Original ArticlePalliative Response and Functional Interference Outcomes Using the Brief Pain Inventory for Spinal Bony Metastases Treated with Conventional Radiotherapy
Introduction
Spinal metastases occur in up to 40% of patients with cancer [1] and about 50–75% of patients with advanced cancer will develop bone metastases during the course of their disease. Back pain tends to be the first presenting symptom, and is reported in 72–91% of patients [2], [3]. Treatment options for spinal metastases include conventional external beam radiotherapy [4], surgery [5], analgesic therapy, bisphosphonates [6], percutaneous vertebral body augmentation [7], systemic radionuclides [8], stereotactic body radiotherapy [9], [10] or a combination of these modalities. Surgery tends to be indicated for mechanical instability, intractable pain or for symptomatic malignant epidural spinal cord compression. Conventional radiotherapy is the most common treatment to palliate pain associated with spine metastases.
The distribution of vertebral metastases varies within the vertebral column such that thoracic, lumbar and cervical spine metastases occur in about 70, 20, and 10% of patients, respectively [11], [12], [13]. It is not known if the functional implications and pain responses after palliative radiation are different based on the location within the spine, given the inherent biomechanical properties of the spine that are location dependent. For example, the cervical spine is the most mobile part of the spine, whereas the thoracic spine has the least capacity for movement due to the attached ribs that provide additional mechanical stabilisation [14], [15].
Although there have been several prospective randomised studies and meta-analyses confirming that palliative radiotherapy is effective in relieving pain from bone metastases [4], there is a lack of data specifically for spine metastases. Moreover, there have been few studies reporting on pain-related outcomes after radiotherapy, such as changes in functional interference caused by bone pain before and after radiotherapy, specifically for spine metastases.
The purpose of this study was to investigate in a cohort of patients treated with conventional radiotherapy to spine metastases, whether the pain and functional interference response varied according to the location within the spine and with radiation dose fractionation up to 3 months. The Brief Pain Inventory (BPI) tool was used in this study as it was designed to document both pain response and functional interference. The BPI is well known, and has been shown to be a reliable and valid tool in depicting pain severity and the extent to which pain interferes with function for bone metastases [16].
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Materials and Methods
Patients treated at the Rapid Response Radiotherapy Program at the Sunnybrook Health Sciences Centre, Toronto, Canada, between May 2003 and June 2005 were enrolled on a prospective institutional research ethics board approved study evaluating radiotherapy response rates with the BPI within the first 3 months after radiotherapy. All patients requiring palliative radiotherapy were approached for enrolment regardless of the site of bone metastases. Patients had to speak English and be able to
Baseline Patient Characteristics
One hundred and nine patients were included in this study and baseline characteristics are summarised in Table 1. The median daily OMED was 30 mg, with patients receiving an average of 66% pain relief from their analgesic use at baseline. The median survival time for all 109 patients was 7.8 months (range 1.1–41.1 months). At 3 months after radiotherapy, the overall survival was 88.1% (95% confidence interval 81–96%). The BPI functional scores at baseline show that pain interfered the most with
Discussion
Few studies have examined the effectiveness of palliative radiotherapy on response and functional interference outcomes specifically for spine metastases and, furthermore, the impact of location within the vertebral column. This study also evaluated if dose fractionation predicted the response to radiotherapy and on functional status according to the seven functional variables assessed by the BPI.
Pain scores and functional interference due to pain are critical when assessing the utility of a
Conclusion
Radiotherapy continues to play an important role in the palliative treatment of spinal metastases. This study provides supportive evidence that a single 8 Gy yields equivalent pain response rates as compared with multiple fraction regimens. Responders tend to have a better mood outcome than non-responders. The location within the vertebral column and dose fractionation do not predict for response and/or on functional interference outcomes. Future studies should continue to incorporate functional
Acknowledgements
The authors wish to thank the Michael and Karyn Goldstein Cancer Research Fund and Stacy Yuen.
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