International Journal of Radiation Oncology*Biology*Physics
ASTRO GuidelinePalliative Radiotherapy for Bone Metastases: An ASTRO Evidence-Based Guideline
Introduction
Bone metastases are a common manifestation of malignancy that can cause severe and debilitating effects, including pain, spinal cord compression, hypercalcemia, and pathologic fracture. The proper care of bone metastasis patients requires interdisciplinary care among radiologists, radiation oncologists, medical oncologists, surgeons, pain medicine specialists, and palliative care professionals. Radiotherapy (RT) provides successful palliation of painful bone metastasis that is time efficient and has been associated with very few side effects. External beam RT (EBRT) can provide significant palliation of painful bone metastases in 50–80% of patients, with up to one-third of patients achieving complete pain relief at the treated site (1).
Widespread variation exists in the worldwide practice patterns for palliative radiation dose fractionation schedules (2). Numerous prospective randomized and retrospective trials have shown similar pain relief outcomes with single-fraction RT schedules compared with longer courses of palliative RT for previously unirradiated bone metastases, with the main advantages to the schedules being the increased convenience with a single fraction and the lower repeat treatment rate with a longer course 1, 2. A wide range of radiotherapeutic options also exists for pain that has recurred after RT (EBRT or radiopharmaceutical agents) has been given for bone metastases. Among these options is a second course of EBRT to the same localized site (repeat RT). Also, painful bone lesions at several anatomic sites have been treated with injectable radiopharmaceutical agents or hemibody RT, depending on the tumor histologic features and the distribution of the metastases. Additionally, great interest has been devoted to the question of whether technological advances in RT delivery, such as stereotactic body RT (SBRT), could improve the results of the primary treatment or repeat treatment of metastatic spinal lesions. The circumstances of spinal cord compression with complete or impending pathologic fracture demand a coordinated care plan between surgeons and radiation oncologists. Although clinical trials with bisphosphonates initially considered the need for EBRT as a failure of therapy endpoint, EBRT to the index symptomatic lesion might provide more prompt and durable symptom relief. Finally, EBRT should be used in conjunction with both kyphoplasty and vertebroplasty in patients who have been treated with these interventions for spinal metastases.
Given the complexities of care for patients with bone metastases and the relative lack of palliative RT guidelines formulated to date, the American Society for Radiation Oncology (ASTRO) Clinical Affairs and Quality Committee convened a Task Force of experts to develop a Guideline regarding the care of patients with bone metastases 3, 4, 5, 6. The recommendations have been based on the results of a systematic data review combined with the expert opinions of the Task Force members. The Guideline is presented herein.
Section snippets
Process
The Guidelines Subcommittee of the Clinical Affairs and Quality Committee, in accordance with established ASTRO policy, recruited a Task Force composed of recognized experts in the fields of palliative RT for bone metastases. These experts represented radiation oncology academic, private practice, and residency groups, as well as neurosurgery and palliative medicine specialties. The Task Force was asked to provide guidance on the use of palliative RT for bone metastases to patients and
Results
The questions and Guideline statements regarding the use of palliative RT for bone metastases are listed below.
1) What fractionation schemes have been shown to be effective for the treatment of painful and/or prevention of morbidity from peripheral bone metastases?
Guideline statement
Multiple prospective randomized trials have shown pain relief equivalency for dosing schema, including 30 Gy in 10 fractions, 24 Gy in 6 fractions, 20 Gy in 5 fractions, and a single 8-Gy fraction for patients with
Conclusions
External beam radiotherapy has been, and continues to be, the mainstay for the treatment of painful, uncomplicated bone metastases. Although various fractionation schemes can provide good rates of palliation, numerous prospective randomized trials have shown that 30 Gy in 10 fractions, 24 Gy in 6 fractions, 20 Gy in 5 fractions, or 8 Gy in a single fraction can provide excellent pain control and minimal side effects. The longer course has the advantage of a lower incidence of repeat treatment
Acknowledgments
The authors thank Drs. Nora Janjan, Peter Johnstone, Daniel Roos, Yvette van der Linden, and Ivy Petersen for their critical review of this report. The authors would also like to recognize the significant contributions made to the literature search by Anushree Vichare, Shari Siuta, Barbara Muth, and Beverly Woodward.
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This document was prepared by the Guidelines Subcommittee of the Clinical Affairs and Quality Committee of the American Society for Radiation Oncology (ASTRO) in coordination with the Third International Consensus Conference on Palliative Radiotherapy.
Before the initiation of this Guideline, all members included on the Task Force were required to complete conflict of interest statements. These statements are maintained at ASTRO Headquarters in Fairfax, VA, and pertinent conflict information has been published with the report. Individuals with disqualifying conflicts were recused from participation in this Guideline.
The ASTRO Guidelines present scientific, health, and safety information and might to some extent reflect scientific or medical opinion. They are made available to ASTRO members and to the public for educational and informational purposes only. Any commercial use of any content in this Guideline without the previous written consent of ASTRO is strictly prohibited.
Adherence to this Guideline will not ensure successful treatment in every situation. Furthermore, this Guideline should not be deemed inclusive of all proper methods of care or exclusive of other methods of care reasonably directed to obtaining the same results. The ultimate judgment and propriety of any specific therapy must be made by the physician and the patient in light of all the circumstances presented by the individual patient. ASTRO assumes no liability for the information, conclusions, and findings contained in its Guidelines. In addition, this Guideline cannot be assumed to apply to the use of these interventions performed in the context of clinical trials, given that clinical studies are designed to evaluate or validate innovative approaches in a disease for which improved staging and treatment are needed or are being explored.
This Guideline was prepared on the basis of information available at the time the Task Group was conducting its research and discussions on this topic. There might be new developments that are not reflected in this Guideline and that might, over time, be a basis for ASTRO to consider revisiting and updating the Guideline.
A. Sahgal and E. Chang have served as consultants to Medtronic Kyphoplasty, although that relationship has ended and the authors did not participate in either the writing or reviewing of the kyphoplasty section of this report. L. Kachnic serves as a consultant to Soligenics. D. Howell serves as a consultant to Web MD and Medscape. S. Lutz has stock ownership in Tosk, Oculus, and Minerva. C. von Gunten has received funding from Wyeth, Progenics, Baxter, and Halozyme. W. Hartsell has a partnership relationship with CPTI. P. Hoskin has received funding from Varian Medical Systems and Nucleotron. E. Chow has received research funding and teaching honorarium from Novartis and Amgen. D. Watkins Bruner has received funding from Varian Medical Systems. The Task Force reviewed these disclosures and determined that they have no impact upon the content of the report.