Trends in radiotherapy fractionation for bone metastases: a multi-center study of practice patterns before, during, and after COVID-19.

PURPOSE: Trials show similar pain outcomes for hypofractionated and multi-fraction regimens in bone metastases, yet clinical adoption of hypofractionation remains limited. The coronavirus disease 2019 (COVID-19) pandemic may have increased hypofractionation to minimize hospital visits and optimize resources. This study evaluated fractionation patterns before, during and after COVID-19 and compared pain outcomes between regimens in routine practice.

MATERIALS AND

METHODS

Data on treatment regimens for bone metastases between 2018 and 2022 were collected from 11 of 22 Dutch radiotherapy departments. Trends in utilization of hypofractionated (1-2 times 8 Gy) and multi-fraction (≥5 fractions) regimens were analyzed. For a subset of patients (n = 278), self-reported pain scores were collected at baseline, 4 and 8 weeks, and 3 months. Pain scores and pain response were compared for hypofractionated and multiple-fraction regimens, with complete (pain score 0) or partial (reduction ≥2 points) response classified as responders.

RESULTS

A total of 17,336 patients were included, receiving 31,677 treatment regimens. The majority of the regimens were hypofractionated (n = 25,790, 81%). The use of hypofractionated regimens ranged from 34% to 99% between radiotherapy departments. A statistically significant increase in hypofractionated regimens was observed since the onset of the COVID-19 pandemic in 2020 (p < 0.001). In an exploratory analysis of patients with available pain scores, pain response in the three months post-treatment did not differ significantly between hypofractionated and multi-fraction regimens (56% vs. 63%, p = 0.406).

CONCLUSION

This study demonstrates a high adoption of hypofractionated regimens, with a slight increase since the COVID-19 pandemic, though considerable variation remains between departments. Pain outcomes were comparable between hypofractionated and multi-fraction regimens, suggesting equal palliation and less treatment burden with hypofractionation.