Detailed radioactive decay reaction after [1].
\r\n\tThe emergence of novel prion strains in animals, which include the only evidenced zoonotic prion C-BSE causing vCJD in humans, has created an important public health concern. Currently, new threats to human and animals may develop because of the plausible zoonotic properties of scrapie, L-BSE and the recently emerging chronic wasting disease in Europe.
\r\n\tThis book will gather experts in prion diseases and present new scientific advances in the field and relations with other amyloid neuropathologies.
The process in which an unstable atomic nucleus loses energy by emitting radiation in the form of particles or electromagnetic waves known as radioactive decay that causes the energy loss from the parent nuclide converting it to daughter nuclide [1]. This chapter has been authorized based mainly on published reference focusing on some basic properties and principles of radiation and how to use this phenomenon for the estimation the absolute geological age depending on the isotope half-life and provides brief summary of only a very few examples of dating applications. Geochronology and tracer studies are two principle applications of geochemistry of radiogenic isotope. Geochronology goes to estimate the absolute time based on the radioactive rate decay from the beginning of decay to its daughter by knowing how much nuclides have decayed. Tracer application relies on the variation in ratio of the radiogenic daughter isotope to other isotopes of the element. The purpose of authoring this chapter is to help those who are interested in this field and to provide what is useful and brief in a simplified way away from the complexity.
The radioactive decay (a phenomenon of natural and artificial) means loss of energy that results in an atom named the parent nuclide converting it to an atom of a different type, called the daughter nuclide. The 14C is a parent, emits radiation and transforms to a 14N representing a daughter [2]. Accordingly, it is easy to understand that the radioactivity decay is that process by which an unstable atomic nucleus loses energy by emitting radiation in the form of particles or electromagnetic waves. Radioactive elements and their radiogenic daughters as well as the radiogenic and radioactive are illustrated in Figure 1.
Periodic table showing the elements of natural radioactive isotopes and their daughters.
The becquerel (symbol Bq) is typically used as a SI unit of radioactive decay and it is defined as one decay/second. The Bq is just a tiny measure of activity; a small part of tera-becquerel (TBq) or giga-becquerel (GBq) that is commonly used. The curie (Ci) is an another unit of radioactivity that was basically defined as the activity of 1 g of pure radium 226Ra. Currently, The Bq is ordinary equal to number of disintegrations per second; where Ci is equal to 3.7 × 1010 disintegrations per second. Low activities are also measured in disintegrations per minute (dpm) [2]. The name of the unit “becquerel” is originated and belonging to the Henri Becquerel, a French scientist, who discovered radiation while he working on phosphorescent materials in 1896. Later, many contributions by Becquerel, Marie Curie, Pierre Curie, Ernest Rutherford and others discovered that radioactivity was significantly more complicated [2].
They are particles (α) emitted during the radioactive decay from the nucleus consisting of two protons and two neutrons tightly bound together (Figure 2). Such this decay is known as alpha-decay. All chemical elements above Pb, in the Periodic Table have at least one isotope which decays by emitting alpha particles. This process is relatively rare due it requires high energy to release two neutrons and two protons out of a nucleus. The alpha particle is expressed as an identical to a helium nucleus.
Alpha particle represents the helium atom nuclei.
They are also known as beta ray or beta radiation, symbolized by β. Beta has high-energy, high-speed electron or positron emitted during decay process of a nuclei and give β− and β+, which yield electrons and positrons respectively (Figure 3).
Bata radiation.
Gamma ray is also named gamma radiation symbolized with γ which is an electromagnetic radiation (Figure 4) emitting from the radioactive decay of atomic nuclei [3]. This type of radiation is very common.
Gamma radiation.
Different decay reactions of the radionuclides, the mass number A and atomic number Z of nucleus defined as A, Z are presented in Table 1. The column (daughter nucleus) represents the difference between the produced nucleus and the parent. Thus, (A–2, Z) means that the mass number is two less than before, but the atomic number is the same as before.
Mode of decay | Participating particles | Daughter nucleus |
---|---|---|
Decays with emission of nucleons | ||
Alpha decay | An alpha particle (A = 4, Z = 2) emitted from nucleus | (A−4, Z−2) |
Proton emission | A proton ejected from nucleus | (A−1, Z−1) |
Neutron emission | A neutron ejected from nucleus | (A−1, Z) |
Double proton emission | Two protons ejected from nucleus simultaneously | (A−2, Z−2) |
Spontaneous fission | Nucleus disintegrates into two or more smaller nuclei and other particles | — |
Cluster decay | Nucleus emits a specific type of smaller nucleus (A1, Z1) smaller than, or larger than, an alpha particle | (A−A1, Z−Z1) + (A1, Z1) |
Different modes of beta decay | ||
Beta-negative decay | A nucleus emits an electron and an antineutrino | (A, Z+1) |
Positron emission, also beta-positive decay | A nucleus emits a positron and a neutrino | (A, Z−1) |
Electron capture | A nucleus captures an orbiting electron and emits a neutrino - The daughter nucleus is left in an excited and unstable state | (A, Z−1) |
Double beta decay | A nucleus emits two electrons and two antineutrinos | (A, Z+2) |
Double electron capture | A nucleus absorbs two orbital electrons and emits two neutrinos - The daughter nucleus is left in an excited and unstable state | (A, Z−2) |
Electron capture with positron emission | A nucleus absorbs one orbital electron, emits one positron and two neutrinos | (A, Z−2) |
Double positron emission | A nucleus emits two positrons and two neutrinos | (A, Z−2) |
Transitions between states of the same nucleus | ||
Gamma decay | Excited nucleus releases a high-energy photon (gamma ray) | (A, Z) |
Internal conversion | Excited nucleus transfers energy to an orbital electron and it is ejected from the atom | (A, Z) |
Detailed radioactive decay reaction after [1].
The daughter nuclide is a result of the radioactive decay of a certain radioactive element. Daughter is stable or may also be radioactive, so the chain still continues to decay. The resulting second and/or third daughter nuclide may be radioactive leading to sequential radiation, so the process known as decay chain. Uranium is very heavy element has 92 atomic number (Figure 5).
Configuration of the uranium atom showing the atomic number and mass number.
Three isotopes are most common of uranium; these are with their relative abundance and half-life (t1/2):
238U has relative abundance 99.2739–99.2752% and half-life 4.4683 × 109 years.
235U has relative abundance 0.7198–0.7202% and half-life 703.8 million years.
234U has relative abundance 0.0050–0.0059% and half-life 245,500 years.
Half-life (t) means the time required for a given amount of radionuclide to lose 50% of its activity, and can be expressed as the exponential relationship (Figure 6) represents the interval of time required for one-half of the atomic nuclei of a radioactive sample to decay and spontaneously changes into other element by emitting particles and energy.
The exponential relationship of half-life with radioactive decay.
The best example for the radioactive decay can be illustrating by the uranium decay chain (Figure 7) [4]. The natural decay chain of 238U which eventually decays to 210Po emitting alpha with a half-life of 140 days to produce finally a stable isotope which is 206Pb.
Natural radioactive decay series of 238U.
Many isotope systems are mostly given as examples for dating geologic materials (Table 2).
Parent | Daughter | Half-life | Range available | Lithology type |
---|---|---|---|---|
238U | 206Pb | 4.47 b.y | >10 m.y | Igneous & sometimes metamorphic rocks and minerals |
235U | 207Pb | 707 m.y | ||
232Th | 208Pb | 14 b.y | ||
40K | 40Ar & 40Ca | 1.28 b.y | >10,000 y | |
87Rb | 87Sr | 48 b.y | >10 m.y | |
147Sm | 143Nd | 106 b.y | ||
14C | 14N | 5730 y | 100 – 70,000 y | Organic Material |
Some radioactive elements with their daughters and dating application.
b.y = billion years; m.y = million years; y = year
It can be done to use this information to date rocks, for example; usually, the amount (N) of an isotope present today, and the amount of a daughter element produced by decay (D*), see Eqs. (1) and (2).
λ, the decay constant
Consequently, it is possible to calculate the age if you have the number of daughter atoms produced by decay (D*), while the number of parent atoms (N) is known now with should pay attention for the number of daughter atoms that may have been present prior to the start of our clock.
We can simplify our isochron equation somewhat by noting that if x is small [7],
so that (eλt − 1) = λt, when λt is small.
For this decay reaction, λ = 1.42 × 10–11/y, t1/2 = 4.8 × 1010 y, at present, 27.85% of natural Rb is 87Rb.
If we use this system to plug into Eq. (3), then
but,
or
Plugging this into Eq. (5)
We still do not know 87Sr0, the amount of 87Sr daughter element initially present.
To account for this, we first note that there is an isotope of Sr, 86Sr, that is:
non-radiogenic (not produced by another radioactive decay process),
non-radioactive (does not decay to anything else).
Thus, 86Sr is a stable isotope, and the amount of 86Sr does not change through time.
If we divide Eq. (8) through by the amount of 86Sr, then we get
This is known as the isochron equation. In case of Sr was isotopically homogeneous, the time (t equal 0). For instance, 87Sr/86Sr was the same in the igneous mineral at the time of crystallization. Typically, rock – forming minerals more may be have a different amount of 87Rb [5], and accordingly, those minerals are ordinary have a different 87Rb/86Sr at the crystallization time. During the natural cooling, the 87Rb in each mineral will decay to 87Sr, and each mineral will have a different 87Rb and 87Sr over time [6].
And simplify to:
Then time (t) can be computed as:
The initial ratio (87Sr/86Sr)0, is useful to use as a geochemical tracer because Rb distributed unequally through the Earth over time [7]. The amount of Rb in the earth mantle is typically low (<0.1 ppm). The mantle thus has a low 87Rb/86Sr ratio and would not change its 87Sr/86Sr ratio very much with time, whilst the earth crust has higher amounts of Rb (>20 ppm) and therefore start out with a relatively high 87Rb/86Sr ratio. Over time, this results in crustal rocks having a much higher 87Sr/86Sr ratio than mantle rocks. Thus, it will be expected if the mantle has a 87Sr/86Sr of say 0.7025, melting of the mantle would produce a magma with a 87Sr/86Sr ratio of 0.7025, and all rocks derived from that mantle would have an initial 87Sr/86Sr ratio of 0.7025.
On the other hand, if the crust with 87Sr/86Sr of 0.710 melts, then the resulting magma would have 87Sr/86Sr of 0.710 and rocks derived from that magma would have an initial 87Sr/86Sr ratio of 0.710. So, the rock derived from the mantle or crust can determine its initial Sr isotopic ratio accordingly.
Many Pb isotopes are produced from U and Th isotopes. 238U and 235U and 232Th can produce Pb isotopes during their radioactive decay that can be described as follows:
232Th does not used in dating.
204Pb is a stable non-radiogenic isotope of Pb, the two isochron equations and get two independent dates from the U-Pb system can be written as:
and
If these two independent dates are concordant, a concordia diagram will show the values of Pb isotopes that would give concordant dates and can plug in t and solve for the be calculated Eqs. (21) and (22) as follows:
and
The Concordia is particularly useful in dating of zircon, that usually contains a lot U and less amounts of Pb, so we expect it has large amounts of radiogenic Pb that can be produced. Apatite and sphene are the two minerals that are commonly can be used in radiometric dating as well. Zircon from the crystallization time to the present represents a closed system in case no loss or gain of uranium or lead. The age of the zircon can be determined from its position on the Concordia after plotting the 206Pb*/238U and 207Pb*/235U ratios on the Concordia diagram. The discordant dates fall out of the Concordia curve.
The both ends of the Discordia intersect are represented by t0, the older and t*, the younger. Many reasons lead to Pb leakage. Metamorphism for example, could heat the crystal to the point where Pb will become mobile. Another possible reason cause U leakage, where the discordia is represented by the two points that would give two ages −t* representing the possible metamorphic event and t0 representing the initial crystallization age of the zircon.
The Pb-Pb isochrons can be normally concluded from combining the two isochron Eqs. (19) and (20).
Then, and by assuming that the 206Pb and 207Pb dates are the same, then Eq. (23) is the equation have a slope.
that passes through the point.
The oldest rock found in Canada, with an age of 3.962 b.y ±3 m.y. This provide only a minimum age of the Earth. The age of the earth can be computed based on the chemical concept that is the 235U/238U ratio may have been 1.0 when the elements formed. So, from:
the
Finally, t is about 6 b.y.
This age represents the maximum age of the Earth. From the Pb-Pb isochron Eq. (23) and based on meteorites that may have been formed at the same time the solar system in which basically the Earth formed as well. The thing to be needed to date meteorites is knowing the initial ratios of the Pb isotopes. Two major types of meteorites are recognized; Fe- meteorites and stony (or chondritic) meteorites. The Fe-meteorites contain troilite (FeS) that has no U. Since the mineral troilite contains no U, all of the Pb present in the troilite is the Pb originally present, and none of it has been produced by U decay. Thus, the troilite in the Fe-meteorites will provide with the initial ratios of 206Pb/204Pb and 207Pb/204Pb.
The Pb ratios can be determined in other meteorites and check if they fall on the isochron of Pb-Pb that passes through the initial ratios determined from troilite in Fe-meteorites. The slope of this isochron (Geochron) estimated the earth age is of 4.55 ± 0.07 × 109 yr. Consequently, the best estimation of the age of the Earth is 4.55 billion years.
147Sm decays to 143Nd by alpha decay with half-life of 106 ± 2 b.y. [8], 147Sm, 148Sm, 149Sm, and 144Nd are radioactive, three nuclides accordingly generated 144Nd, 145Nd, and 140Ce [9].
The isochron equation is described based on whether the 144Nd is stable and non-radiogenic as:
The age of the rock can be estimated later from the isochron equation that basically can be drawn by the determination of the 143Nd/144Nd and 147Sm/144Nd ratios for several minerals.
In the nature, 40K makes up 0.119% of natural K, as it is a radioactive element, its decay can be presented as follows [10]:
The equation above is not used, because 40Ca can be present as both radiogenic and non-radiogenic Ca [10].
For the combined process,
and for the Ar branch of the decay scheme
Argon is a gas easily can escape from a magma or liquid, therefore, the percentage of initial 40Ar is expressed as zero; during the rapid cooling of magma, quanitity of the Ar may be trapped. The date consequently obtained will be older than the date at which the magma erupted.
The dating equation used for K-Ar is:
where
Many points need to have attention when use K-Ar dating, the use of minerals like sanidine or biotite is better to use whole rocks because minerals not contain excess Ar. Other thing, some atmospheric argon originated from volcanic eruptions could be absorbed onto the sample surface, 40Ar should be corrected for accordingly. Additionally, most minerals lose Ar during metamorphism due to high temperature, so the date will represent the metamorphic event (Table 3).
Decay | Decay factor | value |
---|---|---|
40K → 40Ca by β- | λβ- | 4.962 × 10−10 a−1 |
40K → 40Ar by electron capture and γ | λe | 0.572 × 10−10 a−1 |
40K → 40Ar by electron capture | λ’ e | 0.0088 × 10−10 a−1 |
combined value | λ = λβ- + λec + λ’ ec | 5.543 × 10−10 a−1 |
present day 40K/K | 0.0001167 |
Decay constants for K-Ar and Ar-Ar dating [11].
Radiocarbon dating is different than the other methods of dating because it cannot be used to directly date rocks, but can only be used to date organic material produced by once living organisms [12]. Radiocarbon (14C) has a short half-life (5730 y), it is therefore only used to date materials younger than about 70,000 years. The ratio of 14C to 14N in the Earth’s atmosphere is constant and the organism have the same ratio of 14C to 14N as the atmosphere. When an organism dies, the 14C decays back to 14N, with a half-life of 5730 years. Measuring the amount of 14C in this dead material thus enables the determination of the time elapsed since the organism died. Bones, teeth, charcoal, fossilized wood, and shells are materials can be used for dating.
Rhenium has stable 185Re and the radioactive 187Re. The latter is the most abundant (62.6%) and decays to 187Os based on beta decay, typically with a half-life of 41.6 × 109 y [13]. Osmium has seven isotopes; only two are the product of natural decay of radioactive isotopes: 186Os is produced from 190Pt by α-decay (half-life 4.7 × 1011 y, [14]) and 187Os by β-decay of 187Re. The two radiogenic isotopes 187Os (∼2%) and 186Os (∼1.6%) are typically normalized to the stable 188Os (13.24%). Rhenium-osmium (Re-Os), an applicable method was first applied to meteorites [15]; it provides a chronometer for directly dating both of sulfides and oxides ore minerals.
This chapter deals with the various types of radiation emitted by radioactive nuclides with principles of radionuclide decay and its radiations. Here an overview of some of the many dating radioactive techniques that play as significant role in our day-to-day lives. The dating techniques developed for defining reliable ages of geologic events other geochronological studies are recording of the isotope concentrations. All radiometric clocks depend on a radioactive “parent” isotope that decays to a daughter stable isotope of another element at a constant rate on geologic timescales. This process may take single step, or it may involve many stages of decay products before reaching the final stable daughter isotope. The half-life of the initial quantity of parent isotope to decay must be on the same order of magnitude as the time span to be measured. The Concordia–Discordia model has been developed for the U and Pb isotopes. The 235U transforms to 207Pb through a chain of radioactive nuclides, releasing (235–207)/4 = 7α-particles with the constant λ5 = 9.8·10–10. The 238U turns to 206Pb releasing (238–206)/4 = 8α-particles with the constant λ8 = 1.55 · 10–10 [16]. Currently, the ratio of 238U/235U (137.88) is growing. Both isotopes of uranium are closely connected to each other in kinetic processes due to the value √238/235 = 1.0063, which is close to 1. The Discordant values can be obtained from the development of the Concordia–Discordia model as an open system with losses of radiogenic lead in accessory minerals such as zircon, monazite, apatite etc. [17]. A very wide time range, not only the 12 b.y. of the Universe age and the 4.5 b.y. of the Earth’s age can be explore, but also the details related paleontology through the history of the Earth and recent events of the last millennia [12]. The K-Ar dating technique developed soon after the discovery of 40K and provided an important dating tool beside U-Pb and U-He dating methods. The half-life (1250 m.y) made this method is most popular for dating geological events [18]. The K-Ar dating are based on the decay of a 40K to an isotope of 40Ar by a branching process; 10.48% of 40K decays to 40Ar by β + decay, and 89.52% decays to 40Ca by β- to the ground state [10]. The age measured by K-Ar techniques reflects the time since radiogenic argon produced by decay of 40K, became trapped in the mineral or rock. The radiogenic noble gas daughter nuclides provide many methods for determining not only the chronology of events but also thermal histories combined with U-Pb and Rb-Sr dating techniques. This technique uses to conclude the cooling history based on use mineral closure or field estimates [19]. It can be applied for dating young volcanic eruptions and for low-temperature phases such as clay minerals like illite. In addition, they can be used for exploring. Despite the Rhenium–osmium (Re-Os), an applicable method was first applied to meteorites [15]; it also provides a chronometer for directly dating both of sulfides and oxides ore minerals. Recently, this technique is developed and become capable to estimate dating via dealing with very low content of Re and Os. The relative abundance of Osmium is the earth’s core and extraterrestrial material with a very leaser amount (ppt) in the mantle and it can be stored in sulfide and oxide minerals in the crust. It 8is best method for dating the age of gold in auriferous pyrites, it also used for dating marine shale containing coal.
It is difficult to obtain good precision and accuracy for radiocarbon due to its abundancy in the environment and it is possible to contaminate from material of a different age. Consequently, the methods for radiocarbon measuring are well tested, reproduced and carefully controlled under specific lab conditions. Recently, the radiocarbon methods have been developed, over the last 30 years to cover most of the materials suitable for radiocarbon measurement. The AMS system at Oxford was built with very high precision and accuracy for radiocarbon dating by High Voltage Engineering Europa BV. For high precious in situ age dating of Pb-U, Hf and U-Th isotope ratios in very small minerals like zircons, it is recommended to use the Thermo Scientific Neptune XT MC-ICP-MS or Thermo Scientific Element 2 and Thermo Scientific Element XR High-Resolution ICP-MS, combined with a laser ablation system. The Thermo Scientific Triton XT Multicollector Thermal Ionization Mass Spectrometer (TIMS), provides the ultimate precision for U-Pb geochronology, while The Triton XT TIMS is an equipment with high-quality age dating for Rb-Sr, Sm-Nd and Re-Os.
To be useful, result must be accurate, so uncertainty must always be taken into account. The geochronological result is influenced by uncertainty. So, if it does not be known well, result is scientifically meaningless. The uncertainty is coming from error in sampling, laboratory procedure; adaption of methods to the problem in question [12]. Overall, the source of uncertainty obtained from:
collecting samples
Parent decay methods
Long half-life parent daughter methods
Age calculations
The radiogenic isotopes are typically separated from the no-radiogenic isotopes using spectrometer whenever they used as dating tools or tracers. Sample is ionized normally in thermal-ionization mass spectrometer (TIMS). Recently, the induced coupled plasma (ICP) is technique used for the chemical purification before mass spectrometry method. The laser ablation is also used for analyzing mineral with high concentration of radiogenic elements. However, in samples of whole-rocks, in which the concentration of radiogenic isotope is mostly low, it is necessary to pre-concentrate after dissolution and chemical extraction. The silicate geological samples are routinely dissolved in hot method using either concentrated HF acid or HCLO4 acid at atmospheric pressure; so, the most rock-forming minerals are dissolved, but the resistant minerals like zircon must be dissolved under pressure in a bomb at 220°C. The bomb liner and beaker are made of poly-fluorinated ethylene [20]. The formation of fluoride is the most common problem that may encounter after dissolution in HF as an insoluble in HCl acid. Consequently, the refluxing with HNO3 is needed [21]. The additional adding of HNO3 before completely evaporation of HF leads to promote process [22]. If at some stage, complete digestion is not achieved, decant off the solution is recommended and return to undissolved fraction at the previous stage for a second acid attack [23]. Thereafter, the solution rich in isotope is split for isotope-dilution analysis and for accurate-isotope ratio analysis.
The Rb-Sr is used widely as a method provides a great information of igneous rock dating. The naturel process begins from the decay of 87Rb occurred in minerals to 87Sr, so the number of 87Sr daughters produced informs us about t years ago:
Where the 87Sr1 is the number of the initial 87Sr atoms. The given nuclides are of so difficult to measure their absolute abundance, so, it is suitable to find isotope ratio by dividing by 86Sr which is not radiogenic and accordingly still constant with time as follows:
Currently, strontium isotope ratio (p) can be measured by mass spectrometry, and the 87Rb/86Sr is calculated from Rb/Sr weigh ratio. From the initial ratio (87Rb/86Sr)I estimated, time (t) can be computed as:
Over geological time, Rb-rich minerals “like lepidolite” develop ratio (0.712) of 87Rb/86Sr and may use in chronological studies without error. The Rb-Sr method was extended to include other mineral such as mica (biotite and muscovite) as well as potash feldspar that have lower Rb/Sr ratios. The discordant dates are suggested based on the initial ration (0.712) when the real initial ratio was higher. This expressed as a problem and was overcome by the isochron diagram designed by [24] who developed a new way for treating Rb-Sr data based on the principle of linear equation:
In this way, 87Sr/86Sr (
Schematic Rb-Sr isochron diagram for a suit of co-magmatic igneous minerals [
This figure presents a suite of co-magmatic minerals of same age and initial of 87Sr/86Sr ratio, forming a line called isochron. From slop of isochron,
Rb-Sr isochron diagram on axis of equal magnitude showing production of 87Sr as 87Rb is consumed in two hypothetical samples [
The original isotopic composition of mantle is basically inherited in the primary basic magma. The alkali ocean-island basalts were investigated for the Rb-Sr system [26]. The results of fourteen wide range type of ocean- island basalt samples plotted on an isochron displayed a proportional correlation to a slop age of about 2B.y representing the time of mantle isolation [25]. This age is known as a mantle isochrones that is also extended to continental igneous rocks [27]. The ratio of 87Sr/86Sr should correct back to initial ratio at the time of magmatism before plotting versus 87Rb/86Sr, so these are termed as pesud-oisochrons. Data of plotting 30 samples from both volcanic and plutonic continental igneous rock suits formed a roughly linear array. The pesud-oisochrons generates from two lines representing crustal contamination of mantle-derived basaltic magma, Scientist replaced that by timing the mantle differentiation events that established mantle domains of different ratio of Rb/Sr in subcontinental lithosphere. This suggestion does not provide reliable results to ascribe age significantly to erupted isochrones. However, the only isotope-isotope mantle isochrones is reliable and can be interpreted and used significantly as tool for dating the age of mantle differentiation events.
Cancer is a major public health problem worldwide, and colorectal cancer is the third most diagnosed cancer among both men and women in the United States [1], Brazil [2] and, overall, it is the third more frequent malignant disease around the world (1.85 million of new cases/years; 10.2% of total malignancies), with a 2.27% cumulative risk of onset between 0 and 74 years [3].
The mortality from colorectal cancer varies with several factors from the genetic variations of disease to the developmental status of a nation. Tumor staging remains the main prognostic factor.
The last two decades have seen substantial progress in the treatments to metastatic disease offering significant improvements in survival. According to SEER, the 5-year relative survival rate for patients diagnosed from 2008 to 2012 was about 64% for all stages taken together, and it was 14% for patients with metastatic disease [4].
At the time of first diagnosis, approximately 25% of patients present stage IV, with liver metastases, and up to 50% will develop recurrence in the liver during the disease course [5]. Most of these patients have liver metastasis considered unresectable at presentation [6], but about 20–30% of patients have a resectable disease that is confined to the liver [3], and despite a metastatic diagnosis, a half these of patients may benefit from the surgical resection of liver metastasis with curative intent, with improvements in a 5-year survival [7].
Colorectal cancer survival disparities are largely driven by socioeconomic inequalities that result in differences in access to early detection tests, refinements in molecular diagnosis, and the receipt of timely, high-quality treatment [8].
Today, the median overall survival for patients with metastatic colorectal cancer being treated both in phase III trials and in large observational series or registries is about 30 months and is more than double that of 20 years ago [9]. These patients with unresectable disease remain incurable and the treatments are mainly palliative.
We performed a non-systematic literature review of the results of a search in PubMed® with terms “palliative care” and “colorectal cancer” published in the last 5 years without restrictions of language. We found 304 articles that were manually selected for reading and synthesis of this work.
Palliative care has appropriately been receiving increased attention in recent years, due to better comprehension of this field of action and due to incremental costs of antineoplastic therapy disproportionated with clinical results.
From practical standpoint, therapy is considered palliative when resection of all known tumor sites is no longer possible or advisable and chemotherapy have limited benefit rate. Since a cure, as commonly defined, is not possible, the goal of treatment and eventually the success of therapy become judged by the control of symptoms and alleviation of suffering, not more by survival advantages or longer disease-free intervals [10].
Providing optimal palliative care for the patient with advanced colorectal cancer is a complex and challenging process. The success rate depends on proactive multidisciplinary interventions, taken early in metastatic disease [11].
Palliative care can improve all phases of the disease, it allows better decisions in the end-of-life care and potentially reduces health-care expenditures, but the exact understanding of commonly used terms such as “supportive care,” “symptom control” “palliative care,” and “hospice care” was rarely and inconsistently defined in the palliative oncology literature [12].
The roots of palliative medicine may be traced since Hippocrates through medieval medicine until a more recent approach of Cicely Saunders and to a new concept of modern palliative care. It has evolved from a philosophy of care for the dying to an interprofessional discipline that addresses mainly the quality of life for patients and their families throughout the disease trajectory [13].
The best palliative care will ever require a multidisciplinary approach where treatment plans will be made in accordance with the wishes of the patient and his family with a goal of decreasing morbidity and focus on improving quality of life by addressing their physical, emotional, and spiritual needs, and on supporting their families [14].
The provision of optimal palliative care for these patients is a compound and demanding process and becomes more challenging when an incurable and asymptomatic primary progress to advanced metastatic colorectal disease [15].
Surgical resection may provide good palliation of symptoms and prevent future tumor-related complications as we saw before [15].
Better than dividing patients into strict treatment protocols and different models of care, this new concept supports the provision of patient care by a single discipline comprised of a team of health-care professionals with expertise in symptom management, psychosocial care, spiritual support, caregiver care, communication, complex decision-making skills, and end-of-life care [16].
The need for incorporating palliative care into routine oncology practice is still enormous, but the benefits of doing so are even more significant. Outside United States and some places in Europe, financially strained health systems will need cost-effective models of palliative care delivery. As the aging population increases, the number of people diagnosed with cancer, and degenerative disease will increase, raising the need for this kind of approach.
As we see in the United States, as the cancer population grows, an already limited oncology workforce will be further strained. Cost- and resource-effective models of palliative care delivery will be required.
Volunteer work fills a large part of these gaps and can be the way out to overcome difficulties in access and funding [17], but adequate training of volunteers is essential to obtain the appropriate level of performance [16].
Community involvement needs to go beyond resource mobilization. In the current context of health systems, reaching higher levels of participation, involving the community as a partner in the implementation and support of these projects is something more complex and more difficult to achieve. Common barriers include the lack of mandatory preparatory work to understand the community’s social and political dynamics, the facilitators’ values and agenda [18].
Public expectations will rise and require that expectations will rise and require that palliative care be well integrated into all oncology care settings. All these factors will serve to promote the integration of expectations of a new way of oncology care.
The most important goals of palliative care are stablishing a good communication and offer an outstanding symptom control. Without adequate symptom control, no psycho-emotional measures can be adequately developed.
Initial symptoms vary from mild anemia to bowel obstruction. In extremis, two main situations are considered, asymptomatic (or minimally symptomatic) and severely symptomatic patients needing aggressive management, including emergency cases [9].
For a significantly part of symptoms or complications, the main treatment approach is surgery, by resection of the primitive tumor or stoma, eventually resection of liver metastasis, combined with radiotherapy (for rectal cancer) and chemotherapy (adjuvant or for metastatic disease).
Beyond surgery, the management of metastatic disease has significantly changed over the last three decades with the incorporation of antiangiogenics (bevacizumab and panitumumab) and anti EGFR1 agent (cetuximab), and more recently, immunomodulation with anti-PD1 and Anti PD-L1 agents. Nowadays the multidisciplinary approach is essential [19].
Emergency management of colorectal cancer patients still represents a major issue and is associated to high morbidity/mortality, and where there was often no time for patient directives to be established. The two major situations are obstruction and massive bleeding. Perforation is a rare presentation [20]. For these situations, palliative surgery may be the most appropriate approach.
Obstruction is traditionally approached surgically by colonic resection, stoma, or internal by-pass or a stenting [21].
Bleeding may be managed by surgery or less invasive approaches, including radiotherapy, laser therapy and other transanal procedures [12].
Perforation is associated with the highest mortality and remains mostly matter for surgeons, by abdominal lavage/drainage, colonic resection and/or stoma [11].
In cases of more advanced disease, patients may present with jaundice (due to liver metastasis or biliary tract obstruction) or malignant ascites. As the number of patients with malignant distal biliary obstruction who will undergo curative surgery is limited, endoscopy has a crucial role in palliation [22].
Biliary obstruction was most common cause of jaundice, and standard techniques of biliary cannulation by endoscopic retrograde cholangio-pancreatography are the main treatment option. When it fails, endoscopic ultrasound-guided biliary drainage is a better option compared to percutaneous drainage [23].
Biliary obstruction can be the presentation of an advanced stage of disease. Median overall survival after onset of jaundice was 1.5 months but may improved to 9.6 months in patients submitted to a biliary decompression who were able to receive further chemotherapy. Jaundice due to metastatic colorectal cancer is often an ominous finding, representing aggressive tumor biology or exhaustion of therapies [14].
Jaundice represents a major concern for patients, from the unpleasant feeling of itching and to the limitations of social interaction because the change in color of the skin.
Malignant ascites accompanies a variety of abdominal and extra-abdominal metastasis and mainly peritoneal dissemination of disease. It is a cause of high morbidity, major discomfort, and several other symptoms, leading to a significant reduction in the patient’s quality of life. This situation raises several treatment challenges where treatment options include a multitude of different procedures but with limited efficacy, new clinical problems as loss of proteins and electrolyte disorders that may cause diffuse edema, and some degree of risk [24].
Patients with anasarca usually present with great discomfort, with cold, thin skin and with skin transudate. These are situations that may require palliative sedation and suspension of parenteral hydration since excess of fluids worsens symptoms [25].
The treatment of malignant ascites primarily includes paracentesis and diuretics, as first-line treatments. Diuretic therapy is effective at the very beginning of the disease but efficacy declines with tumor progression and was associated with dry mouth and orthostatic hypotension [15].
Paracentesis is widely adopted but it is associated with significant patient discomfort, risks of bleeding or bowel perforation, and loss of significant amount of albumin, with worsening of peripheral edema.
Intraperitoneal chemotherapy, targeted therapy, immunotherapy, and radioisotopes are rarely an option in this situation [13].
Some symptoms of advanced disease may be less specific for colorectal carcinoma and represent a systemic impairment by neoplastic disease, like cachexia/sarcopenia.
Cachexia is a multifactorial syndrome characterized by loss of appetite, weight, and skeletal muscle (sarcopenia) [26], leading to a cluster of symptoms like fatigue, functional impairment, increased treatment-related toxicity, poor quality of life, and reduced survival. Across malignancies, cachexia becomes more prevalent as the disease progresses, impacting approximately half of patients with advanced cancer [27].
Cachexia is a situation where preventive treatment is the most efficient. Once severe sarcopenia is established, the condition is rarely reversible. The nutritional approach should start with the development of anorexia, before weight loss begins [28].
Dietary counseling and physical activities must be offered with the goals of providing patients some advice for the preemptive management of cachexia. Enteral feeding tubes and parenteral nutrition should not be used routinely due to the discomfort, increment of costs and social life limitations.
No specific pharmacological intervention can be recommended as the standard of care, but progesterone analogs and short-term corticosteroids. It may be choose wisely because is associated with thromboembolic risk and gain of more fat gain than muscle mass [16].
Among other nonspecific symptoms of colorectal carcinoma, but often associated with advanced neoplasia, 35–96% of patients experience pain, 32–90% experience fatigue, and 10–70% experience breathlessness [25]. The broad ranges of incidence arise from the forms and time of assessment.
Symptom assessment in patients with advanced disease shows a progressive clustering of cascading events. Patients typically experience more than one symptom at any one time [29]. Grond et al. [16] found that 94% of those referred to a cancer pain clinic experienced additional symptoms, with 15% reporting at least five.
Symptoms may be a result of the interactions of conditions not only caused by the cancer itself, but as indirect consequences of the cancer, early or late adverse effects of treatment, and/or comorbid conditions [30].
Most patients with stage IV colorectal cancer have a poor prognosis, but numerous palliative modalities, as seem, are available today. When a cure is no longer possible, treatment is directed toward providing symptomatic relief, and a better quality of life [31].
It is difficult to draw the line between the usefulness of chemotherapy and therapeutic futility. As more drug options become available, the greater the tendency to prolong antineoplastic treatment.
Functional activity indexes can correctly evaluate disability but need to be combined and integrated with other parameters to assess prognosis.15 Poor performance status values are the main point to assess the possibility of the usefulness of chemotherapy.
Chemotherapy administration near death, showed that this approach did not improve quality of life for patients with poor performance status, and can be detrimental also for patients with good performance status [13]. Third line and beyond treatments prolonged overall survival versus palliative care, in high selected [32].
Aggressive care near the end of life as a sign of poor-quality cancer services [33] but, although numerous studies have measured these indicators, different criteria were used to define populations of interest make a comparison of results difficult [34].
Despite the frequency of symptoms and the limitations of antineoplastic therapy, oncologists did not systematically refer patients to a palliative care specialist, but only requested their intervention for pain and symptom management [35].
We need to change reality and dispel myths and prejudices in relation to palliative care to improve the quality of life between cancer diagnosis and death. It is necessary to change the role of the physician in navigating this course [36], or create referral programs regardless of the physician.
When a cure is no longer possible, treatment is directed toward providing symptomatic relief. The data available today leave little doubt that surgical resection, when feasible, may provide good palliation for some patients with metastatic disease. Although palliative surgery has been the mainstay of palliative care, an individualized multidisciplinary approach, which may involve both surgical and nonsurgical modalities, is probably the best current option [31].
In the last decade major changes in health-care delivery, changing demographics, and new treatment options have significantly changed the cancer patients’ trajectory [37]. Now is the time to adapt the current models of palliative care to achieve the strongest dissemination to all cancer care settings. Implementation of palliative care can be achieved through recognition of emerging best practices and financial support to afford this model of care [38].
The difference between curative and palliative care lies in defining the main goal of treatment, since palliative treatments can extend life [39]. Palliative care is incorrectly associated with the suspension of all forms of antineoplastic therapy, but the persistence of inappropriate antitumor treatments in non-responding patients and overly aggressive care often affects a patient’s quality of life [40].
A report from a retrospective cohort study including all patients who died of colorectal cancer between 2004 and 2012 in Manitoba, Canada, provides the better evidence that early palliative care involvement is associated with decreased odds of dying in hospital and lower health-care utilization and costs in patients with colorectal cancer [41].
The goal of palliative care is improvement of quality of life. Good communication skills and flawless symptom control is associated with improved patient and family quality of life, greater treatment compliance, and may even offer survival advantages [42].
A 2016 meta-analysis evaluated 40 palliative care trials and concluded that this care was associated with improved patient quality of life and control of symptom burden [43].
The American Society of Clinical Oncology (ASCO) recommends the integration of palliative care into oncology practice [23], but despite the increasing evidence of the benefits of palliative care there is little consensus regarding strategies for integrating palliative care into the routine practice of oncology [44]. The lack of qualified professionals, the difficulties of access and the remuneration of professionals are still the biggest obstacles, especially in underdeveloped countries.
Palliative care has emphasized support for family caregivers. Although the family caregiver literature is even more limited than patient-focused studies, there is growing evidence of the benefits of palliative for family caregivers [15], but our current models of remuneration are insufficient to cover the care of the patient’s family members, and especially in the assistance to bereavement.
For palliative care to be truly integrated into oncology care, it will need to take on new forms, expanding for greater use in outpatient and community settings, survivorship clinics, and the most important, primary practice of oncology [45].
In an era of limited resources and incremental costs of health care, expanding palliative care capacity to meet clinical guidelines and population health needs seems to save costs. The major problem is a significant variance in estimates of the effects of treatment on costs, depending on the timing of intervention, the primary diagnosis, and the overall illness burden.
Because ASCO guidelines state that palliative care should be provided concurrently with other treatment from the point of diagnosis onward for all metastatic cancer, a broad evaluation is required to evaluate the cost effects of palliative care across the entire disease trajectory [46].
Colorectal carcinoma is a frequent entity, with many patients being diagnosed with metastatic disease “de novo” or having recurrences of the disease after primary treatment.
Although a fraction of patients may undergo resection of metastases with curative intent, the vast majority will remain eligible only for palliative treatment modalities, which may include surgery or systemic antineoplastic therapy.
Fundamentally, the practice of palliative care includes an impeccable control of symptoms, good communication, and psycho-emotional support for patients and their families.
The demand for palliative care to be integrated throughout the cancer trajectory, combined with a limited palliative care workforce, means that new models of care are needed.
Palliative care began in academic centers with specialty consultation services, and its value to patients, families, and health systems has been evident.
Volunteering can help fill most of the gaps in palliative care, but its implementation is still difficult and restricted to some more developed centers.
This chapter discusses evidence regarding the need for integration of palliative care into routine oncology care and describes the best practices recognized for dissemination of palliative care. The available evidence suggests that palliative care be widely adopted by clinicians in all oncology settings to benefit the patients with cancer and their families. Efforts are needed to adapt and integrate palliative care into community practice.
The benefits of palliative care can only be realized through effective dissemination of these principles of care, with more primary palliative care delivered by oncology clinicians.
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