RT for bone metastases in terminal cancer: More is not necessarily better

Despite more than a decade of medical evidence demonstrating that a single session of radiotherapy provides just as much pain relief to patients with terminal cancer as multiple treatments, the method, known as single-fraction treatment, has yet to be adopted into routine practice. This was the finding of a new study published in JAMA (2013; doi:10.l001/jama.2013.277081).

For cancer patients dealing with the pain of bone metastasis, doctors typically recommend radiation as a palliative therapy. But as in many areas of medicine, more treatment is not necessarily better. In addition, single-fraction treatment offers obvious advantages in patient comfort and convenience, along with associated cost savings.

"Increased use of single-fraction treatment would achieve the Holy Grail of health reform, which is real improvements in patient care at substantial cost savings," said the study's lead author, Justin E. Bekelman, MD, an assistant professor of radiation oncology at Penn Medicine's Abramson Cancer Center in Philadelphia, Pennsylvania. Yet so far, he notes, "despite the evidence, single fraction treatment is used rarely and it's reserved for patients with the poorest prognosis."

Bekelman and his colleagues examined a group of 3,050 patients 65 years and older treated with radiotherapy for advanced prostate cancer and bone metastases. In the analysis of patients drawn from the national Surveillance, Epidemiology, and End Results (SEER)-Medicare database, they found only 3% of patients studied received just single-fraction treatment, and nearly half of the patients had more than 10 treatments. The costs of the excess treatments, the authors found, were substantial: Mean 45-day radiotherapy-related expenditures were 62% lower for patients who received one treatment, at $1,873 for single vs. $4,967 for multiple fractions.

Professional societies have recommended single-fraction treatment over multiple fractions for routine pain control, except in cases with complications that require specialized therapy, such as spinal cord compression or broken bones caused by tumors.

These findings underscore the importance of efforts such as the Choosing Wisely campaign, which seeks to identify and promote medical practices that offer the highest value and best outcome for patients. This data shows that patients are routinely receiving extra radiation treatments, driving up health care costs without conferring additional benefits to patients.

"Whether you get more or less radiation for bone metastases has nothing to do with survival," said Bekelman. "When clear and consistent evidence exists that supports single fraction treatment, we should proceed with the treatment that has equivalent pain control, is more convenient, and gets patients out of treatment quicker."

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