Patterns in Physician Use of Extended-Fraction Radiation Therapy for Bone Metastases

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Routine use of extended-fraction radiation therapy—defined as more than 10 fractions—for the palliative treatment of bone metastases is considered a low-value intervention by the American Society for Radiation Oncology. In a retrospective cohort study reported in JCO Oncology Practice, Gupta et al found that among patients receiving external-beam radiotherapy for bone metastases, extended-fraction radiotherapy was used in approximately one-quarter of patients, and one-third of physicians treating more than 10 patients during the study period used it in at least 30% of patients. 

Study Details

The study involved Medicare fee-for-service data from 12,221 patients who underwent at least one episode of 2- or 3-dimensional external-beam radiotherapy for a primary indication of bone or bone marrow metastasis between January 1, 2016, and December 31, 2018. Patients had a median age of 75.6 years, 40.9% were women, and 87.6% were white.

Key Findings

Overall, 2,863 patients (23.4%) underwent extended-fraction radiotherapy. A total of 1,098 (9.0%) underwent single-fraction radiotherapy. The median number of fractions received were 15 among patients receiving extended-fraction radiotherapy and 8 among patients receiving non–extended-fraction radiotherapy.

A total of 1,432 physicians provided radiotherapy during the study period. Of these, 80.9% were men and 91.1% practiced in urban areas. The median number of patients treated per physician was five. The percentages of physicians who used extended-fraction radiotherapy in 0%, 0% to 10%, and 0% to 20% of cases were 13.9%, 38.7%, and 55.5%, respectively. A total of 382 physicians treated more than 10 patients during the study period. Of these, 127 (33.2%) used extended-fraction radiotherapy in ≥ 30% of cases.  

On multivariate analysis, factors associated with decreased use of extended-fraction radiotherapy were:

  • Years since medical school graduation (adjusted odds ratio [OR] = 0.32, 95% CI = 0.20–0.51, for ≤ 10 years and 0.64, 95% CI = 0.44–0.93, for 11–20 years vs > 31 years)
  • Practicing in the Northeast (adjusted OR = 0.36, 95% CI = 0.22–0.58) or Midwest (adjusted OR = 0.48, 95% CI = 0.31–0.74) vs the South.  

Physicians who treated more than 20 patients vs 11 to 14 patients were significantly more likely to use extended-fraction radiotherapy (adjusted OR = 1.53, 95% CI = 1.10–2.12).

The investigators concluded, “In this study, almost one-fourth of patients received extended-fraction radiotherapy, and one-third of physicians [who treated more than 10 patients] had an extended-fraction radiotherapy use rate of ≥ 30%. Personalized feedback of performance data, clinical pathways, and peer review, [as well as] updated reimbursement models, are potential mechanisms to address this low-value care.”

Martin A. Makary, MD, MPH, of the Division of Surgical Oncology, Johns Hopkins University, is the corresponding author for the Journal of Oncology Practice article.

Disclosure: The study was supported by the Laura and John Arnold Foundation. For full disclosures of the study authors, visit

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