Palliative Radiation Therapy for Bone Metastases

Publication Date: February 1, 2017

Guideline recommendations

An updated review of high-quality data continues to show pain relief equivalency following a single 8 Gy fraction, 20 Gy in 5 fractions, 24 Gy in 6 fractions, and 30 Gy in 10 fractions for patients with previously unirradiated painful bone metastases. Patients should be made aware that SF RT is associated with a higher incidence of retreatment to the same painful site than is fractionated treatment. (Strong, High)

A single 8 Gy fraction provides noninferior pain relief compared with a more prolonged RT course in painful spinal sites and may therefore be particularly convenient and sensible for patients with limited life expectancy. (Strong, High)

There continues to be no suggestion from available high-quality data that SF therapy produces unacceptable rates of long-term side effects that might limit its use for patients with painful bone metastases. The evidence regarding an association between higher risk for pathologic fracture after SF therapy vs fractionated therapy remains equivocal. (Strong, High)

Patients with persistent or recurrent pain more than 1 month following EBRT for symptomatic, peripheral bone metastases should be considered for retreatment while adhering to normal tissue dosing constraints described in the available literature. (Strong, High)

Patients with recurrent spine pain more than 1 month after initial treatment should be considered for EBRT retreatment while adhering to normal tissue dosing constraints described in the available literature. (Strong, High)

Advanced RT techniques such as SBRT as the primary treatment for painful spine bone lesions or for spinal compression should be considered in the setting of a clinical trial or with data collected in a registry given that insufficient data are available to routinely support this treatment currently. (Strong, Moderate)

Advanced radiation techniques such as SBRT retreatment for recurrent pain in spine bone lesions may be feasible, effective, and safe, but the panel recommends that this approach should be limited to clinical trial participation or on a registry given limited data supporting routine use. (Strong, Moderate)

The panel reiterates that the use of surgery, radionuclides, bisphosphonates, or kyphoplasty/vertebroplasty does not obviate the need for EBRT for patients with painful bone metastases, although 2 recent trial has suggested the potential for similar, albeit less rapid, bone pain relief in prostate cancer patients following an infusion of ibandronate when compared with a single fraction of EBRT. (Strong, Moderate)

EBRT, external beam radiation therapy; RT, radiation therapy; SBRT, stereotactic body radiation therapy; SF, single fraction

Recommendation Grading




Palliative Radiation Therapy for Bone Metastases

Authoring Organization

Publication Month/Year

February 1, 2017

Supplemental Implementation Tools

Document Type


External Publication Status


Country of Publication


Document Objectives

The purpose is to provide an update the Bone Metastases Guideline published in 2011 based on evidence complemented by expert opinion. The update will discuss new high-quality literature for the 8 key questions from the original guideline and implications for practice.

Target Patient Population

Patients with bone metastases

Inclusion Criteria

Female, Male, Adolescent, Adult, Older adult

Health Care Settings

Hospice, Hospital, Long term care, Outpatient, Radiology services

Intended Users

Nurse, nurse practitioner, physician, physician assistant


Management, Treatment

Diseases/Conditions (MeSH)

D000072716 - Cancer Pain, D010166 - Palliative Care, D009362 - Neoplasm Metastasis, D017760 - Bone Malalignment


cancer, palliative care, radiation therapy, bone metastases, cancer pain, Adjuvant Radiation Therapy


Number of Source Documents
Literature Search Start Date
December 22, 2009
Literature Search End Date
January 7, 2015