Radiation Therapy for Bone Metastases

Radiation Therapy for Bone Metastases

1. What is the decision or change you are facing or struggling with where a summary of the evidence would be helpful?

The use of radiation therapy in the management of cancer that has metastasized to the bone, referred to as bone metastases, has shown significant variation in care across different clinical settings, and among patients of different socioeconomic status and race. For these reasons and the high incidence and clinical need for palliative radiation for bone metastases, the first guideline produced by the American Society of Radiation Oncology (ASTRO) in 2011 focused on addressing variation in radiation therapy for bone metastases. It was followed by an update to the guideline in 2016. In accordance with the National Academy of Medicine (formerly Institute of Medicine) standards for the development of high quality, evidence-based clinical practice guidelines, ASTRO intends to use the evidence report developed by AHRQ as the basis to replace the previous version of this guideline to ensure that current guidance provided to clinicians is accurate, and reflects current evidence.

The following key questions will be addressed:

KQ 1: What are the appropriate indications for radiation therapy in the palliative treatment of bone metastases?

KQ 2: What is the impact of surgery, radionuclide therapy, bisphosphonate therapy, or kyphoplasty/vertebroplasty on the appropriate indications for radiation therapy in the palliative treatment of bone metastases?

KQ 3: What radiation therapy dose-fractionation schemes, dose-constraints, and techniques are appropriate for the initial palliative treatment of bone metastases?

KQ 4: What radiation therapy dose-fractionation schemes, dose-constraints, and techniques are appropriate for palliative re-irradiation of bone metastases?

KQ 5: In patients with bone metastases receiving palliative radiation therapy, how do the different dose-fractionation schemes and techniques impact on treatment toxicity and quality of life?

The population of patients that will be assisted by this guideline are those with cancer that has metastasized to the bone. These patients frequently experience morbidity from bone metastases, including pain, bone fracture, reduced or lack of mobility, reduced independence and/or quality of life, financial toxicity, challenges with transportation, and side effects related to the need for pain and other supportive care medications.

The intervention that will be evaluated in this guideline is the use of radiation treatment for the palliative management of bone metastases.

The comparison groups that will be utilized in this guideline will include patients who do not receive radiation treatment, patients who are treated with different radiation techniques or treatment dose/fractionation schemes, and patients who receive other interventions such as medications or procedure intended to palliate bone metastases.

The outcomes that will be examined in this guideline include rate and duration of pain relief, dependence on pain medication, need for further pain intervention, quality of life, rate of musculoskeletal event (such as bone fracture), and rate of radiation-related toxicity.

2. Why are you struggling with this issue?

The use of palliative radiation therapy to manage symptoms related to bone metastases is an essential component of supportive care in cancer patients. This patient population is particularly vulnerable given the presence of disseminated, typically incurable cancer, and the high frequency of comorbid conditions as well as psychosocial and emotional challenges related to living with metastatic cancer. It is critical that these patients are offered the most effective, safe, evidence-based, and patient-centered recommendations to optimize the likelihood of benefit and minimize the potential for treatment-related toxicity, whether physical, financial, psychological, or otherwise. Studies have demonstrated substantial variation in the use of palliative radiation therapy for bone metastases, so much so that the first guideline produced by ASTRO focused on addressing this variation in care disparity. Despite an evidence base with findings that support strong, evidence-based recommendations, contemporary studies continue to demonstrate significant variation in care. Clinicians face difficult patient presentations where numerous factors related to estimated life expectancy, patient-specific values and expectations, and varied imaging and clinical features that must be considered, all of which appear to make it more difficult to provide care that is frequently consistent with guideline recommendations. Given the multifactorial issues that face the patient and their healthcare providers, in realizing the benefits of treatment while reducing risk and adhering to evidence-based standards, it is critically important to educate both groups to empower good medical decision-making in the face of metastatic cancer and the myriad of challenges that come with it.

3. What do you want to see changed? How will you know that your issue is improving or has been addressed?

By replacing the clinical practice guideline on the treatment of bone metastases, ASTRO aims to provide current, evidence-based recommendations that will impact practice patterns and increase the rate of guideline concordance for radiation treatment courses used in this setting to optimize patient care. There are several groups that regularly measure patterns of care and publish on adherence with ASTRO guidelines. ASTRO will collaborate and support patterns of care studies to measure and compare rates of concordance with evidence-based recommendations for the palliative treatment of bone metastases to evaluate whether this issue is improving or has been addressed.

4. When do you need the evidence report?

Monday, August 1, 2022

5. What will you do with the evidence report?

ASTRO intends to use the evidence report developed by AHRQ as the basis for a replacement of their evidence-based, clinical practice guideline on Radiation Therapy in the Management of Bone Metastases. An AHRQ report, with a literature search, data extraction, and analysis according to the highest standards of systematic reviews, would significantly aid in the completion of a guideline to provide timely, current, evidence-based recommendations to clinicians in an area of great clinical importance and incidence, with high variation and known potential for disparity in care. ASTRO guidelines are scientifically and methodologically rigorous and are published in high impact journals. They are also widely read and cited by cancer care providers, as demonstrated by citation frequency and quantitative measurement of downloads from the journal website. Once an AHRQ report is available, the ASTRO Guidelines Subcommittee will convene a panel of disease-site experts and general cancer care practitioners from academic, community, and government-run practice settings, including a patient representative and physician-in-training representative, to complete this important guideline. We will be inclusive such that our panel reflects a wide geographic and demographic representation. ASTRO staff with expertise in clinical practice guideline development will support this process.

Supporting Document

Title or short description: Evidence review request on radiation therapy for bone metastases (PDF, 282 KB)

Comments or notes about this file: ASTRO has worked with AHRQ on previous reviews in support of clinical practice guidelines and has an understanding regarding the timelines involved with these processes. This guideline topic was selected based on a high level of confidence that an anticipated timeline of 2 years for completion is appropriate, and our disease-site experts believe there is adequate flexibility based on the recent literature and clinical trial publications, at this timeline will be appropriate for this guideline project.

(Optional) About You

What is your role or perspective? Radiation therapy professional society

If you are you making a suggestion on behalf of an organization, please state the name of the organization: American Society of Radiation Oncology

May we contact you if we have questions about your nomination? Yes

Project Timeline

Radiation Therapy for Bone Metastases

Jan 20, 2022
Topic Initiated
Jan 20, 2022
Jan 20, 2022 - Feb 10, 2022
Page last reviewed March 2021
Page originally created July 2020

Internet Citation: Radiation Therapy for Bone Metastases. Content last reviewed March 2021. Effective Health Care Program, Agency for Healthcare Research and Quality, Rockville, MD.

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