT, stereotactic body radiation, sounds fantastic! High doses where the patients only comes in a few times for it, minimal tissue toxicity and side effects. Gosh! Why isn’t everyone getting SBRT? There must be some catch, right?

Dr. Daphna Spiegel: So there’s so many advantages. However, not everybody’s a candidate. So if we think about patients that can get SBRT for lung cancers for example, its patients with small tumors that are just in the lung with no lymph node spread. 

Dr. Shreya Trivedi: Bummer, okay! So SBRT is really best used in small, early-stage tumors. 

Dr. Sam Kumarasena: Year, totally! A small caveat, there are some exceptions. SBRT can be used in isolated sites of metastases. But I think the big takeaway here, is that in most cases, when we think of SBRT, we’re thinking of early stages, small tumors.

Dr. Shreya Trivedi: And maybe this can really motivate us about lung cancer screening, right? If we catch it really early, then our patients could have a way different or way better experience with their radiation, with less toxicity. We’re fans of SBRT if we can have that for our patients! What about that second alphabet soup you pulled out, SRS – what’s goin on with that?

Dr. Daphna Spiegel: SRS or stereotactic radio-surgery. That’s basically a specialized type of SBRT. And we specifically use that for lesions that are in the brain.  And there are typically single fraction treatments and again, very, very focused and targeted and you just finish your radiation in one treatment. 

Dr. Sam Kumarasena: Really cool! Let’s remember that SRS, or “sterostatic radio-surgery” is still an external beam, pointed at the brain tumor. But, it has “radio-SURGERY” in the name for a reason, right? That’s because SRS is one-and-done, just like surgery is. It’s also highly-focused. Which is great for brain tumors, ‘cause you don’t want to hit healthy brain. 

Dr. Shreya Trivedi: Yeah! Thanks for making that all make sense to me, Sam. I have another question. Often time in these one-liners I see things like Cyberknife, gamma-knife, and gosh, I’ve copied forward that stuff forward so much. But, really, what are those? Are they even fancier or cooler than SBRT?

Dr. Matthew Abrams: Yeah, no one should ever be using the word CyberKnife or gamma. There are a lot of different machines as well. So there’s CyberKnife gamma knife, um, true beam. Um, all of these are, um, trade names. So it’s like saying I drive Lexus or I drive a Toyota. Um, I try to avoid saying all of those names because they’re, they’re somewhat meaningless. The technique, uh, is what’s really important and that’s the 3D conformal IMRT or SBRT. The machine that you use to deliver it, uh, is less important.

Dr. Sam Kumarasena: Oh man, I’m kinda embarrassed now. So the Cyber-gamma stuff is just SBRT, with a brand name. Next time I talk to an oncologist, I’ll just say SBRT. Good to know! Okay, well, now I know what not to put in my one-liner! 

Dr. Shreya Trivedi: Yeah, same! So I guess we talked a little about what not to put in our one-liner, but maybe we should be asking ourselves, what should we be puting in our one-liner of a patient who had radiation?  

Dr. Sam Kumarasena: We asked our radiation oncologists this question. And they told us, we really just need to know the “what”, the “where”, and the “when” of the radiation. As internists, we don’t really need to worry about things like Cyber/gamma, or fractions or Gray or whatever!  We just need to know enough to help us understand any symptoms or side effects our patients might have, in the context of their radiation. 

Dr. Shreya Trivedi: And maybe we can operationalize that with some practice! Sam, can you walk us through a one-liner of a case you’ve seen in the past? 

Dr. Sam Kumarasena: Yeah, absolutely! Let’s get into it. “60 year-old male with borderline-resectable pancreatic cancer, s/p FOLFIRINOX for 4 cycles, followed by 4D-CT IMRT with respiratory gating at 1.8Gy/fraction (total 50.4 Gy) with concurrent capecitabine completed 10/31/2022.” Oh boy, what in the world?!

Dr. Shreya Trivedi: Yikes! Yeah, I honestly feel like my eyes would just glaze through that whole blob of words. Let’s trim that down a bit, what’s really important here, Sam? 

Dr. Sam Kumarasena: Yeah, let’s start with the stuff we know. This patient got induction chemo, that’s the FOLFIRINOX. Great! Next, let’s tackle the jargon. “4D-CT IMRT with respiratory gating,” don’t panic. All we need to pick up in there, is “IMRT.” The rest is just a fancy technique to account for the patient’s breathing during radiation. Which is pretty cool, but we don’t really need to know it. 

Dr. Shreya Trivedi: Yeah, and IMRT, now that I know about it more,  it’s just one of the standard external beam radiation types! So, we probably even just call it “EBRT” or external beam radiation in our one-liner, right Sam?

Dr. Sam Kumarasena: Yeah, exactly! That’s right.

Dr. Shreya Trivedi: Then next, you mentioned, “1.8Gray/fraction (total 50.4 Gray).” I think that’s all radonc-speak for the amount of radiation received. Maybe we can ignore this, too?

Dr. Sam Kumarasena: Totally, we can ignore that bit. But, if you do want to dig a little deeper, and do some math, if you divide the total amount of radiation, that’s 50.4 Gray, by the 1.8 Gray per fraction, you get 28 fractions. So this patient went through 28 fractions, in other words, 28 sessions, of radiation. That’s a pretty long course! Which must mean the rad oncs are going after this lesion pretty aggressively.

Dr. Shreya Trivedi: Yeah, I guess that is a good bit to know, but maybe a little too much math for me! Might need a little more coffee for that! And that last thing you had mentioned was, “concurrent capecitabine completed 10/31/22”. So that just basically means he got some chemo alongside his radiation.

Dr. Sam Kumarasena: One more thing about that, the fact that this patient got radiation on, the Halloween holiday isn’t so much what matters – what matters is that he got it in October. We care about general timeframes: weeks, months, or years ago. Mostly because that can play into how we think about radiation effects. We’ll talk about all that in Part 2 of this series!

Dr. Shreya Trivedi: Let me take a stab at making that one-liner more better. So we have a 60 year-old patient who has a borderline-resectable pancreatic cancer. He got chemotherapy, followed by an extended course of standard EBRT, alongside more chemotherapy. And that treatment ended months ago, in October 2022. How was that, Sam?

Dr. Sam Kumarasena: Hooray! Perfect job! Now we’ve gotten rid of all that extra cognitive baggage. Which means we can actually focus on what actually matters to you as an internist.

Dr. Shreya Trivedi: Yes, yes, yes – I appreciate this so much! I think the other big takeaway I’m going to have is that if I have the patient whose had external beam radiation, EBRT, in the past, I’ll specifically look to see if it was SBRT and SRS in their history. I think that will just help me know if this was highly-targeted, a well-tolerated treatment, and will lower likelihood of thinking if there are side-effects or toxicity from it. 

Dr. Shreya Trivedi: Okay, so we’ve talked a ton about radiation with more of a curative intent. Let’s round out the foundations that we are setting with the other side, palliative radiation!

Dr. Daphna Spiegel: The goal is to palliate symptoms. Our goal is to not cause more problems. So we wanna make patients feel better. These are often patients that have metastatic disease, for example, and are coming in with a particular symptom that’s bothering them. It might be pain, it might be bleeding. And our goal is to try to get the pain to go down, to get the bleeding to stop. And we can use radiation pretty effectively to do that. Radiation can shrink the tumor, help alleviate the pain, cause the bleeding to stop. 

Dr. Sam Kumarasena: And with that palliative intent in mind, these treatments are just a few fractions, unlike the days-to-weeks of sessions of curative radiation. Palliative radiation also uses lower-dose treatments. So the side effects tend to be less ,as well. 

Dr. Shreya Trivedi: I do like hearing that. So, I’m curious, how does palliative radiation actually reduce pain and bleeding?

Dr. Sam Kumarasena: You know, for patient pain, it’s pretty straightforward because tumors cause pain because they destroy nearby tissue, especially with bony destruction or nerve compression. And then radiation goes in and shrinks the tumor, relieves that compression and allows that tissue to heal. But it is important to note that the process takes time, so patients usually start to feel better at 1-2 weeks, and they’ll get “peak relief” at 4-6 weeks.

Dr. Shreya Trivedi: So palliative radiation doesn’t necessarily work right away, when it comes to pain. 

Dr. Sam Kumarasena: Yeah, unfortunately, sometimes it doesn’t. Sometimes people can even have a “pain flare”, in the first 24-48 hours after palliative radiation. 

Dr. Shreya Trivedi: Okay, that’s good to know in terms of prepping out patients for a potential short, initial pain then things will get better. Nice! Okay, What about bleeding? How does radiation reduce bleeding?

Dr. Sam Kumarasena: Radiation activates clot formation to stop bleeding in the short-term. Then in the longer term, radiation causes fibrosis in the vessels to prevent re-bleeding.  

Dr. Daphna Spiegel: So I had a patient who came in a week or two ago and she was bleeding, I mean soaking through pads because of her cervical cancer that was very advanced and she was in a lot of pain because of her cervical cancer also. And we gave her radiation. We did a one-week course of radiation, so five fractions doing a dose that is maybe a third to a half of what we would do in the definitive setting. And the patient’s bleeding totally stopped. Her pain was better. She was using less narcotic medication at the end of those five treatments and was just feeling better. 

Dr. Sam Kumarasena: Wow, that’s really amazing. After just one quick course of radiation!

Dr. Matthew Abrams: I remember a patient with multiple myeloma who had an epidural mass, uh, from uh, his multiple myeloma that was compressing his spinal cord. He presented with inability to walk. Uh, so he came in basically in a wheelchair. We, uh, I saw him urgently in the hospital, um, recommended a short course of five fractions of palliative radiation targeting the epidural mass, causing malignant spinal cord compression. He received his five fractions of palliative external beam radiation while he was in the hospital.

Dr. Sam Kumarasena: That’s 
honestly incredible to hear. What a difference that radiation made for him.

Dr. Shreya Trivedi: Now for cord compression, obviously radiation is a no-brainer. But how about the risk-benefit profile for other symptoms? I think we talked a little bit about pain already, but is there any risk that radiation could actually cause more symptoms than it relieves? I’m just asking cause we talked about pain flares for a little bit. 

Dr. Daphna Spiegel: Sometimes it can but generally, even if it does cause side effects, those side effects are really short lived. So maybe it’s a week or two, but then overall things are better for a while for these patients. And so , you know, that kind of risk benefit is worth it.

Dr. Shreya Trivedi: Okay, I appreciate that clarification. I think alot of  misconceptions come with radiation side effects and we will get to some of that in our next episode. But I guess at least with palliative radiation, we don’t have to worry too much about any long-lasting side effects. So I guess the next question is, when should we be referring patients for palliative radiation?

Dr. Matthew Abrams: When should we refer patients for palliative radiation? All the time. Um, all the time. I would say, if the question ever comes to your mind, if the patient may be a candidate for palliative radiation, you should refer that patient for an evaluation. So there have actually been quite a few studies now, especially in locally advanced, um, and metastatic lung cancer looking at early in initiation of palliative care, and it actually improves survival. 

Dr. Shreya Trivedi: Improves survival! Maybe if I were to summarize this pearl, things I learned is that palliative radiation can used for reducing pain, bleeding, cord compression, and I’m sure there’s a bunch more things we didn’t discuss, but those were the big ones. And then typically, palliative radiation uses lower doses, fewer treatments, so it’s less burdensome for the patient both from an appointment perspective, but also fatigue and other side effects! 

Dr. Sam Kumarasena: And that brings us to the end of this episode! 

Dr. Shreya Trivedi:  If you found this episode helpful, please share with your team and colleagues and give it a rating on Apple podcasts or whatever podcast app you use! It really does help people find us! Tweet us and leave a comment on our website, or on Instagram or facebook page. Thank you to Dr. Sarah Stephens and Dr. Julian Hong for reviewing this episode. Thank you also to Daksh Bhatia for audio editing and to Dr. Kabao Vang for the accompanying graphics. 

Dr. Sam Kumarasena: This episode was made as part of the Digital Education Track at BIDMC – thank you to all our great educators and mentors! 

Dr. Shreya Trivedi: As always, we love hearing feedback! Email us at hello@coreimpodcast.com. Opinions expressed are our own and do not represent the opinions of any affiliated institutions.

References

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