The final variant deals with a patient who has
The final variant deals with a patient who has a poor prognosis due to visceral metastases and who suffers from a single site of painful bone disease. The purpose of the case was to evaluate the panel\'s views of supportive care with analgesic medications plus or minus EBRT. The group did recommend EBRT for the patient, but they were specific in their belief that the dose should be limited to a single 8Gy fraction in an effort to decrease time spent in treatment and discomfort from being transferred on and off the treatment table . The likelihood of an increased need for re-treatment to the same site in this patient is diminished by his short expected lifespan. It was recommended that CT, fluoroscopic, or clinical simulation may be used while preparing treatment through AP and PA directions while sparing a skin strip. Anti-inflammatory medicines were described as the best method to manage any temporary flare reaction that might occur after the single fraction . Finally, direct placement to hospice was thought to be a reasonable directive, either before or after the completion of the single fraction EBRT dosing.
In its text, the ACR Appropriateness Criteria Bone Metastases Group suggested several general statements applicable to most or all five variants. First, EBRT was re-defined as an effective means to palliate the pain caused by metastatic bone disease, with rates of relief of 50%–80% and equivalence for fractionation schemes including 30Gy in 10 fractions, 24Gy in 6 fractions, 20Gy in 5 fractions, and a single 8Gy fraction [4,22,23]. The preferred treatment set-up and prescription points should follow those defined in the International Consensus on Palliative Radiotherapy Endpoints . The group determined that the use of highly conformal therapy with intensity-modulated radiation therapy (IMRT), stereotactic body radiation therapy (SBRT), or purchase RG7388 therapy have not been proven for this subset of patients without spine disease. Lastly, the need for concurrent pain medicine dosing and palliative care was seen to be imperative, with hospice admission not viewed as being mutually exclusive with the delivery of palliative radiotherapy for bone pain.
American Society for Radiation Oncology (ASTRO) bone metastases guidelines The American Society for Radiation Oncology (ASTRO) has only recently begun creating clinical treatment guidelines, especially when compared to the longstanding existence of the ACR Appropriateness Criteria. In 2009 the ASTRO Board of Directors tasked the Health Services Research Committee to create bone metastases treatment guidelines. The ASTRO group consisted of a neurosurgeon and palliative medicine expert as well as radiation oncologists from academic, private practice, and residency settings. The group was asked to create guidelines that were applicable to patients as well as healthcare providers, with one of the main themes being the integration of radiotherapy with other treatment modalities useful in the care of patients with painful bone metastases. The original literature search covered the most recent ten years of citations in the National Library of Medicine\'s PubMed database and yielded over 4000 publications. Within that group of papers were found 25 randomized clinical trials, 20 prospective single-arm studies, and 4 meta-analyses or systematic reviews. Given the complexity of the clinical situations involved in the care of these patients, the task force was divided into subgroups to concentrate on those issues that fit each individual\'s own expertise. The results of the subgroups\' work were subsequently presented to the entire group, made available online for public comment, and approved by the ASTRO board of directors prior to publication . The format of the ASTRO guidelines was based upon the task force answers to several questions posed by the board of directors. The first several questions dealt with the most appropriate external beam radiation therapy (EBRT) fractionation scheme to use for the treatment of painful bone metastases. While the rates of pain relief following EBRT appear to be similar across a wide array of dose fractionation schemes, one recent worldwide survey revealing that more than 101 fractionation schemes are used for this one clinical circumstance . The first goal of the task force was therefore to narrow the list of acceptable fractionation schemes to those which have been sufficiently studied in adequately-powered trials. Similar to the ACR group, they documented that several prospective, randomized trials have evaluated different dose-fractionation schedules, with the results suggesting equivalence in pain relief after schedules including 30Gy in 10 fractions, 24Gy in 6 fractions, 20Gy in 5 fractions, and a single 8Gy fraction [2,4]. The advantage of single fraction radiotherapy was seen to be increased convenience and decreased expense for the patient and their caregivers, while multiple fraction therapy was advantageous because it is associated with a lower incidence of re-treatment to the same painful site than in single fraction treatment (8% versus 20%, respectively) . In answer to concerns raised about the safety of a single 8Gy fraction to anatomic sites historically considered to be sensitive to hypofractionated doses, the task force evaluated the literature but could not find any long term side effect risks that should deter clinicians from using a single dose to spine fields that contain the spinal cord or cauda equina .