# 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
- 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

## 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

## Connected records

- fronts: [Radiation Therapy](https://onco.cc/fronts/radiation/)
- technologies: [IMRT / IGRT (modern external beam)](https://onco.cc/technologies/imrt-igrt/)
- 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/)
- roadmaps: [Radiotherapy roadmap: X-rays → shaped beams → fewer fractions, particles and FLASH](https://onco.cc/roadmaps/radiation-roadmap/)

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