Therapeutic Guidelines for the Treatment of Bone Metastasis: A Report from the American College of Radiology Appropriateness Criteria Expert Panel on Radiation Oncology

Abstract

Bone metastases remain a therapeutic challenge because of the diversity of the problems they cause, the relative paucity of data regarding their treatment, and the necessity for management by a multidisciplinary palliative care team. The American College of Radiology convened an Appropriateness Criteria Expert Panel on Radiation Oncology for the treatment of bone metastasis to create representative clinical case scenarios and then rank the appropriate use of treatment modalities as well as the most reasonable radiotherapy dose schema and treatment planning methods. Here we present both the resulting Appropriateness Criteria and the rationale for making these decisions. The treatment recommendations are placed within the larger framework of the role of radiation in palliative care by discussing the efficiency of palliative radiotherapy schedules, cost effectiveness issues, and the need for additional research regarding the proper multidisciplinary care of patients with symptomatic bone metastasis.

Palliative Radiation Therapy Practice in Patients With Metastatic Non–Small-Cell Lung Cancer: A Cancer Care Outcomes Research and Surveillance Consortium (CanCORS) Study

“…[38][39][40][41][42] Although such guidelines have the potential to improve radiation oncology practice by better educating practitioners, our observation that practice may vary according to reimbursement structure suggests that realignment of financial incentives for treatment may also be warranted.…”

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“…As a result, 8 Gy in singlefraction RT was suggested as the standard of care for the palliation of uncomplicated painful bone metastases in the recent American Society for Radiation Oncology (ASTRO) guidelines (98,100). However, conventional RT is limited by the low tolerance of the spinal cord and cauda equina, leading to subtherapeutic dose delivery for tumor control, particularly for melanoma.…”

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“…Performance status and degree of systemic disease must be considered prior to treatment. (Janjan et al, 2009& Fairchild & Stephen, 2011. Approximately 25 randomized clinical trials and three meta-analysis have demonstrated equivalency of single and multiple fraction radiotherapy for bone relief from uncomplicated bone metastases.…”

“…It is worthwhile to note that the treatment of asymptomatic bone metastases may deferred unless the patient is at risk of a serious adverse outcome such as spinal cord compression or impending pathological fracture (Janjan et al, 2009). …”