Towards Active Use of Palliative Radiotherapy
in cancer treatment

Recommendations

Japanese Society for Radiation Oncology
Alliance for Cancer Treatment

Recommendations
Towards active use of palliative radiotherapy in cancer treatment[Abstract]
Palliative radiotherapy, a type of cancer radiation therapy, aims to maintain and improve
patient's QOL, including ① relieving cancer-specific pain and ② reducing the various
symptoms that cancer causes.
・ Palliative radiotherapy is effective in reducing and alleviating various symptoms
associated with the progression of cancer, such as pain associated with bone metastasis, and
it is desirable to spread and establish it not only from the viewpoint of improving the patient's
QOL, but also from the viewpoint of effective utilization of medical resources. However, in
our country, it is not sufficiently utilized compared with western countries, and the numberof palliative radiotherapy cases is also small.
・ Major factors why palliative radiotherapy is not prevalent include: ① inadequate
coordination between medical institutions for diagnosis and treatment of bone metastases in
the community; ② lack of a multi-professional coordination system for diagnosis andtreatment of bone metastases in the hospital; ③ inadequate knowledge of palliative
radiotherapy by general physicians involved in cancer treatment; ④ low number of radiation
oncologists (specialists); and ⑤ poor opportunities for the public to obtain correct
information on palliative radiotherapy.
・ In this paper, several measures are proposed so that palliative radiotherapy can be used
more actively in the future. The three main areas are as follows:(1)Strengthening collaboration among healthcare professionals (①strengthening
collaboration in regional healthcare system and ② setting up a cancer board specializing inbone metastases).
(2)Training medical personnel such as physicians (improvement of awareness andunderstanding of medical professionals regarding palliative radiotherapy.)(3)Proactive public enlightenment (educating the public in hospitals, providing information
through the media and patient groups, school education)
・ We would like the stakeholders to refer to these specific measures and actively cooperate
in order to utilize palliative radiotherapy further in our country.
1

(Introduction)
Radiotherapy has become one of the major treatments for cancer as well as surgery andanticancer drug therapy. 1 However, in our country, it is not sufficiently utilized incomparison with western countries. 2 In particular, palliative radiotherapy, which is used torelieve symptoms such as pain, has a very low level of awareness among not only patients
but also healthcare professionals.
Palliative radiotherapy can be expected to improve patient’s quality of life, including
relieving pain caused by bone metastases and improving dyspnea caused by lung cancer.
This also improves patient's activities of daily living (ADL) and reduces family burden. Thus,
if palliative radiotherapy is actively utilized, it will not only be beneficial for patients andfamilies, but will also help to reduce the increase in healthcare expenditures throughout thecountry and contribute to the efficient use of healthcare resources. 3 4
For this reason, in this paper, specific measures for the active utilization of palliative
radiotherapy will be proposed, with particular emphasis on palliative radiotherapy for pain
associated with bone metastasis, in order to summarize the current status and challenges ofpalliative radiotherapy. 5

1. What is Palliative Radiotherapy -The Purpose and Extent of Therapy
Radiotherapy, one of the three major treatments for cancer, can be classified for its
therapeutic purposes into two major types: (a) radical radiotherapy and (b) palliative1

In recent years, new therapies, such as molecular targeted agents, have also emerged, and thestrategies involved in cancer treatment have changed significantly, but radiotherapy, surgicaltherapy, and anticancer drug therapy have remained the key pillars of cancer treatment.

2

The utilization rate of radiotherapy is considered to be 50-60% in Europe and the UnitedStates, whereas it is only half that in Japan, which is less than 30%. And the growth of thepatient number of the radiotherapy utilization is low, when it is compared with the increase rateof the whole cancer patient in our country in recent years.
3

Bone metastases, which can occur in any type of cancer, markedly reduce the patient's QOL,
including causing pain and symptoms such as fractures, paralysis, and hypercalcemia.

4

Abbreviation of Activities of Daily Living. It refers to basic activities essential for daily
life, such as eating, dressing, transferring, excreting, and bathing.

5

Although significant progress has been made in the treatment of cancer in the field of radical
irradiation in recent years with high-precision radiotherapy, palliative irradiation, which isaddressed in this paper, has also been able to contribute significantly to reducing distress andimproving QOL in cancer patients, and further expansion is expected in the future.

2

radiotherapy.
(a)Radical radiotherapy, like its name, aims to cure cancer (or long-term survival ofpatients) and often delivers large doses of radiation to the affected area to kill the cancer.
On the other hand, (b) palliative radiotherapy is mainly aimed at ① relieving pain caused
by cancer itself and ② maintaining and improving patient' s QOL, such as reducing various
symptoms caused by cancer (table below). These palliative treatments have also greatly
helped to make patients more susceptible to continuing their primary cancer treatment(radical radiotherapy, anticancer drug administration, etc.) and have been widely utilized
throughout the course of treatment.
Therapeutic purposes
Cure of cancer, long-term survival of patients(a)Radical
radiotherapy(b)Palliative To maintain and improve QOL in reducing pain and otherradiotherapy distress due to cancer progression
Specifically, palliative radiotherapy is used in a variety of ways to improve symptoms
such as difficulties to breathe or swallow food, as well as to reduce pain and numbness (tablebelow).
Main symptoms
Pain and fracture
Numbness, paralysis,
and difficulty walking
Dyspnea
Difficulty swallowing
Visual acuity reduced
Headache, dizziness,
nausea, etc.
Superior vena cava syndrome
Hemorrhage

Major causes and sites (e.g.,)
Bone metastasis
Spinal cord compression associated withbone metastases
Airway stenosis and obstruction caused
by lung cancer
Passage disturbance due to esophageal
cancerOptic nerve compression of perioculartumorsBrain metastases
Lung cancer
Gastrointestinal cancer
Cutaneous metastasis and invasion

Among the palliative treatments for cancer pain listed above, the most common is for pain
associated with bone metastases (painful bone metastases). The outcome is about 70 percent
for pain relief and about 30 percent for pain disappearance, and there is considerably3

favorable results for painful bone metastases. 6

Palliative radiotherapy delivers radiation that is minimally needed to reduce symptoms(rather than eradication of cancer). Therefore, compared with radical radiotherapy, it ischaracterized by shorter treatment duration and fewer side effects, and in some cases reirradiation to the same site is possible. 7
In recent years, attempts have also been made to use stereotactic body radiotherapy (SBRT),a highly accurate radiotherapy, for palliative therapy, and accumulation of future evidence
is desirable.

2. Challenges for the Use of Palliative Radiotherapy
The effectiveness and usefulness of palliative radiotherapy are well known amongradiotherapy specialists, but at present, palliative radiotherapy is not sufficiently utilized in
the treatment of cancer, and the number of procedures is never large.
Various reasons for this lack of widespread use of palliative radiotherapy include: ①
inadequate referral system among medical institutions for diagnosis and treatment of bonemetastases, etc. in the region; ② lack of a multi-professional coordination system fordiagnosis and treatment of bone metastases, etc. in the hospital; ③ insufficient knowledgeof palliative radiotherapy by general physicians involved in cancer treatment; ④ low numberof radiation oncologist (specialists); and ⑤ poor opportunities for the public to obtain correct
information on palliative radiotherapy. 8 96Rich SE, Chow R, Raman S, Liang Zeng K, Lutz S, Lam H, Silva MF, Chow E. Update of thesystematic review of palliative radiation therapy fractionation for bone metastases. RadiotherOncol. 2018 Mar;126(3):547-557.

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In recent years, studies and considerations have been conducted to reduce the number ofpalliative radiotherapy to a greater extent, and the number of patients receiving only a single
dose has also increased. For example, the World Health Organization (WHO) strongly recommends
single-fraction radiation therapy for pain relief in bone metastases, but it has been reported
that a single dose of 8Gy is equally effective compared with multiple doses of 10 doses of 3Gy(gray) (30Gy in total).

8

In addition to the lack of knowledge of patients and physicians other than radiation
oncologists, there are indications of lack of human resources and the uneven distribution ofradiotherapy equipment.

9

The "Basic Plan for the Promotion of Third Stage Cancer Control" was decided by the Cabinet
Council on March 9, 2018 (https://www.mhlw.go.jp/stf/seisakunitsuite/bunya/0000183313.html) to4

(1) Inadequate referral system among medical institutions for diagnosis
and treatment of bone metastases in the region
Even though curative treatments are delivered in the main department, the cancer may
recur and metastasize many years later. Thus, it is of great importance to develop a referral
system of local medical institutions for cancer treatment and palliative radiotherapy. 10 11
For example, it is desirable to be able to request timely from the primary care physician
to designated cancer centers in the regions, when pain possibly caused by bone metastasis
occurs. Especially, in the case of spinal cord compression by bone metastasis, early detectionand early treatment are crucial, and there are not a few cases in which emergency irradiationis required. 12
If medical institutions in the region have a good "face-to-face relations" with which they
may gently consult on a day-to-day basis, it is easier to use radiotherapy equipment in theoutpatients of other hospitals and so on, so radiotherapy including palliative radiotherapy
can be performed in a flexible manner in the region. 13
In order for such diagnosis and treatment including the palliative radiotherapy to beappropriately carried out in the region, it becomes important that the system where
address issues such as the need for further dissemination of knowledge on palliative
radiotherapy.
In addition, as one of the "Comprehensive Research Project for the Promotion of Cancer Control"
based on the plan, "Research for the Evaluation and Dissemination of Palliative Radiotherapy inCancer Treatment" (Japanese Society of Radiation Oncology・Shigematsu group, for 3 years since2019) has been also conducted.
(https://www.mhlw.go.jp/seisakunitsuite/bunya/hokabunya/kenkyujigyou/hojokin-koubo2020/gaiyo/05.html)).
10

In terms of local healthcare delivery systems, there are wide variations in healthcare
professionals, medical institutions and facilities. However, in recent years, various efforts
have accelerated to develop regional healthcare concepts (measures for functional differentiation
and referral system of hospital beds) and regional comprehensive care systems (cooperation toensure comprehensive medical care, nursing care, prevention, housing, and living support in thedaily life area).

11

There has also been a movement toward strengthening regional cooperation regarding cancer
treatment abroad. In the United Kingdom, for example, community family physicians have enhanced
collaboration and improved quality of care by acting as contacts and mediators with cancer
treatment specialists and institutions.

12

In metropolitan areas, the primary medical area is assumed, and in non-metropolitan areas, thesecond medical area is assumed.

13

In medical institutions in the same region, activities such as study groups and interactiongroups provide valuable opportunities for collaboration. After the pandemic coronavirus hasconverged, it is hoped that such exchange opportunities will be increased again.

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information is easily shared among the multi-professionals from the member medical
institutions (① development of consultation and cooperation means, ② sharing of electronic
medical record, ③ online medical care, and ④ securing of transfer means, etc.)(2) There is no multi-professional coordination system in hospital for
diagnosis and treatment of bone metastases, etc.
In the treatment of bone metastasis, appropriate consultation and operation in multiple
medical departments are required, including original cancer treatment, surgery andadministration of bone modifying drugs, and rehabilitation, including embolization andnarcotic use. In addition, because the main department alone may not be able to be aware of
the treatment options of palliative radiotherapy, it is desirable to decide the treatment plan
through a "cancer board specializing in bone metastases" in which many departments andprofessions, such as radiologists, palliative care physicians, and orthopedic surgeons,participate. Then, it is necessary to extensively examine whether drug therapy, radiotherapy,
surgical therapy are appropriate. The ability of radiation oncologists to engage in treatment
decision making from an early stage through a cancer board allows them to provide palliative
radiotherapy with more appropriate timing.
However, such a " cancer board specializing in bone metastases " is set up only about 10%even at the designated cancer control hospitals at present. The main reasons for not having
a cancer board specializing in bone metastases in the hospital are; ① being busy in duty andlack of time and manpower, and ② less interest in bone metastasis. 14(3) Inadequate knowledge of palliative radiotherapy among general
physicians involved in cancer treatment
It is also a challenge that general physicians (other than radiation oncologists) who treat
cancer often do not have adequate expertise in radiation therapy, especially palliative
radiotherapy. 15
In our country, radiation oncologists are rarely the primary physicians of cancer patients,
and according to the site (primary site) where the cancer is first detected, physiciansbelonging to medical departments (primary departments) such as internal medicine and
14

Based on a questionnaire (2016) conducted for 332 designated cancer control hospitals, out of
407, where full-time radiation oncologists work. Of the 136 centers that responded, only 18 (13%of respondents) had a cancer board specializing in bone metastases.

15

The medical professionals such as nurses are also educated mainly on the side effects rather
than on the effects of radiotherapy.

6

surgery are usually the primary physicians.
Then, the treatment and control for radical cure of cancer are mainly carried out by theattending physician, and the drug therapy is often carried out by the attending physician in
the case of the metastasis to other organs. If bone metastases occur, the attending physician
will see the patient. However, if the physician is not necessarily an expert in the field, it isuncommon to refer the patient at the stage where radiotherapy is required. It is notuncommon that by the time the patient comes to consult with the radiotherapy department,
his/her stage is no longer indication for radiotherapy. 16 17
It is necessary for physicians in each department to increase their knowledge andunderstanding of bone metastases and palliative radiotherapy in the future so that analgesic
drug treatment (opioids, etc.) and palliative radiotherapy are one of the first options for pain
relief.

(4) Shortage of radiation oncologists (specialists)
In order to increase the utilization of palliative radiotherapy, it is necessary that there aremany radiation oncologists with expertise and experience who can carry out it appropriately.
However, there is a shortage of such specialists in Japan. There are approximately 850
radiotherapy facilities nationwide, but 1,334 are registered as radiation oncologists (1.06 per
0.1 million population), which is a small number for the number of hospitals (as of
September 2020). 18
Thus, there is a chronic shortage of radiation oncologists, and many institutions have only

16

Radiation oncologists usually provide treatment based on requests from other departments,
making it difficult for radiation oncologists to make early suggestions about the patient's
condition and the need for treatment. It is also said that there is considerable variation in theclinical practice guidelines for "radiotherapy for bone metastases" of each academic society,which raises the hurdle more than necessary for the main department to proceed with radiotherapy.

17

Bone metastases are not painful (asymptomatic) at the time of initial diagnosis and are often
followed up at the discretion of the attending physician. On the other hand, despite theappearance of symptoms such as pain due to spinal cord compression, there are many cases in which
patients are not referred to the radiotherapy department and the appropriate timing of treatment
is missed. Proper diagnosis and determination of indications for treatment by experts are very
important for patients to obtain appropriate timing of palliative radiotherapy.

18

Even in comparison with western developed countries, the number of radiotherapy specialists is
considerably lower. e.g., 5338 in the United States (1.64 per 0.1 million)(https://www.sciencedirect.com/science/article/abs/pii/S1879850020301053)

7

one specialist (so-called "single physician head") in the radiation oncology departments attheir hospital. There are also “blank zones” where no radiation oncologists are located at allin the region or neighborhood, such as east part of Hokkaido, or Okinawa, where there aremany remote islands. 19(5) Poor opportunities for the public to obtain correct information about
palliative radiotherapy
In cancer treatment, radiotherapy is often not informed as an option by the discretion of
the attending physician because the attending physician (the department) decides on thetreatment. However, it is important for patients to raise awareness in advance in order to beable to recognize the symptom of the bone marrow compression, etc. which is the indication
for palliative radiotherapy and to seek medical examination.
The lack of opportunities for the public to obtain correct information about radiotherapy
also hampers the widespread use of palliative radiotherapy. In Japan, in addition to the factthat patients tend to have a negative image of radiotherapy including palliative radiotherapy,
due to the effects of the atomic bomb and nuclear power plant accident, the effectiveness ofradiotherapy for cancer has not been touched on much even in schooling.

3. Recommendations-Toward active use of palliative radiotherapy
As previously mentioned, palliative radiotherapy is one of the effective and usefultherapies for improving QOL in cancer patients, and it is desirable to be utilized moreproactively. 20
In the following, specific measures for the active use of future palliative radiotherapy will
be presented as three important issues, including (1) strengthening collaboration among
healthcare professionals, (2) developing medical personnel, (3) enlightening and publicizing
the public, and (4) others.
We would like the stakeholders to refer to these specific measures and actively cooperate
for the further prevalence of palliative radiotherapy .
19

In these areas, for example, in order to receive postoperative radiotherapy for breastconserving therapy, patients have to visit hospitals in Tokyo or elsewhere far from their places.

20

If palliative radiotherapy becomes more popular, healthcare costs and resources may be used
more effectively and efficiently, such as reducing the use of analgesics such as opioids. In
addition, if cooperation of medical institutions is advanced and palliative radiotherapy isprovided in the region, the work environment of patients and families will improve, and thus theenvironment such as geriatric caring and child rearing will have a favorable effect.

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(1) Strengthening collaboration among healthcare professionals① Strengthening referral system in regional healthcare
The smooth referral with the radiotherapy facilities becomes especially important for thepalliative radiotherapy to be actively utilized in regional medical treatment and home
medical treatment. Appropriate visits and treatment should be made easier by reducing
administrative costs for liaison and coordination among healthcare professionals and thephysical, psychological, and financial burden on patients during transfers.21[Recommendation 1-1] Additional reimbursement fee for Palliative Radiotherapy
Patient’s Referral
Considering the administrative burden of the referring medical institution, it isdesirable that " Additional reimbursement fee for referral" is created. So patients can betransferred more smoothly or treated at other hospitals.22
Enhanced collaboration within these areas not only offers advantages to home doctors
and facilities that do not have radiotherapy equipment, but also allows more patientsfrom outside facilities for the facilities that have radiotherapy equipment, resulting in
the effective use of medical devices such as radiotherapy equipment.
[Recommendation 1-2] Additional reimbursement fee of Palliative Radiotherapy for
Pain Relief in Home-Based Palliative Care
Though " Clinic for Enhanced Home Palliative Care and Clinic and Hospital
Additional fee" becomes very large incentive for the palliative care improvement, thecurrent medical reimbursement is framed with "nursing care" and " pharmacotherapy"
as pillars. For this reason, pharmacotherapy is mainly used to relieve pain. However, it
is desirable to add items related to cooperation with radiotherapy and its outcome to thecalculation requirement of "Clinic for Enhanced Home Palliative Care and Clinic andHospital Additional fee" with a broader target for the point addition.

② Multidisciplinary collaboration within hospitals
21

The introduction of a mechanism to resolve barriers to accessing radiotherapy facilities, suchas① reducing cost burden during patient transfer, ② online consultation with referring medical
institutions, ③ visiting practices by referring physicians, will lead to the promotion of
appropriate visits.
22
In case that there is no hospital bed of the radiation oncology department in the referring
medical institution, and radiotherapy is carried out in the form that the radiation oncology
department treat jointly by taking the hospitalization in the organ-specific medical department,
the hurdle of the radiotherapy hospitalization gets higher.

9For the active use of palliative radiotherapy in the hospital, the promotion of thecooperation between radiation oncologists and other medical doctors becomes important. It
is effective to develop an environment where it is easy for hospitals to set up a cancer board
specializing in bone metastases so that multi-professional cooperation on palliative
radiotherapy can be advanced.
[Recommendation 1-3] Enlightenment to hospitals for the establishment of a cancer
board specializing in bone metastases.
For the prevalence of a cancer board specializing in bone metastases, it is essentialthat academic societies, authorities, and medical professionals cooperate first to actively
promote awareness-raising to hospitals.
[Recommendation 1-4] Additional reimbursement when cancer board specializing
in bone metastases is placed in the hospital
Many designated cancer control hospitals have less cancer boards specializing in bonemetastases, as previously described, for reasons of ① being busy in duty, lack of timeand manpower, and ② less interest in bone metastases. It is desirable to incorporate"establishment and periodic holding of cancer boards specializing in bone metastases
by multiple professionals" in the condition of the evaluation on the medical
reimbursement, and to make clear incentives for the establishment in the hospital.

(2) Training of medical personnel① Improve awareness and understanding of healthcare professionals
regarding palliative radiotherapy
For physicians involved in cancer treatment, knowledge of radiotherapy is essential,
regardless of the specialty department. Therefore, it is necessary to provide continuous
training and information on palliative radiotherapy to clinicians first of all.
[Recommendation 2-1] Obligating the Item of Palliative Radiotherapy in Palliative
Care Training Sessions
Since physicians involved in cancer treatment are required to participate in a
palliative care training session at designated cancer control hospitals, making the subjectof palliative radiotherapy essential in this training would be effective to improveawareness and understanding of palliative radiotherapy.
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Recently, the basic lectures of the training are carried out in e-learning, and since theitem is already prepared as a selection item, it is easy to add it as an essential subject,and early realization is also considered to be realistic.
[Recommendation 2-2] Reference to Single-Dose Delivery of Palliative Irradiation in
Palliative Care Training Session
From the point of view of supporting both employment and treatment of cancer patients,
it is desirable that single-fraction irradiation, which significantly reduces the number ofhospital visits, becomes a more common therapy. Among the subjects of "palliative
radiotherapy" in the above training session, it is desirable to address the significance andmerit 23 of "single dose irradiation" in particular.

② Improving Radiotherapy Related Education for Medical Students andResidents
Further development of radiation oncologists is also mandatory for palliative radiotherapy
to be widely utilized. Therefore, the review of the educational course in the medical school
becomes also important.
As some physicians say, "When I was a student, I didn't know much about bone metastases,
which I address a lot today," more clinically relevant education may also be needed to help
physicians.
[Recommendation 2-3] Enhancement of Radiotherapy Course in Medical School
Education
In the current medical schooling, the lecture and practical training on "radiotherapy"
are not sufficient to meet clinical needs, so it is necessary to improve the education of
the radiotherapy treatment.
[Recommendation 2-4] Increase in the Proportion of Radiotherapy Subjects in the
Physician National Examination
Despite the fact that it has become a significant interest of the public to advanceappropriate cancer treatment and radiotherapy in our country, the questions related to
23 In

addition to securing the patient's employment, the reduction of family burden associatedwith transportation and attendance, and the response to patients with a short life prognosis,
etc.

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radiotherapy accounts for only below 0.5% in the Physician National Examination. And
the content of the questions is mainly on the side effect of radiotherapy, and it becomesthat it does not meet clinical needs.
The number and content of national examinations affect student's interest. It is
expected that increasing the ratio of RT-related questions will allow many medical
students to learn better about the field of radiotherapy.
[Recommendation 2-5] Enhanced participation of residents in a cancer board
specializing in bone metastases
Efforts are needed to incorporate the participation in a cancer board specializing inbone metastases into clinical residency curricula to enable residents to understand andincrease their interest in the role of radiotherapy and radiation oncologists for bonemetastases.

(3) Education and public relations for citizens
The public’s understanding of the effectiveness and usefulness of radiotherapy andpalliative radiotherapy is also not understood well yet. It is very important for the public to
be familiar with radiotherapy, especially palliative radiotherapy, so that they can be accepted
as one of the treatment options for cancer patients and their families.

[Recommendation 3-1] Enlightenment and publicity regarding radiotherapy andpalliative radiotherapy in the hospital
For example, it is said that the importance of early treatment for spinal cord
compression associated with bone metastases is not widely known even among cancer
patients. To begin with, it is desirable to carry out the appropriate enlightenment forpatients in the hospital.
Although some institutions are actively disseminating information, such as placing
unique educational posters created on their own in the hospital, there are limitations ininstitution-based efforts, thus some nationwide actions are required. It is desirable tocollaborate with academic societies and other organizations to develop favorable cases
related to awareness and publicity nationwide in cooperation with local cancer councils
and municipalities.
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[Recommendation 3-2] Enlightenment and publicity regarding radiotherapy andpalliative radiotherapy through the media
As the public’s interest in healthcare-related articles, especially cancer-related articles
is high, it will be fairly effective to continue proactive awareness and dissemination
through the media (including the SNS.)For this purpose, it is important to have major media, medical-specialty media, andmedical journalists correctly understand the effectiveness and usefulness ofradiotherapy and palliative radiotherapy through seminars and workshops.
[Recommendation 3-3] Enlightenment and publicity through patient and support
organizations
In recent years, a large number of cancer patient organizations, support organizations,and joint organizations (such as the National Federation of Cancer Patient Associations
and the NPO Cancer Support Community) have been established, and they are actively
enlightening and disseminating information to patients. It is desirable that healthcare
professionals involved in cancer treatment cooperate more with such organizations toactively raise awareness and disseminate information.
[Recommendation 3-4] Proactive enlightenment of radiotherapy in schooling
In elementary schools and junior high schools, efforts such as cancer education andeducation of life are becoming more common. In this context, the opportunity to touchon the correct knowledge about radiotherapy should be actively increased.

4. Conclusions
Palliative radiotherapy has a great significance from the viewpoint of effective utilizationof medical resources, as well as reduction and relief of various symptoms associated withthe progression of cancer, such as pain associated with bone metastasis, and improvementof the patient's QOL, and is desirable for further utilization and establishment.
However, it is not sufficiently utilized in our country. In addition to healthcare
professionals and related societies, those involved, including administrative authorities andpress agencies, should refer to the recommendations mentioned in this paper, including
specific measures, and should actively cooperate with each other in order to further utilize
palliative radiotherapy in our country.

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5. List of authors and collaborators■Author
Takeo Takahashi
Naoki Nakamura
Atsunori Yorozu

Professor, Department of Radiation Oncology,
Saitama Medical Center, Saitama Medical University
Professor, Department of Radiation Oncology,
St. Marianna University School of Medicine
Director, Department of Radiation Oncology,
National Hospital Organization Tokyo Medical Center■Collaborators
Ryu Kawamorita

Masatoshi Gika

Tomohiro Suzuki
Kiyomi Sumita
Sadamoto Zenda
Tatsuya Takagi
Hisayasu Nagakura
Masato Fushiki
Yoshinori Matsui
Atsushi Matsumoto
Yoshihisa Matsumoto
Misako Miwa

Deputy Director,Department of Medical Technology, Radiology andRadiation Oncology,
Tane General Hospital
Professor, Department of Palliative Medicine, Department of General
Thoracic Surgery,
Saitama Medical Center, Saitama Medical University
Associate professor, Department of Radiology,
Iwate Medical University
Senior Staff, Department of Palliative Medicine,
Shizuoka Cancer Center
Head, Department of Radiation Oncology,
National Cancer Center Hospital East
Department of Medicine for Orthopaedics and Motor Organ,
Juntendo University School of Medicine
Director, Department of Radiology, KKR Sapporo Medical Center
Promotion Office for Cancer Control, Department of Radiation
Oncology, Nagahama City Hospital
Director, Azai-higashi Clinic, Nagahama
Department of Internal Medicine, Misato Kenwa Hospital
Chief, Department of Palliative Medicine,National Cancer Center Hospital East
Director, Department of Radiology, Sendai Kousei Hospital

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6.Reference
P3-6 Rich SE, Chow R, Raman S, Liang Zeng K, Lutz S, Lam H, Silva MF, Chow E. Update of thesystematic review of palliative radiation therapy fractionation for bone metastases. Radiother Oncol. 2018
Mar;126(3):547-557.
Basic Plan for Promotion of P4-9 Cancer Control (Period 3) <March 2018>https://www.mhlw.go.jp/file/06-Seisakujouhou-10900000-Kenkoukyoku/0000196975.pdf
P7-18 James E Bates, Akash D Parekh, Mudit Chowdhary et al. Geographic Distribution of Radiation
Oncologists in the United States. Practical Radiation Oncology. 10 (6) 2020 p436-443

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Towards active use of palliative radiation in cancer radiotherapy
Jan. 2022
Published by
Japanese Society for Radiation Oncology
Alliance for Cancer Treatment
All or any part of this paper is prohibited for unauthorized citation or reproduction.

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