Clinical Oncology
Volume 21, Issue 9 , Pages 649-651, November 2009

Background, Rationale and Goals for the 2010 International Consensus Conference Bone Metastasis Treatment Workshop

  • S.T. Lutz

      Affiliations

    • Department of Radiation Oncology, Blanchard Valley Regional Cancer Center, Findlay, OH 45840, USA
    • Corresponding Author InformationAuthor for correspondence: S. T. Lutz, Department of Radiation Oncology, Blanchard Valley Regional Cancer Center, Findlay, OH 45840, USA. Tel: +1-419-423-3703; Fax: +1-419-427-0212.
    • ,
  • A. Fairchild

      Affiliations

    • Department of Radiation Oncology, Cross Cancer Institute, Edmonton, Alberta, Canada
    • ,
  • E. Chow

      Affiliations

    • Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
    • ,
  • P. Hoskin

      Affiliations

    • Mount Vernon Cancer Centre, Rickmansworth Road, Northwood, Middlesex, UK

Received 28 July 2009; accepted 29 July 2009.

Article Outline

 

External beam radiotherapy continues to be a mainstay for the successful treatment of patients with symptoms caused by cancer. The delivery of palliative radiotherapy is effective, time-efficient, relatively inexpensive and associated with a low risk of side-effects [1]. However, the management of patients with painful bone metastases is complex and requires the integration of several medical disciplines. That complexity, coupled with the lack of palliative care guidelines, helped lead to the formation of the First International Consensus Workshop on radiation in the treatment of metastatic and locally advanced cancer in 1990 [2]. A group of 116 experts met and generated consensus statements for the treatment of bone metastasis, brain metastasis and locally advanced lung cancer. The group reviewed published studies and the results of clinician surveys, subsequently issuing consensus statements about topics that are still pertinent today and that include: treatment decision pathways, international variation in treatment philosophy, the effect of treatment on quality of life and the role of economic factors in treatment decisions.

The Second Workshop on Palliative Radiotherapy and Symptom Control convened in London in 2000. That group confirmed the efficacy of radiotherapy in alleviating metastatic bone pain, and they detailed the available information that suggested equivalent pain relief with either a single 8Gy fraction or a longer course of treatment. The use of radioisotopes was deemed appropriate for the management of patients with widespread pain from either metastatic breast or prostate cancer, with wide-field external beam radiotherapy designated as a reasonable alternative in geographical locales where radioisotopes were not readily available. The group's calls for determining the optimal methods for measuring pain response in these patients spurred the subsequent formation of the International Consensus on Palliative Radiotherapy Endpoints. The Second Workshop concluded with the suggestion that the first 10 years of the new millennium might provide answers about the role of radiotherapy in neuropathic pain and pathological fracture, the underlying cellular mechanisms of pain relief after radiotherapy, and the best means by which to sequence radiotherapy with other palliative interventions [3].

The Third International Consensus Conference Workshop planned for ASTRO 2010 will convene with the goals of evaluating these and other remaining controversies in the management of painful bone metastases. It will seek to refine the answers to remaining questions about single-fraction therapy for painful bone metastases, international variations in palliative radiotherapy practice patterns, retreatment of the same painful site, the integration of external beam radiotherapy with other treatment modalities, and description of the appropriate end points for bone metastasis treatment trials. The spectre of an enlarging elderly population with decreasing medical resources will also lead the group to critically evaluate the cost-effectiveness of the available treatment options. A consensus statement will be offered regarding the usefulness of highly conformal radiotherapy for either the primary or retreatment of painful bone metastasis. The findings of the Third Consensus Conference Workshop are to be submitted for presentation at the 2010 clinical meeting of the American Society of Radiation Oncology (ASTRO). The participants will be drawn from an international faculty representing ASTRO/ESTRO/Trans Tasman Radiation Oncology Group (TROG) and CARO, who will work to formulate the third international literature-based treatment guidelines for palliative radiotherapy.

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Consensus Statement Topics 

Radiotherapy Fractionation 

The Second Workshop highlighted the studies completed by the year 2000, which suggested that single-fraction radiotherapy provides equal pain relief when compared with a lengthier course [3]. On the basis of the results gathered from 10 randomised trials including more than 3500 patients, the group stated that for most patients with metastatic skeletal pain, a single 8Gy fraction was an appropriate treatment. They noted dissenting opinions regarding this suggested approach, and they also documented the uncertainties regarding the appropriate radiotherapy fractionation for patients with pathological fracture or spinal cord compression. The Third Workshop group will incorporate the radiotherapy fractionation research results from the intervening 10 years, including data from the Radiation Therapy and Oncology Group (RTOG) 97-14 protocol 4, 5, and will specifically address issues regarding the need for retreatment to the same painful site as well as both short- and long-term side-effect risks of a single 8Gy fraction.

International Variations in Treatment 

The Second Workshop alluded to international variations in the treatment of patients with painful bone metastases [3], with lengthier treatment courses in the USA when compared with fractionation patterns in other countries. This pattern will be reviewed to incorporate more recent survey results gathered from radiation oncologists around the world [6].

External Beam Retreatment 

The Second Workshop touched on the higher rates of retreatment after single-fraction therapy when compared with a longer treatment course [3]. It has become clear that the choice of the initial fractionation scheme may significantly influence the feasibility of additional dosing to the same painful site [5]. The influence of access to highly conformal radiotherapy on retreatment will also be evaluated.

External Beam Therapy and Other Treatments 

The past 10 years have seen an increase in the use of both systemic therapies and local interventions for the treatment of painful bone metastasis in addition to radionuclides and wide-field external beam radiotherapy [3]. The Third Workshop group will address the role and timing of systemic treatments such as radionuclides, bisphosphonates and chemotherapy, as well as local interventions, including surgery for spinal cord compression or lesions involving long bones, and the use of kyphoplasty or vertebroplasty 7, 8, 9, 10.

Palliative Radiotherapy End Points 

The Second Workshop group highlighted the potential dangers in comparing pain relief both across different trials and from different international co-operative research groups [3]. This has resulted in the international consensus statement on palliative radiotherapy end points and other studies that will inform the outcome measures for consensus statements from the Third Workshop 11, 12, 13.

Cost-effectiveness 

The aging of the populations of many developed countries will combine with the limits in healthcare resources to cause a focus on cost-benefit evaluation of all palliative care interventions. Radiotherapy has been shown to be a cost-effective treatment for painful bone metastasis when compared with the expense of long-term narcotic analgesics, and the Third Workshop group will evaluate that cost-effectiveness in light of more recent data 14, 15, 16, 17. Furthermore, the group will assess the interplay between radiotherapy cost and other palliative disciplines that receive reimbursement per diem, most notably hospices [18]. Finally, the relative financial merits and drawbacks of highly conformal therapy for the treatment of painful bone metastases will be assessed.

Newer Technologies 

The field of radiotherapy has seen significant technological advances since the publication of the consensus statements made by the Second Workshop in 2000. The use of highly conformal computed tomography planned radiotherapy is more prevalent and its role in the primary treatment of bone metastasis and retreatment to areas near radiation-sensitive structures, such as the spinal cord, requires further evaluation, including the effect on resource allocation and patient convenience [10].

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References 

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  2. Hanks G, Maher G, Coia L. An overview of the first International Consensus Workshop on radiation therapy in the treatment of metastatic and locally advanced cancer. Int J Radiat Oncol Biol Phys. 1992;23:201
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  15. van den Hout W, van der Linden Y, Steenland E, et al. Single- versus multiple-fraction radiotherapy in patients with painful bone metastases: cost-utility analysis based on a randomized trial. J Natl Cancer Inst. 2003;95:222–229
  16. Konski A. Radiotherapy is a cost-effective palliative treatment for patients with bone metastasis from prostate cancer. Int J Radiat Oncol Biol Phys. 2005;60:1373–1378
  17. Thomas K, Bohdan N, Fisher C, et al. Cost-effectiveness of surgery plus radiotherapy versus radiotherapy alone for metastatic epidural spinal cord compression. Int J Radiat Oncol Biol Phys. 2006;66:1212–1218
  18. Lutz S, Spence C, Chow E, et al. Survey on utilization of palliative radiotherapy in hospice care. J Clin Oncol. 2004;22:3581–3586

PII: S0936-6555(09)00233-7

doi:10.1016/j.clon.2009.07.012

Clinical Oncology
Volume 21, Issue 9 , Pages 649-651, November 2009

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