Patterns of practice in palliative radiotherapy for painful bone metastases: a survey in Japan. Int J Radiat Oncol Biol Phys. 2012;83:e117-e120. [PMID: 22381902 DOI: 10.1016/j.ijrobp.2011.11.075]

Multi-institutional prospective observational study of radiotherapy for metastatic bone tumor

Purpose of this study is to evaluate patient characteristics, treatments and outcomes in bone metastasis radiotherapy practice. Patients for whom radiotherapy for bone metastasis was planned at 26 institutions in Japan between December 2020 and March 2021 were consecutively registered in this prospective, observational study. Study measures included patient characteristics, pain relief, skeletal-related events (SREs), overall survival and incidence of radiation-related adverse events. Pain was evaluated using a numerical rating scale (NRS) from 0 to 10. Irradiated dose was analyzed by the biologically effective dose (BED) assuming α/β = 10. Overall, 232 patients were registered; 224 patients and 302 lesions were fully analyzed. Eastern Cooperative Oncology Group Performance Status was 0/1/2/3/4 in 23%/38%/22%/13%/4%; 59% of patients had spinal metastases and 84% had painful lesions (NRS ≥ 2). BED was <20 Gy (in 27%), 20-30 Gy (24%), 30-40 Gy (36%) and ≥ 40 Gy (13%); 9% of patients were treated by stereotactic body radiotherapy. Grade 3 adverse events occurred in 4% and no grade 4-5 toxicity was reported. Pain relief was achieved in 52% at 2 months. BED is not related to pain relief. The cumulative incidence of SREs was 6.5% (95% confidence interval (CI) 3.1-9.9) at 6 months; no factors were significantly associated with SREs. With spinal lesions, 18% of patients were not ambulatory at baseline and 50% of evaluable patients in this group could walk at 2 months. The 6-month overall survival rate was 70.2% (95% CI 64.2-76.9%). In conclusion, we report real-world details of radiotherapy in bone metastasis.

Factors associated with quality of life in patients receiving palliative radiotherapy for bone metastases: a secondary cross-sectional analysis of data from a prospective multicenter observational study

OBJECTIVE

To identify factors significantly associated with quality of life (QOL) and determine if these associations are strong enough to predict certain aspects of QOL without measuring them.

METHODS

We conducted an exploratory secondary analysis of baseline data of 224 patients (enrolled between December 2020 and March 2021) from a previously published prospective observational study on radiotherapy for bone metastases at 26 centres. Using univariable linear regression, we assessed the association between patient/treatment factors and QOL scale scores as measured by the European Organization for Research and Treatment of Cancer (EORTC) QOL Questionnaire Core 15-Palliative (QLQ-C15-PAL) and the EORTC QOL Questionnaire Bone Metastases module (QLQ-BM22).

RESULTS

Age and sex were not significantly associated with QOL. Worse performance status, higher pain scores, and opioid and single-fraction use were significantly associated with most QOL scales; these four factors were associated with worse global QOL, worse functioning status, and more severe symptoms. The coefficients of determination for most QOL scales were less than 0.2, indicating that most of the variability in QOL scores was not explained by any of the explanatory variables.

CONCLUSION

Performance status, pain intensity, and opioid and single-fraction use were significantly associated with most QOL scales. However, the associations were not strong enough to estimate QOL.

ADVANCES IN KNOWLEDGE

To date, the association between treatment factors and QOL in patients with bone metastases has not been fully studied. We identified the factors that were significantly associated with QOL and found that these associations were not strong enough to predict QOL.

Comparison of pain-relieving effects by number of irradiations, through propensity score matching and the international consensus endpoint

Background

Palliative radiotherapy for bone metastases utilizes various dose fractionation schedules. The pain-relieving effects of a single fraction (SF) and multiple fractions (MF) are largely debated due to the difficulty in matching patients' backgrounds and in assessing the effectiveness of pain relief. This study aimed to compare the pain-relieving effects of SF and MF palliative radiotherapy for bone metastases using propensity score matching and the international consensus endpoint (ICE).

Materials and methods

Our study included 195 patients irradiated for bone metastasis. The primary endpoint was the pain-relieving effects used by ICE. In addition, the evaluation was performed by using responder (complete response/partial response) and non-responder (pain progression/indeterminate response) categorization. The secondary endpoints were the discharge or transfer rate at one month after irradiation and postirradiation pathological fracture rate. Propensity score matching was used to adjust patient's characteristics and reduce selection bias.

Results

After adapting propensity score matching, the total number of patients was 74. There was no significant difference in the pain-relieving effects between SF and MF (p = 0.184). There were no significant differences in them between SF and MF when using responder and non-responder categorization (p = 0.163). Furthermore, there were no differences in the discharge or transfer rates (p = 0.693) and pathological fracture rates (p = 1.00).

Conclusions

The combination of propensity score matching and ICE revealed no significant difference in the pain-relieving effects between SF and MF for bone metastases, thus, SF has no significant disadvantage compared to MF in pain-relieving effects.

[Ethical stakes in palliative care in radiation oncology]

In 2021, the Ethics Commission of the SFRO has chosen the issue of the practice of palliative care in radiotherapy oncology. Radiation oncology plays a central role in the care of patients with cancer in palliative phase. But behind the broad name of palliative radiotherapy, we actually find a large variety of situations involving diverse ethical issues. Radiation oncologists have the delicate task to take into account multiple factors throughout a complex decision-making process. While the question of the therapeutic indication and the technical choice allowing it to be implemented remains central, reflection cannot be limited to these decision-making and technical aspects alone. It is also a question of being able to create the conditions for a singularity focused care and to build an authentic care relationship, beyond technicity. It is through this daily ethical work, in close collaboration with patients, and under essential conditions of multidisciplinarity and multiprofessionalism, that our fundamental role as caregiver can be deployed.

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.

Single-Fraction Stereotactic vs Conventional Multifraction Radiotherapy for Pain Relief in Patients With Predominantly Nonspine Bone Metastases: A Randomized Phase 2 Trial

Importance

Consensus is lacking as to the optimal radiotherapy dose and fractionation schedule for treating bone metastases.

Objective

To assess the relative efficacy of high-dose, single-fraction stereotactic body radiotherapy (SBRT) vs standard multifraction radiotherapy (MFRT) for alleviation of pain in patients with mostly nonspine bone metastases.

Design, Setting, and Participants

This prospective, randomized, single-institution phase 2 noninferiority trial conducted at a tertiary cancer care center enrolled 160 patients with radiologically confirmed painful bone metastases from September 19, 2014, through June 19, 2018. Patients were randomly assigned in a 1:1 ratio to receive either single-fraction SBRT (12 Gy for ≥4-cm lesions or 16 Gy for <4-cm lesions) or MFRT to 30 Gy in 10 fractions.

Main Outcomes and Measures

The primary end point was pain response, defined by international consensus criteria as a combination of pain score and analgesic use (daily morphine-equivalent dose). Pain failure (ie, lack of response) was defined as worsening pain score (≥2 points on a 0-to-10 scale), an increase in morphine-equivalent opioid dose of 50% or more, reirradiation, or pathologic fracture. We hypothesized that SBRT was noninferior to MFRT.

Results

In this phase 2 noninferiority trial of 96 men and 64 women (mean [SD] age, 62.4 [10.4] years), 81 patients received SBRT and 79 received MFRT. Among evaluable patients who received treatment per protocol, the single-fraction group had more pain responders than the MFRT group (complete response + partial response) at 2 weeks (34 of 55 [62%] vs 19 of 52 [36%]) (P = .01), 3 months (31 of 43 [72%] vs 17 of 35 [49%]) (P = .03), and 9 months (17 of 22 [77%] vs 12 of 26 [46%]) (P = .03). No differences were found in treatment-related toxic effects or quality-of-life scores after SBRT vs MFRT; local control rates at 1 and 2 years were higher in patients receiving single-fraction SBRT.

Conclusions and Relevance

Delivering high-dose, single-fraction SBRT seems to be an effective treatment option for patients with painful bone metastases. Among evaluable patients, SBRT had higher rates of pain response (complete response + partial response) than did MFRT and thus should be considered for patients expected to have relatively long survival.

Trial Registration

ClinicalTrials.gov identifier: NCT02163226.

Single- Versus Multiple-Fraction Radiation Therapy for Painful Bone Metastases: A Systematic Review and Meta-analysis of Nonrandomized Studies

PURPOSE

Single-fraction radiation therapy (RT) is a convenient and cost-effective regimen for the palliation of painful bone metastases, but is still underused. Randomized controlled trials comparing single- versus multiple-fraction RT are limited by generalizability. We compared the pain response rates after single- versus multiple-fraction RT in nonrandomized studies.

METHODS AND MATERIALS

We searched PubMed and Scopus from the inception of each database through August 2018. We sought to identify nonrandomized studies in which data on pain response rates could be extracted for single- and multiple-fraction RT. Our primary outcomes of interest were the overall and complete pain response rates in evaluable patients. The analysis was performed using a random-effects model with the Mantel-Haenszel method.

RESULTS

Of the 3933 articles identified through our search, 9 met our inclusion criteria. Five of 9 included studies did not exclude patients with features of complicated bone metastases. A 1 × 8 Gy radiation schedule was frequently used in single-fraction therapy, and schedules of 5 × 4 Gy and 10 × 3 Gy were frequently used in multiple-fraction therapy. In the 9 studies, the overall response rate was 67% (884 of 1321 patients) for patients in the single-fraction arm and 70% (953 of 1360 patients) for those in the multiple-fraction arm (pooled odds ratio [OR]: 0.85; 95% confidence interval [CI], 0.66-1.08). In 5 studies, the complete response rate was 26% (195 of 753 patients) for patients in the single-fraction arm and 35% (289 of 821 patients) for those in the multiple-fraction arm (pooled OR: 0.89; 95% CI, 0.70-1.13).

CONCLUSIONS

There were no significant differences in the overall and complete response rates between single- and multiple-fraction RT. The effectiveness of single-fraction regimens was shown in nonrandomized settings, which better reflect daily practice than randomized studies. The CIs for the pooled ORs included clinically meaningful differences, and the study results are inconclusive.

Stability and survival analysis of elderly patients with osteolytic spinal bone metastases after palliative radiotherapy : Results from a large multicenter cohort

Purpose

This retrospective study aimed to evaluate the stability and fracture rates of osteolytic spinal bone metastases (SBM) in elderly patients following palliative radiotherapy (RT) and to derive prognostic factors for stability and survival.

Methods

A total of 322 patients aged at least 70 years received palliative RT at two major German academic medical centers or at the German Cancer Research Center. Stability assessment was based on the validated Taneichi score prior to RT and at 3 and 6 months after RT. The survival time following RT was assessed, and prognostic factors for stability and survival were analyzed.

Results

Prior to RT, 183 patients (57%) exhibited unstable SBM and 68 patients (21%) pathological fractures. At 3 and 6 months after RT, significant recalcification and stabilization were evident in 19% (23/118) and 40% (31/78) of surviving patients, respectively. Only 17 patients (5%) experienced new pathological fractures following RT. Tumor histology was found to significantly influence stabilization rates with only breast cancer patients exhibiting increased stabilization compared to patients with other histologies. The median survival time and 6‑month survival rates following RT were 5.4 months (95% confidence interval 4.4–7.2 months) and 48%, respectively. The patients’ performance status was found to be the strongest predictor for survival after RT in this patient cohort; further factors demonstrating a significant association with survival were the application of systemic treatment, the number of SBM and the primary tumor histology. To analyze the influence of age on survival after RT, study patients were stratified into 3 age groups (i.e., 70–74 years, 75–79 years, and ≥80 years). The subgroup of patients aged at least 80 years showed a strong trend towards a worse survival time following RT compared to younger patients (i.e., 6‑month survival rate 39% vs. 51%; p = 0.06, log-rank test).

Conclusions

Prognostic factors influencing overall survival such as performance status and histology should guide the choice for palliative RT for SBM. Strongly hypofractionated RT regimes may be advisable for most elderly patients considering the overall poor prognosis in order to reduce hospitalization times.

[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.

Fracture after radiation therapy for femoral metastasis: incidence, timing and clinical features

We analyzed 428 femoral metastases initially treated with radiotherapy between 2002 and 2011 to clarify the clinical details of post-irradiation fractures of femoral metastasis. Patients included 161 men and 167 women, with a mean age of 62 years. Fracture incidence, fracture site, fracture risk based on X-ray images before radiotherapy, and interval from completion of radiotherapy to fracture occurrence were assessed. In addition, 24 pathological specimens obtained during 27 surgeries for these fractures were examined. Fractures occurred in 7.7% of 428 femoral metastases (total 33: 28 actual fractures and five virtual fractures with progressive pain and bone destruction). The fracture rate was 7.8% in the proximal femur and 1.5% in the shaft (P = 0.001). Fractures occurred a median of 4.4 months after radiotherapy, with 39.4% occurring within 3 months and 63.6% within 6 months. Among femurs with high fracture risk according to Harrington's criteria or Mirels' score, the fracture rate was 13.9% and 11.8%, respectively. Viable tumor cells were detected in all five patients with painful virtual fracture, in 85.7% of femurs with actual fractures that occurred within 3 months, and in only 25.0% of actual fractures occurring after 3 months. Post-irradiation fractures of femoral metastasis most frequently occurred within 3 months after radiotherapy, and were more common in the peritrochanteric area than in the shaft. Radiological evidence of impending fracture did not correlate with a high fracture rate. Actual fractures occurring after more than 3 months were likely caused by post-irradiation fragility of the femur, without viable tumor cells.

The role of radiotherapy in bone metastases: A critical review of current literature

Radiotherapy is considered the treatment of choice for painful bone metastases. However, novel modalities of radiotherapy have emerged in the concept of oligometastasic disease. In addition, the increase of overall survival of patients with bone metastatic disease in the last decades due to systemic treatments has issued the silent topic of re-irradiation. The aim of this manuscript was to present a current thorough search of relevant literature. Originally, 6,087 articles revealed from PubMed database related to radiotherapy and bone metastases. The first objective was to identify prospective randomised phase III studies dealing with bone metastases and which treated primary with radiotherapy. Abstracts and non-English citations were excluded. Twenty-three phase III clinical trials, 17 prospective studies and eight meta-analysis/systemic reviews matching with these criteria, were identified. Eleven randomised studies were comparing single dose fraction to multi-fraction schedules of radiotherapy. The overall response rates and complete response rates were not significant between the two arms. Re-irradiations rates were significantly higher for the single dose fraction arms. Stereotactic radiotherapy showed excellent tumour control rates more than 80%. All trials showed the equivalence of either single or multi-fractionated radiotherapy for metastatic bone lesions. Stereotactic irradiation is feasible and safe for oligometastatic disease. However, it seems that the single fraction of 8 Gy is superior to 4 Gy, in terms of efficacy.

Spine Metastasis Practice Patterns among Korean, Chinese, and Japanese Radiation Oncologists: A Multinational Online Survey Study

This online survey of practising radiation oncologists from Korea, China and Japan was conducted to investigate the current practices in radiotherapy (RT) for spine metastasis and to compare these practices across the three countries. The questionnaire included nine general information questions and two clinical scenarios (representing 'typical' and 'good' prognosis spine metastasis), with seven questions for each scenario. An anonymous web-based survey using Google Docs® was undertaken from 2 September 2014 to 9 April 2015. A total of 54 Korean, 107 Chinese and 104 Japanese radiation oncologists participated in the study. The first scenario involved a typical case of spine metastasis (~25% expected 1-year survival rate), and the preferred fractionation scheme was 10 fractions of 3 Gy, though the pattern was slightly different in each country. The second scenario involved a good prognosis case (>50% expected 1-year survival rate), and 10 fractions of 3 Gy was the preferred practice in all three countries (however, use of a larger fraction dose with a smaller fraction number was more common in Korea). A more conformal RT technique was more prominent in China and Korea, especially for patients with a good prognosis. Avoidance of reirradiation was notable in China. In summary, a preference for multiple fractionation in RT for spine metastasis was observed in the majority of Korean, Chinese and Japanese radiation oncologists, although there were slight differences in practice preferences, especially for patients with a favorable prognosis.

A Nationwide Survey in Japan of Palliative Radiotherapy for Bleeding in Gastrointestinal and Genitourinary Tumor Patients

Background

In end-stage cancer, bleeding may markedly influence the patient’s quality of life, and radiotherapy plays an important role in the control of the bleeding. In particular, there is no clear evidence of the benefit of palliative radiotherapy for cancers including gastric, rectal, and bladder cancers. A clarification of the current status of palliative radiotherapy for bleeding is needed.

Methods

A survey was conducted by the palliative radiotherapy working group of the Japanese Radiation Oncology Study Group (JROSG), focusing on annual cases of radiotherapy for tumors of the upper and lower gastrointestinal tracts and genitourinary organs (excluding the uterus) and applicable fractionated doses for three hypothetical patients.

Results

A total of 54 radiation oncologists at 43 facilities answered. Most of the facilities reported that they conducted hemostatic irradiation for less than one patient per year, though the median annual number of patients treated with radiotherapy in these facilities was 594. The most frequently observed doses per fraction for two of the hypothetical cases were 3.0 and 2.0 Gy. On the other hand, in each case, the numbers of fractions reported varied markedly among the respondents, ranging from 20 Gy in five fractions to over 30 fractions.

Conclusions

Especially in gastric cancer, hemostatic irradiation is rarely performed in most facilities in Japan. An optimal dose fractionation has not been established. Thirty Gy in 10 fractions is one of the most frequently used regimens, but re-bleeding was observed in approximately one-third of the patients.

Variation in Practice Patterns of Korean Radiation Oncologists for Spine Metastasis between 2009 and 2014

PURPOSE

The Korean Society of Radiation Oncologists (KOSRO) conducted the Patterns of Care Study (PCS) of radiotherapy (RT) for spine metastases in 2009. The current study was conducted to investigate current practice patterns and compare them with the results of the PCS.

MATERIALS AND METHODS

The survey questionnaire was composed of 10 questions regarding general information and seven questions for each of two clinical scenarios.

RESULTS

Fifty-four members of the KOSRO answered at least one question on the web-based questionnaire. The yearly number of patients treated who underwent palliative spine RT was greater than 200 in 14 (25.9%), 51 to 100 in 13 (24.1%), and 31 to 50 in 11 respondents (20.4%). Scenario 1 described a patient presenting with cord compressive spine metastasis in multiple bones and liver metastasis from non-small cell lung cancer. Thirty gray (Gy) in 10 fractions was chosen by 35 respondents (64.8%). Scenario 2 described a case of a single spine metastasis without progression after targeted therapy. Thirty Gy in 10 fractions was chosen by 19 respondents (35.2%), and a single fraction or less than four fractions of stereotactic ablative radiotherapy (SABR) were selected by 18 respondents (33.3%). When compared with the 2009 PCS, practice patterns of Korean radiation oncologists had not changed significantly over 5 years, except that SABR emerged as a new treatment modality in the selected population.

CONCLUSION

The 2014 PCS demonstrated that multiple fraction RT is still preferred in a considerable proportion of Korean radiation oncologists.

Fluorodeoxyglucose Uptake on Positron Emission Tomography Is a Useful Predictor of Long-Term Pain Control After Palliative Radiation Therapy in Patients With Painful Bone Metastases: Results of a Single-Institute Prospective Study

PURPOSE

To determine whether fluorodeoxyglucose positron emission tomography (FDG-PET) before and after palliative radiation therapy (RT) can predict long-term pain control in patients with painful bone metastases.

METHODS AND MATERIALS

Thirty-one patients with bone metastases who received RT were prospectively included. Forty painful metastatic treatment fields were evaluated. All patients had undergone pre-RT and post-RT PET/CT scanning. We evaluated the relationships between the pre-RT, post-RT, and changes in maximum standardized uptake value (SUVmax) and the pain response, and between SUVmax and pain relapse of the bone metastases in the treatment field. In addition, we compared the SUVmax according to the length of time from the completion of RT to pain relapse of the bone metastases.

RESULTS

Regarding the pain response at 4 weeks after the completion of RT, there were 36 lesions of 27 patients in the responder group and 4 lesions of 4 patients in the nonresponder group. Changes in the SUVmax differed significantly between the responder and nonresponder groups in both the early and delayed phases (P=.0292 and P=.0139, respectively), but no relationship was observed between the pre-RT and post-RT SUVmax relative to the pain response. The responder group was evaluated for the rate of relapse. Thirty-five lesions of 26 patients in the responder group were evaluated, because 1 patient died of acute renal failure at 2 months after RT. Twelve lesions (34%) showed pain relapse, and 23 lesions (66%) did not. There were significant differences between the relapse and nonrelapse patients in terms of the pre-RT (early/delayed phases: P<.0001/P<.0001), post-RT (P=.0199/P=.0261), and changes in SUVmax (P=.0004/P=.004).

CONCLUSIONS

FDG-PET may help predict the outcome of pain control in the treatment field after palliative RT for painful bone metastases.

[Radiotherapy of bone metastases: Which fractionations?]

First-line palliative radiotherapy for painful bone metastases is an effective treatment whatever its fractionation (single or multiple fractions). It is also indicated after failure or insufficient effect of a first irradiation, or the appearance of new painful site. Other indications are spinal cord compression, either as an adjuvant to surgery or as sole treatment, and after surgery for long bone metastases. The development of high precision techniques (stereotactic conditions) widens the possibility of re-irradiation when tolerance doses to normal tissues have already been delivered. Local control and possibly overall survival could be improved in oligometastatic patients.

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.

Palliative radiotherapy: current status and future directions

For nearly 100 years, palliative radiotherapy has been a time-efficient, effective treatment for patients with metastatic or advanced cancer in any area where local tumors are causing symptoms. Short courses including a single fraction of radiotherapy may be effective for symptom relief with minimal side effects and maximization of convenience for patient and family. With recent advances in imaging, surgery, and other local therapies as well as systemic cancer therapies, palliative radiotherapy has been used frequently in patients who may not yet have symptoms of advanced or metastatic cancer. In this setting, more prolonged radiotherapy courses and advanced radiotherapy techniques including intensity-modulated radiotherapy (IMRT) or stereotactic radiotherapy (SRT) may be useful in obtaining local control and durable palliative responses. This review will explore the use of radiotherapy across the spectrum of patients with advanced and metastatic cancer and delineate an updated, rational approach for the use of palliative radiotherapy that incorporates symptoms, prognosis, and other factors into the delivery of palliative radiotherapy.

Palliative radiotherapy at the end of life: a critical review

When delivered with palliative intent, radiotherapy can help to alleviate a multitude of symptoms related to advanced cancer. In general, time to symptom relief is measured in weeks to months after the completion of radiotherapy. Over the past several years, an increasing number of studies have explored rates of radiotherapy use in the final months of life and have found variable rates of radiotherapy use. The optimal rate is unclear, but would incorporate anticipated efficacy in patients whose survival allows it and minimize overuse among patients with expected short survival. Clinician prediction has been shown to overestimate the length of survival in repeated studies. Prognostic indices can provide assistance with estimations of survival length and may help to guide treatment decisions regarding palliative radiotherapy in patients with potentially short survival times. This review explores the recent studies of radiotherapy near the end of life, examines general prognostic models for patients with advanced cancer, describes specific clinical circumstances when radiotherapy may and may not be beneficial, and addresses open questions for future research to help clarify when palliative radiotherapy may be effective near the end of life.

Assessing Response to Radiation Therapy Treatment of Bone Metastases: Short-Term Followup of Radiation Therapy Treatment of Bone Metastases with Diffusion-Weighted Magnetic Resonance Imaging

This study examined the usefulness of diffusion-weighted (DW) Magnetic Resonance Imaging (MRI) in monitoring bone metastases response to radiation therapy in 15 oligometastatic patients. For each metastasis, both mean apparent diffusion coefficient (ADC) changes and high b-value DW metastasis/muscle signal intensity ratio (SIR) variations were evaluated at 30 ± 5 days and 60 ± 7 days after the end of treatment. On baseline DW-MRI, all bone metastases were hyperintense and had signal intensities higher than normal bone marrow on calculated ADC maps. At follow-up evaluations, 4 patterns of response were identified: (I) decreased high b-value DW SIR associated with increased mean ADC (83.3% of cases); (II) increased mean ADC with no change of high b-value DW SIR (10% of cases); (III) decreased both high b-value DW SIR and mean ADC (3.3% of cases); (IV) a reduction in mean ADC associated with an increase in high b-value DW SIR compared to pretreatment values (3.3% of cases). Patterns (I) and (II) suggested a good response to therapy; pattern (III) was classified as indeterminate, while pattern (IV) was suggestive of disease progression. This pattern approach may represent a useful tool in the differentiation between treatment-induced necrosis and highly cellular residual tumor.

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.

Variability in the point to which single direct field irradiation is prescribed for spinal bone metastases: a survey of practice patterns in Japan

Direct single fields are commonly used in radiotherapy for spinal bone metastases, and it is crucial to define the point for which the dose is prescribed. According to the guidelines from the International Bone Metastases Consensus Working Party (IBMCWP) updated in 2010, different opinions exist on whether this therapy should be prescribed to the mid-vertebral or anterior vertebral body. To our knowledge, no previous studies have surveyed practice patterns regarding this discrepancy. Therefore, we performed an Internet-based survey of members of the Japanese Radiation Oncology Study Group (JROSG) to investigate the current practice patterns in Japan. The respondents mentioned the point to which they prescribed radiotherapy for a single direct field. A total of 52 radiation oncologists from 50 institutions (36% of JROSG institutions) responded. Respondent prescription for radiotherapy varied widely. Only 21% and 6% of respondents prescribed irradiation to the mid-vertebral body and anterior vertebral body, respectively. A larger proportion of respondents (27%) prescribed irradiation to the spinal cord (center of the spinal canal). Still another group of respondents (27%) stated that they never use a single direct field. In conclusion, the point to which irradiation dosages are prescribed varies widely for a single direct field in cases of spinal bone metastases. This variation may lead some radiation oncologists to misunderstand the tolerance dosage of the spinal cord, especially in cases of re-irradiation. Thus, careful consideration is required before any prescriptions are made.

Continuous controversy about radiation oncologists' choice of treatment regimens for bone metastases: should we blame doctors, cancer-related features, or design of previous clinical studies?

Recent studies from Italy, Japan and Norway have confirmed previous reports, which found that a large variety of palliative radiotherapy regimens are used for painful bone metastases. Routine use of single fraction treatment might or might not be the preferred institutional approach. It is not entirely clear why inter-physician and inter-institution differences continue to persist despite numerous randomized trials, meta-analyses and guidelines, which recommend against more costly and inconvenient multi-fraction regimens delivering total doses of 30 Gy or more in a large number of clinical scenarios. In the present mini-review we discuss the questions of whether doctors are ignoring evidence-based medicine or whether we need additional studies targeting specifically those patient populations where recent surveys identified inconsistent treatment recommendations, e.g. because of challenging disease extent. We identify open questions and provide research suggestions, which might contribute to making radiation oncology practitioners more confident in selecting the right treatment for the right patient.