Palliative Radiotherapy Utilisation and Outcomes in Low- and Middle-Income Countries: A Scoping Review

Background Palliative radiotherapy is radiation therapy delivered with the primary intent of symptom relief rather than cure. It is used across a range of oncological indications including painful bone metastases, malignant spinal cord compression, superior vena cava obstruction, haemoptysis, haematuria, symptomatic brain metastases, and fungating tumours. Evidence from high-income settings confirms meaningful symptom control and quality of life benefit from well-delivered palliative radiotherapy (Lutz et al., 2011). In low- and middle-income countries (LMICs), the majority of cancer patients present with locally advanced or metastatic disease (Allemani et al., 2018), meaning palliative intent is, in practice, the most common treatment intent in many radiation oncology departments. Despite this, the evidence base on what indications are treated, what fractionation regimens are used, how LMIC practice compares with international guideline recommendations, and what clinical and patient-reported outcomes result is fragmented across single-centre reports and poorly synthesised at a regional or global level. Objectives This scoping review aims to: (1) map the scope and nature of published evidence on palliative radiotherapy utilisation, clinical practice patterns, and patient outcomes in LMICs; (2) describe the cancer sites, indications, patient populations, and study methodologies represented in the literature; (3) characterise the fractionation regimens used for common palliative indications and compare them with current international guideline recommendations (ASTRO Choosing Wisely, NICE NG101, ESTRO consensus); (4) map available evidence on clinical outcomes and patient-reported outcomes following palliative radiotherapy in LMICs; (5) document barriers to accessing and completing palliative radiotherapy in LMIC settings; and (6) identify evidence gaps and priority areas for future primary research. Methods This review follows the methodological framework of Arksey and O'Malley (2005) as refined by Levac et al. (2010) and will be reported in accordance with the PRISMA Extension for Scoping Reviews (PRISMA-ScR). The Population-Concept-Context (PCC) framework defines eligibility. The population includes cancer patients of any age receiving radiotherapy with palliative intent in any LMIC. The concept covers all palliative radiotherapy indications delivered by external beam or brachytherapy. The context encompasses all LMICs as defined by the World Bank income classification. Primary empirical studies of any design are eligible, including retrospective cohorts, prospective observational studies, clinical audits, and practice surveys. Systematic reviews will be used for citation tracking only. Studies from high-income countries with no LMIC data, and studies examining only curative radiotherapy, will be excluded. The following databases will be searched: PubMed/MEDLINE, EMBASE, CINAHL, Global Index Medicus (including AIM, IMEMR, IMSEAR, WPRIM, and LILACS), African Journals Online (AJOL), Web of Science, and the Cochrane Library. The IAEA DIRAC database and relevant WHO, ESTRO, and ASTRO global health publications will be reviewed as grey literature sources. The date range is January 2000 to present. Two independent reviewers will conduct title/abstract and full-text screening using Rayyan or Covidence. Data will be extracted using a standardised, pre-piloted form. Formal quality appraisal will not be conducted, consistent with scoping review methodology. Findings will be synthesised narratively and thematically across palliative indication, tumour site, geographic region, fractionation practice, and outcome domain. A dedicated summary table will compare documented LMIC fractionation regimens against current international guideline benchmarks. Expected Outputs This review will produce the first comprehensive map of palliative radiotherapy evidence from LMIC settings. Outputs will include a peer-reviewed scoping review manuscript (target journals: Radiotherapy and Oncology, Clinical Oncology, BMC Palliative Care, or JCO Global Oncology), an OSF preprint, a conference abstract for ASTRO or AORTIC, and a palliative radiotherapy fractionation brief for LMIC radiation oncology departments. This work is part of the UCH Ibadan Radiation Oncology Research Programme 2025-2026, Department of Radiation Oncology, University College Hospital, Ibadan, Nigeria. References Allemani C, Matsuda T, Di Carlo V, Harewood R, Matz M, Niksic M, et al. Global surveillance of trends in cancer survival 2000–14 (CONCORD-3): analysis of individual records for 37,513,025 patients diagnosed with one of 18 cancers from 322 population-based registries in 71 countries. Lancet. 2018;391(10125):1023–1075. Arksey H, O'Malley L. Scoping studies: towards a methodological framework. International Journal of Social Research Methodology. 2005;8(1):19–32. Chow E, van der Linden YM, Roos D, Hartsell WF, Hoskin P, Wu JS, et al. Single versus multiple fractions of repeat radiation for painful bone metastases: a randomised, controlled, non-inferiority trial. Lancet Oncology. 2014;15(2):164–171. Levac D, Colquhoun H, O'Brien KK. Scoping studies: advancing the methodology. Implementation Science. 2010;5:69. Lutz S, Berk L, Chang E, Chow E, Hahn C, Hoskin P, et al. Palliative radiotherapy for bone metastases: an ASTRO evidence-based guideline. International Journal of Radiation Oncology Biology Physics. 2011;79(4):965–976. Tricco AC, Lillie E, Zarin W, O'Brien KK, Colquhoun H, Levac D, et al. PRISMA Extension for Scoping Reviews (PRISMA-ScR): checklist and explanation. Annals of Internal Medicine. 2018;169(7):467–473.