Economic analysis of radiation therapy oncology group 97-14: multiple versus single fraction radiation treatment of patients with bone metastases

Continuous controversy about radiation oncologists' choice of treatment regimens for bone metastases: should we blame doctors, cancer-related features, or design of previous clinical studies?

Recent studies from Italy, Japan and Norway have confirmed previous reports, which found that a large variety of palliative radiotherapy regimens are used for painful bone metastases. Routine use of single fraction treatment might or might not be the preferred institutional approach. It is not entirely clear why inter-physician and inter-institution differences continue to persist despite numerous randomized trials, meta-analyses and guidelines, which recommend against more costly and inconvenient multi-fraction regimens delivering total doses of 30 Gy or more in a large number of clinical scenarios. In the present mini-review we discuss the questions of whether doctors are ignoring evidence-based medicine or whether we need additional studies targeting specifically those patient populations where recent surveys identified inconsistent treatment recommendations, e.g. because of challenging disease extent. We identify open questions and provide research suggestions, which might contribute to making radiation oncology practitioners more confident in selecting the right treatment for the right patient.

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.

'Who', 'when' and 'how' in re-irradiation of recurrent painful bone metastases

Re-irradiation of painful bony metastases is increasingly performed since patients are receiving better systemic treatments and having longer life expectancy, and may also be due to the increase use of initial single fraction radiotherapy. However, randomized control trial on the efficacy of re-irradiation is lacking. A recent meta-analysis concluded with a 58% response rate for pain relief by re-irradiation of symptomatic bone metastases. In this review, the effectiveness of re-irradiation in terms of clinical and economical aspects, and clinical questions on who, when, and how to re-irradiate would be discussed. A brief review of other treatment options and comparison with re-irradiation of bone metastases would be performed.

Palliative radiation therapy practice in patients with metastatic non-small-cell lung cancer: a Cancer Care Outcomes Research and Surveillance Consortium (CanCORS) Study

PURPOSE

Randomized data suggest that single-fraction or short-course palliative radiation therapy (RT) is sufficient in the majority of patients with metastatic cancer. We investigated population-based patterns in the use of palliative RT among patients with metastatic non-small-cell lung cancer (NSCLC).

PATIENTS AND METHODS

From patients diagnosed with lung cancer from 2003 to 2005 at a participating geographic or organizational site and who consented to the Cancer Care Outcomes Research and Surveillance Consortium study, we identified patients with metastatic NSCLC who had complete medical records abstractions. Patient characteristics and clinical factors associated with receipt of palliative RT and RT intensity (total dose and number of treatments) were evaluated with multivariable regression.

RESULTS

Of 1,574 patients with metastatic NSCLC, 780 (50%) received at least one course of RT, and 21% and 12% received RT to the chest and bone, respectively. Use of palliative RT was associated with younger age at diagnosis and receipt of chemotherapy and surgery to metastatic sites. Among patients receiving palliative bone RT, only 6% received single-fraction treatment. Among patients receiving palliative chest RT, 42% received more than 20 fractions. Patients treated in integrated networks were more likely to receive lower doses and fewer fractions to the bone and chest.

CONCLUSION

When palliative RT is used in patients with metastatic NSCLC, a substantial proportion of patients receive a greater number of treatments and higher doses than supported by current evidence, suggesting an opportunity to improve care delivery.

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.

Effectiveness of reirradiation for painful bone metastases: a systematic review and meta-analysis

PURPOSE

Reirradiation of painful bone metastases in nonresponders or patients with recurrent pain after initial response is performed in up to 42% of patients initially treated with radiotherapy. Literature on the effect of reirradiation for pain control in those patients is scarce. In this systematic review and meta-analysis, we quantify the effectiveness of reirradiation for achieving pain control in patients with painful bone metastases.

METHODS AND MATERIALS

A free text search was performed to identify eligible studies using the MEDLINE, EMBASE, and the Cochrane Collaboration library electronic databases. After study selection and quality assessment, a pooled estimate was calculated for overall pain response for reirradiation of metastatic bone pain.

RESULTS

Our literature search identified 707 titles, of which 10 articles were selected for systematic review and seven entered the meta-analysis. Overall study quality was mediocre. Of the 2,694 patients initially treated for metastatic bone pain, 527 (20%) patients underwent reirradiation. Overall, a pain response after reirradiation was achieved in 58% of patients (pooled overall response rate 0.58, 95% confidence interval = 0.49-0.67). There was a substantial between-study heterogeneity (I² = 63.3%, p = 0.01) because of clinical and methodological differences between studies.

CONCLUSIONS

Reirradiation of painful bone metastases is effective in terms of pain relief for a small majority of patients; approximately 40% of patients do not benefit from reirradiation. Although the validity of results is limited, this meta-analysis provides a comprehensive overview and the most quantitative estimate of reirradiation effectiveness to date.

Update on the systematic review of palliative radiotherapy trials for bone metastases

AIMS

To update previous meta-analyses of randomised palliative radiotherapy trials comparing single fractions versus multiple fractions.

MATERIALS AND METHODS

All published randomised controlled trials comparing single fraction versus multiple fraction schedules for the palliation of uncomplicated bone metastases were included in this analysis. Odds ratios and 95% confidence intervals were calculated for each trial. Forest plots were created using a random effects model and the Mantel-Haenszel statistic.

RESULTS

In total, 25 randomised controlled trials were identified. For intention-to-treat patients, the overall response rate was similar in patients receiving single fractions (1696 of 2818; 60%) and multiple fractions (1711 of 2799; 61%). Complete response rates were 620 of 2641 (23%) in the single fraction arm and 634 of 2622 (24%) in the multiple fraction arm. No significant difference was seen in overall or complete response rates. Pathological fracture did not favour either arm, but spinal cord compression trended towards favouring multiple fractions; however, neither was statistically significant (P = 0.72 and P = 0.13, respectively). Retreatment rates favoured patients in the multiple fraction arm, where the likelihood of requiring re-irradiation was 2.6-fold greater in the single fraction arm (95% confidence interval: 1.92-3.47; P < 0.00001). Repeated analyses excluding drop-out patients did not alter these findings. In general, no significant differences in acute toxicities were seen.

CONCLUSION

Overall and complete response rates were similar in both intention-to-treat and assessable patients. Single and multiple fraction regimens provided equal pain relief; however, significantly higher retreatment rates occurred in those receiving single fractions.

Comparison of pain response and functional interference outcomes between spinal and non-spinal bone metastases treated with palliative radiotherapy

PURPOSE

The purpose of this study was to compare functional interference and pain response outcomes using the Brief Pain Inventory (BPI) for patients treated with palliative radiotherapy to spine versus non-spine bones and determine if dose fractionation was associated with each group's respective response.

MATERIALS AND METHODS

Patients treated for painful bone metastases with palliative radiotherapy during May 2003 to June 2007 were analyzed. The BPI was utilized at baseline and monthly for 6 months post-radiation. Pain response was determined using International Bone Metastases Consensus response definitions. Wilcoxon rank-sum test (for continuous variable), Fisher exact test (for categorical value), and two-way analysis of variance were used for comparisons, and a p value of ≤ 0.05 was considered statistically significant.

RESULTS

Three hundred eighty-six patients were analyzed, 62% were treated with a single fraction, 38% with multiple fractions. Pain and functional interference scores significantly improved over time in both spine and non-spine sites. At 3 months, 42% of all patients had a partial response, and 25% had a complete response. Location of bone metastases and radiotherapy dose were not predictive factors for pain response nor functional interference following radiation treatment.

CONCLUSION

Spine and non-spine bone metastases exhibited similar pain and functional interference improvements over a period of 6 months post-radiotherapy. There were, however, high attrition rates as expected with palliative studies, with approximately half the patients remaining in this study by 3 months and a fifth by 6 months. A single 8 Gy resulted in equal benefits in terms of both pain response and improvement in function.

Palliative radiotherapy: when is it worth it and when is it not?

Palliative radiotherapy has been prescribed since shortly after the discovery of the x-ray in the late 1800s, and it provides symptom relief that is successful, time-efficient, and cost-effective. Although palliative radiotherapy is worthwhile in a wide variety of clinical circumstances, there are situations where it is less worthwhile. We contrast the effective use of palliative radiotherapy with its ineffective use because of issues related to the patient, treatment, or health care system.

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.