2480 - Radiation Therapy for Palliation of Symptomatic Bone Metastases: An ASTRO Clinical Practice Guideline

S. R. Alcorn¹, A. Artal², L. Bradfield³, M. Brennan⁴, K. Dennis⁵, D. A. Diaz Pardo⁶, Y. C. Doung⁷, S. N. C. Elmore⁸, L. M. Hertan⁹, C. Johnstone¹⁰, J. A. Jones¹¹, N. A. Larrier¹², S. S. Lo¹³, Q. N. Nguyen¹⁴, Y. D. Tseng¹³, D. Yerramilli¹⁵, S. S. Zaky¹⁶, and T. A. Balboni¹⁷; ¹University of Minnesota: Department of Radiation Oncology, Minneapolis, MN, ²Hospital Universitarios Miguel Servet Zaragoza, Zaragoza, Spain, ³American Society for Radiation Oncology, Arlington, VA, ⁴Johns Hopkins University, Baltimore, MD, ⁵Division of Radiation Oncology, The Ottawa Hospital and the University of Ottawa, Ottawa, ON, Canada, ⁶Department of Radiation Oncology, The Ohio State University Comprehensive Cancer Center, Columbus, OH, ⁷Oregon Health and Science University, Portland, OR, United States, ⁸University of North Carolina, Chapel Hill, NC, ⁹Department of Radiation Oncology, Beth Israel Deaconess Medical Center, Boston, MA, ¹⁰Medical College of Wisconsin, Milwaukee, WI, ¹¹University of Pennsylvania, Philadelphia, PA, ¹²Duke University Medical Center, Durham, NC, ¹³Department of Radiation Oncology, University of Washington/ Fred Hutchinson Cancer Center, Seattle, WA, ¹⁴Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, ¹⁵Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, ¹⁶Department of Radiation Oncology, Stanford University School of Medicine, Stanford, CA, ¹⁷Department of Radiation Oncology, Dana-Farber Cancer Institute/Brigham and Women’s Hospital, Harvard Medical School, Boston, MA

Purpose/Objective(s): This guideline provides evidence-based recommendations for palliative radiation therapy (RT) in symptomatic bone metastases. Materials/

Methods: The American Society for Radiation Oncology (ASTRO) convened a task force to address 5 key questions regarding palliative RT in symptomatic bone metastases. Based on a systemic review by the Agency for Health Research and Quality, recommendations using predefined consensus-building methodology were established; evidence quality and recommendation strength were also assessed.
Results: For palliative RT for symptomatic bone metastases, RT is recommended for managing pain from bone metastases and spine metastases with or without spinal cord or cauda equina compression. Regarding other modalities with RT, for patients with spine metastases causing spinal cord or cauda equina compression, surgery and postoperative RT are conditionally recommended over RT alone. Furthermore, dexamethasone is recommended for spine metastases with spinal cord or cauda equina compression. Patients with non-spine bone metastases requiring surgery are recommended postoperative RT. Symptomatic bone metastases treated with conventional RT are recommended 800 cGy in 1 fraction, 2000 cGy in 5 fractions, 2400 cGy in 6 fractions, or 3000 cGy in 10 fractions. Spinal cord or cauda equina compression in patients ineligible for surgery and receiving conventional RT are recommended 800 cGy in 1 fraction, 1600 cGy in 2 fractions, 2000 cGy in 5 fractions, or 3000 cGy in 10 fractions. Symptomatic bone metastases in selected patients with good performance status without surgery or neurological symptoms/signs are conditionally recommended stereotactic body radiotherapy (SBRT) over conventional palliative RT. Spine bone metastases re-irradiated with conventional RT are recommended 800 cGy in 1 fraction, 2000 cGy in 5 fractions, 2400 cGy in 6 fractions, or 2000 cGy in 8 fractions; non-spine bone metastases re-irradiated with conventional RT are recommended 800 cGy in 1 fraction, 2000 cGy in 5 fractions, or 2400 cGy in 6 fractions. Determination of an optimal RT approach/regimen requires whole person assessment, including prognosis, previous RT dose if applicable, risks to normal tissues, quality of life, cost implications, and patient goals and values. Relatedly, for patient-centered optimization of treatment-related toxicities and quality of life, shared decision-making is recommended.
Conclusion: Based on published data, the ASTRO task force’s recommendations inform best clinical practices on palliative RT for symptomatic bone metastases.