Chemoradiation With Capecitabine for Palliation of Pain From Bone Metastasis
Much of the clinical practice of oncology involves palliative care. In this setting ,the
emphasis is on alleviation of symptoms and preservation or improvement of quality of life. A
large body of clinical evidence documents the effectiveness of local-field external beam
radiotherapy in palliation of pain from osseous metastases (1). Despite this general
agreement, controversy remains regarding the optimal dose and fractionation schedule.
Prospective phase III clinical trials (2-6), today, have failed to demonstrate superiority
of one schedule over another ,and as a result, the patterns of practice of remain diverse in
duration and intensity.
Between 1974 and 1980 the RTOG conducted a large national study to determine the
effectiveness of five different dose fractionation schedules(2). A total of 1016 patients
were entered ,266 into a "solitary metastasis" stratum, and 750 into a "multiple metastasis
" stratum. The former were randomly assigned to treatment with 40,5Gy in 15 fractions or
20Gy in 5 fractions. The latter were assigned to 30Gy in 10 fractions, 15 Gy in5 fractions
,20 Gy in 5 fractions, or 25 Gy in 5 fractions. A quantitative measure of pain ,based on
severity and frequency of pain, and the type and frequency of pain medications used, was
devised to evaluate response. Overall, 89% of patients experienced minimal relief. There
were no significant difference between the treatment arms in both strata. The initial pain
score was found to be a useful predictor ; patients with high score were less likely to
respond and were less likely to experience a complete response. Patients with breast and
prostate cancer were significantly more likely to respond than patients with lung or other
primary lesions. Patients completing their treatment as planned had significantly higher
rates of complete response than those who did not .While some relief was experienced almost
invariably within the first four weeks, complete relief was first reported later than four
weeks after start of treatment in about 50 % of patients .The median duration of minimal and
complete pain relief was 20 and 12 weeks ,respectively. There were no significant
differences in duration of pain relief between the different arms It was concluded that all
treatment dose schedules were equally effective.
A reanalysis of the RTOG study was reported by Blitzer (7).Using a stepwise logistic
regression, he examined the effect of the number of fractions, the dose per fraction, and
solitary versus multiple metastases, on the probability of attaining complete pain relief
and the need for retreatment. This multivariate technique allowed patients with solitary and
multiple metastases to be analyzed together. By increasing the number of subjects and events
the statistical power of the analysis was outcome. There was no correlation of the time dose
factor with outcome (8). It was concluded that the more protracted schedules resulted in
improved pain relief.
Price et al. randomized 288 patients to receive either 8 Gy in one fraction or 30 Gy in 10
daily fractions. Pain was assessed using a questionnaire completed by the patients at the
home on a daily basis. No differences were found in the probability of attaining pain
relief, the speed of onset or the duration of relief between the two arms(4).
et al. randomized 270 patients to receive either 4 Gy or 8 Gy in one fraction (3) Pain
assessed by the patient) and analgesic usage were recorded before treatment and at 2,4,8 and
12 weeks. At 4 weeks the response rates were 69% for 8 Gy and 44% for 4 Gy (p<0.001). The
duration of the effect was independent of dose.
Two other randomized trials have been reported (5,6). Given the small difference in the
Biological Effective Dose ( BED) between the arms (6) and the small number of patients
accrued (5,6), it is not surprising that no differences between the treatment arms were
RTOG have reported the results of a pooled data dose response analysis (11). A computerized
literature search was conducted to identify prospectively randomized clinical studies which
addressed this issue and the results of these studies (2 6) were pooled together to form a
database for analysis. The endpoint selected for analysis was complete response (CR). It was
felt that this endpoint was most likely to be evaluated in a consistent fashion by different
investigators. One study (6) was excluded from the analysis because outcome was not reported
using conventional definitions of complete and partial response. To allow comparison of the
different study arms, the BED was calculated for each schedule. Odds ratios calculated for
various dose levels showed a statistically significant increase from 1.00 to 3.32 as the BED
increased from 14.4 Gy to 5 1.4 Gy.
For the first time, RTOG analysis demonstrated a highly significant dose response
relationship for palliation of pain from bone metastases with radiotherapy. Furthermore,
there was no evidence of flattening of the dose¬-response curve within the dose range
tested, suggesting that further gains can be realized at doses outside of the range tested.
We propose a phase II clinical trial in which the biological effective dose will be
increased by the concurrent use of a radiosensitizer. The main advantage of this approach
over escalation of the physical dose is the avoidance of increase in the overall treatment
Capecitabine is a fluoropyrimidine carbamate with antineoplastic activity. It is an orally
administered systemic prodrug of 5' deoxy 5 fluorouridine (5' DFUR) which is converted to 5
Capecitabine is readily absorbed from the gastrointestinal tract. In the liver, a 60 kDa
carboxyesterase hydrolyzes much of the compound to 5' deoxy 5 fluorocytidine (5' DFCR).
Cytidine deaminase, an enzyme found in most tissues, including tumors, subsequently converts
5' DFCR to 5' deoxy 5 fluorouridine (5' DFUR).. The enzyme, thymidine phosphorylase
(dThdPase), then hydrolyzes 5' DFUR to the active drug 5 FU. Many tissues throughout the
body express thymidine phosphorylase. Some human carcinomas express this enzyme in higher
concentrations than surrounding normal tissues. Both normal and tumor cells metabolize 5 FU
to 5¬fluoro 2 deoxyuridine monophosphate (FdUMP) and 5 fluorouridine triphosphate (FUTP).
These metabolites cause cell injury by two different mechanisms. First, HUMP and the folate
cofactor, N5 10¬methylenetetrahydrofolate, bind to thymidylate synthase (TS) to form a
covalently bound ternary complex. This binding inhibits the formation of thymidylate from
uracil. Thymidylate is the necessary precursor of thymidine triphosphate, which is essential
for the synthesis of DNA, so that a deficiency of this compound can inhibit cell division.
Second, nuclear transcriptional enzymes can mistakenly incorporate FUTP in place of uridine
triphosphate (UTP) during the synthesis of RNA. This metabolic error can interfere with RNA
processing and protein synthesis. Capecitabine is already approved for use in patients with
metastatic breast cancer resistant to both paclitaxel and an anthracycline containing
Although 5FU is an established radiosensitizer, the exact mechanism by which it enhances
cell kill is not well understood. Sensitization is schedule dependent and is maximal when a
cytocidal concentration of 5FU is given after the radiation exposure (12). The effect does
not result from increased sublethal damage or inhibition of sublethal damage repair (12,13).
Current evidence suggests that radiosensitization by 5FU is mediated through its effects on
DNA rather then RNA (14). In vivo (15) as well as clinical studies (16) have demonstrated
the superiority of continuous over bolus infusion of 5FU.
Over the last several decades, concurrent 5FU and radiation have been used successfully in a
variety of malignancies. Several important lessons have been learned from clinical trials
(16). Simultaneous delivery of large (IV bolus) doses of 5 fluorouracil with irradiation is
associated with improved survival compared to treatment with radiation alone, but at a price
of increased normal tissue toxicity. These side effects can be ameliorated by using
protracted venous infusion. This is an efficacious approach, with a wide therapeutic index,
which permits concurrent treatment of micrometastatic disease and radiation sensitization.
Combined modality therapy, including irradiation and concurrently administered 5FU based
chemotherapy, has become the mainstay of therapy for anal and rectal cancers. Protracted
venous infusion chemoradiation is also used in the preoperative management of rectal cancer
and in the nonoperative management of anal cancers. The Gastrointestinal Tumor Study Group
(GITSG) has demonstrated a significant survival advantage for patients who receive adjuvant
combined radiation and bolus 5FU following curative resection of pancreatic cancer (17,18).
Similar advantages have been demonstrated in unresectable pancreatic cancers. Significant
advantages have also been shown for concurrent chemotherapy regiments containing 5FU in
esophageal cancer (19), squamous cell carcinoma of the Head and Neck (20,21), and carcinoma
of the cervix (22).
There is very limited experience with the use of capecitabine and radiation. Based on its
relative selectivity and the increase in tumor cell 5FU levels, it should be expected that
capecitabine will provide superior radiosensitization at equivalent or reduced systemic
toxicity levels. Interestingly, it has been recently reported that radiation induces
thymidine phosphorylase and enhances the efficacy of capecitabine in human cancer xenografts
(23). This may further enhance the synergistic effects, and consequently the therapeutic
In RTOG study a substantial number of patients with gastrointestinal malignancies treated
with concurrent radiotherapy and capecitabine at a dose of 1600 mg/m2/day (5 days a week)
with very little toxicity(24 ).In phase II study of chemoradiation for rectal cancer
1650mg/m2/d of capecitabine for 14 days was safe and well-tolerated treatment(25).
In this study we will investigate the feasibility of concurrent Capecitabine and external
beam radiotherapy, as well as collect preliminary data regarding the efficacy of this
Hypothesis: Given the hypothesis that regimens employing greater intensity radiation yield
higher rates of pain relief, radiosensitization using a tumor targeted drug like Xeloda
should improve the rate of complete pain relief as compared to radiosensitization with 5FU
To determine the frequency and duration of pain relief and narcotic relief for the proposed
To determine the toxicity of concurrent Capecitabine and radiotherapy in breast cancer
patients with bone metastases.
Patients with metastatic breast will be allowed on the study regardless of their prior
exposure to chemotherapy. Today, there is no evidence to suggest crossresistance between
radiotherapy and prior chemotherapy, or that response to radiotherapy is related in any way
to the number of lines of chemotherapy used in a particular patient. Good palliative
responses can often be achieved in heavily pretreated patients.
1. The patient must be 18 years of age or older.
2. The patient must have histologically proven breast adenocarcinoma.
3. Radiographic evidence of bone metastasis is required .Acceptable studies include plain
radiographs, radionuclide bone scans, computed tomography scans and magnetic resonance
4 .The patient must have pain that appears to be related to the radiographically documented
5. Patients receiving systemic therapy with Capecitabine to metastatic disease (according to
health basket ).
6. Patients must have an estimated life expectancy of 3 months or greater.
7. Patients will be eligible for treatment of multiple metastases only if these can be
included in no more than two treatment sites.
8. Signed study specific informed consent.
9 Karnofsky Performance Status > 40.
10. Calculated Creatinine Clearance > 50 ml/min
11.ALT and AST no greater than 3 5 times the institutional normal; bilirubin and serum
creatinine no greater than 1.5 times normal; ANC greater than 1500, and platelets at least
1. Prior radiation therapy or prior palliative surgery to the painful site.
2. Impending fracture of the treatment site or planned surgical fixation of the bone.
3. Patients with clinical or radiographic evidence of spinal cord or cauda equina
4. Patients receiving systemic radionuclides (strontium, samarium, etc.) within 60 days
prior to registration.
1. Histologic diagnosis of the primary site. 2. Radiographic assessment, with must include
plain x-ray of the index lesion (s) and a bone scane.
3. Pain assessment score (BPI ). 4. Laboratory studis within 2 weeks of registration (CBC,
serum ALT, AST ,total bilirubin and creatinine).
1. Treatment must be given using 6-15MV photons or 6-18 MeV electrons .
2. All fields must be treated each day. Treatment volume will include the radiographic
abnormality with at least a 2 cm margin. Treatment of the entire bone is not required.
3. Anterior and posterior parallel opposed fields will be used for lumbar spine, sacrum,
and extremity sites. Equal weighting is recommended, although unequal weighting may be
used for the lumbar or sacral spine with a ratio of doses of 1:2 AP:PA. Dose will be
prescribed at mid depth at the central axis, or at the center of target volume if
unequal weighting is used.
Alternatively, the lumbar spine may be treated with a single PA field, with the dose
prescribed to the mid vertebral body as defined by a lateral simulator film.
4. Single posterior fields will be used for the thoracic spine and scapula .The treatment
depth is set at the middle of the vertebral body, as determined by a lateral simulation
5. The cervical spine may be treated with either parallel opposed lateral fields or with a
single posterior field. When lateral fields are used, the isocenter should be at mid
thickness, with the dose prescribed to the mid vertebral body.
6. Pubic. bone lesions will be treated with a single anterior field at a depth determined
by lateral radiograph or CT scan.
7. Clavicular lesions will be treated with a single anterior field at a depth of 3 cm. The
dose will be prescribed to the 3 cm depth. An alternative depth may be used as
determined by CT scan or other radiographs.
8. Rib metastases may be treated with electrons or with photons. When electrons are used,
the appropriate energy should be chosen such that the entire lesion is covered by the
90% (or higher) isodose curve. The dose will be prescribed to the 100% isodose line.
When photons are used, parallel opposed fields may be used, with the depth prescribed
to the mid thickness. Tangential fields are strongly encouraged to avoid treatment of
underlying structures. A single field may be used to cover the lesion, with the depth
set at the estimated depth of the rib lesion, and the dose prescribed to that level.
9. When more than one osseous site is to be included into a treatment field, the treating
radiation oncologist may use different field arrangements at herlhis discretion, with
the goal of providing relatively uniform coverage of the target sites and minimum
inclusion of uninvolved tissues.
All patients will receive radiotherapy to a dose 30 Gy in 10fractions (3 Gy per fraction)
over two weeks.
Chemotherapy with capecitabine tablets will be given concurrently with radiotherapy in the
dose 1400 mg/m2 orally, in two daily divided doses.
Total daily dose rounded to the nearest 500 mg and divided into morning and evening
Doses, as per the following table:
Number of 500 mg tablets to be taken Surface Area Total Daily Dose morning evening (m2)
(mg)* <= 1.08 1000 1 1 1.09 1.4 1500 2 1 1.41 1.71 2000 2 2 1.72 2.02 2500 3 2
*Total Daily Dose rounded to the nearest 500 mg and divided into morning and evening doses.
Dose Limiting Toxicity
i) >grade 3 non hematologic toxicity, except for diarrhea, nausea, vomiting, fatigue,
anorexia, alopecia, fever and/or local reactions.
ii) grade 4 diarrhea lasting >3 days which is not controllable with loperamide or other such
medications. Or grade 4 diarrhea that requires IV hydration.
iii) grade 4 neutropenia lasting >3 days
iv) grade 4 thrombocytopenia
v) grade 2 hand foot syndrome.
Dose adjustments will be as per the following table:
Toxicity NCI Grades During a Course of Therapy Grade 1 Maintain dose Grade
2 1st appearance (non HFS) Interrupt until resolved to grade 0 1
1st appearance of HFS Interrupt until resolved to grade 0 1, then continue at 75 % of
2nd appearance Interrupt until resolved to grade 0 1, then continue at 75 % of original
3rd appearance Interrupt until resolved to grade 0 1, then continue at 50 % of original
4th appearance Discontinue treatment permanently Grade 3
1. st appearance Interrupt until resolved to grade 0 1, then continue at 75 % of original
dose with prophylaxis where possible.
2. nd appearance Interrupt until resolved to grade 0 1, then continue at 50 % of original
3. rd appearance Discontinue treatment permanently Grade 4
1st appearance Discontinue permanently or If physician deems it to be in the patient's best
interest to continue, interrupt until resolved to grade 0 1, then continue at 50 % of
original dose .
Dosage modifications are not recommended for grade 1 events. Therapy with capecitabine
should be interrupted upon the occurrence of a grade 2 or 3 adverse experience. Once the
adverse event has resolved or decreased in intensity to grade 1, then therapy may be
restarted at full dose or as adjusted according to the above table. If a grade 4 experience
occurs, therapy should be discontinued or interrupted until resolved or decreased to grade
1, and therapy should be restarted at 50% of the original dose. Doses of capecitabine
omitted for toxicity are not replaced or restored; instead the patient should resume the
planned treatment cycles. Once the dose has been reduced it should not be increased at a
CAPECITABINE can induce diarrhea, sometimes severe. Patients with severe diarrhea should be
carefully monitored and given fluid and electrolyte replacement if they become dehydrated.
National Cancer Institute of Canada (NCIC grade 2 diarrhea is defined as an increase of 4 to
6 stools/day or nocturnal stools, grade 3 diarrhea as an increase of 7 to 9 stools/day or
incontinence and malabsorption, and grade 4 diarrhea as an increase of >10 stools/day or
grossly bloody diarrhea or the need for parenteral support. If grade 2, 3 or 4 diarrhea
occurs, administration of capecitabine should be immediately interrupted until the diarrhea
resolves or decreases in intensity to grade 1. Following grade 3 or 4 diarrhea, subsequent
doses of capecitabine should be decreased. Standard antidiarrheal treatments (eg,
loperamide) are recommended. Necrotizing enterocolitis (typhlitis) has also been reported.
Hand and foot syndrome (palmar plantar erythrodysesthesia or chemotherapy induced acral
erythema) is characterized by the following: numbness, dysesthesia/paresthesia, tingling,
painless or painful swelling, erythema, desquamation, blistering and severe pain. Grade 2
hand and foot syndrome is defined as painful erythema and swelling of the hands and/or feet
and/or discomfort affecting the patient's activities of daily living. Grade 3 hand and¬foot
syndrome is defined as moist desquamation, ulceration, blistering and severe pain of the
hands and/or feet and/or severe discomfort that causes the patient to be unable to work or
perform activities of daily living. If grade 2 or 3 hand and foot syndrome occurs,
administration of capecitabine should be interrupted until the event resolves or decreases
in intensity to grade 1. Following the occurrence of grade 2 handand foot syndrome,
subsequent doses of capecitabine should be decreased.
There has been cardiotoxicity associated with fluorinated pyrimidine therapy, including
myocardial infarction, angina, dysrhythmias, cardiogenic shock, sudden death and
electrocardiograph changes. These adverse events may be more common in patients with a prior
history of coronary artery disease.
Patients with mild to moderate hepatic dysfunction due to liver metastases should be
carefully monitored when capecitabine is administered. The effect of severe hepatic
dysfunction on the disposition of capecitabine is not known. If drug related grade 2 4
elevations in bilirubin occur, administration of capecitabine should be immediately
interrupted until the hyperbilirubinernia resolves or decreases in intensity to grade 1.
NCIC grade 2 hyperbilirubinernia is defined as 1.5 x normal, grade 3 hyperbilirubinemia as
1.5 3 x normal and grade 4 hyperbilirubinemia as >3 x normal.
Increases in adverse events have been noted in patients with reduced renal function.
Therefore, patients will be excluded for a calculated creatinine clearance of less than 50
Myelosuppression was rare.
Assessment of Response
Pain scores and narcotic scores will be determined using the guidelines in following table:
PAIN AND NARCOTIC CATEGORIES AND SCORES PAIN ANALGESIA Severity 0 No pain 0 None I
Mild I Analgesics (ASA, Bufferin, Tylenol, Anacin, etc.) 2 Moderate 2 Mild Narcotic,
(< 112 gr. codeine, Darvon, etc.) 3 Severe 3 Moderate Narcotic (> 112 < gr. codeine,
Percoan, etc) 4 Strong 4 Narcotic, (> 1 gr. codeine, demerol, morphine, etc) Frequency 0
None 0 None I Occasional (< daily) I p.r.n. (< daily) 2 Intermittent (at least
daily) 2 q.d. (I tab. or cap./day) 3 Frequent (>. I < 3 daily) 3 b.i.d. t.i.d. (> I <
4 tab. or cap./day) 4 Constant (most of the time) 4 > t.i.d. (> 4 tab. or cap./day)
Pain Score = Pain Severity Grade x Pain Frequency Grade Narcotic Score = Analgesia Severity
Grade x Analgesic Frequency Grade
Response will be evaluated by questionnaires at follow up visit at 2, 4 and 8 weeks after
completion of radiotherapy and by phone call interviews (when necessary for completeness) in
poor compliance patients.
The "worst pain score" will be used as response endpoint. The time to maximal pain relief is
the time from the first day of irradiation to the time of the lowest pain score for average
Complete response is defined as an average pain score of 0 for two consecutive analysis
periods. Narcotic consumption must not be increased.
Partial response. A decrease of at least 2 points in the worst pain
score for two consecutive analysis periods. Narcotic consumption must not be increased.
No response (any of the following):
pain score that does not change within 8 weeks from the start of radiation therapy.
A 2 point increase in worst pain score that is sustained at a higher level in the month
following the first day of radiation therapy.
A pain score that drops by at least 2 points and subsequent sustained rise (on 2 successive
questionnaires) of pain score by at least 2 points.
Any patient with progressive pain in the treated area should
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Allocation: Non-Randomized, Endpoint Classification: Efficacy Study, Intervention Model: Single Group Assignment, Masking: Open Label, Primary Purpose: Treatment
Change from Baseline in pain score at 12 wks
Patients were asked to score their pain on a scale of 0 (no pain) to 10 (worst possible pain) before treatment and at 1, 2, 4, 8 and 12 weeks after treatment initiation.
Yulia Kundel, MD
Rabin Medical Center
Israel: Ethics Commission