Elsevier

Radiotherapy and Oncology

Volume 56, Issue 3, 1 September 2000, Pages 305-314
Radiotherapy and Oncology

Palliation of bone metastases: a survey of patterns of practice among Canadian radiation oncologists

https://doi.org/10.1016/S0167-8140(00)00238-3Get rights and content

Abstract

Background: Palliative radiotherapy constitutes nearly 50% of the workload in radiotherapy. Surveys on the patterns of practice in radiotherapy have been published from North America and Europe. Our objective was to determine the current pattern of practice of radiation oncologists in Canada for the palliation of bone metastases.

Method: A survey was sent to 300 practicing radiation oncologists in Canada. Five case scenarios were presented. The first three were patients with a single symptomatic site: breast cancer patient with pelvic metastasis, lung cancer male with metastasis to L3 and L1, respectively. The last two were breast and prostate cancer patients with multiple symptomatic bone metastases.

Results: A total of 172 questionnaires were returned (57%) for a total of 860 responses. For the three cases with a single painful bone metastasis, over 98% would prescribe radiotherapy. The doses ranged from a single 8 to 30 Gy in ten fractions. Of the 172 respondents, 117 (68%) would use the same dose fractionation for all three cases, suggesting that they had a standard dose fractionation for palliative radiotherapy. The most common dose fractionation was 20 Gy in five fractions used by 84/117 (72%), and 8 Gy in one fraction by 19/117 (16%). In all five case scenarios, 81% would use a short course of radiotherapy (single 8 Gy, 17%; 20 Gy in five fractions, 64%), while 10% would prescribe 30 Gy in ten fractions. For the two cases with diffuse symptomatic bone metastases, half body irradiation (HBI) and radionuclides were recommended more frequently in prostate cancer than in breast cancer (46/172 vs. 4/172, P<0.0001; and 93/172 vs. 10/172, P<0.0001, respectively). Strontium was the most commonly recommended radionuclide (98/103=95%). Since systemic radionuclides are not readily available in our health care system, 41/98 (42%) of radiation oncologists who would recommend strontium were not familiar with the dose. Bisphosphonates were recommended more frequently in breast cancer than in prostate cancer 13/172 (8%) vs. 1/172 (0.6%), P=0.001.

Conclusion: Local field external radiotherapy remains the mainstay of therapy, and the most common fractionation for bone metastases in Canada is 20 Gy in five fractions compared with 30 Gy in ten fractions in the US. Despite randomized trials showing similar results for single compared with fractionated radiotherapy, the majority of us still advocate five fractions. The frequency of employing a single fractionation has not changed since the last national survey in 1992. Nearly 70% use a standard dose fractionation to palliate localized painful metastasis by radiotherapy, independent of the site of involvement or tumor type. The pattern of practice of palliative radiotherapy for bone metastases in Canada is different to that reported previously from the US. The reasons why the results of randomized studies on bone metastases have no impact on the patterns of practice are worth exploring.

Introduction

Nearly 50% of the practice of radiotherapy is on palliation, of which the management of bone metastases constitutes the most common palliative workload [17]. As a result of improvement in systemic therapy, patients with bone metastases tend to live longer, and hence, the number of patients requiring palliative radiotherapy has increased.

At present, the therapeutic options for the management of bone metastases include analgesics, chemotherapy, hormonal therapy, bisphosphonates and radiotherapy. The latter can be by external beam local field irradiation (LF), half body irradiation (HBI), or systemic radionuclide therapy (SR). Despite the absence of a dose-response relationship for LF, different dose fractionations are commonly prescribed [6]. The optimal dose and fractionation schemes in the management of bone metastases still remain controversial. HBI and SR represent a more systemic approach for patients with multiple bony metastatic sites, and have been employed with increasing frequency in recent years [12], [27], [28], [36], [41].

Surveys of the radiotherapy community about the management of patients with bone metastases were reported from North America and Europe [7], [13], [20], [30]. Maher et al. reported in their article ‘Treatment strategies in advanced and metastatic cancer: difference in attitude between the USA, Canada and Europe’ published in 1992 that the median doses for the treatment of bone metastases employed by the radiation oncologists in Canada, Europe and USA were 20 (range, 8–30 Gy), 30 (range, 5–50 Gy) and 30 Gy (range, 10–40 Gy), respectively [30]. In the following year, Duncan et al. reported the survey of the radiation oncologists in Canada on the treatment of a breast cancer patient with bone metastases. Fifty-seven percent of respondents prescribed 20 Gy in five fractions and occasionally 25 Gy in five fractions. Only 15% used single fractions. The schedule prescribed ranged from 8 Gy in a single fraction to 30 Gy in ten fractions [13]. Since then, there have been further reports of bone metastases trials in the literature. The Americans have recently done two surveys on the current pattern of practice on treatment of bone metastases [7], [20]. Our objective was to survey the patterns of practice among Canadian Radiation Oncologists, and compare our results with those published previously.

Section snippets

Methods and materials

A survey was mailed to 324 Radiation Oncologists identified in the Canadian Medical Directory and Canadian Association of Radiation Oncologists’ Directory. Three hundred of them were in active practice in Canada at the time of mailing. The others were either retired or had emigrated out of the country. Two previous surveys on the management of bone metastases were reported in USA [7], [20]. We presented five case scenarios in our survey. With the permission of the authors, we used two case

Results

A total of 172 radiation oncologists (57%) returned the survey. One hundred and fifty-six of them were in academic practice. One hundred and thirty-six had their Radiation Oncology training in Canada, 28 in the UK and eight elsewhere. The majority finished their specialty training after 1980; 60 between 1980 and1989, and 71 in the period of 1990–1998.

Eight hundred and nineteen responses (95%) indicated that they would use radiotherapy (LF, HBI, SR) or a combination of these modalities. Overall,

Discussion

Bone metastases are common in breast, prostate and lung cancers. Different treatment modalities may be used. They include local or systemic radiotherapy, narcotics, and systemic therapy, such as chemotherapy, hormones and bisphosphonates. However, no optimal treatment strategy has been identified and studies which compare different treatment modalities are lacking [6], [32], [39], [40].

Our response rate of 57% is similar to those of the previous surveys. Maher and associates reported 278

Conclusion

The most common dose fractionation for bony metastases in Canada is 20 Gy in five fractions compared with 30 Gy in ten fractions in the US. Despite randomized trials showing that a single fraction gives equivalent benefit, the vast majority still advocate fractionated radiotherapy.

The percentages of respondents employing a single 8 Gy were 15% in Duncan's survey and 16% in our current survey. Nearly 70% use a standard dose fractionation to palliate localized painful metastasis by radiotherapy,

Acknowledgements

The authors would like to thank Dr Gillian Thomas for her constructive advice, and Correna LeCoure, Sabrina Montoni-Dinh and Barb Zurowski for their secretarial help. The authors would like to thank all survey participants, Dr Ben-Josef and Dr Hartsell for their permission to use the survey questions. This project was supported by Radiation Program Funds at Toronto–Sunnybrook Regional Cancer Centre.

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