Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate, Inc. and/or its affiliates. All Rights Reserved.

Radiation therapy for the management of painful bone metastases

Lisa A Kachnic, MD
Steven J DiBiase, MD
Section Editor
Steven E Schild, MD
Deputy Editor
Diane MF Savarese, MD


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 [1].

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 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 [2]. 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 the side effects of analgesic medications [3].

The use of RT for palliation of painful bone metastases will be reviewed here. An overview of bone metastases is presented separately, as are other aspects of cancer pain management, including the management of patients with epidural spinal cord compression and the use of image-guided thermal ablation for patients with pain from bone metastases that persists or recurs after RT. (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" and "Treatment and prognosis of neoplastic epidural spinal cord compression, including cauda equina syndrome" and "Image-guided ablation of skeletal metastases".)


For patients with a single or limited number of areas of painful bone metastases, we recommend external beam RT (EBRT). 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 [4]. This typically occurs in the first few days after RT, and the flare in pain generally lasts one to two days.

Single-dose versus fractionated treatment — For most patients, we suggest using a single fraction of 8 Gy to the involved area. This approach provides equal palliation with improved patient convenience and cost-effectiveness compared with fractionated schedules, although retreatment is needed more frequently. For patients with a relatively long life expectancy (such as six months or more), a fractionated regimen (such as 30 Gy in 10 fractions or 20 Gy in five fractions) is a reasonable alternative because of the reduced need for retreatment.

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:

Subscribers log in here

Literature review current through: Nov 2017. | This topic last updated: Nov 07, 2017.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc.
  1. Nielsen OS. Palliative radiotherapy of bone metastases: there is now evidence for the use of single fractions. Radiother Oncol 1999; 52:95.
  2. 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.
  3. 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.
  4. 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.
  5. 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.
  6. 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.
  7. 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. 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.
  9. Rutter CE, Yu JB, Wilson LD, Park HS. Assessment of national practice for palliative radiation therapy for bone metastases suggests marked underutilization of single-fraction regimens in the United States. Int J Radiat Oncol Biol Phys 2015; 91:548.
  10. 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.
  11. 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.
  12. 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.
  13. 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.
  14. Mirels H. Metastatic disease in long bones. A proposed scoring system for diagnosing impending pathologic fractures. Clin Orthop Relat Res 1989; :256.
  15. 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.
  16. Bishop AJ, Tao R, Rebueno NC, et al. Outcomes for Spine Stereotactic Body Radiation Therapy and an Analysis of Predictors of Local Recurrence. Int J Radiat Oncol Biol Phys 2015; 92:1016.
  17. Moussazadeh N, Lis E, Katsoulakis E, et al. Five-Year Outcomes of High-Dose Single-Fraction Spinal Stereotactic Radiosurgery. Int J Radiat Oncol Biol Phys 2015; 93:361.
  18. 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.
  19. 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.
  20. 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.
  21. 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.
  22. Zacho HD, Karthigaseu NN, Fonager RF, Petersen LJ. Treatment with bone-seeking radionuclides for painful bone metastases in patients with lung cancer: a systematic review. BMJ Support Palliat Care 2017; 7:230.
  23. Coleman R, Aksnes AK, Naume B, et al. A phase IIa, nonrandomized study of radium-223 dichloride in advanced breast cancer patients with bone-dominant disease. Breast Cancer Res Treat 2014; 145:411.
  24. 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.
  25. 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.