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  • Review Article
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Treatment of painful bone metastases

Nature Reviews Clinical Oncology volume 7, pages 220–229 (2010)Cite this article

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Abstract

Bone metastases are the most common cause of cancer-related pain. Radiotherapy is a safe and effective therapy and is well established for such a situation. A fractionation regimen with a short overall treatment time (≤1 week) would be preferred if it was as effective as longer courses (2–4 weeks). Randomized clinical trials and meta-analyses have demonstrated that single-fraction radiotherapy with 1 × 8 Gy is as effective for pain relief as multi-fraction regimens such as 5 × 4 Gy in 1 week or 10 × 3 Gy in 2 weeks. Re-irradiation for recurrent pain in the irradiated region is required more often after single-fraction radiotherapy than multi-fraction radiotherapy; however, re-irradiation following single-fraction radiotherapy is safe and effective. Thus, 1 × 8 Gy is considered the standard regimen for uncomplicated painful bone metastases without pathological fractures or spinal cord compression. Multi-fraction radiotherapy results in significantly better remineralization of the osteolytic bone than single-fraction radiotherapy. Remineralization is important for preventing or treating pathological fractures. Multi-fraction long-course radiotherapy results in fewer recurrences of spinal-cord compression within the irradiated spinal region. Thus, long-course multi-fraction radiotherapy should be reserved for patients with a relatively favorable survival prognosis.

Key Points

  • Pain caused by bone metastases can be ameliorated by radiotherapy, opioids and non-opioid medications, bisphosphonates, vertebroplasty and kyphoplasty, and radiopharmaceuticals

  • A variety of opioid analgesics that are used for treating moderate to severe pain are available, so pharmacokinetic considerations and side effect profiles should be considered for the individual patient

  • Radiopharmaceutical treatment is very effective in reducing bone metastases related pain but is also myelosuppressive so chemotherapy can only be safely administered about 6 weeks following radiopharmaceutical treatment

  • Single-fraction radiotherapy with 1 × 8 Gy is as effective for pain relief as multi-fraction radiotherapy and is the standard regimen for uncomplicated painful bone metastases without pathological fractures or spinal cord compression

  • Multi-fraction radiotherapy is significantly better than single-fraction radiotherapy for remineralization of the osteolytic bone and should be used for patients with a favorable survival prognosis

  • The rate of skeletal related events such as pathological fractures and spinal cord compression can be reduced with bisphosphonates and drugs such as anti-DKK1 and denosumab

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Figure 1: Example of stereotactic body radiation therapy (SBRT) of a bone metastasis in the vertebral column.

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Acknowledgements

Désirée Lie, University of California, Irvine, CA, is the author of and is solely responsible for the content of the learning objectives, questions and answers of the MedscapeCME-accredited continuing medical education activity associated with this article.

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Authors and Affiliations

  1. Department of Radiation Oncology, University of Lubeck, Ratzeburger Allee 160, 23538, Lubeck, Germany

    Dirk Rades

  2. Department of Radiation Oncology, Mayo Clinic, 13400 East Shea Boulevard, Scottsdale, 85259, AZ, USA

    Steven E. Schild

  3. Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, 44 Binney Street Shields-Warren 420, Boston, 02115, MA, USA

    Janet L. Abrahm

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D. Rades declares he is on the speaker's bureau and is an Advisory Board member/consultant for Amgen and Novartis, and receives grant/research support from Novartis. J. L. Abrahm declares she is on the speaker's bureau for Janssen—Cilag, Merck, Ortho Biotech and Purdue Pharma. S. E. Schild and the Journal Editor L. Hutchinson declare no competing interests. D. Lie has served as a nonproduct speaker for “Topics in Health” for Merck Speaker Services.

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Rades, D., Schild, S. & Abrahm, J. Treatment of painful bone metastases. Nat Rev Clin Oncol 7, 220–229 (2010). https://doi.org/10.1038/nrclinonc.2010.17

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