Home » Oncology » Making the fractions add up: new radiotherapy techniques and the impact of COVID-19
Innovations in Oncology 2020

Making the fractions add up: new radiotherapy techniques and the impact of COVID-19

iStock / Getty Images Plus

Dr Hannah Tharmalingam

Vice President for Clinical Oncology, The Royal College of Radiologists

Radiotherapy is a fundamental oncological treatment, playing a critical role in both curative and palliative cancer care.


Side effects occur as a result of radiation to normal tissue close to tumour targets. To minimise these effects, treatment has conventionally been delivered in small daily doses, termed “fractions”, over multiple weeks to allow normal tissue to recover.

New delivery of radiotherapy

However, innovative developments in four-dimensional planning systems and advances in image-guidance have resulted in techniques, such as stereotactic ablative body radiotherapy (SABR)., which allows for far more precise local delivery of radiation, better sparing adjacent normal tissue and delivering much larger daily dose fractions.

Curative radiotherapy for prostate cancer, for example, can now be “hypofractionated” and delivered over five days as opposed to four weeks, considerably improving the experience for patients and reducing hospital workloads. Substantial evidence supports this, with two large-scale meta-analyses of men treated with SABR for prostate cancer showing excellent cure rates and a favourable side effect profile.1,2

The last six months have consequently seen a rapid uptake of highly innovative changes in radiation oncology that previously may have taken years to implement.

Moreover, concerns around increased toxicity can now be further allayed by the use of other pioneering technologies, such as the hydrogel rectal spacer. This is a biodegradable device inserted directly into the region between the rectum and the prostate to position the former away from high-dose radiation during treatment.

Despite these innovations, widespread uptake of hypofractionation has been slow. A critical limiting factor is an economic model where radiotherapy services are financially reimbursed per fraction, disincentivising the adoption of shorter regimes and stereotactic techniques.

How coronavirus has accelerated uptake

Paradoxically, however, it may be that the COVID-19 pandemic has a long-lasting positive impact in this respect. The urgent need to reduce patient footfall through radiotherapy departments has significantly accelerated the adoption of evidence-based hypofractionated radiation. Concurrently, the NHS payment model has been temporarily changed to a “block” tariff where centres are reimbursed for a course of radiotherapy, irrespective of treatment fraction numbers or type.

The last six months have consequently seen a rapid uptake of highly innovative changes in radiation oncology that previously may have taken years to implement. It is hoped that this paradigm of “forced agility” due to coronavirus may ultimately be a key driver in equitable access to high-quality radiotherapy for all cancer patients in the future.


1Kishan AU, Dang A, Katz AJ et al. Long-term outcomes of stereo-tactic body radiotherapy for low-risk and intermediate-risk prostate cancer. JAMA Netw Open 2019;2:e188006
2 Jackson WC, Silva J, Hartman HE, et al. Stereotactic body radiation therapy for localized prostate cancer: A systematic review and meta-analysis of over 6,000 patients treated on prospective studies. Int J Radiat Oncol Biol Phys 2019;104:778-789.

Next article