Bone metastases Next Best Step: Steroids, Radiation, or Pain Meds?

[StrangerX]

1-If a patient has generic cancer mets to the bone, is in pain and without spinal cord compression...would you give pain meds OR radiation first?

2-Same case as above but with spinal cord compression...would you give pain meds, radiation, OR streroids first? What would you give second?

3-How would the management change if the patient had primary metastatic prostate cancer mets to the bone...in what order would you use pain meds, radiation, steroids, OR hormone agonists/antagonists?

4-Would scenario 3 change if the cancer was recurrent prostate cancer?

Thanks

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[Rebs28]

1. I would give pain meds before radiation. Radiation takes some coordination, and the patient shouldn't have to suffer while I get things set up.

2. Steroids first in spinal cord compression.

3. Same as above.

4. Same order as above.

 

[AndyRSC]

With prostate mets to bone, the concept being tested is flutamide before leuprolide, to prevent initial surge in activity/growth and prevent spinal compression.

 

[StrangerX]

2. Steroids first in spinal cord compression.

So you would prioritize the steroids over the pain meds? Would you still end up doing the radiation in this case?

With prostate mets to bone, the concept being tested is flutamide before leuprolide, to prevent initial surge in activity/growth and prevent spinal compression.

So do pain meds, then hormonal agents if no compression (but steroids if compression present), then radiotherapy?

 

[Rebs28]

So you would prioritize the steroids over the pain meds? Would you still end up doing the radiation in this case?

In spinal cord compression, I would pick steroids if it asks what the next best step is. But of course IRL, pain meds would be given simultaneously, though steroids can provide some analgesia. On the exam, yes, I would end up doing radiation therapy unless there's bony instability, in which case, if not contraindicated, I would do surgery. But most likely on the exam the answer will be radiation rather than surgery. This is historically how spinal cord compression due to mets has been managed.

 

[AndyRSC]

So do pain meds, then hormonal agents if no compression (but steroids if compression present), then radiotherapy?

I guess it depends on the question. Are pain meds just for pain control while other measures are being done, or are they palliative therapy?

I think it goes like this:
- Pain medication for acute control of bone pain due to mets
- Steroids to prevent further inflammation / damage if evidence of cord compression
- Radiation for long-term management of bone pain and cancer elimination
- Patients with recurrent cancer after radiation go on to hormone therapy
- Patients with recurrent cancer after hormone therapy go on on to chemotherapy
- Patients failing chemotherapy go on pain medication for palliative measures

 

[StrangerX]

In spinal cord compression, I would pick steroids if it asks what the next best step is. But of course IRL, pain meds would be given simultaneously, though steroids can provide some analgesia. On the exam, yes, I would end up doing radiation therapy unless there's bony instability, in which case, if not contraindicated, I would do surgery. But most likely on the exam the answer will be radiation rather than surgery. This is historically how spinal cord compression due to mets has been managed.

I guess it depends on the question. Are pain meds just for pain control while other measures are being done, or are they palliative therapy?

I think it goes like this:
- Pain medication for acute control of bone pain due to mets
- Steroids to prevent further inflammation / damage if evidence of cord compression
- Radiation for long-term management of bone pain and cancer elimination
- Patients with recurrent cancer after radiation go on to hormone therapy
- Patients with recurrent cancer after hormone therapy go on on to chemotherapy
- Patients failing chemotherapy go on pain medication for palliative measures

Thanks for breaking it down for me.

 

[evilbooyaa]

I guess it depends on the question. Are pain meds just for pain control while other measures are being done, or are they palliative therapy?

I think it goes like this:
- Pain medication for acute control of bone pain due to mets
- Steroids to prevent further inflammation / damage if evidence of cord compression
- Radiation for long-term management of bone pain and cancer elimination
- Patients with recurrent cancer after radiation go on to hormone therapy
- Patients with recurrent cancer after hormone therapy go on on to chemotherapy
- Patients failing chemotherapy go on pain medication for palliative measures

Not entirely correct. Radiation therapy has a significant role in palliation of pain from bone mets. It's not curative, but is a better long-term solution than chronic pain meds. Most pts w/ bone mets are not being given radiation for a cure.

I think neurological sx = Steroids.
Acute pain = narcotics.
Chronic worsening mets pain = Radiation/Hormones.