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Continuous controversy about radiation oncologists' choice of treatment regimens for bone metastases: should we blame doctors, cancer-related features, or design of previous clinical studies?

Nieder C, Pawinski A, Dalhaug A - Radiat Oncol (2013)

Bottom Line: Recent studies from Italy, Japan and Norway have confirmed previous reports, which found that a large variety of palliative radiotherapy regimens are used for painful bone metastases.Routine use of single fraction treatment might or might not be the preferred institutional approach.We identify open questions and provide research suggestions, which might contribute to making radiation oncology practitioners more confident in selecting the right treatment for the right patient.

View Article: PubMed Central - HTML - PubMed

Affiliation: Department of Oncology and Palliative Medicine, Nordland Hospital, Bodø, 8092, Norway. carsten.nieder@nlsh.no

ABSTRACT
Recent studies from Italy, Japan and Norway have confirmed previous reports, which found that a large variety of palliative radiotherapy regimens are used for painful bone metastases. Routine use of single fraction treatment might or might not be the preferred institutional approach. It is not entirely clear why inter-physician and inter-institution differences continue to persist despite numerous randomized trials, meta-analyses and guidelines, which recommend against more costly and inconvenient multi-fraction regimens delivering total doses of 30 Gy or more in a large number of clinical scenarios. In the present mini-review we discuss the questions of whether doctors are ignoring evidence-based medicine or whether we need additional studies targeting specifically those patient populations where recent surveys identified inconsistent treatment recommendations, e.g. because of challenging disease extent. We identify open questions and provide research suggestions, which might contribute to making radiation oncology practitioners more confident in selecting the right treatment for the right patient.

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Related in: MedlinePlus

Computed tomography scan in a patient with squamous cell lung cancer (no EGFR mutation, known lung metastases) and uncomplicated bone pain (no neurological complaints), extra-osseous extension and spinal canal invasion present: treated with 3 Gy x10.
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Figure 4: Computed tomography scan in a patient with squamous cell lung cancer (no EGFR mutation, known lung metastases) and uncomplicated bone pain (no neurological complaints), extra-osseous extension and spinal canal invasion present: treated with 3 Gy x10.

Mentions: Figures 1, 2, 3 and 4 show the broad variation of local disease extent, another factor considered by many physicians. Most likely, more radiation oncologists might be reluctant to use single fraction radiotherapy in examples 3 and 4 (large volume disease and/or threat to spinal cord) especially if the patients' survival expectation is not limited to 2–3 months, they are ambulatory and in good general condition. The randomized trials have not specifically addressed patient populations with large volume disease, which consist of some patients with uncomplicated bone pain (bone lesions not causing neurological complaints and without a high risk of pathological fracture) and some patients with impending fracture or spinal cord compression. For reasons including but not limited to medico-legal issues no uniform international threshold for definition of impending spinal cord compression or increased fracture risk exists. Performing retrospective analyses of older randomized trials that identify such challenging patients is difficult and methodologically inferior to conducting trials limited to narrowly defined patient groups and including all relevant endpoints. Future trials could also shed light on other interesting questions many practitioners are struggling with: does the higher biologically effective dose of more intense regimens truly provide more extensive tumor remission and/or superior local control (remember that pain relief is not clearly related to pre-treatment or longitudinal imaging findings) and if so, do serial imaging findings eventually translate into clinically measurable benefit? At the end of the day we care for patients with limited survival expectation and complex disease states, which impair quality of life at different levels. Can we achieve the same outcome by reirradiating those patients who do not experience long-lasting benefit after their first course of radiotherapy?


Continuous controversy about radiation oncologists' choice of treatment regimens for bone metastases: should we blame doctors, cancer-related features, or design of previous clinical studies?

Nieder C, Pawinski A, Dalhaug A - Radiat Oncol (2013)

Computed tomography scan in a patient with squamous cell lung cancer (no EGFR mutation, known lung metastases) and uncomplicated bone pain (no neurological complaints), extra-osseous extension and spinal canal invasion present: treated with 3 Gy x10.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC3643865&req=5

Figure 4: Computed tomography scan in a patient with squamous cell lung cancer (no EGFR mutation, known lung metastases) and uncomplicated bone pain (no neurological complaints), extra-osseous extension and spinal canal invasion present: treated with 3 Gy x10.
Mentions: Figures 1, 2, 3 and 4 show the broad variation of local disease extent, another factor considered by many physicians. Most likely, more radiation oncologists might be reluctant to use single fraction radiotherapy in examples 3 and 4 (large volume disease and/or threat to spinal cord) especially if the patients' survival expectation is not limited to 2–3 months, they are ambulatory and in good general condition. The randomized trials have not specifically addressed patient populations with large volume disease, which consist of some patients with uncomplicated bone pain (bone lesions not causing neurological complaints and without a high risk of pathological fracture) and some patients with impending fracture or spinal cord compression. For reasons including but not limited to medico-legal issues no uniform international threshold for definition of impending spinal cord compression or increased fracture risk exists. Performing retrospective analyses of older randomized trials that identify such challenging patients is difficult and methodologically inferior to conducting trials limited to narrowly defined patient groups and including all relevant endpoints. Future trials could also shed light on other interesting questions many practitioners are struggling with: does the higher biologically effective dose of more intense regimens truly provide more extensive tumor remission and/or superior local control (remember that pain relief is not clearly related to pre-treatment or longitudinal imaging findings) and if so, do serial imaging findings eventually translate into clinically measurable benefit? At the end of the day we care for patients with limited survival expectation and complex disease states, which impair quality of life at different levels. Can we achieve the same outcome by reirradiating those patients who do not experience long-lasting benefit after their first course of radiotherapy?

Bottom Line: Recent studies from Italy, Japan and Norway have confirmed previous reports, which found that a large variety of palliative radiotherapy regimens are used for painful bone metastases.Routine use of single fraction treatment might or might not be the preferred institutional approach.We identify open questions and provide research suggestions, which might contribute to making radiation oncology practitioners more confident in selecting the right treatment for the right patient.

View Article: PubMed Central - HTML - PubMed

Affiliation: Department of Oncology and Palliative Medicine, Nordland Hospital, Bodø, 8092, Norway. carsten.nieder@nlsh.no

ABSTRACT
Recent studies from Italy, Japan and Norway have confirmed previous reports, which found that a large variety of palliative radiotherapy regimens are used for painful bone metastases. Routine use of single fraction treatment might or might not be the preferred institutional approach. It is not entirely clear why inter-physician and inter-institution differences continue to persist despite numerous randomized trials, meta-analyses and guidelines, which recommend against more costly and inconvenient multi-fraction regimens delivering total doses of 30 Gy or more in a large number of clinical scenarios. In the present mini-review we discuss the questions of whether doctors are ignoring evidence-based medicine or whether we need additional studies targeting specifically those patient populations where recent surveys identified inconsistent treatment recommendations, e.g. because of challenging disease extent. We identify open questions and provide research suggestions, which might contribute to making radiation oncology practitioners more confident in selecting the right treatment for the right patient.

Show MeSH
Related in: MedlinePlus