We’ve established that bone metastases are common, and now we’ll talk about approaches to manage pain that often accompanies them. As I mentioned previously, sometimes a metastases occurs in a weight-bearing bone, in which case we often recommend a prophylactic surgical procedure to stabilize the bone at risk for fracture. Radiation can also reduce the risk for fracture and improve pain.
Aside from the risk of fracture, reducing pain is an appropriate goal by itself. There are no randomized trials that compare medication to radiation therapy, and either or both can be used. Pain with bony metastases can be caused by many things, but most typically it’s inflammation and swelling of tissues on the outer surface of the bone, which can lead the nerves in the periosteum (the membrane on the outside of the bone) to transmit pain. External beam radiation (also known as radiation therapy, RT, or XRT) is often very effective in reducing inflammation and killing living tumor cells in that area. Up to 90% of patients have complete or partial improvement in their pain with XRT, and about half of the responding patients have complete relief of their pain (Hoegler summary abstract here). While radiation to a painful metastasis has often been given historically as daily fractions Monday-Friday for 2-3 weeks, recent studies have demonstrated that even a single-day radiation treatment can provide the same degree of pain relief 3 months later, although the single-day treatment had a higher likelihood of needing to re-treat the area, and no differences in survival or likeliood of a later pathologic fracture (Hartsell randomized comparison study, abstract here; summary “meta-analysis” abstract here). The more recent trial, with the abstract above, focused on patients with breast or prostate cancer but would presumably be equally applicable to metastases from other cancers. Overall, multiple trials have shown that a short course of 1-5 “fractions” of radiation can achieve comparable pain control and overall results as longer courses of radiaion. There can sometimes be more side effects to surrounding tissues if a single treatment or just a few are done, so this is a particularly appealing for metastases to extremities, where internal organs are not included in the radiation field.
Although it’s rarely done, there was actually a study that demonstrated that patients who received steroids in combination with XRT had more rapid and prolonged pain relief than the patients who received XRT alone (Teshima abstract here). Steroids do have acute and chronic side effects, including overall bone loss. Overall, this isn’t commonly practiced, but it’s a reasonable option.
There are several additional approaches for the common problem of bone metastases, so I’ll continue on this topic next time.
posted by Dr. West @ 7:19 pm link to this post
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February 18th, 2007 at 7:42 pm
Dr West,
You did it again. I feel so fortunate with these latest posts as this is exactly what my husband is facing in the very near future.
Thank you for this site.
Laurie
February 18th, 2007 at 8:23 pm
Dr. West,
If a total of 3250 cGy was used sucessfully to treat pain and metastatic cancer spread to sacrum (L5-SI), can you still radiate the Thoracic spine for multiple pain causing blastic leisons? The Thoracic spine has never been radiated. hat are the risks?
My wife will start receiving Zometa Feb 19 in the hopes that it will reduce the pain she is having in her Thoracic spine back areas. Since I am the one being proactive I’m not sure if we are choosing the right therapy.
Oncologist is not very proactive. Maybe he has a secret plan down the road.
A 50mcg pain patch works but only 2 days. The pain seems to be getting worst. The bone doctors say there are no fractures or compressions, just numerous blastic leisons.
Is there any way to tell if the pain is caused by what you said: ‘inflammation and swelling of tissues on the outer surface of the bone’?
Thanks - Chanwit
February 18th, 2007 at 9:09 pm
Usually, if one area was radiated, a different area can be radiated without any problem. It becomes more of an issue if there is potential overlap, because the doses of radiation routinely given are often limited by the risk of damage from cumulative radiation dose to particular tissues. So for radiating the spine, radiation oncologists need to ensure that the spinal cord in any particular area doesn’t get too excessive of a cumulative dose. But different areas can be treated pretty much to full dose, independently.
As for the fentanyl patch, I find them often very helpful for my patients, but if she’s needing them changed more frequently, she may do better with a slightly higher dose (unless she develops bad nausea/vomiting on higher doses — I know she’s pretty sensitive to GI side effects).
There’s no way to tell the cause of bone pain, nor does it really change anything. The treatments are the same either way.
And zometa or another bisphosphonate are often used, potentially to help with pain, and largely to reduce the rate of further skeletal complications developing in patients with bone metastases. We’ll cover bisphosphonates more thoroughly in another post in the near future.
-Dr. West
February 20th, 2007 at 6:50 pm
Chanwit,
A year ago I had severe lower back and hip pain due to bone mets from my lung cancer. I have been on Zometa since last late last Feb. By November, my pain was reduced to almost nothing. I have some mild discomfort but have not taken any pain med since November. My bone mets have been dramatically reduced due to chemo of carboplatin, taxol and avastin as well.
John
February 21st, 2007 at 2:33 pm
Thanks John, so Zometa helped reduced your bone met pain over 8 mos. Call it a placebo effect or what but Lisa hasn’t complained as much about the pain since she had her first dose of 4mg IV Zometa on Monday. Can it work that fast? The nurse said that Zometa helps the bone absorb more calcium from the blood. Lisa’s blood calcium is normal. Do you need to take in a calcium supplement as well? She takes an Isotonic Calcium supplement at night. Is Zometa all about bone calcium uptake?
Chanwit
February 21st, 2007 at 10:54 pm
I’m describing zometa and other bisphosphonates in my next post. It basically facilitates bone uptake of calcium from blood.
-Dr. West