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Meta-Analysis
. 2017 Mar 23;3(3):CD003347.
doi: 10.1002/14651858.CD003347.pub3.

WITHDRAWN: Radioisotopes for metastatic bone pain

Marta Roqué I Figuls  1 , Maria José Martinez-Zapata  1 , Martin Scott-Brown  2 , Pablo Alonso-Coello  3
Affiliations
Meta-Analysis

WITHDRAWN: Radioisotopes for metastatic bone pain

Marta Roqué I Figuls et al. Cochrane Database Syst Rev. .

Abstract

Background: This is an update of the review published in Issue 4, 2003. Bone metastasis cause severe pain as well as pathological fractures, hypercalcaemia and spinal cord compression. Treatment strategies currently available to relieve pain from bone metastases include analgesia, radiotherapy, surgery, chemotherapy, hormone therapy, radioisotopes and bisphosphonates.

Objectives: To determine efficacy and safety of radioisotopes in patients with bone metastases to improve metastatic pain, decrease number of complications due to bone metastases and improve patient survival.

Search methods: We sought randomised controlled trials (RCTs) in MEDLINE, EMBASE, CENTRAL, and the PaPaS Trials Register up to October 2010.

Selection criteria: Studies selected had metastatic bone pain as a major outcome after treatment with a radioisotope, compared with placebo or another radioisotope.

Data collection and analysis: We assessed the risk of bias of included studies by their sequence generation, allocation concealment, blinding of study participants, researchers and outcome assessors, and incomplete outcome data. Two review authors extracted data. We performed statistical analysis as an "available case" analysis, and calculated global estimates of effect using a random-effects model. We also performed an intention-to-treat (ITT) sensitivity analysis.

Main results: This update includes 15 studies (1146 analyzed participants): four (325 participants) already included and 11 new (821 participants). Only three studies had a low risk of bias. We observed a small benefit of radioisotopes for complete relief (risk ratio (RR) 2.10, 95% CI 1.32 to 3.35; Number needed to treat to benefit (NNT) = 5) and complete/partial relief (RR 1.72, 95% CI 1.13 to 2.63; NNT = 4) in the short and medium term (eight studies, 499 participants). There is no conclusive evidence to demonstrate that radioisotopes modify the use of analgesia with respect to placebo. Leucocytopenia and thrombocytopenia are secondary effects significantly associated with the administration of radioisotopes (RR 5.03; 95% CI 1.35 to 18.70; Number needed to treat to harm (NNH) = 13). Pain flares were not higher in the radioisotopes group (RR 0.74; 95% CI 0.27 to 2.06). There are scarce data of moderate quality when comparing Strontium-89 (89Sr) with Samarium-153 (153Sm), Rhenium-186 (186Re) and Phosphorus-32 (32P). We observed no significant differences between treatments. Similarly, we observed no differences when we compared different doses of 153Sm (0.5 versus 1.0 mCi).

Authors' conclusions: This update adds new evidence on efficacy of radioisotopes versus placebo, 89Sr compared with other radioisotopes, and dose-comparisons of 153Sm and 188Re. There is some evidence indicating that radioisotopes may provide complete reduction in pain over one to six months with no increase in analgesic use, but severe adverse effects (leucocytopenia and thrombocytopenia) are frequent.

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Conflict of interest statement

None known

Figures

Figure 1
Figure 1
Risk of bias graph: review authors' judgments about each risk of bias item presented as percentages across all included studies.
Figure 2
Figure 2
Risk of bias summary: review authors' judgments about each risk of bias item for each included study.
Analysis 1.1
Analysis 1.1
Comparison 1 Radioisotopes versus placebo (data as published), Outcome 1 Pain relief.
Analysis 1.2
Analysis 1.2
Comparison 1 Radioisotopes versus placebo (data as published), Outcome 2 Improvement in pain.
Analysis 1.3
Analysis 1.3
Comparison 1 Radioisotopes versus placebo (data as published), Outcome 3 Less or equal analgesia consumption.
Analysis 1.4
Analysis 1.4
Comparison 1 Radioisotopes versus placebo (data as published), Outcome 4 Reduction in analgesia consumption.
Analysis 1.5
Analysis 1.5
Comparison 1 Radioisotopes versus placebo (data as published), Outcome 5 Compression of spinal cord.
Analysis 1.6
Analysis 1.6
Comparison 1 Radioisotopes versus placebo (data as published), Outcome 6 Pain flares.
Analysis 1.7
Analysis 1.7
Comparison 1 Radioisotopes versus placebo (data as published), Outcome 7 Side effects grade III‐IV.
Analysis 1.8
Analysis 1.8
Comparison 1 Radioisotopes versus placebo (data as published), Outcome 8 Death.
Analysis 2.1
Analysis 2.1
Comparison 2 Different radioisotopes (data as published), Outcome 1 Pain relief.
Analysis 2.2
Analysis 2.2
Comparison 2 Different radioisotopes (data as published), Outcome 2 Compression of nervous roots.
Analysis 2.3
Analysis 2.3
Comparison 2 Different radioisotopes (data as published), Outcome 3 Hypercalcaemia.
Analysis 2.4
Analysis 2.4
Comparison 2 Different radioisotopes (data as published), Outcome 4 Pain flares.
Analysis 2.5
Analysis 2.5
Comparison 2 Different radioisotopes (data as published), Outcome 5 Final quality of life.
Analysis 3.1
Analysis 3.1
Comparison 3 Samarium dose‐comparison (data as published), Outcome 1 Pain relief.
Analysis 3.2
Analysis 3.2
Comparison 3 Samarium dose‐comparison (data as published), Outcome 2 Change in pain.
Analysis 3.3
Analysis 3.3
Comparison 3 Samarium dose‐comparison (data as published), Outcome 3 Analgesia consumption.
Analysis 3.4
Analysis 3.4
Comparison 3 Samarium dose‐comparison (data as published), Outcome 4 Fracture.
Analysis 3.5
Analysis 3.5
Comparison 3 Samarium dose‐comparison (data as published), Outcome 5 Compression of spinal cord.
Analysis 3.6
Analysis 3.6
Comparison 3 Samarium dose‐comparison (data as published), Outcome 6 Pain flares.
Analysis 3.7
Analysis 3.7
Comparison 3 Samarium dose‐comparison (data as published), Outcome 7 Leucocytopenia III‐IV.
Analysis 3.8
Analysis 3.8
Comparison 3 Samarium dose‐comparison (data as published), Outcome 8 Thrombocytopenia III‐IV.
Analysis 3.9
Analysis 3.9
Comparison 3 Samarium dose‐comparison (data as published), Outcome 9 Anemia III‐IV.
Analysis 3.10
Analysis 3.10
Comparison 3 Samarium dose‐comparison (data as published), Outcome 10 Death.
Analysis 4.1
Analysis 4.1
Comparison 4 Radioisotopes versus placebo (ITT worst case), Outcome 1 Pain relief.
Analysis 4.2
Analysis 4.2
Comparison 4 Radioisotopes versus placebo (ITT worst case), Outcome 2 Less or equal analgesia consumption.
Analysis 5.1
Analysis 5.1
Comparison 5 Radioisotopes versus placebo (ITT control group rate), Outcome 1 Pain relief.
Analysis 5.2
Analysis 5.2
Comparison 5 Radioisotopes versus placebo (ITT control group rate), Outcome 2 Less or equal analgesia consumption.
Analysis 6.1
Analysis 6.1
Comparison 6 Sensitivity: adjuvant radiotherapy, Outcome 1 Pain relief.
Analysis 6.2
Analysis 6.2
Comparison 6 Sensitivity: adjuvant radiotherapy, Outcome 2 Final pain.
Analysis 6.3
Analysis 6.3
Comparison 6 Sensitivity: adjuvant radiotherapy, Outcome 3 Less or equal analgesia consumption.
Analysis 7.1
Analysis 7.1
Comparison 7 Sensitivity: low risk of bias trials, Outcome 1 Pain relief.
Analysis 7.2
Analysis 7.2
Comparison 7 Sensitivity: low risk of bias trials, Outcome 2 Reduction in pain.
Analysis 7.3
Analysis 7.3
Comparison 7 Sensitivity: low risk of bias trials, Outcome 3 Less or equal analgesia consumption.
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References

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