We developed a predictive score system for 30-day mortality after palliative radiotherapy by using predictors from routine electronic medical record. Patients with metastatic cancer receiving first course palliative radiotherapy from 1 July, 2007 to 31 December, 2017 were identified. 30-day mortality odds ratios and probabilities of the death predictive score were obtained using multivariable logistic regression model. Overall, 5,795 patients participated. Median follow-up was 39.6 months (range, 24.5-69.3) for all surviving patients. 5,290 patients died over a median 110 days, of whom 995 (17.2%) died within 30 days of radiotherapy commencement. The most important mortality predictors were primary lung cancer (odds ratio: 1.73, 95% confidence interval: 1.47-2.04) and log peripheral blood neutrophil lymphocyte ratio (odds ratio: 1.71, 95% confidence interval: 1.52-1.92). The developed predictive scoring system had 10 predictor variables and 20 points. The cross-validated area under curve was 0.81 (95% confidence interval: 0.79-0.82). The calibration suggested a reasonably good fit for the model (likelihood-ratio statistic: 2.81, P = 0.094), providing an accurate prediction for almost all 30-day mortality probabilities. The predictive scoring system accurately predicted 30-day mortality among patients with stage iV cancer. oncologists may use this to tailor palliative therapy for patients.Many patients with metastatic cancer receive oncological treatment, and radiotherapy (RT) is an important component of palliative treatment 1 . RT can be an effective tool for palliation of symptoms arising from cancer, including pain from bone metastases or neurological compromise from brain or spinal metastases with cord or nerve root compression. The aim of palliative RT is to alleviate symptoms and improve quality of life. Evidence has shown that palliative RT was received by approximately 10% of patients who died of cancer near their end of life 2,3 . In one population-based study that included 15,287 patients who received RT in the last month of life, 17.8% received more than 10 days of treatment 4 . This finding corroborates with a German study which showed 50% of patients spent more than 60% of remaining 30 days of life receiving RT 4 .RT can be delivered via different dosing regimens (e.g., single fraction on one day versus multiple fractions for weeks) 5-9 . The use of multi-fractionation (split up the total dose into small fractions) is often perceived to be associated with less long-term complications and need for retreatment 4 . While larger fraction size by single-fractionation theoretically has an increased risk of late-onset radiation toxicity. Beside radiobiological consideration, medical training and experience, departmental policies, and insurance reimbursement all influence the decision on the dose-fractionation regimens. Use of hypofractionation or single fractionation is associated with a perceived poor prognosis by the oncologist. Protracted courses of RT can become considerable demand and burden on termina...

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