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

Treatment Terminations During Radiation Therapy: A 10-Year Experience

PURPOSE

Patients undergoing radiation therapy may terminate treatment for any number of reasons. The incidence of treatment termination (TT) during radiation therapy has not been studied. Herein, we present a cohort of TT at a large multicenter radiation oncology department over 10 years.

METHODS AND MATERIALS

TTs between January 2013 and January 2023 were prospectively analyzed as part of an ongoing departmental quality and safety program. TT was defined as any premature discontinuation of therapy after initiating radiation planning. The rate of TT was calculated as a percentage of all patients starting radiation planning. All cases were presented at monthly morbidity and mortality conferences with a root cause reviewed.

RESULTS

A total of 1448 TTs were identified out of 31,199 planned courses of care (4.6%). Six hundred eighty-six (47.4%) involved patients treated with curative intent, whereas 753 (52.0%) were treated with palliative intent, and 9 (0.6%) were treated for benign disease. The rate of TT decreased from 8.49% in 2013 to 3.02% in 2022, with rates decreasing yearly. The most common disease sites for TT were central nervous system (21.7%), head and neck (19.3%), thorax (17.5%), and bone (14.2%). The most common causes of TT were hospice and/or patient expiration (35.9%), patient choice unrelated to toxicity (35.2%), and clinician choice unrelated to toxicity (11.5%).

CONCLUSIONS

This 10-year prospective review of TTs identified a year-over-year decrease in TTs as a percentage of planned patients. This decrease may be associated with the addition of root cause reviews for TTs and discussions monthly at morbidity and mortality rounds, coupled with departmental upstream quality initiatives implemented over time. Understanding the reasons behind TTs may help decrease preventable TTs. Although some TTs may be unavoidable, open discourse and quality improvement changes effectively reduce TT incidents over time.

Factors Affecting Survival and Local Control in Patients with Bone Metastases Treated with Radiotherapy

The aim of this study was to evaluate the expected prognosis and factors affecting local control (LC) of the bone metastatic sites treated with palliative external beam radiotherapy (RT). Between December 2010 and April 2019, 420 cases (male/female = 240/180; median age [range]: 66 [12-90] years) with predominantly osteolytic bone metastases received RT and were evaluated. LC was evaluated by follow-up computed tomography (CT) image. Median RT doses (BED₁₀) were 39.0 Gy (range, 14.4-71.7 Gy). The 0.5-year overall survival and LC of RT sites were 71% and 84%, respectively. Local recurrence on CT images was observed in 19% (n = 80) of the RT sites, and the median recurrence time was 3.5 months (range, 1-106 months). In univariate analysis, abnormal laboratory data before RT (platelet count, serum albumin, total bilirubin, lactate dehydrogenase, or serum calcium level), high-risk primary tumor sites (colorectal, esophageal, hepatobiliary/pancreatic, renal/ureter, and non-epithelial cancers), no antineoplastic agents (ATs) administration after RT, and no bone modifying agents (BMAs) administration after RT were significantly unfavorable factors for both survival and LC of RT sites. Sex (male), performance status (≥3), and RT dose (BED₁₀) (<39.0 Gy) were significantly unfavorable factors for only survival, and age (≥70 years) and bone cortex destruction were significantly unfavorable factors for only LC of RT sites. In multivariate analysis, only abnormal laboratory data before RT influenced both unfavorable survival and LC of RT sites. Performance status (≥3), no ATs administration after RT, RT dose (BED₁₀) (<39.0 Gy), and sex (male) were significantly unfavorable factors for survival, and primary tumor sites and BMAs administration after RT were significantly unfavorable factors for LC of RT sites. In conclusion, laboratory data before RT was important factor both prognosis and LC of bone metastases treated with palliative RT. At least in patients with abnormal laboratory data before RT, palliative RT seemed to be focused on the only pain relief.

Evaluation of Patient-Reported Outcome Differences by Radiotherapy Techniques for Bone Metastases in A Population-Based Healthcare System

We assessed whether advanced RT techniques were associated with differences in patient-reported outcomes (PROs). Patients with bone metastases who completed the brief pain inventory (BPI) before and after RT were identified, and RT technique was categorized as simple (e.g., parallel opposed pair) or advanced (e.g., 3D-conformal RT (3DCRT), intensity-modulated RT (IMRT), or stereotactic ablative RT (SABR)). Pain response and patient-reported interference on quality of life secondary to pain was compared. A total of 1712 patients completed the BPI. From 2017−2021, the rate of advanced RT technique increased significantly (p < 0.001; 2.4%, 2.4%, 9.7%, 5.5%, 9.3%), with most advanced techniques consisting of IMRT, and only 7% of advanced techniques were SABR. Comparing simple vs. advanced technique, neither the complete pain response (12.3% vs. 11.4%; p = 0.99) nor the partial pain response (50.0% vs. 51.8%; p = 0.42) was significantly different. There was no significant patient-reported difference in pain interfering with general activity, mood, walking ability, normal work, relationships, sleep, or enjoyment of life. Given that there is increasing utilization of advanced RT techniques, there is further need for randomized trials to assess their benefits given the increased cost and inconvenience to patients.

Inappropriate use of clinical practices in Canada: a systematic review

Background:

Inappropriate health care leads to negative patient experiences, poor health outcomes and inefficient use of resources. We aimed to conduct a systematic review of inappropriately used clinical practices in Canada.

Methods:

We searched multiple bibliometric databases and grey literature to identify inappropriately used clinical practices in Canada between 2007 and 2021. Two team members independently screened citations, extracted data and assessed methodological quality. Findings were synthesized in 2 categories: diagnostics and therapeutics. We reported ranges of proportions of inappropriate use for all practices. Medians and interquartile ranges (IQRs), based on the percentage of patients not receiving recommended practices (underuse) or receiving practices not recommended (overuse), were calculated. All statistics are at the study summary level.

Results:

We included 174 studies, representing 228 clinical practices and 28 900 762 patients. The median proportion of inappropriate care, as assessed in the studies, was 30.0% (IQR 12.0%–56.6%). Underuse (median 43.9%, IQR 23.8%–66.3%) was more frequent than overuse (median 13.6%, IQR 3.2%–30.7%). The most frequently investigated diagnostics were glycated hemoglobin (underused, range 18.0%–85.7%, n = 9) and thyroid-stimulating hormone (overused, range 3.0%–35.1%, n = 5). The most frequently investigated therapeutics were statin medications (underused, range 18.5%–71.0%, n = 6) and potentially inappropriate medications (overused, range 13.5%–97.3%, n = 9).

Interpretation:

We have provided a summary of inappropriately used clinical practices in Canadian health care systems. Our findings can be used to support health care professionals and quality agencies to improve patient care and safety in Canada.

Prognostic Factors Influencing Survival and a Treatment Pattern Analysis of Conventional Palliative Radiotherapy for Patients with Bone Metastases

BACKGROUND

Treatment indication for bone metastases is influenced by patient prognosis. Single-fraction radiotherapy (SFRT) was proven equally effective as multiple fractionation regimens (MFRT) but continues to be underused.

OBJECTIVE

Primary objectives: (a) to identify prognostic factors for overall survival and (b) to analyze treatment patterns of palliative radiotherapy (proportion of SFRT indication and predictive factors of radiotherapy regimen) for bone metastases.

METHODS

582 patients with bone metastases who underwent conventional radiotherapy between January 1st 2014-31 December 2017 were analyzed. The Cox proportional hazard model was used to identify predictors of overall survival. For the treatment pattern analysis, 677 radiotherapy courses were evaluated. The logistic regression model was used to identify potential predictors of radiotherapy regimen.

RESULTS

The 3-year overall survival was 15%. Prognostic factors associated with poor overall survival were multiple bone metastases [hazard ratio (HR = 5.4)], poor performance status (HR = 1.5) and brain metastases (HR = 1.37). SFRT prescription increased from 41% in 2017 to 51% in 2017. Predictors of SFRT prescription were a poor performance status [odds ratio (OR = 0.55)], lung (OR = 0.49) and urologic primaries (OR = 0.33) and the half-body lower site of irradiation (OR = 0.59). Spinal metastases were more likely to receive MFRT (OR = 2.09).

CONCLUSIONS

Based on the prognostic factors we identified, a selection protocol for patients candidates for palliative radiotherapy to bone metastases could be established, in order to further increase SFRT prescription in our institution.

Evolving Practice Pattern of Palliative Radiation Therapy for Bone Metastases from Lung Cancer in Australia

AIMS

Radiation therapy is an effective treatment for bone metastases. Single-fraction conformal radiation therapy (SF-CRT) is equally effective as multifraction radiation therapy for the management of uncomplicated bone metastases. There has been a rapid development of advanced radiation therapy techniques (ART) in radiation oncology. We evaluated the changing pattern of SF-CRT and ART use for the management of bone metastases in lung cancer.

MATERIALS AND METHODS

This was a state-wide population-based cohort of lung cancer patients from Victoria, Australia, who received radiation therapy for bone metastases between 2012 and 2017. The primary outcomes were proportion of radiation therapy courses using: SF-CRT and ART. We identified a subcohort in which radiation therapy was delivered at the end of life (EOL), i.e. within 30 days of death. The Cochran-Armitage test for trend was used to evaluate the change in pattern of SF-CRT and ART use over time. Multivariable analyses were used to identify factors associated with the primary outcomes.

RESULTS

Of the 4335 courses of radiation therapy for bone metastases in lung cancer, 20% were SF-CRT - increasing from 19% in 2012 to 26% in 2017 (P-trend = 0.004). In multivariate analyses, treatment to the rib, shoulder, hip or extremities, and treatment in public institutions were independently associated with SF-CRT use, but the effect of year of radiation therapy was no longer significant. Five per cent of radiation therapy was delivered using ART, increasing markedly from 2016 onwards (P-trend < 0.001). In multivariate analyses, treatment in private institutions and more recent years of treatment were independently associated with the use of ART. There were 587 courses of radiation therapy delivered at the EOL, with SF-CRT more commonly used closer to death - 53%, 29% and 25% of radiation therapy within 7 days, 8-14 days and 15-30 days of death, respectively.

CONCLUSION

SF-CRT continued to be underutilised for bone metastases in lung cancer in Australia, including at the EOL. We observed an increase in ART use for bone metastases from 2016, which occurred contemporaneously with changes in government funding.

Characteristics and Predictors of Radiographic Local Failure in Patients With Spinal Metastases Treated With Palliative Conventional Radiation Therapy

Purpose

Although local control is an important issue for longer-term survivors of spinal metastases treated with conventional external beam radiation therapy (EBRT), the literature on radiographic local failure (LF) in these patients is sparse. To inform clinical decision-making, we evaluated rates, consequences, and predictors of radiographic LF in patients with spinal metastases managed with palliative conventional EBRT alone.

Methods and Materials

We retrospectively reviewed 296 patients with spinal metastases who received palliative EBRT at a single institution (2006-2013). Radiographic LF was defined as radiologic progression within the treatment field, with death considered a competing risk. Kaplan-Meier, cumulative incidence, and Cox regression analyses determined overall survival estimates, LF rates, and predictors of LF, respectively.

Results

There were 182 patients with follow-up computed tomography or magnetic resonance imaging; median overall survival for these patients was 7.7 months. Patients received a median of 30 Gy in 10 fractions to a median of 4 vertebral bodies. Overall, 74 of 182 patients (40.7%) experienced LF. The 6-, 12-, and 18-month LF rates were 26.5%, 33.1%, and 36.5%, respectively, while corresponding rates of death were 24.3%, 38.1%, and 45.9%. Median time to LF was 3.8 months. Of those with LF, 51.4% had new compression fractures, 39.2% were admitted for pain control, and 35.1% received reirradiation; median time from radiation therapy (RT) to each of these events was 3.0, 5.7, and 9.2 months, respectively. Independent predictors of LF included single-fraction RT (8 Gy) (hazard ratio [HR], 2.592; 95% confidence interval [CI], 1.437-4.675; P = .002), lung histology (HR, 3.568; 95% CI, 1.532-8.309; P = .003), and kidney histology (HR, 4.937; 95% CI, 1.529-15.935; P = .008).

Conclusions

Patients experienced a >30% rate of radiographic LF by 1 year after EBRT. Single-fraction RT and lung or kidney histology predicted LF. Given the high rates of LF for patients with favorable prognosis, assessing the risk of death versus LF is important for clinical decision-making.

Optimal dose-fractionation schedule of palliative radiotherapy for patients with bone metastases: a protocol for systematic review and network meta-analysis

INTRODUCTION

The optimal dose-fractionation schedule of palliative radiotherapy has been debated in patients with bone metastases. Our objective is to comprehensively compare multiple fraction schedules with single fraction radiotherapy in terms of efficacy and toxicities by performing a systematic review and network meta-analysis.

METHODS AND ANALYSIS

Electronic searches of titles/abstracts of palliative radiotherapy for bone metastases will be performed, using PubMed, Cochrane Library, Embase, clinical trials, American Society for Therapeutic Radiology and Oncology and European Society of Radiotherapy and Oncology. The primary outcome of interest is the incidence of skeletal-related event following palliative radiotherapy for bone metastases in prospective studies. The risk of bias and quality of evidence will be evaluated based on Cochrane Collaboration's tool and Grades of Recommendation, Assessment, Development and Evaluation in the network meta-analysis. We will conduct subgroup analysis and sensitivity analysis regardless of heterogeneity estimates.

ETHICS AND DISSEMINATION

This study will synthesise the evidence regarding dose-fractionation schedule of palliative radiotherapy in patients with bone metastases. We hope the findings from this study will help clinicians and patients select optimum palliative radiotherapy by identifying the optimal dose-fractionation schedule of palliative radiotherapy with the most value in terms of patient-important outcomes. The evidence obtained from network meta-analysis will help to guide head-to-head research in the future. The results will be disseminated through international conference reports and peer-reviewed manuscripts. Ethics review board is not required for this network meta-analysis.

PROSPERO REGISTRATION NUMBER

CRD42019135195.

Palliative Radiotherapy: Inpatients, Outpatients, and the Changing Role of Supportive Care in Radiation Oncology

Palliative radiotherapy is an effective treatment in alleviating many symptoms of advanced cancer. Short courses of radiotherapy provide rapid symptom relief and minimize impact on patients. Patients referred for palliative radiotherapy have many concerns beyond radiotherapy; often, these concerns are not fully addressed in traditional radiotherapy clinics. Discussions of prognosis, patient goals, and concerns are areas for improved collaboration. Innovative, dedicated palliative radiotherapy programs have developed over the past 20 years to provide holistic care to patients referred for palliative radiotherapy and have improved patient-focused outcomes. Advanced radiotherapy techniques may provide opportunities to further improve palliative radiotherapy outcomes.

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

PURPOSE

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

METHODS AND MATERIALS

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

RESULTS

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

CONCLUSIONS

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

Personalized Radiation Therapy in Cancer Pain Management

The majority of advanced cancer patients suffer from pain, which severely deteriorates their quality of life. Apart from analgesics, bisphosphonates, and invasive methods of analgesic treatment (e.g., intraspinal and epidural analgesics or neurolytic blockades), radiation therapy plays an important role in pain alleviation. It is delivered to a growing primary tumour, lymph nodes, or distant metastatic sites, producing pain of various intensity. Currently, different regiments of radiation therapy methods and techniques and various radiation dose fractionations are incorporated into the clinical practice. These include palliative radiation therapy, conventional external beam radiation therapy, as well as modern techniques of intensity modulated radiation therapy, volumetrically modulated arch therapy, stereotactic radiosurgery or stereotactic body radiation therapy, and brachytherapy or radionuclide treatment (e.g., radium-223, strontium-89 for multiple painful osseous metastases). The review describes the possibilities and effectiveness of individual patient-tailored conventional and innovative radiation therapy approaches aiming at pain relief in cancer patients.

Are radiation oncologists following guidelines? An audit of practice in patients with uncomplicated bone metastases

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At our center single fraction radiotherapy is used in accordance with guidelines.

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Patient age, performance status and tumor histology influence treatment choice.

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We added a quality indicator to our performance dashboard to improve adherence.

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This strategy can be used in other complex practices and improve quality of care.

Background

Best-practice guidelines recommend single-fraction (SFRT) instead of multi-fraction radiation therapy (MFRT) for uncomplicated symptomatic bone metastases. SFRT is comparable to MFRT in relieving pain, convenient for patients, and cost-effective. Patterns of practice in Canada reveal that SFRT is underused, with significant variability across the country. We audited SFRT use and studied factors that may influence treatment decisions at a large academic tertiary care center in Quebec, Canada.

Methods

Patients who received radiotherapy for uncomplicated bone metastases between February 2014 and March 2015 were reviewed. Age, gender, primary histology, site of metastases and performance status were identified as potential factors affecting fractionation. These were explored by Fisher's test on univariate analysis and logistic regression for multivariate analysis. Retreatment rates were analyzed with cumulative incidence and compared with Gray's test.

Results

254 radiotherapy courses were administered to 165 patients, 85.4% of which were delivered using a single fraction of 8 Gy. Patients age less than 70 years and those with breast histology were more likely to receive MFRT (p = 0.04; p = 0.0046). Performance status (ECOG) was a significant predictor of fractionation because of high correlations between young age, breast histology, and ECOG status (p = 0.03). Follow-up was too short in 40% of patients to derive definitive conclusions on retreatment.

Conclusions

In accordance with current guidelines, our audit confirms that use of SFRT in patients with uncomplicated bone metastases at our center is high. We identified that patient age, primary histology, and performance status influenced fractionation. Incorporation of this quality indicator into our performance dashboard will allow assessment of retreatment differences and other criteria that may also influence treatment choice.

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

PURPOSE

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

METHODS AND MATERIALS

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

RESULTS

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

CONCLUSIONS

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

Single vs multiple fraction palliative radiotherapy for uncomplicated painful bone metastases treated at University of Malaya Medical Centre: A single institutional Malaysian experience

INTRODUCTION

This study was conducted to compare pain response between single and multiple fraction palliative radiotherapy and to describe prognostic factors affecting treatment response in University of Malaya Medical Centre (UMMC).

METHODS

The case records of 162 patients with uncomplicated painful bone metastases treated with palliative radiotherapy from 2006 to 2014 were analyzed. Treatment outcomes were pain score response, analgesic score response, response according to International Consensus Endpoints (complete response and overall response) at 4, 12, and 24 weeks, retreatment rate, symptomatic skeletal events (SSEs), and prognostic factors.

RESULTS

At 24 weeks, pain score response for single and multiple fraction group was 82.3% and 88.5%, analgesic score response was 54.8% and 61.5%, and overall response according to International Consensus Endpoint was 61.3% and 67.7%, respectively. There was no statistically significant difference in treatment response between the 2 treatment groups for all endpoints. ECOG (<2 vs ≥2: aOR 3.405, 95% CI 1.708-6.790, P = .001) and primary breast and prostate (breast vs others: aOR 5.231, 95% CI 1.973-13.869, P = .001; prostate vs others: aOR 5.522, 95% CI 1.493-20.420, P = .01) were significant variables on multivariate analysis.

CONCLUSION

Single fraction radiotherapy is as effective as multiple fraction radiotherapy for the palliation of uncomplicated bone metastases.

Palliative radiation therapy (RT) for prostate cancer patients with bone metastases at diagnosis: A hospital-based analysis of patterns of care, RT fractionation scheme, and overall survival

Prostate cancer (PCa) is one of the most common malignancies associated with bone metastases, and palliative radiation therapy (RT) is an effective treatment option. A total of 2641 patients were identified with PCa and bone metastases at diagnosis from 2010 to 2014 in the NCDB. Fractionation scheme was designated as short course ([SC‐RT]: 8 Gy in 1 fraction and 20 Gy in 5 fractions) vs long course ([LC‐RT]: 30 Gy in 10 fractions and 37.5 Gy in 15 fractions). Patient characteristics were correlated with fractionation scheme using logistic regression. Overall survival was analyzed using the Kaplan‐Meier method, log‐rank test, Cox proportional hazards models, and propensity score‐matched analyses. A total of 2255 (85.4%) patients were included in the LC‐RT group and 386 (14.6%) patients in the SC‐RT group. SC‐RT was more common in patients over 75 years age (odds ratio [OR]: 1.70, 95% confidence interval [CI] 1.32‐2.20), treatment at an academic center (OR: 1.76, 1.20‐2.57), living greater than 15 miles distance to treatment facility (OR: 1.38, 1.05‐1.83), treatment to the rib (OR: 2.99, 1.36‐6.60), and in 2014 (OR: 1.73, 1.19‐2.51). RT to the spine was more commonly long course (P < .0001). In the propensity‐matched cohort, LC‐RT was associated with improved OS (P < .0001), but no OS difference was observed between 37.5 Gy and either 8 Gy in one fraction or 20 Gy in 5 fractions (P > .5). LC‐RT remains the most common treatment fractionation scheme for palliative bone metastases in PCa patients. Use of palliative SC‐RT is increasing, particularly in more recent years, for older patients, treatment at academic centers, and with increasing distance from a treatment center.

Palliation or Prolongation? The Impact of a Peer-Review Intervention on Shortening Radiotherapy Schedules for Bone Metastases

PURPOSE

Shorter fractionation radiation regimens for palliation of bone metastases result in lower financial and social costs for patients and their caregivers and have similar efficacy as longer fractionation schedules, although practice patterns in the United States show poor adoption. We investigated whether prospective peer review can increase use of shorter fractionation schedules.

METHODS

In June 2016, our practice mandated peer review of total dose and fractionation for all patients receiving palliative treatment during our weekly chart rounds. We used descriptive statistics and Fisher's exact test to compare lengths of treatment of uncomplicated bone metastases before and after implementation of the peer review process.

RESULTS

Between July 2015 and December 2016, a total of 242 palliative treatment courses were delivered, including 105 courses before the peer review intervention and 137 after the intervention. We observed greater adoption of shorter fractionation regimens after the intervention. The use of 8 Gy in one fraction increased from 2.8% to 13.9% of cases postadoption. Likewise, the use of 20 Gy in five fractions increased from 25.7% to 32.8%. The use of 30 Gy in 10 fractions decreased from 55.2% to 47.4% ( P = .002), and the use of ≥ 11 fractions decreased from 16.2% before the intervention to 5.8% after ( P = .006).

CONCLUSION

Prospective peer review of palliative regimens for bone metastases can lead to greater adoption of shorter palliative fractionation schedules in daily practice, in accordance with national guidelines. This simple intervention may therefore benefit patients and their caregivers as well as provide value to the health care system.

Programmatic Comparison and Dissemination of an Audit of Single-fraction Radiation Therapy Prescribing Practices for Bone Metastases is Associated with a Meaningful and Lasting Change in Practice on a Population Level

PURPOSE

There is ample evidence that single-fraction radiation therapy (SFRT) is as efficacious as more costly and morbid multifraction regimens. We previously demonstrated that an audit-based intervention increased the use of SFRT in all regional cancer centers the following year. However, other investigators have demonstrated that interventions were only associated with a transient 1-year change in prescribing practices. We sought to determine whether our intervention resulted in a more lasting impact.

METHODS AND MATERIALS

In 2012, we performed an audit of the prescribing practices of individual physicians, which was then presented to leaders and oncologists as an intervention to increase SFRT. We compared the use of SFRT between 2007 to 2011 (preintervention) and 2013 to 2016 (postintervention) in all 31,192 patients treated in our provincial program.

RESULTS

The use of SFRT increased from 49.2% to 58.9% postintervention (P < .001). Rates from 2007 to 2011 were 51%, 51%, 48%, 49%, and 48%, respectively, whereas the postintervention rates from 2013 to 2016 were 60%, 62%, 59%, and 56%, respectively. Postintervention, half of the centers prescribed SFRT in a relatively narrow range (55%-58%). However, across all centers, there was still a broad range, with the lowest and highest users at 35% and 81%, respectively, although the lowest-using center still showed a significant increase (26% to 35%; P < .001).

CONCLUSIONS

Our audit and education-based intervention resulted in a lasting and meaningful 10% change in practice. Our provincial rate is similar to that of a previously recommended benchmark rate of 60%, but we continue to see significant variation by center, suggesting further room for improvement in provincial standardization. With emerging evidence in support of ablative radiation therapy for select populations of patients with bone metastases, future benchmark rates of SFRT should be readdressed. However, our data suggest that programmatic comparison and dissemination of SFRT prescribing practices can achieve a population-based SFRT utilization rate near 60%.

[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.

Update of the systematic review of palliative radiation therapy fractionation for bone metastases

PURPOSE

Radiation therapy is an effective modality for pain management of symptomatic bone metastases. We update the previous meta-analyses of randomized trials comparing single fraction to multiple fractions of radiation therapy in patients with uncomplicated bone metastases.

METHODS

A literature search was conducted in Ovid Medline, Embase, and Cochrane Central Register. Ten new randomized trials were identified since 2010, five with adequate and appropriate data for inclusion, resulting in a total of 29 trials that were analyzed. Forest plots based on each study's odds ratios were computed using a random effects model and the Mantel-Haenszel statistic.

RESULTS

In intention-to-treat analysis, the overall response rate was similar in patients for single fraction treatments (61%; 1867/3059) and those for multiple fraction treatments (62%; 1890/3040). Similarly, complete response rates were nearly identical in both groups (23% vs 24%, respectively). Re-treatment was significantly more frequent in the single fraction treatment arm, with 20% receiving additional treatment to the same site versus 8% in the multiple fraction treatment arm (p < 0.01). No significant difference was seen in the risk of pathological fracture at the treatment site, rate of spinal cord compression at the index site, or in the rate of acute toxicity.

CONCLUSION

Single fraction and multiple fraction radiation treatment regimens continue to demonstrate similar outcomes in pain control and toxicities, but re-treatment is more common for single fraction treatment patients.

Impact of a clinical pathway tool on appropriate palliative radiation therapy for bone metastases

PURPOSE

Clinical pathways increase compliance with treatment guidelines, improve outcomes, and reduce costs. Guidelines recommend single fraction radiation therapy (SFRT) for palliation of uncomplicated bone metastases, but implementation is variable. We examined the effects of a pathway tool on SFRT rates in an academic radiation oncology practice.

METHODS AND MATERIALS

Using published literature, clinical guidelines, and expert input, we designed a clinical pathway for bone metastases radiation therapy displayed on a Web-based electronic interface. In March 2016, the pathway launched on a palliative radiation service at the Dana Farber/Brigham and Women's Cancer Center main campus and at affiliated community sites. Providers were surveyed pre- and postimplementation to assess expectations and elicit feedback. Rates of pathway utilization, compliance with SFRT recommendations, and reasons for noncompliance were assessed.

RESULTS

The final pathway includes 20 endpoints and several validated prognostic scoring systems. It was used in 38% of 723 bone metastases radiation prescriptions, with appropriate SFRT rates rising from 18% before implementation to 48% after launch (P < .01). Major reasons for rejecting recommendations included disagreement with life expectancy prognostication and patient convenience. The pathway increased physicians' confidence regarding compliance with treatment guidelines and made it easier to find well-supported treatment recommendations. Workflow disruptions and the inability to handle nuanced situations emerged as limitations.

CONCLUSIONS

Our experience demonstrates the utility of clinical pathway decision support for bone metastases radiation in complex academic settings. Next steps include increasing the pathway's ease of use, refining the pathway's prognostic abilities, and measuring cost savings related to the pathway.

Diffusion-weighted magnetic resonance imaging in painful bone metastases: Using quantitative apparent diffusion coefficient as an indicator of effectiveness of single fraction versus multiple fraction radiotherapy

PURPOSE

Bone metastases are a common cause of cancer-related pain. The aim of this study is to determine the optimal radiotherapy schedule for the treatment of painful bone metastases and verify if could cause different biological effects on bone. This has been achieved using functional Magnetic Resonance Imaging (MRI) with diffusion-weighted imaging (DWI).

PATIENTS AND METHODS

Fifteen patients received Multiple Fractions Radiation Therapy (MFRT) with a total dose of 30Gy in 10 daily fractions of 3Gy given over 2 weeks and 15 patients received a Single Fraction Radiation Therapy (SFRT) with a dose of 8Gy. Quantitative Apparent Diffusion Coefficient (ADC) values after SFRT or MFRT were compared with response to treatment (pain relief), assessed by Visual Analogue Scale (VAS) before radiotherapy and at 1 and 3 months after the completion of treatment.

RESULTS

The two schedules had equal efficacy in terms of pain control, without any difference at 1 and 3 months post radiotherapy. In both treatments, pain reduction was related to an increase in the ADC. However, the median ADC value had an increase of 575 points between the baseline and 3 months (from 1010 to 1585, p=0.02) in the 30Gy group, while it was only 178 points (from 1417 to 1595) in the 8Gy group.

CONCLUSIONS

The increase in the ADC values after radiotherapy corresponds to increased cell death. Despite an equal pain control, MFRT treatment seems to be more effective to achieve cancer cells kill. Our preliminary data could also explain the higher retreatment rates in SFRT vs MFRT in long survivors.

Preventing Discontinuation of Radiation Therapy: Predictive Factors to Improve Patient Selection for Palliative Treatment

PURPOSE

Approximately one third of patients with cancer require palliative radiation therapy (PRT), yet no guidelines exist for optimal patient selection. We have observed that many patients who begin PRT do not complete their prescribed treatment. Our study sought to identify factors associated with discontinuation of PRT, assess for a relationship with survival, and inform patient selection.

METHODS

We performed an institutional review board-approved retrospective analysis of patients with cancer treated in a multicenter radiation oncology department in 2014. Of 297 patients who began PRT, 60 discontinued and 237 completed treatment. Primary end points included discontinuation and overall survival.

RESULTS

Patient factors were analyzed for association with discontinuation of PRT and overall survival, respectively, using logistic regression and Cox proportional regression models. Factors associated with discontinuation were low Karnofsky performance status (KPS) score, high number of fractions prescribed, and treatment site other than bone metastasis. The odds of discontinuing PRT decreased by approximately 52% for every 10-point increase in KPS score (odds ratio, 0.48; 95% CI, 0.36 to 0.63; P < .001). Factors associated with shorter survival included discontinuation of PRT, low KPS score, community practice location, multiple comorbidities, and treatment of brain metastases. Patients who discontinued treatment were more likely to die than patients who completed treatment, independent of other factors (hazard ratio, 3.67; 95% CI, 2.41 to 5.61; P < .001).

CONCLUSION

Patients with low KPS scores, long treatment courses, and those treated to sites other than bone metastasis were significantly more likely to discontinue treatment. Discontinuation was predictive for poor survival. Pretreatment evaluation of KPS, comorbidities, and brain metastases can help guide appropriate patient selection for PRT.

A review of patterns of practice and clinical guidelines in the palliative radiation treatment of uncomplicated bone metastases

BACKGROUND AND PURPOSE

Single fraction radiation treatment (SFRT) is recommended for its equivalence to multiple-fraction (MF) RT in the palliation of uncomplicated bone metastases (BM). However, adoption of SFRT has been slow.

MATERIALS AND METHODS

Literature searches for studies published following 2014 were conducted using online repositories of gray literature, Ovid MEDLINE, Embase and Embase Classic, and the Cochrane Central Register of Controlled Trials databases.

RESULTS

A total of 32 articles detailing patterns of practice and clinical practice guidelines were included for final synthesis. The majority of organizations have released high level recommendations for SFRT use in treatment of uncomplicated BM, based on evidence of non-inferiority to MFRT. There are key differences between guidelines, such as varying strengths of recommendation for SFRT use over MFRT; contraindication in vertebral sites for SFRT; and risk estimation of pathologic fractures after SFRT. Differences in guidelines may be influenced by committee composition and organization mandate. Differences in patterns of practice may be influenced by individual center policies, payment modalities and consideration of patient factors such as age, prognosis, and performance status.

CONCLUSION

Although there is some variation between groups, the majority of guidelines recommend use of SFRT and others consider it to be a reasonable alternative to MFRT.

The Glasgow prognostic score: Useful information when prescribing palliative radiotherapy

The purpose of the present retrospective study was to investigate whether a score reflecting systemic inflammatory processes [the Glasgow Prognostic Score (GPS)] provides relevant information for radiation oncologists. GPS is a three-tiered score [0: normal C-reactive protein (CRP) and albumin; 1: one abnormal result; 2: increased CRP and low albumin]. Correlations between disease type and extent, resource utilization, survival and GPS were analyzed in 703 patients. In the subgroup with GPS 2, significantly higher rates of lung, adrenal gland and liver metastases were observed. An increasing GPS score was associated with a higher likelihood of anemia, leukocytosis and thrombocytosis. Comparable findings were made regarding utilization of palliative care resources, need for blood transfusion and intravenous administration of antibiotics. Compared with GPS 0 or 1, more patients with GPS 2 did not complete their prescribed course of radiotherapy. One-third of patients with GPS 2 received treatment during the final month of life. Multivariate analysis demonstrated that GPS was a significant prognostic factor for overall survival (median, 479, 136, and 61 days, for GPS 0, 1 and 2, respectively). In patients with GPS 2 and additional leukocytosis, the median survival was 38 days. In conclusion, GPS provides important prognostic information. This biomarker-based score may be considered for deciding fractionation, and should be validated further.

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.

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

BACKGROUND

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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.

Incidence of distal bone metastases in patients treated for palliative radiotherapy and associations with primary tumour types

Purpose

This study assesses the incidence of distal bone metastases in palliative radiotherapy (RT) patients.

Material and methods

All courses of RT for bone metastases from 2007–2011 for patient living in British Columbia (BC) were identified in a provincial RT programme. Treated bone metastases (BoM) were categorized as distal if the BoM was located within or distal to the elbow or knee. Patients were grouped by primary tumour site as breast, lung, prostate gastrointestinal, haematological, melanoma, and other. The incidence of distal bone metastases and associations with primary tumour types were determined.

Results

From 2007 to 2011, 8008 patients were treated with 16,277 courses of RT, of which 425 (3%) were courses of RT for distal BoM. The incidence of distal BoM in decreasing order by primary tumour type was melanoma (5%), haematological (3%), lung (2%), other (2%), prostate (2%), breast (1%) and gastrointestinal (1%). Distal BoM where more commonly identified in the lower extremity (87%, p<0.001). Single fraction RT was used more commonly for distal vs non-distal BoM (66% vs. 49%; p<0.001).

Conclusion

The incidence of distal BoM among patients treated with palliative RT was 3% and most commonly identified in patients with melanoma and haematological malignancies.

Incidence and treatment patterns of complicated bone metastases in a population-based radiotherapy program

INTRODUCTION

There is abundant evidence in support of single fraction (SF) radiation therapy (RT) for uncomplicated bone metastases (BoM). We sought to determine the proportion of BoM that is complicated in a population-based RT program in order to act as a potential guide for assessing SFRT utilization rates.

MATERIALS AND METHODS

A total of 3200 RT courses were prescribed to 1880 consecutive patients diagnosed with BoM in 2013. Associations between choice of RT fractionation and BoM characterization, whether complicated or not, were assessed with logistic regression.

RESULTS

The incidence of complicated BoM was 34.4%, resulting most often from adverse features of actual pathological fracture (42.1%), and neurological compromise (36.3%). Complicated BoM were most common in lung cancers (24.2%) and in the spine (68.5%), followed by extremity (15.2%) and pelvis (14.4%). SFRT was prescribed less commonly in complicated versus un-complicated BoM (39.4% vs. 70.4%; p<0.001), which was confirmed on multivariable analysis (OR 0.32; 95% CI 0.28-0.61; p<0.001).

CONCLUSIONS

This study found that 34.4% of BoM are complicated by fracture, or neurological compromise (i.e. 65.6% were un-complicated), and that they were less likely to receive SFRT. A reasonable benchmark for SFRT utilization should be at least 60%.

Dexamethasone in the prophylaxis of radiation-induced pain flare after palliative radiotherapy for bone metastases: a double-blind, randomised placebo-controlled, phase 3 trial

BACKGROUND

Pain flare occurs after palliative radiotherapy, and dexamethasone has shown potential for prevention of such flare. We aimed to compare the efficacy of dexamethasone with that of placebo in terms of reduction of incidence of pain flare.

METHODS

In this double-blind, randomised, placebo-controlled phase 3 trial, patients from 23 Canadian centres were randomly allocated (1:1) with a web-based system and minimisation algorithm to receive either two 4 mg dexamethasone tablets or two placebo tablets taken orally at least 1 h before the start of radiation treatment (a single 8 Gy dose to bone metastases; day 0) and then every day for 4 days after radiotherapy (days 1-4). Patients were eligible if they had a non-haematological malignancy and bone metastasis (or metastases) corresponding to the clinically painful area or areas. Patients reported their worst pain scores and opioid analgesic intake before treatment and daily for 10 days after radiation treatment. They completed the European Organisation for Research and Treatment of Cancer (EORTC) quality of life QLQ-C15-PAL, the bone metastases module (EORTC QLQ-BM22), and the Dexamethasone Symptom Questionnaire at baseline, and at days 10 and 42 after radiation treatment. Pain flare was defined as at least a two-point increase on a scale of 0-10 in the worst pain score with no decrease in analgesic intake, or a 25% or greater increase in analgesic intake with no decrease in the worst pain score from days 0-10, followed by a return to baseline levels or below. Primary analysis of incidence of pain flare was by intention-to-treat (patients with missing primary data were classified as having pain flare). This study is registered with ClinicalTrials.gov, number NCT01248585, and is completed.

FINDINGS

Between May 30, 2011, and Dec 11, 2014, 298 patients were enrolled. 39 (26%) of 148 patients randomly allocated to the dexamethasone group and 53 (35%) of 150 patients in the placebo group had a pain flare (difference 8·9%, lower 95% confidence bound 0·0, one-sided p=0·05). Two grade 3 and one grade 4 biochemical hyperglycaemic events occurred in the dexamethasone group (without known clinical effects) compared with none in the placebo group. The most common adverse events were bone pain (61 [41%] of 147 vs 68 [48%] of 143), fatigue (58 [39%] of 147 vs 49 [34%] of 143), constipation (47 [32%] of 147 vs 37 [26%] of 143), and nausea (34 [23%] of 147 vs 34 [24%] of 143), most of which were mild grade 1 or 2.

INTERPRETATION

Dexamethasone reduces radiation-induced pain flare in the treatment of painful bone metastases.

FUNDING

The NCIC CTG's programmatic grant from the Canadian Cancer Society Research Institute.

[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.

Patient preferences for timing and access to radiation therapy

PURPOSE

Patient preferences for radiation therapy (rt) access were investigated.

METHODS

Patients completing a course of rt at 6 centres received a 17-item survey that rated preferences for time of day; day of week; actual, ideal, and reasonable travel times for rt; and actual, ideal, and reasonable times between referral and first oncologic consultation. Patients receiving single-fraction rt or brachytherapy alone were excluded.

RESULTS

Of the respondents who returned surveys (n = 1053), 54% were women, and 74% had received more than 15 rt fractions. With respect to appointment times, 88% agreed or strongly agreed that rt between 08h00 and 16h30 was preferred; 14%-15% preferred 07h30-08h00 or 16h30-17h00; 10% preferred 17h00-18h00; and 6% or fewer preferred times before 07h30 or after 18h00. A preference not to receive rt before 07h30 or after 18h00 was expressed by 30% or more of the respondents. When days of the week were considered, 18% and 11% would have preferred to receive rt on a Saturday or Sunday respectively; 52% and 55% would have preferred not to receive rt on those days. A travel time of 1 hour or less for rt was reported by 82%, but 61% felt that a travel time of 1 hour or more was reasonable. A first consultation within 2 weeks of referral was felt to be ideal or reasonable by 88% and 73% of patients respectively.

CONCLUSIONS

An rt service designed to meet patient preferences would make most capacity available between 08h00 and 16h30 on weekdays and provide 10%-20% of rt capacity on weekends and during 07h30-08h00 and 16h30-18h00 on weekdays. Approximately 80%, but not all, of the responding patients preferred a 2-week or shorter interval between referral and first oncologic consultation.

Fractionation of Palliative Radiation Therapy for Bone Metastases in Ontario: Do Practice Guidelines Guide Practice?

PURPOSE

To evaluate the effect of a provincial practice guideline on the fractionation of palliative radiation therapy for bone metastases (PRT.B) in Ontario.

METHODS AND MATERIALS

The present retrospective study used electronic treatment records linked to Ontario's population-based cancer registry. Hierarchical multivariable regression analysis was used to evaluate temporal trends in the use of single fractions (SFs), controlling for patient-related factors associated with the use of SFs.

RESULTS

From 1984 to 2012, 43.9% of 161,835 courses of PRT.B were administered as SFs. The percentage of SF courses was greater for older patients (age <50 years, 39.8% vs age >80 years, 52.5%), those with a shorter life expectancy (survival >12 months, 36.9% vs < 1 month, 53.6%), and those who lived farther from a radiation therapy center (<10 km, 42.1% vs > 50 km, 47.3%). The percentage of SFs to spinal fields was lower than that to other skeletal sites (31.5% vs 57.1%). The percentage of SFs varied among the cancer centers (range, 26.0%-67.8%). These differences were all highly significant in the multivariable analysis (P<.0001). In 2004, Cancer Care Ontario released a practice guideline endorsing the use of SFs for uncomplicated bone metastases. The rate of use of SFs increased from 42.3% in the pre-guideline period (1999-2003) to 52.6% in the immediate post-guideline period (2004-2007). However, it subsequently decreased again to 44.0% (2009-2012). These temporal trends were significant after controlling for patient-related factors in the multivariable analysis (P<.0001). Large intercenter variations in the use of SFs persisted after publication of the guideline.

CONCLUSIONS

The publication of an Ontario practice guideline endorsing the use of SF PRT.B was associated with only a transient increase in the use of SFs in Ontario and did little to reduce intercenter variations in fractionation.