Lutz, S., Berk, L., Chang, E., Chow, E., Hahn, C., Hoskin, P., . . . Hartsell, W. (2011). Palliative radiotherapy for bone metastases: An ASTRO evidence-based guideline. International Journal of Radiation Oncology *Biology* Physics, 79, 965–976. 

DOI Link

Purpose & Patient Population

PURPOSE: To present guidelines for patients and physicians regarding the use of radiotherapy in the treatment of bone metastases according to the current published evidence and complemented expert opinion
 
TYPES OF PATIENTS ADDRESSED: Patients with bone metastases

Type of Resource/Evidence-Based Process

RESOURCE TYPE: Evidence-based guideline  
 
PROCESS OF DEVELOPMENT: A task force searched and reviewed evidence from the literature search to address specific questions posed. The task force developed final guidelines via consensus from the evidence. 
 
DATABASES USED: PubMed
 
KEYWORDS: Radiotherapy, bone metastases
 
INCLUSION CRITERIA: Not specified
 
EXCLUSION CRITERIA: Not specified

Phase of Care and Clinical Applications

PHASE OF CARE: Multiple phases of care
 
APPLICATIONS: Palliative care 

Results Provided in the Reference

The literature search yielded 4,287 articles. Of these, the review of evidence included of the sample 25 randomized clinical trials, 20 prospective single-arm studies, and four meta-analyses/systematic reviews. No method of evaluation of study quality was described.

Guidelines & Recommendations

Radiotherapy is a successful and time efficient method to palliate and/or prevent the morbidity of bone metastases. This guideline reviews the available data to define its proper use and provide consensus views concerning contemporary controversies or unanswered questions that warrant prospective trial evaluation.
  • Various fractionation schedules can provide significant palliation of symptoms and/or prevent the morbidity of bone metastases.
  • Stereotactic body radiation holds theoretical promise in the treatment of new or recurrent spine lesions, and the task force recommended it be limited to highly selected patients, preferably within a prospective trial.
  • Surgical decompression and postoperative radiotherapy is recommended for spinal cord compression or spinal instability in highly selected patients with sufficient life expectancy and performance status.
  • The use of biophosphonates, radionuclides, vertebroplasty, and kyphoplasty for the treatment or prevention of cancer-related symptoms does not obviate the need for external beam radiotherapy in appropriate patients.  
No unacceptable rates of long-term side effects with single fraction therapy were seen. Sites of recurrent pain may be palliated with repeat radiation therapy; however, it was recommended that these patients be treated within an available clinical trial, and care is needed if the field includes the spinal cord due to the risk of myelopathy. The use of radiopharmaceuticals is most appropriate when there are multiple sites of chronic pain. No definitive statement could be made regarding combined external beam radiation therapy and radiopharmaceuticals.

Limitations

  • Limited search database
  • No stated method of evaluating or grading study quality

Nursing Implications

This systematic review provides information for nurses about evidence regarding use of radiation therapy for the palliation of pain from bone metastases. It points out that use of bone-modifying agents does not preclude use of radiation therapy. It also points out that for patients with multiple sites of disease-related pain, the use of radiopharmaceuticals may be more useful.