- For patients with a single or limited number of areas of painful bone metastases, we recommend external beam radiation therapy (Grade 1A).
- We suggest using a single fraction of 8 Gy to the involved area (Grade 2A). This approach provides equal palliation with improved patient convenience and cost effectiveness compared with fractionated schedules, although retreatment is needed more frequently.
- For patients with a relatively long life expectancy, a fractionated regimen (such as 30 Gy in ten fractions or 20 Gy in five fractions) may also be considered.
- Reirradiation may be indicated if there is an incomplete response to initial treatment or if severe pain recurs, and the patient’s overall condition permits. Clinical trials data suggest that acceptable regimens include a single fraction of 8 Gy or a brief fractionated regimen of 20 Gy, although the latter can be associated with higher acute toxicity. For selected patients with good performance status and recurrence in the spine, stereotactic body radiation therapy (SBRT) can also be considered.
- Surgical fixation may be indicated prior to the institution of radiation therapy for bone metastases involving the long bones or other weight bearing bones to treat or prevent a pathologic fracture.
- For patients with widespread painful bone metastases who cannot be effectively managed with external beam radiation therapy, either radiopharmaceuticals or hemibody irradiation may provide meaningful palliation.