Palliative radiotherapy for advanced malignancies in a changing oncologic landscape: guiding principles and practice implementation

Palliative radiotherapy has provided a cornerstone of symptom management for patients with advanced and metastatic cancer for more than 100 years (1). Since shortly after the discovery of the X-ray in 1896, clinicians have been utilizing radiotherapy to help patients to manage bothersome symptoms of advanced cancer, including pain and bleeding. The ability to palliate symptoms of advanced cancer that were deeper than skin or bone improved dramatically with the advent of megavoltage radiation in the 1950s and 1960s, allowing radiation therapy to penetrate deeper and provide relief from symptoms not previously well palliated with kilovoltage irradiation, including neurologic symptoms from brain metastases (2) and obstructive symptoms from visceral tumors. By the 1960s, clinicians had outlined certain principles of palliative radiotherapy that were distinct from the principles of “curative” or “definitive” radiotherapy: namely, that the provision of radiotherapy delivered for its palliative effect mandated minimization of side effects, consideration of patient convenience and consideration of cost (3). In addition, there was increasing recognition that radiation oncologists must provide palliation in the context of therapies provided by other clinicians, including chemotherapy, surgery, pharmacologic symptom management, and anesthesiology and other interventional procedures