External Beam Radiation Therapy for Palliation of Symptomatic Bone Metastases

Publication Date: May 22, 2024
Last Updated: May 24, 2024

Indications for RT in palliative treatment

For patients with symptomatic bone metastases, RT is recommended to reduce pain from osseous metastasis. (S, )
High Quality of Evidence for Overall Pain
Moderate Quality of Evidence for Neuropathic Pian
620
For patients with symptomatic spine bone metastases, including those causing compression of the spinal cord or cauda equina, RT is recommended to improve ambulatory status, sphincter function, and reduce pain. (S, H )
Implementation remark: Before initiating RT, evaluation for spine stability and surgery are necessary.
620
For patients with symptomatic bone metastases and an anticipated life expectancy of ≥4 weeks, RT is conditionally recommended to improve quality of life (eg, functional status, mobility). (C, L )
620

Impact of other treatments for bone metastases on indications for RT in palliative treatment

For patients with spine bone metastases causing compression of the spinal cord or cauda equina, surgery with postoperative RT is conditionally recommended over RT alone. (C, L )
620
For patients who have undergone surgery for non-spine bone metastases or for spine metastases without spinal cord or cauda equina compression, postoperative RT is recommended. (S, L )
620
For patients with spine bone metastases causing compression of the spinal cord or cauda equina, RT combined with dexamethasone is recommended over RT alone. (S, L )
620

Dose-fractionation, dose-constraints, and techniques for initial palliative treatment of bone metastases

In patients with spine bone metastases causing compression of the spinal cord or cauda equina who are not eligible for initial surgical decompression and are treated with conventional palliative RT, 800 cGy in 1 fraction, 1600 cGy in 2 fractions, 2000 cGy in 5 fractions, or 3000 cGy in 10 fractions are recommended. (S, H )
Implementation remark: Consider patient and disease factors in dose-fractionation selection (eg, prognosis and radiosensitivity).
620
For patients with spine bone metastases causing compression of the spinal cord or cauda equina treated with dose-escalated palliative RT, the use of highly conformal planning and delivery techniques (eg, IMRT) is conditionally recommended. (C, L )
620
For patients with symptomatic bone metastases treated with SBRT, 1200 to 1600 cGy in 1 fraction (non-spine) and 2400 cGy in 2 fractions (spine) are recommended. (S, M )
Implementation remark: Other established SBRT dose and fractionation regimens (eg, 3-5 fraction) with similar BEDs may be an option based on patient tumor and normal tissue factors, and physician experience.
620
For patients with symptomatic bone metastases with ECOG PS 0-2, receiving no surgical intervention, and absent neurological symptoms, SBRT is conditionally recommended over conventional palliative RT. (C, M )
Implementation remark: Other factors to consider include life expectancy, tumor radiosensitivity, and metastatic disease burden.
620

Dose-fractionation, dose-constraints, and techniques for palliative reirradiation

For patients with spine bone metastases that would benefit from reirradiation to the same site, conventional palliative RT regimens of 800 cGy in 1 fraction, 2000 cGy in 5 fractions, 2400 cGy in 6 fractions, or 2000 cGy in 8 fractions are recommended. (S, M )
Implementation remark: Consider prior RT dose, time interval, and total spinal cord tolerance when determining RT dose-fractionation.
620
For patients with spine bone metastases that would benefit from reirradiation to the same site, treatment with SBRT is conditionally recommended. (C, CC)
Implementation remarks:
  • Consider patient factors (eg, urgency of treatment, prognosis, and radio-resistance) when determining if SBRT is indicated.
  • Consider prior RT dose, time interval, and total spinal cord tolerance when determining RT dose-fractionation.
620
For patients with symptomatic non-spine bone metastases that would benefit from reirradiation to the same site, single-fraction (800 cGy in 1 fraction) or multifraction conventional palliative RT (2000 cGy in 5 fractions or 2400 cGy in 6 fractions) are recommended. (S, M )
620

Impact of dose-fractionation and techniques on toxicity and QoL

For patients with bone metastases receiving palliative RT, a shared decision-making approach is recommended to determine dose, fractionation, and use of supportive measures to optimize QoL. (S, CC)
620

Recommendation Grading

Abbreviations

  • ECOG: Eastern Cooperative Oncology Group
  • FX: Fractionation
  • IMRT: Intensity Modulated Radiation Therapy
  • KQ: Key Question
  • PS: Performance Status
  • QOL: Quality Of Life
  • RT: External Beam Radiation Therapy
  • SBRT: Stereotactic Body Radiation Therapy

Disclaimer

The information in this patient summary should not be used as a substitute for professional medical care or advice. Contact a health care provider if you have questions about your health.

Overview

Title

External Beam Radiation Therapy for Palliation of Symptomatic Bone Metastases

Authoring Organization

Publication Month/Year

May 22, 2024

Last Updated Month/Year

May 29, 2024

Document Type

Guideline

Country of Publication

US

Document Objectives

This guideline provides evidence-based recommendations for palliative external beam radiation therapy (RT) in symptomatic bone metastases.

PICO Questions

1. In adult patients with symptomatic bone metastases, what are the appropriate indications for RT in the palliative treatment of bone metastases?

2. In adult patients with symptomatic bone metastases, what is the impact of surgery, radiopharmaceutical therapy, bisphosphonate therapy, or kyphoplasty/vertebroplasty on the appropriate indications for RT in the palliative treatment of bone metastases?

3. In adult patients with symptomatic bone metastases, what RT dose-fx regimens, dose-constraints, and techniques are appropriate for the initial palliative treatment of bone metastases?

4. In adult patients with symptomatic bone metastases, what RT dose-fx regimens, dose-constraints, and techniques are appropriate for palliative reirradiation of bone metastases?

5. In adult patients with symptomatic bone metastases receiving palliative RT, how do the different dose-fx schemes and techniques impact on treatment toxicity and QoL?

Inclusion Criteria

Male, Female, Adult, Older adult

Health Care Settings

Outpatient, Radiology services

Intended Users

Nurse, nurse practitioner, physician, physician assistant, radiology technologist

Scope

Treatment, Management

Diseases/Conditions (MeSH)

D018787 - Radiation Oncology

Keywords

bone metastases, External Beam Radiation Therapy

Source Citation

Sara Alcorn, Ángel Artal Cortés, Lisa Bradfield, Margaret Brennan, Kristopher Dennis, Dayssy A. Diaz, Yee-Cheen Doung, Shekinah Elmore, Lauren Hertan, Candice Johnstone, Joshua Jones, Nicole Larrier, Simon S. Lo, Quynh-Nhu Nguyen, Yolanda D. Tseng, Divya Yerramilli, Sandra Zaky, Tracy Balboni, External Beam Radiation Therapy for Palliation of Symptomatic Bone Metastases: An ASTRO Clinical Practice Guideline, Practical Radiation Oncology, 2024, ISSN 1879-8500, https://doi.org/10.1016/j.prro.2024.04.018

Supplemental Methodology Resources

Data Supplement, Data Supplement, Data Supplement

Methodology

Number of Source Documents
115
Literature Search Start Date
January 1, 1985
Literature Search End Date
January 30, 2023