Valeriani, M., Scaringi, C., Blasi, L., Carnevale, A., De Sanctis, V., Bonome, P., . . . Enrici, R.M. (2015). Multifraction radiotherapy for palliation of painful bone metastases: 20 Gy versus 30 Gy. Tumori, 101, 318–322. 

To compare multifraction radiation therapy schedules for the palliation of pain from bone metastases

The medical records of patients treated with either 20 Gy in five fractions or 30 Gy in 10 fractions of radiotherapy were used for data collection. Pain was assessed prior to and one month after treatment. Clinical response was graded as complete response (CR, pain resolution), partial response (PR, reductions of at least two points on a numeric scale), or no response (NR). The two groups' outcomes were compared according to radiotherapy schedule.

• N = 105
• MEDIAN AGE = 66.5 years (range = 32–86 years)
• MALES: 56%, FEMALES: 44%
• KEY DISEASE CHARACTERISTICS: Multiple tumor types were included, most commonly breast, lung, and prostate. In total, 140 painful lesions were included, and 29 patients had multiple lesions. The most common site was the spine.

• SITE: Single site  
• SETTING TYPE: Outpatient  
• LOCATION: Italy

• PHASE OF CARE: Late effects and survivorship
• APPLICATIONS: Palliative care 

Retrospective, descriptive study

• 11-point Numeric Rating Scale (NRS)
• Radiation Therapy Oncology Group (RTOG) criteria for adverse events

The overall response rate was 88.9%. In the 30 Gy group, the CR rate was 19% compared to 6.5% in the 20 Gy group (p = 0.019). The PR rate in the 30 Gy group was 68.3% compared to 83.1% in the 20 Gy group. There was no difference between groups in overall response rates. The mean decline in pain score was 3.2 in the 20 Gy group and 3.6 in the 30 Gy group. More patients in the 30 Gy group had multiple sites of bone metastases. The incidence of toxicity was higher in the 30 Gy arm (p = 0.0001). The most common toxicities were nausea, vomiting, and diarrhea. In the regression analysis, incorporating variables of age, radiation therapy site, gender, tumor type, and analgesic use did not reveal a statistic difference in outcomes between the groups.

Optimal doses and fractionation for the palliation of bone metastases-related pain were not defined. This study demonstrated similar pain relief with a more abbreviated course of treatment, suggesting that a shorter treatment course may be as effective as long-course treatment for pain palliation. This may result in less toxicity from radiation treatment.

• Risk of bias (no random assignment)
• Measurement validity/reliability questionable
• Other limitations/explanation: Type of pain measurement was unclear (i.e., was worst, current, or average pain measured). No information regarding the use of bone modifying agents or changes in pain medication during the study was provided.

The findings of this study suggested that short-term radiation treatment for pain from bone metastases may be as beneficial as longer term treatment, and it may have fewer adverse side effects. Additional research to develop evidence for the most beneficial radiation schedule is needed.