ASTRO issues updated guideline for symptomatic bone metastases
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The American Society for Radiation Oncology has issued an updated clinical guideline that outlines best practices for addressing symptomatic bone metastases and improving quality of life for these patients.
The guideline, which updates recommendations released in 2017, is based on results of several trials that showed the benefits of advanced radiation techniques — including intensity-modulated radiation therapy and stereotactic body radiation therapy — for delivering a targeted, escalated radiation dose to individuals with bone or spine metastases.
Bone metastases can cause complications such as pain, broken bones or spinal cord compression. Current treatments seek to relieve symptoms, prevent fractures and suppress further growth of metastatic bone disease.
“With better, more effective systemic therapies, patients are living longer and experiencing more bone metastases,” Tracy Balboni, MD, MPH, chair of the guideline task force and professor/clinical director of skeletal radiation oncology at Harvard Medical School and Dana-Farber Cancer Institute/Brigham and Women’s Hospital, told with Healio. “We need better evidence to guide the use of various technologies available within radiation oncology. The hope is that as we move forward, we will begin to understand how best to prevent skeletal events.”
Healio spoke with Balboni and Sara Alcorn, MD, MPH, PhD, vice chair of the guideline task force and associate professor/vice chair of clinical strategy in the department of radiation oncology at University of Minnesota Medical Center, about the key recommendations in the updated guideline and how they promote a patient-centered approach to caring for patients with symptomatic bone metastases.
Healio: What impact do symptomatic bone metastases have on patients?
Alcorn: Approximately 300,000 patients per year develop bone metastases. Bone metastases are associated with significant morbidity, including pain, pathologic fracture, hypercalcemia, and compromise to the neuraxis, including spinal cord compression. This can lead to patients needing to take pain medications, come on or off of systemic therapies, or undergo surgery. There are significant decrements to quality-of-life associated specifically with bone metastasis.
Healio: Why is an updated guideline needed?
Balboni: The last ASTRO guideline on bone metastases was published 7 years ago. A variety of studies have been published since that time, and some inform clinically relevant scenarios, such as re-irradiation, as well as developments in technologies within radiation oncology. There also is updated information about adjunctive interventions for the management of bone metastases, such as vertebroplasty.
Healio: How did you develop the updated guideline?
Balboni: The ASTRO bone metastasis guideline was developed with the assistance of the Agency for Health Research and Quality, which did a systematic review of the literature regarding symptomatic bone metastases from January 1985 to January 2023. An expert panel reviewed that evidence. The panel — comprised of providers from both community practice and academic practice — included individuals who practice in radiation oncology and other disciplines, such as medical oncology, palliative care and surgical oncology.
Healio: Can you summarize the key recommendations?
Alcorn: The guidelines strongly recommend radiation to manage pain and other symptoms attributable to bone metastases, including neurologic symptoms from spinal cord or cauda equina compression. That’s an across-the-board recommendation. There may be the need for multimodality treatments for patients with spine metastases that cause spinal cord or cauda equina compression. In these cases, surgery and dexamethasone combined with radiation is recommended over radiation alone. For patients with nonspine bone metastasis requiring surgery, postoperative radiation is recommended.
Our guidelines also include a host of palliative radiation treatment schemes that could be considered, including conventional radiation delivered in single or multiple fractions, intensity-modulated radiation therapy, and stereotactic radiation therapy for dose escalation.
In select cases — such as those with spinal cord or cauda equina compression, and stereotactic radiation in select cases — there is a conditional preference for stereotactic radiation for the treatment of bone metastases. Stereotactic radiation is recommended for patients who have good performance status and who don’t require surgery or display neurologic symptoms other than pain. This recommendation is based on evidence showing the superiority of pain control or treatment durability with stereotactic radiation compared with conventional radiation. However, this guidance is conditional because there are some discrepancies among the studies regarding the pain control outcome, and we also think that the appropriate modality and fractionation scheme needs to consider factors such as patient prognosis, tumor radiosensitivity, and metastatic disease burden.
Similarly, both conventional radiation and stereotactic modalities may be appropriate when re-irradiating symptomatic bone metastases. Again, there is a conditional preference for the use of stereotactic radiation for select patients when re-irradiating spine bone metastases, particularly for patients with excellent prognosis and radioresistant tumors.
Lastly, the guideline points to future work that is needed to better define patients who would most benefit from specific radiation approaches such as multi-fraction, conventional radiation or stereotactic radiation, as well as research done to better incorporate patient quality-of-life, preference, and goals of care into the treatment decision.
Healio: How does this guideline emphasize patient-centered care?
Balboni: The panel recommends a shared decision-making approach. There are a variety of ways this plays out in the scenarios addressed in the guideline. One example is that of pain flare in the setting of radiation therapy for symptomatic bone metastases, which is quite common. There is a randomized trial regarding the use of dexamethasone to prevent pain flare and it exhibited a reduction in pain flare incidence. However, dexamethasone is known to cause its own side effects or may even be contraindicated, such as when patients are actively receiving immunotherapy. Weighing the potential decrease in incidence of pain flare with steroids versus the side effects of steroids requires a shared decision-making approach. It’s valuable to speak with patients about the possibility for pain flare and the effectiveness of their current pain management, together with the potential toxicities of dexamethasone.
Another example is surgery in the setting of spinal cord of cauda equina compression. This requires a multidisciplinary approach that includes surgeons, medical oncologists, radiation oncologists and palliative care clinicians. Patients’ values and preferences are central to that decision-making. For example, some may prefer not to undergo surgery even at the risk they might not retain some neurologic function. Other patients would rather take the risk of having potential morbidity from surgery because any neurologic loss is not tolerable to them. Central to patient-centered care in management of bone metastases is multi-disciplinary input that partners with patients in decision-making and honors their values and goals.
Alcorn: There is an extensive range of options in terms of how to deliver palliative radiation. We hope our guideline provides radiation oncologists with an evidence-based resource to guide decision-making while also emphasizing the work that needs to be done to better select patients for appropriate regimens.
Reference:
For more information:
Sara Alcorn, MD, PhD, MPH can be reached at alcor049@umn.edu.
Tracy Balboni, MD, MPH can be reached at tbalboni@bwh.harvard.edu.
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