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Title: Palliative Radiotherapy for Bone Metastases: An ASTRO Evidence-Based Guideline

Abstract

Purpose: To present guidance for patients and physicians regarding the use of radiotherapy in the treatment of bone metastases according to current published evidence and complemented by expert opinion. Methods and Materials: A systematic search of the National Library of Medicine's PubMed database between 1998 and 2009 yielded 4,287 candidate original research articles potentially applicable to radiotherapy for bone metastases. A Task Force composed of all authors synthesized the published evidence and reached a consensus regarding the recommendations contained herein. Results: The Task Force concluded that external beam radiotherapy continues to be the mainstay for the treatment of pain and/or prevention of the morbidity caused by bone metastases. Various fractionation schedules can provide significant palliation of symptoms and/or prevent the morbidity of bone metastases. The evidence for the safety and efficacy of repeat treatment to previously irradiated areas of peripheral bone metastases for pain was derived from both prospective studies and retrospective data, and it can be safe and effective. The use of stereotactic body radiotherapy holds theoretical promise in the treatment of new or recurrent spine lesions, although the Task Force recommended that its use be limited to highly selected patients and preferably within a prospective trial. Surgical decompressionmore » and postoperative radiotherapy is recommended for spinal cord compression or spinal instability in highly selected patients with sufficient performance status and life expectancy. The use of bisphosphonates, radionuclides, vertebroplasty, and kyphoplasty for the treatment or prevention of cancer-related symptoms does not obviate the need for external beam radiotherapy in appropriate patients. Conclusions: Radiotherapy is a successful and time efficient method by which to palliate pain and/or prevent the morbidity of bone metastases. This Guideline reviews the available data to define its proper use and provide consensus views concerning contemporary controversies or unanswered questions that warrant prospective trial evaluation.« less

Authors:
 [1];  [2];  [3];  [4];  [5];  [6];  [7];  [8];  [9];  [10];  [11];  [12];  [13];  [14];  [15];  [16];  [17]
  1. Department of Radiation Oncology, Blanchard Valley Regional Cancer Center, Findlay, OH (United States)
  2. Department of Radiation Oncology, Moffitt Cancer Center, Tampa, FL (United States)
  3. Department of Radiation Oncology, University of Texas M.D. Anderson Cancer Center, Houston, TX (United States)
  4. Department of Radiation Oncology, Sunnybrook Odette Cancer Center, University of Toronto, Toronto, ON (Canada)
  5. Department of Radiation Oncology, Duke University, Durham, NC (United States)
  6. Mount Vernon Centre for Cancer Treatment, Middlesex (United Kingdom)
  7. Department of Radiation Oncology, University of Michigan, Mt. Pleasant, MI (United States)
  8. Department of Radiation Oncology, Wayne State University, Detroit, MI (United States)
  9. Department of Radiation Oncology, Boston Medical Center, Boston, MA (United States)
  10. Department of Radiation Oncology, Ohio State University, Columbus, OH (United States)
  11. Department of Radiation Oncology, Sunnybrook Odette Cancer Center and the Princess Margaret Hospital, University of Toronto, Toronto, ON (Canada)
  12. 21st Century Oncology, Sarasota, FL (United States)
  13. Institute for Palliative Medicine, San Diego Hospice, San Diego, CA (United States)
  14. Neurological Surgery, Ohio State University, Columbus, OH (United States)
  15. Department of Radiation Oncology, Cleveland Clinic Foundation, Cleveland, OH (United States)
  16. University of Pennsylvania School of Nursing, Philadelphia, PA (United States)
  17. Department of Radiation Oncology, Good Samaritan Cancer Center, Downers Grove, IL (United States)
Publication Date:
OSTI Identifier:
21491653
Resource Type:
Journal Article
Resource Relation:
Journal Name: International Journal of Radiation Oncology, Biology and Physics; Journal Volume: 79; Journal Issue: 4; Other Information: DOI: 10.1016/j.ijrobp.2010.11.026; PII: S0360-3016(10)03577-7; Copyright (c) 2011 Elsevier Science B.V., Amsterdam, The Netherlands, All rights reserved.
Country of Publication:
United States
Language:
English
Subject:
62 RADIOLOGY AND NUCLEAR MEDICINE; METASTASES; NEOPLASMS; RADIOTHERAPY; RECOMMENDATIONS; SURGERY; VERTEBRAE; BODY; DISEASES; MEDICINE; NUCLEAR MEDICINE; ORGANS; RADIOLOGY; SKELETON; THERAPY

Citation Formats

Lutz, Stephen, E-mail: slutz@bvha.or, Berk, Lawrence, Chang, Eric, Chow, Edward, Hahn, Carol, Hoskin, Peter, Howell, David, Konski, Andre, Kachnic, Lisa, Lo, Simon, Sahgal, Arjun, Silverman, Larry, Gunten, Charles von, Mendel, Ehud, Vassil, Andrew, Bruner, Deborah Watkins, and Hartsell, William. Palliative Radiotherapy for Bone Metastases: An ASTRO Evidence-Based Guideline. United States: N. p., 2011. Web. doi:10.1016/j.ijrobp.2010.11.026.
Lutz, Stephen, E-mail: slutz@bvha.or, Berk, Lawrence, Chang, Eric, Chow, Edward, Hahn, Carol, Hoskin, Peter, Howell, David, Konski, Andre, Kachnic, Lisa, Lo, Simon, Sahgal, Arjun, Silverman, Larry, Gunten, Charles von, Mendel, Ehud, Vassil, Andrew, Bruner, Deborah Watkins, & Hartsell, William. Palliative Radiotherapy for Bone Metastases: An ASTRO Evidence-Based Guideline. United States. doi:10.1016/j.ijrobp.2010.11.026.
Lutz, Stephen, E-mail: slutz@bvha.or, Berk, Lawrence, Chang, Eric, Chow, Edward, Hahn, Carol, Hoskin, Peter, Howell, David, Konski, Andre, Kachnic, Lisa, Lo, Simon, Sahgal, Arjun, Silverman, Larry, Gunten, Charles von, Mendel, Ehud, Vassil, Andrew, Bruner, Deborah Watkins, and Hartsell, William. 2011. "Palliative Radiotherapy for Bone Metastases: An ASTRO Evidence-Based Guideline". United States. doi:10.1016/j.ijrobp.2010.11.026.
@article{osti_21491653,
title = {Palliative Radiotherapy for Bone Metastases: An ASTRO Evidence-Based Guideline},
author = {Lutz, Stephen, E-mail: slutz@bvha.or and Berk, Lawrence and Chang, Eric and Chow, Edward and Hahn, Carol and Hoskin, Peter and Howell, David and Konski, Andre and Kachnic, Lisa and Lo, Simon and Sahgal, Arjun and Silverman, Larry and Gunten, Charles von and Mendel, Ehud and Vassil, Andrew and Bruner, Deborah Watkins and Hartsell, William},
abstractNote = {Purpose: To present guidance for patients and physicians regarding the use of radiotherapy in the treatment of bone metastases according to current published evidence and complemented by expert opinion. Methods and Materials: A systematic search of the National Library of Medicine's PubMed database between 1998 and 2009 yielded 4,287 candidate original research articles potentially applicable to radiotherapy for bone metastases. A Task Force composed of all authors synthesized the published evidence and reached a consensus regarding the recommendations contained herein. Results: The Task Force concluded that external beam radiotherapy continues to be the mainstay for the treatment of pain and/or prevention of the morbidity caused by bone metastases. Various fractionation schedules can provide significant palliation of symptoms and/or prevent the morbidity of bone metastases. The evidence for the safety and efficacy of repeat treatment to previously irradiated areas of peripheral bone metastases for pain was derived from both prospective studies and retrospective data, and it can be safe and effective. The use of stereotactic body radiotherapy holds theoretical promise in the treatment of new or recurrent spine lesions, although the Task Force recommended that its use be limited to highly selected patients and preferably within a prospective trial. Surgical decompression and postoperative radiotherapy is recommended for spinal cord compression or spinal instability in highly selected patients with sufficient performance status and life expectancy. The use of bisphosphonates, radionuclides, vertebroplasty, and kyphoplasty for the treatment or prevention of cancer-related symptoms does not obviate the need for external beam radiotherapy in appropriate patients. Conclusions: Radiotherapy is a successful and time efficient method by which to palliate pain and/or prevent the morbidity of bone metastases. This Guideline reviews the available data to define its proper use and provide consensus views concerning contemporary controversies or unanswered questions that warrant prospective trial evaluation.},
doi = {10.1016/j.ijrobp.2010.11.026},
journal = {International Journal of Radiation Oncology, Biology and Physics},
number = 4,
volume = 79,
place = {United States},
year = 2011,
month = 3
}
  • Purpose: Multiple randomized controlled trials have demonstrated the equivalence of multifraction and single-fraction (SF) radiotherapy for the palliation of painful bone metastases (BM). However, according to previous surveys, SF schedules remain underused. The objectives of this study were to determine the current patterns of practice internationally and to investigate the factors influencing this practice. Methods and Materials: The members of three global radiation oncology professional organizations (American Society for Radiology Oncology [ASTRO], Canadian Association of Radiation Oncology [CARO], Royal Australian and New Zealand College of Radiologists) completed an Internet-based survey. The respondents described what radiotherapy dose fractionation they would recommendmore » for 5 hypothetical cases describing patients with single or multiple painful BMs from breast, lung, or prostate cancer. Radiation oncologists rated the importance of patient, tumor, institution, and treatment factors, and descriptive statistics were compiled. The chi-square test was used for categorical variables and the Student t test for continuous variables. Logistic regression analysis identified predictors of the use of SF radiotherapy. Results: A total of 962 respondents, three-quarters ASTRO members, described 101 different dose schedules in common use (range, 3 Gy/1 fraction to 60 Gy/20 fractions). The median dose overall was 30 Gy/10 fractions. SF schedules were used the least often by ASTRO members practicing in the United States and most often by CARO members. Case, membership affiliation, country of training, location of practice, and practice type were independently predictive of the use of SF. The principal factors considered when prescribing were prognosis, risk of spinal cord compression, and performance status. Conclusion: Despite abundant evidence, most radiation oncologists continue to prescribe multifraction schedules for patients who fit the eligibility criteria of previous randomized controlled trials. Our results have confirmed a delay in the incorporation of evidence into practice for palliative radiotherapy for painful bone metastases.« less
  • Purpose: To provide data on the pattern of practice of palliative radiotherapy (RT) on the African continent. Methods and Materials: A questionnaire was distributed to participants in a regional training course of the International Atomic Energy Agency in palliative cancer care and sent by e-mail to other institutions in Africa. Requested information included both infrastructure and human resources available and the pattern of RT practice for metastatic and locally advanced cancers. Results: Of 35 centers contacted, 24 (68%) completed the questionnaire. Although RT is used by most centers for most metastatic cancers, liver and lung metastases are treated with chemotherapy.more » Of 23 centers, 14 (61%) had a single RT regimen as an institutional policy for treating painful bone metastases, but only 5 centers (23%) of 23 used 8 Gy in 1 fraction. Brain metastases were being treated by RT to the whole brain to 30 Gy in 10 fractions, either exclusively (n = 13, 56%) or in addition to the use of 20 Gy in 5 fractions (n = 3, 14%). Conclusion: Radiotherapy is a major component of treatment of cancer patients in African countries. There is consensus among few centers for treatment schedules for almost all sites regarding time and dose-fractionation characteristics of RT regimens used and/or indications for the use of RT in this setting.« less
  • Purpose: To determine the incidence of pain flare following radiotherapy (RT) for painful bone metastases. Materials and Methods: Patients with bone metastases treated with RT were eligible. Worst pain scores and analgesic consumption were collected before, daily during, and for 10 days after treatment. Pain flare was defined as a 2-point increase in the worst pain score (0-10) compared to baseline with no decrease in analgesic intake, or a 25% increase in analgesic intake with no decrease in worst pain score. Pain flare was distinguished from progression of pain by requiring the worst pain score and analgesic intake return tomore » baseline levels after the increase/flare (within the 10-day follow-up period). Results: A total of 111 patients from three cancer centers were evaluable. There were 50 male and 61 female patients with a median age of 62 years (range, 40-89 years). The primary cancers were mainly breast, lung, and prostate. Most patients received a single 8 Gy (64%) or 20 Gy in five fractions (25%). The overall pain flare incidence was 44/111 (40%) during RT and within 10 days following the completion of RT. Patients treated with a single 8 Gy reported a pain flare incidence of 39% (27/70) and, with multiple fractions, 41% (17/41). Conclusion: More than one third of the enrolled patients experienced a pain flare. Identifying at-risk individuals and managing potential pain flares is crucial to achieve an optimal level of care.« less
  • Purpose: To investigate the efficacy of palliative radiotherapy (RT) in relieving metastatic bone pain in elderly patients. Methods and Materials: The response to RT for palliation of metastatic bone pain was evaluated from a prospective database of 558 patients between 1999 and 2008. The pain scores and analgesic intake were used to calculate the response according to the International Bone Metastases Consensus Working Party palliative RT endpoints. Subgroup analyses for age and other demographic information were performed. Results: No significant difference was found in the response rate in patients aged >=65, >=70, and >=75 years compared with younger patients atmore » 1, 2, or 3 months after RT. The response was found to be significantly related to the performance status. Conclusion: Age alone did not affect the response to palliative RT for bone metastases. Elderly patients should be referred for palliative RT for their painful bone metastases, regardless of age, because they receive equal benefit from the treatment.« less
  • Purpose: External beam radiotherapy (RT) is commonly indicated for the palliation of symptomatic bone metastases, but there is evidence of underutilization of this treatment modality in palliative care for cancer populations. This study was conducted to investigate factors that influenced the use of palliative RT services at a regional comprehensive cancer center. Methods and Materials: A cohort of patients with radiographically confirmed bone metastases and first-time users of palliative RT between 2003 and 2005 was retrospectively reviewed from the time of initial diagnosis of bone metastases to death or last follow-up. Type of radiation treatment service provider used (rapid accessmore » or routine access) and patient-, tumor-, and treatment-related factors were analyzed for their influences on the number of treatment courses given over the duration of disease. Results: A total of 887 patients received 1,354 courses of palliative RT for bone metastases at a median interval of 4.0 months between courses. Thirty-three percent of patients required more than one RT course. Increased age and travel distance reduced the likelihood and number of treatment courses, while service through a rapid access clinic was independently associated with an increase in subsequent use of palliative RT. Conclusions: A rapid access service model for palliative RT facilitated access to RT. Travel distance and other factors remained substantial barriers to use of palliative RT services. The pattern of practice suggests an unmet need for symptom control in patients with bone metastases.« less