Updated Guideline for Palliative Radiotherapy for Bone Metastases

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Bone metastases can cause pain, as well as pathologic fracture and spinal cord compression.
Bone metastases can cause pain, as well as pathologic fracture and spinal cord compression.

An update to the American Society for Radiation Oncology (ASTRO) guideline for palliative radiotherapy for bone metastases reflects recent evidence that continues to support the efficacy and safety of palliative radiation therapy for this indication. The update was published in Practical Radiation Oncology.1

Bone metastases can cause pain as well as pathologic fracture and spinal cord compression, and may successfully be treated with radiation therapy, which  is associated with acceptable short-term and long-term toxicity profiles.1-3 In some patients, the pain relief provided by radiation therapy is sufficient to eliminate the need for narcotics.2

The 2011 ASTRO guideline for palliative radiotherapy for bone metastases provided recommendations based on available evidence and expert opinion.4 As part of a formal review process, the panel assembled to formulate updated guidelines and re-evaluate the 2011 recommendations in a systematic review of recent high-quality data.

A total of 20 randomized controlled trials (RCTs), 32 prospective nonrandomized studies, and 4 meta-analyses were included for analysis.

The findings of this review confirm that single-fraction radiotherapy is as effective for treating painful spine lesions as a more prolonged radiotherapy course. Single-fraction therapy has acceptable long-term toxicity that is unlikely to limit its use, although it is unclear whether it increases the risk for pathologic fracture compared with fractionated therapy.

External beam radiation therapy (EBRT) is effective as retreatment for recurrent pain from spine lesions, according to results from a meta-analysis and an RCT.

The evidence also supports the recommendation that “the use of surgery, radionuclides, bisphosphonates, or kyphoplasty/vertebroplasty does not obviate the need for EBRT for patients with painful bone metastases.”

Limited data exist to support advanced radiation techniques such as stereotactic body radiation therapy, which the panel recommends using only in the setting of a clinical trial or registry data collection.

Summary and Clinical Applicability

An update to the 2011 ASTRO guideline for palliative radiotherapy for bone metastases found that the efficacy and safety of palliative radiotherapy for this indication are supported by recent high-quality data. The update panel made no significant changes to the 2011 guideline recommendations.

“Although adherence to evidence-based medicine is critical, thorough expert radiation oncology physician judgment and discretion regarding number of fractions and advanced techniques are also essential to optimize outcomes when considering the patient's overall health, life expectancy, comorbidities, tumor biology, anatomy, previous treatment including prior radiation at or near current site of treatment, tumor and normal tissue response history to local and systemic therapies, and other factors related to the patient, tumor characteristics, or treatment,” the panel wrote.

Limitations and Disclosures

The recommendations for EBRT for retreatment of spine lesions were reaffirmed based on a single meta-analysis and a single RCT.

No new high-quality data were available regarding surgical spinal decompression plus EBRT or kyphoplasty/vertebroplasty plus EBRT.

Several panel members report financial relationships with Templeton Foundation, Elekta, Accuray, and Varian.

References

  1. Lutz S, Balboni T, Jones J, et al. Palliative radiation therapy for bone metastases: update of an ASTRO evidence-based guideline. Pract Radiat Oncol. 2017;7(1):4-12. doi:10.1016/j.prro.2016.08.001
  2. Hartsell WF, Scott CB, Bruner DW, et al. Randomized trial of short- versus long-course radiotherapy for palliation of painful bone metastases. J Natl Cancer Inst. 2005;97(11):798-804. doi:10.1093/jnci/dji139
  3. Howell DD, James JL, Hartsell WF, et al. Single-fraction radiotherapy versus multifraction radiotherapy for palliation of painful vertebral bone metastases-equivalent efficacy, less toxicity, more convenient: a subset analysis of Radiation Therapy Oncology Group trial 97-14. Cancer. 2013;119(4):888-896. doi:10.1002/cncr.27616
  4. Lutz S, Berk L, Chang E, et al; American Society for Radiation Oncology (ASTRO). Palliative radiotherapy for bone metastases: an ASTRO evidence-based guideline. Int J Radiat Oncol Biol Phys. 2011;79(4):965-976. doi:10.1016/j.ijrobp.2010.11.026

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