Radiation therapy for the management of painful bone metastases
- Lisa A Kachnic, MD
Lisa A Kachnic, MD
- Chair and Professor
- Department of Radiation Oncology
- Vanderbilt University School of Medicine
- Steven J DiBiase, MD
Steven J DiBiase, MD
- Professor of Radiation Oncology
- Tulane University School of Medicine
- Medical Director, Department of Radiation Oncology
- Tulane Cancer Center
Bone metastases are a common manifestation of distant relapse from many types of solid cancers, especially those arising in the lung, breast, and prostate. As many as 80 percent of patients with solid tumors will develop painful bone metastases to the spine, pelvis, and extremities during the course of their illness .
The goals of palliative treatment of bone metastases are pain relief, preservation of function, and maintenance of skeletal integrity. When bone pain is limited to a single or a limited number of sites, local field external beam radiation therapy (RT) to the painful sites can provide pain relief in approximately 60 to 85 percent of cases, with complete pain response reported in 15 to 58 percent . If symptomatic lesions are widespread, radiopharmaceuticals or hemibody radiation may provide useful palliative alternatives. Although treatment can be effective for patients with mild, moderate, or severe pain, early intervention may be useful in maintaining quality of life and minimizing side effects of analgesic medications .
The use of RT will be reviewed here. An overview of bone metastases is presented separately, as are other aspects of cancer pain management. (See "Overview of the epidemiology, clinical presentation, diagnosis, and management of adult patients with bone metastasis" and "Cancer pain management: General principles and risk management for patients receiving opioids".)
EXTERNAL BEAM RT
Radiation therapy (RT) is effective in partially or completely relieving pain in a majority of patients with bone metastases, although a transient worsening of pain may occur in some patients . This typically occurs in the first few days after RT, and the flare in pain generally lasts one to two days.
Surgical fixation may be indicated prior to external beam radiation therapy (EBRT) to decrease pain and facilitate rehabilitation in symptomatic bone metastases causing a pathologic fracture involving the long bones or other weight-bearing bones. In other cases, prophylactic fixation to prevent pathologic fractures, or surgical stabilization of an unstable spine may be recommended prior to EBRT. Mirels' scoring system was developed to address the void in objective criteria for predicting fracture risk in the setting of metastatic disease to long bones, and it is outlined in the table and discussed in more detail separately (table 1) , as is the Spinal Instability Neoplastic Score (SINS) for vertebral metastases (table 2). (See "Evaluation and management of complete and impending pathologic fractures in patients with metastatic bone disease, multiple myeloma, and lymphoma", section on 'Assessing the risk of fracture' and "Evaluation and management of complete and impending pathologic fractures in patients with metastatic bone disease, multiple myeloma, and lymphoma", section on 'Assessing spinal stability'.)
- Nielsen OS. Palliative radiotherapy of bone metastases: there is now evidence for the use of single fractions. Radiother Oncol 1999; 52:95.
- Lutz S, Balboni T, Jones J, et al. Palliative radiation therapy for bone metastases: Update of an ASTRO Evidence-Based Guideline. Pract Radiat Oncol 2017; 7:4.
- Kirou-Mauro A, Hird A, Wong J, et al. Is response to radiotherapy in patients related to the severity of pretreatment pain? Int J Radiat Oncol Biol Phys 2008; 71:1208.
- Hird A, Chow E, Zhang L, et al. Determining the incidence of pain flare following palliative radiotherapy for symptomatic bone metastases: results from three canadian cancer centers. Int J Radiat Oncol Biol Phys 2009; 75:193.
- Mirels H. Metastatic disease in long bones. A proposed scoring system for diagnosing impending pathologic fractures. Clin Orthop Relat Res 1989; :256.
- Steenland E, Leer JW, van Houwelingen H, et al. The effect of a single fraction compared to multiple fractions on painful bone metastases: a global analysis of the Dutch Bone Metastasis Study. Radiother Oncol 1999; 52:101.
- van der Linden YM, Lok JJ, Steenland E, et al. Single fraction radiotherapy is efficacious: a further analysis of the Dutch Bone Metastasis Study controlling for the influence of retreatment. Int J Radiat Oncol Biol Phys 2004; 59:528.
- Hartsell WF, Scott CB, Bruner DW, et al. Randomized trial of short- versus long-course radiotherapy for palliation of painful bone metastases. J Natl Cancer Inst 2005; 97:798.
- 8 Gy single fraction radiotherapy for the treatment of metastatic skeletal pain: randomised comparison with a multifraction schedule over 12 months of patient follow-up. Bone Pain Trial Working Party. Radiother Oncol 1999; 52:111.
- Dennis K, Makhani L, Zeng L, et al. Single fraction conventional external beam radiation therapy for bone metastases: a systematic review of randomised controlled trials. Radiother Oncol 2013; 106:5.
- Hoskin P, Rojas A, Fidarova E, et al. IAEA randomised trial of optimal single dose radiotherapy in the treatment of painful bone metastases. Radiother Oncol 2015; 116:10.
- McDonald R, Ding K, Brundage M, et al. Effect of Radiotherapy on Painful Bone Metastases: A Secondary Analysis of the NCIC Clinical Trials Group Symptom Control Trial SC.23. JAMA Oncol 2017.
- Chow E, Meyer RM, Ding K, et al. Dexamethasone in the prophylaxis of radiation-induced pain flare after palliative radiotherapy for bone metastases: a double-blind, randomised placebo-controlled, phase 3 trial. Lancet Oncol 2015; 16:1463.
- Huisman M, van den Bosch MA, Wijlemans JW, et al. Effectiveness of reirradiation for painful bone metastases: a systematic review and meta-analysis. Int J Radiat Oncol Biol Phys 2012; 84:8.
- Chow E, van der Linden YM, Roos D, et al. Single versus multiple fractions of repeat radiation for painful bone metastases: a randomised, controlled, non-inferiority trial. Lancet Oncol 2014; 15:164.
- Gerszten PC, Burton SA, Ozhasoglu C, Welch WC. Radiosurgery for spinal metastases: clinical experience in 500 cases from a single institution. Spine (Phila Pa 1976) 2007; 32:193.
- Sahgal A, Atenafu EG, Chao S, et al. Vertebral compression fracture after spine stereotactic body radiotherapy: a multi-institutional analysis with a focus on radiation dose and the spinal instability neoplastic score. J Clin Oncol 2013; 31:3426.
- Boyce-Fappiano D, Elibe E, Schultz L, et al. Analysis of the Factors Contributing to Vertebral Compression Fractures After Spine Stereotactic Radiosurgery. Int J Radiat Oncol Biol Phys 2017; 97:236.
- Parker C, Nilsson S, Heinrich D, et al. Alpha emitter radium-223 and survival in metastatic prostate cancer. N Engl J Med 2013; 369:213.
- Salazar OM, Sandhu T, da Motta NW, et al. Fractionated half-body irradiation (HBI) for the rapid palliation of widespread, symptomatic, metastatic bone disease: a randomized Phase III trial of the International Atomic Energy Agency (IAEA). Int J Radiat Oncol Biol Phys 2001; 50:765.
- Hurwitz MD, Ghanouni P, Kanaev SV, et al. Magnetic resonance-guided focused ultrasound for patients with painful bone metastases: phase III trial results. J Natl Cancer Inst 2014; 106.