Palliative Care Delivery Systems and Integration With Palliative Care Teams

Abstract

Radiotherapy (RT) plays a critical role in the palliation of symptoms in patients with advanced or metastatic cancer. To address the growing need for these services, multiple dedicated palliative RT programs have been established. This article serves to highlight the novel ways in which palliative RT delivery systems support patients with advanced cancer. Through early integration of multidisciplinary palliative supportive services, rapid access programs facilitate best practices for oncologic patients at the end of life.

Introduction

RT has played an integral role in the care of patients with advanced cancer for over a century. Previous literature suggests anywhere between 30%−50% of RT courses are delivered with palliative intent.^1–3 Advancements in systemic therapy have lengthened patient life expectancy. In turn, the field of palliative RT has gained considerable visibility within the oncologic community for its role in symptomatic relief or functional improvement. As such, the need for palliative RT services has increased exponentially. To meet this growing need, dedicated outpatient and inpatient palliative RT programs have been developed around the world.^4,5 The article will provide an overview of how various palliative care delivery systems have risen to meet the needs of a unique patient cohort. Dedicated palliative radiotherapy delivery systems have taken various forms to meet the needs of advanced cancer patients, including those that provide: (1) rapid access to outpatient evaluation for and delivery of palliative RT; (2) rapid multidisciplinary evaluation of specific complex palliative RT presentations; (3) comprehensive clinical services providing clinical team-based inpatient and outpatient palliative RT evaluation and management; and (4) the use of advance practice providers for palliative RT care coordination. Their collective published experience highlights the critical role that dedicated palliative RT delivery systems can play in meeting the urgent and complex needs inherent to this patient population. This will be followed by a discussion of how palliative care specialists can be integrated into the workflow of radiation oncologists (ROs) and the broader oncologic team to optimize care at end of life.

Palliative Radiotherapy Care Delivery Systems

Table 1 summarizes the various types of clinics initiated with the goal to improve palliative care services. In 1996, the first outpatient rapid access palliative RT program was developed at the Odette Cancer Center in Toronto, Ontario, Canada.^6,7 The Rapid Response Radiotherapy Program (RRRP) was established due to long wait times for symptomatic patients with advanced or metastatic cancer. When appropriate, patients were scheduled for consultation, simulation and treatment all on the same day. In Canada, after active cancer treatment is completed, medical oncologist may refer patients back to his or her family practitioner (FP).⁸ The FP may then manage and coordinate supportive services among other palliative care needs. When surveyed, less than half of patients at the RRRP felt their FP was actively involved in their cancer care and less than a third had a follow up appointment scheduled. When patients perceived their FP to be involved in their cancer care, there was increased satisfaction with the FP.⁸ The FP often has a well-established relationship with the patient and can provide easily accessible, personalized care for those often too sick to travel far distances. Given these findings, the RRRP sought to improve communication and ensure continuity of care by sending the consultation report to the referring physician and FP.^8,9 The FP may re-refer the patient back to the RRRP when necessary.⁷

Table 1.

Evidence-Based Methods for Improving the Quality of Palliative Care Within Radiation Oncology and for Integrating Specialty Palliative Care

Systems for Quality Palliative Care within Radiation Oncology	Description of Model	Example Program/Citations
Rapid Access Outpatient Clinics	Same day consultation, simulation and radiation treatment for palliation of symptomatic metastases	Rapid Response Radiotherapy Program (RRRP), Odette Cancer Center, Toronto, Ontario, Canada6–9 Palliative Radiation Oncology (PRO) Clinic, Cross Center Institute, Edmonton, Alberta, Canada10–13
Multidisciplinary Specialty Palliative Clinics	Rapid multidisciplinary evaluation for site specific palliative radiotherapy, e.g. brain, bone and thoracic cancers	Brain metastases clinic, University of North Carolina at Chapel Hill, North Carolina, USA14 Rapid Access Bone Metastasis Clinic, MD Anderson Cancer Center, Houston Texas, USA15,16 Vancouver Rapid Access Clinic, BC Cancer Agency for the North, Vancouver, Canada17,18
Comprehensive inpatient and outpatient palliative radiotherapy services	Inpatient and outpatient consult services provide comprehensive and cost effective cancer care for those in need of palliative radiation	Palliative Radiation Oncology (PRO), Lubeck, Germany19 Palliative Radiation Oncology Consult service, Mount Sinai, NewYork, USA20,21 Palliative inpatient radiotherapy service, University of Pennsylvania, Pennsylvania, USA Inpatient Radiation Oncology Consult Service (IROC), MSKCC, NewYork, USA
Use of an advanced practice clinicians for palliative care coordination	Implementation of advanced providers can address gaps in care and expedite radiation treatment planning	Palliative Advanced Practice Radiation Therapists, Ontario Canada & Brisbane Australia22–24 Consultant Radiographer25–27
Systems for Integration of Specialty Pall Care Within Radiation Oncology	Description of Model	Examples/Citations
Palliative care tumor boards	Multidisciplinary tumor board discussion provides forum for discussion of difficult patient cases and facilitates transition of care from inpatient to outpatient settings	Palliative Oncology Tumor Board (POTB), Penn Medicine. Lancaster General Health, Pennsylvania, USA28 Palliative and Supportive Oncology Tumor Board, Mount Sinai, New York, USA29
Joint palliative care/radiation oncology evaluation	Integration of palliative care and radiation services increases rates of palliative care referrals, advanced care planning discussions and improves patient selection for cancer treatment and results in reduction of care costs	Radiotherapy and Palliative Care (RaP) clinic, Meldola, Italy30 Supportive and Palliative Radiation Oncology Program (SPRO), Dana-Farber/Brigham and Women’s Cancer Center, Boston, USA31–33 Palliative RT Clinic, Tom Baker Cancer Center, Calgary, Canada34 Palliative Care Clinic, Chandigarh, India35
Patient reported outcomes with triggers to prompt palliative care referrals	Integration of patient reported outcome into electronic medical record quickly refers those in need of services to the palliative care team leading to fewer end of life hospitalizations and	CARE Track Palliative Care Team, University of Virginia, Virginia, USA36

Similarly, in 2007, the Palliative Radiation Oncology (PRO) clinic was established at the Cross Center Institute in Edmonton, Alberta, Canada. Initially designed to treat patients with symptomatic bone metastases, the program expanded its scope in 2009 to include patients with brain metastases.^10,11 In both settings, typical clinic day included consultation with a RO or nurse practitioner (NP), simulation and treatment, if appropriate. The implementation of a NP allowed for 58% more patients to be seen in consultation, expanding access to those who need urgent treatment for symptomatic bone metastases. No differences were noted between the RO and NP assessments regarding symptom severity, performance status and decision pertaining to the need for RT for symptomatic bone metastases.¹²

An innovative component of the PRO clinic allows for additional evaluations from specialist and supportive services while patients wait for RT. Patients meet with a clinical pharmacist who provides recommendations for optimization of analgesia, screening for opioid toxicity and side effect management. Based on other identified needs, patients can receive evaluations from occupational therapy, a registered dietician or social work.^10,11 Social work placed referrals for supportive counseling, addressed financial concerns related to medications, coordinated transportation for treatment or home services and facilitated end of life planning.¹³ Specialist referrals to orthopedics, neurosurgery, neurology, medical oncology, or palliative care can also be placed^10,11 Importantly, at the end of the clinic day, patients were provided written materials summarizing the recommendations of all team members. At 4 week follow up, patients reported improvements in pain, fatigue, anxiety and overall well-being.¹³

Not surprisingly, the multidisciplinary needs of patients with bone and brain metastases were found to differ.¹¹ Many patients in the brain metastasis clinic were on corticosteroids that were managed by the RO rather than a clinical pharmacist. Patients with bone metastases were more likely to see an occupational therapist to obtain adaptive equipment whereas those with brain metastases more often consulted with a registered dietician for weight loss and poor appetite. Patients with brain metastases were less likely to see a social worker as compared to those with bone metastases, which authors concluded was due to poorer prognosis.¹¹

Multidisciplinary Specialty Palliative Clinics

Given the complex needs of this patient population, outpatient clinics centered on rapid multidisciplinary evaluation for palliative RT were developed. In 2012, a dedicated brain metastasis clinic was established at The University of North Carolina at Chapel Hill for patients with breast cancer.¹⁴ This multidisciplinary clinic allows patients to be seen by RO, medical oncology, and neurosurgery on the same day. Similarly to the PRO clinic in Alberta, a needs assessment is performed for additional supportive services, including palliative care, physical therapy, psychiatry, and nutrition.¹⁴ These services are offered either through referral or same day consultation. In addition to multidisciplinary care, this program highlights the unique opportunity for clinical trial enrollment. For patients who did not have the clinical trial therapies available locally, the program facilitates transition of care. As a result, one-third of patients seen in the clinic were enrolled on a trial. For those who were previously receiving care locally, patients were then transitioned back to their local oncologist at their discretion at completion of trial participation.¹⁴

The implementation of the NP role within a multidisciplinary rapid access clinic to improve patient access to care is also described at the MD Anderson Cancer Center (MDACC) Rapid Access Bone Metastasis clinic (RABC).^15,16 Patients seen in the RABC were evaluated on the same day by RO and orthopedic surgery.¹⁵ While the NP did not see consultations independently, roles included patient triage, coordination of multidisciplinary teams, initiation of insurance approval and imaging scheduling. Use of a NP navigator decreased time from consultation to treatment and increased the incidence of same day treatment.¹⁶ When compared to patients not seen in the RABC, patients reported significantly less out of pocket costs which most often associated with longer travel distance for treatment.¹⁵

While the utility of rapid access clinics has been established for management of bone and brain metastases, the Vancouver Rapid Access (VARA) clinic was developed in 2011 at the BC Cancer Agency for the North in Vancouver, Canada in response to the complex needs of patients with newly diagnosed metastatic lung cancer.¹⁷ In this setting patients were most commonly treated with RT to the bone, lung, and brain. A goal of the program was not only to expedite care of patients with advanced lung cancer, but to optimize the quality of care they received. Prior to program development, patients were often urgently double booked on to an already busy clinic schedule. Consequently, given lack of time and resources, only one third of patients were referred to other supportive services. After the development of the VARA clinic, patients were more likely to be referred to the BC Palliative Benefits program, where patients received access to home care services and medication for no cost. Other supportive services included referrals to home care nursing, medical oncology, nutrition, and counseling. Patient could also receive medications for symptom management or referral for a thoracentesis.¹⁸

Comprehensive Inpatient and Outpatient Palliative Radiotherapy Services

The rise of inpatient RO consultation teams has also shown to be an efficient and cost-effective model of care delivery.^19,37,20,21 In Germany, the Palliative Radiation Oncology (PRO) team at Lubeck was established to provide multi-disciplinary palliative care for patients in need of palliative radiotherapy. The team includes radiation oncologists, nurses, physiotherapists, psychologists and social workers and provides full evaluation and support for physical, psycho-social and spiritual needs of inpatients receiving palliative RT from a dedicated team.¹⁹ The Palliative Radiation Oncology Consult (PROC) service established at Mount Sinai Hospital demonstrated a statistically significant decrease in length of hospital stay for treated patients.^37,20 Patients were also more likely to be referred to palliative care services and treated with shorter RT courses. The presence of an inpatient service allowed for PROC team member engagement in multidisciplinary goals of care discussions with patients and families often prior to initiation of RT.^37,20 After the program was established, PROC reported an average per patient savings of approximately $20,000 in hospitalization costs.²⁰ Similarly, the Inpatient Radiation Oncology Consult Service (IROC) at Memorial Sloan Kettering Cancer Center decreased the length of stay by 3.5 days for patients who had indication for RT.²¹ When dedicated inpatient RT services are available, results suggest significant financial savings and decreased healthcare resource utilization.²¹

In addition to care costs and efficiency, dedicated comprehensive palliative radiation oncology services have been found to improve other care quality measures. The Supportive and Palliative Radiation Oncology (SPRO) program at the Dana-Farber/Brigham and Women’s Cancer Center Department of Radiation Oncology. Established in 2011, it was one of the first dedicated inpatient and outpatient palliative RT services in the United States that includes rotating attendings and residents, together with dedicated nurse practitioners and nurses.^31,32 A survey-based study of clinicians’ perceptions of SPRO’s impact on care quality found that the presence of the program was associated with improvements in multiple components of quality palliative cancer care, including time spent with the patient, time to treatment delivery, and use of hypofractionated RT.³² The University of Pennsylvania palliative inpatient radiotherapy service established in 2012 has also demonstrated evidence for palliative radiation oncology care quality improvements.^38,39 Additionally, this service illustrates how a nurse practitioner, or other advance practice provider, can play a critical role by facilitating care coordination within a dedicated palliative radiation oncology service. The service has the NP coordinating both outpatient and inpatient care, including triaging inpatient consult requests and independently seeing consultations with input from the attending physician. Furthermore, the NP facilitates complex coordination of care while patients are receiving RT.^38,39

Advance Practice Providers Providing Palliative Radiation Oncology Care Coordination

Another method for addressing the needs of palliative RT patients is through the implementation of an advance practice provider to coordinate palliative RT patient care. At the University of California, San Francisco, a dedicated inpatient palliative NP was shown to expedite care, allowing more patients to complete simulation the same day as consultation.⁴⁰ In turn this resulted in shorter times to initiation of RT. After a dedicated palliative NP was implemented, inpatients selected for RT had a higher performance status and were more likely to complete their treatment course.⁴⁰ These experiences provide evidence for the utilization of an experienced inpatient advanced practice provider to facilitate better patient care coordination and selection for palliative RT. To address high patient volumes, institutions in Canada, Australia, and the United Kingdom (UK) created an advanced radiation practice provider role. This role has varying levels of autonomy and responsibility but in all experiences, the redistribution of clinical tasks from ROs to advanced providers, clinics can reduce the time from referral to treatment for both patients and their caregivers. In Ontario, Canada, Advanced Practice Radiation Therapists (APRT) complete a 3 phase credentialing process prior to full certification.²² APRTs responsibilities include the delivery of longitudinal, patient-centered care; clinical consultations and decisions in regard to dose/fractionation; participation in continued program evaluation, identification of gaps in clinical practice to be addressed through research; assistance in developing new evidence-based techniques and procedures; and serving as a leader, mentor, and patient advocate. This has shown to have positive impacts in multiple areas including system capacity, quality of care and influence.²² This approach allows ROs to focus on complex cases and simultaneously allows for expedited patient care. Though mostly providing patient care independently, advanced providers work closely with clinical oncologists for continued mentorship and collaboration.

In the UK, the Royal College of Radiologists project a critical shortage of clinical oncologists.²⁵ The advanced radiographer role was created to address this expected gap in cancer care. At Northampton General Hospital, a retrospective review of clinical data showed that patients ≥ 70 years old were more likely to be planned by a radiographer and treated with 8 Gy in a single fraction versus 20 Gy in multiple fractions. In those treated in a single fraction, the median referral to treatment time was 3 days for a radiographer compared to 7 days for a clinical oncologist.²⁶ This data suggests that radiographer-led services can expedite care for those need treatment quickly who may have a shorter life expectancy with minimal inconvenience.²⁶

One UK cancer center performed audits to assess the impact of a RT (PRT) consultant radiographer (CR) who independently consults with and delivers treatment to patients in need of palliative radiation.²⁷ Two locally designed prospective audits were completed 1 year apart in all patients receiving palliative radiotherapy. The most common indication for radiation was a painful bone metastasis. The first audit took place during the CR training period and the second audit occurred when the CR was practicing independently. From audit 1 to audit 2, the proportion of patients with bone metastases planned independently by the CR increased from 14% to 60%.²⁷ The proportion of cases planned by the CR in conjunction with the CCO dropped from 36% to 3%. After the introduction of the CR, the interval from decision-to-treat to the first fraction of radiotherapy within 14 days increased from 73% to 85%.²⁷ Despite lack of statistical significance between the 2 audits, authors concluded that the clinical benefit provided by the CR paid dividends in reducing wait times for care.

Practice patterns in Australia soon followed suit. In Brisbane, a new referral pathway was developed utilizing an APRT improve access to care.^23,24 The old model consisted of a fax referral to the administrative staff which was then handed off to the RO and treatment coordinator. In the new pathway, APRTs become the first point of contact for patient referrals. Relevant patient information was synthesized then triaged as needed to the appropriate RO depending on disease site and availability. The APRT would then coordinate consultation, treatment planning and appointments with the RO. If feasible, the patient would then be treated on the same day.²³ On review of patients who were referred directly to the APRT in comparison to the standard pathway, a significant reduction in the mean wait time from 8.1 to 3.5 days from referral. Additionally, more patients completed treatment with less visits to the department.²³ The role of the APRT was then expanded to include design of RT fields on a digitally reconstructed image. In a subsequent study, this was compared to the RO field definition and blindly evaluated for clinical acceptability.²⁴ Of the 92 designed fields, 85 were deemed clinically acceptable. In sum, the APRT decreased wait times for patients and offload clinic tasks from the RO leading to improved patient workflows.^23,24

Integration With Palliative Care Teams

In 2017, the American Society of Clinical Oncology (ASCO) established guidelines recommending that interdisciplinary palliative care services should be offered early in the disease course and concurrently with treatment in all patients with advanced or symptomatic cancer.⁴¹ The utilization of palliative care services in this patient population, however, remains low, often with referrals occurring late in the disease trajectory.^42,43 In 1 institutional experience, less than half of patients referred for palliative RT also received palliative care services.⁴⁴ Integration of early palliative care has previously been shown to improve both overall survival and quality of life with reduction of aggressive treatment measures when compared to standard care.⁴⁵ Furthermore, the integration of an inpatient palliative care consultation service is associated with significant hospital savings.⁴⁶ When clear treatment goals are established, patients at end of life may avoid overly burdensome medical services that provide minimal benefit and do not extend life expectancy. The next section will discuss how palliative care teams can be incorporated into RO workflows to facilitate best practices for patients at end of life. Methods that have been used and that will be discussed below, include: (1) integration of palliative care onto tumor boards; (2) joint palliative care/radiation oncology clinical evaluations; and (3) patient reported outcome with accompanying triggers to prompt referrals, including to palliative care.

Palliative Care Tumor Boards

A palliative care tumor board, for instance, can bridge gaps in care as patients transition from the inpatient to outpatient setting. It can also provide a forum for providers to discuss complex patient cases. Moreover, data shows that patients have improved clinical outcomes from multidisciplinary tumor board discussion.⁴⁷ Relevant patient cases for presentation include those with symptoms that are difficult to control and challenging social situations or goal of care discussions amongst patients and families.⁴⁸ Attendees should include palliative care, nursing, primary care, social work, and community care (including hospice and home care). Specialists including RO, medical oncology, surgical oncology, radiology, among others could participate as deemed necessary by each patient case. Authors recommend that all patients with palliative care needs ought to be discussed, not just those with cancer. Importantly, palliative care tumor boards should serve as a link between the inpatient wards and community care.⁴⁸

At Penn Medicine Lancaster General Health (LGH), the hematology and oncology team created a palliative oncology tumor board (POTB) to address the needs of hospitalized patients with serious illness who exhibit complex symptom management or psychosocial challenges. A secondary goal was to improve collaboration between inpatient oncology, outpatient oncology and palliative care teams. In their published experience, forty patients were presented at a weekly POTB. Tumor sites included lung, breast, pancreatic and unknown primary. The most common topics discussed included challenging communication with patients and/or family, prognosis, treatment recommendations, involvement of additional team members and transition between inpatient and outpatient settings.²⁸ A review of patient outcomes 30 days after presentation at POTB showed 10 patients were readmitted to the hospital, 4 of which passed away. There were 18 referrals to hospice and 50 new referrals to inpatient palliative care, oncology support services or outpatient palliative care.²⁸

Similarly, the Palliative and Supportive Oncology Tumor Board was developed in 2015 at Mount Sinai Hospital in New York.²⁹ The monthly tumor board was attended by a multidisciplinary team of oncologists, interventional radiologist, pain management specialists, a social worker, palliative care specialists, and trainees. In an effort to discuss complex oncologic patients with refractory symptoms from advanced cancer, this multidisciplinary tumor board facilitated expert consultation within 1 day of presentation. Of the 32 patients presented in a 12-month period, 7 were transferred to the inpatient palliative care service and 5 were readmitted to the hospital within 30 days in the setting of uncontrolled pain.²⁹ The majority of patients had multiple myeloma, gastrointestinal or genitourinary primary cancers. The tumor board was well received by clinicians and fostered interdisciplinary collaboration and comprehensive patient management.²⁹

Joint Palliative Care/Radiation Oncology Evaluation

Favorable outcomes from integration of palliative care services in RO clinics has been well established. At 1 Italian institution, the Radiotherapy and Palliative Care (RaP) outpatient clinic allows for joint patient assessments from a RO and palliative care physician.³⁰ For patients in whom RT was not indicted, patients were considered for home care or hospice. Follow up analysis showed that of the 260 patients evaluated in clinic, 142 had died, of which 67% were in either hospice or with home care.³⁰

As part of the SPRO service developed in 2011, shared evaluation of palliative cases by radiation oncology and the specialty palliative care team occurs on a regular basis, with mutual discussion to coordinate an overall plan of care. Furthermore, at the same institution, a spine program was subsequently created to provide weekly multidisciplinary input for patients with spinal tumors,³³ including neuroradiology, orthopedics, neurosurgery, RO, medical oncology and palliative care. The presence of palliative care specialists aided in group clinical decision making, symptom management and facilitated goals of care discussions when needed. For instance, increased consideration was placed on use of alternative treatment options such as steroid injections and intrathecal catheter placement. This also allowed for a significant number of direct referrals for palliative care services to be made.³³

The Palliative RT Clinic at the Tom Baker Cancer Center in Calgary Canada developed an outpatient multidisciplinary brain metastases clinic in 2011 to allow for integrated assessments by palliative care, RO, a spiritual care patient counseling consultant and allied health professionals.³⁴ Goals of care and advanced care planning discussions were initiated in over half of patient encounters. For patients initially deemed suitable for RT, 9% died within 30 days of the first fraction and 1% died within 14 days. This represented a decrease from historical controls of 19 and 6%, respectively. Of the 25 patients who did not receive RT, 10 passed away within 30 days of initial consultation.³⁴ When a multidisciplinary palliative approach is used, there can be improvements in patient selection for fitness for treatment.

In the Department of Radiotherapy, Postgraduate Institute of Medical Education and Research (PGIMER) in Chandigarh, India, a palliative care clinic was established to overcome the perceived gap in accessibility to these services for patients with advanced cancer.³⁵ The clinic consisted of a physician trained in palliative care, nurse and volunteers working in conjunction with a RO. While there were no differences in the identification of pain or dyspnea among the RO and the palliative care team, cachexia, constipation, and bed sores were more commonly identified by the palliative care team. Over two-thirds of patients evaluated by the palliative care team required pain management despite previous treatment. By the third follow up visit, half of patients reported a 75%−100% improvement in pain relief.³⁵

Patient Reported Outcomes with Triggers to Prompt Palliative Care Referrals

When in person or joint consultations are not feasible, the use of electronic patient reported outcome (PRO) based monitoring can facilitate integration of palliative care. At the University of Virginia, a novel program was developed to deliver palliative stereotactic body radiation therapy (SBRT) to painful bone metastases.^49,50,36 In this setting, simulation, treatment planning, quality assurance and initial treatment delivery are all completed on the same day. Patients deemed eligible for the program were treated in 1–5 fractions with high rates of satisfaction.^49,50,36 Interestingly, a patient-reported outcomes (PRO) database was incorporated into the electronic medical record which triggered alerts to a comprehensive assessment and rapid evaluation and treatment (CARE Track) palliative care team.³⁶ When compared to non-CARE Track patients, those who engaged with the palliative team were more likely to receive hospice care, had fewer end of life hospitalizations and hospital deaths with over $7000 in care costs saved in the last 90 days of life.³⁶

Conclusion

To meet the urgent, complex needs of palliative RT patients, dedicated clinical systems have been successfully implemented with various formats depending on the primary clinical needs they are addressing. Delivery systems included rapid access outpatient clinics within radiation oncology, multidisciplinary outpatient clinics for complex palliative RT presentations, comprehensive palliative radiation oncology services addressing inpatient and outpatient palliative radiation oncology care, and advance practice providers coordinating palliative patient care. Each of these formats have demonstrated mechanisms to address the needs of specific patients referred for palliative RT and are informative as models for the development of systems to address the unique clinical needs of this population of patients. Furthermore, methods of integrating palliative RT care with specialty palliative care have been successful, including through the creation of palliative oncology tumor boards, through radiation oncology/palliative care co-evaluation, and through PRO based triggers for palliative care referrals.

Taken together, the creation of dedicated programs to enhance palliative radiotherapy together with the various mechanisms by which care is integrated between radiation oncology and specialty palliative care provide radiation oncologists with evidence-based formats to systematically improve the quality of care for this patient population. Systems that support expedited, high quality palliative RT for patients with advanced or metastatic cancer together with standardized integration of palliative services into clinical workflows hold promise to meet the many complex needs of this patient population, improving patient satisfaction and quality of life.