Bone metastasis Management Radiotherapy for persistent or recurrent pain Consider re-treatment in patients with persistent or recurrent pain for > 1 month following external beam radiation therapy to symptomatic, peripheral bone metastases, while adhering to normal tissue dosing constraints described in the available literature. B General principles Provide multidisciplinary management to patients with metastatic bone disease, drawing from relevant expertise in radiation therapy, orthopedic surgery, radiology and palliative care medicine. B Indications for bone-targeted therapy Initiate bone-targeted therapy at diagnosis of metastatic bone disease, and continue such therapy indefinitely throughout the course of the disease. B Choice of antiresorptive agent Use zoledronic acid as the most effective bisphosphonate for prevention of morbidity from metastatic bone disease. B Use denosumab as a more effective alternative to zoledronic acid for prevention of skeletal morbidity from solid tumours. B Indications for radiotherapy Q Does the patient have localized bone pain due to bone metastasis? No Continue management with bone-targeted therapy and follow-up as clinically appropriate. Yes Offer radiotherapy as the treatment of choice for palliation of localized bone pain. B Dosing of radiotherapy For patients with previously unirradiated painful bone metastases, high-quality data shows equivalent pain relief between a single 8 Gy fraction, 20 Gy in 5 fractions, 24 Gy in 6 fractions, and 30 Gy in 10 fractions. Inform patients that single fraction radiotherapy is associated with a higher incidence of retreatment to the same painful site than is fractionated treatment. A Stereotactic body radiation therapy Consider advanced radiation therapy techniques like stereotactic body radiation therapy as the primary treatment for painful spine bone lesions or for spinal compression in the setting of a clinical trial or data registry. B