Prompt Pain Relief From Bone Metastases: The Virtual Simulation Program

Abstract

Purpose: Rapid pain relief for patients with bone metastases can be a challenge due to the lengthy and complex radiation therapy workflow. The purpose of this study was to evaluate the time (in days) between initial radiation oncology consultation and start of palliative radiation treatment after implementing an alternative virtual simulation palliative workflow.

Methods and materials: Patients meeting strict criteria were selected for virtual simulation, which included only those with painful bone metastases who were recommended palliative radiation therapy using standard anterior-posterior/posterior-anterior or opposed lateral fields. A recent (within 30 days) diagnostic computed tomography (CT) scan clearly visualizing the target volume was required for treatment planning. For comparison, a reference group of 40 consecutive patients with bone metastases who underwent in-person CT simulation before virtual simulation implementation was reviewed.

Results: Forty-five patients were treated for painful bone metastases as part of the virtual simulation program from May 2021 to October 2022. Regarding travel distance, 23 patients lived locally (<50 miles from the treatment center) and 22 patients were distant (≥50 miles from the treatment center). Average time from consultation to treatment for all patients undergoing virtual simulation was 3.7 days, compared with 7.5 days for patients undergoing in-person CT simulation (3.8 days sooner, on average; P ≤ .001). Before full implementation of the virtual simulation program, 5 eligible patients participated in a virtual simulation pilot from April 2021 to May 2021, in which each patient was contoured and planned on both a pre-existing diagnostic CT scan and a standard CT simulation scan. For virtual simulation-based plans, the average V90, V95, and V99 were 99.99%, 99.87%, and 96.70%. No significant planning target volume (PTV) coverage difference was found on subsequent in-person CT simulation scans.

Conclusions: The virtual simulation program decreased the time from consultation to start of treatment by more than 50% for patients recommended palliative radiation therapy for painful bone metastases. This benefit was most significant for outpatients traveling ≥50 miles for treatment. Virtual simulation-based planning can be considered for patients anxious to proceed with radiation therapy quickly or in underserved settings with limited transportation options to regional treatment centers.

Figure 1

Standard palliative treatment workflow relative to time (in days) and staff stress levels. *Treatment planning includes initiation of treatment planning (simulation image upload into planning software), physician contouring, draft prescription, dosimetry beam placement, physician review, and physics quality assurance.

Figure 2

Pilot dosimetric validation demonstrating comparable target dose coverage. Left: virtual simulation; center: in-person computed tomography simulation; and right: virtual simulation plan superimposed on in-person computed tomography simulation image.

Figure 3

Impact effort matrix, which categorizes palliative workflow sources of delay by intervention potential.

Figure 4

Time-based outcomes depicted on box plots comparing planning based on virtual simulation (VS) and in-person computed tomography simulation (CTS). Average time from consult to treatment for all VS patients was 3.7 days, compared with 7.5 days (P < .001) for all standard in-person CTS patients. Average time from initiation of treatment planning to start of treatment for all VS patients was 3.3 days, compared with 4.5 days (P = .06) for all CTS patients.