Palliative radiation therapy for bone metastases: Update of an ASTRO Evidence-Based Guideline.
OBJECTIVE
The purpose is to provide an update the Bone Metastases Guideline published in 2011 based on evidence complemented by expert opinion. The update will discuss new high-quality literature for the 8 key questions from the original guideline and implications for practice.


METHODS
A systematic PubMed search from the last date included in the original Guideline yielded 414 relevant articles. Ultimately, 20 randomized controlled trials, 32 prospective nonrandomized studies, and 4 meta-analyses/pooled analyses were selected and abstracted into evidence tables. The authors synthesized the evidence and reached consensus on the included recommendations.


RESULTS
Available literature continues to support pain relief equivalency between single and multiple fraction regimens for bone metastases. High-quality data confirm single fraction radiation therapy may be delivered to spine lesions with acceptable late toxicity. One prospective, randomized trial confirms both peripheral and spine-based painful metastases can be successfully and safely palliated with retreatment for recurrence pain with adherence to published dosing constraints. Advanced radiation therapy techniques such as stereotactic body radiation therapy lack high-quality data, leading the panel to favor its use on a clinical trial or when results will be collected in a registry. The panel's conclusion remains that surgery, radionuclides, bisphosphonates, and kyphoplasty/vertebroplasty do not obviate the need for external beam radiation therapy.


CONCLUSIONS
Updated data analysis confirms that radiation therapy provides excellent palliation for painful bone metastases and that retreatment is safe and effective. Although adherence to evidence-based medicine is critical, thorough expert radiation oncology physician judgment and discretion regarding number of fractions and advanced techniques are also essential to optimize outcomes when considering the patient's overall health, life expectancy, comorbidities, tumor biology, anatomy, previous treatment including prior radiation at or near current site of treatment, tumor and normal tissue response history to local and systemic therapies, and other factors related to the patient, tumor characteristics, or treatment.
Department of Radiation Oncology, Eastern Woods Radiation Oncology, 15990 Medical Drive South, Findlay, Ohio 45840. Electronic address: slutz@bvhealthsystem.org.
Stephen
S
Lutz
Department of Radiation Oncology, and Department of Psychosocial Oncology and Palliative Care Brigham and Women's Hospital and Dana-Farber Cancer Institute, Boston, Massachusetts.
Tracy
T
Balboni
Department of Radiation Oncology, University of Pennsylvania Health System, Philadelphia, Pennsylvania.
Joshua
J
Jones
Department of Radiation Oncology, University of Washington School of Medicine, Seattle, Washington.
Simon
S
Lo
Department of Radiation Oncology, University of Colorado Health, Fort Collins, Colorado.
Joshua
J
Petit
Hospice and Palliative Medicine, Mayo Clinic College of Medicine, Jacksonville, Florida.
Shayna E
SE
Rich
Department of Radiation Oncology, Princess Margaret Hospital, Toronto, Ontario, Canada.
Rebecca
R
Wong
Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina.
Carol
C
Hahn
D001859:Bone Neoplasms / Q000532:radiotherapy* / Q000556:secondary*; D004164:Diphosphonates / Q000627:therapeutic use; D019317:Evidence-Based Medicine; D006801:Humans; D058498:Kyphoplasty; D010166:Palliative Care; D017410:Practice Guidelines as Topic; D039781:PubMed; D019275:Radiopharmaceuticals; D054854:Vertebroplasty
D004164:Diphosphonates; D019275:Radiopharmaceuticals