Dr. Kalyani Premchandra, Dr.Hasib A. G, Dr. Athiyamaan, Dr. Sandesh, Dr. Sharaschandra, Dr. Hepsiba Sriram



Bone metastasis is a common manifestation of malignancy and is the third most common organ affected by metastasis. Bone metastases can cause various morbidities and affect the quality of life. The treatment intent in bone metastases is palliative. External beam radiotherapy is the mainstay of treatment of uncomplicated painful bone metastases. Different radiotherapy fractionation schedules are in practice for palliation of painful bone metastases.


To report the outcomes of various fractionation schedules of radiation therapy in terms of pain relief and improvement of quality of life in patients with painful bone metastases.


A prospective randomised study performed on 80 patients were randomised to 4 treatment arms with different radiation therapy fractionation schedules at the Dept. of Radiation Oncology, Father Muller Medical College Hospital. The fractionation radiation doses used in the study were 8 Gy in 1 fraction, 20 Gy in 5 fractions, 24 Gy in 6 fractions and 30 Gy in 10 fractions. Patients were assessed for pain by Visual Analog Scale (VAS) and Rupee scale, performance status, analgesic usage, quality of life before initiating the treatment, on the day of completion of treatment, 1 week, 1 month and 3 months post completion of treatment.


In our study majority of the metastases were from the breast of 33.75%,  25% from the lungs, 18.75% from the head and neck, and 12.5% from prostate. Cervix (2.5%), esophagus (1.25%), stomach (1.25%), liver (1.25%), ovary (1.25%) comprised the other primary sites. 2.5% of the metastases were from unknown primary. In total  27.5% of the patients had metastases to the thoracic vertebra, 26.25% to the lumbar vertebra, 22.5% to the pelvis, 8.75% to the sternum, 6.25% each to cervical vertebra and femur and 1.25% each to humerus and ribs. The pain reduction was significant in all the 4 arms. The mean VAS score was 5.23 prior to start of treatment. The score reduced to 2.88 at the completion of treatment and further dropped to 1.57, 0.79, and 0.81 at 1 week, 1 month and 3 months post completion of radiation therapy. Similar results were obtained using the Rupee scale for assessment of pain. The mean score prior to treatment was 54.23 in the entire study group. It is reduced to 33.81, 25.87, 12.78 and 12.84 on the day of treatment completion, 1 week, 1 month and 3 months post completion of radiation therapy. Complete pain relief occured in 40% of the patients. 25% of the patients in 8 Gy in 1 fraction had complete relief of pain whereas the complete relief in the remaining 3 arms was 45% each. Improvement in the quality of life was observed in all the arms, both in terms of symptoms and function.



This prospective study demonstrated that various radiation fractionation schedules used in the treatment of painful bone metastases have been effective in reducing the pain. The  pain reduction by various fractionation schedules are similar and no statistically significant difference was noted. Quality of life improved in all the four treatment arms post radiation therapy. 8 Gy in single fraction may be considered for treatment of painful bone metastases


Bone metastases; VAS; Rupee scale; Pain; Quality of Life

Full Text:



Yu HH, Tsai YY, Hoffe SE. Overview of diagnosis and management of metastatic disease to bone. Cancer Control 2012 Apr; 19(2):84–91.

Hartsell WF, Yajnik S. Palliation of Bone Metastases. In: Halperin EC, Wazer DE, Perez CA, Brady LW, editors. Perez and Brady’s Principles and Practice of Radiation Oncology. 6th ed. Philadelphia: Lippincott Williams & Wilkins; 2013.

Chow E, Finkelstein JA, Sahgal A, Coleman RE. Metastatic Cancer to the Bone. In: Devita VT, Lawrence TS, Rosenberg SA, editors. Devita, Hellman & Rosenberg's Cancer Principles & Practice of Oncology. 9th ed. Philadelphia: Lippincott Williams & Wilkins; 2011.

Lutz S, Berk L, Chang E, Chow E, Hahn C, Hoskin P, et al. Palliative Radiotherapy for Bone Metastases: An ASTRO Evidence-Based Guideline. Int J Radiat Oncol Biol Phys 2011 Mar 15; 79(4):965–76.

Diel IJ, Kaufmann M, Bastert G. Metastatic Bone Disease Fundamental and Clinical Aspects. Heidelberg: Springer-Verlag; 1994.

Steenland E, Leer JW, van Houwelingen H, Post WJ, van den Hout WB, Kievit J, et al. The effect of a single fraction compared to multiple fractions on painful bone metastases: a global analysis of the Dutch Bone Metastases Study. Radiother Oncol 1999; 52(2):101–9.

Nielsen OS, Bentzen SM, Sandberg E, Gadeberg CC, Timothy AR. Randomized trial of single dose versus fractionated palliative radiotherapy of bone metastases. Radiother Oncol 1998; 47(3):233-40.

Ratasvuori M, Wedin R, Hansen BH, Keller J, Trovik C, Zaikova O, et al. Prognostic role of en-bloc resection and late onset of bone metastasis in patients with bone-seeking carcinomas of the kidney, breast, lung, and prostate: SSG study on 672 operated skeletal metastases. J Surg Oncol 2014 Sept; 110(4):360-5.

Chow E, Nguyen J, Zhang L, Tseng LM, Hou MF, Fairchild A et al.. International field testing of the reliability and validity of the EORTC QLQBM22 module to assess health-related quality of life in patients with bone metastases. Cancer 2012; 118(5):1457-65.


  • There are currently no refbacks.