Initiate Conversations About Radiation Therapy for Bone Metastases

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Although the American Society for Radiation Oncology (ASTRO) has recommended extended-fraction radiation therapy (more than 10 fractions) not be routinely used for palliation of bone metastases,1 a recently published retrospective cohort study using Medicare data for more than 12,000 patients found that almost one-fourth did receive extended-fraction radiotherapy.2

The recommendations, first released in 2013 and updated in 2017, are part of ASTRO’s Choosing Wisely initiative. An important component of that initiative is “to start a conversation between patients and providers, to acknowledge that each patient and each situation is unique,” Fumiko Chino, MD, of the Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, told The ASCO Post. Dr. Chino is a coauthor of the recent study. “Within radiation oncology, we have always done customized radiation plans for everyone. There is no one-size-fits-all in radiation,” she said, but she appreciates efforts encouraging a discussion “to evaluate the true risks and benefits for each person.”

ASTRO Recommendations

Here are the major points of the ASTRO recommendations:

  • Studies suggest equivalent pain relief following 30 Gy in 10 fractions, 20 Gy in 5 fractions, or a single 8-Gy fraction.
  • A single treatment is more convenient but may be associated with a slightly higher rate of retreatment to the same site.
  • Strong consideration should be given to a single 8-Gy fraction for patients with a limited prognosis or with transportation difficulties.

Shift in Thinking

The recommendations reflect a “shift in our thoughts on how we in radiation oncology treat people with the shortest, most effective treatment regimen, even though it may go against what we have done historically, if we have good evidence that shorter is as effective,” Dr. Chino commented.

Complex conversations about the potential risks and benefits of types of radiation treatment and shared decision-making are “becoming much more common within radiation oncology, which is fantastic. I think that focus on truly patient-centered care, on having patients be actively involved in the conversation about what their priorities are, is really important, and I love that it is part of the evolution of how we provide cancer care.”

It is also becoming more common for patients to advocate for themselves and use the Internet to become more informed, Dr. Chino noted. “There are more patient advocacy groups, discussions online, and patient chat rooms about radiation treatments and what is within the realm of normal. I certainly do have patients asking, ‘What’s the shortest time I can get this done?’” 

DISCLOSURE: Dr. Chino has received research support from Varian, Chanel Endowment for Survivorship Research, and the Radiation Oncology Institute.


1. Choosing Wisely: ASTRO releases list of five radiation oncology treatments to question as part of national Choosing Wisely campaign. September 23, 2013. Available at Accessed June 8, 2020.

2. Gupta A, Wang P, Sedhom R, et al: Physician practice variability in the use of extended-fraction radiation therapy for bone metastases: Are we choosing wisely? JCO Oncol Pract. Apr 13, 2020 (early release online).


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