Huisman, M., Verkooijen, H.M., van der Linden, Y.M., van den Bosch, M.A., & van Vulpen, M. (2015). Effectiveness of repeat radiotherapy for painful bone metastases in clinical practice: A 10 year historical cohort study. Clinical Oncology, 27, 472–478. 

To assess the effectiveness of retreatment with radiotherapy for painful bone metastases

Data were collected from medical records. Only evaluable patients with pain response documentation were included in the analysis. Information from records was used to categorize pain because no numerical pain scores were recorded. For patients with available data, the pain response proportion was calculated. For those with no response data, it was assumed that these were nonresponders for the calculation of a worst-case scenario.

• N = 247
• MALES: 57%, FEMALES: 43%
• KEY DISEASE CHARACTERISTICS: Various tumor types
• OTHER KEY SAMPLE CHARACTERISTICS: Overall, 56% of patients had multiple bone metastases, and the most frequent sites were spine, pelvis, and hips.

• SITE: Single site 
• SETTING TYPE: Outpatient 
• LOCATION: Netherlands

• PHASE OF CARE: Late effects and survivorship
• APPLICATIONS: Palliative care 

Retrospective, descriptive study

Not applicable

Overall, 66% of evaluable patients indicated responses with decreases in pain. In the worst-case analysis, the overall response rate was 43%. The use of systemic analgesia (overall response [OR] = 0.39, p = 0.037) and prior pain response to radiotherapy (OR = 1.01, p = 0.049) were predictors of response to repeat radiotherapy. Patients who had an initial response were more likely to respond to retreatment, and those having used systemic therapy were less likely to respond. The toxicities experienced were all grades 1 and 2, including nausea and vomiting, fatigue, diarrhea, and skin reactions. In 4% of patients, a pathologic fracture at the retreated site was reported, and one patient developed radiation-induced femoral head necrosis requiring a total hip replacement. For the initial treatment, it was reported that 13% of patients received no pain medication, and 43% had only levels 1 and 2 analgesia according to the World Health Organization analgesic ladder.

The findings of this study suggested that retreatment with radiation therapy for bone metastases can be effective for pain reduction. Prior response to radiation therapy for pain suggested better odds that retreatment would produce a response.

• Risk of bias (no control group)
• Risk of bias (no blinding)
• Risk of bias (no random assignment) 
• Unintended interventions or applicable interventions not described that would influence results
• Measurement/methods not well described
• Measurement validity/reliability questionable
• Other limitations/explanation: No information was provided regarding whether any bone modifying agents were used. The initial analgesia used was low, and it was not clear if pain was maximally treated.

Patients who have initial pain responses to radiation therapy for bone metastases may benefit from repeat radiotherapy.