Lower-Cost Radiation Regimen for Bone Metastasis Rarely Used

October 26, 2013
Anna Azvolinsky

A palliative single-fraction radiation therapy is as good as multiple-fraction radiation therapy for pain relief from bone metastases. The single-fraction regimen is also less expensive. Yet, a University of Pennsylvania study shows that the recommended treatment, tested in two randomized US and international trials, has not been widely adopted in the United States. The results are published in JAMA.

[[{"type":"media","view_mode":"media_crop","fid":"20284","attributes":{"alt":"","class":"media-image media-image-right","id":"media_crop_1363308847858","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"1286","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"float: right;","title":"Advanced prostate cancer patient with hypercalcemia and diffuse osteoblastic bone metastases. Source: Wan-Hsiu Liao et al.","typeof":"foaf:Image"}}]]Justin E. Bekelman, MD, of the University of Pennsylvania’s Perelman School of Medicine in Philadelphia, and colleagues tested how widely the single-fraction regimen was being used for prostate cancer patients on Medicare. The authors analyzed 3,050 men with prostate cancer with bone metastases, diagnosed between 2006 and 2009, from the Surveillance, Epidemiology, and End Results (SEER)-Medicare database. Costs for procedures were calculated from amounts reimbursed by Medicare. The patients’ median age was 78, and 85% were white.

“Evidence has consistently shown that single-fraction radiotherapy yields durable and equivalent pain control from the patients’ perspective and similar progression rates to multiple-fraction treatment,” said Bekelman.

Bekelman believes the underuse of single-fraction treatment is a result of multiple factors, including fear of recurrence, concern for retreatment, and variability in medical training and reimbursement.

Only 3.3% of the patients received single-fraction radiotherapy, and 50.3% received more than 10 fractions. Thirteen percent of patients received between 2 and 5 fractions, and 33.4% received between 6 and 10 fractions.

Among 2,028 patients who have not had previous complications, 3.8% received the single-fraction regimen.

Those who received single-fraction radiotherapy had the poorest prognosis, “perhaps reflecting the perception that single-fraction treatment should be reserved for patients with limited life expectancy or poor performance status,” stated the authors.

Single-fraction radiotherapy is given as a large dose of radiation in a single session. The multiple-fraction regimen is the same dose but given over a longer time period. Neither type of palliative radiotherapy is associated with improvement in survival.

The cost analysis found single-fraction radiotherapy to be 62% less expensive compared with multiple-fraction therapy. The average radiotherapy expenditures for 45 days were $1,873 for single fractions vs $4,967 for multiple fractions. Total healthcare expenditures were $13,112 and $11,702 for patients who received single- and multiple-fraction radiotherapy, respectively. The high total cost for patients receiving single-fraction radiotherapy was attributable to other medical services at the end of life.

Single-fraction treatment as palliative care does benefit patients, as determined by a 2005 randomized phase III trial of more than 800 patients.[1] “Single-fraction treatment improves quality of life and is more convenient for patients and their families,” said Bekelman. “There will always be clinical exceptions, which require more intensive or longer treatment schedules, but single-fraction treatment should be standard of care based on the evidence and the guidelines of medical societies.”

“It’s just good for patients,” he added.

At the University of Pennsylvania, Bekelman says single-fraction radiation is used for uncomplicated bone metastases. A comprehensive and multidisciplinary palliative care program also includes a specialist double-boarded in radiation oncology and palliative care who is part of the department of radiation oncology.

The authors are currently working with physicians, national societies, and insurers to understand whether alternative payment and service delivery models would provide a better incentive for high-quality cancer care that includes single-fraction radiation.


1. Hartsell WF, Scott CB, Bruner DW, et al. Randomized trial of short- versus long-course radiotherapy for palliation of painful bone metastases. J Natl Cancer Inst. 2005;97:798-804.