Scoring the effect of radiotherapy for painful bone metastases

Urinary biomarkers in metastatic bone pain: Results from a multicentre randomized trial of ibandronate compared to single dose radiotherapy for localized metastatic bone pain in prostate cancer (RIB)

Background

The Radiotherapy IBandronate (RIB) trial compared single dose radiotherapy and a single infusion of ibandronate in 470 bisphosphonate naïve patients with metastatic bone pain from prostate cancer randomised into a non-inferiority two arm study. Results for the primary endpoint of pain score response at 4 weeks showed that the ibandronate arm was non-inferior to single dose radiotherapy.

Patients and method

In addition to pain assessments including analgesic use made at baseline, 4, 8, 12, 26 and 52 weeks, urine was collected at baseline, 4 and 12 weeks. It was subsequently analysed for urinary N-telopeptide (NTx) and cystatin C. Linear regression models were used to compare the continuous outcome measures for urinary markers within treatment arms and baseline measurements were included as covariates. Interaction terms were fitted to allow for cross-treatment group comparisons.

Results

The primary endpoint of the RIB trial was worst pain response at 4 weeks and there was no treatment difference seen. Urine samples and paired pain scores at 4 weeks were available for 273 patients (radiotherapy 168; ibandronate 159)The baseline samples measured for the RIB trial had an average concentration of 193 nM BCE/mM creatinine (range of 7.3-1871) compared to the quoted normal range of 33 nM BCE/mM creatinine (3 to 63). In contrast the average value of Cystatin C was 66 ng/ml (ranges ND - 1120 ng/ml) compared to the quoted normal range of 62.9 ng/ml (ranges 12.6-188 ng/ml). A statistically significant reduction in NTx concentrations between baseline and 4 weeks was seen in the ibandronate arm but not in the radiotherapy arm. No correlation between pain response and urinary marker concentration was seen in either the ibandronate or radiotherapy cohort at any time point.

Conclusion

NTx was significantly raised compared to the normal range consistent with a role as a biomarker for bone metastases from prostate cancer. A significant reduction in NTx 4 weeks after ibandronate is consistent with its action in osteoclast inhibition which was not seen after radiotherapy implying a different mode of action for radiation. There was no correlation between bone biomarker levels and pain response.

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.

Predictors of the Predominance of NonIndex Pain After Palliative Radiation Therapy for Painful Tumors

Purpose

Even when index pain (pain caused by the irradiated tumor) is palliated after radiation therapy (RT), patients may not derive the full benefits of RT in the presence of another, more intense pain. In this case-control study with prospectively collected data, we sought to identify predictors of the predominance of nonindex pain after palliative RT.

Methods and Materials

Brief Pain Inventory data were collected from patients who received RT for painful tumors. The treating radiation oncologists prospectively evaluated the intensity and origin of nonindex pain. Patients were diagnosed with predominance of other pain (POP) if nonindex pain of malignant or unknown origin was present and had a greater worst pain score than the index pain at the 1- or 2-month follow-up. Changes in pain interference from baseline to follow-up were compared between the 2 groups using Mann-Whitney U tests. Using variables that were identified as significant in a multivariable logistic regression analysis, we developed a prediction model for POP.

Results

Of the 170 patients who were evaluable at the 2-month follow-up, 24 (14%) were diagnosed with POP. At the 2-month follow-up examination of the patients with POP, none of the items of the pain interference scores were reduced from baseline; in contrast, patients without POP experienced significant reductions in all items. Multivariable analysis using the backward elimination method indicated that age ≤65 years, the presence of nonindex pain of malignant or unknown origin at baseline, and no opioid analgesic use at baseline were significant independent predictors of POP. As the number of the risk factors increased, the proportion of patients with POP increased.

Conclusions

We identified three predictors of POP. For patients likely to have POP, careful follow-up is important, and new palliative RT or analgesics should be used when needed.

A Multicenter Randomized Trial of Ibandronate Compared With Single-Dose Radiotherapy for Localized Metastatic Bone Pain in Prostate Cancer

BACKGROUND

The radiotherapy or ibandronate (RIB) trial was a randomized multicenter nonblind two-arm trial to compare intravenous ibandronate given as a single infusion with single-dose radiotherapy for metastatic bone pain.

METHODS

Four hundred seventy prostate cancer patients with metastatic bone pain who were suitable for local radiotherapy were randomly assigned to radiotherapy (single dose, 8 Gy) or intravenous infusion of ibandronate (6mg) in a noninferiority trial. Pain was measured using the Brief Pain Inventory at baseline and four, eight, 12, 26, and 52 weeks. Pain response was assessed using World Health Organization (WHO) criteria and the Effective Analgesic Score (EAS); the maximum allowable difference was ±15%. Patients failing to respond at four weeks were offered retreatment with the alternative treatment. Quality of life (QoL) was assessed at baseline and four and 12 weeks. Because the trial was designed with a 5% one-sided test, we provide 90% confidence intervals (two-sided) for differences in pain response.

RESULTS

Overall, pain response was not statistically different at four or 12 weeks (WHO: -3.7%, 90% confidence interval [CI] = -12.4% to 5.0%; and 6.7%, 90% CI = -2.6 to 16.0%, respectively). Corresponding differences using the EAS were -7.5% and -3.5%. However, a more rapid initial response with radiotherapy was observed. There was no overall difference in toxicity, although each treatment had different side effects. QoL was similar at four and 12 weeks. Overall survival was similar between the two groups but was better among patients having retreatment than those who did not.

CONCLUSIONS

A single infusion of ibandronate had outcomes similar to a single dose of radiotherapy for metastatic prostate bone pain. Ibandronate could be considered when radiotherapy is not available.

Conventional cancer treatment alone or with regional hyperthermia for pain relief in lung cancer: A case-control study

OBJECTIVE

To investigate the effect of combining conventional treatment with regional hyperthermia on cancer pain in lung cancer patients.

DESIGN

Case-control study.

SETTING

One Korean university hospital and three complementary cancer clinics.

MAIN OUTCOMES AND MEASURES

Main outcome was effective analgesic score (EAS, PI[1+(M/10)], 1: anti-inflammatory drug consumption at a regular dosage, M: weekly dose (mg) of oral morphine equivalent and PI: pain intensity) at four time points (baseline (days -30 to 0), time 1 (days 1-60), time 2 (days 61-120), and time 3 (days 121-180)). Propensity score matching between the hyperthermia and control groups was performed using a 1:5 ratio. A linear mixed effects model was employed to measure EAS changes over time in the two groups.

RESULTS

At baseline, there were 83 subjects in the control group and 32 subjects in the hyperthermia group. At time 3, there were 49 subjects in the control group and 16 subjects in the hyperthermia group. Analyses showed rate of change of EAS, treatment×time was significant (p=0.038). This significant difference was mainly observed for time 1 (mean difference: 101.76 points, 95% confidence interval: 10.20-193.32 points, p=0.030).

CONCLUSIONS

Our results indicate an increase in cancer pain in lung cancer patients administered regional hyperthermia, particularly during the early stage of hyperthermia treatment.

When the progression of disease lowers opioid requirement in cancer patients

OBJECTIVE

To describe 2 cases in which an abrupt progression of disease compromising pain pathways and inducing some relief of existing pain or limiting drug delivery to central nervous system.

METHODS

Case reports which a significant decrease of opioid requirement was reported, either systematically and spinally.

RESULTS

The progression of disease produced changes in pain input or limited the effects of opioids given spinally.

DISCUSSION

The data presented suggest that physicians should be aware of the possibility that opioid doses have to be reduced, where presumably specific events related to the progression of disease can change the pain syndrome or reduce the delivery of opioids when using particular routes of administration. This problem needs to be recognized and treated appropriately when it occurs.

Metastatic bone pain: treatment options with an emphasis on bisphosphonates

INTRODUCTION

One of the key targets for metastatic cancer cells is the skeleton. Once metastatic cells are established within the bone matrix, skeletal integrity becomes increasingly compromised. Bone lesions lead to various complications, including bone pain, fractures and spinal cord compression.

MECHANISMS OF BONE PAIN

Bone pain is debilitating and affects quality of life of the patient. In addition, it increases the use of health care resources. Many patients with metastatic bone disease experience substantial bone pain despite state-of-the-art systemic analgesic treatment. Incident pain is the predominant pain syndrome.

TREATMENT OPTIONS FOR BONE PAIN

Typically, this syndrome requires moderate baseline analgesia with increased on-demand doses. Other techniques for treating bone pain, including radiation therapy, neuraxial application of analgesics, nerve blocks and local stabilisation procedures, should be considered. In addition, therapy with bisphosphonates targeting bone-specific pain is an important strategy. This review discusses the various management options for bone pain arising from metastatic bone disease.

Management of painful bone metastases

PURPOSE OF REVIEW

This review examines recent data on the pathophysiology and mechanisms of bone pain; it highlights the use of multiple and interdisciplinary treatments rather than sole use of traditional analgesics.

RECENT FINDINGS

Bone pain has been shown to have a unique pathophysiology. Recent experimental (animal) models have revealed that, parallel to increased bone destruction, ipsilateral spinal cord segments that receive primary input from the cancerous femur exhibit several notable neurochemical changes. These mandate the use of opioid doses sufficient to inhibit the observed nociceptive behaviours; these doses are greater than those required to alleviate pain behaviours of comparable magnitude generated by inflammatory pain. Several substances have been tested in this animal model.

SUMMARY

According to new preclinical data, treatment of bone cancer pain requires multidisciplinary therapies such as radiotherapy applied to the painful area along with systemic treatment (hormone therapy or chemotherapy) and supportive care (analgesic therapy and bisphosphonates). In some selected cases use of radioisotopes and other noninvasive or minimally invasive techniques may be useful in the management of metastatic bone pain. The treatment should be individualized according to the patient's clinical condition, life expectancy, and quality of life.