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Radiation Therapy for Bone Metastases

Key Questions Jan 20, 2022
Radiation Therapy for Bone Metastases

Draft Key Questions

Key Question 1: What is the effectiveness and what are the harms of radiation therapy in the palliative treatment of bone metastases?

  1. Which patient characteristics (e.g., age, sex, social determinants of health, histology of the primary tumor) are associated with effectiveness of radiation therapy in the palliative treatment of bone metastases?
  2. Do additional therapies (i.e., surgery, radionuclide therapy, bisphosphonate therapy, or kyphoplasty/vertebroplasty) affect outcomes?

Key Question 2: For adults with bone metastases who will receive initial radiation, what is the comparative effectiveness and what are the comparative harms of dose-fractionation schemes, dose-constraints, and other techniques (e.g., three-dimensional conformal radiation therapy, stereotactic body radiation)?

Key Question 3: For adults with bone metastases who will receive re-irradiation, what is the comparative effectiveness and harms of dose-fractionation schemes, dose constraints, and other techniques (e.g., three-dimensional conformal radiation therapy, stereotactic body radiation)?

Contextual Questions:

  1. What are common barriers and facilitators to implementing guidance in cancer care, particularly radiation oncology?
  2. What strategies could be used to promote the use and implementation of guidance in cancer care, particularly radiation oncology?

Background

Metastasis is the spread of cancer from its origin to distal parts of the body.1 Bone metastasis is the third most common type of metastasis. In the United States, around 350,000 people die each year as the result of bone metastases. A 2020 population-based study found that the incidence of bone metastases in individuals with prostate cancer, breast cancer, and renal cancer was approximately 89, 54, and 39 percent, respectively.2 The median survival from diagnosis of bone metastasis ranges from 6 months in melanoma to 48 months in thyroid cancer. Bone metastasis is characterized by severe pain, and represents the most common type of pain from cancer.

External radiation therapy provides palliation for localized metastatic bone pain.3 The goals of radiation therapy are to improve the patient’s quality of life, reduce analgesic requirements, and maintain or ameliorate skeletal function.4 The 2016 guidelines from the American Society for Radiation Oncology5 on bone metastasis provide recommendations on the delivery of radiation therapy for bone metastases. A new systematic review will inform their planned guideline update. The review will address the effectiveness and harms of initial radiation therapy for bone metastases and reirradiation6 for cases of reoccurring cancer, and whether factors may influence the effectiveness and harms of treatment such as patient characteristics, additional therapies, and how radiation is delivered.

Draft Analytic Framework

Figure 1: This figure depicts key question 1 within the context of the PICO Framework described in Table 1. In general, the figure illustrates how interventions such as palliative radiation therapy, no radiation therapy, other type of radiation therapy or other type of palliative treatment (with or without co-interventions) may result in health outcomes such as quality of life, pain (including level and duration), use of pain medication, skeletal function, need for other pain relief intervention, and harms among adults with cancer that has metastasized to the bone. Also, adverse events may occur after the intervention is received. The relationship between intervention and outcomes may be different among subgroups of patients based on age, sex, social determinants of health, histology of primary tumor of site of metastasis.

 

Figure 2: This figure depicts key questions 2 and 3 within the context of the PICO Framework described in Table 1. In general, the figure illustrates how different dose-fractionation schemes, dose-constraints, or different techniques of radiation therapy including three-dimensional conformal radiation therapy and stereotactic body radiation may result in health outcomes such as quality of life, pain (including level and duration), use of pain medication, skeletal function, need for other pain relief intervention, and harms among adults with cancer that has metastasized to the bone who receive initial radiation therapy (for key question 2) or re-irradiation (for key question 3). Also, adverse events may occur after the intervention is received.

Table 1. Key Questions and PICO

Key Questions

1. Effectiveness and harms of RT

2. Dose fractionation, dose constraints, RT techniques in initial radiation

3. Dose fractionation, dose constraints, RT techniques in re-irradiation

Population

Adults with cancer that has metastasized to the bone.

1a. Consider patient characteristics (e.g., age, sex, social determinants of health, histology of the primary tumor, site of metastases)

Adults with cancer that has metastasized to the bone who will receive initial RT

Adults with cancer that has metastasized to the bone who will receive re-irradiation

Interventions

RT for the palliative management of bone metastases

1b. Co-interventions: additional therapies  (i.e., surgery, radionuclide therapy, bisphosphonate therapy, or kyphoplasty/ vertebroplasty)

  • Different dose-fractionation schemes
  • Dose-constraints
  • Techniques (e.g., three-dimensional conformal RT, SBR)
  • Different dose-fractionation schemes
  • Dose-constraints
  • Techniques (e.g., three-dimensional conformal RT, SBR)

Comparators

  • No radiation
  • Other type of radiation treatment
  • Other treatment for palliative treatment

1b. No co-intervention

  • Other dose-fractionation scheme
  • Other dose constraint
  • Other technique
  • Other dose-fractionation scheme
  • Other dose constraint
  • Other technique

Outcomes

Quality of life, pain (level and duration), use of pain medication, skeletal function, need for other intervention for pain relief, harms (e.g., rate of radiation/treatment toxicity, fracture rates, reduced mobility, reduced independence, financial harm), adverse events (fatigue, skin changes, etc.)

Quality of life, pain (level and duration), use of pain medication, skeletal function, need for other intervention for pain relief, skeletal function, harms (e.g., rate of radiation/ treatment toxicity, fracture rates, reduced mobility, reduced independence, financial harm), adverse events (fatigue, skin changes, etc.)

Quality of life, pain (level and duration), use of pain medication, skeletal function, need for other intervention for pain relief, skeletal function, harms (e.g., rate of radiation/ treatment toxicity, fracture rates, reduced mobility, reduced independence, financial harm), adverse events (fatigue, skin changes, etc.)

Abbreviations: RT=radiation therapy; SBR=stereotactic body radiation

References

  1. Metastatic Cancer: When Cancer Spreads. National Institutes of Health, National Cancer Institute. doi: https://www.cancer.gov/types/metastatic-cancer.
  2. Huang J-F, Shen J, Li X, et al. Incidence of patients with bone metastases at diagnosis of solid tumors in adults: a large population-based study. Ann Transl Med. 2020;8(7):482-. doi: https://doi.org/10.21037/atm.2020.03.55. PMID: 32395526.
  3. Macedo F, Ladeira K, Pinho F, et al. Bone Metastases: An Overview. Oncol. 2017;11(1):321-. doi: https://doi.org/10.4081/oncol.2017.321. PMID: 28584570.
  4. De Felice F, Piccioli A, Musio D, et al. The role of radiation therapy in bone metastases management. Oncotarget. 2017;8(15):25691-9. doi: https://doi.org/10.18632/oncotarget.14823. PMID: 28148890.
  5. Lutz S, Balboni T, Jones J, et al. Palliative radiation therapy for bone metastases: Update of an ASTRO Evidence-Based Guideline. Pract Radiat Oncol. 2017;7(1):4-12. doi: https://doi.org/10.1016/j.prro.2016.08.001.
  6. Nieder C, Langendijk JA. Re-irradiation. In: Brady LW, Yaeger TE, eds. Encyclopedia of Radiation Oncology. Berlin, Heidelberg: Springer Berlin Heidelberg; 2013:739-48.

Project Timeline

Radiation Therapy for Bone Metastases

Jan 20, 2022
Jan 20, 2022
Key Questions
Page last reviewed January 2022
Page originally created January 2022

Internet Citation: Key Questions: Radiation Therapy for Bone Metastases. Content last reviewed January 2022. Effective Health Care Program, Agency for Healthcare Research and Quality, Rockville, MD.
https://effectivehealthcare.ahrq.gov/products/radiation-therapy-bone-metastases/draft-comments

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