Palliative Radiation Therapy for Bone Metastases: Update of an ASTRO Evidence-Based Guideline

Key Points

  • The updated guideline maintains the 4 previously recommended dosing schedules for external radiotherapy to treat previously unirradiated tumors: a single 8-Gy dose; 20 Gy administered in 5 fractions; 24 Gy in 6 fractions; or 30 Gy in 10 fractions.
  • In addition to primary treatment, the guideline addresses retreatment of bone metastases. It recommends that reirradiation should be considered if patients experience recurrent or persistent pain more than 1 month following external-beam radiation therapy to treat peripheral bone metastases or spinal lesions.
  • The guideline recommends that the use of advanced radiotherapy techniques for primary treatment or retreatment of spinal lesions should be considered only in clinical trial or registry settings.

The American Society for Radiation Oncology (ASTRO) recently published an updated clinical guideline that underscores the safety and effectiveness of palliative radiation therapy for treating painful bone metastases. Based on recent clinical trial data, the guideline recommends optimal radiotherapy dosing schedules for pain relief, including options for retreatment. The guideline was published by Lutz et al in Practical Radiation Oncology.

Dose Scheduling

The updated guideline maintains the 4 previously recommended dosing schedules for external radiotherapy to treat previously unirradiated tumors: a single 8-Gy dose; 20 Gy administered in 5 fractions; 24 Gy in 6 fractions; or 30 Gy in 10 fractions. Research indicates that patients experience similar pain relief and toxicity rates with each of the fractionation options.

Although clinical trials have cited higher retreatment rates for patients who received single-dose radiotherapy, the convenience of this option may make it the optimal choice for patients with limited life expectancy. A recent analysis of clinical trial data published by McDonald et al in JAMA Oncology recommended that “a single 8-Gy radiotherapy dose for bone metastases should be offered to all patients, even those with poor survival.”

Greater adoption of the single-dose approach—which requires only one visit—also may reduce the disparity between the number of patients who would benefit from this therapy and the markedly small number who actually receive it. Surveys of palliative care professionals, such as a survey published by McCloskey et al in Cancer, indicate that the vast majority consider radiotherapy an important and effective component of hospice care but do not actually refer many of their patients for the therapy.

In a study published by Lutz et al in the Journal of Clinical Oncology, for example, 88% of hospice professionals said that painful bone metastases merited referral for palliative radiotherapy, but only 3% of hospice patients nationwide actually received the treatment. Barriers including cost, transportation, and length of treatment were cited as key reasons for underutilization.

“Decades of research and many clinical trials have established that radiation therapy provides safe, effective, and quick pain relief for patients suffering from bone metastases,” said Stephen Lutz, MD, FASTRO, Chair of the Task Force that developed the guideline update and a radiation oncologist at Blanchard Valley Regional Health Center in Findlay, Ohio. “Moreover, this relief can be achieved in as little as a single fraction, which alleviates the additional burdens of time, travel, and cost for the patient.”

Retreatment of Metastases and More

In addition to primary treatment, the guideline also addresses retreatment of bone metastases. It recommends that reirradiation should be considered if patients experience recurrent or persistent pain more than a month following external-beam radiation therapy (EBRT) to treat peripheral bone metastases or spinal lesions. Research demonstrates moderate effectiveness for reirradiation; a 2014 systematic review and meta-analysis found an overall pain response rate of 58%.

The guideline also considers the role of advanced radiotherapy techniques, such as stereotactic body radiation therapy (SBRT), in primary treatment and retreatment of painful bone metastases. The precise targeting of SBRT can be particularly important for tumor sites near multiple surrounding organs, such as the lung or prostate, or complex sites, such as the neural system.

While emerging evidence points to the potential of SBRT to treat spinal metastases, research in this area is limited compared with the data supporting EBRT. Accordingly, the guideline recommends that the use of advanced radiotherapy techniques for primary treatment or retreatment of spinal lesions should be considered only in clinical trial or registry settings. It also recommends that physicians consult the current ASTRO white paper on SBRT to inform their treatment decisions.

The guideline was based on a systematic literature review of studies published from December 2009, the last date that was searched for the original 2011 guideline, through January 2015. A total of 414 abstracts were retrieved from PubMed, and the 56 articles that met inclusion criteria (including 20 randomized controlled trials, 32 nonrandomized prospective studies, and 4 meta-analyses or pooled analyses) were abstracted into evidence tables and evaluated by an 8-member expert panel of radiation oncologists and topic experts in metastatic disease. The clinical practice statement was approved by ASTRO's Board of Directors following a period of public comment.

The content in this post has not been reviewed by the American Society of Clinical Oncology, Inc. (ASCO®) and does not necessarily reflect the ideas and opinions of ASCO®.


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