Single- vs. multi-fraction radiation therapy for metastatic, bone-related cancer pain

Data published in 2005 and later have clearly shown that — for most patients — single-fraction radiation therapy (e.g., a single dose of 8 Gy) is better than multi-fraction radiation therapy (e.g., 30 Gy given over 10 treatments) for the treatment of bone pain consequent to metastatic cancer that has spread into the bones (in prostate cancer and other forms of cancer).

However, a research letter (by Bekelman et al.) just published in the Journal of the American Medical Association has shown that, between 2006 and 2009, this type of single-session treatment was given to only about 3 percent of Medicare-eligible patients receiving palliative radiation therapy for prostate cancer that had spread to the bones, and that as many as half of the patients went through more than 10 treatments.

The evidence supporting single-fraction treatment as opposed to multi-fraction treatment has been developing since the 1990s, and so it is clear that radiation oncologists may not have been adapting their clinical practices to the available scientific evidence in a sufficiently timely manner. While there are several possible reasons for this, Dr. Colleen Lawton, the chair of the Board of Directors for the American Society of Radiation Oncology (ASTRO)  is quoted in a HealthDay report on this new paper as having stated very clearly that most patients should get a single session of radiation; that some may then need another treatment after about a year, but that “that’s still a lot better than going in for multiple treatments.”

The message to patients is also a clear one. If your radiation oncologist tells you you are going to need multi-fraction palliative treatment for bone pain, you should certainly be asking why, given the clear evidence that single-fraction treatment is both effective and defined as the standard of care. While there are certainly some patients who may need multi-fraction therapy (e.g., when the cancer has spread to the bones and also to nearby soft tissue), according to Lawton this would be only about 10 percent of patients.

We should note that this type of radiation therapy has nothing to do with extending life. It is used only to palliate pain associated with the progression of prostate cancer. Having a single session of radiation as opposed to multiple sessions will not impact overall survival in a negative manner.

3 Responses

  1. Thank you for this post. Another article to save for later (much, much later in my case, I hope). It begs the question, “If you can’t trust your radiation oncologist, then who can you trust?” It would seem that a change in practice habits in this area would save Medicare dollars for other purposes and also keep patients from treatment which is not helpful.

  2. Mike


    This may be an option for me and it is good to know.


  3. Hypofractionation (fewer, more intense doses) seems to do a better job of prostate cancer cell killing whether it’s localized or metastasized to the lymph nodes or bones. After it was established that the alpha/beta ratio for prostate cancer is only around 1.5 (i.e., that fewer, more intense doses kill the cancer better), and now that we have the machines that can deliver that with exquisite accuracy, it no longer made sense to deliver radiation any other way. The one exception is salvage radiation therapy, where a wider, less knife-edged, net is cast. Even there, development of improved imaging techniques will eventually make SBRT a better idea.

    While it’s true that radiation oncologists may see their income slashed in half by this, they stand to lose it all if they don’t get with the program.

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