Radiotherapy For Bone Metastases Research Articles

Variation in the Use of Single- Versus Multifraction Palliative Radiation Therapy for Bone Metastases in Australia

To evaluate the use of single-fraction palliative radiation therapy (SFRT) for the management of bone metastases (BM) in Victoria, Australia. This is a population-based cohort of patients with cancer who received radiation therapy for BM between 2012 and 2017 as captured in the Victorian Radiotherapy Minimum Data Set. The primary outcome was proportion of SFRT use. The Cochrane-Armitage test for trend was used to evaluate changes in practice over time. Multivariable logistic regression was used to assess factors associated with SFRT use. Of the 18,158 courses of radiation therapy for BM delivered to a total of 10,956 patients, 17% were SFRT. There was no significant change in SFRT use over time, from 18% in 2012 to 19% in 2017 (P = .07). SFRT was less commonly given to the skull (4%) and spine (14%), compared with the shoulder (37%) and ribs (53%). Patients with lung cancer (21%) were most likely to receive SFRT, followed by those with prostate cancers (18%) and gastrointestinal cancers (16%). Patients from regional/remote areas were more likely to have SFRT compared with those in major cities (22% vs 16%, P < .001). Patients treated in public institutions were more likely to have SFRT compared with those treated in private institutions (22% vs 10%, P < .001). In multivariable analyses, increasing age, lung cancer, higher socioeconomic status, residence in regional/ remote areas, and being treated in public institutions were factors independently associated with increased likelihood of receiving SFRT. SFRT appears underused for BM in Australia over time, with variation in practice by patient, tumor, sociodemographic, geographical, and institutional provider factors.

Utilization of Radiation Fractionation for Bone Metastases at the End of Life in the Era of SBRT: A Large Single Institution Longitudinal Experience

Radiation therapy (RT) is effective in managing painful bone metastases. Multiple randomized trials have demonstrated that single fraction radiotherapy is not inferior to multi-fraction treatments for symptom relief. ASTRO treatment guidelines recommend a single 8Gy fraction to bone metastases for patients with limited life expectancy. We sought to evaluate the use of RT fractionation and the ability of physicians to predict short life expectancy as reflected by their choice of treatment regimen. All patients who received RT for bone metastases (BM) between 2016-2018 at a single institution were identified, as was the subset of patients who died within 30 days after receiving RT for BM. To understand longitudinal trends, treatments were binned into 6-month intervals by date of final radiation treatment. RT fractions were grouped by 8Gy in a single fraction (8Gy x 1), 30Gy in 10 fractions (3Gy x 10), other conventional RT fractionations, and stereotactic body RT (SBRT). To determine the presence of an increasing or decreasing trend, proportions were compared over time using a Chi-square test. The overall change in the use of an RT fractionation was also assessed between the beginning and end of the study period using a 2-sample proportion test. From 2016-2018, 3,056 patients underwent 6,811 palliative RT courses for BM, and 480 patients (16%) died within 30 days of their last treatment. The total number of treatments for BM increased by 27% during the study period. Among all BM treated, use of SBRT had an increasing trend (p<0.001) with a difference in use over the study period (37% to 48%, p<0.001), while 3Gy x10 has a decreasing trend (p<0.001) with a change in use (25% to 11%, p <0.001) and 8Gy x1 has remained stable over time (p=0.4) with no significant difference in use (4.5% to 4.8%, p= 0.8). The trends were mirrored among patients dying within 30 days of RT; SBRT with an increasing trend (p=0.039) and change in use (18% to 33% p= 0.03), 3Gy x10 with a decreasing trend (p<0.001) and change in use (32% to 7%, p<0.001), while the number of patients treated with 8Gyx1 remained stable (p=0.4) with no significant difference in use (9% to 17%, p= 0.2). A 33% relative reduction (9.5% to 6.6%) in death within 30 days of RT was observed. Our study demonstrates an increase in patients undergoing RT for BM over time while the overall rate of death within 30 days of RT has decreased, most likely due to more patients getting treated earlier in their disease course. Of the patients dying within 30 days of RT for bone metastases, a significant decline in the use of 3Gy x10 was observed during the study period, but the use of 8Gy x1 did not increase, potentially related to the increase in use of SBRT. Our results warrant further investigation into algorithms predicting short life expectancy and implementation strategies to increase use 8Gy x1 at the end of life.

Treatment-Related Lymphopenia after Radiotherapy for Bone Metastasis from Hepatocellular Carcinoma

Treatment-Related Lymphopenia after Radiotherapy for Bone Metastasis from Hepatocellular Carcinoma

Net Pain Relief After Palliative Radiation Therapy for Painful Bone Metastases: A Useful Measure to Reflect Response Duration? A Further Analysis of the Dutch Bone Metastasis Study

PurposePain response rates are equivalent after single 8 Gy and fractionated palliative radiation therapy for bone metastases. Reirradiation remains more frequent after a single fraction, although this does not simply reflect pain recurrence. Given the possible role of stereotactic radiation therapy in providing durable pain control, measures of durability are required. Net pain relief (NPR), the proportion of remaining life spent with pain response, may provide this. This study assesses the use of NPR as an outcome measure after palliative radiation therapy for bone metastases.Methods and MaterialsThis is a secondary analysis of data collected in the Dutch Bone Metastasis Study, a randomized trial comparing palliative radiation therapy delivered as 8 Gy in a single fraction and 24 Gy in 6 fractions. NPR was assessed by survival cohorts, treatment regimen, and primary diagnoses. The consequences of missing data upon the use of NPR in future studies were considered within sensitivity analyses.ResultsPatients whose pain improved after palliative radiation therapy experienced improvement for 56.6% of their remaining lives. Missing responses in questionnaires mean the range of uncertainty in NPR is 36.1% to 62.1%. When response beyond reirradiation was excluded, NPR after treatments of single-fraction 8 Gy and 24 Gy in 6 fractions was 49.0% and 56.5%, respectively (P = .004). Differential willingness to reirradiate may be influencing this outcome. When response beyond reirradiation was included, this difference was not seen (NPR of 55.4% vs 57.7%, respectively [P = .191]).ConclusionsPatients who responded to conventional radiation therapy experienced improved pain control for approximately half of their remaining life. NPR may provide valuable information in assessing pain response durability. Missing data are, however, inevitable in this population. This must be minimized and the consequences recognized and reported. Additionally, reirradiation protocols and the frequency and duration of trial follow-up may have a significant impact upon this outcome, requiring careful consideration during trial design if NPR is to be used in future studies.

Effect of the types of pretreatment imaging modalities on the treatment response to palliative radiation for painful bone metastases from solid cancer: a single-center retrospective analysis

BackgroundDetermining the appropriate gross tumor volume is important for irradiation planning in addition to palliative radiation for bone metastases. While irradiation planning is commonly performed using simulation computed tomography (CT), magnetic resonance imaging (MRI), bone scintigraphy, and 18fluorodeoxyglucose-positron emission tomography-CT (18FDG-PET-CT) are more sensitive for detecting bone metastasis and invasion areas. Therefore, this study evaluated whether pretreatment imaging modalities influenced the response to palliative radiation therapy (i.e., the irradiation effect) for painful bone metastases from solid malignant carcinomas.MethodsConsecutive patients with painful bone metastases treated with palliative radiation between January 2013 and December 2017 at our institution were included. We retrospectively investigated the pretreatment images from the different imaging modalities (CT, MRI, bone scintigraphy, and 18FDG-PET-CT) obtained between 1 month before and the initiation of palliative radiation and determined the primary site of carcinoma, histological type, metastatic lesion type (osteolytic, osteoblastic, or mixed), pathological fracture, and metastatic site (vertebral or not). We then evaluated the relationship between these factors and treatment response. We defined “response” as the condition in which patients achieved pain relief or reduced the use of painkiller medicines.ResultsIn total, 131 patients (78 men and 53 women) were included; the median age was 66 years (range, 24–89 years). Prescribed doses were 8–50 Gy/1–25 fractions with 2–8 Gy/fraction. Among the 131 patients, 105 were responders (response rate, 80%). The imaging modalities performed before irradiation were CT in 131 patients, MRI in 54, bone scintigraphy in 56, and 18FDG-PET-CT in 14. The Welch t-test and chi-square test showed no significant association between treatment response and each factor. Multiple logistic regression analysis including the imaging modality, metastatic site, and pathological fracture also showed no significant association with each factor.ConclusionsThere was no significant relationship between the type of pretreatment imaging and treatment response for painful bone metastases. Thus, setting the appropriate radiation field according to CT images and clinical findings could help avoiding further image inspection before palliative radiation for painful bone metastases.

Australian population-based study of single- versus multi-fraction palliative radiotherapy for bone metastases.

6568 Background: Single fraction palliative radiotherapy (SFRT) has been shown to be equivalent to multi-fraction radiotherapy (MFRT) for bone metastases symptom management. Remuneration for radiotherapy (RT) in Australia are largely determined by fractions delivered. We aim to determine the use of SFRT for bone metastases in Australia. Methods: We did a population-based linkage study of multiple administrative healthcare databases in Victoria, Australia: the Victorian Radiotherapy Minimum Data Set (VRMDS), the Victorian Cancer Registry (VCR), and the Birth, Death and Marriage registry (BDM). All patients with solid tumour (excluding primary bone cancer) who received palliative radiotherapy for bone metastases between 2012 and 2017 were included. The primary outcome was use of SFRT. The Cochrane-Armitage test for trend was used to evaluate SFRT use over time. Multivariable logistic regression was used to identify factors associated with SFRT use. Results: A total of 15,668 courses of RT for bone metastases were delivered to 10,351 patients. The overall proportion of SFRT was 18% (2,746/ 15,668). There was no significant change in SFRT use over time, from 18% in 2012 to 20% in 2017 (P = 0.06). Older patients were more likely to have SFRT (mean age 69.4 vs. 68.2, P &lt; 0.001). Patients who had lung cancer (21%) and prostate cancer (19%) were more likely to have SFRT compared to other tumour types (P &lt; 0.001). Spine RT was associated with lower use of SFRT compared to other treatment sites (14% vs. 22%, P &lt; 0.001). Patients from remote area were more likely to have SFRT compared to patients from major cities (22% vs. 17%, P &lt; 0.001). Patients treated in private institutions were less likely to have SFRT compared to those treated in public institutions (10% vs. 22%, P &lt; 0.001). In multivariate analyses, patients’ age, tumour type, area of residence, and treatment institutions were independently associated with SFRT use. Conclusions: This is the largest Australian population-based cohort treated with RT for bone metastases, with low utilisation of SFRT over time. There is large variation in SFRT use depending on patient-, tumour-, geographical and institutional factors. Further work is needed to increase uptake, and reduce unwarranted variation, in SFRT use.

Palliative Radiation Therapy for Bone Metastases in Neuroendocrine Neoplasms

PurposeBone metastases are reported in 10% to 12% of patients with neuroendocrine neoplasms (NENs) and can lead to pain and skeletal-related events (SREs), resulting in diminished quality of life and functional status. In other solid tumors with bone metastases, radiation therapy (RT) is an established treatment approach for SREs, yet few data are available in NENs historically considered to be radioresistant. We hypothesize that RT is effective for pain and other SREs in NENs and aimed to delineate any differences in pain palliation and time until progression of pain between different fractionation and dosing schedules of RT. Methods and MaterialsWe retrospectively reviewed 686 records of patients with NENs treated at the institution between 2011 and 2018 and identified 28 (4.1%) patients treated with RT for 61 cases of SREs. The primary endpoint was change in patient reported pain scores after RT. ResultsAll 28 patients experienced bone pain. Nineteen sites were treated with a single fraction (doses of 800-1800 cGy) and 42 sites with fractionated regimens (doses of 900-3750 cGy over 3-15 fractions). In 55 of 61 cases (90%), patients experienced improvement in pain after RT. The median time to recurrence or progression of pain was 3.5 months. Significant differences were found between primary site and change in performance status (P = .024), sex, and reported magnitude of pain score decrease after RT (P = .025). There were no differences in the time to the progression of pain, change in performance status, and degree of improvement in pain based on age, chemotherapy received during RT, or radiation site. Outcomes were similar for patients who received single-fraction versus fractionated regimens (P = .545) and between those receiving palliative versus ablative RT regimens (P = .812). ConclusionsAlthough the majority of cases in this NEN cohort benefited from RT, additional studies on the use of RT in the treatment of painful bone metastases are warranted.

PO-0880 Validation of a predictive model for survival in patients receiving radiotherapy for bone metastases

PO-0880 Validation of a predictive model for survival in patients receiving radiotherapy for bone metastases

EP-1615 Impact of pretreatment imaging modality on the response to palliative radiation for bone metastases

EP-1615 Impact of pretreatment imaging modality on the response to palliative radiation for bone metastases

The clinical feature of bone metastases in lung cancer patients with different pathological types

Objective Based on lung cancer center database, we analyzed the clinical characteristics of lung patients with bone metastases. The relationship between bone metastases, skeletal-related events, survival time and different pathological subtypes of lung cancer were also evaluated in this study. Methods A total of 861 patients with lung cancer were studied from May 2010 to April 2012 at Tianjin Medical University Cancer Institute and Hospital. As to follow-up situation, patients' survival status and treatment information were collected by telephone follow-up and (or) examinationsin outpatient. The clinical characteristics, skeletal-related events and survival of bone metastaticpatients with different pathological types of lung cancer were analyzed. Logistic regression analysis was used to identify risk factors for bone metastases. The relationship between histological subtypes and the incidence of bone metastases was evaluated using Odds Ratios (ORs). The chi-square test was used to compare the proportion of bone metastases, synchronous bone metastases and SREs among different histological subtypes patients. The overall survivals was evaluated using the Kaplan Meier. Results A total of861 patients with lung cancerwere enrolled in this study, including 293 cases with bone metastases.The average follow-up of our population was 14.2 months and the last follow-up time was September 2017. Among different pathological types of lung cancer, adenocarcinoma (39.14%, 173/442) has the highest incidence of bone metastases, followed by other types (29.91%, 35/117), squamous cell carcinoma (29.47%, 56/190) and SCLC (25.89%, 29/112). Spine (59.73%, 175/293) was the most common location site of the bone metastases, followed by the ribs (49.15%, 144/293), pelvis (20.48%, 60/293), femur (16.38%, 48/293) and sternal (16.38%, 48/293). Lung adenocarcinoma was a risk factor for bonemetastases (P=0.002). In ORs analyze, adenocarcinoma patients were more likely to develop bone metastases [OR=1.60, 95%CI (1.21~2.13)]. In our cohort, 58.36% of patients with lung cancer had skeletal related events. Among various types of skeletal related events of patients with bone metastases, the most common one was radiotherapy for bone metastases (51.88%, 152/293), followed by pathological fractures (15.02%, 44/293), spinal cord compression (6.48%, 19/293), bone instability requiring surgery (4.78%, 14/293) and hypercalcemia (1.71%, 5/293). There was no significant difference between different types of skeletal related events. The median survival time of the patients with bone metastases was 11.5 months. There was no significant difference in survival between adenocarcinoma patients and non-adenocarcinoma patients (P=0.111). Conclusion This study suggested that the incidence of bone metastasis in lung adenocarcinoma was 39.14% and lung adenocarcinoma was a risk factor for bone metastases, which supported early screening and monitoring of bone metastasis in the patients. Key words: Lung neoplasms; Pathology; Neoplasm metastasis; Prognosis

Long-term survival in patients with NSCLC treated with single-fraction vs. multi-fraction palliative radiotherapy in the case of lung tumor, brain metastases and bone metastases

Background: Patients with advanced non-small cell lung cancer (NSCLC) are candidates for different types of treatment, including chemotherapy and radiotherapy or supportive care. Despite the fatal prognosis in advanced disease, many experienced radiation oncologists will apply radiation at low doses with the intention of palliative care. Methods: We used an extensive database of medical patients diagnosed with NSCLC, treated with palliative radiotherapy at the Oncology Centre in Bydgoszcz, from June 1998 to December 2013. A group of 3202 patients was divided into subgroups: Group A)1762 patients irradiated on the lung tumor (without distant metastases): Total dose: A1) 6Gy/1 fr.(n=19); A2) 8Gy/1fr.(n=276); A3) 20Gy/5fr.(n=1349); A4) 30Gy/10fr.(n=118). Group B) 548 patients irradiated on the central nervous system (CNS) metastases: B1) 20Gy/5fr.(n=476); B2) 30Gy/10fr.(n=72). Group C) 892 patients irradiated on the bone metastases: C1) 8Gy/1fr.(n=452); C2) 10Gy/1fr.(n=30); C3) 20Gy/5fr.(n=341); C4) 30Gy/10fr.(n=69). Results: Patients with irradiation of a lung tumor: The longest OS was observed in the group of patients irradiated with doses of 20 Gy (76%) and 30 Gy (7%). Patients with irradiation of bone metastases: No significant differences in OS were observed between the employed fractionation regimens. Patients with irradiation of CNS metastases: The choice of a higher dose of radiation therapy did not demonstrate differences in median OS values compared to a lower dose. Conclusions: The patients who were prescribed single fraction palliative radiotherapy did not have poorer prognoses or experience shorter survival than patients who were prescribed multi-fraction pRT in the case of lung tumor, brain metastases and bone metastases.

Predicting the survival of patients with bone metastases treated with radiation therapy: a validation study of the Katagiri scoring system

BackgroundThe selection of radiation therapy dose fractionation schedules for bone metastases is often based on the estimation of life expectancy. Therefore, accurate prognosis prediction is an important issue. It is reported that the Katagiri scoring system can be used to predict the survival of patients with bone metastases. We aimed to assess prognostic factors and validate the Katagiri scoring system in patients who were treated with radiation therapy for bone metastases.Materials/MethodsWe retrospectively reviewed data of all patients who were treated with radiation therapy for bone metastases between 2004 and 2013. Age, sex, Karnofsky performance status (KPS), Eastern Cooperative Oncology Group performance status (ECOG PS), primary site (lesions and characteristics), visceral metastases, laboratory data, previous chemotherapy, and multiple bone metastases were analyzed for associations with overall survival (OS). Katagiri scores were calculated for each patient and were used to compare OS.ResultsOut of the 616 patients included in this analysis, 574 had died and 42 remained alive. The median follow-up time for survivors was 42 months. Univariate analysis revealed that age (P = 0.604) and multiple bone metastases (P = 0.691) were not significantly associated with OS. Multivariate analysis revealed that sex, ECOG PS, KPS, primary characteristics, visceral metastases, laboratory data, and previous chemotherapy were significantly associated with OS. The survival rates at 3, 6, 12, and 24 months, categorized by Katagiri score, were as follows: score 0–3, 94.4, 77.8, and 61.1%, respectively; score 4–6, 67.7, 48.7, and 31.2%, respectively; and score 7–10, 39.1, 22.1, and 9.0%, respectively (P < 0.001).ConclusionSex, ECOG PS, KPS, primary characteristics, visceral metastases, laboratory data, and previous chemotherapy were significant predictors of survival in patients with bone metastases. The Katagiri scoring system was significantly correlated with OS and can help us select the optimal dose-fractionation.

A Population-Based Study of Palliative Radiation Therapy for Bone Metastases in Patients Dying of Prostate Cancer

PurposeIncreasing the survival of patients with metastatic prostate cancer (PCa) may affect the demand for palliative radiation to bone (PRTB). Our aim was to characterize the use of PRTB in patients who died of PCa in British Columbia between 2003 and 2015. Methods and MaterialsAll patients with a diagnosis of PCa who died during the study period (n = 23,260) were identified from a population-based provincial registry. Patient and treatment characteristics were analyzed. PRTB utilization rate was calculated by year and location. Survival was calculated from the first and the last course of PRTB. ResultsA total of 5701 patients died of PCa, with a median survival from diagnosis of 5.2 years. The overall PRTB utilization rate was 38.6%, with an increasing trend over time. Multiple courses of PRTB were frequent, with 51% of patients receiving ≥2 courses of PRTB. Of the patients who died of PCa (15.2% of the PRTB cohort), 5.4% received PRTB within the last 4 weeks of life, 60% of whom received multiple fractions. Rural areas had a lower referral rate and lower use of PRTB. Patients with longer survival tended to receive multiple courses of treatment. The median survival after the first course of PRTB increased from 8.2 months in 2003 to 2004 to 9.4 months in 2013 to 2014 (P = .04). ConclusionsPRTB is only used in a minority of patients dying of PCa. The majority who die of PCa after PRTB do so within a year of their first course. The use of multifractionation was common in the last 4 weeks of life. Survival after first PRTB increased minimally over time, and additional research is required to identify its association with recent changes in practice. The referral rate and PRTB utilization rate differ between rural and nonrural locations, underlying the importance of accessibility and referral for utilization of PRTB. Investigating other barriers and ensuring equitable access to radiation are needed.

Results of an educational tool for residents and referring physicians on palliative radiation for bone metastases.

82 Background: Palliative radiation therapy (RT) for painful bone metastases is underutilized in the United States (U.S.), perhaps due to inappropriate use of multi-fraction (MF) regimens over more convenient, less costly, and equally effective single fraction (SF) regimens. Practice patterns may change with improved knowledge of radiation oncology residents (ROR) and non-radiation oncology physicians who refer patients for palliative RT. The aim of this study was to provide evidence-based educational content to these groups, and assess knowledge and views before and after. Methods: In April - June 2017, an electronic educational tool was sent to medical oncology and palliative care physicians, and ROR in the U.S. Multiple choice questions assessed knowledge, and were followed by evidence supporting the correct answer. Likert and sliding scales gaged tool impact. Chi-square and Mann-Whitney tests compared groups and pre/post-test responses. Results: Responses were obtained from 109 (2%) referring physicians (RP) and 135 (21%) ROR. ROR had higher scores than RP for 8 of 9 objective questions. RP were less likely to know that SF and MF are equivalent in terms of pain response (64 v. 91%, p &lt; 0.01) and subsequent analgesic use (86 v. 95%, p = 0.02), or that SF is associated with a higher retreatment rate (27 v. 93%, p &lt; 0.01). ROR were less likely to know that SF and MF are equivalent for patients with a high likelihood of long term survival (25 v. 56%, p &lt; 0.01). After viewing the content, ROR felt more knowledgeable [ mdn 3 (IQR 3 - 4) v. 4 (IQR 3 - 4), p &lt; 0.01], and RP felt more empowered [ mdn 3 (IQR 2 - 4) v. 4 (IQR 3 - 4), p &lt; 0.01]. RP found the survey more helpful, and knew less of the data prior [ mdn 50 (IQR 25 - 75%) v. 80% (IQR 66.3 - 90%), p &lt; 0.01]. Despite knowing the data, ROR preferred SF less than RP at completion (67 v. 85%, p &lt; 0.01). Conclusions: This study demonstrates a need for educational content for multidisciplinary providers on appropriate palliation of bone metastases. Despite ample knowledge, the bias of practicing radiation oncologists for MF is being passed onto residents. Greater knowledge may translate into more effective referral patterns and patient advocacy by RP, and potentially improve utilization of palliative RT in the U.S.

Application of Forcing Functions to Electronic Health Records Results in Improved Pain Control for Patients Undergoing Radiation Therapy for Bone Metastases

Documentation of cancer pain is a metric used by national organizations including the American Society of Clinical Oncology and National Quality Foundation to measure quality of care. However, consistent documentation of pain remains sub-optimal in daily practice despite this imperative. The use of constraint systems, such as forcing functions, may improve physician compliance. This approach requires pain to be scored before the electronic health record (EHR) can be closed. We reviewed pain documentation rates at our institution, which recently installed changes to our EHR with successively more robust constraint systems. We hypothesized that these changes would lead to increase rates of pain documentation resulting in improved pain management for patients undergoing palliative radiation for painful bone metastases. We retrospectively compared patient on-treatment visit (OTV) pain scores from three different periods of documentation strategy: free-form (Aug-Oct 2014), pain score prompt (Jan-Mar 2015) and forcing function (May-June 2017). Patients were randomly selected from a 3-month period immediately before or after implementation of each new EHR design. The first and last OTV pain scores for patients with secondary bone metastases were selected from Jan to Dec 2016 (pain score prompt) and May to Dec 2017 (forcing function). Those with only one OTV were excluded. Pain score was documented as a numeric rating score (NRS). There were 150 patient OTVs studied for each documentation strategy (n = 450). The rate of documentation for free-form was 11% (95% CI: 7, 18); pain score prompts was 87% (95% CI: 81, 92); and forcing functions was 97% (95% CI: 93, 99). Documentation rates were different across the three groups (p < 0.001). The difference between each strategy was significant (p < 0.001 for free-form vs. prompt; p = 0.002 for prompt vs. forced function; p < 0.001 for free-form vs. forced function). Patients with secondary bone metastases (n = 72) had greater decreases in pain over the course of treatment using EHRs with forcing functions compared to pain score prompts (p = 0.026). The median improvement in NRS with use of forcing functions was -1.5 (IQR: -4 to 0), compared to pain score prompts, 0 (IQR: -1.25 to 0). Our results demonstrate that constraint systems applied to EHRs increase pain documentation rates. Forcing functions, being the most restrictive, have the highest rate of documentation. This improvement in pain documentation rates resulted in significant decreases in pain as compared to less restrictive documentation strategies for patients receiving palliative radiation therapy for painful bone metastases.

Trends in Regimen for Palliative Radiation Therapy of Bone Metastases in Patients with Non-Small Cell Lung Cancer

Non-small cell lung cancer (NSCLC) is among one of the most common solid malignancies associated with bone metastases (BM). Palliative radiation therapy (RT) is the standard of care to alleviate symptoms associated with BM. Multiple randomized trials have shown equivalent pain relief with single fraction or short-course RT compared to longer palliative RT courses. In this study, we reviewed the NCDB to report on trends of short- and long-course palliative RT for BM in patients with NSCLC. There were 10,271 patients with NSCLC and BM treated with palliative RT between 2004 and 2014 were identified in the NCDB. Fractionation scheme was defined as short-course [(SC-RT): 8 Gy in 1 fractions and 20 Gy in 5 fractions] versus long-course [(LC-RT): 30 Gy in 10 fractions and 37.5 Gy in 15 fractions]. Patients coded with metastases to the ‘spinal cord’ were excluded. Trends in use of SC-RT versus LC-RT in the years 2004-2014 were analyzed with Chi Square test and ANOVA. Patient demographics and disease characteristics were correlated with fractionation scheme using multivariable logistic regression. A total of 1933 (18.8%) patients were included in the SC-RT group and 8338 (81.2%) patients in the LC-RT group. Sites of BM were spine (57.2%), extremity (13.9%), hip/pelvis (21.9%) ribs (6.1%), and skull (0.9%). The use of SC-RT has increased from 12.2% in 2004 to 27.6% in 2014 (p<0.0001). Factors associated with increased use of SC-RT included: academic treatment facility [Odds ratio (OR): 0.58 (95% CI, 0.52-0.65); p<0.0001], living > 20 miles from treatment facility [OR: 0.69 (95% CI, 0.55-0.87); p=0.002], treatment to the rib [OR: 0.68 (95% CI, 0.55-0.84); p<0.0001], treatment in the year 2010 [OR: 0.63 (95% CI, 0.46-0.85); p=0.003], treatment in the year 2011 [OR: 0.55 (95% CI, 0.41-0.74); p<0.0001], treatment in the year 2012 [OR: 0.55 (95% CI, 0.41-0.74); p<0.0001], treatment in the year 2013 [OR: 0.43 (95% CI, 0.32-0.57); p<0.0001], and treatment in 2014 [OR: 0.37 (95% CI, 0.28-0.49); p<0.0001]. Increasing age trended toward association of SC-RT [OR: 0.99 (95% CI, 0.99-1.00); p=0.071] though did not reach statistical significance. Factors associated with increased utilization of LC-RT included living <5 miles to treatment facility [OR: 1.15 (95% CI, 1.01-1.30); p=0.029], treatment to the hip/pelvis [OR: 1.43 (95% CI, 1.21-1.67); p<0.0001], and treatment to the spine [OR: 2.51 (95% CI, 2.17-2.90); p<0.0001]. Our analysis reveals that LC-RT remains the most common fractionation scheme for palliative treatment of BM in NSCLC patients. Use of palliative short-course RT is increasing, and has more than doubled between 2004 and 2014. SC-RT is more common in academic facilities and for patients who live a large distance from a treatment facility. Although randomized evidence supports equivalent pain relief with SC-RT, its use remains under-utilized and requires further advocacy for palliative treatment of BM.

A Prospective, Interventional Study Evaluating the Use of a Prompt to Improve Compliance with Documentation of a Plan of Care for Pain in Patients with Bone Metastases Seen for Palliative Radiation Therapy

Management of cancer-related pain is an essential component of comprehensive oncologic care. Undertreated pain results in adverse clinical outcomes, undue suffering, and decreased quality of life. Furthermore, there are significant disparities in pain management, with racial/ethnic minorities and underserved populations at higher risk for undertreated cancer related pain. We studied whether the use of a simple electronic medical record (EMR) prompt could increase compliance with documentation of pain interventions in patients seen for palliative radiotherapy for bone metastases. A prospective, interventional study was approved by the Resident and Fellow Quality Improvement Incentive Program at our institution. Evaluable patients were seen in consultation for palliative radiation therapy for bone metastases. Resident physicians were asked to imbed a prompt in their consultation note, including pain scale (0/10) and plan of care for pain management. The primary endpoint was compliance rate of documenting a plan of care for >50% of audited patient encounters. The protocol aligned with Merit-based Incentive Payment System (MIPS) quality measures as defined by the Centers for Medicare Services. Quarterly EMR review was performed, with charts selected at random for auditing. Prior to initiation of the QI protocol, a pain intervention was documented in just 17.2% of patients. In the first 6 months following institution of the QI protocol, a plan of care for pain was documented in 65.5% of patients. The analgesic regimen was assessed or modified in 35% of consultations, urgent radiation therapy undertaken in 26%, communication with primary provider or oncologist in 10%, and referral to the Palliative Care service in just 4%. After institution of this protocol for patients being evaluated for palliative radiotherapy for bone metastases, substantially more patients had documentation of a plan of care for pain in accordance with MIPS quality guidelines. In addition to offering palliative radiation therapy, analgesics regimens were adjusted, referrals to palliative care were offered, and pain control was discussed with the referring provider. Ongoing efforts in our department are aimed at improving pain management and integrating radiation therapy with specialized palliative care providers.

Prescription of Evidence-Based Single Fraction Radiation Therapy for Bone Metastases Can be Increased in a Meaningful and Sustained Way on a Population Level Using Quality Assurance Data

There is ample evidence that a single fraction of radiation therapy (SFRT) is as equally efficacious as more costly and potentially morbid multi-fraction regimens. In our large provincial program, we previously demonstrated that a multi-pronged educational and audit intervention increased the use of SFRT in all regional cancer centers the year following. However, other investigators have demonstrated interventions focused on guideline dissemination were only associated with a transient one year change in prescribing practices, and therefore we sought to determine if our use of SFRT also returned to baseline or persisted. Several province-wide interventions were implemented in 2012 to increase the use of SFRT, including an audit of prescribing practices of individual physicians (anonymized) and center averages (non-anonymized) and subsequent presentation of these results to leaders and oncologists. After individual patient chart review, we subsequently compared the use of SFRT in all patients treated with bone metastases in our provincial program from 2007-2011 (pre-intervention) and 2013-2016 (post-intervention), and performed comparison across all six provincial cancer centers. Prior to the intervention, the rates of SFRT in 2007, 2008, 2009, 2010, and 2011 were 51, 51, 48, 49, and 48, while the rates post intervention in 2013, 2014, 2015, and 2016 were 60, 60, 57, and 54% (p <0.001). In the most recent year of this study (2016), 4 of the 6 provincial centers prescribed in a relatively narrow range (45, 48, 53, and 54%). However, there was little change in the center with the lowest use of SFRT (26% to 25%) or in the center with the highest use of SFRT (73% to 75%). Our audit and educational based intervention resulted in a lasting change in practice. A small trend toward decreasing SFRT in recent years was observed, though rates were still above our pre-intervention level and well above international comparisons. Our provincial rate is similar to a previously published recommended benchmarks rate of 60%, though we continue to see significant variation by center, suggesting further room for improvement in provincial standardization. With the potential of emerging evidence in support of stereotactic ablative radiation therapy for select populations of patients with bone metastases, future benchmark rates of SFRT use should be readdressed, though our data suggest programmatic comparison and dissemination of SFRT prescribing practices can achieve a population based SFRT utilization rate of over 50%.

Strontium-89 Chloride Delivery for Painful Bone Metastasis in Patients with History of Previous Radiation

Re-irradiation of previously irradiated site must be done with careful consideration to minimizing dose to organs at risk. In particular, re-irradiation of the spine carries significant morbidity due to risk of myelitis. Strontium-89 chloride (Sr-89) is widely used for treatment of painful bone metastasis. The purpose of this study is to evaluate pain response and safety of Sr-89 administration for painful bone metastasis in the setting of prior radiation. After institutional review board approval, records of patients who received Sr-89 injection for painful bone metastasis in previously irradiated sites were retrospectively reviewed. Patients with follow-up of less than 1 month were excluded from analysis. Efficacy of pain control was evaluated with the verbal rating scale (VRS), documentation of the analgesic dose employing the World Health Organization (WHO) pain relief ladder. Adverse events were measured using CTCAE v4.0. Twenty-three patients met study inclusion criteria, of which 12 were male and 11 were female. Median age at treatment was 69 years (50-83). Primary sites were lung (n=11), prostate (n=3), breast (n=2), uterine cervix (n=2), kidney (n=1), and other (n=4). Median follow-up was 8 (1-49) months. Twelve patients treated with SR-89 had prior history of palliative radiation therapy for bone metastasis. The remainder had received radiation for non-bony metastasis as follows: concurrent chemo-radiotherapy (CCRT) for lung cancer (n=7), post-operative radiotherapy to regional lymph nodes of breast cancer (n=1), pre-operative CCRT for rectal cancer (n=1), radical CCRT for cervical cancer (n=1), and radiotherapy to tumor bed for recurrent prostate cancer (n=1). Prior to administration of Sr-89, the VRS grade of 0/1/2/3 was n=1/5/12/5, respectively. Analgesic score 0/1/2/3/4/5/6 was n=3/9/2/4/3/1/1, respectively. After administration of Sr-89, VRS grade didn’t change in 3 patients, and improved in 20; 17 occurred after 1 month, 2 after 2 months, and 1 after 3 months. Analgesic score didn’t change in 15 but improved in 8 patients; 4 after 1 month, 2 after 2 months, 2 after 3 months. In two patients neither the VRS nor the analgesic score improved and in two patients the VRS improved but the analgesic score increased, hence difficult to evaluate efficacy of SR-89. This made the response rate of evaluable patients 90.1%. Flare phenomenon was observed in 3 patients, but all were controlled with analgesic and improved within one week. No grade 2 or worse adverse events was observed. Administration of strontium-89 chloride to patients with painful bone metastasis at previously irradiated sites is an effective and safe treatment options for palliation of symptoms at the end of life.

The impact of radiation treatment planning technique on unplanned hospital admissions

PurposeTreatment burdens and toxicities related to palliative radiation therapy (RT) may lead to unplanned hospital admissions (UHAs). The likelihood for these toxicities may be related to treatment technique. We compared rates of UHA between patients receiving nonconformal (2-dimensional) and conformal (3-dimensional or higher) radiation treatments to bone metastases involving the vertebral column. Methods and materialsWe retrospectively analyzed patients treated with RT for bone metastases at a single tertiary care center between 2010 and 2017. We compared rates of RT-related UHA within 90 days of receiving radiation using Cox competing risk regression models. ResultsWe identified 326 patients with bone metastases involving the vertebral column, 139 of whom received radiation by nonconformal technique and 187 by conformal technique. On multivariable analysis, conformal techniques were associated with a reduced risk of 90-day UHA (hazard ratio [HR]: 0.35; 95% confidence interval [CI], 0.14-0.88). Other significant factors include hematologic cancer (HR: 0.17; 95% CI, 0.03-0.82) and baseline Eastern Cooperative Oncology Group score ≥2 (HR: 3.02; 95% CI, 1.05-8.69). ConclusionsThe utilization of conformal (non-2-dimensional) radiation treatment plans may help reduce treatment-related toxicities and consequently UHAs after palliation of bone metastases.