Radiotherapy is a cost-effective palliative treatment for patients with bone metastasis from prostate cancer

Association of patient socioeconomic status with outcomes after palliative treatment for disseminated cancer

BACKGROUND

Palliative treatment has been associated with improved quality of life and survival for a wide variety of metastatic cancers. However, it is unclear whether the benefits of palliative treatment are uniformly experienced across the US cancer population. We evaluated patterns and outcomes of palliative treatment based on socioeconomic, sociodemographic and treating facility characteristics.

METHODS

Patients diagnosed between 2008 and 2019 with Stage IV primary cancer of nine organ sites were analyzed in the National Cancer Database. The association between identified variables, and outcomes concerning the administration of palliative treatment were analyzed with multivariable logistic regression and Cox proportional hazard models.

RESULTS

Overall 238,995 (23.6%) of Stage IV patients received palliative treatment, which increased over time for all cancers (from 20.7% in 2008 to 25.6% in 2019). Palliative treatment utilization differed significantly by region (West less than Northeast, OR: 0.55 [0.54-0.56], p < 0.001) and insurance payer status (uninsured greater than private insurance, OR: 1.35 [1.32-1.39], p < 0.001). Black race and Hispanic ethnicity were also associated with lower rates of palliative treatment compared to White and non-Hispanics respectively (OR for Blacks: 0.91 [0.90-0.93], p < 0.001 and OR for Hispanics: 0.79 [0.77-0.81] p < 0.001).

CONCLUSIONS

There are important differences in the utilization of palliative treatment across different populations in the United States. A better understanding of variability in palliative treatment use and outcomes may identify opportunities to improve informed decision making and optimize quality of care at the end-of-life.

Real-World Cost-Effectiveness of Palliative Care for Terminal Cancer Patients in a Japanese General Hospital

Background: The concept of cost-effectiveness is necessary for optimal utilization of limited health care resources. However, few studies have assessed the cost-effectiveness of palliative care using quality-adjusted life years (QALYs), considered common outcomes in health economics. Objective: We aimed to perform a cost-effectiveness analysis of palliative care for terminal cancer patients by using QALYs. Design: A retrospective cohort study was performed. Setting/Patients: We included 401 patients with stage IV cancer, who were hospitalized and died at a Japanese general hospital during the period April 2014 to March 2019. Methods: Using the hospital database, we compared the total admission costs and QALYs based on pain levels of patients admitted to the palliative care (PC) department with those of patients admitted to other usual care (UC) departments. Patients in each group were matched through propensity scores to reduce bias. Bootstrapping estimated the 95% confidence intervals (95% CIs) and the probability that PC was more cost-effective than UC. Results: After matching, 128 patients in each group were selected. Converting 1 U.S. dollar (USD) to 100 Japanese yen, PC reduced mean total admission costs by 1732 USD (95% CI: 1584-1879) and improved mean health benefits by 0.0028 QALYs (95% CI: 0.0025-0.0032) compared with UC. Based on the Japanese cost-effectiveness threshold, there was an 82% probability that PC was more cost-effective than UC. Conclusions: Our results indicated that admission of terminal cancer patients to the PC department was associated with improvement in cost-effectiveness. This finding could support the introduction of palliative care for terminal cancer patients. Our study was approved at St. Luke's International University (receipt number 18-R061 and at the Graduate School of Pharmaceutical Sciences, The Univesity of Tokyo (receipt number 31-29).

Cost-effectiveness analysis of magnetic resonance-guided focused ultrasound ablation for palliation of refractory painful bone metastases

OBJECTIVE

The aim of this study was to determine if magnetic resonance-guided focused ultrasound (MRgFUS) is cost-effective compared with medication, for refractory pain from bone metastases in the United States.

METHODS

We constructed a Markov state transition model using TreeAge Pro software (TreeAge Software, Inc., Williamstown, MA, USA) to model costs, outcomes, and the cost-effectiveness of a treatment strategy using MRgFUS for palliative treatment of painful bone metastases compared with a Medication Only strategy (Figure 1). Model transition state probabilities, costs (in 2018 US$), and effectiveness data (quality-adjusted life-years [QALYs]) were derived from available literature, local expert opinion, and reimbursement patterns at two U.S. tertiary academic medical centers actively performing MRgFUS. Costs and QALYs, discounted at three percent per year, were accumulated each month over a 24-month time horizon. One-way and probabilistic sensitivity analyses were performed.

RESULTS

In the base-case analysis, the MRgFUS treatment strategy costs an additional $11,863 over the 2-year time horizon to accumulate additional 0.22 QALYs, equal to a $54,160/QALY ICER, thus making MRgFUS the preferred strategy. One-way sensitivity analyses demonstrate that for the base-case analysis, the crossover point at which Medication Only would instead become the preferred strategy is $23,341 per treatment. Probabilistic sensitivity analyses demonstrate that 67 percent of model iterations supported the conclusion of the base case.

CONCLUSIONS

Our model demonstrates that MRgFUS is cost-effective compared with Medication Only for palliation of painful bone metastases for patients with medically refractory metastatic bone pain across a range of sensitivity analyses.

Radiotherapy in the Caribbean: a spotlight on the human resource and equipment challenges among CARICOM nations

BACKGROUND

There is limited data on access to radiotherapy services for CARICOM nations.

METHODS

This was a descriptive mixed-methods observational study which used data collected via survey from staff working in Radiation Oncology in 14 CARICOM countries. Benchmark recommendations from the International Atomic Energy Agency were compared to existing numbers. The Directory of Radiotherapy Centers, World Bank, and Global Cancer Observatory databases were all accessed to provide information on radiotherapy machines in the region, population statistics, and cancer incidence data respectively. Both population and cancer incidence-based analyses were undertaken to facilitate an exhaustive review.

RESULTS

Radiotherapy machines were present in only 50% of the countries. Brachytherapy services were performed in only six countries (42.9%). There were a total of 15 external beam machines, 22 radiation oncologists, 22 medical physicists, and 60 radiation therapists across all nations. Utilizing patient-based data, the requirement for machines, radiation oncologists, medical physicists, and radiation therapists was 40, 66, 44, and 106, respectively. Only four (28.6%) countries had sufficient radiation oncologists. Five (35.7%) countries had enough medical physicists and radiation therapists. Utilizing population-based data, the necessary number of machines, radiation oncologists, and medical physicists was 105, 186, and 96 respectively. Only one county (7.1%) had an adequate number of radiation oncologists. The number of medical physicists was sufficient in just three countries (21.4%). There were no International Atomic Energy Agency population guidelines for assessing radiation therapists. A lower economic index was associated with a larger patient/population to machine ratio. Consequentially, Haiti had the most significant challenge with staffing and equipment requirements, when compared to all other countries, regardless of the evaluative criteria. Depending on the mode of assessment, Haiti's individual needs accounted for 37.5% (patient-based) to 59.0% (population-based) of required machines, 40.1% (patient-based) to 59.7% (population-based) of needed radiation oncologists, 38.6% (patient-based) to 58.3% (population-based) of medical physicists, and 42.5% (patient-based) of radiation therapists.

CONCLUSION

There are severe deficiencies in radiotherapy services among CARICOM nations. Regardless of the method of comparative analysis, the current allocation of equipment and staffing scarcely meets 50% of regional requirements.

The efficacy of three-dimensional conformal radiation therapy on pain and quality of life in patients with painful bone metastases: a prospective study

AIM

To evaluate the efficacy of radiation therapy in alleviating pain and improving the quality of life (QoL) with validated questionnaires in patients with painful bone metastases (BoM).

METHODS

This prospective, observational study recruited 167 patients with painful BoM who were treated with palliative radiotherapy (PRT) from February 2015 to February 2018. After the first clinical assessment, the patients filled out specific questionnaires and underwent a fast radiotherapy treatment within 48 hours. The patients were followed up for eight weeks.

RESULTS

The median age was 66.30 years. The most common primary cancer was lung cancer (31.1%). The most often prescribed scheme was 8 Gy in one fraction (70%). The patients experienced significant pain response and improved QoL compared with baseline, especially in the first two weeks after radiation. Overall, reduced pain and drug score were reported at two weeks of PRT in 68 (51.5%) and 37 (28%) of patients, respectively.

CONCLUSIONS

PRT is an effective treatment option for patients with painful BoM.

STAT-ART: The Promise and Practice of a Rapid Palliative Single Session of MR-Guided Online Adaptive Radiotherapy (ART)

This work describes a novel application of MR-guided online adaptive radiotherapy (MRgoART) in the management of patients whom urgent palliative care is indicated using statum-adaptive radiotherapy (STAT-ART). The implementation of STAT-ART, as performed at our institution, is presented including a discussion of the advantages and limitations compared to the standard of care for palliative radiotherapy on conventional c-arm linacs. MR-based treatment planning techniques of STAT-ART for density overrides and deformable image registration (DIR) of diagnostic CT to the treatment MR are also addressed.

Single- Versus Multiple-Fraction Radiation Therapy for Painful Bone Metastases: A Systematic Review and Meta-analysis of Nonrandomized Studies

PURPOSE

Single-fraction radiation therapy (RT) is a convenient and cost-effective regimen for the palliation of painful bone metastases, but is still underused. Randomized controlled trials comparing single- versus multiple-fraction RT are limited by generalizability. We compared the pain response rates after single- versus multiple-fraction RT in nonrandomized studies.

METHODS AND MATERIALS

We searched PubMed and Scopus from the inception of each database through August 2018. We sought to identify nonrandomized studies in which data on pain response rates could be extracted for single- and multiple-fraction RT. Our primary outcomes of interest were the overall and complete pain response rates in evaluable patients. The analysis was performed using a random-effects model with the Mantel-Haenszel method.

RESULTS

Of the 3933 articles identified through our search, 9 met our inclusion criteria. Five of 9 included studies did not exclude patients with features of complicated bone metastases. A 1 × 8 Gy radiation schedule was frequently used in single-fraction therapy, and schedules of 5 × 4 Gy and 10 × 3 Gy were frequently used in multiple-fraction therapy. In the 9 studies, the overall response rate was 67% (884 of 1321 patients) for patients in the single-fraction arm and 70% (953 of 1360 patients) for those in the multiple-fraction arm (pooled odds ratio [OR]: 0.85; 95% confidence interval [CI], 0.66-1.08). In 5 studies, the complete response rate was 26% (195 of 753 patients) for patients in the single-fraction arm and 35% (289 of 821 patients) for those in the multiple-fraction arm (pooled OR: 0.89; 95% CI, 0.70-1.13).

CONCLUSIONS

There were no significant differences in the overall and complete response rates between single- and multiple-fraction RT. The effectiveness of single-fraction regimens was shown in nonrandomized settings, which better reflect daily practice than randomized studies. The CIs for the pooled ORs included clinically meaningful differences, and the study results are inconclusive.

Cost-effectiveness analysis of abiraterone, docetaxel or placebo plus androgen deprivation therapy for hormone-sensitive advanced prostate cancer

OBJECTIVE

To evaluate the cost-effectiveness of the addition of chemotherapy or abiraterone to androgen deprivation.

METHODS

We developed an analytical model to determine the cost-effectiveness of the addition of docetaxel or abiraterone versus androgen deprivation therapy alone. Direct and indirect costs were included in the model. The effects were expressed in Quality-Adjusted Life Years adjusted for side effects.

RESULTS

Compared to androgen deprivation therapy alone, the addition of chemotherapy and of abiraterone generated 0.492 and 0.999, respectively, in Quality-Adjusted Life Years. Abiraterone led to a Quality-Adjusted Life Years gain of 0.506 compared to docetaxel. The incremental costs per Quality-Adjusted Life Years were R$ 133.649,22 for docetaxel, R$ 330.828,70 for abiraterone and R$ 571.379,42 for abiraterone compared to docetaxel, respectively.

CONCLUSION

The addition of chemotherapy to androgen deprivation therapy is more cost-effective than the addition of abiraterone to androgen deprivation therapy. However, discounts on abiraterone cost might improve cost-effectiveness.

Are radiation oncologists following guidelines? An audit of practice in patients with uncomplicated bone metastases

•

At our center single fraction radiotherapy is used in accordance with guidelines.

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Patient age, performance status and tumor histology influence treatment choice.

•

We added a quality indicator to our performance dashboard to improve adherence.

•

This strategy can be used in other complex practices and improve quality of care.

Background

Best-practice guidelines recommend single-fraction (SFRT) instead of multi-fraction radiation therapy (MFRT) for uncomplicated symptomatic bone metastases. SFRT is comparable to MFRT in relieving pain, convenient for patients, and cost-effective. Patterns of practice in Canada reveal that SFRT is underused, with significant variability across the country. We audited SFRT use and studied factors that may influence treatment decisions at a large academic tertiary care center in Quebec, Canada.

Methods

Patients who received radiotherapy for uncomplicated bone metastases between February 2014 and March 2015 were reviewed. Age, gender, primary histology, site of metastases and performance status were identified as potential factors affecting fractionation. These were explored by Fisher's test on univariate analysis and logistic regression for multivariate analysis. Retreatment rates were analyzed with cumulative incidence and compared with Gray's test.

Results

254 radiotherapy courses were administered to 165 patients, 85.4% of which were delivered using a single fraction of 8 Gy. Patients age less than 70 years and those with breast histology were more likely to receive MFRT (p = 0.04; p = 0.0046). Performance status (ECOG) was a significant predictor of fractionation because of high correlations between young age, breast histology, and ECOG status (p = 0.03). Follow-up was too short in 40% of patients to derive definitive conclusions on retreatment.

Conclusions

In accordance with current guidelines, our audit confirms that use of SFRT in patients with uncomplicated bone metastases at our center is high. We identified that patient age, primary histology, and performance status influenced fractionation. Incorporation of this quality indicator into our performance dashboard will allow assessment of retreatment differences and other criteria that may also influence treatment choice.

A Population-Based Study of Palliative Radiation Therapy for Bone Metastases in Patients Dying of Prostate Cancer

PURPOSE

Increasing the survival of patients with metastatic prostate cancer (PCa) may affect the demand for palliative radiation to bone (PRTB). Our aim was to characterize the use of PRTB in patients who died of PCa in British Columbia between 2003 and 2015.

METHODS AND MATERIALS

All patients with a diagnosis of PCa who died during the study period (n = 23,260) were identified from a population-based provincial registry. Patient and treatment characteristics were analyzed. PRTB utilization rate was calculated by year and location. Survival was calculated from the first and the last course of PRTB.

RESULTS

A total of 5701 patients died of PCa, with a median survival from diagnosis of 5.2 years. The overall PRTB utilization rate was 38.6%, with an increasing trend over time. Multiple courses of PRTB were frequent, with 51% of patients receiving ≥2 courses of PRTB. Of the patients who died of PCa (15.2% of the PRTB cohort), 5.4% received PRTB within the last 4 weeks of life, 60% of whom received multiple fractions. Rural areas had a lower referral rate and lower use of PRTB. Patients with longer survival tended to receive multiple courses of treatment. The median survival after the first course of PRTB increased from 8.2 months in 2003 to 2004 to 9.4 months in 2013 to 2014 (P = .04).

CONCLUSIONS

PRTB is only used in a minority of patients dying of PCa. The majority who die of PCa after PRTB do so within a year of their first course. The use of multifractionation was common in the last 4 weeks of life. Survival after first PRTB increased minimally over time, and additional research is required to identify its association with recent changes in practice. The referral rate and PRTB utilization rate differ between rural and nonrural locations, underlying the importance of accessibility and referral for utilization of PRTB. Investigating other barriers and ensuring equitable access to radiation are needed.

Cost-effectiveness analyses and cost analyses in castration-resistant prostate cancer: A systematic review

Background

Treatment of metastatic prostate cancer is associated with high personal and economic burden. Recently, new treatment options for castration-resistant prostate cancer became available with promising survival advantages. However, cost-effectiveness of those new treatment options is sometimes ambiguous or given only under certain circumstances. The aim of this study was to systematically review studies on the cost-effectiveness of treatments and costs of castration-resistant prostate cancer (CRPC) and metastasizing castration-resistant prostate cancer (mCRPC) on their methodological quality and the risk of bias.

Methods

A systematic literature search was performed in the databases PubMed, CINAHL Complete, the Cochrane Library and Web of Science Core Collection for costs-effectiveness analyses, model-based economic evaluations, cost-of-illness analyses and budget impact analyses. Reported costs were inflated to 2015 US$ purchasing power parities. Quality assessment and risk of bias assessment was performed using the Consolidated Health Economic Evaluation Reporting Standards checklist and the Bias in Economic Evaluations checklist, respectively.

Results

In total, 38 articles were identified by the systematic literature search. The methodological quality of the included studies varied widely, and there was considerable risk of bias. The cost-effectiveness treatments for CRPC and mCRPC was assessed with incremental cost-effectiveness ratios ranging from dominance for mitoxantrone to $562,328 per quality-adjusted life year gained for sipuleucel-T compared with prednisone alone. Annual costs for the treatment of castration-resistant prostate cancer ranged from $3,067 to $77,725.

Conclusion

The cost-effectiveness of treatments of CRPC strongly depended on the willingness to pay per quality-adjusted life year gained/life-year saved throughout all included costs-effectiveness analyses and model-based economic evaluations. High-quality cost-effectiveness analyses based on randomized controlled trials are needed in order to make informed decisions on the management of castration-resistant prostate cancer and the resulting financial impact on the healthcare system.

Cost-Effectiveness of Treatments for the Management of Bone Metastases: A Systematic Literature Review

BACKGROUND

Metastatic cancers occur when cancer cells break away from the primary tumour. One of the most common sites of metastasis is the bone, with several therapeutic options currently available for managing bone metastases. In a resource-constrained environment, policy makers and practitioners need to know which options are cost effective.

OBJECTIVE

The aim of this systematic review was to review and appraise published economic evaluations on treatments for the management of bone metastases.

METHODS

We searched eight bibliographic databases (MEDLINE, MEDLINE in Process, EMBASE, CSDR, DARE, HTA, EED and CPCI) for relevant economic evaluations published from each database's inception date until March 2017. Study selection, quality assessment and data extraction were carried out according to published guidelines.

RESULTS

Twenty-four relevant economic analyses were identified. Seventeen of these studies focused on bone metastases resulting from a particular type of cancer, i.e. prostate (n = 8), breast (n = 7), lung (n = 1) or renal (n = 1), while seven report results for various primary tumours. Across types of cancer, evidence suggests that bisphosphonates result in lower morbidity and improved quality of life, for an additional cost, which is typically below conventional cost-effectiveness thresholds. While denosumab leads to health gains compared with zoledronic acid, it also results in substantial additional costs and is unlikely to represent value for money. The limited literature on the radiopharmaceutical strontium-89 (Sr89) and external beam radiotherapy (EBR) suggest that these treatments are cost effective compared with no treatment.

CONCLUSIONS

The reviewed evidence suggests that bisphosphonate treatments are cost-effective options for bone metastases, while denosumab is unlikely to represent value for money. Evidence on EBR and Sr89 is limited and less conclusive.

Update of the systematic review of palliative radiation therapy fractionation for bone metastases

PURPOSE

Radiation therapy is an effective modality for pain management of symptomatic bone metastases. We update the previous meta-analyses of randomized trials comparing single fraction to multiple fractions of radiation therapy in patients with uncomplicated bone metastases.

METHODS

A literature search was conducted in Ovid Medline, Embase, and Cochrane Central Register. Ten new randomized trials were identified since 2010, five with adequate and appropriate data for inclusion, resulting in a total of 29 trials that were analyzed. Forest plots based on each study's odds ratios were computed using a random effects model and the Mantel-Haenszel statistic.

RESULTS

In intention-to-treat analysis, the overall response rate was similar in patients for single fraction treatments (61%; 1867/3059) and those for multiple fraction treatments (62%; 1890/3040). Similarly, complete response rates were nearly identical in both groups (23% vs 24%, respectively). Re-treatment was significantly more frequent in the single fraction treatment arm, with 20% receiving additional treatment to the same site versus 8% in the multiple fraction treatment arm (p < 0.01). No significant difference was seen in the risk of pathological fracture at the treatment site, rate of spinal cord compression at the index site, or in the rate of acute toxicity.

CONCLUSION

Single fraction and multiple fraction radiation treatment regimens continue to demonstrate similar outcomes in pain control and toxicities, but re-treatment is more common for single fraction treatment patients.

The INTER-ROMA Project - a Survey among Italian Radiation Oncologists on Their Approach to the Treatment of Bone Metastases

Aims and background

Radiotherapy has an established palliative role for bone metastases but despite the large number of patients treated there is still controversy surrounding the optimal radiotherapy schedule to prescribe. The aim of this survey was to determine the decision patterns of Italian radiation oncologists in four different clinical cases of patients with bone metastases.

Methods and study design

During the latest national meeting of the Italian Association of Radiation Oncology (AIRO), four clinical cases were presented to attending radiation oncologists. The cases were different with respect to the histology of the primary tumor, performance status, pain before and after analgesics, tumor site, and radiological characteristics of the metastatic lesions. For each clinical case the respondents were asked to give an indication for treatment; prescribe doses, volumes and treatment field arrangements; decide whether to prescribe prophylactic supportive therapy or not; and provide information about factors that particularly influenced prescription. Finally, a descriptive statistical analysis was performed.

Results

Three hundred questionnaires were distributed to radiation oncologists attending the congress. One hundred twenty-five questionnaires were returned but only 122 (40.6%) were adequately completed and considered for the analysis. Considerable differences were observed among radiation oncologists in prescribing and delivering radiotherapy for bone metastases. There was also a notable divergence from international guidelines, which will be discussed in this report.

Conclusions

Despite the results of clinical trials, Italian radiation oncologists differ considerably in their decisions on treatment doses and volumes. National guidelines are needed in order that patients can be treated uniformly and better data will become available for evidence-based palliative radiotherapy.

Cost effectiveness of chemohormonal therapy in patients with metastatic hormone-sensitive and non-metastatic high-risk prostate cancer

Objective

To assess the cost-effectiveness of chemohormonal therapy in patients with metastatic hormone-sensitive and non-metastatic high-risk prostate cancer.

Methods

An analytical decision model was developed to determine the cost-effectiveness of chemohormonal therapy versus androgen deprivation therapy alone in patients with metastatic hormone-sensitive prostate cancer and patients with non-metastatic high-risk prostate cancer. The cost-effectiveness in metastatic patients with a high-volume disease was assessed separately. The model used data from randomized clinical trials and drug acquisition costs in Brazil. In addition, the costs of post-progression therapies have been included in this model. The benefits to health are expressed as the quality-adjusted life-years, and the incremental cost-effectiveness ratios were calculated.

Results

Chemohormonal therapy may be associated with improved quality-adjusted life-years for all patient. The improvement was more than six times greater for patients with high-volume metastatic disease. In these patients, the incremental cost-effectiveness ratios were up to 74% lower than the incremental cost-effectiveness ratios of patients with non-metastatic disease.

Conclusion

Chemohormonal therapy has been more cost-effective in patients with high-volume metastatic disease.

Treatment patterns and trends in patients dying of prostate cancer in Quebec: a population-based study

INTRODUCTION

Since just after the year 2000 in Quebec, the management of metastatic castration-resistant prostate cancer (mcrpc) has evolved considerably, with the inclusion of docetaxel-based chemotherapy, bone-targeted therapies (zoledronic acid and denosumab), and more recently, abiraterone, enzalutamide, and cabazitaxel for docetaxel-refractory patients. In the present study, we aimed to analyze contemporary mcrpc management patterns and therapy utilization trends in Quebec.

METHODS

The study cohort consisted of patients dying of prostate cancer (pca) between January 2001 and December 2013, selected from Quebec public health care insurance databases. Patient selection was based on death from a pca-related cause or therapy used according to the Canadian Urological Association guidelines on mcrpc management. Treatments included chemotherapy (mitoxantrone before 2005 and docetaxel after 2005), abiraterone, bone-targeted therapy (zoledronic acid or denosumab, or both), and palliative radiation therapy (rt). During the study period, neither enzalutamide nor cabazitaxel was publicly reimbursed in Quebec, and as a result, no capture of their use was possible for this study. Multivariate logistic regression was used to identify factors associated with the probability of receiving chemotherapy, bone-targeted therapies, and palliative rt before death from pca.

RESULTS

Overall, the database search identified 3106 patients who died of pca between January 2001 and December 2013. Median age of death was 78 years. Of those 3106 patients, just 2568 (83%) received mcrpc-specific treatments: chemotherapy, abiraterone, palliative rt, or bone-targeted therapy; the other 17% of the patients were managed solely with maximum androgen blockade (androgen deprivation therapy plus anti-androgens) despite a record of pca-related death. Logistic regression analyses indicate that patients dying after 2005 were more likely to have received chemotherapy [odds ratio (or): 1.51; 95% ci: 1.22 to 1.85] and bone-targeted therapy (or: 1.97; 95% ci: 1.64 to 2.37). Age was a significant predictor for the use of chemotherapy, bone-targeted therapy, and palliative rt (ors in the range 0.96-0.98, p < 0.05).

CONCLUSIONS

Patient age seems to be a strong determinant in the of selection mcrpc therapy, affecting the probability of the use of chemotherapy, bone-targeted therapy, or palliative rt. Although chemotherapy is still used only in a small percentage of patients, the introduction of new therapies-such as bone-targeted therapy, docetaxel, and abiraterone-affected treatment selection over time. The availability of enzalutamide since February 2014 will likely produce additional changes in mcrpc management.

The use of Quality-Adjusted Life Years in cost-effectiveness analyses in palliative care: Mapping the debate through an integrative review

BACKGROUND

In cost-effectiveness analyses in healthcare, Quality-Adjusted Life Years are often used as outcome measure of effectiveness. However, there is an ongoing debate concerning the appropriateness of its use for decision-making in palliative care.

AIM

To systematically map pros and cons of using the Quality-Adjusted Life Year to inform decisions on resource allocation among palliative care interventions, as brought forward in the debate, and to discuss the Quality-Adjusted Life Year's value for palliative care.

DESIGN

The integrative review method of Whittemore and Knafl was followed. Theoretical arguments and empirical findings were mapped.

DATA SOURCES

A literature search was conducted in PubMed, EMBASE, and CINAHL, in which MeSH (Medical Subject Headings) terms were Palliative Care, Cost-Benefit Analysis, Quality of Life, and Quality-Adjusted Life Years.

FINDINGS

Three themes regarding the pros and cons were identified: (1) restrictions in life years gained, (2) conceptualization of quality of life and its measurement, including suggestions to adapt this, and (3) valuation and additivity of time, referring to changing valuation of time. The debate is recognized in empirical studies, but alternatives not yet applied.

CONCLUSION

The Quality-Adjusted Life Year might be more valuable for palliative care if specific issues are taken into account. Despite restrictions in life years gained, Quality-Adjusted Life Years can be achieved in palliative care. However, in measuring quality of life, we recommend to-in addition to the EQ-5D- make use of quality of life or capability instruments specifically for palliative care. Also, we suggest exploring the possibility of integrating valuation of time in a non-linear way in the Quality-Adjusted Life Year.

THE EFFECT OF RADIATION THERAPY FOR BONE METASTASIS IN URINARY ORGAN CANCER

(Objective) Bone metastasis symptoms are complications that greatly reduce the quality of life (QOL) of cancer patients. We report a retrospective study on the efficacy of radiation therapy for patients with bone metastasis in urinary organ cancer. (Subjects and methods) Subjects are comprised of 17 patients; total irradiated areas consist of 25 sites. There are 5 patients diagnosed with renal cell carcinoma, 1 patient with bladder cancer and 11 patients with prostatic cancer. All of them have undergone radiation therapy for bone metastasis in urinary organ cancer between April 2007 and March 2014 in the Department of Urology, Kanazawa Medical University. The mean age of the patients was 66.7 years old. We looked at irradiated areas, exposure dose and changes of symptom in all patients. (Results) Irradiated areas are thoracolumbar vertebrae (14 sites), cranial base (2 sites), pubic bone (1 site), ilium bone (2 sites), sacral bone (1 site), rib bone (1 site) and hip joint (1 site). The mean exposure dose of one area is 37.5 Gy (13.5-60). 19 irradiated sites which were previously reported to have sharp pain have gained improvement at 16 sites. These 16 sites have comparatively lesser pain or no pain. 8 cases in acknowledgment of walk difficulty, it was with 7 cases walking alone possibility again. (Conclusion) This study showed that radiation therapy have significant improvement in terms of symptoms and QOL for the patients with bone metastasis in urinary organ cancer.

Economic evaluation of single-fraction versus multiple-fraction palliative radiotherapy for painful bone metastases in breast, lung and prostate cancer

INTRODUCTION

Single- and multiple-fraction external beam radiotherapy (SFX-EBRT and MFX-EBRT) are palliative treatment options for localized metastatic bone pain. MFX is the preferred choice in many developed countries. Evidence shows little difference in how effectively SFX and MFX reduce pain. However, SFX is associated with higher retreatment and (in one meta-analysis) pathological fracture rates. MFX is, however, more time-consuming and expensive. We estimated the cost-effectiveness of SFX versus MFX for metastatic bone pain in breast, prostate and lung cancer in New Zealand.

METHODS

We constructed a Markov microsimulation model to estimate health gain (in quality-adjusted life-years or QALYs), health system costs (in real 2011 NZ dollars) and cost-effectiveness. The model was populated using effect estimates from randomized controlled trials and other studies, and New Zealand cancer and cost data. Disability weights from the 2010 Global Burden of Disease study were used in estimating QALYs.

RESULTS

Across all three cancers, QALY gains were similar for SFX compared to MFX, and per patient costs were less for SFX than MFX, with a difference of NZ$1469 (95% uncertainty interval $1112 to $1886) for lung cancer, $1316 ($810 to $1854) for prostate cancer and $1344 ($855 to $1846) for breast cancer. Accordingly, from a cost-effectiveness perspective, SFX was the preferable treatment option. Various sensitivity analyses did not overturn the clear preference for SFX.

CONCLUSION

For all three cancers, SFX was clearly more cost-effective than MFX. This adds to the case for desisting from offering MFX to patients with metastatic bone pain, from a cost-effectiveness angle.

Radiotherapy cannot prolong overall survival of young prostate cancer patients with bone metastases

BACKGROUND

Patients with prostate cancer is commonly diagnosed with bone metastases. With the growing use of prostate-specific antigen testing, the frequency of prostate cancer has progressively increased in patients younger than 70 years. Radiotherapy is recognized for its effect on local control of bone metastases, but whether it could prolong overall survival is still controversial.

METHODS

A total of 113 prostate cancer patients (<70y) with bone metastases were retrospectively analyzed. The Kaplan-Meier method was used for survival analysis with log-rank test. Multivariate analysis was performed to find the prognostic factors with the COX regression model.

RESULTS

The 1-, 2-, 3-, 5-, 7- and 10-year survival rates were 97.14, 82.86, 62.61, 38.76, 25.83 and 13.84 % respectively in the radiotherapy group, and 92.75, 73.91, 54.66, 36.63, 26.03 and 17.85 % respectively in the non-radiotherapy group, which showed no significant difference. Multivariate COX regression showed the overall survival was associated with alkaline phosphatase when bone metastases occurred and the number of bone metastases.

CONCLUSION

With the advances in life-prolonging treatment of metastatic prostate cancer, radiotherapy may not be the first choice for young bone metastatic prostate cancer patients in order to improve survival.

Diagnostic imaging to detect and evaluate response to therapy in bone metastases from prostate cancer: current modalities and new horizons

Different therapeutic options for the management of prostate cancer (PC) have been developed, and some are successful in providing crucial improvement in both survival and quality of life, especially in patients with metastatic castration-resistant PC. In this scenario, diverse combinations of radiopharmaceuticals (for targeting bone, cancer cells and receptors) and nuclear medicine modalities (e.g. bone scan, SPECT, SPECT/CT, PET and PET/CT) are now available for imaging bone metastases. Some radiopharmaceuticals are approved, currently available and used in the routine clinical setting, while others are not registered and are still under evaluation, and should therefore be considered experimental. On the other hand, radiologists have other tools, in addition to CT, that can better visualize bone localization and medullary involvement, such as multimodal MRI. In this review, the authors provide an overview of current management of advanced PC and discuss the choice of diagnostic modality for the detection of metastatic skeletal lesions in different phases of the disease. In addition to detection of bone metastases, the evaluation of response to therapy is another critical issue, since it remains one of the most important open questions that a multidisciplinary team faces when optimizing the management of PC. The authors emphasize the role of nuclear modalities that can presently be used in clinical practice, and also look at future perspectives based on relevant clinical data with novel radiopharmaceuticals.

Challenges and opportunities to advance pediatric neuro-oncology care in the developing world

PURPOSE

As the morbidity and mortality associated with communicable diseases continue to decrease in the developing world, the medical burden of childhood cancer continues to expand. Although international aid and relief groups such as the World Health Organization recognize the importance of childhood cancer, their main emphasis is on the more easily treated malignancies, such as leukemias and lymphomas, and not pediatric brain tumors, which are the second most common malignancy in children and the leading cause of cancer-related deaths in the pediatric population. Addressing the needs of these children is a growing concern of several professional neuro-oncology-related societies. Thus, the goal of this review is to describe the current state of pediatric neuro-oncology care in the developing world, address the current and future needs of the field, and help guide professional societies' efforts to contribute in a more holistic and multidisciplinary manner.

METHODS

We reviewed the literature to compare the availability of neuro-oncology care in various regions of the developing world with that in higher income nations, to describe examples of successful initiatives, and to present opportunities to improve care.

RESULTS

The current challenges, previous successes, and future opportunities to improve neuro-oncology care are presented. The multidisciplinary nature of neuro-oncology depends on large teams of highly specialized individuals, including neuro-oncologists, neurosurgeons, neurologists, radiologists, radiation oncologists, pathologists, palliative care specialists, oncology nurses, physical therapists, occupational therapists, speech therapists, pediatric intensivists, and social workers, among others.

CONCLUSION

Pediatric neuro-oncology is one of the most complex types of medical care to deliver, as it relies on numerous specialists, subspecialists, support staff, and physical resources and infrastructure. However, with increasing collaboration and advancing technologies, developed nations can help substantially improve neuro-oncology care for children in developing nations.

The role of radiation therapy in the treatment of metastatic castrate-resistant prostate cancer

In the setting of castrate-resistant prostate cancer, patients present with a variety of symptoms, including bone metastases, spinal cord compression and advanced pelvic disease. Fortunately, a variety of radiotherapeutic options exist for palliation. This article focuses on these options, including both external beam radiotherapy and radiopharmaceuticals.

Radiation therapy at the end of life: a population-based study examining palliative treatment intensity

Background

To examine factors associated with the use of radiation therapy (RT) at the end of life in patients with breast, prostate, or colorectal cancer.

Methods

Using data from the Surveillance, Epidemiology, and End Results (SEER) – Medicare database, patients were over age 65 and diagnosed between January 1, 2004 and December 31, 2011 with any stage of cancer when the cause of death, as defined by SEER, was cancer; or with stage 4 cancer, who died of any cause. We employed multiple logistic regression models to identify patient and health systems factors associated with palliative radiation use.

Results

50% of patients received RT in the last 6 months of life. RT was used less frequently in older patients and in non-Hispanic white patients. Similar patterns were observed in the last 14 days of life. Chemotherapy use in the last 6 months of life was strongly correlated with receiving RT in the last 6 months (OR 2.72, 95% CI: 2.59-2.88) and last 14 days of life (OR 1.55, 95% CI: 1.40-1.66). Patients receiving RT accrued more emergency department visits, radiographic exams and physician visits (all comparisons p < 0.0001).

Conclusions

Among patients with breast, colorectal, and prostate cancer, palliative RT use was common. End-of-life RT correlated with end-of-life chemotherapy use, including in the last 14 days of life, when treatment may cause increased treatment burden without improved quality of life. Research is needed optimize the role and timing of RT in palliative care.

Electronic supplementary material

The online version of this article (doi:10.1186/s13014-014-0305-4) contains supplementary material, which is available to authorized users.

Assessment of national practice for palliative radiation therapy for bone metastases suggests marked underutilization of single-fraction regimens in the United States

PURPOSE

To characterize temporal trends in the application of various bone metastasis fractionations within the United States during the past decade, using the National Cancer Data Base; the primary aim was to determine whether clinical practice in the United States has changed over time to reflect the published randomized evidence and the growing movement for value-based treatment decisions.

PATIENTS AND METHODS

The National Cancer Data Base was used to identify patients treated to osseous metastases from breast, prostate, and lung cancer. Utilization of single-fraction versus multiple-fraction radiation therapy was compared according to demographic, disease-related, and health care system details.

RESULTS

We included 24,992 patients treated during the period 2005-2011 for bone metastases. Among patients treated to non-spinal/vertebral sites (n=9011), 4.7% received 8 Gy in 1 fraction, whereas 95.3% received multiple-fraction treatment. Over time the proportion of patients receiving a single fraction of 8 Gy increased (from 3.4% in 2005 to 7.5% in 2011). Numerous independent predictors of single-fraction treatment were identified, including older age, farther travel distance for treatment, academic treatment facility, and non-private health insurance (P<.05).

CONCLUSIONS

Single-fraction palliative radiation therapy regimens are significantly underutilized in current practice in the United States. Further efforts are needed to address this issue, such that evidence-based and cost-conscious care becomes more commonplace.

Palliative radiotherapy for bone metastases from lung cancer: Evidence-based medicine?

To review current recommendations for palliative radiotherapy for bone metastases secondary to lung cancer, and to analyze surveys to examine whether global practice is evidence-based, English language publications related to best practice palliative external beam radiotherapy (EBRT) for bone metastases (BM) from lung cancer were sought via literature search (2003-2013). Additional clinical practice guidelines and consensus documents were obtained from the online Standards and Guidelines Evidence Directory. Eligible survey studies contained hypothetical case scenarios which required participants to declare whether or not they would administer palliative EBRT and if so, to specify what dose fractionation schedule they would use. There is no convincing evidence of differential outcomes based on histology or for spine vs non-spine uncomplicated BM. For uncomplicated BM, 8Gy/1 is widely recommended as current best practice; this schedule would be used by up to 39.6% of respondents to treat a painful spinal lesion. Either 8Gy/1 or 20Gy/5 could be considered standard palliative RT for BM-related neuropathic pain; 0%-13.2% would use the former and 5.8%-52.8% of respondents the latter (range 3Gy/1-45Gy/18). A multifraction schedule is the approach of choice for irradiation of impending pathologic fracture or spinal cord compression and 54% would use either 20Gy/5 or 30Gy/10. Survey results regarding management of complicated and uncomplicated BM secondary to lung cancer continue to show a large discrepancy between published literature and patterns of practice.

Single fraction radiotherapy versus multiple fraction radiotherapy for bone metastases in prostate cancer patients: comparative effectiveness

External beam radiotherapy (EBRT) is an effective treatment for symptomatic bone metastases from a variety of primary malignancies. Previous meta-analyses and systematic reviews have reported on the efficacy of EBRT on bone metastases from multiple primaries. This review is focused on the comparative effectiveness of single fraction radiotherapy versus multiple fraction radiotherapy for bone metastases in prostate cancer patients.

The cost-effectiveness of external beam radiation therapy in bone metastases

PURPOSE OF REVIEW

Bone is the third common organ affected by metastases, and about 70% of patients with breast cancer or prostate cancer will develop bone metastases. External beam radiation therapy (EBRT) is a mainstay of treatment for patients with bone metastases. However, the effectiveness and cost-effectiveness of EBRT in patients with bone metastases have not been adequately understood. The current work aims at reviewing recent cost-effectiveness literature of EBRT on patients with bone metastases.

RECENT FINDINGS

Studies have consistently shown that EBRT is associated with significant pain relief, and existing cost-effectiveness studies have suggested that single fraction radiation therapy is more cost effective than multiple fraction radiation therapy in pain palliation. However, due to the high dependence of the data among these studies and the absence of significant amount of information, the current findings may require supports from further research in validating the results.

SUMMARY

This work sheds the light on future economic models in applying individual preference to survey questionnaires, such as, contingent valuation/conjoint choice, to carefully measure utility improvements from a treatment. In addition, research with focus on patient-centered outcome is encouraged to help clinician better understand patients' perceived outcomes of EBRT.

Biomechanical properties of bone treated by magnetic resonance-guided focused ultrasound - an in vivo porcine model study

The magnetic resonance-guided focused ultrasound (MRgFUS) system uses MR imaging for real-time aiming of thermal ablation of bone and soft tissue tumors. Past clinical studies showed no increase in fracture rate after MRgFUS treatment. The purpose of this study was to determine the effect of MRgFUS treatment on mechanical properties of bone and correlate the effect to histological findings of treated bone. Four fully grown mini-pigs were treated by MRgFUS. Six consecutive right normal ribs were treated in each animal, and the left corresponding ribs served as controls. The animals were sacrificed at pre-set intervals (0, 2, 6 and 12weeks after treatment), and the treated and control bones were extracted. Mechanical properties of each bone were examined using three points bending studies for comparing treated bones to the corresponding controls. Histologic properties using Masson and hematoxylin-eosin stains were also compared. The ratio between treated and control biomechanical properties showed reduction in bone biomechanical properties at 6weeks post-MRgFUS treatment. The mean±SD yield load ratio and maximum ratios were 0.69±0.11 and 0.71±0.13, respectively (both p=0.031). These findings showed some recovery trend at 12weeks after treatment. Histological analysis showed a reduction in mean osteon size at 2weeks after treatment (0.58×10(-3)±0.1×10(-3)mm and 0.16×10(-3)±0.017×10(-3)mm) in control vs. treated bones, respectively (p=0.005). Treatment with the MRgFUS system resulted in a ~30% reduction in mechanical strength at 6weeks post-treatment. The reduction showed a reversible trend, with a 25%-20% decrease in strength at 12weeks post-treatment.

Clinical, economic and humanistic burdens of skeletal-related events associated with bone metastases

Despite effective skeletal-related event (SRE)-limiting therapies such as zoledronic acid and denosumab, SREs continue to place a meaningful burden on patients, providers and payers. However, studies of SRE-related effects on clinical (i.e., survival), economic (i.e., cost per event) and humanistic (i.e., quality of life) outcomes often report results in a composite manner and frequently do not differentiate the effects by SRE-type (i.e., bone radiation, bone surgery, hypercalcemia, pathological fracture and spinal cord compression). Nevertheless, understanding the differential burdens of individual SRE types, which vary in severity and duration of effect, is an important consideration - particularly in pharmacoeconomic evaluations of SRE-limiting therapies. In this review of the clinical, economic and humanistic SRE burden, it was found that SRE types can be differentiated by these outcomes, although economic outcomes are far more frequently reported than clinical or humanistic.

Reducing the burden of bone metastases: current concepts and treatment options

BACKGROUND

Bone metastases occur frequently in patients with solid tumours such as those of the prostate, breast and lung, and are associated with an increased risk of skeletal-related events (SREs). This article reviews the personal, social and economic burdens of bone metastases and SREs, and approaches to treatment.

METHODS

PubMed searches were conducted using a broad range of search terms. Articles identified were refined by author review of abstracts. Additional material was identified by searching recent relevant congress abstracts.

RESULTS

Bone metastases often decrease quality of life, but quantitative data on the extent of this effect are limited. Data from the USA demonstrate a significant financial burden associated with bone metastases; similar trends are now being uncovered in Europe as the number of assessments of health economics and healthcare resource utilisation in the region increases. The bisphosphonate zoledronic acid reduces the incidence of SREs compared with placebo. Recent phase 3 studies have shown that therapy with the RANK ligand inhibitor denosumab is superior to zoledronic acid for preventing or delaying SREs in patients with bone metastases from solid tumours. Denosumab also has a comparable safety profile to bisphosphonates, with reduced risk of renal toxicity and acute phase reactions. Data from Europe suggest that denosumab is cost-effective for the prevention of SREs compared with zoledronic acid. Additionally, several new experimental bone-targeted agents show promise.

CONCLUSION

Recent progress may help to reshape evidence-based guidelines to improve patient care and reduce the economic burden of bone metastases.

The role of palliative external beam radiation therapy in boney metastases pain management

Bone is the third most common organ affected by neoplastic metastases, and about 70% of patients with breast cancer or prostate cancer that develop metastases will have osseous involvement. As part of a multi-pronged approach to pain management in these patients, external beam radio therapy (EBRT) continues to be a mainstay of treatment for metastatic bone pain. This article reviews the role of radiation therapy in palliative management strategies for patients with bone metastases, including the clinical and cost-effectiveness of single fraction (SFRT) versus multiple fraction (MFRT) EBRT in pain relief. Studies indicate that SFRT is more cost-effective than MFRT, yet both are clinically effective in pain management. Therefore, EBRT use retains an important place among analgesia, bone modifying agents, chemotherapy, and hormone therapy in improving quality of life (QoL) and reducing morbidity from metastatic bone pain.

Cost of palliative radiation to the bone for patients with bone metastases secondary to breast or prostate cancer

BACKGROUND

To estimate the costs (paid amounts) of palliative radiation episodes of care (REOCs) to the bone for patients with bone metastases secondary to breast or prostate cancer.

METHODS

Claims-linked medical records from patients at 98 cancer treatment centers in 16 US states were analyzed. Inclusion criteria included a primary neoplasm of breast or prostate cancer with a secondary neoplasm of bone metastases; ≥2 visits to ≥1 radiation center during the study period (1 July 2008 through 31 December 2009) on or after the metastatic cancer diagnosis date; radiation therapy to ≥1 bone site; and ≥1 complete REOC as evidenced by a >30-day gap pre- and post-radiation therapy.

RESULTS

The total number of REOCs was 220 for 207 breast cancer patients and 233 for 213 prostate cancer patients. In the main analysis (which excluded records with unpopulated costs) the median number of fractions per a REOC for treatment of metastases was 10. Mean total radiation costs (i.e., radiation direct cost + cost of radiation-related procedures and visits) per REOC were $7457 for patients with breast cancer and $7553 for patients with prostate cancer. Results were consistent in sensitivity analyses excluding patients with unpopulated costs.

CONCLUSIONS

In the US, current use of radiation therapy for bone metastases is relatively costly and the use of multi-fraction schedules remains prevalent.

Authentication of Algorithm to Detect Metastases in Men with Prostate Cancer Using ICD-9 Codes

Background

Metastasis is a crucial endpoint for patients with prostate cancer (PCa), but currently lacks a validated claims-based algorithm for detection.

Objective

To develop an algorithm using ICD-9 codes to facilitate accurate reporting of PCa metastases.

Methods

Medical records from 300 men hospitalized at Robert Wood Johnson University Hospital for PCa were reviewed. Using the presence of metastatic PCa on chart review as the gold standard, two algorithms to detect metastases were compared. Algorithm A used ICD-9 codes 198.5 (bone metastases), 197.0 (lung metastases), 197.7 (liver metastases), or 198.3 (brain and spinal cord metastases) to detect metastases, while algorithm B used only 198.5. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) for the two algorithms were determined. Kappa statistics were used to measure agreement rates between claim data and chart review.

Results

Algorithm A demonstrated a sensitivity, specificity, PPV, and NPV of 95%, 100%, 100%, and 98.7%, respectively. Corresponding numbers for algorithm B were 90%, 100%, 100%, and 97.5%, respectively. The agreement rate is 96.8% for algorithm A and 93.5% for algorithm B.

Conclusions

Using ICD-9 codes 198.5, 197.0, 197.7, or 198.3 in detecting the presence of PCa metastases offers a high sensitivity, specificity, PPV, and NPV value.

Variation in the use of palliative radiotherapy at end of life: examining demographic, clinical, health service, and geographic factors in a population-based study

Palliative radiotherapy (PRT) can improve quality of life for people dying of cancer. Variation in the delivery of PRT by factors unrelated to need may indicate that not all patients who may benefit from PRT receive it. In this study, 13,494 adults who died of cancer between 2000 and 2005 in Nova Scotia, Canada, were linked to radiotherapy records. Multivariate logistic regression was used to examine the relationships among demographic, clinical, service, and geographic variables, and PRT consultation and treatment. Among the decedents, 4188 (31.0%) received PRT consultation and 3032 (22.3%) treatment. PRT declined with increased travel time and community deprivation. Females, older persons, and nursing home residents also had lower PRT rates. Variations were observed by cancer site and previous oncology care. Variations in PRT use should be discussed with referring physicians, and improved means of access to PRT considered. Benchmarks for optimal rates of PRT are needed.

Model averaging in the presence of structural uncertainty about treatment effects: influence on treatment decision and expected value of information

BACKGROUND

Standard approaches to estimation of Markov models with data from randomized controlled trials tend either to make a judgment about which transition(s) treatments act on, or they assume that treatment has a separate effect on every transition. An alternative is to fit a series of models that assume that treatment acts on specific transitions. Investigators can then choose among alternative models using goodness-of-fit statistics. However, structural uncertainty about any chosen parameterization will remain and this may have implications for the resulting decision and the need for further research.

METHODS

We describe a Bayesian approach to model estimation, and model selection. Structural uncertainty about which parameterization to use is accounted for using model averaging and we developed a formula for calculating the expected value of perfect information (EVPI) in averaged models. Marginal posterior distributions are generated for each of the cost-effectiveness parameters using Markov Chain Monte Carlo simulation in WinBUGS, or Monte-Carlo simulation in Excel (Microsoft Corp., Redmond, WA). We illustrate the approach with an example of treatments for asthma using aggregate-level data from a connected network of four treatments compared in three pair-wise randomized controlled trials.

RESULTS

The standard errors of incremental net benefit using structured models is reduced by up to eight- or ninefold compared to the unstructured models, and the expected loss attaching to decision uncertainty by factors of several hundreds. Model averaging had considerable influence on the EVPI.

CONCLUSIONS

Alternative structural assumptions can alter the treatment decision and have an overwhelming effect on model uncertainty and expected value of information. Structural uncertainty can be accounted for by model averaging, and the EVPI can be calculated for averaged models.

Cost-effectiveness studies in radiation therapy

The field of radiation therapy has made dramatic technical advances over the past 20 years. 3D conformal radiotherapy, intensity-modulated radiation therapy and proton beam therapy have all been developed in an attempt to improve the therapeutic ratio: higher cure rates with lower toxicity. Unfortunately, although the costs of radiation therapy are certainly increasing, it is unclear whether its clinical benefit has also improved. Cost-effectiveness analyses are designed to formally evaluate the cost of a treatment relative to an associated change in quality-adjusted survival. As the cost of oncologic care is increasing, it is critically important to assess the cost-effectiveness of radiation therapy. This article will describe the issues surrounding the delivery and cost of radiation therapy, and it will summarize the work that has been done to evaluate the use of cost-effectiveness in radiation oncology.

Radiotherapy for metastatic bone disease: current standards and future prospectus

Changes in population dynamics will require increased end-of-life cancer care in the coming years. Palliative radiotherapy successfully relieves symptoms of advanced cancer, with the most common indication for its use being uncomplicated painful bone metastases. Single-fraction radiotherapy provides successful, time-efficient and cost-effective management of bone metastases. Newer technologies, such as stereotactic body radiotherapy, hold promise for some patients with spine metastases, although their niche has not been properly defined and their use outside of a protocol setting is inappropriate. Surgery should be considered for circumstances of completed or impending pathologic fracture, spinal instability, or spinal cord compression in patients who have adequate performance status and prognosis. Multiple sites of painful metastases may be treated with injectible radiopharmaceuticals or hemibody radiation. The future developments in palliative radiotherapy for bone metastases will mirror several forces affecting all of medicine, including resource allocation, the adoption of clinical guidelines and the integration of newer technologies.

Burden of metastatic bone disease from genitourinary malignancies

Bone metastases are common among patients with stage IV genitourinary cancers. Most patients with bone metastases develop at least one debilitating and potentially life-limiting skeletal-related event. These events are associated with increased medical expenses and decreased quality of life. Current guidelines recommend screening for bone metastases in men with high-risk prostate cancer, but guidance for screening and treatment of bone metastases from genitourinary cancers varies by country and setting. Several bisphosphonates have been evaluated in the advanced genitourinary cancer setting. Zoledronic acid has demonstrated efficacy in significantly reducing the risk of skeletal-related events in patients with bone metastases from a broad range of solid tumors including prostate, renal and bladder cancers, and is recommended for preserving bone health.

Anabolic and antiresorptive drugs improve trabecular microarchitecture and reduce fracture risk following radiation therapy

Many patients with symptomatic bone metastases receive radiation therapy, even though radiation is known to have potential adverse effects on bone. We hypothesized that the concurrent use of a bisphosphonate drug (zoledronic acid, ZA) or a combination of ZA plus an anabolic agent (parathyroid hormone, PTH) would lead to improvements in the microarchitecture and mechanical properties of irradiated bone. Human breast cancer cells were injected into the distal femur of 56 female nude mice, which were then divided into four groups: no treatment (0 Gy), radiation administered 4 weeks postinjection (20 Gy), radiation plus ZA (12.5 microg/kg weekly from weeks 4 to 12) (20 Gy + ZA), and radiation followed by ZA (25 microg/kg weekly from weeks 4 to 8) and PTH(1-34) (100 microg microg/kg daily from weeks 8 to 12) (20 Gy + ZA + PTH). Left limbs served as normal control bones. Bone loss over the 12-week study was tracked with serial radiography and bone densitometry. At the end of the study, micro-computed tomography and mechanical testing were used to quantify bone microarchitecture and bone strength. Radiation alone failed to prevent tumor-induced decreases in bone mineral density (BMD), trabecular bone volume, and bone strength. Treatment with 20 Gy + ZA or 20 Gy + ZA + PTH as adjuncts to radiation was effective at preserving trabecular bone architecture and bone strength at normal levels. ZA reduced the risk of mechanical fragility following irradiation of a lytic bone lesion. Supplemental use of PTH did not result in further increases in bone strength but was associated with significant increases in BMD and bone mass, suggesting that it may be beneficial in enhancing bone architecture following radiation therapy.

New multidisciplinary prostate bone metastases clinic: first of its kind in Canada

Prostate cancer is the most common non-skin malignancy in men. Almost all men who die from prostate cancer have hormone-refractory prostate cancer with metastasis to bone. Emerging supportive treatments—including chemotherapy, bisphosphonates, and surgery—require integration that is optimized in a multidisciplinary setting. A multidisciplinary clinic for bone metastases has been in place at Toronto–Sunnybrook Regional Cancer Centre since 1999, combining orthopedic surgery, radiation oncology, interventional radiology, and palliative medicine for all patients with bone metastases. The addition of a prostate-focused multidisciplinary clinic integrates these services for patients with advanced prostate cancer.