Hemostatic Radiotherapy Represents Tool for Management of GI Bleeding in Advanced Cancer

Hemostatic radiation is a method of managing bleeding in patients with gastrointestinal (GI) cancers or GI metastases from other primary tumors; however, a multidisciplinary team is required to implement this method, according to Marnee M. Spierer, MD, MBA.¹

“[Radiation oncologists] are part of the curative, definitive approach for esophageal cancer, rectal cancer, and anal cancer,” Spierer said during a presentation at the Advances and Innovations in Endoscopic Oncology and Multidisciplinary Gastrointestinal Cancer Care conference in Scottsdale, Arizona. “Another role that we have as radiation oncologists is for palliative treatment. We treat brain metastases and bone metastases. [Managing] bleeding is something that we are also often called to do by many of our colleagues.”

Spierer is a radiation oncologist and the chief of staff of City of Hope Phoenix in Arizona.

GI bleeding can stem from sites of metastasis from a primary tumor, such as breast cancer, or from a primary GI tumor, Spierer said. Bleeding can present as occult bleeding, macroscopic bleeding, or profound bleeding, and it occurs in approximately 10% of patients with advanced cancer.

“[Bleeding] can end a patient’s life. [Furthermore], it can prolong their cancer care if we can’t control it,” Spierer explained.

Hemostatic radiotherapy works by acutely increasing the adhesion of platelets to the vascular endothelium. The long-term goal of this method is vessel fibrosis and tumor remission. The effects of hemostatic radiotherapy are often visible after the administration of only a few fractions.

Spierer noted that patients with primary lung tumors or metastases around the lung are often referred to radiation oncologists for palliative care, and randomized controlled trials are looking at the use of radiation to reduce hemoptysis in patients with primary non–small cell lung cancer.

Smaller retrospective studies have examined the use of hemostatic radiotherapy in other malignancies, including vaginal bleeding in patients with cervical or endometrial cancer, and bleeding from locally advanced bladder, prostate, rectal, and gastric cancer.

“Cervical cancers, upon presentation, can be extraordinarily bloody, and I am often asked to palliate those [patients] to bridge them to definitive care,” Spierer said. “While I am planning their radiation for their curative pelvic radiation concomitantly with chemotherapy, I’m palliating them with a few fractions to stop their bleeding.”

Additionally, a single-center retrospective study analyzed 112 patients who received radiation for emergent palliation of bleeding tumors, and results showed that the overall primary bleeding control rate was 89%.2 Specifically, in gastrointestinal, genitourinary, head and neck, thoracic, extremity, and gynecologic sites, the bleeding control rates were 89% (n = 31/35), 80% (n = 16/20), 88% (n = 14/16), 93% (n = 13/14), 100% (n = 9/9), and 100% (n = 6/6), respectively.

Following initial bleeding control, the re-bleeding rate was 25%, and the median time of re-bleeding was 84 days. The rates of bleeding control at 3, 6, and 12 months were 83%, 76%, and 56.4%., respectively.

The study also showed that longer fractionation regimens of more than 5 fractions were not associated with a reduced incidence of re-bleeding (P = .65); however, longer fractionation regimens were associated with increased treatment interruptions (P = .02).

In a meta-analysis of palliative radiotherapy, investigators included data from 7 non-comparative observational studies of patients with locally advanced gastric cancer.3 Among the 291 patients included, the most common fractionations used were 1, 5, and 10 Gy.

Pooled overall response rates were 74%, 67%, and 68% for bleeding, pain, and obstruction, respectively. Additionally, there was no difference in response rates for bleeding with regimens of at least 39 Gy or below 39 Gy (P = .39). Additionally, grade 3/4 adverse effects occurred in up to 15% of patients treated with radiotherapy alone vs up to 25% of patients treated with chemoradiotherapy.

When evaluating the effectiveness of hemostatic radiotherapy, Spierer said the primary measures are the need for additional interventions, blood transfusions needed before and after radiotherapy, and changes in hemoglobin levels. Across the 7 studies included in the meta-analysis, responses for bleeding ranged from 50% to 91%, and duration of response ranged from 1.5 months to 11.4 months.

Spierer concluded her presentation by noting that palliative radiation has a use in many oncologic emergencies, and hemostatic radiotherapy should be considered for patients with bleeding from a GI source.

“The idea [is] that you can call upon your radiation oncologist to consider hemostatic radiation for a bleeding GI malignancy, [and] your other medical oncology colleagues who have [patients with] metastases, whether from breast, gynecologic, or lung [cancer], should keep hemostatic radiation in mind. Clearly, the multidisciplinary team approach is required,” Spierer concluded.

References

1. Spierer MM. Hemostatic RT: capitalizing on the multidisciplinary approach to malignant GI bleeding. Presented at: 2023 Endoscopic Oncology and Multidisciplinary Gastrointestinal Cancer Care; April 15, 2023. Scottsdale, AZ.
2. Sapienza LG, Ning MS, Jhingran A, et al. Short-course palliative radiation therapy leads to excellent bleeding control: a single centre retrospective study. Clin Transl Radiat Oncol. 2018;14:40-46. doi:10.1016/j.ctro.2018.11.007
3. Tey J, Soon YY, Koh WY, et al. Palliative radiotherapy for gastric cancer: a systematic review and meta-analysis. Oncotarget. 2017;8(15):25797-25805. doi:10.18632/oncotarget.15554