Palliative RT relieves pain in end-stage liver cancer

Treatment with single fraction radiation therapy (RT) results in lesser hepatic pain in most patients with end-stage hepatocellular carcinoma (HCC) or liver metastases, according to a study presented at the recent ASCO Gastrointestinal Cancers Symposium (ASCO GI 2023).

A multicentre phase III trial included 66 patients with painful liver cancer. They were randomized to receive single fraction RT (8 Gy) or best supportive care. Patients had end-stage disease not fitting for local, regional, or systemic therapies, >4 weeks since chemotherapy or transarterial chemoembolization, >2 weeks since targeted therapy or immunotherapy, and no planned systemic therapy.

Lead author Laura A. Dawson from Princess Margaret Cancer Centre in Toronto, Canada, and her team sought to determine whether the proportion of patients with improved liver cancer pain “intensity at worst” on Brief Pain Inventory (BPI) by ≥2 points from baseline to 1 month (primary endpoint) was higher after RT compared to best supportive care alone.

In addition, they also determined the number of patients alive at 3 months, with improvement ≥2 points in BPI at 1 and 3 months, with a 25-percent reduction in opioids at 1 month, and with improved quality of life, defined by Functional Assessment of Cancer Therapy-Hepatobiliary (FACT-Hep) hepatobiliary subscale (HBS) change score ≥5 and Trial Outcome Index ≥7 at 1 month.

Of the eligible patients, 43 had liver metastases (12 colorectal, five breast, four pancreas, three lung, and 19 others) and 23 had HCC. Majority (59 percent) had ECOG performance status 2 or 3, while 64 percent had Child Pugh score A compared with 36 percent with Child Pugh score B or C. [ASCO GI 2023, abstract LBA492]

Either the whole liver or near whole liver was irradiated (median 2,013 cc). Forty-two patients (24 on RT and 18 on best supportive care) completed assessments at baseline at 1 month. At baseline, the average pain at worst score was 7/10. From baseline to 1 month, more patients on RT than on best supportive care showed significant improvement in the primary endpoint (67 percent vs 22 percent; p=0.004).

Likewise, more patients on RT had improved “worst” pain at 1 month, with no increase in opioid use (21 percent vs 0 percent; p=0.07). The proportion of patients with a substantial improvement in BPI “pain at its least” (63 percent vs 28 percent; p=0.03) and “percentage relief in pain by treatment” (59 percent vs 25 percent; p=0.04) from baseline to 1 month was also higher for RT than best supportive care.

On sensitivity analysis, BPI “worst” pain improved in 49 percent of patients on RT and 12 percent on best supportive care alone (p=0.002). At 1 month, 11 patients on best supportive care switched to RT, and improvements in FACT HBS occurred at 1 month after RT versus best supportive care (p=0.07), with no statistically significant difference in other FACT-Hep subscales.

Notably, more patients on RT experienced grade ≥2 adverse events (58 percent vs 33 percent; p=0.05). Grade ≥3 adverse events were rare. In addition, 3-month survival was better with RT than best supportive care alone (51 percent vs 33 percent; p=0.07).

The study was funded by the Canadian Cancer Society.