Single- versus multiple-fraction radiotherapy in patients with painful bone metastases: cost-utility analysis based on a randomized trial

Health Utility of Pain Response Versus Nonresponse to Palliative Radiation Therapy for Symptomatic Bone Metastases: Analyses Based on Real-World Data from 26 Centers

Background: Utility values of responders and nonresponders are essential inputs in cost-effectiveness studies of radiation therapy for painful bone metastases but, to our knowledge, they have not been reported separately. Objective: We sought to determine the utility values of responders and nonresponders using data from a prospective observational study on bone metastases. Methods: The original prospective observational study was conducted at 26 centers in Japan. Of 232 enrolled patients, 181 whose pain scores at baseline were ≥2 were analyzed. Health-related quality of life (QOL) was measured using the EuroQol 5-dimensions 5-levels (EQ-5D-5L) instrument at baseline and 2- and 6-month follow-up assessments. At follow-up assessments, patients were categorized as responders or nonresponders. Pain response was assessed using the International Consensus Pain Response Endpoints. Results: Of the 181 patients analyzed, 133 (73%) and 84 (46%) were evaluable at the 2- and 6-month follow-up assessment, respectively. The EQ-5D-5L index score (utility) increased from baseline to the 2- and 6-month follow-up assessments; regarding opioid analgesic use, no clear trend was observed during the same period. The mean utility was significantly higher in responders than in nonresponders at both follow-up times. The mean daily oral morphine equivalent dose was significantly lower in responders than in nonresponders at both follow-up times. Conclusion: We determined utility values for responders and nonresponders. Pain response was associated with better QOL and less opioid use. Our utility values according to response status can be used for model input in future cost-effectiveness studies on radiation therapy for bone metastases.

A Comprehensive Perspective on Educational and Economic Barriers for Utilization of Palliative Radiation Therapy in Hospice: A Narrative Review

Purpose

Despite the agreed-on efficacy and benefits of palliative radiation therapy (PRT) to alleviate end-of-life complications related to cancer progression, PRT remains an underused treatment in the hospice-care setting.3-4,6-7 Common barriers for hospice patient use of PRT include educational and economic limitations. This paper discussed these barriers and ways to eliminate them based on previously published interventions.

Methods and Materials

Literature search on PubMed; 30 articles were selected by the authors. All articles included are published after the year 2000 in peer reviewed journals.

Results

Educational barriers for medical practitioners outside radiation oncology can be addressed by creating formal education programs that reduce knowledge gaps previously identified by survey-based research studies. For radiation oncologists, continued education should focus on increasing competence and comfort with end-of-life conversations and indications for use of single-fraction radiation for patients with advanced cancer. More information on radiation oncology options should be provided to patients. As for economic barriers, rapid-access programs that use advanced level practitioners can increase PRT access by the hospice population. Also, these programs can increase use of single-fraction radiation therapy (SFX RT) in patients with a shorter projected prognosis. SFX RT is beneficial in this setting because it decreases hospice expense and is as efficacious at palliating pain in patients with advanced cancer as multiple-fraction radiation.

Conclusions

The barriers of education and economic limitations can be addressed by: expanding the PRT curriculum for all practicing physicians, improving radiation oncologist palliative care knowledge, increasing PRT resources for patients, increasing number of rapid-access radiation therapy programs, and, when indicated, encouraging use of single-fraction radiation treatment for hospice patients.

An Economic Analysis of SC24 in Canada: A Randomized Study of SBRT Compared With Conventional Palliative RT for Spinal Metastases

PURPOSE

The Canadian Cancer Trials Group (CCTG) Symptom Control 24 protocol (SC.24) was a multicenter randomized controlled phase 2/3 trial conducted in Canada and Australia. Patients with painful spinal metastases were randomized to either 24 Gy/2 stereotactic body radiation therapy (SBRT) or 20 Gy/5 conventional external beam radiation therapy (CRT). The study met its primary endpoint and demonstrated superior complete pain response rates at 3 months following SBRT (35%) versus CRT (14%). SBRT planning and delivery is resource intensive. Given its benefits in SC.24, we performed an economic analysis to determine the incremental cost-effectiveness of SBRT compared with CRT.

METHODS AND MATERIALS

The trial recruited 229 patients. Cost-effectiveness was assessed using a Markov model taking into account observed survival, treatments costs, retreatment, and quality of life over the lifetime of the patient. The EORTC-QLU-C10D was used to determine quality of life values. Transition probabilities for outcomes were from available patient data. Health system costs were from the Canadian health care perspective and were based on 2021 Canadian dollars (CAD). The incremental cost-effectiveness ratio (ICER) was expressed as the ratio of incremental cost to quality-adjusted life years (QALY). The impact of parameter uncertainty was investigated using deterministic and probabilistic sensitivity analyses.

RESULTS

The base case for SBRT compared with CRT had an ICER of $9,040CAD per QALY gained. Sensitivity analyses demonstrated that the ICER was most sensitive to variations in the utility assigned to "No local failure" ($5,457CAD to $241,051CAD per QALY), adopting low and high estimates of utility and the cost of the SBRT (ICERs ranging from $7345-$123,361CAD per QALY). It was more robust to variations in assumptions around survival and response rate.

CONCLUSIONS

SBRT is associated with higher upfront costs than CRT. The ICER shows that, within the Canadian health care system, SBRT with 2 fractions is likely to be more cost-effective than CRT.

Palliative Radiotherapy in Non-small Cell Lung Cancer: Patterns of Use and Predictors of 30-Day Mortality in End-of-Life Care

Introduction Lung cancer is the leading cause of cancer-related deaths worldwide, with non-small cell lung cancer (NSCLC) being the most common type. More than half of patients require radiotherapy throughout their treatment. Palliative radiotherapy (PRT) is an important tool for symptom control and quality of life improvement in advanced NSCLC patients. However, the benefits of PRT must be balanced against possible disadvantages, especially in end-of-life (EOL) care. This study aims to describe the profile of PRT-treated deceased NSCLC patients, quantify the proportion of PRT recipients in the last 30 days of life and identify short-term survival prognostic factors in this group. Materials and methods This retrospective analysis was performed at two radiotherapy facilities within the Kent Oncology Centre, UK, for two years, running from January 1, 2022, to January 1, 2024. Data were collected from 857 deceased NSCLC patients who received PRT. Demographics, cancer diagnosis, histology, tumour, node, metastasis (TNM) staging, radiotherapy details, recent treatments, performance status (PS) and comorbidities were analysed. Patients have been stratified as long-term survivors (more than 30 days after PRT initiation, LTS group) along with short-term survivors (STS) (died within 30 days, STS group). Descriptive statistics, chi-squared tests, t-tests and multivariable logistic regression have been used in the data analysis. Results Out of 857 patients, 148 (17.3%) died within 30 days of PRT initiation. PS was considerably worse (p = 0.027), Adult Comorbidity Evaluation 27 (ACE-27) scores were higher (p = 0.018), and metastatic disease was more prevalent (60.1% vs. 47.5%, p = 0.02) in STS group patients. Fewer patients in the STS group completed their treatment compared to the LTS group (63.5% vs. 82.8%, p < 0.001). The STS group also received lower mean radiation dose (17.7 Gy vs. 19.6 Gy, p = 0.022) and fewer fractions (4.4 vs. 5.2, p = 0.019). The most common RT regimen in both cohorts was 20 Gy in five fractions, used in 55.4% of STS and 49.8% of LTS patients, with no significant difference in single fraction RT use between groups (33.1% in STS vs. 36.8% in LTS, p = 0.401). Multivariate logistic regression identified significant predictors of 30-day mortality: poorer PS (adjusted OR: 1.981, 95% CI: 1.33-3.12, p = 0.001), metastatic disease (adjusted OR: 2.02, 95% CI: 1.246-3.571, p = 0.002), incomplete PRT (adjusted OR: 0.337, 95% CI: 0.21-0.514, p < 0.001) and no recent chemotherapy (adjusted OR: 0.542, 95% CI: 0.342-0.941, p = 0.044). Conclusion This study demonstrated that compared with previous reports, a higher proportion of NSCLC patients who received PRT died within 30 days of treatment initiation, and low treatment adherence rates highlight challenges in EOL settings. Identification of poor PS and metastatic disease as predictors of short-term mortality would help inform PRT decision-making. The underutilisation of single-fraction radiotherapy and the link between recent chemotherapy and lower 30-day mortality warrant further study. These results highlight the need for better prognostic tools and more selective use of PRT, including increased consideration of single-fraction radiotherapy, in NSCLC patients approaching end of life and emphasise the importance of balancing benefit against treatment burden in this vulnerable population.

Comparative efficacy of palliative radiotherapy dose schedules in advanced bladder cancer-associated gross hematuria

Introduction

Gross hematuria (GH) in advanced/inoperable bladder cancer patients causes significant morbidity. Patients frequently need multiple transfusions. Hypofractionated radiotherapy (RT) has been shown to be effective in symptom palliation. In this study, we explore the efficacy of various fractionation regimens in these patients.

Methods

This single institute retrospective analysis was conducted on 60 consecutive patients treated with palliative RT. Fractionation (single versus multiple) and biologically equivalent doses (BED; high ≥36 Gy versus low <36 Gy) were used to compare the efficacy of various fractionation regimens. The primary outcome was the difference in objective response rate (ORR) between various strata at 2, 4, 8 and 12 weeks. Major secondary outcomes were differences in ORR according to Eastern Cooperative Oncology Group (ECOG) performance status (PS) and tumour node metastases (TNM) stage, and the proportion of patients requiring re-transfusion(s) at 12 weeks. Data were analysed using SPSS 23.

Results

Overall ORR at 2, 4, 8 and 12 weeks was 86%, 77%, 67% and 55%, respectively. There was no statistically significant difference in response rates between single or multi-fraction, or high versus low BED groups (All p = >0.05). Moreover, ECOG PS (p = 0.11) or TNM stage (p = 0.58) also had no impact on the response rate at 12 weeks. Nearly one-third (31%) of patients required further transfusions at 12 weeks.

Conclusion

RT is an effective modality to control GH. No difference in ORR was found between single fractions versus multiple fractions, or high versus low BED regimens. Single fraction RT can be offered to these patients considering low cost, patient convenience and minimal side effects.

An Update on the Management of Bone Metastases

PURPOSE OF REVIEW

Increasing life expectancy among patients with advanced cancer has placed a greater emphasis on optimizing pain control and quality of life. Concurrently, significant advancements in radiotherapy for bone metastases have permitted for dose escalation strategies such as stereotactic radiotherapy. This review aims to provide updated information on the management of bone metastases in light of these developments.

RECENT FINDINGS

We reviewed recent studies regarding the role and details of external beam radiotherapy for bone metastases, with emphasis on differences by treatment site as well as intention (palliative versus ablative for oligometastases). Conventional palliative radiotherapy remains a mainstay of management. While stereotactic radiotherapy may augment durability of pain relief and even survival time, there are significant questions remaining regarding optimal dosing and patient selection. Radiotherapy for bone metastases continues to evolve, particularly with increasing use of stereotactic radiotherapy. Future studies are needed to clarify optimal dose, fractionation, modality, and patient selection criteria among different radiotherapy approaches.

Replacing performance status with a simple patient-reported outcome in palliative radiotherapy prognostic modelling

Background and purpose

Prognostication is key to determining care in advanced incurable cancer. Although performance status (PS) has been shown to be a strong prognostic predictor, inter-rater reliability is limited, restricting models to specialist settings. This study assessed the extent to which a simple patient-reported outcome measure (PROM), the EQ-5D, may replace PS for prognosis of patients with bone metastases.

Materials and methods

Data from 1,011 patients in the Dutch Bone Metastasis Study were used. Cox proportional hazards models were developed to investigate the prognostic value of models incorporating PS alone, the EQ-5D SC dimension alone, all EQ-5D dimensions and EQ-VAS, and finally all dimensions and PS. Three prognostic groups were identified and performance assessed using the Harrell's C-index and Altman-Royston index of separation.

Results

Replacing performance status (PS) with the self-care (SC) dimension of the EQ-5D provides similar model performance. In our SC-based model, three groups are identified with median survival of 86 days (95 % CI 76-101), 174 days (95 % CI 145-213), and 483 days (95 % CI 431-539). Whilst not statistically significantly different, the C-index was 0.706 for the PS-only model, 0.718 for SC-only and 0.717 in our full model, suggesting patient-report outcome models perform as well as that based on PS.

Conclusion

Prognostic performance was similar across all models. The SC model provides prognostic value similar to that of PS, particularly where a prognosis of<6 months is considered. Larger, more contemporaneous studies are needed to assess the extent to which PROMs may be of prognostic value, particularly where specialist assessment is less feasible.

Single fraction image guided radiation therapy for management of bone metastases during the COVID-19 pandemic

Aim: Radiation therapy (RT) plays a major role in management of bone metastases, however, various dose-fractionation schemes are utilized taking into account patient, tumor, and treatment characteristics. The aim of this study was to assess Image Guided Single Fraction Radiation Therapy (IG-SFRT) for management of painful bone metastases during the COVID-19 pandemic. Material and Method: Patients receiving IG-SFRT for painful bone metastases were assessed for age, gender, primary cancer diagnosis, location of metastases, performance status, analgesic intake, pain relief, and overall treatment efficacy in this study. Results: Out of the total 65 patients treated with IG-SFRT during the course of COVID-19 pandemic at our department, 54 patients were evaluable for overall treatment efficacy analysis. Based on the international consensus on palliative RT endpoints, rates of complete response (CR), partial response (PR), pain progression (PP), and indeterminate response (IR) were 16.67%, 59.26%, 9.26%, 14.81%, respectively corresponding to an overall response rate of 75.93%. IG-SFRT was well tolerated by all patients without toxicity. Conclusion: For patients with bone metastases, pain palliation is a critical aspect of management. In view of the high rate of overall treatment efficacy achieved with IG-SFRT in our study, we suggest routine utilization of this image guided radiotherapeutic approach for management of painful bone metastases which additionally allows for minimization of treatment visits thereby improving patient and treatment facility convenience under the special circumstances of the recent COVID-19 pandemic.

Do Sustainable Palliative Single Fraction Radiotherapy Practices Proliferate or Perish 2 Years after a Knowledge Translation Campaign?

In early 2017, the Canadian Partnership Against Cancer and CancerCare Manitoba undertook a comprehensive knowledge translation (KT) campaign to improve the utilization of single fraction radiotherapy (SFRT) over multiple fraction radiotherapy (MFRT) for palliative management of bone metastases. The campaign significantly increased short-term SFRT utilization. We assess the time-dependent effects of KT-derived SFRT utilization 12–24 months removed from the KT campaign in a Provincial Cancer Program. This study identified patients receiving palliative radiotherapy for bone metastases in Manitoba in the 2018 calendar year using the provincial radiotherapy database. The proportion of patients treated with SFRT in 2018 was compared to 2017. Logistic regression analyses identified risk factors associated with MFRT receipt. In 2018, 1008 patients received palliative radiotherapy for bone metastasis, of which 63.3% received SFRT, a small overall increase in SFRT use over 2017 (59.1%). However, 41.1% of ROs demonstrated year-over-year decreases in SFRT utilization, indicative of a time-dependent loss of SFRT prescription habits derived from KT. Although SFRT use increased slightly overall in 2018, evidence of compliance fatigue was observed, suggestive of a time-perishing property of RO prescription behaviours derived from KT methodologies. Verification of the study’s findings in larger cohorts would be beneficial. These findings highlight the need for additional longitudinal KT reinforcement practices in the years following KT campaigns.

Translational Strategies to Target Metastatic Bone Disease

Metastatic bone disease is a common and devastating complication to cancer, confounding treatments and recovery efforts and presenting a significant barrier to de-escalating the adverse outcomes associated with disease progression. Despite significant advances in the field, bone metastases remain presently incurable and contribute heavily to cancer-associated morbidity and mortality. Mechanisms associated with metastatic bone disease perpetuation and paralleled disruption of bone remodeling are highlighted to convey how they provide the foundation for therapeutic targets to stem disease escalation. The focus of this review aims to describe the preclinical modeling and diagnostic evaluation of metastatic bone disease as well as discuss the range of therapeutic modalities used clinically and how they may impact skeletal tissue.

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.

Advances in radiotherapy in bone metastases in the context of new target therapies and ablative alternatives: A critical review

In patients with bone metastases (BM), radiotherapy (RT) is used to alleviate symptoms, reduce the risk of fracture, and improve quality of life (QoL). However, with the emergence of concepts like oligometastases, minimal invasive surgery, ablative therapies such as stereotactic ablative RT (SABR), radiosurgery (SRS), thermal ablation, and new systemic anticancer therapies, there have been a paradigm shift in the multidisciplinary approach to BM with the aim of preserving mobility and function survival. Despite guidelines on using single-dose RT in uncomplicated BM, its use remains relatively low. In uncomplicated BM, single-fraction RT produces similar overall and complete response rates to RT with multiple fractions, although it is associated with a higher retreatment rate of 20% versus 8%. Complicated BM can be characterised as the presence of impending or existing pathologic fracture, a major soft tissue component, existing spinal cord or cauda equina compression and neuropathic pain. The rate of complicated BM is around 35%. Unfortunately, there is a lack of prospective trials on RT in complicated BM and the best dose/fractionation regimen is not yet established. There are contradictory outcomes in studies reporting BM pain control rates and time to pain reduction when comparing SABR with Conventional RT. While some studies showed that SABR produces a faster reduction in pain and higher pain control rates than conventional RT, other studies did not show differences. Moreover, the local control rate for BM treated with SABR is higher than 80% in most studies, and the rate of grade 3 or 4 toxicity is very low. The use of SABR may be preferred in three circumstances: reirradiation, oligometastatic disease, and radioresistant tumours. Local ablative therapies like SABR can delay change or use of systemic therapy, preserve patients' Qol, and improve disease-free survival, progression-free survival and overall survival. Moreover, despite the potential benefit of SABR in oligometastatic disease, there is a need to establish the optial indication, RT dose fractionation, prognostic factors and optimal timing in combination with systemic therapies for SABR. This review evaluates the role of RT in BM considering these recent treatment advances. We consider the definition of complicated BM, use of single and multiple fractions RT for both complicated and uncomplicated BM, reirradiation, new treatment paradigms including local ablative treatments, oligometastatic disease, systemic therapy, physical activity and rehabilitation.

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.

Forequarter amputation post transarterial chemoembolization and radiation in synovial sarcoma: A case report

INTRODUCTION AND IMPORTANCE

Forequarter amputation or interscapulathoracalis amputation is a major amputation procedure that involves the entire upper extremity, scapula, and a whole or part of the clavicula. Forequarter amputation is commonly used to control bleeding in malignant tumor cases in which no treatment is available for the extremities.

CASE PRESENTATION

We report a case of forequarter amputation in a 25-year-old patient with synovial sarcoma. Transarterial chemoembolization (TACE) and radiation synovial sarcoma were performed in the patient to reduce bleeding. This technique may also be used for treating synovial sarcoma with massive bleeding.

CLINICAL DISCUSSION

Despite forequarter amputation indications in malignant tumor cases and recurrent cancer cases, the effectiveness of this technique remains unclear. The patient was readmitted with a recurrent mass three months after surgery.

CONCLUSION

In this study, TACE and radiotherapy are effective in controlling bleeding preoperatively and intraoperatively in patients with synovial sarcoma.

Single-Fraction Radiotherapy (SFRT) For Bone Metastases: Patient Selection And Perspectives

Bone metastases are a frequent and important source of morbidity in cancer patients. Stereotactic body radiation therapy (SBRT) is an established treatment option for local control and pain relief of bone metastases, and it is increasingly used as upfront treatment, postoperative consolidation or salvage treatment after prior RT. However, heterogeneity of dose schedules described in literature represents a severe limitation in the definition of the role of SBRT as a standard of care. No consensus is available on the use of single versus multiple fraction SBRT for bone metastases. Advantages of single-fraction SBRT include shorter overall duration of treatment, absence of inter-fraction uncertainty, improved compliance, theoretical increased efficacy, and lower costs. However, caution has been advised due to reports of severe late toxicities, in particular, vertebral collapse fracture (VCF). The aim of this paper is to review dose fractionation and indications for the management of bone metastases using SBRT.

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.

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.

Single-Fraction Stereotactic Body Radiotherapy for Oligometastatic Lymph Node Relapse in Prostate Cancer

BACKGROUND

Stereotactic body radiotherapy (SBRT) emerged as a treatment option in oligometastatic (≤3 metastases) patients experiencing lymph node relapse from treated prostate cancer. No recommendations are available concerning dose schedule, and available studies report the use of multiple-fraction regimens due to theoretical lower toxicity and higher cumulative dose delivered to the target. The aim of the present study was to evaluate the safety and efficacy of a dose-intensive, single-fraction SBRT regimen.

PATIENTS AND METHODS

Retrospective data on outcome and toxicity from 27 treatments on 23 consecutive patients were collected. Statistical analysis was performed.

RESULTS

Median follow-up was 22 months (range 6-63, interquartile range 15-28). Biochemical progression-free survival (bPFS) at 6 months, 1 year, and 2 years were 65%, 40%, and 26%, respectively. In 2 cases acute toxicity of grade 1 were observed.

CONCLUSION

Single-fraction SBRT for lymph node relapse of oligometastatic prostate cancer resulted in promising biochemical control with minimal toxicity.

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.

Real-world cost-effectiveness of cetuximab in the third-line treatment of metastatic colorectal cancer based on patient chart review in the Netherlands

OBJECTIVE

To assess the cost effectiveness of cetuximab in third-line treatment of patients with KRAS wild-type (wt) metastatic colorectal cancer (mCRC) in routine clinical practice compared with best supportive care (BSC).

METHODS

Patients (n = 287) with KRAS wt mCRC treated with cetuximab or BSC in eight hospitals in the Netherlands between 2009 and 2012 were included in our real-world study. Outcome measures were costs per life-year (LY) and costs per quality-adjusted LY (QALY) gained. A Markov model was developed, and a time horizon of four years was applied. Outcomes were calculated from Kaplan-Meier survival curves from patient-level data and literature. Direct medical costs were estimated in all centers (2013 values), and incremental cost-effectiveness ratios (ICERs) were calculated. Results were discounted, and a probabilistic sensitivity analysis was performed.

RESULTS

Administration of cetuximab in third-line treatment of mCRC resulted in a gain of 0.29 LYs and 0.25 QALYs compared with BSC. In the four-year study period, average discounted healthcare costs were €36,637 in the cetuximab group vs. €3648 in the BSC group. The discounted ICERs of cetuximab vs. BSC in the real-world setting were €114,907and €133,527 per LY and QALY gained, respectively.

CONCLUSIONS

Results of this cost-effectiveness analysis showed that third-line treatment with cetuximab for patients with KRAS (exon 2) wt mCRC offered clinical benefits at additional cost. The real-world ICERs were in line with those of previously published cetuximab and panitumumab cost-utility models.

A Palliative Radiation Oncology Consult Service Reduces Total Costs During Hospitalization

CONTEXT

Palliative radiation therapy (PRT) is a highly effective treatment in alleviating symptoms from bone metastases; however, currently used standard fractionation schedules can lead to costly care, especially when patients are treated in an inpatient setting. The Palliative Radiation Oncology Consult (PROC) service was developed in 2013 to improve appropriateness, timeliness, and care value from PRT.

OBJECTIVES

Our primary objective was to compare total costs among two cohorts of inpatients with bone metastases treated with PRT before, or after, PROC establishment. Secondarily, we evaluated drivers of cost savings including hospital length of stay, utilization of specialty-care palliative services, and PRT schedules.

METHODS

Patients were included in our observational cohort study if they received PRT for bone metastases at a single tertiary care hospital from 2010 to 2016. We compared total costs and length of stay using propensity score-adjusted analyses. Palliative care utilization and PRT schedules were compared by χ² and Mann-Whitney U tests.

RESULTS

We identified 181 inpatients, 76 treated before and 105 treated after PROC. Median total hospitalization cost was $76,792 (range $6380-$346,296) for patients treated before PROC and $50,582 (range $7585-$620,943) for patients treated after PROC. This amounted to an average savings of $20,719 in total hospitalization costs (95% CI [$3687, $37,750]). In addition, PROC was associated with shorter PRT schedules, increased palliative care utilization, and an 8.5 days reduction in hospital stay (95% CI [3.2,14]).

CONCLUSION

The PROC service, a radiation oncology model integrating palliative care practice, was associated with cost-savings, shorter treatment courses and hospitalizations, and increased palliative care.

Hypofractionated radiotherapy for complicated bone metastases in patients with poor performance status: a phase II international trial

Purpose:

To evaluate the efficacy and safety of hypofractionated radiotherapy (16 Gy in 2 fractions, 1 week apart) in patients with complicated bone metastases and poor performance status.

Methods:

A prospective single-arm phase II clinical trial was conducted from July 2014 to May 2016. The primary endpoint was pain response as defined in the International Consensus on Palliative Radiotherapy Endpoints. Secondary endpoints included quality of life as measured by quality of life questionnaire (QLQ) PAL-15 and QLQ-BM22 European Organisation for Research and Treatment of Cancer guidelines, pain flare, adverse events, re-irradiation, and skeletal complications.

Results:

Fifty patients were enrolled. There were 23 men with a median age of 58 years (range 26-86). Of the 50 patients, 38 had an extraosseous soft tissue component, 18 needed postsurgical radiation, 3 had neuropathic pain, and 3 had an impending fracture in a weight-bearing bone. At 2 months, 33 patients were alive (66%). Four (12.5%) had a complete response and 12 (37.5%) had a partial response. A statistically significant improvement was seen in the functional interference (p = 0.01) and psychosocial aspects (p = 0.03) of the BM22. No patient had spinal cord compression. One patient required surgery for pathologic fracture, and another re-irradiation.

Conclusions:

Hypofractionated radiotherapy (16 Gy in 2 fractions of 8 Gy 1 week apart) achieved satisfactory pain relief and safety results in patients with complicated bone metastases and poor performance status.

Comparative Evaluation of Two Hypofractionated Radiotherapy Regimens for Painful Bone Metastases

Aims and background

In 75% of the patients with bone metastases (BM) pain is the dominant symptom. Radiotherapy (XRT) plays a major role in the palliation of pain in patients with BM. Several schedules of short and long fractionation XRT are used in clinical practice, with hypofractionated treatments being even more attractive for practical reasons. A considerable body of evidence supports the clinical use of short schedules and single-dose XRT. We retrospectively evaluated the efficacy of two short fractionated schedules of 8 Gy as a single dose and 20 Gy in 5 fractions in relieving pain in patients with multiple uncomplicated BM.

Method

From January to December 2001, 130 patients with 146 painful BM were treated with palliative localized XRT. There were 42 males and 88 females with a median age of 58 years (range 28–84). The commonest sites of treatment were the spine (59.6%) and pelvis (14.4%). The primary endpoint was clinically significant pain relief in the first six months of follow-up evaluated with the IAEA (International Atomic Energy Agency) pain measurement score measuring pain severity and pain frequency. Analgesic use was also recorded before and after treatment as drug frequency and drug severity. Patients with painful BM from any primary tumor site were irradiated. Treatment schedules consisted of a course of XRT with 4 Gy/fraction/day (total dose: 20 Gy/5 fractions) (group A, 59 lesions) or with a single dose of 8 Gy (group B, 87 lesions).

Results

There was no significant difference in complete response (CR) rates between treatment schedules: complete pain relief was achieved in 17/59 lesions (29%) in the fractionated group and in 29/87 lesions (33%) in the single-dose group. Also the overall response (complete + partial) was similar: 35/59 lesions (60%) in group A and 60/87 (69%) in group B. The minimum, maximum and median follow-up was 3, 23, and 9 months, respectively, for group A and 3, 20, and 11 months for group B. The actuarial median duration of pain relief was similar: 4.5 months in group A and 4 months in group B. No particular side effects were recorded in either group.

Conclusions

There were no differences between the two fractionation schedules used in our study with regard to pain relief and use of analgesics. Palliation of pain was obtained in approximately two thirds of patients with both schedules, providing further evidence of the similar efficacy between single and multiple fractions. With regard to pain response these data justify a recommendation for the use of a more simple and convenient 8 Gy single fraction for the palliation of uncomplicated BM.

Cost-Effectiveness of Treatments for the Management of Bone Metastases: A Systematic Literature Review

BACKGROUND

Metastatic cancers occur when cancer cells break away from the primary tumour. One of the most common sites of metastasis is the bone, with several therapeutic options currently available for managing bone metastases. In a resource-constrained environment, policy makers and practitioners need to know which options are cost effective.

OBJECTIVE

The aim of this systematic review was to review and appraise published economic evaluations on treatments for the management of bone metastases.

METHODS

We searched eight bibliographic databases (MEDLINE, MEDLINE in Process, EMBASE, CSDR, DARE, HTA, EED and CPCI) for relevant economic evaluations published from each database's inception date until March 2017. Study selection, quality assessment and data extraction were carried out according to published guidelines.

RESULTS

Twenty-four relevant economic analyses were identified. Seventeen of these studies focused on bone metastases resulting from a particular type of cancer, i.e. prostate (n = 8), breast (n = 7), lung (n = 1) or renal (n = 1), while seven report results for various primary tumours. Across types of cancer, evidence suggests that bisphosphonates result in lower morbidity and improved quality of life, for an additional cost, which is typically below conventional cost-effectiveness thresholds. While denosumab leads to health gains compared with zoledronic acid, it also results in substantial additional costs and is unlikely to represent value for money. The limited literature on the radiopharmaceutical strontium-89 (Sr89) and external beam radiotherapy (EBR) suggest that these treatments are cost effective compared with no treatment.

CONCLUSIONS

The reviewed evidence suggests that bisphosphonate treatments are cost-effective options for bone metastases, while denosumab is unlikely to represent value for money. Evidence on EBR and Sr89 is limited and less conclusive.

The rise of reimbursement-based medicine: the case of bone metastasis radiation treatment

It has been hypothesised that the reimbursement system pertaining to radiotherapy is influencing prescription practices for patients with cancer with bone metastases. In this paper, we present and discuss the results of an empirical study that was undertaken on patient records, referred to radiotherapy for the treatment of bone metastases, in a medium-size city, in southern Brazil, during the period of March 2006 to March 2014. Our findings seem to confirm this hypothesis: after a change in the reimbursement method, radiation prescriptions were adapted accordingly, in order to maximise profits. Once such patients become highly vulnerable due to their diagnoses, they also become susceptible to a subtle form of exploitation; physicians let patients believe that more radiation will be better for their health, and they do so despite knowing otherwise, and as it seems, out of pecuniary interests.

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.

Quality of life assumptions determine which cervical cancer screening strategies are cost-effective

Quality-adjusted life years are used in cost-effectiveness analyses (CEAs). To calculate QALYs, a "utility" (0-1) is used for each health state induced or prevented by the intervention. We aimed to estimate the impact of quality of life (QoL) assumptions (utilities and durations of health states) on CEAs of cervical cancer screening. To do so, 12 alternative sets of utility assumptions were retrieved from published cervical cancer screening CEAs. Two additional sets were based on empirical QoL data that were integrally obtained through two different measures (SF-6D and EQ-5D) from eight groups of women (total n = 3,087), from invitation for screening to diagnosis with cervical cancer. Per utility set we calculated the number of quality-adjusted days lost (QADL) for each relevant health state in cervical cancer screening, by multiplying the study-specific assumed disutilities (i.e., 1-utility) with study-specific durations of the loss in QoL, resulting in 14 "QADL-sets." With microsimulation model MISCAN we calculated cost-effectiveness of 342 alternative screening programs (varying in primary screening test [Human Papillomavirus (HPV) vs. cytology], starting ages, and screening interval) for each of the 14 QADL-sets. Utilities used in CEAs appeared to differ largely. We found that ten QADL-sets from the literature resulted in HPV and two in cytology as preferred primary test. The SF-6D empirical QADL-set resulted in cytology and the EQ-5D one in HPV as preferred primary test. In conclusion, assumed utilities and health state durations determine cost-effectiveness of cervical cancer screening. Also, the measure used to empirically assess utilities can be crucial for CEA conclusions.

The INTER-ROMA Project - a Survey among Italian Radiation Oncologists on Their Approach to the Treatment of Bone Metastases

Aims and background

Radiotherapy has an established palliative role for bone metastases but despite the large number of patients treated there is still controversy surrounding the optimal radiotherapy schedule to prescribe. The aim of this survey was to determine the decision patterns of Italian radiation oncologists in four different clinical cases of patients with bone metastases.

Methods and study design

During the latest national meeting of the Italian Association of Radiation Oncology (AIRO), four clinical cases were presented to attending radiation oncologists. The cases were different with respect to the histology of the primary tumor, performance status, pain before and after analgesics, tumor site, and radiological characteristics of the metastatic lesions. For each clinical case the respondents were asked to give an indication for treatment; prescribe doses, volumes and treatment field arrangements; decide whether to prescribe prophylactic supportive therapy or not; and provide information about factors that particularly influenced prescription. Finally, a descriptive statistical analysis was performed.

Results

Three hundred questionnaires were distributed to radiation oncologists attending the congress. One hundred twenty-five questionnaires were returned but only 122 (40.6%) were adequately completed and considered for the analysis. Considerable differences were observed among radiation oncologists in prescribing and delivering radiotherapy for bone metastases. There was also a notable divergence from international guidelines, which will be discussed in this report.

Conclusions

Despite the results of clinical trials, Italian radiation oncologists differ considerably in their decisions on treatment doses and volumes. National guidelines are needed in order that patients can be treated uniformly and better data will become available for evidence-based palliative radiotherapy.

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.

Cost evaluations of radiotherapy: What do we know? An ESTRO-HERO analysis

Although economic evidence is becoming mandatory to support health care decision-making, challenges remain in generating high quality cost data, especially for complex and rapidly evolving treatment modalities, such as radiotherapy. The overall aim of this systematic literature review was to critically analyse the type and quality of radiotherapy cost information available in cost calculation studies, from the health care provider's perspective, published since 1981. A selection process, based on strict and explicit criteria, yielded 52 articles. In spite of meeting our criteria these studies displayed large heterogeneity in scope, costing method, inputs and outputs. The limited use of conventional costing methodologies along with insufficient information on resource inputs hampered comparability across studies. A consistent picture of radiotherapy costs, based on methodologically sound costing studies, has yet to emerge. These results call for developing a well-defined and generally accepted cost methodology for performing economic evaluation studies in radiotherapy.

Cost-Utility Analysis of Single-Fraction Versus Multiple-Fraction Radiotherapy in Patients with Painful Bone Metastases: An Iranian Patient's Perspective Study

OBJECTIVES

To evaluate two of the various treatment strategies of bone metastasis- single-fraction radiotherapy and multiple-fraction radiotherapy.

METHODS

A multistage Markov decision model was applied to assess the incremental costs per quality-adjusted life-year (QALY) gained of single fraction against multiple fractions. The model had a monthly cycle length over a lifetime horizon with 1000 hypothetical cohort samples. The EuroQol five-dimensional questionnaire was used to estimate the health-related quality of life in patients. To cope with parameters of uncertainty, we conducted a probabilistic sensitivity analysis using a Monte-Carlo simulation technique. Both cost and utility variables were discounted by 3% in the base model. Strategies were assessed considering a willingness-to-pay threshold of US $6578 per QALY gained.

RESULTS

The expected mean cost and quality-adjusted life-years were, respectively, US $447.28 and 5.95 months for patients receiving single-fraction radiotherapy and US $1269.66 and 7.87 months for those receiving multiple-fraction radiotherapy. The incremental cost-utility ratio was US $428.38 per QALY. Considering the Iranian gross domestic product per capita (US $6578) as the recommended willingness to pay for 1 QALY gained, the multiple-fraction method was found to be a cost-effective strategy.

CONCLUSIONS

Policymakers should advocate the multiple-fraction method instead of the single-fraction method in the treatment of patients with painful bone metastases.

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.

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 use of Quality-Adjusted Life Years in cost-effectiveness analyses in palliative care: Mapping the debate through an integrative review

BACKGROUND

In cost-effectiveness analyses in healthcare, Quality-Adjusted Life Years are often used as outcome measure of effectiveness. However, there is an ongoing debate concerning the appropriateness of its use for decision-making in palliative care.

AIM

To systematically map pros and cons of using the Quality-Adjusted Life Year to inform decisions on resource allocation among palliative care interventions, as brought forward in the debate, and to discuss the Quality-Adjusted Life Year's value for palliative care.

DESIGN

The integrative review method of Whittemore and Knafl was followed. Theoretical arguments and empirical findings were mapped.

DATA SOURCES

A literature search was conducted in PubMed, EMBASE, and CINAHL, in which MeSH (Medical Subject Headings) terms were Palliative Care, Cost-Benefit Analysis, Quality of Life, and Quality-Adjusted Life Years.

FINDINGS

Three themes regarding the pros and cons were identified: (1) restrictions in life years gained, (2) conceptualization of quality of life and its measurement, including suggestions to adapt this, and (3) valuation and additivity of time, referring to changing valuation of time. The debate is recognized in empirical studies, but alternatives not yet applied.

CONCLUSION

The Quality-Adjusted Life Year might be more valuable for palliative care if specific issues are taken into account. Despite restrictions in life years gained, Quality-Adjusted Life Years can be achieved in palliative care. However, in measuring quality of life, we recommend to-in addition to the EQ-5D- make use of quality of life or capability instruments specifically for palliative care. Also, we suggest exploring the possibility of integrating valuation of time in a non-linear way in the Quality-Adjusted Life Year.

Health-related Quality of Life in Patients with Metastatic Spinal Cord Compression

OBJECTIVE

Improvements in cancer treatment have resulted in an increased number of patients with metastatic spinal cord compression (MSCC). Because patients with MSCC often have a limited expected survival time, maintenance of a high functional level and quality of life are important. However, there is limited information about health-related quality of life (HRQoL) in patients with MSCC. The aim of this study was to examine the feasibility of routine assessment of HRQoL based on the Euroqol-5 dimensions (EQ-5D) questionnaire in a cohort of patients consecutively admitted for evaluation of acute symptoms of MSCC.

METHODS

From 1 January to 31 December 2011, 544 patients diagnosed with acute symptoms of MSCC were consecutively enrolled in a cohort study. All patients were evaluated through a centralized referral system at one treatment facility. Data were prospectively registered, the variables age, sex, primary oncologic diagnosis, Tokuhashi Revised score, EQ-5D score and treatment modality being recorded on admission. The study patients were treated conservatively with radiotherapy alone or with surgery and subsequent radiotherapy. The EQ-5D questionnaire was administered on admission (baseline) and 6, 12, 26 and 52 weeks after admission. Response rates, completion rates and HRQoL scores were analyzed by relevant subgroups. Response rates were based on all questionnaires returned regardless of whether or not they had been completed, whereas completion rates were based on fully completed questionnaires (i.e., containing responses to all five questions.

RESULTS

The mean age was 65 years (range, 20-95 years); 57% of the patients were men. The overall response rate to the Euroqol-5 dimensions (EQ-5D) questionnaires was 84% and the overall completion rate 72%. At baseline, mean EQ-5D scores were significantly lower for patients treated with surgery and subsequent radiotherapy 0.28 (95% CI, 0.19-0.36) than for those treated with radiotherapy alone 0.42 (95% CI, 0.38-0.46). At the one-year follow-up, the mean EQ-5D scores had improved to 0.71 (95% CI, 0.64-0.77) for patients treated with surgery and subsequent radiotherapy and 0.63 (95% CI, 0.56-0.70) for patients treated with radiotherapy alone.

CONCLUSIONS

Measurement of HRQoL in patients consecutively admitted for evaluation of acute symptoms of MSCC is feasible and detects significant changes over time between treatment modalities and different strata of expected survival.

A Simple Scoring System Predicting the Survival Time of Patients with Bone Metastases after RT

Objectives

This study aimed to develop a scoring system to predict the survival time of patients with bone metastases after radiation therapy (RT). The scoring system can guide physicians to a better selection of appropriate treatment regimens.

Materials and Methods

The medical records of 125 patients with bone metastases treated with RT between January 2007 and September 2010 were reviewed retrospectively. Fifteen potential prognostic factors were investigated: sex, age, Karnofsky performance score (KPS), type of primary tumor, resection of tumor before bone metastases, interval between primary tumor diagnosis and diagnosis of bone metastases, Carcinoembryonic Antigen(CEA), lung metastases before bone metastases, liver metastases before bone metastases, brain metastases before bone metastases, stage, T, N, M, and degree of cellular differentiation.

Results

In an univariate analysis, 10 factors were significantly associated with survival time after bone metastasis: sex, KPS, breast cancer, esophageal cancer, colorectal cancer, interval between tumor diagnosis and diagnosis of bone metastases, CEA, lung metastases before bone metastases, T-staging, and differentiation. In a multivariate analysis, 7 factors were found to be significant: sex, KPS, esophageal cancer, colorectal cancer, interval between tumor diagnosis and diagnosis of bone metastases, T-staging, and differentiation. The median survival of all patients with bone metastases after RT was 14.1 months. There were significant differences in the median survival of patients with bone metastases after RT of 4.9 months, 10.5 months, and 29.7 months in groups 1, 2, and 3, respectively (P<0.001).

Conclusion

According to this scoring system, the survival time of patients after bone metastasis can be estimated.

Economic evaluation of single-fraction versus multiple-fraction palliative radiotherapy for painful bone metastases in breast, lung and prostate cancer

INTRODUCTION

Single- and multiple-fraction external beam radiotherapy (SFX-EBRT and MFX-EBRT) are palliative treatment options for localized metastatic bone pain. MFX is the preferred choice in many developed countries. Evidence shows little difference in how effectively SFX and MFX reduce pain. However, SFX is associated with higher retreatment and (in one meta-analysis) pathological fracture rates. MFX is, however, more time-consuming and expensive. We estimated the cost-effectiveness of SFX versus MFX for metastatic bone pain in breast, prostate and lung cancer in New Zealand.

METHODS

We constructed a Markov microsimulation model to estimate health gain (in quality-adjusted life-years or QALYs), health system costs (in real 2011 NZ dollars) and cost-effectiveness. The model was populated using effect estimates from randomized controlled trials and other studies, and New Zealand cancer and cost data. Disability weights from the 2010 Global Burden of Disease study were used in estimating QALYs.

RESULTS

Across all three cancers, QALY gains were similar for SFX compared to MFX, and per patient costs were less for SFX than MFX, with a difference of NZ$1469 (95% uncertainty interval $1112 to $1886) for lung cancer, $1316 ($810 to $1854) for prostate cancer and $1344 ($855 to $1846) for breast cancer. Accordingly, from a cost-effectiveness perspective, SFX was the preferable treatment option. Various sensitivity analyses did not overturn the clear preference for SFX.

CONCLUSION

For all three cancers, SFX was clearly more cost-effective than MFX. This adds to the case for desisting from offering MFX to patients with metastatic bone pain, from a cost-effectiveness angle.

Cost-effectiveness of using a gene expression profiling test to aid in identifying the primary tumour in patients with cancer of unknown primary

We aimed to investigate the cost-effectiveness of a 2000-gene-expression profiling (GEP) test to help identify the primary tumor site when clinicopathological diagnostic evaluation was inconclusive in patients with cancer of unknown primary (CUP). We built a decision-analytic-model to project the lifetime clinical and economic consequences of different clinical management strategies for CUP. The model was parameterized using follow-up data from the Manitoba Cancer Registry, cost data from Manitoba Health administrative databases and secondary sources. The 2000-GEP-based strategy compared to current clinical practice resulted in an incremental cost-effectiveness ratio (ICER) of $44,151 per quality-adjusted life years (QALY) gained. The total annual-budget impact was $36.2 million per year. A value-of-information analysis revealed that the expected value of perfect information about the test's clinical impact was $4.2 million per year. The 2000-GEP test should be considered for adoption in CUP. Field evaluations of the test are associated with a large societal benefit.

The potential harms of primary human papillomavirus screening in over-screened women: a microsimulation study

BACKGROUND

It is well acknowledged that HPV testing should not be performed at young age and at short intervals. Cytological screening practices have shown that over-screening, i.e., from a younger age and at shorter intervals than recommended, is hard to avoid. We quantified the consequences of a switch to primary HPV screening for over-screened women, taking into account its higher sensitivity but lower specificity than cytology.

METHODS

The health effects of using the HPV test instead of cytology as the primary screening method were determined with the MISCAN-Cervix model. We varied the age women start screening and the interval between screens. In the sensitivity analyses, we varied the background risk of cervical cancer, the HPV prevalence, the discount rate, the triage strategy after cytology, and the test characteristics of both cytology and the HPV test.

RESULTS

For women screened 5 yearly from age 30, 32 extra deaths per 100,000 simulated women were prevented when switching from primary cytology to primary HPV testing. For annual screening from age 20, such a switch resulted in 6 extra deaths prevented. It was associated with 9,044 more positive primary screens in the former scenario versus 76,480 in the latter. Under all conditions, for women screened annually, switching to HPV screening resulted in a net loss of quality-adjusted life years.

CONCLUSION

For over-screened women, the harms associated with a lower test specificity outweigh the life years gained when switching from primary cytology to primary HPV testing. The extent of over-screening should be considered when deciding on inclusion of primary HPV screening in cervical cancer screening guidelines.