Roos D E
Department of Radiation Oncology, Royal Adelaide Hospital, North Terrace, Adelaide, South Australia, 5000 Australia.
Radiother Oncol. 2000 Sep;56(3):315-22. doi: 10.1016/s0167-8140(00)00250-4.
To survey Australian and New Zealand (ANZ) radiation oncologists on their preferred fractionation regimens for pain due to bone metastases in the context of similar overseas surveys and the large body of evidence from randomized trials.
Delegates to the October 1998 Royal ANZ College of Radiologists Annual Scientific Meeting were asked to state their fractionation for four hypothetical cases viz. local bone pain from metastatic breast, prostate and lung cancer and neuropathic (radicular) pain from metastatic lung cancer. In addition to demographic data, respondents were asked to select reasons for their choices and indicate what factors would influence a change in their recommended fractionation.
Twelve of 32 trainees and 41 of 82 specialists completed the survey, giving an overall response rate of 46%. There was decreasing use of shorter fractionation schedules from lung through prostate to breast cancer with, in particular, single fractions recommended by, respectively, 42, 28 and 15% of respondents for local bone pain (P=0.013). However, the presence of neuropathic pain from metastatic lung cancer led to lower use of single fractions (15%, P=0.0046). There were no statistically significant differences in preferred fractionation with respect to other variables assessed in this survey. The commonest reasons cited for fractionating were desire to minimize recurrent pain and the influence of training, with desire to minimize the risk of neurological progression and optimize tumour regression also important for neuropathic pain. By contrast, use of single fractions was most commonly based upon literature results and patient convenience. Changing from multiple to single fractions was most influenced by poor performance status, while the presence of neurological signs/symptoms had the reverse effect.
The findings from this ANZ survey largely reflect the results from other surveys performed in the UK, Europe, Canada and USA. Although debate continues in the literature, the continuing preference of radiation oncologists to fractionate for local bone pain is contrary to the 16 randomized trials published to date which give little support for a dose-response relationship above a single 6-8 Gy in this setting. This practice has significant implications for departmental workload, costs to the healthcare system and patient convenience. There is no objective evidence on the influence of fractionation for neuropathic bone pain in the literature at present, although an ANZ randomized trial addressing this problem is under way (TROG 96.05).
在海外类似调查以及大量随机试验证据的背景下，对澳大利亚和新西兰（澳新）的放射肿瘤学家进行调查，了解他们对于骨转移疼痛所偏好的分割方案。
向1998年10月参加澳新皇家放射科医师学院年度科学会议的代表询问他们针对四个假设病例的分割方案，即转移性乳腺癌、前列腺癌和肺癌引起的局部骨痛，以及转移性肺癌引起的神经性（神经根性）疼痛。除人口统计学数据外，还要求受访者选择其选择的原因，并指出哪些因素会影响他们推荐的分割方案的改变。
32名实习生中有12名、82名专家中有41名完成了调查，总体回复率为46%。从肺癌到前列腺癌再到乳腺癌，采用较短分割方案的情况逐渐减少，特别是对于局部骨痛，分别有42%、28%和15%的受访者推荐单次分割（P = 0.013）。然而，转移性肺癌引起的神经性疼痛导致单次分割的使用较少（15%，P = 0.0046）。在本次调查中评估的其他变量方面，偏好的分割方案没有统计学上的显著差异。分割最常见的原因是希望将复发性疼痛降至最低以及培训的影响，对于神经性疼痛，希望将神经进展风险降至最低并优化肿瘤退缩也很重要。相比之下，单次分割的使用最常见的依据是文献结果和患者便利性。从多次分割改为单次分割受患者身体状况不佳影响最大，而神经体征/症状的出现则有相反的效果。
本次澳新调查的结果在很大程度上反映了在英国、欧洲、加拿大和美国进行的其他调查的结果。尽管文献中仍有争论，但放射肿瘤学家对局部骨痛继续倾向于分割的做法与迄今发表的16项随机试验结果相反，这些试验几乎没有支持在这种情况下单次6 - 8 Gy以上存在剂量反应关系。这种做法对科室工作量、医疗系统成本和患者便利性有重大影响。目前文献中没有关于分割对神经性骨痛影响的客观证据，尽管一项澳新解决此问题的随机试验正在进行中（TROG 96.05）。
