Patterns of fractionation for palliation of bone metastases

[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.

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

PURPOSE

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Use of single- versus multiple-fraction palliative radiation therapy for bone metastases: population-based analysis of 16,898 courses in a Canadian province

PURPOSE

There is abundant evidence that a single fraction (SF) of palliative radiation therapy (RT) for bone metastases is equivalent to more protracted and costly multiple fraction courses. Despite this, there is low utilization of SFRT internationally. We sought to determine the utilization of SFRT in a population-based, publicly funded health care system.

METHODS AND MATERIALS

All consecutive patients with bone metastases treated with RT during 2007 to 2011 in British Columbia (BC) were identified. Associations between utilization of SFRT and patient and provider characteristics were investigated.

RESULTS

A total of 16,898 courses of RT were delivered to 8601 patients. SFRT was prescribed 49% of the time. There were positive relationships among SFRT utilization and primary tumor group (P<.001; most commonly in prostate cancer), worse prognosis (P<.001), increasing physician experience (P<.001), site of metastases (P<.001; least for spine metastases), and area of training (P<.001; most commonly for oncologists trained in the United Kingdom). There was wide variation in the prescription of SFRT across 5 regional cancer centers, ranging from 25.5% to 73.4%, which persisted after controlling for other, potentially confounding factors (P<.001).

CONCLUSIONS

The large variability in SFRT utilization across BC Cancer Agency (BCCA) cancer centers suggests there is a strong cultural effect, where physicians' use of SFRT is influenced by their colleagues' practice. SFRT use in BC was similar to that in other Canadian and western European reports but strikingly higher than in the United States. Further work is needed to standardize SFRT prescribing practices internationally for this common indication for RT, with the potential for huge health system cost savings and substantial improvements in patients' quality of life.

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.

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.

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.

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.

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.

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.

Primary treatment endpoint following palliative radiotherapy for painful bone metastases: need for a consensus definition?

OBJECTIVES

To compare and contrast the definitions of primary treatment endpoints in randomized studies of dose-fractionation schedules for treating bone metastases and to identify basic characteristics of treatment endpoint that may require consensus among investigators.

METHODS

Randomized controlled trials (RCTs) of various dose-fractionation schedules for painful bone metastases, published between 1980 and 1999, and on-going trials whose protocols were available, were systematically reviewed based on the following features of the primary treatment endpoint: (i) degree of pain relief; (ii) timing of the pain response assessment; (iii) effect of co-interventions on pain relief; (iv) the reduction of analgesic as a treatment response; and (v) quantification of response duration.

RESULTS

Ten published RCTs (each sampled over 100 patients), plus two current trial protocols were reviewed. Five of the 12 studies defined any reduction in pain score as the primary endpoint. Three trials defined response at pre-determined time points, whereas eight studies attributed pain improvement at any time during follow-up to the effect of radiotherapy. No trial incorporated effect of systemic treatments on response. Only two trials incorporated analgesic scores into the primary endpoint criteria, although several trials reported results of combined pain and analgesic relief. Eight trials reported duration of response. Three provided some estimation of duration with respect to survival: two of them employing actuarial time to pain progression, and one calculated the ratio of pain response to median survival duration (percent net relief). Quality of life was measured in four of 12 studies, as secondary endpoint.

CONCLUSION

Although available data suggest similarity in pain relief among various dose-fractionation schedules, accurate and consistent description of the degree of benefit from radiotherapy is lacking. While pain relief is a consistent primary treatment goal among randomized trials, a consensus on several important features of treatment endpoint is needed in order to establish common grounds for future trials in palliative radiotherapy.

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.

Palliative radiotherapy of bone metastases: an evaluation of outcome measures

The objective of this study was to identify and evaluate important patient-based outcomes that are specific to the palliative radiotherapy of bone metastases. We first conducted a literature review to identify and evaluate outcomes that are currently in use. To identify outcomes that are important to patients, in-depth patient interviews were conducted. Finally, issues identified through the interviews were quantified through a prospective survey, in which patients completed a questionnaire prior to commencing radiotherapy and again after 6 weeks. In our literature review, we found that there was no standardized definition of either response to radiotherapy or assessment of pain relief. Pain measurement in many studies was undertaken using very simple measures, which could possibly yield inaccurate results. The vast majority of studies did not include quality of life as an endpoint. The patient interviews and survey showed that chronic pain and associated limitation of movement were the disease symptoms causing the most concern. Having a clear, alert mind and being able in self-care were the aspects of daily living given the highest priority. Sustained pain relief and minimizing the risk of future complications were the main priorities relating to radiotherapy treatment. The practical aspects of treatment (travelling distance, remaining at home and brevity of treatment) were of least importance. This study indicates the complexity of evaluating the outcomes of palliative interventions, and confirms the deficiencies of pain relief as the primary end-point. The patient's quality of life is affected by many factors other than pain (such as limited mobility, reduced performance, side effects and impaired role functioning); hence a wider range of end-points is required. Greater sensitivity is required than in currently used end-points. Concurrent diseases as well as concurrent therapies can make it difficult to attribute effects with precision. Unless such factors are considered in research design, the results may prove unreliable.

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

PURPOSE

To survey Australian and New Zealand (ANZ) radiation oncologists on their preferred fractionation regimens for pain due to bone metastases in the context of similar overseas surveys and the large body of evidence from randomized trials.

METHODS

Delegates to the October 1998 Royal ANZ College of Radiologists Annual Scientific Meeting were asked to state their fractionation for four hypothetical cases viz. local bone pain from metastatic breast, prostate and lung cancer and neuropathic (radicular) pain from metastatic lung cancer. In addition to demographic data, respondents were asked to select reasons for their choices and indicate what factors would influence a change in their recommended fractionation.

RESULTS

Twelve of 32 trainees and 41 of 82 specialists completed the survey, giving an overall response rate of 46%. There was decreasing use of shorter fractionation schedules from lung through prostate to breast cancer with, in particular, single fractions recommended by, respectively, 42, 28 and 15% of respondents for local bone pain (P=0.013). However, the presence of neuropathic pain from metastatic lung cancer led to lower use of single fractions (15%, P=0.0046). There were no statistically significant differences in preferred fractionation with respect to other variables assessed in this survey. The commonest reasons cited for fractionating were desire to minimize recurrent pain and the influence of training, with desire to minimize the risk of neurological progression and optimize tumour regression also important for neuropathic pain. By contrast, use of single fractions was most commonly based upon literature results and patient convenience. Changing from multiple to single fractions was most influenced by poor performance status, while the presence of neurological signs/symptoms had the reverse effect.

CONCLUSIONS

The findings from this ANZ survey largely reflect the results from other surveys performed in the UK, Europe, Canada and USA. Although debate continues in the literature, the continuing preference of radiation oncologists to fractionate for local bone pain is contrary to the 16 randomized trials published to date which give little support for a dose-response relationship above a single 6-8 Gy in this setting. This practice has significant implications for departmental workload, costs to the healthcare system and patient convenience. There is no objective evidence on the influence of fractionation for neuropathic bone pain in the literature at present, although an ANZ randomized trial addressing this problem is under way (TROG 96.05).

A role for radiotherapy in neuropathic bone pain: preliminary response rates from a prospective trial (Trans-tasman radiation oncology group, TROG 96.05)

PURPOSE

Radiotherapy (RT) has a proven role in palliation of pain from bone metastases with numerous randomized trials obtaining response rates (RRs) of typically 70-80% regardless of the fractionation employed. However RT for neuropathic bone pain (NBP), i.e., pain with a radiating cutaneous component due to compression/irritation of nerves by tumor has not previously been studied, and its role is thus uncertain.

METHODS AND MATERIALS

In February 1996, the Trans-Tasman Radiation Oncology Group (TROG) initiated a multicenter randomized trial comparing a single 8 Gy fraction with 20 Gy in 5 fractions for NBP with an accrual target of 270. Formal interim analyses were planned at 90 and 180 patients. The 90th patient was accrued in June 1998, and data from the first interim analysis with both arms combined form the basis of this report.

RESULTS

Forty-four patients were randomized to a single 8 Gy, 46 to 20 Gy in 5 fractions. The commonest primary sites were prostate (34%), lung (28%) and breast (10%). Median age was 68 years (range 37-89). The index site was spine (86%), rib (13%), base of skull (1%). On an intention-to-treat basis, the overall RR was 53/90 = 59% (95% CI = 48-69%), with 27% achieving a complete response and 32% a partial response. The overall RR for eligible patients was 49/81 = 60% (95% CI = 49-71%) with 27% and 33% achieving complete and partial responses respectively. Estimated median time to treatment failure was 3.2 months (95% CI = 2.1-5.1 months), with estimated median survival of 5.1 months (95% CI = 4.2-7.2 months). To date, six spinal cord/cauda equina compressions and four new or progressive pathological fractures have been detected at the index site after randomization, although one cord compression occurred before radiotherapy was planned to commence. In February 1999, the Independent Data Monitoring Committee strongly recommended continuation of the trial.

CONCLUSION

Although these results are preliminary, it seems clear that there is indeed a role for RT in the treatment of NBP. Analysis of outcome by treatment arm awaits completion of the randomized trial.

Radiotherapy for bone metastases: a critical appraisal of outcome measures

Pain from bone metastases is a common problem in patients with advanced cancer, and radiotherapy plays an important role in its palliation. Single fraction treatments are often prescribed, but there is no clear consensus on this issue and clinical practice shows significant variability. This situation is unsatisfactory for all patients--the patient, the clinician, and the health care administrator. Randomized trials may use poor outcome measures and this contributes to practice variability. The credibility of outcome studies is often reduced due to poor study design, small sample sizes, and the use of endpoints that are both unreliable and unsuitable. The endpoints used have been narrowly defined, the patient's perspective has generally been overlooked, and quality of life has only once been used as an endpoint. A review of the current literature suggests that instruments specific to bone metastases are required. These must be based on patient experience, and rely on self-report. In addition, there is a need to understand the relative priority that patients attribute to treatment outcomes. The use of better instruments and methodologies in future trials will enhance the credibility of results and reduce practice variations.

Symptom duration and delay in referral for palliative radiotherapy in cancer patients: a pilot study

OBJECTIVE

To estimate the frequency of delay in referral for palliative radiotherapy (PRT), and to identify factors associated with delay.

DESIGN

Prospective survey over three months in 1997.

SETTING

Radiotherapy department of a cancer centre in Melbourne, Victoria.

PARTICIPANTS

158 consecutive patients prescribed PRT in the lung, breast, urology and haematology units.

MAIN OUTCOME MEASURES

Duration of symptoms; incidence of "unreasonable" delay in referral; and incidence of negative clinical outcome associated with referral delay.

RESULTS

The median duration of symptoms before prescription of radiotherapy was four weeks. Thirty-eight patients (24%) were considered to have had an unreasonable delay in referral, with median symptom duration of 15 weeks, and median delay in referral of 12 weeks. Causes of delay were classified as "diagnostic uncertainty" (29%), "other treatment given" (18%), "patient related" (18%), "language difficulty" (3%), and "unexplained" (32%). Twenty-seven of these 38 patients (71%) had negative outcomes, including persistent pain, neurological deterioration and persistent respiratory symptoms.

CONCLUSIONS

These data suggest that delay in referral for PRT is not uncommon, has a variety of causes and can result in negative clinical outcomes. There appears to be a need for greater awareness of patients' symptoms and of the role of PRT among clinicians caring for patients with cancer.

Audit in radiation therapy: long-term survival and cost of treatment

In order to determine the cost of radiation treatment and the survival rate of a cohort of patients treated in a 6-month period in 1988, estimates of the capital and recurrent costs of this service were made for the calendar year 1988, expressed as $A(1988). Data collected prospectively included workload statistics, including number of attendances, field treated and complexity of treatment. Patient and tumour-related data included tumour site, intent of treatment and survival. The survival rate of patients during this period was determined in June 1995. The cost per field in 1988 was estimated at $A44.32. The 1988 costs of courses of definitive, adjuvant and palliative radiation therapy were estimated at $A2545, $A2482 and $A929, respectively. The major contributor to the cost was salaries and consumables within the Radiation Oncology Department (81.6%), with capital costs accounting for 13.5%, overheads accounting for 4.5% of the costs and planned admissions accounting for 0.2%. The median survival time of 580 patients with malignant disease treated during this period in 1988 was 12.4 months. The overall 5-year survival rate was 27%. For 105 patients treated definitively with radiation therapy, the median and 5-year survival rate figures were 26.0 months and 40%. For 149 patients treated with adjuvant radiation therapy, the 5-year survival rate was 62% (median survival rate not reached). For 279 patients treated palliatively, median and 5-year survival rate figures were 5.2 months and 3%. The cost per month of survival for all patients with malignancy was $A67, the figures for definitive, adjuvant and palliative treatments being $A74, $A48 and $A105, respectively. A sensitivity analysis indicated that these figures were robust. The cost of radiation treatment per field was comparable to reports for other centres and emphasizes the utility of radiation therapy as a cost-effective cancer treatment modality. With increasing pressure on treatment facilities in the public sector, further cost/benefit analysis is required to optimize the use of restricted resources.

Clinical audit in radiation oncology: results from one centre

This study aims to determine workload statistics and to document patterns of fractionation in a single centre in two time periods separated by 4 years. Patient, tumour and treatment-related data were collected for courses of radiation treatment that were commenced within two 6-month periods in both 1988 and 1993. In both time periods, 45-49% of patients were treated with curative intent. Of these, one-third were irradiated definitively and two-thirds in an adjuvant setting. Most of the remainder were treated with palliative intent. A few were treated for non-neoplastic conditions. The re-treatment rate in 1993 was 13%. In both time periods, breast and lung tumours represented approximately 20% each of the total treatment courses. Skin, head and neck, gynaecological, urological and haematological primary tumours accounted for 5-10% each. Treatment intents differed markedly for different primary sites. For example, in 1993 65% of patients with breast primaries were treated curatively compared with 6% of patients with lung primaries. Treatment schedules for curative intent were similar in both time periods and for the majority of treatment sites. Median fraction numbers were 25 (excluding skin primaries), reflecting conventional daily fractionation. Treatment schedules for palliation showed greater variation and there was a trend towards shorter treatment courses in 1993. For palliative treatment of bone, brain and lung, from either primary or metastatic disease, treatment schedules with 10-15 fractions were used most frequently in 1988. In 1993, however, the majority of patients received 1-5 fractions. In 1993, the breakdown of techniques according to treatment intent showed that for treatment with curative intent, single, parallel opposed and more complex field arrangements were used in 27% (includes skin primaries), 12% and 61% of treatment courses, respectively, compared with 29%, 59% and 12%, respectively, for palliative treatment courses. In 1993, one-third of patients receiving radiation treatment lived in the local health area. Patients living in areas with rural postcodes were more likely to receive palliative irradiation and had a higher incidence of melanoma than patients living in areas with Sydney metropolitan postcodes. As approximately 50% of patients were treated with palliative intent, changes in the fractionation patterns used can alter significantly the utilization and availability of megavoltage equipment. However, any reduction in attendances caused by hypofractionation for palliation may be offset by the trend to use hyperfractionation for curative treatments. The data support the hypothesis of reduced availability and use of radiation therapy in patients with cancer from rural areas.