Ruminations 3

Ruminations 3: Radiation Therapy Decisions

By Tom Vogl

March 22, 2007

As I mentioned in the first of these rumination,

Reprise, medical decisions are intrinsically synthetic

rather than analytic.  My currently imminent decision

on whether or not to undertake radiation therapy is,

unfortunately for me, a case study in making decisions

on inadequate information. First, a summary of the

available information. I found seven papers relevant

to radiation therapy:

Ballo, M.T. et al., “Combined-Modality Therapy for

Patients with Regional Nodal Metastases from Melanoma”

Int. J. Radiation Oncology Biol. Phys., 64:106-113

(2006)

Kienstra, M.A., & Padhya, T.A., “Head and Neck

Melanoma”, Cancer Control 12: 242-247 (2005)

Grunhagen, D.J. et al., “Prognostic Factors After

Cervical Lymph Node Dissection for Cutaneous Melanoma

Metastases”, Melanoma Research 15: 179 – 184 (2005)

Owens, J.M. et al., “The Role of Postoperative

Adjuvant Radiation Therapy in the Treatment of Mucosal

melanomas of the Head and Neck Region”, Arch.

Otolaryngol. Head Neck Surg. 119:864-868 (2003)

Ballo, M.T., et al., “Adjuvant Irradiation for

Cervical Lymph Node Metastases from Melanoma”, Cancer

97: 1789 – 1796 (2003)

Lengyel, E., et al., “Malignant Mucosal melanoma of

the Head and Neck – a Review”, Pathology Oncology

Research, 9: 7-12 (2003) Also at:

www.webio.hu/por/2003/9/1/0007

Lee, R.J., et al., Nodal Basin Recurrence Following

Lymph Node Dissection for melanoma: Implications for

Adjuvant Radiotherapy”, Int. J. Radiation Oncology

Biol. Phys.,46: 467 – 474 (2000)

I will try to summarize what each of these papers

presents from the perspective of its relevance to me,

which as you will see, is fraught with uncertainty for

several unavoidable reasons.  The patient populations

they study, although they all have melanoma, are very

heterogeneous in terms of site of the primary lesion

and the extent of disease at the time treatment was

started.  Despite this heterogeneity, the number of

patients in each study, and particularly when broken

down into cells, is small.  The vast majority of the

patients in these studies have cutaneous (skin)

melanoma (CM) because the mucosal melanoma (MM, which

I have) is so rare and carries distinctly different

genetic alterations and biochemical pathway activity

[Curtin et al., NEJM 353: 2135 (2005)].

Kienstra (2005) notes that MM “are rare lesions but

have a poor prognosis. Because of their development in

hidden, clinically silent areas, diagnosis often

occurs late [not in my case] … contributing to the

poorer outcome.” 

Lengyel (2003), which is the only paper focusing on

MM, reviews 10 studies (some as early as the 1950’s)

and concludes that “CM had a mean [5 year] survival

rate that was higher (81 – 85%) than that (17.1%

[range 0 – 48%]) for MM.”  He points out that “The

characteristics of the survival curves explained by

the very different possible clinical courses of

malignant melanomas, ranging from the

highly-malignant, aggressive disease to a relatively

low grade tumor.”

Grunhagen (2005) reports on 66 consecutive patients

(over a 22 year period) an overall 50% survival of 27

months after cervical lymph node dissection. 15

received post operative radiation therapy; 4 of the 15

developed cervical recurrence. With more than one

metastatic lymph node at dissection, the 50% survival

rate was reached at 18 months.

Ballo (2006) reports considerably more optimistic

numbers, with the 5-year survival of 49%.  Since this

is the most recent data and on a relatively large

(245) group of patients, this study has to be given

considerable weight taking into account the

heterogeneity of the study population. His abstract

concludes: “Although regional nodal disease can be

satisfactorily controlled with lymphadenectomy and

radiation, the risk of distant metastases and melanoma

death remains high. A management approach to these

patients that accounts for the competing risks of

distant metastases, regional failure, and long-term

toxicity is needed.”  The long-term toxicity issue is

not significant for cervical lymph nodes, but the

probability of cervical recurrence is high.

Lee’s (2000) survival figures are similar (50% at 24

months) with the highest rate of recurrence in the

cervical basin at 43% at 10 years, compared to 28% and

24% in the axillary and inguinal basins.  The number

of positive nodes also predicts nodal basin failure

with the presence of 4 – 10 positive nodes predictive

of a 46% failure rate.  He concludes: “In summary,

there are sufficient data to suggest that adjuvant

radiation therapy to the nodal basin in high-risk

patients with malignant melanoma decreases nodal basin

failure rates. The impact on survival is uncertain, as

many patients develop distant metastases and die of

disease. However, the importance of local-regional

control cannot be overlooked, and as more effective

systemic therapy is developed and distant spread is

decreased, the importance of local control may

increase.”

Owens (2003) “The addition of radiotherapy tended to

decrease the rate of local failure but did not

significantly improve survival because of the high

rate of distant metastatic disease.”

I will not bore you further before getting to the

point: Should I, or should I not, agree to radiation

therapy? The rationale for doing it is clear.  It

reduces local recurrence which may – it is really a

pious theoretical hope without a shred of evidence –

decrease the likelihood distant metastases.

The rationale for not doing it is not quite a clear

but, I think, equally convincing.  It may indeed be

the case that my immune system may kick back in, or

that the melanoma becomes indolent, or for some other

reason I will end up surviving another ten or more

years; this outcome has low probability.  More likely

is the generally accepted figure of 25-50% at five

years with the odds for the lower end because of the

six positive lymph nodes and that it is MM and not CM.

I also know, from my experience with radiation therapy

18 months ago, that the therapy itself is quite

tolerable, all the more so because the current

recommendation is for a high dose of radiation twice a

week rather than a lower dose daily, which means that

I would travel far less frequently. However, it took

me about eight months to get over the radiation

therapy and return to full functionality.  Most of

that time I spent in my recliner, too exhausted to do

much of anything.

Statistically, the most probable, but hardly

inevitable, outcome for me is that distant metastases

will develop sometime in the next 18 months and that I

will live another 12 months after that. Does it make

sense for me to spend 8 of those 18 good months

exhausted from therapy that has only a marginal

probability of extending my life or changing the

outcome?

Time for a pop quiz: What would you decide and, more

importantly, what is the rationale for your decision.

Today, Thursday March 22, I had a long and very useful

conversation with Dr. McAnaw, the oncological

radiation therapist at Cape Cod Hospital who did the

radiation therapy following my first operation.  We

had an extensive, wide ranging conversation covering

radiation modalities and dosages (electrons vs.

photons  -- hyper vs hypo-fractionation of radiation

dosage, etc.) and the importance of shaping any

radiation field to miss those areas that have

previously been irradiated. We agreed that the growth

characteristics of my melanoma were such that it would

probably be 12 -18 month before a macroscopic tumor

reappeared. We shall see. In the meantime, we decided

to await the results of the PET scan scheduled for

April 3 and call in the experts at Dana-Farber before

making a decision on Radiation treatment at the end of

April.

[This is Katherine.  It was a tough but not unexpected

day, at leaast when talking to the doctor.  It feels

very odd to be talking about end of life decisions,

when Tom is feeling so well and so strong.  But that

is part of the process and we understand that, more or

less.

As we were leaving the clinic, a carload of Island

cancer patients drove up and we had a nice - slightly

gallows dinged visit.  Then we found a fantastic

(though pricey used bookstore in Hyannis (Tims Used

Books Inc 386 Main St.) and found books both new and

old on that we wanted.  The radiologist knows food and

directed us to Ying's http://www.yings.net/ for lunch.

It is a wonderful storefront Japanese/Thai/Korean

place. We had an incredible Koren hot and sour soup, a

Thai green curry, and a beef Bibampup (sp?) which is

our radiologist's favorite.  Excellent food!

The baby chicks did fine while we were gone and for an

afternoon treat got scraps of green lettuce and some

leftover banana bread.  They are now sound asleep

after a long day! 

tags: melanoma