BACKGROUND:

Bone metastasis is a common manifestation of malignancy and is the third most common organ affected by metastasis. Bone metastases can cause various morbidities and affect the quality of life. The treatment intent in bone metastases is palliative. External beam radiotherapy is the mainstay of treatment of uncomplicated painful bone metastases. Different radiotherapy fractionation schedules are in practice for palliation of painful bone metastases.

OBJECTIVES

To report the outcomes of various fractionation schedules of radiation therapy in terms of pain relief and improvement of quality of life in patients with painful bone metastases.

METHODS:

A prospective randomised study performed on 80 patients were randomised to 4 treatment arms with different radiation therapy fractionation schedules at the Dept. of Radiation Oncology, Father Muller Medical College Hospital. The fractionation radiation doses used in the study were 8 Gy in 1 fraction, 20 Gy in 5 fractions, 24 Gy in 6 fractions and 30 Gy in 10 fractions. Patients were assessed for pain by Visual Analog Scale (VAS) and Rupee scale, performance status, analgesic usage, quality of life before initiating the treatment, on the day of completion of treatment, 1 week, 1 month and 3 months post completion of treatment.

RESULTS:

In our study majority of the metastases were from the breast of 33.75%,  25% from the lungs, 18.75% from the head and neck, and 12.5% from prostate. Cervix (2.5%), esophagus (1.25%), stomach (1.25%), liver (1.25%), ovary (1.25%) comprised the other primary sites. 2.5% of the metastases were from unknown primary. In total  27.5% of the patients had metastases to the thoracic vertebra, 26.25% to the lumbar vertebra, 22.5% to the pelvis, 8.75% to the sternum, 6.25% each to cervical vertebra and femur and 1.25% each to humerus and ribs. The pain reduction was significant in all the 4 arms. The mean VAS score was 5.23 prior to start of treatment. The score reduced to 2.88 at the completion of treatment and further dropped to 1.57, 0.79, and 0.81 at 1 week, 1 month and 3 months post completion of radiation therapy. Similar results were obtained using the Rupee scale for assessment of pain. The mean score prior to treatment was 54.23 in the entire study group. It is reduced to 33.81, 25.87, 12.78 and 12.84 on the day of treatment completion, 1 week, 1 month and 3 months post completion of radiation therapy. Complete pain relief occured in 40% of the patients. 25% of the patients in 8 Gy in 1 fraction had complete relief of pain whereas the complete relief in the remaining 3 arms was 45% each. Improvement in the quality of life was observed in all the arms, both in terms of symptoms and function.

CONCLUSION:

This prospective study demonstrated that various radiation fractionation schedules used in the treatment of painful bone metastases have been effective in reducing the pain. The  pain reduction by various fractionation schedules are similar and no statistically significant difference was noted. Quality of life improved in all the four treatment arms post radiation therapy. 8 Gy in single fraction may be considered for treatment of painful bone metastases.