Radiation therapy for asymptomatic bone metastases prolongs survival, prevents pain
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Palliative radiation therapy for high-risk asymptomatic bone metastases significantly prolonged OS while reducing skeletal-related events compared with standard therapy, phase 2 trial results showed.
Findings from the randomized study — presented at American Society for Radiation Oncology Annual Meeting — suggest that painful complications related to solid tumors can be prevented by treating asymptomatic bone metastases with radiation therapy, the investigators noted.
Background
Radiation therapy is the standard of care for symptomatic bone metastases, and much evidence exists on its benefit for treating pain in patients with cancer, according to Erin F. Gillespie, MD, assistant attending radiation oncologist at Memorial Sloan Kettering Cancer Center.
“The question has frequently arisen about whether to treat asymptomatic bone metastases — particularly those that arise in critical locations that we know can be associated with further complications,” she said during the presentation.
Her group's experience suggests that bone metastases can become painful and lead to subsequent hospitalizations. Furthermore, Gillespie said these lesions are often present in previous imaging.
“The question we asked is can radiation applied to these lesions — before they become painful — actually prevent complications ... and improve patient quality of life?"
Methodology
Gillespie and colleagues enrolled 78 patients with 122 bone metastases for the phase 2 study to examine prophylactic use of palliative radiation therapy in adults with high-risk asymptomatic bone metastases vs. standard-of-care therapy.
The most common primary disease types included lung cancer (27%), breast cancer (24%) and prostate cancer (22%). Eligible patients had at least five metastatic lesions, including one asymptomatic, high-risk lesion.
Investigators randomly assigned patients in a 1:1 ratio to receive either prophylactic radiation therapy (n = 39) or standard of care with no radiation therapy (n = 39).
Skeletal-related events, including fracture, cord compression or surgical/radiation intervention, served as the study’s primary outcome — analyzed as time from treatment randomization until either death or 1-year follow-up. Researchers sought to determine whether prophylactic treatment of asymptomatic lesions couple prevent these events, which may increase risk for death and health care costs.
Median follow-up was 2.4 years.
Key findings
Results showed significantly fewer skeletal-related events in the radiation therapy group compared with the standard-of-care group (1.6% vs. 29%; P < .001).
Investigators reported no patients hospitalized for skeletal related events in the radiation therapy group compared with 11% of those in the standard-of-care group (P = .045).
Researchers also reported significantly longer median OS in the radiation therapy group compared with the standard-of-care group (1.7 years vs. 1 year; HR = 0.5; 95% CI, 0.28-0.91).
Patients who received radiation reported reduced pain at 3 months compared with the standard-of-care group (P < .05) and better pain-related quality of life at 1 year after therapy, the investigators noted.
Clinical implications
"This first randomized trial of its kind suggests radiation for high-risk bone metastases in patients without pain may be a promising new treatment approach,” Gillespie told the audience. “Future research is needed to confirm the overall survival benefit, as well as optimize which patients to treat and ensure timely referral.”
Perspective
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Jessica Wong, MD, MEng
This exciting study by Gillespie and colleagues challenges the current standard that radiation should be reserved for bone metastases already causing symptoms and suggests there is benefit to treating these lesions before they become a problem. Most interestingly, not only does early treatment prevent pain, it also can decrease risk for fracture, prevent hospitalization and even increase OS.
Although this is a small study, it shows a great deal of promise that will hopefully be borne out in larger trials. This may be practice changing for patients with metastatic bone lesions, increasing the role of palliative radiation therapy and improving outcomes for patients with metastatic disease.
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Gillespie EF, et al. Abstract LBA 04. Presented at: American Society for Radiation Oncology Annual Meeting; Oct. 23-26, 2022; San Antonio.
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