Patient selection for palliative radiotherapy, oligometastatic stereotactic body radiation therapy, diabetic foot reconstruction, and low-salt diets

The May 2023 issues of Annals of Palliative Medicine featured 12 Original Articles, 4 Editorials, 1 Review Article, 2 Editorial Commentary Articles, and 1 Case Report. Additionally, that issue also featured articles from five different columns, including a Palliative Radiotherapy Column narrative review, an Oncology Nursing review, a Medical Oncology narrative review, an Editorial Commentary on Palliative Reconstructive Surgery, and an Editorial Commentary on The Human Experience. This Message from the Editor-in-Chief focuses on those five column articles and highlights the ongoing columns (1) that help to ensure, in addition to our standard article types, that cutting-edge, impactful, clinically useful, and provocative content are regularly published in Annals of Palliative Medicine.

Annals of Palliative Medicine is proud to have recurring columns that include Palliative Radiotherapy, Ethics, Pain, Oncology Nursing, Medical Oncology, Palliative Surgery, and The Human Experience. Several of these columns were active in the May 2023 issue.

First, in the Palliative Radiotherapy Column, a group of international palliative radiation oncology experts (2) conducted a narrative review assessing the appropriateness of using the 30-day expected mortality metric when considering patients for palliative radiation treatment. The authors found that several trials have reported patient populations achieving significant pain responses and/or improvements in bleeding in as few as two weeks and more commonly four weeks following radiation therapy. Therefore, the authors concluded that radiation therapy should be considered in patients with symptoms amenable to improvement with palliative radiotherapy regardless of life expectance, and that the 30-day mortality metric should not be the only tool used when considering offering radiotherapy.

The merits of single fraction palliative radiotherapy have been reported extensively in this journal (3-5) and others, and such an abbreviated yet effective treatment approach should be preferentially used in patients with a limited life expectancy. This international review also underscores not withholding radiotherapy for patients with a limited life expectancy, especially considering life expectancy in terminal cancer patients is notoriously difficult to predict accurately and since prognostic discordance between physicians and their patients or patient surrogates is common (6,7).

In the Oncology Nursing Column, Galassi and colleagues (8) wrote a review on the global challenges and initiatives in oncology nursing education. With an increasing armamentarium of systemic therapy options beyond cytotoxic chemotherapy, including target therapies and immunotherapies, with recent advances in surgical procedures and perioperative management, and with increasing use of advanced radiation therapy modalities, including stereotactic body radiation therapy (SBRT), intensity-modulated radiation therapy (IMRT) and proton therapy, there is increasing need for specialized training for nursing in oncology disciplines beyond general nursing education. The authors discuss critical challenges, including current nursing staffing shortages and limited qualified oncology nursing faculty. These challenges are compounded by the growing public health burden of cancer. The authors discuss recommendations on nursing education from international authorities, and they detail economic, human resource, social, cultural, and governmental interventions that have the potential to overcome current challenges relating to optimizing oncology nursing education.

Next, in the Medical Oncology Column, Mikropoulos et al. (9) wrote a narrative review on the current state of oligometastatic prostate cancer. The landscape of oligometastatic cancer, typically defined as 5 or fewer sites of disease (10), has been rapidly changing, and radiation therapy is playing an increasing role in the non-palliative management of patients with oligometastatic disease (11,12). The authors focus on the role of and data for SBRT to treat oligometastatic prostate cancer, and they report on several recent trials demonstrating improvements in clinical outcomes when delivering SBRT to sites of metastases in this patient population (13-15). The authors, however, underscore the existing challenges with current studies, which to date are predominantly phase 2 trials, with phase 3 data lacking. Additional larger studies are needed to better clarify the role of SBRT in both oligometastatic and oligoprogressive prostate cancer.

The Palliative Reconstructive Surgery Column featured an Editorial Commentary written by Christos Tsagkaris (16) on diabetic foot reconstruction. Diabetic foot, a foot ulceration in patients with diabetes, can have a considerable impact on patient quality of life and can lead to chronic wounds, osteomyelitis, and amputations (17,18). The author discusses plastic reconstruction of diabetic foot, including the manipulation of the soft tissue to enhance wound healing and prevent or decrease the extent of amputation, and he describes common techniques utilized for this surgery. He also talks about patient access to diabetic foot reconstruction and European Union initiatives to improve equitable access to healthcare. The author highlights the burden that diabetic foot has on patients and society, and he discusses why diabetic foot reconstruction should be given a higher priority for funding.

Lastly, for The Human Experience Column, Nike Izmaylov (19) wrote a compelling and compassionate Editorial Commentary on nutritional needs for patients. The author describes the challenges of weighing dietary restrictions in a patient with renal disease, which can serve to delay the progression of his renal dysfunction, with the wishes of the patient to eat salty food. While this patient was able to start dialysis and had what is inferred to be a good clinical outcome, this fun narrative underscores the importance of treating patients humanely, respecting their wishes, and shared decision making—all things that are great lessons and critically important for us as palliative care and more extended healthcare providers.

Acknowledgments

Funding: None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Annals of Palliative Medicine. The article did not undergo external peer review.

Conflicts of Interest: The author has completed the ICMJE uniform disclosure form (available at https://apm.amegroups.com/article/view/10.21037/apm-23-491/coif). The author serves as the Editor-in-Chief of Annals of Palliative Medicine. The author has no other conflicts of interest to declare.

Ethical Statement: The author is accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Simone CB 2nd. Current focus and future advances for Annals of Palliative Medicine. Ann Palliat Med 2014;3:37-8. [PubMed]
2. Navarro-Domenech I, Behroozian T, Hoskin P, et al. Appropriateness of the 30-day expected mortality metric in palliative radiation treatment: a narrative review. Ann Palliat Med 2023;12:620-32. [Crossref] [PubMed]
3. Tsang DS, Yau V, Raziee H, et al. Debate: single-fraction treatment should be standard in the retreatment of uncomplicated bone metastases. Ann Palliat Med 2015;4:207-13. [PubMed]
4. Chow R, Hoskin P, Hollenberg D, et al. Efficacy of single fraction conventional radiation therapy for painful uncomplicated bone metastases: a systematic review and meta-analysis. Ann Palliat Med 2017;6:125-42. [Crossref] [PubMed]
5. Yerramilli D, Simone CB 2nd, Dharmarajan KV. One & done: treating cord compression with single-fraction radiation therapy. Ann Palliat Med 2019;8:356-9. [Crossref] [PubMed]
6. White DB, Ernecoff N, Buddadhumaruk P, et al. Prevalence of and Factors Related to Discordance About Prognosis Between Physicians and Surrogate Decision Makers of Critically Ill Patients. JAMA 2016;315:2086-94. [Crossref] [PubMed]
7. Simone CB 2nd. Discordant expectations about prognosis in critically ill patients. Ann Palliat Med 2016;5:225-6. [Crossref] [PubMed]
8. Galassi A, Anwarali S, Challinor J. Global challenges and initiatives in oncology nursing education. Ann Palliat Med 2023;12:633-45. [Crossref] [PubMed]
9. Mikropoulos C, Saxby H, Boussios S. Prostate cancer—what about oligometastatic disease and stereotactic ablative radiotherapy?—a narrative review. Ann Palliat Med 2023;12:646-52. [Crossref] [PubMed]
10. Iyengar P, All S, Berry MF, et al. Treatment of Oligometastatic Non-Small Cell Lung Cancer: An ASTRO/ESTRO Clinical Practice Guideline. Pract Radiat Oncol 2023; Epub ahead of print. [Crossref] [PubMed]
11. Biswas T, Simone CB 2nd, Lo SS, et al. Defining the role of curative local therapy in oligometastatic cancer: a new era. Ann Palliat Med 2021;10:5919-22. [Crossref] [PubMed]
12. Amini A, Verma V, Simone CB 2nd, et al. American Radium Society Appropriate Use Criteria for Radiation Therapy in Oligometastatic or Oligoprogressive Non-Small Cell Lung Cancer. Int J Radiat Oncol Biol Phys 2022;112:361-75. [Crossref] [PubMed]
13. Phillips R, Shi WY, Deek M, et al. Outcomes of Observation vs Stereotactic Ablative Radiation for Oligometastatic Prostate Cancer: The ORIOLE Phase 2 Randomized Clinical Trial. JAMA Oncol 2020;6:650-9. [Crossref] [PubMed]
14. Ost P, Reynders D, Decaestecker K, et al. Surveillance or Metastasis-Directed Therapy for Oligometastatic Prostate Cancer Recurrence: A Prospective, Randomized, Multicenter Phase II Trial. J Clin Oncol 2018;36:446-53. [Crossref] [PubMed]
15. Palma DA, Olson R, Harrow S, et al. Stereotactic ablative radiotherapy versus standard of care palliative treatment in patients with oligometastatic cancers (SABR-COMET): a randomised, phase 2, open-label trial. Lancet 2019;393:2051-8. [Crossref] [PubMed]
16. Tsagkaris C. Making a stand for diabetic foot reconstruction in the palliative patient in the European Union. Ann Palliat Med 2023;12:653-5. [Crossref] [PubMed]
17. Alexiadou K, Doupis J. Management of diabetic foot ulcers. Diabetes Ther 2012;3:4. [Crossref] [PubMed]
18. Guariguata L, Whiting DR, Hambleton I, et al. Global estimates of diabetes prevalence for 2013 and projections for 2035. Diabetes Res Clin Pract 2014;103:137-49. [Crossref] [PubMed]
19. Izmaylov N. The nutrition our patients need. Ann Palliat Med 2023;12:656-7. [Crossref] [PubMed]