Despite Evidence Suggesting Comparable Pain Relief at Lower Cost, Treatment Regimen for Bone Metastases Not Widely Used


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Justin E. Bekelman, M.D., of the University of Pennsylvania Perelman School of Medicine, Philadelphia, and colleagues conducted a study to examine whether single-fraction radiation treatment, shown to be as effective as multiple-fraction treatment with less potential for harm, has been incorporated into routine clinical practice for Medicare beneficiaries with prostate cancer and at what cost savings. Single-fraction radiotherapy is where a large dose of radiation is given in one session; with multiple-fraction radiotherapy, radiation is delivered in smaller doses over a longer period of time.

“Palliative radiotherapy, comprising l or more fractions (i.e., treatments) of daily radiation, is the mainstay of treatment for painful bone metastases. In 2005, a U.S.-based randomized trial demonstrated no difference in pain relief between single- and multiple-fraction radiotherapy for uncomplicated bone metastases, confirming results from international trials,” according to background information in the article appearing in the October 9 issue of JAMA.

As reported in the Research Letter, the authors selected patients age 65 years or older with prostate cancer and bone metastases and subsequent courses of radiotherapy from January 2006 through December 2009 from the Surveillance, Epidemiology and End Results (SEER)-Medicare database. For each patient, the researchers identified the initial outpatient course of radiotherapy following the first diagnosis of bone metastasis (index course) and determined the dates and number of radiotherapy fractions based on Medicare claims for radiation delivery (Medicare reimburses each radiotherapy fraction individually).

Of 3,050 patients included in the study, 3.3 percent had single-fraction radiotherapy and 50.3 percent received more than 10 fractions.  Average 45-day radiotherapy-related expenditures were a relative 62 percent lower for patients treated with single relative to multiple fractions ($1,873 for single vs. $4,967 for multiple fractions).

“Despite evidence demonstrating comparable pain relief for single-fraction treatment, only 3.3 percent of Medicare beneficiaries with bone metastases from prostate cancer received single-fraction treatment. Patients who received single-fraction radiotherapy had poorer prognoses, perhaps reflecting the perception that single-fraction treatment should be reserved for patients with limited life expectancy or poor performance status. However, single-fraction treatment has substantial benefits for patient-centric palliative care, including greater quality of life and convenience, reduced travel time, and lower treatment costs,” the authors conclude.

(doi:10.l001/jama.2013.277081; Available pre-embargo to the media at

Editor’s Note: This study was supported by grants from the National Cancer Institute and American Cancer Society, and with funding from the Leonard Davis Institute for Health Economics. The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr. Bekelman reported receiving honoraria from the American Society for Clinical Oncology; and travel expenses from the Radiation Oncology Institute. Dr. Epstein reported receiving institutional grant support from the Institute for Health Technology Studies. No other disclosures were reported.

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