Supportive Care in Cancer

, Volume 15, Issue 4, pp 451–455 | Cite as

Pain flare in patients with bone metastases after palliative radiotherapy—a nested randomized control trial

  • D. Andrew Loblaw
  • Jackson SY Wu
  • Peter Kirkbride
  • Tony Panzarella
  • Katherine Smith
  • Julie Aslanidis
  • Padraig WardeEmail author
Short Communication



Short-course radiotherapy is a common treatment for the palliation of painful osseous metastases. Pain flare can be problematic, but its incidence has previously not been well-documented. The objectives of this study were to determine (1) the incidence of pain flare after palliative radiation for painful osseous metastases, and (2) whether single-fraction radiotherapy increases the risk of pain flare.

Materials and methods

Patients accrued to a prospective randomized control trial comparing 8 Gy in one fraction to 20 Gy in five fractions (the Canadian Bone Metastasis Study) were approached to fill out a daily pain and analgesia diary for the 7 days post-radiotherapy. Patients assessed their average pain at the index site using the Present Pain Intensity (PPI) scale of the McGill–Melzack pain questionnaire and recorded their daily analgesic medications, which were translated into an analgesic score. Pain flare was defined as a two-point increase in the PPI with no decrease in analgesic score or a 50% increase in analgesic score with no decrease in PPI on at least two consecutive days.


Forty-seven patients agreed to fill out the diary and 44 (94%) completed it. Fifteen of 44 (34.1%) patients experienced a pain flare that lasted a median of 3 days. Ten of 23 (43.5%) and 5/21 (23.8%) of patients who received 8 Gy and 20 Gy had a pain flare, respectively.


Pain flare is common after palliative radiotherapy for osseous metastases and patients receiving single fraction radiotherapy may be at higher risk. Further study is warranted to determine predictors and preventive interventions.


Bone metastases Radiotherapy Palliation Pain flare 


  1. 1.
    Foley KM (1985) The treatment of cancer pain. New Engl J Med 313:84–94PubMedCrossRefGoogle Scholar
  2. 2.
    Malawer MM, Delanet TF (1993) Treatment of metastatic cancer to bone. In: Devita VT, Hellman S, Rosenberg SA (eds) Cancer—principles and practice of oncology. Lippincott, Philadelphia, pp 2225–2244Google Scholar
  3. 3.
    Hoegler D (1997) Radiotherapy for palliation of symptoms in incurable cancer. Curr Probl Cancer 21:129–183PubMedCrossRefGoogle Scholar
  4. 4.
    Wu JSY, Wong R, Johnston M, Bezjak A, Whelan T (2003) On behalf of the Cancer Care Ontario Practice Guidelines Initiative Supportive Care Group. Meta-analysis of dose-fractionation radiotherapy trials for the palliation of painful bone metastases. Int J Radiat Oncol Biol Phys 55:594–605PubMedCrossRefGoogle Scholar
  5. 5.
    Price P, Hoskin P, Easton D, Austin D, Palmer SC, Yarnold JR (1986) Prospective randomized trial of single and multifraction radiotherapy schedules in the treatment of painful bony metastases. Radiother Oncol 6:247–255PubMedGoogle Scholar
  6. 6.
    Nielsen OS, Bentzen SM, Sandberg E, Gadeberg CC, Timothy AR (1998) Randomized trial of single dose versus fractionated palliative radiotherapy of bone metastases. Radiother Oncol 47:233–240PubMedCrossRefGoogle Scholar
  7. 7.
    Steenland E, Leer JW, van Houwelingen H et al (1999) The effect of a single fraction compared to multiple fractions on painful bone metastases: a global analysis of the Dutch Bone Metastasis Study. Radiother Oncol 52:101–109PubMedCrossRefGoogle Scholar
  8. 8.
    Koswig S, Budach V (1999) Remineralization and pain relief in bone metastases after different radiotherapy fraction (10 times 3 Gy vs. 1 time 8 Gy). A prospective study (German). Strahlenther Onkol 175:500–508PubMedCrossRefGoogle Scholar
  9. 9.
    Kirkbride P, Warde P, Panzarella A et al (2000) A randomized trial comparing the efficacy of single fraction radiation therapy plus ondansetron with fractionated radiation therapy in the palliation of skeletal metastases (abstract). Int J Radiat Oncol Biol Phys 48:185CrossRefGoogle Scholar
  10. 10.
    Gaze MN, Kelly CG, Kerr GR et al (1997) Pain relief and quality of life following radiotherapy for bone metastases: a randomized trial of two fractionation schemes. Radiother Oncol 45:109–116PubMedCrossRefGoogle Scholar
  11. 11.
    Cole DJ (1989) A randomized trial of single treatment versus conventional fractionation in the palliative radiotherapy of painful bone metastases. Clin Oncol (R Coll Radiol) 1:59–62Google Scholar
  12. 12.
    Bone Pain Trial Working Party (1999) 8 Gy single fraction radiotherapy for the treatment of metastatic skeletal pain: randomized comparison with a multifraction schedule over 12 months of patient follow-up. Radiother Oncol 52:111–121CrossRefGoogle Scholar
  13. 13.
    Melzack R, Torgerson WS (1971) On the language of pain. Anesthesiology 34:50–59PubMedCrossRefGoogle Scholar
  14. 14.
    Tannock IF, Osoba D, Stockler MR et al (1996) Chemotherapy with mitoxantrone plus prednisone or prednisone alone for symptomatic hormone-resistant prostate cancer: a Canadian randomized trial with palliative end points. J Clin Oncol 14:1756–1764PubMedGoogle Scholar
  15. 15.
    Chow E, Wu JS, Hoskin P, Coia LR, Bentzen SM, Blitzer PH (2002) International consensus on palliative radiotherapy endpoints for future clinical trials in bone metastases. Radiother Oncol 64:275–280PubMedCrossRefGoogle Scholar
  16. 16.
    Chow E, Ling A, Davis L, Panzarella T, Danjoux C (2005) Pain flare following external beam radiotherapy and meaningful change in pain scores in the treatment of bone metastases. Radiother Oncol 75:64–69PubMedCrossRefGoogle Scholar
  17. 17.
    Fleiss JL (1981) Statistical methods for rates and proportions. Wiley, New YorkGoogle Scholar
  18. 18.
    Chow E, Wong R, Hruby G et al (2001) Prospective patient-based assessment of effectiveness of palliative radiotherapy for bone metastases. Radiother Oncol 61:77–82PubMedCrossRefGoogle Scholar
  19. 19.
    Chow E, Davis L, Holden L et al (2004) A comparison of radiation therapy outcomes of bone metastases employing international consensus endpoints and traditional endpoints. Support Cancer Therapy 1:173–178CrossRefGoogle Scholar
  20. 20.
    Loblaw DA, Bunston T, Bezjak A (1999) Development and testing of a visit—specific patient satisfaction questionnaire: the Princess Margaret Hospital Satisfaction with Doctor Questionnaire (PMH/PSQ-MD). J Clin Oncol 17:1931–1938PubMedGoogle Scholar
  21. 21.
    Lanciano R, Sherman DM, Michalski J, Preston AJ, Yocom K, Friedman C (2001) The efficacy and safety of once-daily Kytril (granisetron hydrochloride) tablets in the prophylaxis of nausea and emesis following fractionated upper abdominal radiotherapy. Cancer Invest 19:763–772PubMedCrossRefGoogle Scholar
  22. 22.
    Franzen L, Nyman J, Hagberg H et al (1996) A randomised placebo controlled study with ondansetron in patients undergoing fractionated radiotherapy. Ann Oncol 7:587–592PubMedGoogle Scholar

Copyright information

© Springer-Verlag 2006

Authors and Affiliations

  • D. Andrew Loblaw
    • 1
  • Jackson SY Wu
    • 2
  • Peter Kirkbride
    • 3
  • Tony Panzarella
    • 4
    • 5
  • Katherine Smith
    • 6
  • Julie Aslanidis
    • 7
  • Padraig Warde
    • 7
    Email author
  1. 1.Department of Radiation Oncology, Sunnybrook Health Sciences CentreUniversity of TorontoTorontoCanada
  2. 2.Department of Radiation OncologyTom Baker Cancer CenterCalgaryCanada
  3. 3.Department of OncologySheffield Cancer CenterSheffieldUK
  4. 4.Department of Public Health SciencesUniversity of TorontoTorontoCanada
  5. 5.Department of Clinical Study Coordination and BiostatisticsPrincess Margaret Hospital, University Health NetworkTorontoCanada
  6. 6.Department of Radiation OncologySunnybrook and Women’s College Health Sciences CentreTorontoCanada
  7. 7.Department of Radiation OncologyPrincess Margaret Hospital/University Health NetworkTorontoCanada

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