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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 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 [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 side effects of analgesic medications [3].

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".)


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 [4]. 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) [5], 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'.)

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Literature review current through: Sep 2017. | This topic last updated: Mar 21, 2017.
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