Is Radiation-before-pathology a Feasible Approach in the Palliative Oncology Setting? A Pragmatic Clinical Trial

Official title

Is Radiation-before-pathology a Feasible Approach in the Palliative Oncology Setting? A Pragmatic Clinical Trial (RT-NOW)

Overview

When a doctor suspects cancer, often a biopsy is taken for testing to confirm if cancer is present. Usually, doctors would wait for the results of a biopsy before delivering radiation, but this may lead to a patient having to wait for a treatment that he or she urgently needs. With long wait times for biopsies in Canada, this may lead to symptoms and risks of complications from cancer in the meantime. Therefore, this study is being done to answer the following question: Is it safe and feasible to deliver radiation before obtaining a biopsy in a carefully selected group of patients who urgently need radiation treatment.

Primary outcome measures

• Percent of Inappropriate Use of Radiation Therapy in Participants with Urgent Indications Treated Prior to Biopsy Results [Time frame: 2 weeks after biopsy results]

Secondary outcome measures (9)

• Histological Diagnostic Accuracy [Time frame: 2 weeks after biopsy results]
• Molecular Testing Accuracy [Time frame: 2 weeks after biopsy results]
• Number of Biopsy Attempts Required [Time frame: 2 weeks after biopsy]
• Biopsy Complication Rates [Time frame: 2 weeks after biopsy]
• Time from Enrollment to First Fraction of Radiation Therapy [Time frame: Within 1 year after enrollment]
• Time from Enrollment to Biopsy [Time frame: Within 1 year after enrollment]
• Evidence of Radiation Effect in Biopsy [Time frame: 2 weeks after biopsy results]
• Overall Survival [Time frame: 1 year after enrollment]
• Edmonton Symptom Assessment System Revised Scores [Time frame: 2 weeks after radiation therapy of 2 weeks after biopsy]

Eligibility criteria

Inclusion criteria

• Age 18 years or older
• Willing to provide informed consent
• Palliative treatment intent: either metastatic or incurable locally advanced disease
• Tissue diagnosis is not required for determination of dose/fractionation scheme
• Recent cross-sectional imaging \[for example - Computed Tomography (CT), Magnetic Resonance Imaging (MRI), Positron Emission Tomography/Computed Tomography (PET/CT)\] of the area to be treated, done within the past 3 months
• Treating physician considers the pre-test probability of cancer greater than 95 percent based on clinical judgement and radiological findings.
• The patient has at least 1 site of cancer amenable to biopsy

• As per standard practices, if the radiation oncologist will be radiating the only site available to biopsy, they should proceed with caution. Participants should only be enrolled on trial if the risk of harm from delaying Radiation Therapy (RT) significantly outweighs the risks of possible non-diagnostic tissue. If the participant may potentially be eligible for systemic therapy, the treating radiation oncologist should consult a medical oncologist for an opinion regarding the risks of non-diagnostic molecular testing. The weighing of these priorities should be thoroughly discussed with the participant and the discussion should be documented.
• Reasons for radiating a participant with a single lesion prior to biopsy include:

• Spinal cord compression (actual or impending) and inoperable
• Brain metastasis with significant symptoms or neurologic deficits and inoperable
• Other lesions causing neurologic deficit
• Pulmonary lesion causing or threatening lung obstruction
• Uncontrolled bleeding (including hemoptysis and hematuria)
• Superior vena cava obstruction (actual or impending)
• Limited upside to molecular testing, as determined by the medical oncologist (for example - participant unfit for available systemic therapies, limited options for systemic therapy)
• Radiation is considered urgent (for example - participant should receive radiation prior to biopsy date) o Urgent indications may include but are not limited to the reasons listed previously, as well as the following:

• Painful metastases or primary lesion not adequately responding to analgesia
• Symptomatic brain metastases
• Bleeding
• Impending pathologic fracture

Exclusion criteria

• Participant is potentially eligible for curative treatment
• Clinical suspicion of lymphoma o Some features may be suggestive of lymphoma, including fever or night sweats (for example - B symptoms excluding weight loss), or imaging showing well-defined, homogenous lymphadenopathy. These findings are not exclusion criteria specifically, but should be considered by the clinician in formulating their differential diagnosis.

Criteria are shown verbatim from the registry (in English). Final eligibility is always assessed by the study center.

Healthy volunteers: No

Study design

Observational model

Cohort

Study locations

Canada · 1 center

• London Regional Cancer Program, London Health Sciences Centre — London

Publications

• Young S, O'Neil M, Laba JM, Nguyen TK, Qu XM, Goodman CD, Bauman GS, Warner A, Cecchini M, Palma DA. Radiation-before-pathology approach in the palliative oncology setting: a pragmatic clinical trial protocol (RT-NOW). BMC Palliat Care. 2025 Apr 7;24(1):96. doi: 10.1186/s12904-025-01724-3. PMID 40189509

Identifiers

NCT: NCT06156800 · RT-NOW

Primary sources (government registries)

• ClinicalTrials.gov (US NIH)

View this study on ClinicalTrials.gov ↗