External radiotherapy is the treatment of choice for metastatic localized bone pain without adequate response to analgesic drugs. 1 Previous clinical studies that measure analgesic response to radiation therapy in advanced cancer patients accepted both an improvement in the intensity of pain or a reduction in the dose of analgesic drugs (morphine equivalent) as response criteria. 2 Recently, we developed a prospective study in advanced cancer patients with painful bone metastases: 29 palliative radiotherapy treatments were administered to 25 patients to alleviate malignant bone pain secondary to clinically evident bone metastases. Four episodes were not included in the analysis because three patients died and one developed symptomatic brain metastases before evaluation. Pain intensity was measured on a scale of 0 (no pain) to 10 (maximum pain). We found a reduction of 3.5 points (95% confidence interval [CI]: 2.5 to 4.8; P Ͻ 0.001, Wilcoxon test) in median pain intensity after radiotherapy. However, this pain reduction was associated only to a slight decrease of 6.0 mg (95% CI: Ϫ 12.0 to 30.0; P ϭ 0.53, Wilcoxon test) in median daily dose of oral morphine equivalent. In only two episodes (8%), the threshold of significant dose reduction of 50% or more in opioid consumption was exceeded; in both of them a parallel reduction of basal pain was achieved as well. No significant differences were observed in the proportion of patients receiving nonsteroidal anti-inflammatory drugs or adjuvant analgesics before and after radiotherapy (Table 1).Palliative radiotherapy for painful bone metastases decreases pain intensity 3 but, according to our data, does not reduce overall analgesic needs in advanced cancer patients. We suppose that overwhelming progressing disease in advanced cancer patients does not allow a reduction in analgesic therapy even when an adequate local bone pain control is achieved with palliative radiotherapy. Thus, decrease in opioid intake is not a good independent criteria of response to palliative radiotherapy for bone metastases related pain in advanced cancer patients.
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