In patients with metastatic cancers of the prostate, lung and breast, bone metastases are seen in over 85%. In most of these, pain will become a dominant management problem. This pain is often severe and progressive, requiring escalating doses of narcotic analgesics to achieve palliation. Associated symptoms such as depression, anxiety and fear can also erode patients' quality of life. It has been estimated that up to 50% of patients with cancer metastatic to bone have inadequate control of their symptoms. Table 6 outlines strategies that may be used to achieve symptom control.

In patients with multiple sites of pain, recurrent pain in a radiation field or with progressive symptoms, palliation may be achieved by the administration of bone seeking radiopharmaceuticals, of which strontium-89 (Metastron®) is the most commonly used (Table 5). Strontium-89 is a pure |3 emitter with a half life of 50.5 days. Biologically strontium is metabolized by the same pathway as calcium; it is incorporated into the inorganic matrix and the degree of uptake is proportional to osteoblastic activity. There is increased retention of strontium-89 in metastases which show increased uptake of activity on a bone scan—typically there is a ratio of about 10:1 between metastatic lesions and normal bone.

Prerequisites for the use of strontium-89 have been extensively discussed in the literature and are summarized in Table 7. Appropriate patient selection is important to the effectiveness of the treatment. Contraindications to the use of this treatment for pain palliation have been established (Table 8).

Most efficacy data have been published for patients with prostate and breast cancer metastatic to bone, although the therapy has been reported as effective in most primary cancers which have metastases with positive bone scans. Overall response rate is about 75-80% and approximately one-third of these patients become pain free. Responses typically take 7-10 days to develop and are sustained, on average,

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