Palliative radiotherapy: Evolving role and policy challenges

Radiotherapy remains a key modality in the palliation of advanced malignancy managing both local primary tumour effects such as pain and bleeding as well as the sequelae of metastatic disease. Its role continues to evolve in line with advances in radiation technology, which have facilitated dose escalation and reduced toxicity. Injudicious use of such advancements has the potential to magnify the cost of delivering palliative radiotherapy without achieving significant gains in terms of outcomes, and therefore well-designed trials to assess the clinical efficacy are essential. From a policy perspective a key concern remains the heterogeneity in dose fractionation schedules currently utilised internationally which lack a strong evidence base and may be influenced by reimbursement policy that incentivises longer, more complex and less cost-effective schedules. International consensus is required on study end-points in palliative radiotherapy research to enable comparison between case series and facilitate randomised controlled trial design. Patient reported outcome measures should be developed that capture the value of radiation treatment for different indications both in achieving symptom control but also improving quality of life. The timing and appropriate use of radiation therapy are generally guided by the clinical assessment of the radiation oncologist, once a referral has been made. An analysis of outcomes from national-level epidemiological studies has the potential to guide appropriate utilisation and identify those patients most likely to derive benefit from radiotherapy in different tumour types. Lastly education and training remain at the heart of reducing inequalities in access to radiotherapy for patients who would benefit. This includes both radiation oncologists for whom many training schemes do not prioritise palliative care and the wider multidisciplinary team who are involved in the management of cancer patients at all stages. (C) 2016 Elsevier Ltd. All rights reserved