# Single-fraction radiotherapy as the default for painful bone metastases

Source: https://onco.cc/ideas/idea-acc-single-fraction-palliative-radiotherapy-default/  
OnCo record `idea-acc-single-fraction-palliative-radiotherapy-default` (Idea). Data CC BY-NC 4.0, attribute "Data from OnCo (onco.cc)"; commercial use needs a licence.

## TL;DR

Randomised trials and meta-analyses show a single 8 Gy radiotherapy session relieves pain from uncomplicated bone metastases as well as ten sessions, with a higher retreatment rate, yet habit and per-fraction payment keep most patients on the longer course. Making one session the default, with an opt-out justification and payment neutrality, would spare patients trips and free machines.

## Summary

Multiple randomised trials and meta-analyses show a single 8 Gy fraction is as effective as multi-fraction schedules for pain from uncomplicated bone metastases, with a higher retreatment rate but no difference in overall pain control. Despite guidelines, single-fraction use remains a minority in many countries because of habit and reimbursement. A default protocol with an opt-out justification, plus payment neutrality, would align practice with evidence and release capacity.

## Fields

- Kind: Idea
- Last checked: 2026-09-08
- Tags: protocol-upgrade; upgrade:proven-unevenly-used; evidence:strong
- Hypothesis: Departments adopting single-fraction default will raise single-fraction use for uncomplicated bone metastases above 70% and reduce time to treatment start for palliative referrals, with no change in patient-reported pain response.
- Rationale: The evidence is as strong as any in radiotherapy; the barrier is behavioural and financial, both addressable by policy.
- Proposed test: Audit fraction use, time to treatment, pain response, and retreatment rates before and after policy change across a national network.
- Maturity: being-tested-at-scale
- Actor: clinic

## Notes

- Measured adoption gap: a 2012 audit of bone metastasis radiotherapy in British Columbia found single-fraction use varied from 26 to 73 per cent between regional centres; after the audit data were shown to every radiation oncologist, use rose from 48.0 per cent of courses in 2011 to 59.7 per cent of 3,200 courses in 2013. In a United States health system of 2 academic and 12 community departments, single-fraction treatment rose from 7 per cent of courses in 2016 to 11 per cent in 2020. A systematic review of 24 randomised trials found 8 Gy in a single fraction was the dose given to 84 per cent of single-fraction patients and was superior to 4 Gy.

## Sources

- Bottleneck evidence (Pain relief and palliative care are unavailable to most): WHO fact sheet, Palliative care: https://www.who.int/news-room/fact-sheets/detail/palliative-care
- Dennis et al., Single fraction conventional external beam radiation therapy for bone metastases: a systematic review of randomised controlled trials (Radiotherapy and Oncology 2013): https://doi.org/10.1016/j.radonc.2012.12.009
- Olson et al., Impact of using audit data to improve the evidence-based use of single-fraction radiation therapy for bone metastases in British Columbia (International Journal of Radiation Oncology, Biology, Physics 2016): https://doi.org/10.1016/j.ijrobp.2015.06.044
- Koduri et al., Utilization patterns of single-fraction and short-course radiotherapeutic schedules in the management of bone metastases (Advances in Radiation Oncology 2023): https://doi.org/10.1016/j.adro.2023.101176

## Connected records

- ideas: [Four weeks or five treatments, not seven and a half weeks, for prostate radiotherapy](https://onco.cc/ideas/idea-pu-prostate-hypofractionation-default/), [One week of breast radiotherapy in five treatments as the default after surgery](https://onco.cc/ideas/idea-pu-five-fraction-breast-default/)
- fronts: [Radiation Therapy](https://onco.cc/fronts/radiation/)
- technologies: [IMRT / IGRT (modern external beam)](https://onco.cc/technologies/imrt-igrt/), [Palliative radiotherapy](https://onco.cc/technologies/palliative-radiotherapy/)
- terms: [Bone metastases and skeletal-related events](https://onco.cc/terms/bone-metastases/)
- trials: [Dutch Bone Metastasis Study](https://onco.cc/trials/dutch-bone-metastasis-study/)
- bottlenecks: [Most of the world has almost no cancer care](https://onco.cc/bottlenecks/b-global-access/), [Pain relief and palliative care are unavailable to most](https://onco.cc/bottlenecks/b-palliative/), [Surgery and radiotherapy cure most, get least](https://onco.cc/bottlenecks/b-surgery-radiation-innovation/)
- key papers: [Palliative radiation therapy for bone metastases: Update of an ASTRO Evidence-Based Guideline](https://onco.cc/key-papers/paper-lutz-pract-radiat-oncol/)
- roadmaps: [Radiotherapy roadmap: X-rays → shaped beams → fewer fractions, particles and FLASH](https://onco.cc/roadmaps/radiation-roadmap/)

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