Rationale: Cancer induced bone pain (CIBP) as a result of bone metastases strongly interferes with quality of life and daily functioning of patients with advanced cancer. The current standard of care for patients with painful bone metastasis includes palliative external beam radiotherapy (EBRT). While EBRT is a well-established treatment option, it takes up to 4-6 weeks for EBRT to induce optimal pain relief, and 30-40% of patients do not respond to EBRT. Pain palliation may be improved by including magnetic resonance image guided high intensity focused ultrasound (MR-HIFU) as alternative or in addition to EBRT.~Study design: The FURTHER study is a multicenter, three-armed randomized controlled trial, performed in six hospitals in four European countries, all of which are partners in the FURTHER consortium. The UMC Utrecht is coordinating center. A total of 216 patients with painful bone metastases will be randomized in a 1:1:1 ratio to receive EBRT only, MR-HIFU only, or EBRT followed by MR-HIFU.~Study population: The study will be performed in male and female adult (≥ 18 years) cancer patients capable of giving informed consent, who were referred to the department of radiation oncology for treatment of painful bone metastases (pain score on Numerical Rating Scale (NRS) ≥ 4).~Intervention: The intervention under study is MR-HIFU alone or in combination with EBRT. The intervention is aimed at rapid and persistent relief of CIBP. The intervention will be compared with standard treatment EBRT.~Main study endpoints: Primary outcome of the trial will be pain response at 14 days after completion of the treatment. Secondary outcomes include pain response at 14 days after inclusion, and pain scores, toxicity, adverse events, quality of life and survival in the first 6 months after treatment, and cost-effectiveness of the treatments.
The FURTHER study aims to evaluate the effectiveness and cost-effectiveness of MR-HIFU (alone or in combination with EBRT) compared to EBRT alone, the standard-of-care, as a palliative treatment option to relieve CIBP. This multicenter, three-armed randomized controlled trial will be performed in six hospitals in four European countries, and will include a total of 216 patients with painful bone metastases.