The aim of this study was to determine if magnetic resonance-guided focused ultrasound (MRgFUS) is cost-effective compared with medication, for refractory pain from bone metastases in the United States.

We constructed a Markov state transition model using TreeAge Pro software (TreeAge Software, Inc., Williamstown, MA, USA) to model costs, outcomes, and the cost-effectiveness of a treatment strategy using MRgFUS for palliative treatment of painful bone metastases compared with a Medication Only strategy (Figure 1). Model transition state probabilities, costs (in 2018 US$), and effectiveness data (quality-adjusted life-years [QALYs]) were derived from available literature, local expert opinion, and reimbursement patterns at two U.S. tertiary academic medical centers actively performing MRgFUS. Costs and QALYs, discounted at three percent per year, were accumulated each month over a 24-month time horizon. One-way and probabilistic sensitivity analyses were performed.

In the base-case analysis, the MRgFUS treatment strategy costs an additional $11,863 over the 2-year time horizon to accumulate additional 0.22 QALYs, equal to a $54,160/QALY ICER, thus making MRgFUS the preferred strategy. One-way sensitivity analyses demonstrate that for the base-case analysis, the crossover point at which Medication Only would instead become the preferred strategy is $23,341 per treatment. Probabilistic sensitivity analyses demonstrate that 67 percent of model iterations supported the conclusion of the base case.

Our model demonstrates that MRgFUS is cost-effective compared with Medication Only for palliation of painful bone metastases for patients with medically refractory metastatic bone pain across a range of sensitivity analyses.

There is abundant evidence of the comparative efficacy of single-fraction (SF) radiotherapy and multi-fraction (MF) radiotherapy when treating patients with bone metastases. Despite this, previous surveys have shown SF schedules to be underutilised.

To determine current patterns of practice in patients with bone metastasis and to investigate the factors that influence practice.

An electronic audit was performed amongst 46 physicians, within 7 hospital trusts in the UK. The audit comprised of four hypothetical cases in which consultants and registrars chose which dose and fractionation they would recommend and their reasons for this recommendation.

SF radiotherapy was the most common radiotherapy schedule in hypothetical cases 1, 3 and 4. SF radiotherapy was recommended by 65% of respondents in case 1, 47% in case 2, 89% in case 3 and 46% in case 4. For case 2, 50% proposed MF radiotherapy. For case 4, 22% of respondents recommended Stereotactic Body Radiotherapy (SABR). The following deciding factors were cited as influencing choice of an SF schedule: prognosis, published evidence, performance status and spinal cord compression.

The most common radiotherapy schedule selected was SF. However, there were inter-institution differences regarding the use of SF radiotherapy. Furthermore, the survey had shown that a third of respondents recommended an MF regime, despite evidence supporting the efficacy of an SF schedule.

Meta-analyses demonstrate single-fraction radiotherapy to be as effective as multi-fraction treatment in palliating painful bone metastases, although surveys suggest reluctance in prescribing single fractions.

Assess the factors influencing the choice of dose-fractionation regimen in an unselected population; examine retreatment rates and subsequent skeletal events.

Data were extracted from case notes for 120 patients treated in 2000 and 2006 in a single centre serving a defined population; analysis used χ2 and Fisher's exact statistical tests.

An 8 Gy fraction was the commonest regimen prescribed (single-fraction delivery rate 53·6%). Tumour site was a significant factor in choice of dose-fractionation schedule. Patients with metastatic breast carcinoma were significantly less likely to receive single-fraction treatment compared with those with metastatic lung carcinoma (year 2000: p = 0·038, 2006: p = 0·001). There was a significantly higher retreatment rate following single-fraction compared with multi-fraction treatment (11% versus 3%). There were two subsequent neural axis compressions and four pathological fractures.

Single-fraction treatment is the commonest regimen but multiple fractions are still frequently delivered. Better prognosis groups appear more likely to receive multi-fraction treatment, possibly to avoid the need for retreatment. Subsequent skeletal events are rare but carry high morbidity when they occur.