Painful bone metastases: radiation, bone agents and cord compression

External beam radiation is the core treatment for painful bone metastases, and a single 8 Gy fraction relieves pain as well as longer courses. Cord compression needs dexamethasone and urgent surgical and radiation review; bone agents are adjuncts, not analgesics.

1. Radiate painful bone metastases. ASTRO 2024 recommends radiation for pain from bone and spine metastases, with or without cord or cauda equina compression ¹.
2. Single fraction equals multiple fractions for pain. Acceptable conventional regimens are 8 Gy in 1, 20 Gy in 5, 24 Gy in 6 or 30 Gy in 10 fractions, and pain relief is equivalent between single and multiple fractions ¹².
3. Choose by the whole person. The regimen should reflect prognosis, prior radiation, normal-tissue risk, quality of life, cost and patient goals, with shared decision-making ¹.
4. SBRT is for selected patients. It is conditionally recommended over conventional radiation only for good performance status without need for surgery or neurologic signs ¹.
5. Cord compression: steroids, then surgery plus radiation. Dexamethasone is recommended for spine metastases compressing the cord or cauda equina, and surgery with postoperative radiation is conditionally preferred over radiation alone ¹.
6. Bone-modifying agents prevent events but barely treat pain. ASCO-CCO recommends them for breast cancer with bone metastases; their analgesic effect is modest, so they should not be used alone for bone pain; analgesics, radiotherapy and supportive care continue ³.

Metastatic compression of the spinal cord or cauda equina is not managed with analgesics and observation: give dexamethasone and involve surgery and radiation oncology, since surgery plus radiation is conditionally preferred ¹.

• Retreatment of recurrent pain at peripheral or spine sites is safe and effective within published dose constraints ².
• Surgery, radionuclides, bisphosphonates and vertebral augmentation do not remove the need for external beam radiation ².
• For surgery-ineligible cord compression, ASTRO lists 8 Gy/1, 16 Gy/2, 20 Gy/5 or 30 Gy/10 ¹.
• Patients with nonspine bone metastases needing surgery are recommended postoperative radiation ¹.
• Evidence is insufficient to prefer one bone-modifying agent over another ³.
• Denosumab is contraindicated in hypocalcemia, which must be corrected first; supplement calcium and vitamin D ⁴.
• Perform an oral examination before denosumab and avoid invasive dental work because of osteonecrosis of the jaw ⁴.

• Assuming longer fractionated courses relieve pain better than a single 8 Gy fraction ².
• Assuming single fractions are unsafe for spine lesions; high-quality data show acceptable late toxicity ².
• Relying on a bisphosphonate to treat acute cord compression ¹³.
• Offering SBRT to a patient with poor performance status ¹.