title: The effect of a single fraction compared to multiple fractions on painful bone metastases: a global analysis of the Dutch Bone Metastasis Study.
abstract: OBJECTIVE
  To answer the question whether a single fraction of radiotherapy that is considered more convenient to the patient is as effective as a dose of multiple fractions for palliation of painful bone metastases.
  
  
  METHODS
  1171 patients were randomised to receive either 8 Gy x 1 (n = 585) or 4 Gy x 6 (n = 586). The primary tumour was in the breast in 39% of the patients, in the prostate in 23%, in the lung in 25% and in other locations in 13%. Bone metastases were located in the spine (30%), pelvis (36%), femur (10%), ribs (8%), humerus (6%) and other sites (10%).
  
  
  METHODS
  Questionnaires were mailed to collect information on pain, analgesics consumption, quality of life and side effects during treatment. The main endpoint was pain measured on a pain scale from 0 (no pain at all) to 10 (worst imaginable pain). Costs per treatment schedule were estimated.
  
  
  RESULTS
  On average, patients participated in the study for 4 months. Median survival was 7 months. Response was defined as a decrease of at least two points as compared to the initial pain score. The difference in response between the two treatment groups proved not significant and stayed well within the margin of 10%. Overall, 71% experienced a response at some time during the first year. An analysis of repeated measures confirmed that the two treatment schedules were equivalent in terms of palliation. With regard to pain medication, quality of life and side effects no differences between the two treatment groups were found. The total number of retreatments was 188 (16%). This number was 147 (25%) in the 8 Gy x 1 irradiation group and 41 (7%) in the 4 Gy x 6 group. It was shown that the level of pain was an important reason to retreat. There were also indications that doctors were more willing to retreat patients in the single fraction group because time to retreatment was substantially shorter in this group and the preceding pain score was lower. Unexpectedly, more pathological fractures were observed in the single fraction group, but the absolute percentage was low. In a cost-analysis, the costs of the 4 Gy x 6 and the 8 Gy x 1 treatment schedules were calculated at 2305 and 1734 Euro respectively. Including the costs of retreatment reduced this 25% cost difference to only 8%. The saving of radiotherapy capacity, however, was considered the major economic advantage of the single dose schedule.
  
  
  CONCLUSIONS
  The global analysis of the Dutch study indicates the equality of a single fraction as compared to a 6 fraction treatment in patients with painful bone metastases provided that 4 times more retreatments are accepted in the single dose group. This equality is also shown in long term survivors. A more detailed analysis of the study is in progress.
authors.affiliation: University Hospital Nijmegen, The Netherlands.
authors.forename: E
authors.initials: E
authors.lastname: Steenland
authors.forename: J W
authors.initials: JW
authors.lastname: Leer
authors.forename: H
authors.initials: H
authors.lastname: van Houwelingen
authors.forename: W J
authors.initials: WJ
authors.lastname: Post
authors.forename: W B
authors.initials: WB
authors.lastname: van den Hout
authors.forename: J
authors.initials: J
authors.lastname: Kievit
authors.forename: H
authors.initials: H
authors.lastname: de Haes
authors.forename: H
authors.initials: H
authors.lastname: Martijn
authors.forename: B
authors.initials: B
authors.lastname: Oei
authors.forename: E
authors.initials: E
authors.lastname: Vonk
authors.forename: E
authors.initials: E
authors.lastname: van der Steen-Banasik
authors.forename: R G
authors.initials: RG
authors.lastname: Wiggenraad
authors.forename: J
authors.initials: J
authors.lastname: Hoogenhout
authors.forename: C
authors.initials: C
authors.lastname: Wárlám-Rodenhuis
authors.forename: G
authors.initials: G
authors.lastname: van Tienhoven
authors.forename: R
authors.initials: R
authors.lastname: Wanders
authors.forename: J
authors.initials: J
authors.lastname: Pomp
authors.forename: M
authors.initials: M
authors.lastname: van Reijn
authors.forename: I
authors.initials: I
authors.lastname: van Mierlo
authors.forename: E
authors.initials: E
authors.lastname: Rutten
authors.forename: J
authors.initials: J
authors.lastname: Leer
authors.forename: T
authors.initials: T
authors.lastname: van Mierlo
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001859:Bone Neoplasms / Q000401:mortality / Q000532:radiotherapy* / Q000556:secondary*; D018450:Disease Progression; D019583:Dose Fractionation, Radiation; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D010146:Pain / Q000150:complications / Q000209:etiology; D059408:Pain Management; D010166:Palliative Care; D011788:Quality of Life; D011878:Radiotherapy / Q000009:adverse effects; D011879:Radiotherapy Dosage; D011795:Surveys and Questionnaires; D015996:Survival Rate