Table 2.

Management of the acute side effects of palliative radiotherapy by organ or tissue

Anatomical site	Side effects	Management	Supporting evidence
Bone	35% of patient in the first week after treatment to bone metastases experience a pain flare. This resolves within a median of 3 days76 77	Oral dexamethasone 8 mg once daily before treatment and for 4 days after, possibly with oral proton pump inhibitor	Rate of flare significantly reduced with dexamethasone (26% v 35%, P=0.05) (RCT, 298 patients)76
Lung	Cough after treatment is not well documented but common in practice	Routinely managed with medication (such as weak opioids)	Limited evidence supporting any specific intervention (SR, 326 patients, 9 studies)78
Mediastinum	Oesophagitis results in odynophagia or dysphagia in 14-22% of treated lung cancer patients (SR)20 21 79 and 28% of oesophageal cancer patients.25 Chest discomfort within the first few weeks after treatment	Antacid mixed with local anaesthetic, simple analgesia, proton pump inhibitors, and soft bland diet. Dietetic referral and enteral feeding maybe required, particularly in patients with compromised swallow before treatment	Recommendation based on a recent literature review as no randomised evidence was identified to inform acute supportive management79
Bowel or stomach	Nausea (such as seen during treatment to bone metastases in 61% or treatment for rectal cancer in 36%)40 80	Antiemetics 30-60 minutes before, during, and after treatment (such as 5-HT3 receptor antagonists)	5-HT3 antagonists reduced emesis compared with conventional antiemetics or placebo (SR of RCTs) and are recommended in international guidelines81 82
	Diarrhoea and abdominal discomfort during treatment for pelvic tumours in 20-40%,39 40 42 resolves within 6 weeks	Loperamide 2-4 mg and hyoscine butylbromide 20 mg as required. If diarrhoea severe (>6 bowel movements daily) or fails to improve within 12 hours, discuss with the treating oncology team	Recommendation based on regional guidelines and palliative prescribing as no randomised evidence identified83 84
Bladder	Dysuria, frequency, and nocturia. During the first few weeks after treatment in 33% and 20% of bladder and prostate cancer patients treated to the primary tumour39 42	Simple analgesia, good fluid intake, and anticholinergic agents are used in routine care. Cranberry capsules can be considered	Recommendation based on regional practise as no randomised evidence identified.85 Four small RCTs investigated role of cranberry supplements; two found reduced cystitis86
Brain	Fatigue	Exercise, as possible, has been shown to reduce fatigue in cancer patients generally	Standardised mean difference in fatigue −0.27 (95% CI −0.37 to −0.17) with exercise (MA, 2648 patients, 38 trials).87 Small RCTs of psycho-stimulants show mixed results in cancer related fatigue (SR).88-90 No evidence in whole brain radiotherapy specifically
	Headache (32%)33	Simple analgesia with dexamethasone 4 mg once daily if persistent	Recommendation based on routine palliative care prescribing84
	Nausea and vomiting (10-16%)	Antiemetics (such as cyclizine) and dexamethasone if persistent	Recommendation based on routine palliative care prescribing84
	Otitis externa (5%)	Otitis externa is often asymptomatic, steroid drops can be used if troublesome	No randomised evidence identified91
Skin	Sunburn-like erythema over treated area, peaks late in treatment and for about 10 days afterwards. Severity is dictated by dose	Daily washing, unperfumed emollient creams or soaps, and non-adhesive dressings. For more severe reactions (with skin breakdown) the treating department should be contacted for advice	Recommendation based on regional guidelines92 93 as no strong conclusions reached in two literature reviews94-96
	Hair loss (most patients undergoing palliative radiotherapy to brain)33 97 98	Wig referral before treatment can be arranged, although timing this can be difficult in the palliative setting	Information and alternative approaches to hair loss are available through a variety of websites99 100
Oral cavity and oropharynx	Oral or pharyngeal mucositis (63%) with pain and thickened secretions.37 Dysphagia (85%)37 and risk of aspiration pneumonia. Side effects peak at the end of treatment to two weeks beyond, then resolve over a month	Oral hygiene, regular mouth washes (such as saline, sodium bicarbonate), topical analgesia or gels, nebulised saline and analgesia (including NSAIDs and opiates in appropriate formulations). Concerns for swallowing safety and nutritional status should be discussed with the treating team	No strong conclusions were reached for the management of existing mucositis in multiple SRs.101-103 Recommendations reflect national and international guidelines.101 104 105 Enteral feeding was required in 12% of patients in one observational UK series68

RCT=randomised controlled trial, SR=systematic review, MA=meta-analysis, NSAID=non-steroidal anti-inflammatory drug.