It has been speculated that the geographical variation among

It has been speculated that the geographical variation among radiotherapy prescription is a function of the respective healthcare systems within each region. If physicians receive greater reimbursement for multiple fractions compared to a single fraction, they will likely have greater willingness to ignore guidelines and prescribe a longer course. Lievens et al. [47] confirmed this about 20 yuan in a study published in 2000. The authors investigated reimbursement methods and their relation to the delivery of different radiotherapy dose fractionation schedules in Western Europe. Payment methods included case payment, where a department is reimbursed per patient or per case, and fee-for-service, where each individual service performed (i.e., planning, fixation, treatment) is reimbursed separately [47]. The authors found that countries that employ a case payment method of remuneration (Spain, Netherlands, and the United Kingdom) also more frequently prescribe SFRT. In contrast, countries such as Germany that reimburse physicians using a fee-for-service method have a greater prescription of MFRT [47]. These results are consistent with those found in our review. The privately funded health care system most prevalent in the United States might also explain the increased prescription of MFRT; radiation oncologists will be paid more by private insurance companies for prescribing protracted courses of treatment. The international under-prescription of SFRT may also be related to inadequate knowledge translation and communication; if physicians are unaware of the most recent evidence for various dose fractionation schedules, patients will not be receiving those recommended treatments [48]. In this way, it is crucial that the dissemination of knowledge is a priority among all physicians and cancer organizations. It is only through this that all patients will be able to receive the best standard of care. Furthermore, this review focuses only on conventional radiation therapy. With the advent of new technology, guidelines and practice must be continuously revisited and adjusted appropriately. Stereotactic body radiation therapy (SBRT), which allows for the delivery of radical doses of radiation to oligometastatic disease with great precision [49], is particularly useful for patients with prolonged survival, radioresistant tumors, or those receiving re-irradiation [50–52]. Guidelines for practice for SBRT are much different than those for conventional radiotherapy. Future studies investigating patterns of practice in this setting would be beneficial.
Conclusions
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Acknowledgments