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    • The authors of the NCCN non

    2019-04-20

    The authors of the NCCN non-small cell lung cancer guidelines provide the most guidance about radiotherapy dosing for painful bone metastases of any of the primary sites evaluated [39]. Bone metastases due to non-small cell lung cancer are separated into those “with soft tissue mass” versus those “without soft tissue mass”, with recommendations for 20–30Gy in 5–10 fractions for the former circumstance and 8–30Gy in 1–10 fractions for the latter. The small cell lung cancer guidelines go so far as to only state that radiotherapy may provide excellent palliation of painful bone lesions [40]. The kidney cancer guidelines hint at the notion of radiotherapy for oligometastases, describing that long-term progression-free survival has been noted in patients treated with radiotherapy for a single bone metastases and controlled primary disease [41]. The multiple myeloma guidelines recommend a “low dose” of how to find molarity therapy to between 10 and 30Gy for bone pain, impending pathologic fracture, or impending spinal cord compression. The multiple myeloma authors caution clinicians to limit the volume of irradiated fields to minimize the impact upon bone marrow given the potential for additional chemotherapy or stem cell harvest [42]. The prostate cancer guidelines suggest that a single 8Gy dose should be used to treat painful bone disease, though in contradistinction to the ACR and ASTRO guidelines, the NCCN prostate cancer authors suggest that vertebral metastases should receive a fractionated rather than single fraction dose. They also offer a recommendation to use radiopharmaceuticals such as strontium 89 or samarium 153 for widespread bony metastases [43]. Similarly, the thyroid cancer group only mentions EBRT in the setting of optimization of dosimetry for Iodine 131 for treatment of painful bone metastases [44]. The NCCN adult cancer pain guidelines suggest that radiotherapy be considered for painful lesions which are “likely to respond to antineoplastic therapies” [45]. Lastly, neither the breast cancer treatment guidelines nor the palliative care guidelines mention the use of radiotherapy for painful bone disease [46,47].
    Implications of bone metastases guidelines The publication of treatment guidelines may cause angst for practitioners, given justifiable concerns that their decision-making autonomy may be threatened by a need to pigeon-hole clinical circumstances into pre-determined bins. It is certainly true that third party payers and the Centers for Medicare and Medicaid Services are interested in using guidelines to reward literature-based patterns of care while questioning treatment patterns that deviate sharply from those data. Still, the advantages for the use of treatment guidelines include the provision of a minimum standard of care and a delineation of those topics which remain controversial enough to spur additional clinical trials to reach consensus on outcomes. The interest for the bone metastases treatment guidelines has been high, as is evidenced by the fact that the ASTRO bone metastases treatment guidelines were the most frequently downloaded articles in 2011 from the International Journal of Radiation Oncology, Biology, and Physics website [48]. One might foresee that ongoing interest in guidelines, in general, will spur more formal comparisons of formatting and content that will aid in standardization across the publications from different societies. This convergence of guidelines would most certainly decrease any discrepancies that currently exist in recommendations offered by the task force groups. The National Quality Forum (NQF) has been tasked with measuring quality of care for specific clinical circumstances, to analyze reports of how frequently those quality measures are employed, and to provide guidance that improves patterns of care [49]. The Affordable Care Act requires that the NQF provide annual input to the Department of Health and Human Services regarding a National Quality Strategy that provides measures and tracks progress toward fulfilling those goals. The NQF Cancer Endorsement 2011 group will evaluate EBRT dose fractionation schemes for bone metastases treatment as its first potential measure of radiation oncology quality. If the NQF Cancer Committee and Board of Directors accept that measure, then the full implications of bone metastases guidelines will be ascertained.