Continuing reluctance to use single fractions of radiotherapy for metastatic bone pain: an Australian and New Zealand practice survey and literature review

The changing radiation oncology landscape in New Zealand

INTRODUCTION

This paper outlines the New Zealand (NZ) responses to the biennial facilities surveys of the Royal Australian and New Zealand College of Radiation Oncologists (RANZCR), Faculty of Radiation Oncology (FRO) from 2011 to 2019.

METHODS

The facilities survey is conducted by the FRO Economics and Workforce Committee (FROEWC) and focuses on equipment, treatment activities and staffing.

RESULTS

The number of facilities increased by two to 10, both in the private sector. The total number of linear accelerators (linacs) increased by four; one in public and three in private. The majority of linacs were over 8 years old (62.5%). Treatment courses have increased by 19% and fraction numbers by 13.7%. Courses per linac have remained relatively constant. There was growth in IMRT, orthovoltage, high dose rate brachytherapy and paediatric treatments. There was a slow increase in number of radiation oncologists and trainees. The number of radiation therapists was unchanged with a 20% increase in treatment courses per radiation therapist. Physicist numbers have increased but 61.4% of physicists are overseas-trained and vacancies persist.

CONCLUSION

The survey results indicate a rapidly changing radiation oncology landscape in NZ between 2011 and 2019. The challenges of increases in cancer numbers, treatment courses and complexity of treatments and a need to focus on quality standards against a set of minimal increase in machine numbers, ageing machines, static or slowly increasing staffing numbers and heavy reliance on overseas staffing require a national review of radiation oncology services to ensure a sustainable future.

Radiotherapy Practice for Treatment of Bone Metastasis in Ethiopia

PUROSE

Ethiopia has one cobalt radiotherapy (RT) machine to serve a population of more than 100 million. The purpose of this study was to report on patterns of palliative RT of bone metastasis in a severely low-capacity setting.

PATIENTS AND METHODS

Patient and treatment characteristics of patients irradiated for palliation of symptomatic bone metastasis were extracted from a retrospective database of patients treated between May 2015 and January 2018. This database included a random sample of 1,823 of the estimated 4,000 patients who were treated with RT within in the study period. Associations between the applied RT schedule and patient and tumor characteristics were evaluated with the χ² test. Hypothetical savings of RT sessions and time were compared in the case of a single-fraction policy.

RESULTS

From the database, 234 patients (13%) were treated for bone metastasis. Most patients were ≤ 65 years of age (n = 189; 80%) and female (n = 125; 53%). The most common primary sites were breast (n = 82; 35%) and prostate (n = 36; 15%). Fractionated regimens were preferred over single fraction: 20 Gy in 5 fractions (n = 192; 82.1%), 30 Gy in 10 fractions (n = 7; 3%), and 8 Gy in 1 fraction (n = 28; 12%). Factors associated with single-fraction RT included nonaxial sites of bone metastasis (P < .01) and an address outside Addis Ababa (P ≤ .01). If single-fraction RT would have been given uniformly for bone metastasis, this would have resulted in a 78% reduction in the number of RT sessions and 76% reduction in total RT time.

CONCLUSION

The pattern of palliative RT for bone metastasis in Ethiopia favors fractionated regimens over single fraction. Efforts should be made to adopt evidence-based and cost-effective guidelines.

Variation in the Use of Single- Versus Multifraction Palliative Radiation Therapy for Bone Metastases in Australia

PURPOSE

To evaluate the use of single-fraction palliative radiation therapy (SFRT) for the management of bone metastases (BM) in Victoria, Australia.

METHODS AND MATERIALS

This is a population-based cohort of patients with cancer who received radiation therapy for BM between 2012 and 2017 as captured in the Victorian Radiotherapy Minimum Data Set. The primary outcome was proportion of SFRT use. The Cochrane-Armitage test for trend was used to evaluate changes in practice over time. Multivariable logistic regression was used to assess factors associated with SFRT use.

RESULTS

Of the 18,158 courses of radiation therapy for BM delivered to a total of 10,956 patients, 17% were SFRT. There was no significant change in SFRT use over time, from 18% in 2012 to 19% in 2017 (P = .07). SFRT was less commonly given to the skull (4%) and spine (14%), compared with the shoulder (37%) and ribs (53%). Patients with lung cancer (21%) were most likely to receive SFRT, followed by those with prostate cancers (18%) and gastrointestinal cancers (16%). Patients from regional/remote areas were more likely to have SFRT compared with those in major cities (22% vs 16%, P < .001). Patients treated in public institutions were more likely to have SFRT compared with those treated in private institutions (22% vs 10%, P < .001). In multivariable analyses, increasing age, lung cancer, higher socioeconomic status, residence in regional/ remote areas, and being treated in public institutions were factors independently associated with increased likelihood of receiving SFRT.

CONCLUSIONS

SFRT appears underused for BM in Australia over time, with variation in practice by patient, tumor, sociodemographic, geographical, and institutional provider factors.

Comparison of Single Versus Multifraction Radiotherapy in Palliation of Painful Bone Metastases

Background

Bone is a common site of dissemination in advanced cancer accounting for one-third of all distant metastases. Various fractionation schedules of radiotherapy have been used for palliation of bone metastases. The aim of this study was to compare three schedules of external radiation therapy (8 Gy single session versus 20 Gy/5 fractions versus 30 Gy/10 fractions) for palliative management of bone metastases.

Methods

In the present study, 60 patients of bone metastases from any primary site were enrolled and randomly divided into three groups of 20 patients each by draw of lots. These patients received palliative external beam radiation therapy to the involved site. Patients were given 8 Gy single session, 20 Gy/5 fractions/1 week and 30 Gy/10 fractions/2 weeks in groups I, II and III, respectively.

Results

The percentage of patients with overall pain relief was 80% in group I, 75% in group II and 85% in group III (P = 0.7). The number of patients with complete pain relief was 4 (20%) in each group. Maximum patients got pain relief at 4 weeks post-radiotherapy. The number of patients with improved performance status was 4 (20%) in group II and 2 (10%) each in groups I and III (P = 0.5). Thirteen (65%) patients in each of the groups had decreased analgesic requirement at 2-month follow-up. Retreatment rate was more in the single fraction (20%) compared to only 5% in group II and none in the group III (P = 0.05).

Conclusion

From the present study we conclude that 8 Gy single fraction is as effective as multifraction radiotherapy for the palliation of painful bone metastases. However, for a center like ours being the only Government Tertiary Cancer Care Centre in the State, general consensus drawn after this study, recommends external radiation therapy 20 Gy/5 fraction regimen to be an appropriate means of palliation of painful bone metastases.

Choosing Wisely at the End of Life: Use of Shorter Courses of Palliative Radiation Therapy for Bone Metastasis

PURPOSE

American Society for Radiation Choosing Wisely guidelines recommend ≤10 fractions of radiation therapy (RT) for bone metastasis, with consideration for 1 fraction in patients with a poor prognosis. The purpose of this analysis was to evaluate characteristic differences in guideline concordance to fractionation regimens in a modern cohort of older patients with a diagnosis of bone metastasis.

METHODS AND MATERIALS

Medicare beneficiaries aged ≥65 years treated with RT for bone metastasis from 2012 to 2015 were identified. Guideline-concordant RT fractionation was defined in the entire cohort as ≤10 fractions. Utilization of 1 fraction versus ≥2 fractions was analyzed in deceased patients. Patient demographic, disease, and facility characteristics associated with shorter fractionation were analyzed.

RESULTS

In 569 patients treated with RT, the median age at diagnosis was 73 years. The most common cancer types were lung (37%), genitourinary (26%), breast (15%), and gastrointestinal (10%). Among all patients, 34%, 30%, and 36% received 1 fraction, 2 to 10 fractions, and ≥11 fractions, respectively. In comparison with receipt of 1 to 10 fractions, receipt of ≥11 fractions was associated with a $1467 increase in per-patient cost to Medicare during the calendar quarter of RT. Almost two-thirds of patients who died within 30 days of RT completion were treated with >1 fraction.

CONCLUSIONS

Although guideline concordance was high overall, a large number of patients received longer courses of RT at the end of life. Strong consideration should be made for utilization of shorter courses, particularly in patients with a limited prognosis.

External Beam Irradiation in the Palliation of Bone Metastases: A Practice Analysis among Sicilian Departments of Radiation Oncology

Background

In the treatment of bone metastases, the choice of radiation fractionation, total radiation dose, delivery technique, and imaging studies before treatment varies among radiation oncologists. Surveys on this issue, using case scenarios, have been published by groups from Europe, North America, and Australia-New Zealand. Our objective was to analyze retrospectively the “real” practice in nine radiotherapy centers located in Sicily.

Method

A questionnaire including 17 items was distributed to 30 practicing radiation oncologists working in seven departments of four Sicilian cities (Messina, Catania, Ragusa and Palermo) during a meeting of the Sicilian Division of the Associazione Italians Radioterapia Oncologica (AIRO). Participants were asked to answer the questions using a card for every patient treated with external beam irradiation from 1 January to 31 December, 2000.

Results

Six centers returned the questionnaires; 332 cards were valuable for a total of 5644 responses. All six responding departments used linear accelerators for treatment delivery. The most common dose fractionation was 30 Gy in 10 fractions and the most common technique used was opposed parallel local fields. Before the start of irradiation a bone scan was performed in 325 of the 332 (98%) patients treated and CT and/or MRI was performed in 320 (96%); surprisingly, standard roentgenograms were used in only 142 of 332 patients (42.8%).

Conclusion

The “real” radiation practice for bone metastases in the region of Sicily confirms the results of the previously reported international surveys: there is a clear preference for fractionated treatment and local field therapy. The results of randomized studies, which demonstrated both the efficacy and the feasibility of a single 6–8 Gy fraction in the palliation of bone metastases, have little or no impact on the pattern of practice.

[Radiotherapy of bone metastases in France: A descriptive monocentric retrospective study]

PURPOSE

Bone metastases cause pain and affect patients' quality of life. Radiation therapy is one of the reference analgesic treatments. The objective of this study was to compare the current practices of a French radiotherapy department for the treatment of uncomplicated bone metastases with data from the literature in order to improve and optimize the management of patients.

MATERIAL AND METHODS

A retrospective monocentric study of patients who underwent palliative irradiation of uncomplicated bone metastases was performed.

RESULTS

Ninety-one patients had 116 treatments of uncomplicated bone metastases between January 2014 and December 2015, including 44 men (48%) and 47 women (52%) with an average age of 63years (25-88years). Primary tumours most commonly found were breast cancer (35%), lung cancer (16%) and prostate cancer (12%). The regimens used were in 29% of cases 30Gy in ten fractions (group 30Gy), in 21% of cases 20Gy in five fractions (group 20Gy), in 22% of cases 8Gy in one fraction (group 8Gy) and in 28% of cases 23.31Gy in three fractions of stereotactic body irradiation (stereotactic group). The general condition of the patient (P<0.001), pain score and analgesic (P<0.001), oligometastatic profile (P=0.003) and practitioner experience (P<0.001) were factors influencing the choice of the regimen irradiation. Age (P=0.46), sex (P=0.14), anticancer treatments (P=0.56), concomitant hospitalization (P=0.14) and the distance between the radiotherapy centre and home (P=0.87) did not influence the decision significantly. A total of three cases of spinal compression and one case of post-therapeutic fracture were observed, occurring between one and 128days and 577days after irradiation, respectively. Eight percent of all irradiated metastases were reirradiated with a delay ranging between 13 and 434days after the first irradiation. The re-irradiation rate was significantly higher after 8Gy (P=0.02). The rate of death was significantly lower in the stereotactic arm (P<0.001) and overall survival was significantly greater in the stereotactic arm (P<0.001).

CONCLUSION

This study showed that patients' analysed was comparable to the population of different studies. Predictive factors for the choice of the treatment regimen were identified. Non-fractionnated therapy was underutilised while stereotactic treatment was increasingly prescribed, showing an evolution in the management of 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.

Use of low-value radiotherapy practices in Canada: an analysis of provincial cancer registry data

BACKGROUND

As part of Choosing Wisely Canada (a national campaign to encourage patient-provider conversations about unnecessary medical tests, treatments, and procedures), a list of ten oncology practices that could be low-value in some instances was developed. Of those practices, two were specific to radiation therapy (rt): conventional fractionation as part of breast-conserving therapy (bct) for women with early-stage breast cancer, and multifraction radiation for palliation of uncomplicated painful bone metastases. Here, we report baseline findings for the current utilization rates of those two rt practices in Canada.

RESULTS

The use of conventional fractionation as part of bct varied substantially from province to province. Of women 50 years of age and older, between 8.8% (Alberta) and 36.5% (Saskatchewan) received radiation in 25 fractions (excluding boost irradiation) as part of bct. The use of hypofractionated rt (that is, 16 fractions excluding boost irradiation)-a preferred approach for many patients-was more common in all 6 reporting provinces, ranging from 43.2% in Saskatchewan to 94.7% in Prince Edward Island. The use of multifraction rt for palliation of bone metastases also varied from province to province, ranging from 40.3% in British Columbia to 69.0% in Saskatchewan. The most common number of fractions delivered to bone metastases was 1, at 50.2%; the second most common numbers were 2-5 fractions, at 41.7%.

CONCLUSIONS

Understanding variation in the use of potentially low-value rt practices can help to inform future strategies to promote higher-value care, which balances high-quality care with the efficient use of limited system resources. Further work is needed to understand the factors contributing to the interprovincial variation observed and to develop benchmarks for the appropriate rate of use of these rt practices.

Utilization of palliative radiotherapy for bone metastases near end of life in a population-based cohort

BACKGROUND

Palliative radiotherapy (PRT) can significantly improve quality of life for patients dying of cancer with bone metastases. However, an aggressive cancer treatment near end of life is an indicator of poor-quality care. But the optimal rate of overall palliative RT use near the end of life is still unknown. We sought to determine the patterns of palliative radiation therapy (RT) utilization in patients with bone metastases towards their end of life in a population-based, publicly funded health care system.

METHODS

All consecutive patients with bone metastases treated with RT between 2007 and 2011 were identified in a provincial Canadian cancer registry database. Patients were categorized as receiving RT in the last 2 weeks, 2-4 weeks, or >4 weeks before their death. Associations between RT fractionation utilization by these categories, and patient and provider characteristics were assessed through logistic regression.

RESULTS

Of the 16,898 courses 1734 (10.3) and 709 (4.2%) were prescribed to patients in the last 2-4 weeks and <2 weeks of their life, respectively. Primary lung (8%) and gastrointestinal (6.9%) cancers received palliative RT more commonly in the last 2 weeks of life (OR 3.72 [2.86-4.84] & 3.33 [2.42-4.58] respectively, p <0.001). Among the 709 patients who received RT in the last 2 weeks of life, 350 (49), 167 (24), and 127 (18%) were for spine, pelvis, and extremity metastases, respectively. RT was prescribed most frequently to spine (5%) and extremity (4%) metastases p <0.001 in the last two weeks of life, though only varied between 1% (sternum) and 5% (spine) by site of metastases. Single fraction RT was prescribed more commonly in the last 2 weeks of life (64.2%), compared to individuals who received RT 2-4 weeks (54.5), and >4 weeks (47.9%) before death (p <0.001).

CONCLUSIONS

This population-based analysis found that only 4% of patients with bone metastases received radiation therapy during the last 2 weeks of their life in our population-based, publicly funded program, though it was significantly higher in patients with lung cancer and those with metastases to the spine or extremity. Appropriately, use of multiple fractions palliative RT was less common in patients closer to death.

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.

Review of international patterns of practice for the treatment of painful bone metastases with palliative radiotherapy from 1993 to 2013

BACKGROUND AND PURPOSE

Numerous randomized controlled trials and meta-analyses have affirmed that single and multiple fractions of radiotherapy provide equally efficacious outcomes in the palliation of painful, uncomplicated bone metastases (UBM). We aim to determine geographic, temporal and ancillary factors that influence the global patterns of practice in this setting.

MATERIALS AND METHODS

A literature search was conducted on Ovid MEDLINE and EMBASE. Studies were included if they disclosed prescription patterns of single fraction radiotherapy, either through hypothetical cases or actual patient data. Weighted analysis of variance was conducted for binary predictors while weighted linear regression analysis was performed for continuous parameters.

RESULTS

Nine hypothetical case studies and thirteen actual patterns of practice articles were included from 301 search results. Radiation oncologists prescribed dose fractionations ranging from 3Gy×1 to 2Gy×30, with a median of 3Gy×10, for the palliation of UBM. Actual data demonstrated a weak, non-significant, negative linear relationship between the use of single fraction radiotherapy and the year of treatment. Geographical location of treatment was a key predictor of prescription patterns.

CONCLUSION

In the last twenty years, there was an overall global reluctance to practice evidence-based medicine by employing single fractions for UBM.

Patients who die during palliative radiotherapy. Status survey

BACKGROUND AND PURPOSE

Palliative radiotherapy (RT) is routinely used in end of life care of patients with advanced malignancies; however, unnecessarily burdensome treatment shortly before death should be avoided. There is little knowledge on incidence and causes of intercurrent deaths during palliative RT.

PATIENTS AND METHODS

In this study death events among inpatients receiving palliative RT between January 2009 and December 2011 at this department were retrospectively analyzed. Among epidemiological factors, treatment schedule and chronology, latency and duration of treatment in relation to the actual survival were identified.

RESULTS

In this study 52 patients died during or shortly after palliative RT. Symptomatic bone metastases and brain metastases represented the most common RT indications. The general health status was poor with a median Karnofsky performance score of 50 %, RT was realized with a median single dose of 2.5 Gy to a median total dose of 30.5 Gy and was stopped prematurely in 73 % of patients. On average 53 % of the remaining lifetime was occupied by latency to starting RT. Once RT was begun the treatment duration required a median 64 % of the still remaining lifetime.

CONCLUSION

The majority of patients who died had explicitly adverse pre-existing factors and rarely completed RT as scheduled. Latency to RT and RT duration occupied more than half of the remaining lifetime.

A survey of patterns of practice on palliative radiation therapy for bone metastasis in Korea

PURPOSE

The aim of this study was to understand the practice patterns of palliative radiation therapy for bone metastasis in Korea among Korean radiation oncologists by survey and to determine the decision factors affecting the prescription of radiation therapy fractionation schedules.

METHODS

An Internet-based survey was performed from October 5 to October 23, 2009, among 177 active full members of the Korean Society for Radiation and Oncology (KOSRO). The survey questionnaire included general information about the respondent, three types of clinical scenario, depending on the life expectancy of the patients, and the decision factors that affected the prescription of a radiation therapy schedule.

RESULTS

The most prescribed schedule was 30 Gy in 10 fractions regardless of the life expectancy of the patient. Also, it was found that a single fraction was seldom prescribed routinely in Korea. An increasing number prescribed fewer than 10 fractions as the life expectancy shortened; however, the prescription rate of a single fraction was still low. The general performance (and/or accompanying diseases) of patients and the life expectancy were the most considered factors in deciding the prescription of radiation therapy.

CONCLUSIONS

Despite the abundant evidence supporting the equivalence of single- and multi-fraction radiation therapy, still, most Korean radiation oncologists continue to prescribe multi-fraction schedules depending on the general performance and life expectancy of the patients. Thus, we confirmed that there was a gap between evidence and practice, and treatment prescriptions can be strongly affected by decision factors other than published literature results.

Radiotherapy for bone metastases: practice in Norway 1997-2007. A national registry-based study

Numerous randomised clinical trials have shown that the efficacy of single fraction radiotherapy for metastatic bone pain corresponds to that of multiple fractions of radiotherapy for the majority of patients. It is not clear to which extent single fraction radiotherapy has been implemented into clinical practice.

MATERIAL AND METHODS

A Norwegian national registry-based study was conducted, including all radiotherapy schedules of 8 Gy × 1 and 3 Gy × 10 delivered to bone metastases in 1997-2007. Binomial regression analyses were used to study whether treatment centre, primary diagnosis, anatomical region irradiated, age, sex, and travel distance, were associated with the choice of fractionation.

RESULTS

A total of 14 380 radiotherapy episodes were identified. During the period 31% of the treatments were delivered as 8 Gy × 1. The proportion of single fraction treatments increased from 16% in 1997 to 41% in 2007. There were substantial differences in the proportion of single fraction treatments between the treatment centres (range 25-54%). These differences persisted after adjustment for sex, age, primary diagnosis, anatomical region, and travel distance.

CONCLUSIONS

The study demonstrates an underutilisation of single fraction treatment for bone metastases in Norway during the study period.

Palliative radiotherapy for bone metastases: assessment of factors influencing dose-fractionation schedules at a UK cancer centre

Context

Meta-analyses demonstrate single-fraction radiotherapy to be as effective as multi-fraction treatment in palliating painful bone metastases, although surveys suggest reluctance in prescribing single fractions.

Aims

Assess the factors influencing the choice of dose-fractionation regimen in an unselected population; examine retreatment rates and subsequent skeletal events.

Methods

Data were extracted from case notes for 120 patients treated in 2000 and 2006 in a single centre serving a defined population; analysis used χ2 and Fisher's exact statistical tests.

Results

An 8 Gy fraction was the commonest regimen prescribed (single-fraction delivery rate 53·6%). Tumour site was a significant factor in choice of dose-fractionation schedule. Patients with metastatic breast carcinoma were significantly less likely to receive single-fraction treatment compared with those with metastatic lung carcinoma (year 2000: p = 0·038, 2006: p = 0·001). There was a significantly higher retreatment rate following single-fraction compared with multi-fraction treatment (11% versus 3%). There were two subsequent neural axis compressions and four pathological fractures.

Conclusions

Single-fraction treatment is the commonest regimen but multiple fractions are still frequently delivered. Better prognosis groups appear more likely to receive multi-fraction treatment, possibly to avoid the need for retreatment. Subsequent skeletal events are rare but carry high morbidity when they occur.

The failures and challenges of bone metastases research in radiation oncology

Bone metastases affect a large portion of the cancer population. As treatment options continue to evolve, many added failures and challenges arise. This narrative review details such in palliative radiation therapy for bone metastases. We begin by describing the incidence rates of bone metastases in the cancer population, the current standards of practice in recent literature and clinical trial data. Inconsistencies in end point definitions along with difficulties in measuring response to treatment and controversial areas are outlined. Current literature suggests that there is a discrepancy in physician and patient perspective on treatment options as well as quality of life. The added challenges of treatment side effects are addressed and a review of recent trials is given. Stereotactic radiation therapy is a relatively new treatment option for patients with bone metastases. Therefore, a review of the safety and efficacy of this treatment is provided. Other new areas of bone metastases treatment and research such as high intensity focused ultrasound and nanoparticles are discussed. Physicians need to prevent unwanted side effects of treatment in addition to determining how to integrate many new upcoming treatment options for patients with bone metastases. A continued reluctance to practice evidence based medicine needs to be addressed.

Single Fraction versus Multiple Fraction Radiotherapy for Palliation of Painful Vertebral Bone Metastases: A Prospective Study

Context:

Metastatic bone disease is a commonly encountered problem in oncology practice. The most useful and cost effective treatment is radiotherapy (RT). Different fractionation schedule of RT can be used to treat such condition.

Aims:

Assessment of pain response in patients with vertebral bone metastasis after treating them with various radiation fractionations and to compare the toxicity profile in the treatment arms.

Settings and Design:

A prospective randomized study was designed to include total 64 patients from July 2010 to May 2011. Patients with histopathologically proven primary malignancy having symptomatic secondary deposits to vertebra were selected for the study. Patients were randomized to two arms receiving multiple fraction of RT with 30 Gy in 10 fractions and 8 Gy in single fraction RT, respectively.

Materials and Methods:

Patients with age >75 years, Karnofsky Performance Status (KPS) <40, features of cord compression were excluded from study. Initial pain response was assessed using Visual Analogue Scale (VAS) and compared using the same scale at weekly interval up to 1 month after treatment completion.

Results:

Arm A comprised of 33 patients while 31 patients were enrolled in Arm B. Baseline patient characteristics were comparable. Eleven patients were lost to follow-up. Initial pain scores were 7.23 ± 0.765 and 7.51 ± 0.55 in arm A and arm B, respectively. Pain scores reduced significantly in both the arms after 1 month (4.39 ± 1.82 in arm A; 5.25 ± 2.39 in arm B). Time of initiation of pain response was earlier in arm A (P = 0.0281), statistically significant. Mild G-I toxicity was noted in both the arms but differences in two arms were not statistically significant (P = 0.49), no interruption of treatment was required because of side effects.

Conclusions:

Different fractionation of radiation has same response and toxicity in treatment of vertebral bone metastasis. Single fraction RT may be safely used to treat these cases as this is more cost effective and less time consuming. Studies may be conducted to find out particular subgroup of patients to be benefitted more by either fractionation schedule; however, our study cannot comment on that issue.

[Evaluation of professional practices: improving cancer related-pain management in radiation oncology]

Radiation oncologist often faced cancer pain, regardless the stage of cancer. Given the high prevalence of cancer pain, and its potential for profound adverse consequences, all patients with active malignancy should be routinely screened and treated for pain. Using a questionnaire developed by the pain center of the Institut de cancérologie de la Loire, we questioned in a routine day 154 patients receiving radiation in our department. On 154 assessed patients, 92% (n = 143) were treated with curative intent and 8% (n = 11) with analgesic intent. Sixty-seven (44%) and 14 (9%) declared to feel pain outside and during radiotherapy, respectively. Using the visual analogic scale, 39, 41 and 20% rated their pain between 1 and 3, 4 and 6 and more than 7, respectively. One third of patients suffering from pain had no analgesic treatment and 55% of patients felt inadequately relieved. Almost all (97%) of these noted an impact on their quality of life. Half of them (54%) were aware of a specific consultation for pain. A pain consultation was offered to 19% of respondents and 26% of patients were referred for a specialized consultation at the end of the investigation. Despite the existence of a pain center in the Institute, the pain seems insufficiently assessed and supported for patients receiving radiation therapy. Better communication between caregivers and better information should enable a more comprehensive assessment and specific treatment for cancer-pain related.

Use of palliative radiotherapy in brain and bone metastases (VARA II study)

INTRODUCTION

Metastases are detected in 20% of patients with solid tumours at diagnosis and a further 30% after diagnosis. Radiation therapy (RT) has proven effective in bone (BM) and brain (BrM) metastases. The objective of this study was to analyze the variability of RT utilization rates in clinical practice and the accessibility to medical technology in our region.

PATIENTS AND METHODS

We reviewed the clinical records and RT treatment sheets of all patients undergoing RT for BM and/or BrM during 2007 in the 12 public hospitals in an autonomous region of Spain. Data were gathered on hospital type, patient type and RT treatment characteristics. Calculation of the rate of RT use was based on the cancer incidence and the number of RT treatments for BM, BrM and all cancer sites.

RESULTS

Out of the 9319 patients undergoing RT during 2007 for cancer at any site, 1242 (13.3%; inter-hospital range, 26.3%) received RT for BM (n = 744) or BrM (n = 498). These 1242 patients represented 79% of all RT treatments with palliative intent, and the most frequent primary tumours were in lung, breast, prostate or digestive system. No significant difference between BM and BrM groups were observed in: mean age (62 vs. 59 yrs, respectively); gender (approximately 64% male and 36% female in both); performance status (ECOG 0-1 in 70 vs. 71%); or mean distance from hospital (36 vs. 28.6 km) or time from consultation to RT treatment (13 vs. 14.3 days). RT regimens differed among hospitals and between patient groups: 10 × 300 cGy, 5 × 400 cGy and 1x800cGy were applied in 32, 27 and 25%, respectively, of BM patients, whereas 10 × 300cGy was used in 49% of BrM patients.

CONCLUSIONS

Palliative RT use in BM and BrM is high and close to the expected rate, unlike the global rate of RT application for all cancers in our setting. Differences in RT schedules among hospitals may reflect variability in clinical practice among the medical teams.

Patterns of practice in palliative radiotherapy for painful bone metastases: a survey in Japan

PURPOSE

To determine the current patterns of practice in Japan and to investigate factors that may make clinicians reluctant to use single-fraction radiotherapy (SF-RT).

METHODS AND MATERIALS

Members of the Japanese Radiation Oncology Study Group (JROSG) completed an Internet-based survey and described the radiotherapy dose fractionation they would recommend for four hypothetical cases describing patients with painful bone metastasis (BM). Case 1 described a patient with an uncomplicated painful BM in a non-weight-bearing site from non-small-cell lung cancer. Case 2 investigated whether management for a case of uncomplicated spinal BM would be different from that in Case 1. Case 3 was identical with Case 2 except for the presence of neuropathic pain. Case 4 investigated the prescription for an uncomplicated painful BM secondary to oligometastatic breast cancer. Radiation oncologists who recommended multifraction radiotherapy (MF-RT) for Case 2 were asked to explain why they considered MF-RT superior to SF-RT.

RESULTS

A total of 52 radiation oncologists from 50 institutions (36% of JROSG institutions) responded. In all four cases, the most commonly prescribed regimen was 30 Gy in 10 fractions. SF-RT was recommended by 13% of respondents for Case 1, 6% for Case 2, 0% for Case 3, and 2% for Case 4. For Case 4, 29% of respondents prescribed a high-dose MF-RT regimen (e.g., 50 Gy in 25 fractions). The following factors were most often cited as reasons for preferring MF-RT: "time until first increase in pain" (85%), "incidence of spinal cord compression" (50%), and "incidence of pathologic fractures" (29%).

CONCLUSIONS

Japanese radiation oncologists prefer a schedule of 30 Gy in 10 fractions and are less likely to recommend SF-RT. Most Japanese radiation oncologists regard MF-RT as superior to SF-RT, based primarily on the time until first increase in pain.

Palliative radiotherapy tailored to life expectancy in end-stage cancer patients: reality or myth?

BACKGROUND

The purpose of the study was to investigate the adequacy of palliative radiation treatment in end-stage cancer patients.

METHODS

Of 216 patients referred for palliative radiotherapy, 33 died within 30 days and constitute the population of the study. Symptoms, Karnofsky Performance Status (KPS), laboratory tests, and survival estimates were obtained. Treatment course was evaluated by medical records. Univariate analyses were performed by using the 2-sided chi-square test. With significant variables, multiple regression analysis was performed.

RESULTS

Median age was 65 years, and median survival was 15 days. Prevailing primary cancer types were lung (39%) and breast (18%). Metastases were present in 94% of patients, brain (36%), bone (24%) and lung (18%). In 91%, KPS was < 0%. KPS, lactate dehydrogenase, dyspnea, leucocytosis, and brain metastases conveyed a poor prognosis. From 85 survival estimates, only 16% were correct, but 21% expected more than 6 months. Radiotherapy was delivered to 91% of patients. In 90% of radiation treatments, regimens of at least 30 Gy with fractions of 2-3 Gy were applied. Half of the patients spent greater than 60% of their remaining lifespan on therapy. In only 58% of patients was radiotherapy completed. Progressive complaints were noted in 52% and palliation in 26%.

CONCLUSIONS

Radiotherapy was not appropriately customized to these patients considering the median treatment time, which resembles the median survival time. About half of the patients did not benefit despite spending most of their remaining lives on therapy. Prolonged irradiation schedules probably reflect overly optimistic prognoses and unrealistic concerns about late radiation damage. Single-fraction radiotherapy was too seldom used.

International variations in radiotherapy fractionation for bone metastases: geographic borders define practice patterns?

Although it may be argued that single fraction (SF) radiotherapy (RT) should be regarded as the standard palliative treatment for pain due to uncomplicated bone metastases, its widespread clinical use is still underexploited. In this chapter, the authors discuss a number of surveys investigating doctors and patients' preferences for palliative RT schedules, discuss the possible reasons for this phenomenon, and suggest potential strategies to increase the use of SF.

International patterns of practice in palliative radiotherapy for painful bone metastases: evidence-based practice?

PURPOSE

Multiple randomized controlled trials have demonstrated the equivalence of multifraction and single-fraction (SF) radiotherapy for the palliation of painful bone metastases (BM). However, according to previous surveys, SF schedules remain underused. The objectives of this study were to determine the current patterns of practice internationally and to investigate the factors influencing this practice.

METHODS AND MATERIALS

The members of three global radiation oncology professional organizations (American Society for Radiology Oncology [ASTRO], Canadian Association of Radiation Oncology [CARO], Royal Australian and New Zealand College of Radiologists) completed an Internet-based survey. The respondents described what radiotherapy dose fractionation they would recommend for 5 hypothetical cases describing patients with single or multiple painful BMs from breast, lung, or prostate cancer. Radiation oncologists rated the importance of patient, tumor, institution, and treatment factors, and descriptive statistics were compiled. The chi-square test was used for categorical variables and the Student t test for continuous variables. Logistic regression analysis identified predictors of the use of SF radiotherapy.

RESULTS

A total of 962 respondents, three-quarters ASTRO members, described 101 different dose schedules in common use (range, 3 Gy/1 fraction to 60 Gy/20 fractions). The median dose overall was 30 Gy/10 fractions. SF schedules were used the least often by ASTRO members practicing in the United States and most often by CARO members. Case, membership affiliation, country of training, location of practice, and practice type were independently predictive of the use of SF. The principal factors considered when prescribing were prognosis, risk of spinal cord compression, and performance status.

CONCLUSION

Despite abundant evidence, most radiation oncologists continue to prescribe multifraction schedules for patients who fit the eligibility criteria of previous randomized controlled trials. Our results have confirmed a delay in the incorporation of evidence into practice for palliative radiotherapy for painful bone metastases.

Did the pattern of practice in the prescription of palliative radiotherapy for the treatment of uncomplicated bone metastases change between 1999 and 2005 at the rapid response radiotherapy program?

AIMS

Since 1999, randomised clinical trials and meta-analyses have reported equal efficacy of pain relief from single- and multiple-fraction radiotherapy for bone metastases. A number of factors, including limited radiotherapy resources, waiting times, and patient convenience, suggest single fraction to be the treatment of choice for patients. However, international patterns of practice indicate that multiple fractions are still commonly used. This study examined whether dose-fractionation schemes used for the treatment of bone metastases at the Rapid Response Radiotherapy Program (RRRP) at the Odette Cancer Centre have changed since 1999.

MATERIALS AND METHODS

A retrospective review of the prospective RRRP database and hospital records were conducted for all patients treated with palliative radiotherapy for uncomplicated bone metastases at the RRRP in 1999 (or baseline), 2001, 2004 and from 1 January to 31 July 2005. Data were collected on patient demographics and clinical characteristics.

RESULTS

Of the 693 patients, 65 and 35% were prescribed single fraction (predominantly single 8 Gy) and multiple fractions (predominantly 20 Gy/five fractions), respectively. The administration of single treatments generally increased over time, from 51% in 1999 to 66% in 2005 (P=0.0001). On the basis of multiple logistic regression analyses, patients were more likely to be prescribed single-fraction radiotherapy if they had prostate cancer, had a poorer performance status, were treated to the limbs, hips, shoulders, pelvis, ribs, scapula, sternum, or clavicle (compared with the spine), were treated by a radiation oncologist who had been trained in earlier years, and who were treated after 1999.

CONCLUSIONS

Between 1999 and 2005, the use of single-fraction radiotherapy increased, corresponding to publications showing equal efficacy of pain relief between single and multiple fractions in the management of uncomplicated bone metastases. However, about a third of patients still received multiple fractions.

Patterns of practice of palliative radiotherapy in Africa, Part 1: Bone and brain metastases

PURPOSE

To provide data on the pattern of practice of palliative radiotherapy (RT) on the African continent.

METHODS AND MATERIALS

A questionnaire was distributed to participants in a regional training course of the International Atomic Energy Agency in palliative cancer care and sent by e-mail to other institutions in Africa. Requested information included both infrastructure and human resources available and the pattern of RT practice for metastatic and locally advanced cancers.

RESULTS

Of 35 centers contacted, 24 (68%) completed the questionnaire. Although RT is used by most centers for most metastatic cancers, liver and lung metastases are treated with chemotherapy. Of 23 centers, 14 (61%) had a single RT regimen as an institutional policy for treating painful bone metastases, but only 5 centers (23%) of 23 used 8 Gy in 1 fraction. Brain metastases were being treated by RT to the whole brain to 30 Gy in 10 fractions, either exclusively (n=13, 56%) or in addition to the use of 20 Gy in 5 fractions (n=3, 14%).

CONCLUSION

Radiotherapy is a major component of treatment of cancer patients in African countries. There is consensus among few centers for treatment schedules for almost all sites regarding time and dose-fractionation characteristics of RT regimens used and/or indications for the use of RT in this setting.

Palliative radiotherapy trials for bone metastases: a systematic review

PURPOSE

The objective is to update previous meta-analyses with a systematic review of randomized palliative radiotherapy (RT) trials comparing single fractions (SFs) versus multiple fractions (MFs).

METHODS

The analysis includes all published reports from randomized trials comparing SF or MF schedules for the treatment of painful bone metastases with localized RT. A systematic review was performed using the random-effects model with Review Manager version 4.1 (Cochrane Collaboration, Oxford, UK). The odds ratio and 95% CI were calculated for each trial and presented in a forest plot.

RESULTS

A total of 16 randomized trials from 1986 onward were identified. For intention-to-treat patients, the overall response (OR) rates for pain were similar for SF at 1,468 (58%) of 2,513 patients and MF RT at 1,466 (59%) of 2,487 patients. The complete response (CR) rates for pain were 23% (545 of 2,375 patients) for SF and 24% (558 of 2,351 patients) for MF RT. No significant differences were found in response rates. Trends showing an increased risk for SF RT arm patients in terms of pathological fractures and spinal cord compressions were observed, but neither were statistically significant (P = .75 and P = .13, respectively). The likelihood of re-treatment was 2.5-fold higher (95% CI, 1.76 to 3.56) in SF RT arm patients (P < .00001). Repeated analysis of these end points, excluding dropout patients, did not alter the conclusions. Generally, no significant differences with respect to acute toxicities were observed between the arms.

CONCLUSION

No significant differences in the arms were observed for overall and CR rates in both intention-to-treat and assessable patients. However, a significantly higher re-treatment rate with SFs was evident.

Review of patterns of practice and patients’ preferences in the treatment of bone metastases with palliative radiotherapy

INTRODUCTION

Since the 1980s, randomized clinical trials showed that single fraction radiotherapy (RT) provided equal pain relief as multiple fractions of RT in the treatment of bone metastases.

MATERIALS AND METHODS

Using Medline, a literature search was conducted on patterns of practice among radiation oncologists and patients' preferences of dose fractionations for the treatment of bone metastases.

RESULTS AND DISCUSSION

Fifteen studies on international patterns of practice published between 1966 and May 2006 were identified. Surveys of Canadian radiation oncologists indicated approximately 85% preferred multiple fractions, most often as 20 Gray in five fractions (20 Gy/5). Surveys in the United States indicated that 30 Gy/10 was most commonly used, and 90-100% of these oncologists preferred multiple over single fraction RT. Multiple fractions were most commonly used in the United Kingdom, Western Europe, Australia and New Zealand, and India; however, more radiation oncologists in these countries would prescribe a single fraction than in North America. Three studies investigated patients' preferences of dose fractionations. In the Australian study, most patients favored single fraction RT as long as long-term outcomes were not compromised. Durability of pain relief was considered more important than short-term convenience factors. In the Singapore study, 85% of patients would choose extended courses of RT (24 Gy/6) compared to a single 8 Gy. In the Canadian study, most patients (76%) would choose a single 8 Gy over 20 Gy/5 of palliative RT due to greater convenience.

CONCLUSION

Despite strong evidence supporting the use of single fraction RT, current practices and preferences favor multiple fractions for the treatment of bone metastases. This has significant implications for the overall quality of life, RT department workload, costs to healthcare systems, and patient convenience.

Radiation Therapy and Radio-nuclides for Palliation of Bone Pain

Bone pain from metastatic prostate cancer can be effectively palliated by a single fraction of 8 Gy with no increase in toxicity, which can occur with more protracted fractionation schemes. Re-treatment, if required, is simple and effective. For multiple painful sites on the same side of the diaphragm, hemi-body radiotherapy is rapidly effective; pre-medication with odanstetron and steroids has markedly improved tolerance. For multiple painful sites on both sides of the diaphragm, radiopharmaceuticals can be considered but will not treat adjacent soft tissue disease or neurologic compromise.

Patients with a favourable prognosis are equally palliated with single and multiple fraction radiotherapy: results on survival in the Dutch Bone Metastasis Study

BACKGROUND AND PURPOSE

In the prospectively, randomized Dutch Bone Metastasis Study on the effect of a single fraction of 8 Gy versus 24 Gy in six fractions on painful bone metastases, 28% of the patients survived for more than 1 year. Purpose of the present study was to analyze the palliative effect of radiotherapy in long-term surviving patients, and to identify prognostic factors for survival.

MATERIAL AND METHODS

Response rates were compared in all patients surviving>52 weeks. The Cox proportional hazards model stratified by primary tumour was used for multivariate (MV) analyses of prognostic factors for survival.

RESULTS

In 320 patients surviving>52 weeks, responses were 87% after 8 Gy and 85% after 24 Gy (P=0.54). Duration of response and progression rates were similar. For all primary tumours, prognostic factors for survival were a good Karnofsky Performance Score, no visceral metastases, and non-opioid analgesics intake (all factors, MV P<0.001).

CONCLUSIONS

Single fraction radiotherapy should be the standard dose schedule for all patients with painful bone metastases, including patients with an expected favourable survival. General prognosticators as the Karnofsky Performance Score and metastatic tumour load are useful in predicting survival.

Factors Influencing the Use of Single vs Multiple Fractions of Palliative Radiotherapy for Bone Metastases: A 5-Year Review

AIMS

Evidence from a number of randomised trials and meta-analyses supports the use of single-fraction radiotherapy for the palliation of painful bone metastases. This study explores patient and treatment factors that influence the choice of single compared with multiple-fraction radiotherapy for the treatment of bone metastases in clinical practice.

MATERIALS AND METHODS

The Princess Margaret Hospital Palliative Radiation Oncology Program Database served as the basis for our report. All courses of treatment delivered for bone metastases were extracted. Courses were classified into single or multiple fractions. Clinical characteristics were compared between the two groups.

RESULTS

Between 1998 and 2002, 882 courses of radiotherapy were delivered for the treatment of bone metastases, of which 283 (32%) were a single fraction. The proportion of single-fraction treatments was 37% in 1998, 30% in 1999 and 43% in 2000, but dropped to 26% and 28% in 2001 and 2002, respectively (P = 0.02). Patients treated with single fractions were significantly older (68 +/- 12 years vs 64 +/- 12 years), and had more weight loss and poor performance status. Single fractions included 20% of treatments in palliative irradiation of the spine, 36% in the pelvis and long bones, and 59% in the chest wall (P < 0.001). There was no significant difference in patients' gender, primary cancers, number of metastatic sites, treating physicians, enrollment in a clinical trial and general radiotherapy waiting time in our department. Multivariate analysis indicated age (P = 0.001), performance status (P < 0.001), anatomical site (P < 0.001) and year of radiotherapy (P = 0.006) as significant.

CONCLUSION

One-third of palliative radiotherapy courses for bone metastases in our programme were given as single fractions. Performance status, age and anatomical site were significant factors affecting single compared with multiple fractionation. The variation in the use of single fractions over time may reflect the dynamic process of interpretation and application of evidence from clinical trials to practice.

Radiotherapy fractionation for the palliation of uncomplicated painful bone metastases - an evidence-based practice guideline

BACKGROUND

This practice guideline was developed to provide recommendations to clinicians in Ontario on the preferred standard radiotherapy fractionation schedule for the treatment of painful bone metastases.

METHODS

A systematic review and meta-analysis was performed and published elsewhere. The Supportive Care Guidelines Group, a multidisciplinary guideline development panel, formulated clinical recommendations based on their interpretation of the evidence. In addition to evidence from clinical trials, the panel also considered patient convenience and ease of administration of palliative radiotherapy. External review of the draft report by Ontario practitioners was obtained through a mailed survey, and final approval was obtained from the Practice Guidelines Coordinating Committee.

RESULTS

Meta-analysis did not detect a significant difference in complete or overall pain relief between single treatment and multifraction palliative radiotherapy for bone metastases. Fifty-nine Ontario practitioners responded to the mailed survey (return rate 62%). Forty-two percent also returned written comments. Eighty-three percent of respondents agreed with the interpretation of the evidence and 75% agreed that the report should be approved as a practice guideline. Minor revisions were made based on feedback from the external reviewers and the Practice Guidelines Coordinating Committee. The Practice Guidelines Coordinating Committee approved the final practice guideline report.

CONCLUSION

For adult patients with single or multiple radiographically confirmed bone metastases of any histology corresponding to painful areas in previously non-irradiated areas without pathologic fractures or spinal cord/cauda equine compression, we conclude that: Where the treatment objective is pain relief, a single 8 Gy treatment, prescribed to the appropriate target volume, is recommended as the standard dose-fractionation schedule for the treatment of symptomatic and uncomplicated bone metastases. Several factors frequently considered in clinical practice when applying this evidence such as the effect of primary histology, anatomical site of treatment, risk of pathological fracture, soft tissue disease and cord compression, use of antiemetics, and the role of retreatment are discussed as qualifying statements.Our systematic review and meta-analysis provided high quality evidence for the key recommendation in this clinical practice guideline. Qualifying statements addressing factors that should be considered when applying this recommendation in clinical practice facilitate its clinical application. The rigorous development and approval process result in a final document that is strongly endorsed by practitioners as a practice guideline.

Survey on use of palliative radiotherapy in hospice care

PURPOSE

Radiation oncologists and hospice professionals both provide end-of-life care for oncology patients, and little has been written about the interface between these two groups of specialists. Hospice professionals were surveyed to assess the perceived need for palliative radiotherapy in the hospice setting, to investigate factors that limit the access of hospice patients to radiotherapy, and to suggest areas of future collaboration on education, research, and patient advocacy.

PATIENTS AND METHODS

Members of the National Hospice and Palliative Care Organization (NHPCO) and American Society for Therapeutic Radiology and Oncology jointly authored a questionnaire to investigate the beliefs of hospice professionals toward the use of radiotherapy for oncology patients in hospice. The questionnaire was distributed to all NHPCO member institutions, and the results were compiled and statistically analyzed.

RESULTS

Four hundred eighty of more than 1,800 surveyed facilities responded to the questionnaire. The findings suggest that the majority of hospice professionals feel that radiotherapy is important in palliative oncology and that radiotherapy is widely available in the United States. Yet less than 3% on average of hospice patients served by hospices responding to the survey actually received radiotherapy in 2002. The most common barriers to radiotherapy in hospice care include radiotherapy expense, transportation difficulties, short life expectancy, and educational deficiencies between the specialties.

CONCLUSION

Multiple barriers act to limit the use of palliative radiotherapy in hospice care. Finding ways to surmount these obstacles will provide opportunity for improvement in the end-of-life care of cancer patients.

Single fraction radiotherapy is efficacious: a further analysis of the Dutch Bone Metastasis Study controlling for the influence of retreatment

PURPOSE

The Dutch Bone Metastasis Study on the effect on painful bone metastases of 8 Gy single fraction (SF) vs. 24 Gy in multiple fractions (MF) showed 24% retreatment after SF vs. 6% after MF (p < 0.001). The purpose of the present study was to evaluate factors influencing retreatment and its effect on response.

METHODS AND MATERIALS

The database on all randomized patients was reanalyzed with separately calculated responses to initial treatment and retreatment.

RESULTS

Response to initial treatment was 71% after SF vs. 73% after MF (p = 0.84). Retreatment raised response to 75% for SF; MF remained unaltered (p = 0.54). The response status after initial treatment did not predict occurrence of retreatment: 35% SF vs. 8% MF nonresponders and 22% SF vs. 10% MF patients with progressive pain were retreated. Logistic regression analyses showed the randomization arm and the pain score before retreatment to significantly predict retreatment (p < 0.001). Retreatment for nonresponders was successful in 66% SF vs. 33% MF patients (p = 0.13). Retreatment for progression was successful in 70% SF vs. 57% MF patients (p = 0.24).

CONCLUSIONS

With or without the effect of retreatment, SF and MF radiotherapy provided equal palliation for painful bone metastases. Irrespective of response to initial treatment, physicians were more willing to retreat after a single fraction. Overall, retreatment was effective in 63% of retreated patients.

Publication rates of abstracts presented at annual scientific meetings: how does the Royal Australian and New Zealand College of Radiologists compare?

The abstract to publication ratio (APR) is a measure of the quality of scientific meetings. The aim of the present study was to determine the publication rate of abstracts presented at annual Royal Australian and New Zealand College of Radiologists (RANZCR) conferences, and to identify the publishing journals. All free paper research abstracts (oral or poster) presented by RANZCR radiologists, radiation oncologists and trainees at the four consecutive meetings between 1996 and 1999 were identified retrospectively from conference programmes. The PubMed database (http://www.ncbi.nlm.nih.gov/PubMed/) was searched to determine whether or not the abstract had been published as a full paper. Of the 480 free paper research abstracts, 168 (35%) had been published as full articles. The overall abstract to publication ratio for radiology was 29% and for radiation oncology was 41%. Papers were published in a variety of journals but Australasian Radiology accounted for 27%. The mean time between presentation and publication was 16.5 months (median 17 months). These overall abstract to publication ratios are lower than those reported for overseas-based meetings in each respective area. Guidelines to scientific committees could increase the APR by more rigorous selection of abstracts. Future research should look at barriers to the publication of research findings, and identify ways to assist the publication process.

Palliation of metastatic bone pain: single fraction versus multifraction radiotherapy--a systematic review of randomised trials

Recent randomised studies have reported that single fraction radiotherapy is as effective as multifraction radiotherapy in relieving pain caused by bone metastasis. However, there are concerns about the higher re-treatment rates and the efficacy of preventing future complications, such as pathological fracture and spinal cord compression, by single fraction radiotherapy. A systematic review of randomised studies, examining the effectiveness of single fraction radiotherapy versus multiple fraction radiotherapy for metastatic bone pain relief and prevention of bone complications, was conducted to help answer this controversy. Randomised studies comparing single fraction radiotherapy with multifraction radiotherapy on metastatic bone pain were identified. The analyses were performed using intention-to-treat principle. The results were pooled using meta-analysis to estimate the effect of treatment on pain response, re-treatment rate, pathological fracture rate and spinal cord compression rate. Twelve trials involving 3621 sites were included in the meta-analysis. The overall pain-response rates for single fraction radiotherapy and multifraction radiotherapy were 60% (1080/1814) and 59% (1060/1807), respectively, giving an odds ratio (OR) of 1.03 (95% confidence interval [CI] 0.90-1.19), indicating no difference between the two radiotherapy schedules. There was also no difference in complete pain response rates for single fraction radiotherapy (34% [508/1476]) and multifraction radiotherapy (32% [475/1473]), with an OR of 1.10 (950% CI 0.94-1.30). Patients treated by single fraction radiotherapy had a higher re-treatment rate, with 21.5% (267/1240) requiring re-treatment compared with 7.4% (91/1236) of patients in the multifraction radiotherapy arm (OR 3.44 [95% CI 2.67-4.43]). The pathological fracture rate was also higher in single fraction radiotherapy arm patients. Three per cent (37/1240) of patients treated by single fraction radiotherapy developed pathological fracture compared with 1.6% (20/1236) for those treated by multifraction radiotherapy (OR 1.82 [95% CI 1.06-3.11]). The spinal cord compression rates were similar for both arms (OR 1.41 [95% CI 0.72-2.75]). Single fraction radiotherapy was as effective as multifraction radiotherapy in relieving metastatic bone pain. However, the re-treatment rate and pathological fracture rate were higher after single fraction radiotherapy. Studies with quality of life and health economic end points are warranted to find out the optimal treatment option.

Palliation of metastatic bone pain: single fraction versus multifraction radiotherapy - a systematic review of the randomised trials

BACKGROUND

Recent randomised studies reported that single fraction radiotherapy was as effective as multifraction radiotherapy in relieving pain due to bone metastasis. However, there are concerns about the higher re-treatment rates and the efficacy of preventing future complications such as pathological fracture and spinal cord compression by single fraction radiotherapy.

OBJECTIVES

To undertake a systematic review and meta-analysis of single fraction radiotherapy versus multifraction radiotherapy for metastatic bone pain relief and prevention of bone complications.

SEARCH STRATEGY

Trials were identified through MEDLINE, EMBASE, Cancerlit, reference lists of relevant articles and conference proceedings. Relevant data was extracted.

SELECTION CRITERIA

Randomised studies comparing single fraction radiotherapy with multifraction radiotherapy on metastatic bone pain

DATA COLLECTION AND ANALYSIS

The analyses were performed using intention-to-treat principle. The results were pooled using meta-analysis to estimate the effect of treatment on pain response, re-treatment rate, pathological fracture rate and spinal cord compression rate.

MAIN RESULTS

Eleven trials that involved 3435 patients were identified. Of 3435 patients, 52 patients were randomised more than once for different painful bone metastasis sites. Altogether, 3487 painful sites were randomised. The trials included patients with painful bone metastases of any primary sites, but were mainly prostate, breast and lung. The overall pain response rates for single fraction radiotherapy and multifraction radiotherapy were 60% (1059/1779) and 59% (1038/1769) respectively, giving an odds ratio of 1.03 (95% confidence interval [CI], 0.89 - 1.19) indicating no difference between the two radiotherapy schedules. There was also no difference in complete pain response rates for single fraction radiotherapy (34% [497/1441]) and multifraction radiotherapy (32% [463/1435]) with an odds ratio of 1.11 (95%CI 0.94-1.30). Patients treated by single fraction radiotherapy had a higher re-treatment rate with 21.5% (267/1240) requiring re-treatment compared to 7.4% (91/1236) of patients in the multifraction radiotherapy arm (odds ratio 3.44 [95%CI 2.67-4.43]). The pathological fracture rate was also higher in single fraction radiotherapy arm patients. Three percent (37/1240) of patients treated by single fraction radiotherapy developed pathological fracture compared to 1.6% (20/1236) for those treated by multifraction radiotherapy (odds ratio 1.82 [95%CI 1.06-3.11]). The spinal cord compression rates were similar for both arms (odds ratio 1.41 [95%CI 0.72-2.75]). Repeated analyses excluding dropout patients gave similar results.

REVIEWERS' CONCLUSIONS

Single fraction radiotherapy was as effective as multifraction radiotherapy in relieving metastatic bone pain. However, the re-treatment rate and pathological fracture rates were higher after single fraction radiotherapy. Studies with quality of life and health economic end points are warranted to find out the optimal treatment option.

A prospective trial of short-fractionation radiotherapy for the palliation of liver metastases

The purpose of this study was to prospectively examine the effectiveness and tolerability of a simple radiotherapy technique for the palliation of symptomatic liver metastases. Twenty-eight patients with symptomatic liver metastases were enrolled from seven centres, and received targeted (partial or whole) liver irradiation consisting of 10 Gy in two fractions over 2 days. Symptoms at baseline were hepatic pain (27 patients), abdominal distension (19), night sweats (12), nausea (18) and vomiting (eight). Twenty-two patients (76%) had failed previous treatment with chemotherapy, hormonal therapy and/or high-dose steroids. Symptoms and potential toxicities were prospectively assessed at the time of treatment, then 2, 6 and 10 weeks later. Individual symptom response rates were 53-66% at 2 weeks. Partial or complete global symptomatic responses were noted in 15 patients (54%) overall. The treatment was well tolerated with two patients (7%) experiencing grade 3 toxicity (one vomiting and one diarrhoea); however, four patients reported temporary worsening of pain shortly after treatment. This simple and well-tolerated treatment achieves useful palliation.

Patient preference for radiotherapy fractionation schedule in the palliation of painful bone metastases

PURPOSE

The radiotherapeutic management of painful bone metastases is controversial, with several institutional and national guidelines advocating use of single-fraction radiotherapy. We aimed to determine patient choice of fractionation schedule after involvement in the decision-making process by use of a decision board.

PATIENTS AND METHODS

Advantages and disadvantages of two fractionation schedules (24 Gy in six fractions v 8 Gy in one fraction) used in the randomized Dutch Bone Metastasis Study were discussed with patients using a decision board. Patients were asked to choose a fractionation schedule, to give reasons for their choice, and to indicate level of satisfaction with being involved in decision making.

RESULTS

Sixty-two patients were entered. Eighty-five percent (95% confidence interval, 74% to 93%) chose 24 Gy in six fractions over 8 Gy in one fraction (P <.0005). Variables including age, sex, performance status, tumor type, pain score, and paying class were not significantly related to patient choice. Multiple fractionation was chosen for lower re-treatment rates (92%) and fewer fractures (32%). Single-fraction treatment was chosen for cost (11%) and convenience (89%). Eighty-four percent of patients expressed positive opinions about being involved in the decision-making process.

CONCLUSION

Decision board instruments are feasible and acceptable in an Asian population. The vast majority of patients preferred 24 Gy fractionated radiotherapy compared with a single fraction of 8 Gy. These results indicate the need for further research in this important area and serve to remind both clinicians and national or institutional policy makers of the importance of individual patient preference in treatment decision making.

Quality assurance experience with the randomized neuropathic bone pain trial (Trans-Tasman Radiation Oncology Group, 96.05)

BACKGROUND AND PURPOSE

Trans-Tasman Radiation Oncology Group 96.05 is a prospective randomized controlled trial comparing a single 8 Gy with 20 Gy in five fractions of radiotherapy (RT) for neuropathic pain due to bone metastases. This paper summarizes the quality assurance (QA) activities for the first 234 patients (accrual target 270).

MATERIALS AND METHODS

Independent audits to assess compliance with eligibility/exclusion criteria and appropriateness of treatment of the index site were conducted after each cohort of approximately 45 consecutive patients. Reported serious adverse events (SAEs) in the form of cord/cauda equina compression or pathological fracture developing at the index site were investigated and presented in batches to the Independent Data Monitoring Committee. Finally, source data verification of the RT prescription page and treatment records was undertaken for each of the first 234 patients to assess compliance with the protocol.

RESULTS

Only one patient was found conclusively not to have genuine neuropathic pain, and there were no detected 'geographical misses' with RT fields. The overall rate of detected infringements for other eligibility criteria over five audits (225 patients) was 8% with a dramatic improvement after the first audit. There has at no stage been a statistically significant difference in SAEs by randomization arm. There was a 22% rate of RT protocol variations involving ten of the 14 contributing centres, although the rate of major dose violations (more than +/-10% from protocol dose) was only 6% with no statistically significant difference by randomization arm (P=0.44).

CONCLUSIONS

QA auditing is an essential but time-consuming component of RT trials, including those assessing palliative endpoints. Our experience confirms that all aspects should commence soon after study activation.

Meta-analysis of dose-fractionation radiotherapy trials for the palliation of painful bone metastases

PURPOSE

To compare pain relief among various dose-fractionation schedules of localized radiotherapy (RT) in the treatment of painful bone metastases.

METHODS AND MATERIALS

A systematic search for randomized trials of localized RT on bone metastases using different dose fractionations was performed using Medline (1966 to February 2001) and other sources. The primary outcomes of interest were complete and overall pain relief. The studies were divided into three groups: comparisons of doses given as a single fraction, single vs. multiple fractions, and comparisons of doses given as multiple fractions. The complete and overall pain responses for studies comparing single vs. multiple fractions were pooled. Exploratory analyses of the dose-response relationship, using the biologic effective dose (alpha/beta = 10), were performed using results from all three groups of trials.

RESULTS

Two trials comparing single vs. single, eight trials comparing single vs. multiple, and six trials comparing multiple vs. multiple fractions were included. The complete and overall response rates from studies comparing single-fraction RT (median 8 Gy, range 8-10 Gy) against multifraction RT (median 20 Gy in 5 fractions, range 20 Gy in 5 fractions to 30 Gy in 10 fractions) were homogeneous and allowed pooling of data. Of 3260 randomized patients in seven studies, 539 (33.4%) of 1613 and 523 (32.3%) of 1618 patients achieved a complete response after single and multifraction RT, respectively, giving a risk ratio of 1.03 (95% confidence interval 0.94-1.14; p = 0.5). The overall response rate was in favor of single-fraction RT (1011 [62.1%] of 1629) compared with multifraction (958 [58.7%] of 1631; risk ratio 1.05, 95% confidence interval 1.00-1.11, p = 0.04), reaching statistical significance. However, when the analysis was restricted to evaluated patients alone, the overall response rates were similar for single fraction and multifraction RT, at 1011 (72.7%) of 1391 and 958 (72.5%) of 1321, respectively (risk ratio 1.00; p = 0.9). Exploratory analyses by biologic effective dose did not reveal any dose-response relationship among the fractionation schedules used (single 8 Gy to 40 Gy in 15 fractions). Of the other results and observations reported in the trials, only the re-irradiation rates were consistently different between the treatment arms (more frequent re-irradiation in lower dose arms among trials reporting re-irradiation rates).

CONCLUSION

Meta-analysis of reported randomized trials shows no significant difference in complete and overall pain relief between single and multifraction palliative RT for bone metastases. No dose-response relationship could be detected by including data from the multifraction vs. multifraction trials. Additional data are needed to evaluate the role of re-irradiation and the impact of RT on other treatment end points such as quality of life.

Single- versus multiple-fraction radiotherapy in patients with painful bone metastases: cost-utility analysis based on a randomized trial

BACKGROUND

Radiotherapy is an effective palliative treatment for cancer patients with painful bone metastases. Although single- and multiple-fraction radiotherapy are thought to provide equal palliation, which treatment schedule provides better value for the money is unknown. We compared quality-adjusted life expectancy (the overall valuation of the health of the patients) and societal costs for patients receiving either single- or multiple-fraction radiotherapy.

METHODS

A societal cost-utility analysis was performed on a Dutch randomized, controlled trial of 1157 patients with painful bone metastases that compared pain responses and quality of life from a single-fraction treatment schedule of 8 Gy with a treatment schedule of six fractions of 4 Gy each. The societal values of life expectancies were assessed with the EuroQol classification system (EQ-5D) questionnaire. A subset of 166 patients also answered additional questionnaires to estimate nonradiotherapy and nonmedical costs. Statistical tests were two-sided.

RESULTS

Comparing the single- and multiple-fraction radiotherapy schedules, no differences were found in life expectancy (43.0 versus 40.4 weeks, P =.20) or quality-adjusted life expectancy (17.7 versus 16.0 weeks, P =.21). The estimated cost of radiotherapy, including retreatments and nonmedical costs, was statistically significantly lower for the single-fraction schedule than for the multiple-fraction schedule ($2438 versus $3311, difference = $873, 95% confidence interval [CI] on the difference = $449 to $1297; P<.001). The estimated difference in total societal costs was larger, also in favor of the single-fraction schedule, but it was not statistically significant ($4700 versus $6453, difference = $1753, 95% CI on the difference = -$99 to $3604; P =.06). For willingness-to-pay between $5000 and $40 000 per quality-adjusted life year, the single-fraction schedule was statistically significantly more cost-effective than the multiple-fraction schedule (P< or =.05).

CONCLUSIONS

Compared with multiple-fraction radiotherapy, single-fraction radiotherapy provides equal palliation and quality of life and has lower medical and societal costs, at least in The Netherlands. Therefore, single-fraction radiotherapy should be considered as the palliative treatment of choice for cancer patients with painful bone metastases.

Prospective patient-based assessment of effectiveness of palliative radiotherapy for bone metastases

PURPOSE

The primary objective of this report is to prospectively evaluate pain control provided by palliative radiotherapy for all irradiated patients with bone metastases by using their own assessments.

MATERIALS AND METHODS

A prospective database was set up for all patients referred for palliative radiotherapy for bone metastases. Patients were asked to rate their pain intensity using an 11 categorical point scale (0=lack of pain, 10=worst pain imaginable). Analgesic consumption during the preceding 24 h was recorded and converted into equivalent total daily dose of oral morphine. For those who received radiotherapy, follow-up was conducted via telephone interviews at week 1, 2, 4, 8 and 12 post treatment using the same pain scale and analgesic diary. Radiotherapy outcome was initially assessed by pain score alone. Complete response (CR) was defined as a pain score of 0. Partial response (PR) was defined as a reduction of score > or =2 or a> or =50% reduction of the pre-treatment pain score. We further analyzed outcomes using integrated pain and analgesic scores. Response was defined as either a reduction of pain score > or =2 with at least no increase in analgesics or at least stable pain score with a > or =50% reduction in analgesic intake.

RESULTS

One hundred and five patients were treated with palliative radiotherapy. When response evaluation was by pain score alone, the PR rates at 2, 4, 8 and 12 weeks were 44, 42, 30 and 38%, respectively; while the CR rates were 24, 32, 31 and 29%, respectively. The overall response rate at 12 weeks was 67%. When assessed by the integrated pain and analgesic scores, the response rates were 50, 46, 43 and 43%, respectively.

CONCLUSION

The response rate in our patient population is comparable with those reported in clinical trials. This is important when counselling our patients on the expected effectiveness of radiotherapy outside of clinical trials. Our observations confirm the generalizability of the trials conducted to date. While randomized trials still remain the gold standard of research, observational studies can serve as useful adjuncts to randomized trials to confirm the efficacy and guide the design of new controlled trials.

[Gross tumor volume and clinical target volume in radiotherapy: bone metastasis]

Bone is one of the three most favored sites of solid tumor metastasis. Skeletal metastasis may be identified by four clinical imaging methods: plain film radiography, computed tomography scanning, radioisotope scanning, and magnetic resonance imaging. The dose per fraction, total dose, and anatomic distribution of the radiation (dosimetry) are important factors in determining the efficacy and normal tissue tolerance to radiotherapy. Controversies about fractionation of palliative radiotherapy for bone metastasis are steel ongoing. The most commonly used schedules are a single treatment of 8 Gy, 30 Gy in 10 fractions and 20 Gy in 5 fractions. Treatment volumes and safety margins depend on the location and the extent of the bone metastasis, and are also determined by the symptoms felt by the patient.