Dexamethasone reduces radiation-induced pain flare among patients with bone metastases

Dexamethasone appeared to reduce pain flare and improve quality of life among patients with advanced cancer undergoing radiotherapy for bone metastases, according to results of a double blind controlled trial presented at the ASTRO Annual Meeting.

Perspective from Brian D. Kavanagh, MD, MPH, FASTRO

Palliative radiation therapy is often used for patients with advanced cancer and bone metastases to reduce bone pain; however, the radiation can cause temporary pain flare.

According to the U.S. National Cancer Data Base, almost 25,000 patients with breast, lung or prostate cancer underwent radiation therapy for bone metastases between 2005 and 2011.

Alysa Fairchild, MD, radiation oncologist at Cross Cancer Institute and University of Alberta in Edmonton, and colleagues compared the efficacy and safety of dexamethasone and placebo to reduce pain flare. Secondary endpoints included toxicity and quality-of-life impact.

The analysis included 298 patients with bone metastases from 23 centers in Canada. All patients underwent a single 8 Gy fraction of radiotherapy to one or two bone metastases.

Researchers randomly assigned patients to receive 8 mg oral dexamethasone daily for 5 days starting on the first day of radiation (n = 148) or oral placebo (n = 150).

Patients reported their worst pain scores before radiotherapy began and then daily for 10 days following treatment. The patients completed European Organization for Research and treatment of Cancer Quality of Life Questionnaires at baseline, day 10 and day 42.

Overall, patients in the dexamethasone arm experienced fewer episodes of pain flare and, when they did experience pain flare, it was less severe than that of patients in the placebo arm.

In the intent-to-treat analysis, 26.4% of the dexamethasone arm had pain flare compared with 35.3% in the placebo group. Results of a sensitivity analysis showed 17.6% of patients assigned dexamethasone experienced pain flare compared with 29.3% of those assigned placebo.

Based on the data culled from the questionnaires 10 days after treatment, patients in the dexamethasone group experienced significantly improved functional interference, appetite and nausea from their baseline scores compared with the placebo group.

“The potential side effects of radiation treatment for bone metastases can be well managed in the majority of people, and therefore pain flare should not be viewed as a barrier to receiving this highly effective therapy for symptom control,” Fairchild said in a press release. “Based on our results, we recommend that patients who are scheduled to receive radiation therapy to control painful bone metastases also receive a short course of dexamethasone to reduce the risk [for] experiencing an acute pain flare.” – by Anthony SanFilippo

For more information: Chow E, et al. Abstract LBA-6663. Presented at: ASTRO Annual Meeting; Oct. 18-21, 2015; San Antonio, Texas.

Disclosure: HemOnc Today was unable to confirm the researchers’ relevant financial disclosures at the time of reporting.

Perspective

Brian D. Kavanagh, MD, MPH, FASTRO

The results of over 2,000 scientific studies were presented at the ASTRO Annual Meeting, the theme of which was “Technology Meets Patient Care.” Among the best presentations that exemplify that theme were two randomized clinical trials, one involving the use of radiotherapy in the curative treatment of early-stage prostate cancer presented by Lee and colleagues, and one involving the use of radiotherapy for palliation late in the course of prostate cancer presented by Chow and colleagues. The Radiation Therapy Oncology Group (RTOG) 0415 trial compared two schedules of radiotherapy in the treatment of early-stage prostate cancer, and a randomized trial performed by the National Cancer Institute of Canada (NCIC) explored the use of dexamethasone as prophylactic treatment prior to radiotherapy to relieve pain in metastatic disease.
The studies are noteworthy for several reasons. First, they illustrate the value of radiotherapy across the entire spectrum of cancer care, in one study as a means of eradicating early-stage disease in selected cases and in the other study as an effective method of relieving symptoms for patients whose cancer progresses to involve the bones. Second, they demonstrate two different but equally important approaches to enhancing the value of radiotherapy. The concept of value in medical care is classically understood as the quality of the outcome achieved divided by the cost of the services. In the RTOG study, a shorter and thus less costly approach to treatment achieved an identical high rate of success in preventing the recurrence of early-stage prostate cancer without any added side effects. This success is achieved by the strategic implementation of modern image-guided treatment techniques and sophisticated treatment delivery technology not available 20 years ago. In the NCIC study, rather than using a high-tech means of improving value, the investigators used a very low-cost medication — dexamethasone — given over a few days to help patients avoid a temporary but bothersome side effect that is experienced by some patients who receive radiotherapy to relieve pain in the bone. The net result in both studies is enhanced value, in the first case because of reduced cost with no compromise to quality and in the second case due to improved quality with a negligible increase in cost.
Finally, in both studies, the investigators placed a major emphasis on patient-reported outcomes to guide patient care rather than just relying on lab tests or scans to evaluate the success of treatment. Ultimately, this focus on listening to the patient with cancer and responding to his or her needs and feelings is perhaps the most important and enduring lesson from both studies.

Brian D. Kavanagh, MD, MPH, FASTRO

University of Colorado School of Medicine

ASTRO president-elect

Disclosures: Kavanagh reports no relevant financial disclosures.