{"entity":{"id":"idea-acc-single-fraction-palliative-radiotherapy-default","kind":"idea","name":"Single-fraction radiotherapy as the default for painful bone metastases","aka":[],"tldr":"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.","asOf":"2026-09-08","links":[{"label":"Bottleneck evidence (Pain relief and palliative care are unavailable to most): WHO fact sheet, Palliative care","url":"https://www.who.int/news-room/fact-sheets/detail/palliative-care"},{"label":"Dennis et al., Single fraction conventional external beam radiation therapy for bone metastases: a systematic review of randomised controlled trials (Radiotherapy and Oncology 2013)","url":"https://doi.org/10.1016/j.radonc.2012.12.009"},{"label":"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)","url":"https://doi.org/10.1016/j.ijrobp.2015.06.044"},{"label":"Koduri et al., Utilization patterns of single-fraction and short-course radiotherapeutic schedules in the management of bone metastases (Advances in Radiation Oncology 2023)","url":"https://doi.org/10.1016/j.adro.2023.101176"}],"tags":["protocol-upgrade","upgrade:proven-unevenly-used","evidence:strong"],"related":["idea-pu-five-fraction-breast-default","idea-pu-prostate-hypofractionation-default"],"cancers":[],"sections":["radiation"],"technologies":["imrt-igrt","palliative-radiotherapy"],"targets":[],"drugs":[],"companies":[],"institutions":[],"pathways":[],"terms":["bone-metastases"],"trials":["dutch-bone-metastasis-study"],"people":[],"bottlenecks":["b-palliative","b-surgery-radiation-innovation","b-global-access"],"keyPapers":["paper-lutz-pract-radiat-oncol"],"journals":[],"dependsOn":[],"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."],"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.","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","cost":"small","horizonYears":1},"route":"/ideas/idea-acc-single-fraction-palliative-radiotherapy-default/","neighbours":{"idea":[{"id":"idea-pu-prostate-hypofractionation-default","kind":"idea","name":"Four weeks or five treatments, not seven and a half weeks, for prostate radiotherapy","route":"/ideas/idea-pu-prostate-hypofractionation-default/"},{"id":"idea-pu-five-fraction-breast-default","kind":"idea","name":"One week of breast radiotherapy in five treatments as the default after surgery","route":"/ideas/idea-pu-five-fraction-breast-default/"}],"section":[{"id":"radiation","kind":"section","name":"Radiation Therapy","route":"/fronts/radiation/"}],"technology":[{"id":"imrt-igrt","kind":"technology","name":"IMRT / IGRT (modern external beam)","route":"/technologies/imrt-igrt/"},{"id":"palliative-radiotherapy","kind":"technology","name":"Palliative radiotherapy","route":"/technologies/palliative-radiotherapy/"}],"term":[{"id":"bone-metastases","kind":"term","name":"Bone metastases and skeletal-related events","route":"/terms/bone-metastases/"}],"trial":[{"id":"dutch-bone-metastasis-study","kind":"trial","name":"Dutch Bone Metastasis Study","route":"/trials/dutch-bone-metastasis-study/"}],"bottleneck":[{"id":"b-global-access","kind":"bottleneck","name":"Most of the world has almost no cancer care","route":"/bottlenecks/b-global-access/"},{"id":"b-palliative","kind":"bottleneck","name":"Pain relief and palliative care are unavailable to most","route":"/bottlenecks/b-palliative/"},{"id":"b-surgery-radiation-innovation","kind":"bottleneck","name":"Surgery and radiotherapy cure most, get least","route":"/bottlenecks/b-surgery-radiation-innovation/"}],"paper":[{"id":"paper-lutz-pract-radiat-oncol","kind":"paper","name":"Palliative radiation therapy for bone metastases: Update of an ASTRO Evidence-Based Guideline","route":"/key-papers/paper-lutz-pract-radiat-oncol/"}],"roadmap":[{"id":"radiation-roadmap","kind":"roadmap","name":"Radiotherapy roadmap: X-rays → shaped beams → fewer fractions, particles and FLASH","route":"/roadmaps/radiation-roadmap/"}]}}