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

Abstract

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...

Creation of clinical algorithms for decision-making in oncology: an example with dose prescription in radiation oncology

“…They state that a SF of 1 × 8 Gy may be particularly convenient for patients with limited life expectancy. Furthermore, as there is level I evidence showing equivalency of SF and MF regarding pain relief, it is proposed to use 1 × 8 Gy for the treatment of most uncomplicated bone metastases [ 34 ]. Yet, the majority of radiation oncologists continue to prescribe MF schemes in situations that can be considered “uncomplicated” [ 35 ].…”