Clinical Investigations
Radiotherapeutic Management of Osseous Metastases: A Survey of Current Patterns of Care

https://doi.org/10.1016/S0360-3016(97)00927-9Get rights and content

Abstract

Purpose: Radiotherapy plays a major role in the management of painful osseous metastases. This survey was conducted to study the current approaches to this clinical problem in the radiotherapy community.

Methods and Materials: A questionnaire was sent to 2500 members of the American Society for Therapeutic Radiology and Oncology. It consisted of 30 multiple-choice questions regarding four hypothetical clinical scenarios likely to be encountered in daily practice. Questions related to the technique of choice [local field (LF) vs. hemibody radiotherapy (HBI)], the use of systemic radionuclides (SR), fractionation schemes, dose, the integration of modalities, and the follow-up of these patients. The analysis is based on 817 (33%) responses received regarding 3268 cases.

Results: Local field is the most common form of therapy. Overall, LF was used, alone or in combination with other forms of therapy, in 54% and 74% of patients, respectively. LF was used more frequently in patients with breast cancer than in patients with prostate cancer (79% vs. 45%; p = 0.0001). Long fractionation schemes were used by 90% of physicians in 96% of cases. Short fractionation schemes were used by 7% of physicians in 4% of cases. This tendency was more pronounced in private practice than in the university or government/multidisciplinary settings (p = 0.008) and in physicians starting their practice before 1982 (p = 0.05). The most common schedule was 30 Gy in 10 fractions, used by 77% of physicians in 64% of cases. HBI was used, alone or in combination with other forms of therapy, in 1% and 2% of patients, respectively. It was used more frequently in patients with prostate cancer than in patients with breast cancer (1.2% vs. 0.1%, respectively; p < 0.0001). SR were used alone or in combination with local-field irradiation in 21% and 40% of cases, respectively. SR were used more frequently in patients with prostate cancer than in those with breast cancer (28% vs. 0.2%, respectively; p < 0.00001). The most common radionuclide in use is Sr-89 (99%) at a dose of 4 mCi (73%) or 10.8 mCi (26%).

Conclusions: Although LF remains the mainstay of therapy, our results demonstrate the emergence of a new pattern of practice: LF to the painful site in combination with SR for clinically occult metastases. Despite an ongoing academic debate regarding fractionation schemes, the vast majority of American practitioners advocate long schedules.

Introduction

Osseous metastases represent the most common cause of intractable pain in cancer patients [1]. Bone metastases develop in up to 70% of newly diagnosed cancer patients [2]and result in immobility, anxiety, and depression, severely diminishing the patients’ quality of life. Despite a variety of treatment options, cancer pain remains inadequately managed for most patients 3, 4. This underscores the need for physicians treating cancer patients to become familiar with the management of this problem.

Pain secondary to osseous metastases can be managed with analgesics, cytotoxic chemotherapy, hormonal therapy, bisphosphonates, and radiotherapy. The goal of palliation is to provide expedient and durable relief of pain. Local-field external-beam irradiation (LF) has been the mainstay of treatment, as it is effective in 70% of patients [5]. The optimal dose and fractionation schemes have not yet been well defined, with most studies failing to demonstrate a dose–response effect 5, 6, 7.

Alternative radiotherapeutic approaches include the use of hemibody irradiation (HBI) and systemic radionuclide therapy (SR). Both of these types of therapy represent a more systemic approach, addressing more (or all) involved sites. HBI can produce complete and partial responses in 20% and 73% of cases, respectively [8]. However, it is an elaborate undertaking which may require hospitalization and has been associated with substantial morbidity. The Radiation Therapy Oncology Group (RTOG) reported severe and life-threatening gastrointestinal and hematological toxicity in 13% and 10% of patients, respectively, with the use of lower- and middle-half-body irradiation, and 16% and 32% of patients, respectively, with the use of upper-half-body irradiation [8]. In a later study limiting the HBI dose to 8 Gy, RTOG reported grade 3/4 gastrointestinal and hematological toxicity in 2% and 7% of patients, respectively [9].

Recently approved by the Food and Drug Administration, strontium-89 is a useful addition to available treatment options. Selective absorption into bone metastases limits irradiation of normal tissues and increases the therapeutic ratio. Administration as a single intravenous injection in the outpatient clinic is a further advantage for many patients. Other radionuclides, including samarium-153 and rhenium-186, are under clinical investigation.

With several effective options available, some just recently introduced, we sought to survey the current approaches of the radiotherapy community to the management of patients with bone metastases.

Section snippets

Methods and Materials

A total of 2500 questionnaires were sent to members of the American Society for Therapeutic Radiology and Oncology in the United States. A sample questionnaire is included in the Appendix A. Briefly, it consisted of 30 multiple-choice questions regarding four hypothetical clinical scenarios likely to be encountered in daily practice. Questions related to the radiotherapeutic technique of choice [local field vs. hemibody radiotherapy], the use of systemic radionuclides, fractionation schemes,

Results

A total of 817 physicians (33%) returned responses, for a total of 3268 cases. The distribution of the first year of practice and type of practice in the population of responders are shown in Fig. 1, Fig. 2, respectively. Data on the distribution of the type of practice were obtained from the research department of the American College of Radiology (ACR). These data were collected during the ACR 1995 survey. A comparison between the population and sample vectors of proportions using the

Discussion

The vast majority of patients with bone metastases can be managed successfully with LF external-beam radiotherapy [11]. Our results suggest that this is commonly believed by the radiation oncology community in the United States, where it is the most commonly used modality. LF was used, alone or in combination with other forms of therapy, in 54% and 74% of patients, respectively.

Despite a number of prospective clinical trials (Table 4), the optimal dose and fractionation have not yet been

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