Randomized trial of 8Gy in 1 versus 20Gy in 5 fractions of radiotherapy for neuropathic pain due to bone metastases (Trans-Tasman Radiation Oncology Group, TROG 96.05)

Roos, Daniel; Turner, Sandra; O’Brien, Peter C.; Smith, Jennifer; Spry, Nigel; Burmeister, Bryan; Hoskin, Peter; Ball, David

doi:10.1016/j.radonc.2004.09.017

Cited by 226 publications

(130 citation statements)

References 17 publications

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“…There was no difference in the overall or the complete response rate. There were no statistically significant differences in the rates of retreatment, spinal cord compression or pathological fracture between the two regimens [24]. Time to treatment failure was slightly worse for the single-fraction arm compared with the multiple-fraction arm (2.4 vs 3.7 months), although the overall outcomes did not show any statistical significance.…”

mentioning

confidence: 72%

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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confidence: 72%

Section: Expert Commentarymentioning

confidence: 99%

Section: Editorialmentioning

confidence: 99%

mentioning

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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“…Although the efficacy and safety of radiotherapy using a single direct field for spinal bone metastases have been proven through numerous clinical trials for both single-and multi-fraction radiotherapy [7][8][9][10][11][12][13][14][15], a large number of respondents stated that they never use a single direct field for spinal bone metastases. Those who never use a single direct field may prefer to use parallel opposing fields or highly conformal radiotherapy.…”

Section: Discussionmentioning

confidence: 99%

Variability in the Point to Which Single Direct Field Irradiation is Prescribed for Spinal Bone Metastases: A Survey of Practice Patterns in Japan

Nakamura¹,

Shikama

Wada³

et al. 2012

International Journal of Radiation Oncology*Biology*Physics

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

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Implementation Strategies to Promote Short-Course Radiation for Bone Metastases

Gillespie,

Santos,

Curry

et al. 2024

JAMA Netw Open

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ImportanceFor patients with nonspine bone metastases, short-course radiotherapy (RT) can reduce patient burden without sacrificing clinical benefit. However, there is great variation in uptake of short-course RT across practice settings.ObjectiveTo evaluate whether a set of 3 implementation strategies facilitates increased adoption of a consensus recommendation to treat nonspine bone metastases with short-course RT (ie, ≤5 fractions).Design, Setting, and ParticipantsThis prospective, stepped-wedge, cluster randomized quality improvement study was conducted at 3 community-based cancer centers within an existing academic-community partnership. Rollout was initiated in 3-month increments between October 2021 and May 2022. Participants included treating physicians and patients receiving RT for nonspine bone metastases. Data analysis was performed from October 2022 to May 2023.ExposuresThree implementation strategies—(1) dissemination of published consensus guidelines, (2) personalized audit-and-feedback reports, and (3) an email-based electronic consultation platform (eConsult)—were rolled out to physicians.Main Outcomes and MeasuresThe primary outcome was adherence to the consensus recommendation of short-course RT for nonspine bone metastases. Mixed-effects logistic regression at the bone metastasis level was used to model associations between the exposure of physicians to the set of strategies (preimplementation vs postimplementation) and short-course RT, while accounting for patient and physician characteristics and calendar time, with a random effect for physician. Physician surveys were administered before implementation and after implementation to assess feasibility, acceptability, and appropriateness of each strategy.ResultsForty-five physicians treated 714 patients (median [IQR] age at treatment start, 67 [59-75] years; 343 women [48%]) with 838 unique nonspine bone metastases during the study period. Implementing the set of strategies was not associated with use of short-course RT (odds ratio, 0.78; 95% CI, 0.45-1.34; P = .40), with unadjusted adherence rates of 53% (444 lesions) preimplementation vs 56% (469 lesions) postimplementation; however, the adjusted odds of adherence increased with calendar time (odds ratio, 1.68; 95% CI, 1.20-2.36; P = .003). All 3 implementation strategies were perceived as being feasible, acceptable, and appropriate; only the perception of audit-and-feedback appropriateness changed before vs after implementation (19 of 29 physicians [66%] vs 27 of 30 physicians [90%]; P = .03, Fisher exact test), with 20 physicians (67%) preferring reports quarterly.Conclusions and RelevanceIn this quality improvement study, a multicomponent set of implementation strategies was not associated with increased use of short-course RT within an academic-community partnership. However, practice improved with time, perhaps owing to secular trends or physician awareness of the study. Audit-and-feedback was more appropriate than anticipated. Findings support the need to investigate optimal approaches for promoting evidence-based radiation practice across settings.

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Randomized trial of 8Gy in 1 versus 20Gy in 5 fractions of radiotherapy for neuropathic pain due to bone metastases (Trans-Tasman Radiation Oncology Group, TROG 96.05)

Cited by 226 publications

References 17 publications

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

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

Variability in the Point to Which Single Direct Field Irradiation is Prescribed for Spinal Bone Metastases: A Survey of Practice Patterns in Japan

Implementation Strategies to Promote Short-Course Radiation for Bone Metastases

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