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Cancer care poses a significant economic burden, challenging healthcare budgets to balance patient benefits with affordability. Radiotherapy takes up only a limited part of oncology budgets, but the cost is rarely clear-cut due to influential factors such as complexity of treatments, highly-trained personnel and technologies. Health-economic appraisal is complex and can be performed in several ways, balancing costs and outcomes, but not all approaches are equally suitable for assessment of radiotherapy interventions. The concept of «value-based healthcare» offers a broader perspective to health-economic appraisal, considering various outcomes and the cost of the total cycle of care, thus addressing some of the challenges in radiotherapy: the diversity of interventions, a broad range of outcomes (including organ preservation or local control) and challenges in evidence generation. However, as the existing value-based frameworks in oncology are aimed at systemic therapies, a tailored approach for radiotherapy interventions is necessary to enhance access to innovative care and optimize resource allocation. This article explores the economic aspects of radiotherapy, providing an overview of radiotherapy cost determinants and calculations, discussing different health-economic strategies and value-based healthcare, and how these can address the specific challenges in radiotherapy.

Radiation therapy is one of the core components of multidisciplinary cancer care. Although ~ 50% of all European cancer patients have an indication for radiotherapy at least once in the course of their disease, more than one out of four cancer patients in Europe do not receive the radiotherapy they need. There are multiple reasons for this underutilisation, with limited availability of the necessary resources - in terms of both trained personnel and equipment - being a major underlying cause of suboptimal access to radiotherapy. Moreover, large variations across European countries are observed, not only in available radiotherapy equipment and personnel per inhabitant or per cancer patient requiring radiotherapy, but also in workload. This variation is in part determined by the country's gross national income. Radiation therapy and technology are advancing quickly; hence, recommendations supporting resource planning and investment should reflect this dynamic environment and account for evolving treatment complexity and fractionation schedules. The forecasted increase in cancer incidence, the rapid introduction of innovative cancer treatments and the more active involvement of patients in the healthcare discussion are all factors that should be taken under consideration. In this continuously changing oncology landscape, reliable data on the actual provision and use of radiotherapy, the optimal evidence-based demand and the future needs are crucial to inform cancer care planning and address and overcome the current inequalities in access to radiotherapy in Europe., (© 2020 The Authors. Published by FEBS Press and John Wiley & Sons Ltd.)

Reimbursement is a key factor in defining which resources are made available to ensure quality, efficiency, availability, and access to specific health-care interventions. This Policy Review assesses publicly funded radiotherapy reimbursement systems in Europe. We did a survey of the national societies of radiation oncology in Europe, focusing on the general features and global structure of the reimbursement system, the coverage scope, and level for typical indications. The annual expenditure covering radiotherapy in each country was also collected. Most countries have a predominantly budgetary-based system. Variability was the major finding, both in the components of the treatment considered for reimbursement, and in the fees paid for specific treatment techniques, fractionations, and indications. Annual expenses for radiotherapy, including capital investment, available in 12 countries, represented between 4·3% and 12·3% (average 7·8%) of the cancer care budget. Although an essential pillar in multidisciplinary oncology, radiotherapy is an inexpensive modality with a modest contribution to total cancer care costs. Scientific societies and policy makers across Europe need to discuss new strategies for reimbursement, combining flexibility with incentives to improve productivity and quality, allowing radiation oncology services to follow evolving evidence., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Purpose/objective: Health economic evaluations (HEE) are increasingly having an impact on policymakers, although the results greatly depend on the quality of the methodology used and on transparent reporting. The two main objectives of this study were to evaluate the quality of cost analyses of external beam radiotherapy (EBRT) and to assess the comprehensiveness and relevance of cost criteria defined in three validated quality-assessment instruments., Materials and Methods: The selection of articles was based on a previous systematic literature review of EBRT-costing studies retrieved from January 2004 to January 2015 (Period 1) in MEDLINE, Embase, and NHS-EED databases and completed in a second time period from January 2015 to November 2018 (Period 2). Three validated instruments to assess the methodology quality with the CHEC and the QHES, and the methodology with the CHEERS checklists were used. The quality was evaluated by both quantitative and qualitative analyses. The scoring robustness was examined with the Kendall coefficient of concordance and inter-class correlation coefficients., Results: In total, twenty-three articles were selected. The main geographic areas of cost analyses were Canada (n = 5), France (n = 4), and the USA (n = 4). The most commonly studied pathologies and technologies were prostate (n = 7) and head and neck cancer (n = 5) and IMRT (n = 8) and IGRT (n = 2), respectively. The mean instrument scores demonstrated a fair degree of methodological quality, with 69.7% for the CHEC, 73.6% for the QHES, as well as for the reporting quality, with 59.4% for CHEERS for Period 1 (74.4%, 71.5%, and 66.1%, respectively, for Period 2). An additional qualitative analysis per criterion revealed that certain items, essential for understanding the costing methodology and the results (e.g., the time horizon, discount rate, sensitivity analysis) were often only partially completed. Statistical analysis confirmed that the reviewers' scoring was consistent. The instruments identified the same top three articles, albeit with a degree of variation in the ranking., Conclusion: Qualitative and quantitative assessment of cost analyses in EBRT exhibits a fair level of study quality in terms of the methodology and reporting transparency. The impact of cost calculations on the final HEE result appears to be underestimated, and increased transparency of the data sources and the methodologies is needed., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Background: The Health Economics in Radiation Oncology (ESTRO-HERO) project aims to provide a knowledge base for health economics in European radiotherapy. A cost-accounting model, providing data on national resource requirements and costs of external beam radiotherapy (EBRT), was developed., Materials and Methods: Time-driven activity-based costing (TD-ABC) was applied from the healthcare provider perspective at national level. TD-ABC allocates resource costs to treatment courses through the activities performed, based on time estimates., Results: The model is structured in three layers. The central layer, EBRT-Core, accounts for EBRT care-pathway activities and follows TD-ABC allocation principles. Activities supporting radiation oncology (RO) (RO-Support) and multidisciplinary oncology (Beyond-EBRT) follow standard allocation principles. To demonstrate the model's capabilities, a dataset was constructed for the hypothetical country Europalia, based on published evidence on resources and treatments, whereas time estimates were expert opinions. Applying the TD-ABC model to this example, treatment delivery activities represent 68.4% of the costs; treatment preparation 31.6%. The cost per course shows large variation for different indications, techniques, and fractionation schedules, ranging between €838 and €7193. Resource utilization was estimated to be within the available capacity. Scenario analyses on changes in fractionation and treatment complexity are presented. The ESTRO-HERO TD-ABC tool can model EBRT costs and resource requirements. While the Europalia example illustrates its potential, the results cannot be generalized nor used as a proxy for national evidence. Only real-world data, tailored to the specificities of individual countries, will support National Radiation Oncology Societies with investment planning and access to innovative radiotherapy., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Background: With increasing recognition of growing cancer incidence globally, efficient means of expanding radiotherapy capacity is imperative, and understanding the factors impacting human and financial needs is valuable., Materials and Methods: A time-driven activity-based costing analysis was performed, using a base case of 2-machine departments, with defined cost inputs and operating parameters. Four income groups were analysed, ranging from low to high income. Scenario analyses included department size, operating hours, fractionation, treatment complexity, efficiency, and centralised versus decentralised care., Results: The base case cost/course is US$5,368 in HICs, US$2,028 in LICs; the annual operating cost is US$4,595,000 and US$1,736,000, respectively. Economies of scale show cost/course decreasing with increasing department size, mainly related to the equipment cost and most prominent up to 3 linacs. The cost in HICs is two or three times as high as in U-MICs or LICs, respectively. Decreasing operating hours below 8h/day has a dramatic impact on the cost/course. IMRT increases the cost/course by 22%. Centralising preparatory activities has a moderate impact on the costs., Conclusions: The results indicate trends that are useful for optimising local and regional circumstances. This methodology can provide input into a uniform and accepted approach to evaluating the cost of radiotherapy., (Copyright © 2017 The Author(s). Published by Elsevier B.V. All rights reserved.)

Background: Planning radiation oncology equipment and staffing is necessary in public healthcare systems in Europe., Methods: Three different data inputs were considered: evidence-based indications for radiotherapy, the incidence of cancer, and the stage at diagnosis of each cancer type, both the latter using population-based data from cancer registries. The availability of these data and the implications for the estimation of the proportion of new cancer patients who would need radiotherapy treatment at least once during the course of the disease is reviewed., Results: Depending on the frequency of cancers and the stage at diagnosis, it has been estimated that between 47% and 53% of incident cases among European countries would require external beam radiotherapy. When the actual data of utilization is compared with the evidence-based target, only one country in Europe has achieved full coverage., Conclusion: It is argued that these should be considered the optimal proportions of cancer patients, but a more realistic policy target could be set at 80% or higher of the optimal proportion. This realistic target also takes into account the inherent uncertainties in the assessment of evidence, and other factors that influence clinical decision-making in cases of multi-morbidity or patient preferences. Other factors are associated with problems that should be dealt with in the framework of a cancer plan, such as accessibility, preference bias in physician evaluation of the indication or shortage of resources, and the impact of the reimbursement system. Finally, it is argued that a cancer plan is the framework for achieving policy targets in the appropriate coverage of the evidence-based indications for radiation oncology forecasts.

Radiotherapy costs are an often underestimated component of the economic assessment of new radiotherapy treatments and technologies. That the radiotherapy budget only consumes a finite part of the total cancer and healthcare budget does not relieve us from our responsibility to balance the extra costs to the additional benefits of new, more advanced, but typically also more expensive treatments we want to deliver. Yet, in contrast to what is the case for oncology drugs, literature evidence remains limited, as well for economic evaluations comparing new radiotherapy interventions as for cost calculation studies. Even more cumbersome, the available costing studies in the field of radiotherapy fail to accurately capture the real costs of our treatments due to the large variation in cost inputs, in scope of the analysis, in costing methodology. And this is not trivial. Accurate resource cost accounting lays the basis for the further steps in health technology assessment leading to radiotherapy investments and reimbursement, at the local, the national and the worldwide level. In the current paper we review some evidence from the existing costing literature and discuss how such data can be used to support reimbursement setting and investment cases for new radiotherapy equipment and infrastructure.

Background and Purpose: In planning to meet evidence based needs for radiotherapy, guidelines for the provision of capital and human resources are central if access, quality and safety are not to be compromised. A component of the ESTRO-HERO (Health Economics in Radiation Oncology) project is to document the current availability and content of guidelines for radiotherapy in Europe., Materials and Methods: An 84 part questionnaire was distributed to the European countries through their national scientific and professional radiotherapy societies with 30 items relating to the availability of guidelines for equipment and staffing and selected operational issues. Twenty-nine countries provided full or partial evaluable responses., Results: The availability of guidelines across Europe is far from uniform. The metrics used for capital and human resources are variable. There seem to have been no major changes in the availability or specifics of guidelines over the ten-year period since the QUARTS study with the exception of the recent expansion of RTT staffing models. Where comparison is possible it appears that staffing for radiation oncologists, medical physicists and particularly RTTs tend to exceed guidelines suggesting developments in clinical radiotherapy are moving faster than guideline updating., Conclusion: The efficient provision of safe, high quality radiotherapy services would benefit from the availability of well-structured guidelines for capital and human resources, based on agreed upon metrics, which could be linked to detailed estimates of need., (Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.)

Background: Documenting the distribution of radiotherapy departments and the availability of radiotherapy equipment in the European countries is an important part of HERO - the ESTRO Health Economics in Radiation Oncology project. HERO has the overall aim to develop a knowledge base of the provision of radiotherapy in Europe and build a model for health economic evaluation of radiation treatments at the European level. The aim of the current report is to describe the distribution of radiotherapy equipment in European countries., Methods: An 84-item questionnaire was sent out to European countries, principally through their national societies. The current report includes a detailed analysis of radiotherapy departments and equipment (questionnaire items 26-29), analyzed in relation to the annual number of treatment courses and the socio-economic status of the countries. The analysis is based on validated responses from 28 of the 40 European countries defined by the European Cancer Observatory (ECO)., Results: A large variation between countries was found for most parameters studied. There were 2192 linear accelerators, 96 dedicated stereotactic machines, and 77 cobalt machines reported in the 27 countries where this information was available. A total of 12 countries had at least one cobalt machine in use. There was a median of 0.5 simulator per MV unit (range 0.3-1.5) and 1.4 (range 0.4-4.4) simulators per department. Of the 874 simulators, a total of 654 (75%) were capable of 3D imaging (CT-scanner or CBCT-option). The number of MV machines (cobalt, linear accelerators, and dedicated stereotactic machines) per million inhabitants ranged from 1.4 to 9.5 (median 5.3) and the average number of MV machines per department from 0.9 to 8.2 (median 2.6). The average number of treatment courses per year per MV machine varied from 262 to 1061 (median 419). While 69% of MV units were capable of IMRT only 49% were equipped for image guidance (IGRT). There was a clear relation between socio-economic status, as measured by GNI per capita, and availability of radiotherapy equipment in the countries. In many low income countries in Southern and Central-Eastern Europe there was very limited access to radiotherapy and especially to equipment for IMRT or IGRT., Conclusions: The European average number of MV machines per million inhabitants and per department is now better in line with QUARTS recommendations from 2005, but the survey also showed a significant heterogeneity in the access to modern radiotherapy equipment in Europe. High income countries especially in Northern-Western Europe are well-served with radiotherapy resources, other countries are facing important shortages of both equipment in general and especially machines capable of delivering high precision conformal treatments (IMRT, IGRT)., (Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.)

Purpose: To quantify changes in radiotherapy costs occurring in a decade of medical-technological evolution., Materials and Methods: The activity-based costing (ABC) model of the University Hospitals Leuven (UHL) radiotherapy (RT) department was adapted to current RT standards. It allocated actual resource costs to the treatments based on the departmental work-flow and patient mix in 2009. A benchmark with the former model analyzed the cost increases related to changes in RT infrastructure and practice over 10 years., Results: A considerable increase in total RT costs was observed, resulting from higher capital investments (96%) and personnel cost (103%), the latter dominating the total picture. Treatment delivery remains the most costly activity, boosted by the cost of improved quality assurance (QA), 23% of total product costs, coming along with more advanced RT techniques. Hence, cost increases at the product level are most obvious for complex treatments, such as intensity-modulated radiotherapy (IMRT), representing cost increases ranging between 38% and 88% compared to conformal approaches., Conclusions: The ABC model provides insight into the financial consequences of evolving technology and practice. Such data are a mandatory first step in our strive to prove RT cost-effectiveness and thus support optimal reimbursement and provision of radiotherapy departments., (Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.)

Background and Purpose: Innovative therapies are not only characterized by major uncertainties regarding clinical benefit and cost but also the expected recruitment of patients. An original model was developed to simulate patient recruitment to a costly particle therapy by varying layout of the facility and patient referral (one vs. several countries) and by weighting the treated indication by the expected benefit of particle therapy., Material and Methods: A multi-step probabilistic spatial model was used to allocate patients to the optimal treatment strategy and facility taking into account the estimated therapeutic gain from the new therapy for each tumour type, the geographical accessibility of the facilities and patient preference. Recruitment was simulated under different assumptions relating to the demand and supply., Results: Extending the recruitment area, reducing treatment capacity, equipping all treatment rooms with a carbon ion gantry and inclusion of proton protocols in carbon ion facilities led to an increased proportion of indications with the highest expected benefit. Assuming the existence of a competing carbon ions facility, lower values of therapeutic gain, and a greater unwillingness of patients to travel for treatment increased the proportion of indications with low expected benefit., Conclusions: Modelling patient recruitment may aid decision-making when planning new and expensive treatments., (Copyright 2010 Elsevier Ireland Ltd. All rights reserved.)

Background and Purpose: Adequate and equitable access to radiotherapy (RT) must be a reasonable health care goal for the EU. However, there are large variations among the EU countries and even regional variations within countries in the provision of RT. In this report, we combine the best available evidence on the indications for RT with national epidemiological data to arrive at estimates for the appropriate level of RT infrastructure in the 25 EU countries., Patients and Methods: Data from three systematic overviews of the best available evidence for the indication for RT in 23 main cancer types are combined with epidemiological data from the EUCAN and GLOBOCAN databases on the crude incidence of each of these cancers in the 25 EU countries. Together with published benchmarks for accelerator throughput this allows estimation of the number of linear accelerators per million people required to facilitate appropriate RT utilization rates in each country. Where possible, the estimates are compared with the detailed data available from Sweden., Results: The crude incidence of the main cancer types shows large variation among the 25 EU countries. This reflects in part differences in exposure to aetiological risk factors and partly differences among the countries in population age structure. Correspondingly, the estimate of the required number of linear accelerators per million people showed considerable variation: ranging from 4.0 in Cyprus to 8.1 in Hungary. The average for the 25 countries was 5.9 per million people. These estimates were compared with available national guidelines and actual data on RT infrastructure and large shortfalls were found in many countries. Implications for health economics and capacity planning are briefly discussed., Conclusions: The QUARTS project has developed a model that establishes a direct and transparent link between epidemiological data and indications for RT based on the best available evidence. Comparison of the model estimates with current levels of RT infrastructure has revealed major inequalities in provision of RT in the 25 EU countries. Continuation of this study is recommended as a way of improving RT provision on rational grounds throughout the European community and as a model for health care planning in the EU.

Background and Purpose: The aim of this study was to collect the available guidelines for infrastructure and staffing throughout Europe and to develop general guidelines., Materials and Methods: Questionnaires were sent to representatives in all European countries. Countries were divided into three groups, based on the GDP per capita (low, medium and high resource countries). Based on the results, general guidelines were developed., Results: 41 countries (93.2%), representing over 99% of the European population responded. Guidelines for the number of linear accelerators and personnel were available in about 40% of the countries. For accelerators, the average was 1 per 183,000 inhabitants in the high, 1 per 284,000 in the medium and 1 per 500,000 in the low resource countries. For radiation oncologists, it varied between 1 per 150-400 patients (average: 250) and there was no clear difference between high, medium and low resource countries. For physicists, the average was 1 per 530 patients for high and 1 per 610 for medium or low resource countries. Guidelines for other equipment and staffing are highly dependent on local habits and complexity of the treatments., Conclusion: An accurate overview of existing guidelines for radiotherapy infrastructure and staffing is obtained. It is suggested to have one linear accelerator per 450 patients, one radiation oncologist per 200-250 patients and one physicist per 450-500 patients (or one per linac). It should be stressed, however, that these are only crude guidelines and that the actual needs heavily depend on population structure, cancer incidence and treatment strategies, which differ between the various countries.

Background and Purpose: To investigate the financial consequences and the impact on daily implementation of CHART in lung cancer., Patients and Methods: A cost-effectiveness and cost-utility analysis were performed using Markov models, comparing the early and delayed costs and effects of CHART for NSCLC over a 4-year time span from a societal viewpoint. The outcome estimates were based on the CHART literature, the cost estimates on the standard practice of the Leuven University Hospitals, the radiotherapy costs being derived from an activity-based costing (ABC) programme developed in the department., Results: The additional societal cost per life-year gained was 9164 Euro, the incremental cost per quality-adjusted life-year 11,576 Euro. Sensitivity analyses confirmed the robustness of these results, the incremental cost-utility ratio remaining well under 20,000 Euro/QALY in all tested circumstances. The threshold analyses found the results of the study to be sensitive to the cost of CHART and to the quality of life after treatment. More specifically, standard treatment would become the optimal treatment if CHART would have a higher cost or would result in more long-term side effects., Conclusion: CHART should not be denied to patients with NSCLC on the basis of clinical or economic arguments. Other factors such as socio-economical, institutional, practical departmental and physician-bound barriers most probably explain the lack of implementation into daily practice.

Purpose: The activity-based costing method was used to compute radiotherapy costs. This report describes the model developed, the calculated costs, and possible applications for the Leuven radiotherapy department., Methods and Materials: Activity-based costing is an advanced cost calculation technique that allocates resource costs to products based on activity consumption. In the Leuven model, a complex allocation principle with a large diversity of cost drivers was avoided by introducing an extra allocation step between activity groups and activities. A straightforward principle of time consumption, weighed by some factors of treatment complexity, was used. The model was developed in an iterative way, progressively defining the constituting components (costs, activities, products, and cost drivers)., Results: Radiotherapy costs are predominantly determined by personnel and equipment cost. Treatment-related activities consume the greatest proportion of the resource costs, with treatment delivery the most important component. This translates into products that have a prolonged total or daily treatment time being the most costly. The model was also used to illustrate the impact of changes in resource costs and in practice patterns., Conclusion: The presented activity-based costing model is a practical tool to evaluate the actual cost structure of a radiotherapy department and to evaluate possible resource or practice changes.

BackgroundThe COVID-19 pandemic has caused radiotherapy resource pressures and led to increased risks for lung cancer patients and healthcare staff. An international group of experts in lung cancer radiotherapy established this practice recommendation pertaining to whether and how to adapt radiotherapy for lung cancer in the COVID-19 pandemic.MethodsFor this ESTRO & ASTRO endorsed project, 32 experts in lung cancer radiotherapy contributed to a modified Delphi consensus process. We assessed potential adaptations of radiotherapy in two pandemic scenarios. The first, an early pandemic scenario of risk mitigation, is characterized by an altered risk-benefit ratio of radiotherapy for lung cancer patients due to their increased susceptibility for severe COVID-19 infection, and minimization of patient travelling and exposure of radiotherapy staff. The second, a later pandemic scenario, is characterized by reduced radiotherapy resources requiring patient triage. Six common lung cancer cases were assessed for both scenarios: peripherally located stage I NSCLC, locally advanced NSCLC, postoperative radiotherapy after resection of pN2 NSCLC, thoracic radiotherapy and prophylactic cranial irradiation for limited stage SCLC and palliative thoracic radiotherapy for stage IV NSCLC.ResultsIn a risk-mitigation pandemic scenario, efforts should be made not to compromise the prognosis of lung cancer patients by departing from guideline-recommended radiotherapy practice. In that same scenario, postponement or interruption of radiotherapy treatment of COVID-19 positive patients is generally recommended to avoid exposure of cancer patients and staff to an increased risk of COVID-19 infection. In a severe pandemic scenario characterized by reduced resources, if patients must be triaged, important factors for triage include potential for cure, relative benefit of radiation, life expectancy, and performance status. Case-specific consensus recommendations regarding multimodality treatment strategies and fractionation of radiotherapy are provided.ConclusionThis joint ESTRO-ASTRO practice recommendation established pragmatic and balanced consensus recommendations in common clinical scenarios of radiotherapy for lung cancer in order to address the challenges of the COVID-19 pandemic.

Complex surgery and radiotherapy are the central pillars of loco-regional oncology treatment. This paper describes the reimbursement schemes used in radiation and complex surgical oncology, reports on literature and policy reviews. A systematic review of the literature of the reimbursement models has been carried out separately for radiotherapy and complex cancer surgery based on PRISMA guidelines. Using searches of PubMed and grey literature, we identified articles from scientific journals and reports published since 2000 on provider payment or reimbursement systems currently used in radiation oncology and complex cancer surgery, also including policy models. Most European health systems reimburse radiotherapy using a budget-based, fee-for-service or fraction-based system; while few reimburse services according to an episode-based model. Also, the reimbursement models for cancer surgery are mostly restricted to differences embedded in the DRG system and adjustments applied to the fees, based on the complexity of each surgical procedure. There is an enormous variability in reimbursement across countries, resulting in different incentives and different amounts paid for the same therapeutic strategy. A reimbursement policy, based on the episode of care as the basic payment unit, is advocated for. Innovation should be tackled in a two-tier approach: one defining the common criteria for reimbursement of proven evidence-based interventions; another for financing emerging innovation with uncertain definitive value. Relevant clinical and economic data, also collected real-life, should support reimbursement systems that mirror the actual cost of evidence-based practice. [ABSTRACT FROM AUTHOR]

In 2023, the Common Sense Oncology (CSO) movement was launched with the goal of recalibrating cancer care to focus on outcomes that matter to patients. We extend the three CSO pillars – evidence generation, interpretation and communication – to radiation oncology and advocate for better evidence demonstrating the value of our modality. [ABSTRACT FROM AUTHOR]

Purpose: 2-[18F]FDG PET/CT is of utmost importance for radiation treatment (RT) planning and response monitoring in lung cancer patients, in both non-small and small cell lung cancer (NSCLC and SCLC). This topic has been addressed in guidelines composed by experts within the field of radiation oncology. However, up to present, there is no procedural guideline on this subject, with involvement of the nuclear medicine societies. Methods: A literature review was performed, followed by a discussion between a multidisciplinary team of experts in the different fields involved in the RT planning of lung cancer, in order to guide clinical management. The project was led by experts of the two nuclear medicine societies (EANM and SNMMI) and radiation oncology (ESTRO). Results and conclusion: This guideline results from a joint and dynamic collaboration between the relevant disciplines for this topic. It provides a worldwide, state of the art, and multidisciplinary guide to 2-[18F]FDG PET/CT RT planning in NSCLC and SCLC. These practical recommendations describe applicable updates for existing clinical practices, highlight potential flaws, and provide solutions to overcome these as well. Finally, the recent developments considered for future application are also reviewed. [ABSTRACT FROM AUTHOR]

• Radiotherapy innovation consists of a broad range of intervention types. • Appropriate evidence should be generated considering each type of innovation. • Innovations providing real benefit to patients, at fair prices, should be endorsed. • Current oncology value tools insufficiently address radiotherapy-relevant outcomes. • The HERO-VBHC project aims to develop a value framework dedicated to radiotherapy. Radiotherapy interventions are rapidly evolving and improving, holding promise for better patient outcomes, yet at the possible detriment of higher societal costs. The ESTRO-HERO value-based radiotherapy project aims to develop a framework defining and assessing the value of radiotherapy innovations, to support clinical implementation and equitable access, within a sustainable healthcare system. [ABSTRACT FROM AUTHOR]

• Approximately 37% of bone metastases are classified as complicated. • The vast majority are of spinal origin. • The majority of complications were related to impending fracture. • Patients with complicated bone metastases have a median survival of 4 months. Despite the encouraging results of the SCORAD trial, single fraction radiotherapy (SFRT) remains underused for patients with complicated bone metastases with rates as low as 18–39%. We aimed to evaluate the incidence and treatment patterns of these metastases in patients being referred to a tertiary centre for palliative radiotherapy. We performed a retrospective review of all bone metastases treated at our centre from January 2013 until December 2017. Lesions were classified as uncomplicated or complicated. Complicated was defined as associated with (impending) fracture, existing spinal cord or cauda equina compression. Our protocol suggests using SFRT for all patients with complicated bone metastases, except for those with symptomatic neuraxial compression and a life expectancy of ≥28 weeks. Overall, 37 % of all bone metastases were classified as complicated. Most often as a result of an (impending) fracture (56 %) or spinal cord compression (44 %). In 93 % of cases, complicated lesions were located in the spine, most commonly originating from prostate, breast and lung cancer (60 %). Median survival of patients with complicated bone metastases was 4 months. The use of SFRT for complicated bone metastases increased from 51 % to 85 % over the study period, reaching 100 % for patients with the poorest prognosis. Approximately 37 % of bone metastases are classified as complicated with the majority related to (impending) fracture. Patients with complicated bone metastases have a median survival of 4 months and were mostly treated with SFRT. [ABSTRACT FROM AUTHOR]

• Metastasis-directed radiotherapy (MDRT) has the potential to prolong survival. • Definitions and reporting of oligometastatic disease (OMD) are heterogeneous. • OMD is typically based on the imaging-detected number of metastases, but definitions in the literature are inconsistent and warrant further study. No formal clinical or molecular biomarkers currently exist to aid classification as OMD. • Currently no clinical or molecular biomarkers exist to aid classification of OMD. • Advanced technologies are mandatory to guarantee safe MDRT and improve outcome. • Consensus for extra-cranial OMD defines maximum 5 metastatic lesions off-protocol. Recognizing the rapidly increasing interest and evidence in using metastasis-directed radiotherapy (MDRT) for oligometastatic disease (OMD), ESTRO and ASTRO convened a committee to establish consensus regarding definitions of OMD and define gaps in current evidence. A systematic literature review focused on curative intent MDRT was performed in Medline, Embase and Cochrane. Subsequent consensus opinion, using a Delphi process, highlighted the current state of evidence and the limitations in the available literature. Available evidence regarding the use of MDRT for OMD mostly derives from retrospective, single-centre series, with significant heterogeneity in patient inclusion criteria, definition of OMD, and outcomes reported. Consensus was reached that OMD is largely independent of primary tumour, metastatic location and the presence or length of a disease-free interval, supporting both synchronous and metachronous OMD. In the absence of clinical data supporting a maximum number of metastases and organs to define OMD, and of validated molecular biomarkers, consensus supported the ability to deliver safe and clinically meaningful radiotherapy with curative intent to all metastatic sites as a minimum requirement for defining OMD in the context of radiotherapy. Systemic therapy induced OMD was identified as a distinct state of OMD. High-resolution imaging to assess and confirm OMD is crucial, including brain imaging when indicated. Minimum common endpoints such as progression-free and overall survival, local control, toxicity and quality-of-life should be reported; uncommon endpoints as deferral of systemic therapy and cost were endorsed. While significant heterogeneity exists in the current OMD definitions in the literature, consensus was reached on multiple key questions. Based on available data, OMD can to date be defined as 1–5 metastatic lesions, a controlled primary tumor being optional, but where all metastatic sites must be safely treatable. Consistent definitions and reporting are warranted and encouraged in ongoing trials and reports generating further evidence to optimize patient benefits. [ABSTRACT FROM AUTHOR]

The article presents a commentary on Value-based health care. Topics discussed include aspects regarding utility and monetary exchange are crucial; conditions of potential benefits or losses, which may be relevant for patients in non-curative situations; and value of a treatment is based on scientific value judgments, including a clinical and an economic evaluation.

ESTRO surveyed European radiation oncology department heads to evaluate the impact of COVID-19. Telemedicine was used in 78% of the departments, and 60% reported a decline in patient volume. Use of protective measures was implemented on a large scale, but shortages of personal protective equipment were present in more than half of the departments. [ABSTRACT FROM AUTHOR]

Abstract Introduction A series of health economic evaluations (HEE) has analysed the efficiency of new fractionation schedules and techniques for adjuvant breast radiotherapy. This overview assembles the available evidence and evaluates to what extent HEE-results can be compared. Methods Based on a systematic literature review of HEEs from 1/1/2000 to 30/10/2016, all cost comparison (CC) and cost-effectiveness analyses (CEA) comparing different adjuvant breast radiotherapy approaches were analysed. Costs were extracted and converted to Euro 2016 and costs per QALY were summarized in cost-effectiveness planes. Results Twenty-four publications are withheld, comparing different fractionation schedules and/or irradiation techniques or evaluating the value of adding radiotherapy. Normofractionation and intensity-modulated, interstitial or intraluminal techniques are important cost-drivers. Highest reimbursements are observed in the US, but may overestimate the real cost. Hypofractionation is cost-effective compared to normofractionation, the results of partial breast irradiation are less unequivocal. Intra-operative and external beam approaches seem the most cost-effective for favourable risk groups, but whole breast irradiation is superior in terms of health effect and omission of radiotherapy in terms of costs. Conclusion Hypofractionation may be considered the most relevant comparator for new strategies in adjuvant breast radiotherapy, with omission of radiotherapy as an interesting alternative in the very favourable subcategories, especially for partial breast techniques. Although comparison of CC and CEA is hampered by the variability in clinical and economic settings, HEE-based evidence can guide decision-making to tailor-made strategies, allocating the optimal treatment in terms of effectiveness as well as efficiency to the right indication. [ABSTRACT FROM AUTHOR]

The article discusses a study focusing on the use of adaptive radiotherapy for treating locally advanced non-small cell lung cancer (NSCLC). Topics discussed include the outcomes of concurrent chemoradiotherapy (cCRT) for the NSCLC, the use of 18F-fludeoxyglucose–positron emission tomography or computed tomography during therapy, and the complication from the underdosage of microscopic disease (MD).

Purpose To investigate, in a prospective phase 1 to 2 trial, the safety and feasibility of delivering external beam radiation therapy in 5 fractions to the breast or thoracic wall, including boost and/or lymph nodes if needed, to women aged ≥65 years with breast cancer. Methods and Materials Ninety-five patients aged ≥65 years, referred for adjuvant radiation therapy, were treated in 5 fractions over 12 days with a total dose of 28.5 Gy/5.7 Gy to the breast or thoracic wall and, if indicated, 27 Gy/5.4 Gy to the lymph node regions and 32.5 Gy/6.5 Gy to 34.5 Gy/6.9 Gy to the tumor bed. The primary endpoint was clinically relevant dermatitis (grade ≥2). Results Mean follow-up time was 5.6 months, and mean age was 73.6 years. Clinically relevant dermatitis was observed in 11.6% of patients and only occurred in breast irradiation with boost (17.5% grade 2-3 vs 0% in the no-boost group). Although doses were high, treatment delivery with intensity modulated radiation therapy was swift, except for complex treatments, including lymph nodes for which single-arc volumetric modulated arc therapy was needed to reduce beam-on time. Conclusion Accelerated radiation therapy in 5 fractions was technically feasible and resulted in low acute toxicity. Clinically relevant erythema was only observed in patients receiving a boost, but still at an acceptable rate. Although the follow-up is still short, the results on acute toxicity after accelerated radiation therapy were encouraging. A 5-fraction schedule is well tolerated in the elderly and may lower the threshold for radiation therapy in this population. [ABSTRACT FROM AUTHOR]

Background and purpose:In early-stage classical Hodgkin lymphoma (HL) the target volume nowadays consists of the volume of the originally involved nodes. Delineation of this volume on a post-chemotherapy CT-scan is challenging. We report on the interobserver variability in target volume definition and its impact on resulting treatment plans. Materials and methods:Two representative cases were selected (1: male, stage IB, localization: left axilla; 2: female, stage IIB, localizations: mediastinum and bilateral neck). Eight experienced observers individually defined the clinical target volume (CTV) using involved-node radiotherapy (INRT) as defined by the EORTC-GELA guidelines for the H10 trial. A consensus contour was generated and the standard deviation computed. We investigated the overlap between observer and consensus contour [Sørensen-Dice coefficient (DSC)] and the magnitude of gross deviations between the surfaces of the observer and consensus contour (Hausdorff distance). 3D-conformal (3D-CRT) and intensity-modulated radiotherapy (IMRT) plans were calculated for each contour in order to investigate the impact of interobserver variability on each treatment modality. Similar target coverage was enforced for all plans. Results:The median CTV was 120 cm3(IQR: 95–173 cm3) for Case 1, and 255 cm3(IQR: 183–293 cm3) for Case 2. DSC values were generally high (>0.7), and Hausdorff distances were about 30 mm. The SDs between all observer contours, providing an estimate of the systematic error associated with delineation uncertainty, ranged from 1.9 to 3.8 mm (median: 3.2 mm). Variations in mean dose resulting from different observer contours were small and were not higher in IMRT plans than in 3D-CRT plans. Conclusions:We observed considerable differences in target volume delineation, but the systematic delineation uncertainty of around 3 mm is comparable to that reported in other tumour sites. This report is a first step towards calculating an evidence-based planning target volume margin for INRT in HL. [ABSTRACT FROM AUTHOR]

Background The objective of this HERO study was to assess the number of new cancer patients that will require at least one course of radiotherapy by 2025. Methods European cancer incidence data by tumor site and country for 2012 and 2025 was extracted from the GLOBOCAN database. The projection of the number of new cases took into account demographic factors (age and size of the population). Population based stages at diagnosis were taken from four European countries. Incidence and stage data were introduced in the Australian Collaboration for Cancer Outcomes Research and Evaluation (CCORE) model. Results Among the different tumor sites, the highest expected relative increase by 2025 in treatment courses was prostate cancer (24%) while lymphoma (13%), head and neck (12%) and breast cancer (10%) were below the average. Based on the projected cancer distributions in 2025, a 16% expected increase in the number of radiotherapy treatment courses was estimated. This increase varied across European countries from less than 5% to more than 30%. Conclusion With the already existing disparity in radiotherapy resources in mind, the data provided here should act as a leverage point to raise awareness among European health policy makers of the need for investment in radiotherapy. [ABSTRACT FROM AUTHOR]

Background and purpose The absolute number of new cancer patients that will require at least one course of radiotherapy in each country of Europe was estimated. Material and methods The incidence and relative frequency of cancer types from the year 2012 European Cancer Observatory estimates were used in combination with the population-based stage at diagnosis from five cancer registries. These data were applied to the decision trees of the evidence-based indications to calculate the Optimal Utilization Proportion (OUP) by tumour site. Results In the minimum scenario, the OUP ranged from 47.0% in the Russian Federation to 53.2% in Belgium with no clear geographical pattern of the variability among countries. The impact of stage at diagnosis on the OUP by country was rather limited. Within the 24 countries where data on actual use of radiotherapy were available, a gap between optimal and actual use has been observed in most of the countries. Conclusions The actual utilization of radiotherapy is significantly lower than the optimal use predicted from the evidence based estimates in the literature. This discrepancy poses a major challenge for policy makers when planning the resources at the national level to improve the provision in European countries. [ABSTRACT FROM AUTHOR]

Non-small-cell lung cancer (NSCLC) is the leading cause of death from cancer for both men and women. Chemotherapy is the mainstay of treatment in advanced disease, but is only marginally effective. In about 30% of patients with advanced NSCLC in East Asia and in 10-15% in Western countries, epidermal growth factor receptor (EGFR) mutations are found. In this population, first-line treatment with the tyrosine kinase inhibitors (TKIs) erlotinib, gefitinib, or afatinib is recommended. The treatment beyond progression is less well-defined. In this paper, we present three patients, EGFR mutation positive, with local progression after an initial treatment with TKI.These patients were treated with local radiotherapy. TKI was temporarily stopped and restarted after radiotherapy. We give an overview of the literature and discuss the different treatment options in case of progression after TKI: TKI continuation with or without chemotherapy, TKI continuation with local therapy, alternative dosing or switch to next-generation TKI or combination therapy. There are different options for treatment beyond progression in EGFR mutation positive metastatic NSCLC, but the optimal strategy is still to be defined. Further research on this topic is ongoing. [ABSTRACT FROM AUTHOR]

Background The ESTRO Health Economics in Radiation Oncology (HERO) project has the overall aim to develop a knowledge base of the provision of radiotherapy in Europe and build a model for health economic evaluation of radiation treatments at the European level. The first milestone was to assess the availability of radiotherapy resources within Europe. This paper presents the personnel data collected in the ESTRO HERO database. Materials and methods An 84-item questionnaire was sent out to European countries, through their national scientific and professional radiotherapy societies. The current report includes a detailed analysis of radiotherapy staffing (questionnaire items 47–60), analysed in relation to the annual number of treatment courses and the socio-economic status of the countries. The analysis was conducted between February and July 2014, and is based on validated responses from 24 of the 40 European countries defined by the European Cancer Observatory (ECO). Results A large variation between countries was found for most parameters studied. Averages and ranges for personnel numbers per million inhabitants are 12.8 (2.5–30.9) for radiation oncologists, 7.6 (0–19.7) for medical physicists, 3.5 (0–12.6) for dosimetrists, 26.6 (1.9–78) for RTTs and 14.8 (0.4–61.0) for radiotherapy nurses. The combined average for physicists and dosimetrists is 9.8 per million inhabitants and 36.9 for RTT and nurses. Radiation oncologists on average treat 208.9 courses per year (range: 99.9–348.8), physicists and dosimetrists conjointly treat 303.3 courses (range: 85–757.7) and RTT and nurses 76.8 (range: 25.7–156.8). In countries with higher GNI per capita, all personnel categories treat fewer courses per annum than in less affluent countries. This relationship is most evident for RTTs and nurses. Different clusters of countries can be distinguished on the basis of available personnel resources and socio-economic status. Conclusions The average personnel figures in Europe are now consistent with, or even more favourable than the QUARTS recommendations, probably reflecting a combination of better availability as such, in parallel with the current use of more complex treatments than a decade ago. A considerable variation in available personnel and delivered courses per year however persists among the highest and lowest staffing levels. This not only reflects the variation in cancer incidence and socio-economic determinants, but also the stage in technology adoption along with treatment complexity and the different professional roles and responsibilities within each country. Our data underpin the need for accurate prediction models and long-term education and training programmes. [ABSTRACT FROM AUTHOR]

Abstract: New evidence based regimens and novel high precision technology have reinforced the important role of radiotherapy in the management of cancer. Current data estimate that more than 50% of all cancer patients would benefit from radiotherapy during the course of their disease. Within recent years, the radiotherapy community has become more than conscious of the ever-increasing necessity to come up with objective data to endorse the crucial role and position of radiation therapy within the rapidly changing global oncology landscape. In an era of ever expanding health care costs, proven safety and effectiveness is not sufficient anymore to obtain funding, objective data about cost and cost-effectiveness are nowadays additionally requested. It is in this context that ESTRO is launching the HERO-project (Health Economics in Radiation Oncology), with the overall aim to develop a knowledge base and a model for health economic evaluation of radiation treatments at the European level. To accomplish these objectives, the HERO project will address needs, accessibility, cost and cost-effectiveness of radiotherapy. The results will raise the profile of radiotherapy in the European cancer management context and help countries prioritizing radiotherapy as a highly cost-effective treatment strategy. This article describes the different steps and aims within the HERO-project, starting from evidence on the role of radiotherapy within the global oncology landscape and highlighting weaknesses that may undermine this position. [Copyright &y& Elsevier]

Abstract: A large amount of clinical evidence has recently accumulated supporting the efficacy and safety of hypofractionated radiotherapy for post-operative breast cancer. These schedules, typically delivering a lower total dose in fewer, but larger than 2 Gy fractions, are more convenient for the patients by limiting the number of treatment attendances. Moreover, the reduced resource use in terms of personnel and machine time is advantageous for radiotherapy departments and translates into lower treatment costs. In order to formally validate this therapeutic approach from a societal perspective, however, cost-effectiveness evaluations weighing long-term outcome against the societal costs incurred until many years after treatment are needed. [Copyright &y& Elsevier]

Abstract: Time measurements were performed on daily treatment delivery with the aim to quantify the impact of quality assurance (QA) using an electronic portal imaging device (EPID) on RT delivery time and to validate the time burden of intensity modulated radiation therapy (IMRT) as an example of advanced technology. Both increased QA and the delivery of IMRT were found to be significant parameters determining daily treatment time (TT), which in turn translates in increased treatment costs. [Copyright &y& Elsevier]

Purpose: To investigate the financial implications of radiotherapy (RT) to the internal mammary and medial supraclavicular lymph node chain (IM-MS) in postoperative breast cancer. Methods and Materials: A cost-effectiveness and cost-utility analysis were performed, using Markov models, comparing the early and delayed costs and effects of IM-MS during a 20-year time span from a societal viewpoint. The outcome estimates were based on Level I evidence from postoperative RT literature and the cost estimates on the standard practice of the Leuven University Hospitals, with the RT costs derived from an activity-based costing program developed in the department. Results: On the basis of the assumptions of the model and seen during a 20-year time span, primary treatment including IM-MS RT results in a cost savings (approximately €10,000) compared with a strategy without RT. Because IM-MS RT also results in better clinical effectiveness and greater quality of life, the treatment with IM-MS dominates the approach without IM-MS. Sensitivity analyses confirmed the robustness of these results in all tested circumstances. Although threshold values were found for the cost of IM-MS, the cost at relapse, and the quality of life after treatment, these were substantially different from the baseline estimates, indicating that it is very unlikely that omitting IM-MS would become superior. Conclusion: This ex-ante cost evaluation of IM-MS RT showed that the upfront costs of locoregional RT are easily compensated for by avoiding the costs of treating locoregional and distant relapse at a later stage. The cost-sparing effect of RT should, however, be evaluated for a sufficiently long time span and is most specifically found in tumors with a rather slow natural history and a multitude of available systemic treatments at relapse, such as breast cancer. [Copyright &y& Elsevier]

This study shows the feasibility of accelerated vindesine–ifosfamide–cisplatin chemotherapy, immediately followed by intensive radiotherapy to the residual tumour in responding patients, in 16 patients with pathologically proven stage IIIB non-small lung cancer. All toxicities were reversible, with only two of ten patients experiencing grade 3 oesophagitis, no treatment-related deaths and no serious late effects. [Copyright &y& Elsevier]

• Nodal definition and delineation for lung cancer is variable in clinical practice. • Knowledge of anatomy and strict guidelines are crucial for high contouring quality. • A qualitative review is essential to understanding interobserver variability. • Quantitative evaluations are more robust if performed after a qualitative review. • Standardization and peer review of clinical practice at country level is feasible. The Quality Assurance project for stage III non-small cell lung cancer radiotherapy ProCaLung performed a multicentric two-step exercise evaluating mediastinal nodal Target Volume Definition and Delineation (TVD) variability and the opportunity for standardization. The TVD variability before and after providing detailed guidelines and the value of qualitative contour reviewing before applying quantitative measures were investigated. The case of a patient with stage III NSCLC and involved mediastinal lymph nodes was used as a basis for this study. Twenty-two radiation oncologists from nineteen centers in Belgium and Luxembourg participated in at least one of two phases of the project (before and after introduction of ProCaLung contouring guidelines). The resulting thirty-three mediastinal nodal GTV and CTV contours were then evaluated using a qualitative-before-quantitative (QBQ) approach. First, a qualitative analysis was performed, evaluating adherence to most recent guidelines. From this, a list of observed deviations was created and these were used to evaluate contour conformity. The second analysis was quantitative, using overlap and surface distance measures to compare contours within qualitative groups and between phases. A 'most robust' reference volume for these analyses was created using the STAPLE-algorithm and an averaging method. Five GTV and seven CTV qualitative groups were identified. Second step contours were more often in higher-conformity groups (p = 0.012 for GTV and p = 0.024 for CTV). Median Residual Mean Square Distances improved from 2.34 mm to 1.36 mm for GTV (p = 0.01) and from 4.53 mm to 1.58 mm for CTV (p < 0.0001). Median Dice coefficients increased from 0.81 to 0.84 for GTV (p = 0.07) and from 0.82 to 0.89 for CTV (p ≤ 0.001). Using HC-contours only to generate references translated in more robust quantitative evaluations. Variability of mediastinal nodal TVD was reduced after providing the ProCaLung consensus guidelines. A qualitative review was essential for providing meaningful quantitative measures. [ABSTRACT FROM AUTHOR]

Background: Bone metastases represent an important source of morbidity in cancer patients, mostly due to severe pain. Radiotherapy is an established symptomatic treatment for painful bone metastases, however, when conventional techniques are used, the effectiveness is moderate. Stereotactic body radiotherapy (SBRT), delivering very high doses in a limited number of fractions in a highly conformal manner, could potentially be more effective and less toxic.Methods: This is a phase III, randomized-controlled, single-blind, multicenter study evaluating the response rate of antalgic radiotherapy for painful bone metastases and the acute toxicity associated with this treatment. A total of 126 patients will be randomly assigned to receive either the standard schedule of a single fraction of 8.0 Gy delivered through three-dimensional conformal radiotherapy or a single fraction of 20.0 Gy delivered through SBRT. Primary endpoint is pain response at the treated site at 1 month after radiotherapy. Secondary endpoints are pain flare at 24-48-72 h after radiotherapy, duration of pain response, re-irradiation need, acute toxicity, late toxicity, quality of life and subsequent serious skeletal events. In a supplementary analysis, patient-compliance for a paper-and-pencil questionnaire will be compared with an electronic mode.Discussion: If a dose-escalated approach within the context of single fraction stereotactic body radiotherapy could improve the pain response to radiotherapy and minimize acute toxicity, this would have an immediate impact on the quality of life for a large number of patients with advanced cancer. Potential disadvantages of this technique include increased pain flare or a higher incidence of radiation-induced fractures.Trial Registration: The Ethics committee of the GZA Hospitals (B099201732915) approved this study on September 4th 2018. Trial registered on Clinicaltrials.gov ( NCT03831243 ) on February 5th 2019. [ABSTRACT FROM AUTHOR]