Radiotherapy fractionation for the palliation of uncomplicated painful bone metastases – an evidence-based practice guideline

Wu, Jackson; Wong, Rebecca; Lloyd, Nancy; Johnston, Mary; Bezjak, Andrea; Whelan, Timothy J.

doi:10.1186/1471-2407-4-71

Cited by 124 publications

(93 citation statements)

References 29 publications

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“…The bone metastases from pca are often radiosensitive, and most men will experience partial or complete pain relief with radiation to a specific lesion. Studies have shown that a single fraction is as effective as 5 fractions in providing palliation 31 , but more patients receiving a single fraction require re-treatment for pain recurrence.…”

Section: Palliative Radiationmentioning

confidence: 99%

Current Management of Castrate-Resistant Prostate Cancer

2010

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Prostate cancer (pca) is the most frequently diagnosed cancer in North America. Castrate-resistant pca presents a spectrum of disease ranging from rising psa levels in the absence of metastases or symptoms and despite androgen-deprivation therapy, to metastases and significant debilitation from cancer symptoms. Castrate-resistant pca is usually suspected in patients with new symptoms on androgen deprivation therapy, with a rising psa, or with new evidence of disease on bone scans or computed tomography scans. Institution of treatment and the choice of systemic or local therapy depend on a number of factors. This review discusses the various currently available treatments for patients with castrate-resistant pca, from secondary hormonal manipulations to options for postdocetaxel systemic therapy. KEY WORDSCastrate-resistant prostate cancer, systemic treatment

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Section: Palliative Radiationmentioning

confidence: 99%

Current Management of Castrate-Resistant Prostate Cancer

2010

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“…Radiation can improve pain symptoms in 50%-60% of patients and should routinely be considered. For most patients, data support the use of short-course radiation (that is, a single faction) rather than longer courses 61,62 . To support patient-centred care, many institutions have set up specific radiation clinics for the management of symptomatic bone metastases.…”

Section: Bone Directed Therapymentioning

confidence: 99%

The Importance of Multidisciplinary Team Management of Patients with Non-Small-Cell Lung Cancer

Ellis

2012

Current Oncology

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Historically, a simple approach to the treatment of non-small-cell lung cancer (nsclc) was applicable to nearly all patients. Recently, a more complex treatment algorithm has emerged, driven by both pathologic and molecular phenotype. This increasing complexity underscores the importance of a multidisciplinary team approach to the diagnosis, treatment, and supportive care of patients with nsclc. A team approach to management is important at all points: from diagnosis, through treatment, to end-of-life care. It also needs to be patient-centred and must involve the patient in decision-making concerning treatment. Multidisciplinary case conferencing is becoming an integral part of care. Early integration of palliative care into the team approach appears to contribute significantly to quality of life and potentially extends overall survival for these patients. Supportive approaches, including psychosocial and nutrition support, should be routinely incorporated into the team approach. Challenges to the implementation of multidisciplinary care require institutional commitment and support. KEY WORDSNon-small-cell lung cancer, multidisciplinary care INTRODUCTIONLung cancer is a major public health problem and the cause of the largest number of deaths from cancer in Canada, with approximately 25,500 new cases having been diagnosed and 20,600 deaths having occurred in 2011 1 . Despite the magnitude of this health problem, significant stigmas are associated with a diagnosis of lung cancer 2,3 . Questions have even been raised about whether treatment should be offered for a smoking-related illness. Historically, much nihilism surrounds the effectiveness of systemic therapies, and only since the early 1990s has sufficient evidence been developed to support the routine use of chemotherapy for advanced nonsmall-cell lung cancer (nsclc) 4 .Fortunately, significant advances in the management of nsclc have been made since 2000. Data have emerged supporting not only first-, but also secondand third-line therapies [5][6][7] . Postoperative adjuvant therapy has become the standard of care for many patients with resected nsclc 8,9 . Combined-modality treatment approaches-either chemoradiation 10 or trimodality treatments 11 -are widely adopted for well-functioning patients with locally advanced disease. Histologic differentiation of squamous from non-squamous disease has become a factor in treatment selection 12 , and the discovery of molecular abnormalities in the EGFR (epidermal growth factor receptor) gene 13,14 and the ALK (anaplastic lymphoma kinase) gene 15 have led to treatment approaches driven by the molecular profile of tumours 16,17 . All of those changes have moved treatment from a simple approach applicable in most patients to a more complicated algorithm in which histology and molecular phenotype are important factors. This increasing complexity underscores the importance of taking a multidisciplinary approach to management that extends throughout the continuum of care from diagnosis to supportive and end-of-lif...

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Section: Expert Commentarymentioning

confidence: 99%

“…The slow adoption of evidencebased practice is most probably caused by factors other than highquality scientific evidence. For certain subgroups of patients with neuropathic pain [24], soft-tissue component around the bone metastasis [28], good performance status and limited or absent extraosseous metastases [25][26][27], multiple-fraction radiotherapy may offer an advantage. In the TROG trial comparing a single 8-Gy fraction and 20 Gy in five fractions for neuropathic pain, the latter was demonstrated to be marginally better than the former dose regimen.…”

Section: Editorialmentioning

confidence: 99%

“…In the rare situation where very limited uncomplicated bone metastases from favorable histologies, such as breast cancer, are present without associated extraosseous metastases, a multiple-fraction regimen delivering a higher total dose may be beneficial [25][26][27]. Also, in circumstances where there is presence of a soft-tissue mass around the bone metastasis or the bone metastasis is located in a weight-bearing bone, or when there is neuropathic pain associated with the bone metastasis, multiple-fraction radiotherapy may be appropriate in patients with good performance status [24,28].For patients with high-risk femoral metastases (defined as axial cortical involvement of >3 cm) not suitable for prophylactic fixation, a multiple-fraction regimen delivering a higher dose of radiation may be appropriate to reduce the risk of pathological fracture [29]. Unfortunately, this well-researched standard of care of using a single 8-Gy fraction has not been adopted worldwide, especially in the USA.…”

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confidence: 99%

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Should all patients with uncomplicated bone metastases be treated with a single 8-Gy fraction?

Holden

Lutz

et al. 2010

Expert Review of Pharmacoeconomics & Outcomes Research

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Should all patients with uncomplicated bone metastases be treated with a single 8-Gy fraction?Expert Rev. Pharmacoeconomics Outcomes Res. 10(2), 95-98 (2010) "Most patients with metastatic disease have a limited lifespan.Protracted treatment regimens may consume a significant proportion of the patient's remaining life; therefore, a single 8-Gy fraction can be a very timely and cost-effective treatment."A substantial proportion of cancer patients will develop metastatic disease in the skeleton. Bone metastases can cause significant morbidity, resulting from severe pain and pathological fracture. The treatment options for painful bone metastases include analgesics, bisphosphonates, surgical intervention and radiotherapeutic treatments, including external beam radiation therapy, hemibody irradiation and radiopharmaceuticals [1,2]. For patients with complicated bone metastases, such as spinal cord compression associated with vertebral metastases or pathological/impending fracture, surgical intervention in the form of decompression surgery or prophylactic/ therapeutic internal fixation may be needed together with radiation treatment. For uncomplicated bone metastases, nonsurgical approaches are typically used. External beam radiotherapy is arguably the most commonly used modality for the treatment of uncomplicated bone metastases. The goal of palliative radiotherapy for bone metastases is to rapidly improve the quality of life of patients. The most desirable treatment should be clinically efficacious, minimally toxic, time efficient and cost effective. Different radiotherapy regimens, including single-fraction and multiplefraction regimens, are used [2][3][4][5][6]. Multiple randomized trials have demonstrated the equivalence of single-fraction and multiple-fraction palliative radio therapy for uncomplicated bone metastases [3][4][5][6][7][8][9][10][11][12][13][14][15][16]. The question is: should all patients with uncomplicated bone metastases be treated with a single fraction of 8 Gy? [14]. In this trial, the late toxicity rates were similar between the two groups [14]. From the financial stand point, a single 8-Gy fraction costs much less than a multiple-fraction regimen [2]. Cons of a single 8-Gy fractionIn a reana lysis of an RTOG study, Blitzer found that number of fractions related to complete combined relief in terms of absence of pain and cessation of the use of narcotics was statistically significant [18].Simon S Lo, MB, ChB, DABR Ben-Josef et al. suggested that there was a radiation dose-response relationship for pain relief, and that a higher prescribed total dose would provide better long-term palliation of pain compared with short-course lower total dose treatment [19]. Koswig and Budach found that more remineralization occurred in patients treated with a multiple-fraction regimen of 30 Gy in ten fractions compared with those treated with a single 8-Gy fraction [20]. In multiple randomized trials comparing single-fraction and multiple-fraction radiation therapy for the palliation of painful bone met...

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Radiotherapy fractionation for the palliation of uncomplicated painful bone metastases – an evidence-based practice guideline

Abstract: Background: This practice guideline was developed to provide recommendations to clinicians in Ontario on the preferred standard radiotherapy fractionation schedule for the treatment of painful bone metastases.

Cited by 124 publications

References 29 publications

Current Management of Castrate-Resistant Prostate Cancer

Current Management of Castrate-Resistant Prostate Cancer

The Importance of Multidisciplinary Team Management of Patients with Non-Small-Cell Lung Cancer

Should all patients with uncomplicated bone metastases be treated with a single 8-Gy fraction?

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