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

Abstract

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

Hospice Providers Awareness of the Benefits and Availability of Single-Fraction Palliative Radiotherapy

“…This can include nausea, abdominal cramping, constipation, cognitive impairment, and hallucinations. 6,14 Unfortunately, as in earlier reports demonstrating less than 10% of hospice agencies utilize radiotherapy in any of their cancer patients, 6 very few patients (G1%) from the surveyed agencies were referred for palliative RT over the past year. 4 This alternative approach, although more clinically effective than opioids, is unfortunately rarely used for hospice patients because of the expense and travel burden of multiple visits.…”

Management of Patients With Metastatic Renal Cell Cancer and Bone Metastases

“…Finally, the subgroup of patients who developed bone metastases later during the course of disease was too small to perform meaningful analyses. The optimal integration of local treatment, such as surgery or stereotactic radiotherapy, especially in patients with few metastatic lesions, is a topic of ongoing research (22,23). In principle, such approaches may contribute to bone stability, reduced symptoms and better disease control.…”

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

“…Uncomplicated bone metastasis is defined as bone lesion not causing neurological complaints and without a high risk of pathological fracture 7. The data were prospectively collected from a database in which physicians register their prescriptions online for the sake of reimbursement.…”

“…Estimated Medicare reimbursement is US$603 in the first case and between US$1508 and US$2221 in the following one 10. In contrast, in countries with case-payment strategies rather than fee-for-service strategies, such as in Canada or in Norway, approximately 40% of patients with the same diagnosis receive single-dose irradiation treatment 7. This percentage is still low compared with what is suggested by the clinical evidence, but the contrast with the previous examples is stark.…”