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Clinical Implementation of Simulation-Free Palliative Radiation Therapy: Consensus Recommendations From a Modified
Melissa O'Neil1, Vivian S Tan2,3, Thilo Schuler4,5
1Department of Radiation Therapy, London Health Sciences Centre, London, Ontario, Canada.
Advances in Radiation Oncology
|February 18, 2026
Summary
Simulation-free radiation therapy (sim-free RT) expedites palliative care by using diagnostic scans for treatment planning. Expert consensus provides guidance for its safe implementation in palliative radiation therapy (PRT) practice.
Area of Science:
- Medical Physics
- Radiation Oncology
- Radiotherapy Technology
Background:
- Simulation-free radiation therapy (sim-free RT) leverages diagnostic CT scans, bypassing traditional simulation CTs for treatment planning.
- This approach aims to streamline palliative radiation therapy (PRT) and improve resource allocation.
- Standardized guidelines are lacking, hindering widespread adoption of sim-free RT.
Purpose of the Study:
- To establish expert consensus on clinical, technical, and educational aspects of sim-free RT implementation in PRT.
- To develop evidence-based recommendations for integrating sim-free RT into palliative care settings.
Main Methods:
- A modified Delphi process involving international experts in sim-free RT (radiation oncologists, medical physicists, radiation therapists).
- Multiple survey rounds assessing agreement on 12 domains related to sim-free RT.
- Consensus defined as ≥75% agreement, with strong support at ≥90%.
Main Results:
- Consensus reached on 95% of statements, with strong support for sim-free RT in low-risk palliative sites using conventional fractionation.
- Key prerequisites include high-quality recent diagnostic scans, rigorous quality assurance, and multidisciplinary oversight.
- Limited agreement exists regarding the use of older scans, cervical spine targets, and advanced planning techniques (IMRT/VMAT).
Conclusions:
- Expert consensus provides recommendations for the safe implementation of sim-free RT in palliative radiation therapy.
- Identified suitable indications, workflow safeguards, and training requirements for sim-free RT.
- Further dosimetric validation and evaluation in diverse settings are necessary to support broader adoption.
