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One dose of radiotherapy relieves the pain of a bone secondary as well as six, which means one journey to hospital instead of six.
Painful bone metastases are common in lung cancer and radiotherapy relieves them in most patients. The question was whether a longer course works better. The Dutch Bone Metastasis Study randomised patients with painful bone metastases to a single 8 Gy fraction or 24 Gy in multiple fractions. The single-fraction arm had a much higher retreatment rate, 24 against 6 percent, which raised the suspicion that its apparent equivalence was an artefact of retreatment.
The 2004 reanalysis separated response to initial treatment from response to retreatment. Response to initial treatment was 71 percent after a single fraction against 73 percent after multiple fractions (p=0.84); allowing for retreatment raised the single-fraction figure to 75 percent while the multiple-fraction figure was unchanged (p=0.54). Response status after initial treatment did not predict who was retreated: 35 percent of single-fraction non-responders were retreated against 8 percent of multiple-fraction non-responders, and 22 against 10 percent of those with progressive pain. Randomisation arm and pain score before retreatment, not need, predicted retreatment, and retreatment worked in 63 percent of those who received it.
The practical conclusion is that a single 8 Gy fraction is the default for uncomplicated painful bone metastases, and that doctors, not the evidence, were the reason for the retreatment gap.
Numbers are from the trial as recorded here; see the source links in the table below. This is orientation, not medical advice: ask your team how closely the trial population matches you.
1,157 randomised.
| Endpoint | Arm | n | Value | HR (95% CI) | p | Source |
|---|---|---|---|---|---|---|
| Pain response to initial treatmentprimary | 8 Gy single fraction | - | 71% | - | 0.84 | link |
| 24 Gy in multiple fractions | - | 73% |
Shares Palliation in lung cancer: breathlessness, pleural effusion, blocked airway, bone and brain, Palliative, Palliative radiotherapy, Lung cancer (all types).
Shares Palliation in lung cancer: breathlessness, pleural effusion, blocked airway, bone and brain, Palliative, Lung cancer (all types), Small-cell lung cancer.
Shares Palliation in lung cancer: breathlessness, pleural effusion, blocked airway, bone and brain, Palliative, Lung cancer (all types), Small-cell lung cancer.
Shares Palliative, Hypofractionated radiotherapy, Lung cancer (all types).
Shares Palliation in lung cancer: breathlessness, pleural effusion, blocked airway, bone and brain, Palliative radiotherapy, Lung cancer (all types), Non-small-cell lung cancer.
Shares Palliative, Lung cancer (all types), Small-cell lung cancer.
Shares Palliation in lung cancer: breathlessness, pleural effusion, blocked airway, bone and brain, Lung cancer (all types), Small-cell lung cancer, Non-small-cell lung cancer.
Shares Palliation in lung cancer: breathlessness, pleural effusion, blocked airway, bone and brain, Bone metastases and skeletal-related events, Lung cancer (all types), Non-small-cell lung cancer.