Real-world implementation of simulation-free radiotherapy (SFRT-1000): A propensity score-matched analysis of 1000 consecutive palliative courses delivered in routine care.

Abstract

The feasibility of simulation-free radiotherapy (SFRT) has been demonstrated but information regarding its routine care impact and scalability is lacking. METHODS: In this single institution retrospective cohort study, all patients receiving palliative radiotherapy (RT) at an XXX tertiary cancer centre were eligible for consideration of SFRT unless mask immobilisation, a stereotactic technique, or a definitive dose was indicated. Co-primary endpoints were SFRT utilisation, impact on consultation-to-RT time and on-couch treatment duration. Timing metrics were compared to a contemporary local cohort that received simulation-based palliative RT using unadjusted Wilcoxon rank-sum tests and a propensity score-matched regression. Electronic patient-reported outcomes (ePROs) captured 2-week toxicity and pain response. RESULTS: Between April 2018 and February 2024, 2849 palliative radiation courses were delivered, of which 1904 were eligible. 1000 of the 1904 courses (52.5% SFRT utilisation) received SFRT, including 668 using IMRT/VMAT. 788 individual patients received SFRT and the median age was 71 years (IQR 61 - 80) with 59% being male and 42% being ECOG 2-4. SFRT utilization increased from 41% to 54% between years 2018-19 and 2022-24. SFRT reduced median consultation-to-RT time from 7.0 to 5.1 days (p<0.0001) corresponding to an adjusted average treatment effect in the treated (aATT) of -2.1 days (95%CI -2.8 to -1.3). SFRT increased median on-couch treatment duration from 17.8min to 20.5min (p<0.0001; aATT 2.6min, 95%CI 1.3 to 3.9). PRO-CTCAE grade 3 acute toxicity was 9% and at 4 weeks post RT patients with moderate/severe pain at baseline (≥ 5/10) had a mean pain reduction of 3.5 points (7.1 to 3.6; p<0.0001). CONCLUSIONS: Using widely available technologies the SFRT-1000 cohort demonstrates routine care scalability with patient-centred and workflow benefits. SFRT is an attractive new paradigm implementable in most settings following adaptation to local requirements. Thus, SFRT opens new avenues to potentially improve access to palliative RT, which remains a global area of need.