Oct. 16--Patients enduring the excruciating pain of cancer that has spread to
the bones are often given multiple doses of radiation.
There is strong evidence, however, that one dose controls pain as effectively as
10 or more. In addition, one treatment is cheaper and far more convenient for
patients who already have plenty on their minds.
Yet a new study by University of Pennsylvania researchers has found that only
3.3 percent of Medicare patients receiving radiation for prostate cancer that
had metastasized to the bone received a "single-fraction" treatment.
While 10 fractions, or treatments, was long considered the standard, more than
half the 3,050 patients whose records were reviewed received more than 10
About 250,000 patients a year suffer from cancer bone pain, said Justin
Bekelman, a radiation oncologist at Penn Medicine's Abramson Cancer Center, who
led the study. Typically, their cancers cannot be cured. Radiation only reduces
the pain. It does not extend life.
Bekelman said the study illustrates how difficult it is to change medical
practice, especially when payment systems reward doctors for sticking to the
Doctors are paid more when they give more treatments. According to the study,
published last week in the Journal of the American Medical Association, Medicare
pays an average of $1,873 for a single treatment compared with $4,967 for a
group of treatments.
"It's profoundly difficult to change practice," Bekelman said. While he said
most doctors are simply doing what they have always done, he conceded that it
might take more than publicity about newer evidence to change their behavior.
"Pretty clearly, practice change might only materialize if payment reform
incentivizes high-quality care," he said. "In this case, it's not incentivizing
high-quality care. In fact, it's the opposite."
Ezekiel Emanuel, chair of Penn's department of medical ethics and health policy,
and senior author of the study, called that "a perfect example of misalignment"
between goals and financial incentives. Insurers should begin paying doctors the
same amount for one radiation treatment as for a series, he said.
Single-fraction patients are given a relatively larger dose in one treatment. In
multiple-fraction radiation, patients get smaller doses, usually on consecutive
work days. That means that patients, often older and not feeling well, must come
repeatedly to the treatment center.
Bekelman said a large clinical trial in 2005 concluded that the two regimens
provide equal pain control with similar side effects. Some say patients are more
likely to require a second round of treatment with single-fraction therapy, but
Bekelman said evidence was mounting that the two forms of treatment are equal,
even when it comes to retreatment.
The American Society for Radiation Oncology (ASTRO) 2011 guidelines favored a
single treatment, he said. ASTRO and the American Academy of Hospice and
Palliative Medicine include multiple-fraction radiation in lists of potentially
unnecessary treatments doctors and patients should discuss.
Penn analyzed data from 2006 through 2009. That was after research supporting
shorter courses emerged, but before ASTRO's guidelines. Bekelman said he and
Emanuel were examining more recent data from private insurers and finding that
still, less than 5 percent of patients get single-fraction treatment.
Bekelman became interested in the issue several years ago after treating a man
who came to the hospital in terrible pain on New Year's Eve. Bekelman prescribed
multiple radiation treatments. As he got to know the man and his family better,
Bekelman realized how difficult the many trips to the hospital had been for
"It became so clear to me," he said, "that we could have done better for him."
Bekelman was aware of the study that had found that short and long regimens were
equal, but he had not thought much through the implications.
"Ten treatments are not wrong," he said. "It's just that a single treatment is
just as effective."
While his study focused on prostate cancer patients, Bekelman said single
treatments are also recommended for patients with other cancers that spread to
bones, such as breast or lung. Doctors still should use multiple treatments for
some metastases, especially those in the spine.
Bekelman, who uses single-fraction treatment whenever possible, said 50 percent
to 80 percent of patients should be candidates.
Radiation oncologists at Fox Chase Cancer Center and Thomas Jefferson University
said researchers at their institutions were involved in earlier work on this
topic and they already use single-fraction in half or more of patients they
treat for bone pain.
"We didn't need this study to tell us about the standard of care," said Adam
Dicker, chair of the department of radiation oncology at Jefferson.
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