Posted on behalf of the Soft Tissue Sarcoma Guideline Task Force

ASTRO’s latest clinical practice guideline, Radiation Therapy for Treatment of Soft Tissue Sarcoma in Adults, was published on July 26, 2021, in Practical Radiation Oncology. ASTRO’s first guideline on soft tissue sarcoma (STS) provides guidance on the use of radiation therapy to treat adult patients. Recommendations outline optimal radiation dosing, techniques and treatment planning for patients with localized, operable STS of the trunk and extremities, with a focus on preserving long-term functionality through individualized care. The guideline additionally addresses the role for radiation therapy for retroperitoneal sarcoma.

The guideline was developed through a systematic literature review of articles published from January 1980 through September 2020. The multidisciplinary task force included radiation, medical, orthopedic and surgical oncologists, a radiation oncology resident, a pathologist, a medical physicist and a patient representative. And, new to ASTRO guidelines, this guideline includes an appendix of reflections written by the patient representative that provides guidance to current patients and recommendations for oncology providers.

We encourage you to read the full guideline in PRO and listen to the podcast. And here, we specifically spotlight the recommendations written by the task force patient representative, Maria Voermans, BS, to oncology providers. These valuable insights serve as a reminder that patient-centered care should always lead our work.

Patient to Provider Recommendations

Excerpt from Radiation Therapy for Treatment of Soft Tissue Sarcoma in Adults: An ASTRO Clinical Practice Guideline

1. Do not make assumptions about a patient based on what you see in terms of current life situation. This is particularly crucial in conversations surrounding long term effects on fertility as a result of treatment. A patient may be married with children but to assume that he or she does not want the opportunity to explore fertility preservation methods is erroneous.

2. Encourage your patients to bring with them a support person or two to help listen and take notes at important visits. No matter how medically savvy a patient seems, absorbing personal medical information once a cancer diagnosis is received can be extremely overwhelming, and having at least one additional set of ears to take in and take down the information presented by the medical team is vital to information retention.

3. Be supportive if your patient wants to pursue a second opinion. After all, the treatment of their cancer could have significant long-term impact on the rest of their life. The last thing a patient should deal with when navigating the treatment decision making process is feeling guilty that they may offend their medical team by exploring a second opinion. A second opinion is not indicative of mistrust or lack of respect for your medical abilities, rather it is a chance for patients to feel that they have some control over their own situation, and in many cases it is an opportunity for patients to get confirmation that they are making the best decision for themselves.

4. Engage your patients as part of the team by including them in the decision-making process.

5. Be cautious when throwing around medical jargon. Although you may be used to saying these terms dozens of times per day, patients are not always used to hearing it, especially in the beginning, and it can provoke anxiety.

6. Encourage your patients to seek out psych-oncology support. Regardless of a patient’s seemingly firm grasp on their mental health, receiving a cancer diagnosis is devastating. Often, patients do not realize the extent of their own anxiety until they talk to a professional trained to deal with the emotions surrounding cancer.

7. Recognize and respect the unique needs of the adolescent and young adult (AYA) patient population and learn about the myriad of resources available to this group.

8. If you would like your patients to stay off the internet, provide reputable online resources if they want to research their diagnosis/treatment plan. They will feel empowered.

9. Do not be afraid to talk about sexual side effects. Your patients may be afraid to ask, but they want to know what to expect and how to manage it.

Additional Resources

Access the full guideline, published in Practical Radiation Oncology.
Read ASTRO’s news release.
Listen to the podcast.

The new ASTRO clinical practice guideline provides recommendations on the use of radiation therapy to treat patients diagnosed with the most common types of skin cancers

By Phillip M. Devlin, MD, FASTRO, and Anna Likhacheva, MD, PhD

Skin cancer is the most prevalent cancer in the United States, with more than five million cases diagnosed each year. More than 95% of these diagnoses are basal and cutaneous squamous cell carcinomas (BCC, cSCC), which, in contrast to melanomas, respond well to radiation therapy if treated promptly and properly. Although surgery to remove the lesion is considered the primary approach for definitive/curative treatment of these non-melanoma skin cancers, radiation therapy can play an integral role in both the curative and post-operative settings.

ASTRO's first guideline for skin cancer was published on December 9, 2019 in Practical Radiation Oncology. The guideline details when radiation treatments are appropriate as stand-alone therapy or following surgery for BCC or cSCC, and it suggests dosing and fractionation for these treatments. ASTRO developed the guideline to provide clarity about treatment options since there is wide variation in practice about when and how radiation should be used for non-melanoma skin cancers, largely because few randomized studies have compared modern treatment options head-to-head.

The guideline was based on a systematic literature review which produced more than 1,500 articles, of which 143 (published from May 1988 through June 2018) were then carefully evaluated. The task force included a multidisciplinary team of radiation, medical and surgical oncologists, a radiation oncology resident, medical physicist, dermatologists and dermatopathologists.

The guideline first defines appropriate indications for radiation therapy as the following: definitive/curative treatment for BCC and cSCC; adjuvant treatment following surgery; and definitive or adjuvant treatment for disease that has spread to a patient's regional lymph nodes.

Recommendations are as follows:

• In the definitive/curative setting, radiation is strongly recommended for patients with BCC or cSCC who cannot undergo or decline surgical resection. It is conditionally recommended for patients with BCC or cSCC located in anatomically sensitive areas such as the nose or lips, where surgery could compromise function or cosmetic outcomes. Definitive radiation therapy is discouraged, however, for patients with genetic conditions that predispose them to be more sensitive to radiation.
• In the adjuvant/post-operative setting, radiation following surgery is recommended for patients at high risk of cancer recurrence, including a strong recommendation when there is evidence that BCC or cSCC has spread to a patient's nerves. Post-operative radiation is also recommended for patients at high risk of recurrence following surgical resection, including strong recommendations for high-risk patients with cSCC and conditional recommendations for high-risk patients with the relatively less aggressive BCC. Recommendations also outline prognostic features that indicate which patients are at greater risk for recurrence and spread.
• For patients with BCC or cSCC that has spread to regional lymph nodes, surgical removal of the affected lymph nodes followed by radiation is strongly recommended for both BCC and cSCC, although not for patients with one small involved lymph node without extracapsular spread. The guideline also strongly recommends definitive radiation for patients with regional cSCC spread who cannot undergo surgery.

The guidelines also address technical aspects of radiation therapy, suggest dosing and fractionation schedules and include a brief discussion of the different types of radiation delivery methods.

The task force concluded that the appropriate use of any of the major radiation modalities results in similar cancer control and cosmetic outcomes. The guideline also considers the use of drug therapies such as chemotherapy, biologic and immunotherapy agents in combination with radiation.

Read the executive summary of Definitive and Postoperative Radiation Therapy for Basal and Squamous Cell Cancers of the Skin: An ASTRO Clinical Practice Guideline and the full-text of the guideline in PRO.

Phillip Devlin, MD, FASTRO, is a world renowned brachytherapist practicing medicine at Harvard Medical School. He is the author of two acclaimed textbooks and scores of academic articles regarding the development of brachytherapy and skin applications. He serves as chair of the task force that developed the guideline.

Anna Likhacheva, MD, is an internationally recognized radiation oncologist and brachytherapist who leads the teaching effort for ABS/ASTRO in the area of brachytherapy and skin cancer. She currently practices radiation oncology at Sutter Medical Center in Sacramento, California, and serves as vice-chair of the task force that developed the guideline.