Early Radiation Palliative Relief Demonstrated For Painful Bone Metastases

A single dose of radiation may provide significant benefit to patients with painful bone metastases

medwireNews: Research indicates that around 40% of patients with painful bone metastases may experience pain relief and a significant improvement in their quality of life within 10 days of receiving one dose of radiation.

"[T]hus, a single 8-Gy dose of radiotherapy for painful bone metastases should be offered to all patients, even those with poor survival", recommend Edward Chow, from Sunnybrook Health Sciences Centre in Toronto, Ontario, Canada, and co-workers in JAMA Oncology.

They report secondary analysis of the NCIC Clinical Trials Group Symptom Control Trial SC.23 which looked at the impact of dexamethasone for the prevention of pain flare after radiotherapy in patients with one or two painful bone metastases with a worst pain score of at least 2 on a scale of 1–10.

The study used the International Bone Metastases Consensus Endpoint Definitions for a complete pain response to radiation – a pain score of 0 without an increase in analgesic intake – and partial response – a pain reduction score of 2 or more without an increase in analgesics, or an analgesic reduction of at least 25%.

In all, 40.9% of 298 patients experienced a complete (n=37) or partial response (n=85) to radiation by day 10. At day 42, the overall response rate was 38.9%, with 61 complete and 55 partial responses.

Quality of life (QoL) data were available for 72.1% of patients at day 10 and 62.7% at day 42; among these patients, 54.5% had a pain response by day 42.

Patients with a pain response were significantly more likely than those without to achieve a clinically meaningful 10-point or greater change in QoL on the EORTC Quality of Life Questionnaire Bone Metastases Module (QLQ-BM22) at day 10 than those without for pain characteristics (64.0 vs 42.6%) and psychosocial aspects (37.0 vs 20.9%).

At day 42, patients who responded to radiation had at least a 10-point difference in the average physical, emotional and global scores on the EORTC QLQ Core 15 Palliative (C15-PAL) assessment to those of nonresponders, with pain score showing the greatest difference.

These benefits included a greater reduction on the QLC C15-PAL in symptoms of pain, fatigue, appetite loss and constipation, pain characteristics, functional interference and psychosocial aspects, the researchers say, as well as significantly better responses on the QLQ-BM22 for painful sites, pain characteristics, functional interference and psychosocial aspects.

As expected, the QoL items that did not improve with pain relief, such as insomnia and dyspnoea, were not significantly better in patients who responded to radiation than those who did not.

“Thus, physicians should use other more appropriate treatment modalities to address these symptoms separately”, write Edward Chow et al.

They add: “Our evaluation time points (days 10 and 42) should be used in future studies that involve similar patient populations because they are more relevant than evaluating those with poor expected survival at 2 or even 3 months after treatment.”

Charles Thomas Jr, from the Oregon Health Sciences University in Portland, USA, writes in an accompanying editor’s note that the current study is “a step forward” from earlier reports of pain relief in this population because it used a uniform dose of radiation.

“Early pain relief may be a surrogate de facto marker of future short-term improved QOL”, he writes.

“In fact, the current trial may be immediately beneficial to patients with advanced disease and their respective caregivers and health care practitioners.”

Indeed, Charles Thomas Jr emphasizes that “the NCIC CTG SC.23 observations are candidate metrics that can be incorporated into quality indicators of pain assessment by patients, caregivers, practice guidelines, health care systems, and third-party payers, all of whom are involved in value-based palliative care initiatives.”

References 

McDonald R, Ding K, Brundage M, et al. Effect of radiotherapy on painful bone metastases. A secondary analysis of the NCIC Clinical Trials Group Symptom Control Trial SC.23.JAMA Oncol; Advance online publication 9 February 2017. doi:10.1001/jamaoncol.2016.6770 

Thomas CR Jr. Single-fraction radiotherapy and early subjective improvement in pain. JAMA Oncol; Advance online publication 9 February 2017. doi:10.1001/jamaoncol.2016.6723

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