Radiotherapy for the palliation of painful bone metastases
Editorial Group: Cochrane Pain, Palliative and Supportive Care Group
Published Online: 8 OCT 2008
Assessed as up-to-date: 17 MAY 1999
Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
How to Cite
McQuay HJ, Collins S, Carroll D, Moore RA. Radiotherapy for the palliation of painful bone metastases. Cochrane Database of Systematic Reviews 1999, Issue 3. Art. No.: CD001793. DOI: 10.1002/14651858.CD001793.
- Publication Status: Edited (no change to conclusions)
- Published Online: 8 OCT 2008
Radiotherapy is used commonly to provide pain relief for painful bone metastases, and there is a perception that of the three-quarters of patients who achieve pain relief, half of these stay free from pain. However, the precise contribution from radiotherapy may be unclear because of difficulties in assessing the numbers of people achieving relief, the extent of relief and its duration, and the influence of other contemporaneous interventions, such as analgesics.
To assess pain relief from:
1. localised bone metastases achieved by radiotherapy, comparing the efficacy of different fractionation schedules
2. more generalised metastatic disease achieved by radiotherapy or radioisotopes.
Studies were identified by searching Medline (1966 to August 1998), Embase (1980 to 1998), the Cochrane Library (1998 Issue 3) and the Oxford Pain Relief Database (1950 to 1994).
The inclusion criteria used were: full journal publication, patients with pain due to bone metastases, and random allocation to a radiotherapeutic intervention (either external irradiation or administration of radioisotopes).
Data collection and analysis
The number of patients achieving complete pain relief and at least 50% at one month were compared with an assumed natural history of 1 in 100 patients achieving pain relief without treatment to obtain the number-needed-to-treat (NNT).
Summed pain relief or pain intensity difference over four to six hours was extracted, converted into dichotomous information yielding the number of patients with at least 50% pain relief, and used to calculate the relative benefit and the NNT for one patient to achieve at least 50% pain relief.
Twenty trials reported on 43 different radiotherapy fractionation schedules and eight studies of radioisotopes.
Radiotherapy produced complete pain relief at one month in 395/1580 (25%) patients, and at least 50% relief in 788/1933 (41%) patients at some time during the trials. There were no differences in the proportions of patients achieving these outcomes between single or multiple fraction schedules. The number-needed-to-treat (NNT) to achieve complete relief at one month (compared with an assumed natural history of 1 in 100 patients whose pain resolved without treatment) was 4.2 (95% CI 3.7-4.7).
No pooled estimates of speed of onset of relief, or of its duration, could be obtained. In the largest trial (759 patients) 52% of those who had complete relief had achieved it within four weeks, and the median duration of complete relief was 12 weeks.
For more generalised disease, radioisotopes produced similar analgesic results to external irradiation.
Adverse effect reporting was poor. There were no obvious differences between the various fractionation schedules in the incidence of nausea and vomiting, diarrhoea or pathological fractures.
Radiotherapy is clearly effective at reducing pain from painful bone metastases. There was no evidence of any difference in efficacy between different fractionation schedules, nor indeed of a dose-response with total dose of radiation. For treatment of generalised bone pain both hemibody irradiation and radioisotopes can reduce the number of painful new sites.
Plain language summary
Radiotherapy for pain relief in patients with untreatable secondary cancer tumours
Secondary cancer tumours (metastases) located in bone tissue can cause high levels of pain and distress in patients with terminal cancer. Radiotherapy is used commonly to provide pain relief, however, the precise effectiveness of radiotherapy may be unclear. The objectives of this systematic review were to assess pain relief from localised bone metastases by radiotherapy, and from generalised metastases in other parts of the body by radiotherapy or radioisotopes. Several important findings were made. One patient in four will get complete pain relief after one month's radiotherapy treatment, while one patient in three will experience at least 50% relief after one month. Overall, radiotherapy produced at least 50% pain relief in a little less than half of patients at some other point during the study. Patients receiving radiotherapy plus strontium reported higher levels of well-being than those receiving radiotherapy plus placebo. Radioisotopes alone were found to produce a similar extent of relief to that provided by radiotherapy. The results confirm that both external irradiation and radioisotopes can provide effective pain relief for painful bone metastases. This is a significant finding given that analgesic drug regimes are often ineffective for this type of pain. Limitations of the review include poor reporting in the included studies about adverse effects of radiotherapy, e.g. vomiting and diarrhoea, and about the speed with which relief occurs or its duration.
從以下兩種方式來評估疼痛的緩解:1. 局部的骨轉移，比較不同放射治療的分次劑量與時程所達之療效。2. 全身性的骨轉移，使用放射治療或放射性同位素所達之療效。
從Medline (1966 to August 1998), Embase(1980 to 1998), the Cochrane Library (1998 Issue 3) 及the Oxford Pain Relief Database (1950 to 1994)中搜尋出相關試驗。
共收納了20臨床試驗，其中包括43種不同放療劑量時程和8個使用放射線同位素的臨床試驗。其中使用放射治療止痛在一個月中有25％(395/1580)患者達到完全疼痛緩解，有41％(788/1933)患者達到至少50％的疼痛緩解。使用單次和多次照射者並無差異。在一個月治療後達到完全緩解所需之NNT為4.2(假設在無任何治療下每100個病人中有1人可達到疼痛緩解)(95%信賴區間 3.7 – 4.7)。沒有彙集資料可供分析達到治療效果的速度，或其療效可維持多久。在收案數最多的臨床試驗(759例)中，52％的病人在四個星期內可達到完全疼痛緩解，達完全緩解時間的中位數為12個星期。對較全身性擴散之骨轉移，放射性同位素可以產生和體外照射類似的止痛效果。副作用之報告不足，噁心、嘔吐、腹瀉或病理性骨折之發生率不會因放療劑量規劃不同而有差異。
此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌。