Patterns of Practice on Palliation of Painful Bone Metastases Among Radiation Oncologists in the Philippines

Abstract

Introduction

There is substantial number of patients needing palliation for symptomatic bone metastasis. While multiple treatment options are available at this time, external beam radiotherapy (EBRT) is still one of the cornerstones for managing this symptom. There are numerous available fractionations and schedules that have been studied and been utilized in palliative EBRT, which include single fraction EBRT, short course EBRT and longer course EBRT. Current reviews showed that the single and multiple fractionation EBRT showed similar pain relief with more retreatment for single fraction. The optimal radiation dose and fractionation for bone metastases are yet to be defined.

Objective
The objective of this study is to report the perceived effectiveness and utilization of different fractionation schemes among Filipino radiation oncologists in the treatment of painful bone metastases.

Materials and Methods
An in-person survey containing questions on perception and utilization different fractionations of EBRT for bone metastasis was given to radiation oncologists and residents registered in the roster of Philippine Radiation Oncology Society during the annual meeting. Follow up email and phone call were made in case of non-response. Descriptive statistics, analyses of difference between different fractionation schemesusing ANOVA and correlation of perceived effectiveness and utilization among respondents were reported at 95% level of significance.

Results
All residents and 43 out of the 66 (65%) radiation oncology consultants completed the survey with a total response rate of 77%. Among longer course EBRT, 30 Gy in 10 fractions was deemed to be effective by the majority of the respondents (91%) followed by 37.5Gy in 15 fractions (61%) and 40Gy in 20 fractions (59%). Among shorter course EBRT, only about half (53%) perceived 8Gy in single fraction to be effective, followed by 20Gy in 5 fractions (47%) and 36Gy in 6 fractions (26%). More respondents perceived fractions ≥ 10 to be more effective that shorter course treatment in bone metastasis. Almost all of the respondents reported to have utilized 30 Gy in 10 fractions followed by 40 Gy in 20 fractions (65%) and 37.5Gy in 15 fractions (65%). There is less respondents that reported to have utilized shorter fractionation schedule with only 37%, 33% and 15% have used 8 Gy in single fraction, 20 Gy in 5 fractions and 36 Gy in 6 fractions in their practice.

Conclusion
The result is in parallel with that done in the US, Canada and Europe that showed preference for multiple fractionation EBRT for bone metastasis. The majority of the radiation oncologists still defaults to utilizing 30 Gy in 10 fractions in treating bone metastasis. There is a discordance between perceived effectiveness and utility in actual practice. Despite almost half of the respondents believed that shorter fractionationschedules are effective in providing palliation for bone metastasis, this does not translate to their clinical practice. With the current emphasis for cost effective medicine especially in low to middle income countries, short course radiotherapy should be considered in adequately selected patients. Focus on palliative care in radiation oncology training and continuing educational sessions may be beneficial to increase knowledge, information dissemination and subsequent utilization of short course. There is also a need to explore the present barriers against short course RT.