COST-EFFECTIVE APPLICATION OF RADIOTHERAPY IN PALLIATIVE CARE: A NARRATIVE REVIEW WITH FOCUS ON LOW-INCOME COUNTRIES
Main Article Content
Keywords
Palliative radiotherapy; Bone metastases; Hemostatic radiotherapy; Superior vena cava syndrome; Hypofractionation; Cost-effectiveness; Low- and middle-income countries; Global oncology; Resource-constrained settings
Abstract
Background: Radiotherapy (RT) is one of the most effective modalities for palliation of cancer-related symptoms, especially in conditions such as painful bone metastases, malignant bleeding, and superior vena cava syndrome (SVCS). In low- and lower-middle-income countries (LIC/LMICs), where resources are constrained, hypofractionated palliative RT schedules provide a cost-effective means to deliver rapid symptom relief while maximizing machine capacity.
Objective: This review explores the application of cost-effective RT regimens for common palliative indications and compares approaches across different country settings.
Methods: A narrative review of literature was conducted using PubMed, Scopus, and Web of Science databases (2015–2025), along with guidelines from ASTRO, IAEA DIRAC data, and WHO reports. Relevant studies, guidelines, and national reports were synthesized to highlight evidence-based regimens, delivery adaptations, and global access patterns. Country-wise comparative data on RT availability and utilization for palliative care were tabulated for selected LIC/LMICs.
Results: For bone metastases, single-fraction RT (8 Gy × 1) provides equivalent pain relief to multi-fraction regimens, with reduced patient burden and higher system efficiency. Hemostatic RT (8 Gy × 1, 20 Gy × 5, or 30 Gy × 10) offers rapid bleeding control in gastrointestinal, genitourinary, and gynecologic cancers. In SVCS, endovascular stenting provides the fastest relief, but RT remains an effective option in settings without interventional radiology, particularly for radiosensitive tumors. Country-wise comparisons demonstrate disparities in machine density, workforce, and access, underscoring the role of simplified, hypofractionated schedules as an immediate solution.
Conclusion: Palliative RT, when delivered with cost-effective, hypofractionated schedules, represents one of the highest-value cancer care interventions in LIC/LMICs. Wider adoption of evidence-based single- or short-course regimens, supported by national policy and workforce training, can expand access, reduce costs, and improve quality of life for patients.
References
2. Lutz S, Balboni T, Jones J, et al. Palliative Radiation Therapy for Bone Metastases: An ASTRO Evidence-Based Guideline. Pract Radiat Oncol. 2017;7(1):4–12.
3. Rades D, Stalpers LJ, Veninga T, et al. Evaluation of Single-Fraction Versus Multiple-Fraction Radiotherapy for Painful Bone Metastases: Results From a Randomized Trial. J Clin Oncol. 2016;34(6):628–635.
4. Foro Arnalot P, Fontanals AV, Galceran JC, et al. Randomized Clinical Trial With Two Palliative Radiotherapy Schedules in Painful Bone Metastases: 8 Gy Single Fraction Versus 20 Gy in 5 Fractions. Radiother Oncol. 2008;89(2):150–155.
5. van der Linden YM, Lok JJ, Steenland E, et al. Single Fraction Radiotherapy is Efficacious: A Further Analysis of the Dutch Bone Metastasis Study Controlling for the Influence of Retreatment. Int J Radiat Oncol Biol Phys. 2004;59(2):528–537.
6. Hartsell WF, Scott CB, Bruner DW, et al. Randomized Trial of Short- Versus Long-Course Radiotherapy for Palliation of Painful Bone Metastases. J Natl Cancer Inst. 2005;97(11):798–804.
7. Dennis K, Wong K, Zhang L, et al. Palliative Radiotherapy for Bone Metastases: Update of an ASTRO Evidence-Based Guideline. Pract Radiat Oncol. 2024;14(2):85–98.
8. Mitera G, Probyn L, Earle CC, et al. Outcomes of Single-Fraction vs Multiple-Fraction Radiotherapy for Bone Metastases: Population-Based Study. Radiother Oncol. 2019;137:70–75.
9. Vassiliou V, Kalogeropoulou C, Plataniotis GA. Hemostatic Radiotherapy for Advanced Cancer Patients: Review of the Literature. World J Radiol. 2023;15(6):137–145.
10. Kouloulias V, Plataniotis G, Vavatsiklis M, et al. Hypofractionated Radiotherapy for Bleeding Control in Advanced Malignancies. Clin Transl Oncol. 2020;22(8):1332–1338.
11. Vavassori A, Jereczek-Fossa BA, Santoro L, et al. Hemostatic Radiotherapy in the Management of Bleeding in Advanced Cancer Patients: A Prospective Study. Tumori. 2012;98(2):e45–e50.
12. Spencer K, Cocks K, Bezjak A, et al. Patient-Reported Outcomes in Palliative Radiotherapy: EORTC and International Consensus. Lancet Oncol. 2014;15(7):e286–e294.
13. Fairchild A, Pantarotto J, Ball D, et al. International Patterns of Practice in Palliative Radiotherapy for Bone Metastases: A Survey of the International Atomic Energy Agency. Int J Radiat Oncol Biol Phys. 2009;75(5):1501–1510.
14. Stevens MJ, Hoskin P, Blomgren H, et al. Palliative Radiotherapy in the Era of Resource Constraints: Recommendations from ESTRO. Clin Transl Radiat Oncol. 2021;28:28–34.
15. Lutz ST, Chow E, Hoskin P, et al. Updated International Consensus on Palliative Radiotherapy Endpoints. Radiother Oncol. 2018;126(3):556–564.
16. Bezjak A, Tu D, Seymour L, et al. Symptom Improvement After Palliative Radiotherapy for Patients with Lung Cancer: A Systematic Review. J Clin Oncol. 2002;20(7):1378–1386.
17. Simone CB, Wildt B, Lock M, et al. Palliative Radiotherapy for Bleeding Tumors: Evidence-Based Review. Ann Palliat Med. 2020;9(4):2826–2835.
18. Nieder C, Pawinski A, Dalhaug A, et al. Symptom Relief Following Palliative Radiotherapy of Bleeding Tumors: Predictive Factors. Strahlenther Onkol. 2013;189(9):745–749.
19. Wilson LD, Detterbeck FC, Yahalom J. Superior Vena Cava Syndrome With Malignant Causes. N Engl J Med. 2007;356:1862–1869.
20. Schraufnagel DE, Hill R, Leech JA, Pare JA. Superior Vena Caval Obstruction. Medicine (Baltimore). 1981;60(2):115–128.
21. Lanciego C, Chacón JL, Julián A, et al. Endovascular Stenting as the First Step in the Overall Management of Malignant Superior Vena Cava Syndrome. AJR Am J Roentgenol. 2001;177(3):585–593.
22. Rowell NP, Gleeson FV. Steroids, Radiotherapy, Chemotherapy and Stents for Malignant Superior Vena Cava Obstruction: A Systematic Review. Clin Oncol (R Coll Radiol). 2002;14(5):338–351.
23. Yu JB, Wilson LD, Detterbeck FC. Superior Vena Cava Syndrome – A Proposed Classification System and Algorithm. J Thorac Oncol. 2008;3(8):811–814.
24. Armstrong BA, Perez CA, Simpson JR, Hederman MA. Role of Irradiation in the Management of Superior Vena Cava Syndrome. Int J Radiat Oncol Biol Phys. 1987;13(4):531–539.
25. Rosenzweig KE, Braman SS, Rusch VW, et al. Palliative Thoracic Radiotherapy for Lung Cancer: Evidence and Controversies. Clin Lung Cancer. 2004;5(3):202–208.
26. Ferreira BC, Lopes MC. Palliative Radiotherapy: Overview of Techniques and Global Access. Rep Pract Oncol Radiother. 2019;24(4):361–367.
27. Brierley JD, Gospodarowicz MK, Wittekind C (eds). TNM Classification of Malignant Tumours, 8th Edition. Wiley-Blackwell; 2017.
28. International Atomic Energy Agency. Directory of Radiotherapy Centres (DIRAC). Vienna: IAEA; 2024.
29. Atun R, Jaffray DA, Barton MB, et al. Expanding Global Access to Radiotherapy. Lancet Oncol. 2015;16(10):1153–1186.
30. Zubizarreta EH, Fidarova E, Healy B, Rosenblatt E. Need for Radiotherapy in Low and Middle Income Countries – The Silent Crisis Continues. Clin Oncol (R Coll Radiol). 2015;27(2):107–114.
31. Rodin D, Jaffray D, Atun R, et al. The Need to Expand Global Access to Radiotherapy. Lancet Oncol. 2017;18(6):e366–e377.
32. Abdel-Wahab M, Zubizarreta E, Polo A, et al. Global Access to Radiotherapy by 2035: A Lancet Oncology Commission Report. Lancet Oncol. 2015;16(10):1123–1145.
33. International Atomic Energy Agency (IAEA). Radiotherapy in Africa: A Decade of Development. Vienna: IAEA; 2022.
34. Bray F, Ferlay J, Soerjomataram I, et al. Global Cancer Statistics 2020: GLOBOCAN Estimates of Incidence and Mortality Worldwide. CA Cancer J Clin. 2021;71(3):209–249.
35. World Health Organization. Global Report on Cancer: Setting Priorities for National Cancer Control. Geneva: WHO; 2020.
36. Farmer P, Frenk J, Knaul FM, et al. Expansion of Cancer Care and Control in Countries of Low and Middle Income: A Call to Action. Lancet. 2010;376:1186–1193.
37. Pramesh CS, Badwe RA, Bhoo-Pathy N, et al. Priorities for Cancer Research in Low- and Middle-Income Countries: A Global Perspective. Nat Med. 2022;28(4):649–657.
38. Sullivan R, Alatise OI, Anderson BO, et al. Global Cancer Surgery: Delivering Safe, Affordable, and Timely Cancer Surgery. Lancet Oncol. 2015;16(11):1193–1224.
39. Rwagasore E, Niyonsaba E, Murenzi G, et al. Establishing Radiotherapy Services in Rwanda: Lessons Learned and Future Perspectives. ecancermedicalscience. 2021;15:1245.
40. Orem J, Wabinga H. The Role of the Uganda Cancer Institute in Expanding Radiotherapy Services in Sub-Saharan Africa. Infect Agent Cancer. 2016;11:28.
41. Fonn S, Egesah O, Cole DC. Building Capacity for Cancer Care in Africa: Focus on Malawi. ecancermedicalscience. 2020;14:1010.
42. Abdel-Rahman O, Zekri J. Radiotherapy in Mozambique: Challenges and Opportunities. Lancet Oncol. 2020;21(7):e302.
43. Gedefaw A, Abebe M, Worku A, et al. Radiotherapy Services in Ethiopia: Current Status and Future Directions. JCO Glob Oncol. 2022;8:e2100255.
44. Stevens C, Zubizarreta E, Chao M, et al. Radiotherapy for Cervical Cancer in Low-Resource Settings: Clinical Outcomes and Practical Solutions. Clin Oncol (R Coll Radiol). 2017;29(7):453–461.
45. International Atomic Energy Agency. Patterns of Care for Palliative Radiotherapy in Africa. Vienna: IAEA; 2021.
46. Hanna TP, Bartelink H, Mornex F, et al. Global Standards for Palliative Radiotherapy. Radiother Oncol. 2021;156:100–107.
47. Dandekar P, Laskar S, Ghosh-Laskar S. Palliative Radiotherapy in India: Practice Patterns and Challenges. Indian J Palliat Care. 2019;25(2):163–170.
48. Mohanti BK. Challenges in Delivering Palliative Radiotherapy in Developing Countries. Nat Rev Clin Oncol. 2010;7(2):70–74.
49. Sung H, Ferlay J, Siegel RL, et al. Global Cancer Statistics 2020. CA Cancer J Clin. 2021;71(3):209–249.
50. Efstathiou JA, Heunis T, Karas TZ, et al. Task-Sharing in Global Radiation Oncology: A Roadmap for LICs. Lancet Oncol. 2020;21(12):e647–e658.
51. O’Brien M, Whelan T, Mackillop WJ. The Economic Burden of Radiotherapy in Resource-Limited Settings. Clin Oncol (R Coll Radiol). 2018;30(7):410–417.
52. International Agency for Research on Cancer (IARC). World Cancer Report 2020: Cancer Research for Cancer Prevention. Lyon: IARC; 2020.
53. Choudhury A, Gupta T, Jalali R. Palliative Radiotherapy in India: Bridging the Gaps. JCO Glob Oncol. 2020;6:679–681.
54. Ndlovu N. Radiotherapy Treatment in Cancer Control and Its Important Role in Africa. ecancermedicalscience. 2019;13:942.
55. Abdel-Wahab M, Bourque JM, Pynda Y, et al. Global Radiotherapy Availability: An Update 2020. Lancet Oncol. 2020;21(9):e564–e573.
56. Barton MB, Frommer M, Shafiq J. Role of Radiotherapy in Cancer Control in Low-Income and Middle-Income Countries. Lancet Oncol. 2006;7(7):584–595.
57. Sharma DN, Rath GK. Hypofractionated Palliative Radiotherapy in Resource-Constrained Settings. South Asian J Cancer. 2013;2(2):89–92.
58. Teckie S, Wang K, McCloskey SA. Hypofractionated Palliative Radiotherapy: Rationale, Evidence, and Future Directions. Clin Oncol (R Coll Radiol). 2020;32(10):678–687.
59. Bentzen SM. Radiotherapy and Palliative Care: Past, Present, and Future. Lancet Oncol. 2006;7(2):157–164.
60. Laskar SG, Mohanty S, Gupta S, et al. Real-World Outcomes of Palliative Radiotherapy in Advanced Cancer Patients in India. Indian J Palliat Care. 2021;27(3):400–407.
Article Sidebar
Article Details
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
All articles published in JPTCP are licensed under Copyright Creative Commons Attribution-NonCommercial 4.0 International License.
Dr Swarnendu Biswas
MBBS, DA, MD (Radiation Oncology) CCEPC-1 Consultant Radiation Oncology, Ruby Cancer Centre, Kolkata, West Bengal. Reg No- 62775 of WBMC Villa No A7, Santi Green Complex, Daspara Bazar, Mukundapur, Kolkata 152, West Bengal, India
Dr.Pinki Kundu
MBBS, DCH, Consultant Paediatrician Lal Path Lab, Sinthi Branch, Kolkata 700050