Palliative radiation oncology in pediatric patients

Radiation therapy (RT) provides an effective and often rapid means to alleviate symptomatic progression in pediatric patients with advanced or metastatic cancer. As part of a comprehensive, multimodality approach to pediatric palliative care, RT can be a useful tool to manage pain, spinal cord compression, dyspnea, neurologic compromise, bleeding, and bowel or urinary obstruction. Whether such symptoms present earlier in the disease course or in children and adolescents approaching the end of life, they can significantly impact the quality of life of patients and caregivers. Control of symptoms is therefore an important aspect in maximizing end of life care. Outcomes for palliative RT in both children and adults are favorable. While RT has been widely adopted as a component of palliative oncologic care for many adult malignancies, it remains infrequently utilized in pediatric patients despite the relative radiosensitivity of many pediatric tumors. Potential barriers to palliative radiation for pediatric patients include insufficient understanding by care providers regarding the utility of RT for a given symptom, lack of comfort in discussing a transition away from definitive management, concern over radiation-related side effects, and hesitancy toward radiation treatment on the part of parents and caregivers. Delivery of palliative RT can also be impeded by logistical obstacles including lack of on-site radiation facilities, unavailability of radiation oncologists comfortable with pediatric treatments, and the potential need for specialized medical care such as pediatric anesthesia. The aim of this review is to foster a more complete understanding of the benefits and limitations of palliative RT in the pediatric oncology setting, including common symptoms experienced by children and adolescents with cancer that may be indications for the integration of RT into palliative care paradigms, as well as the expected efficacy of treatment. We describe the logistics, delivery, common doses for palliative radiation regimens, and management of potential side effects. While palliative RT is generally well tolerated in the pediatric population, we also discuss potential side effects of RT to various body sites and approaches for prevention or mitigation.