Radiation plays an important role in cancer treatment, but deciding when to use radiation, what type to use, and what dose to give requires careful clinical judgment. Many factors can influence a physician’s decision-making. The authors’ research particularly focuses on curative radiation therapy, including dose schedules and newer technologies.

Some radiation therapies have strong clinical trial evidence, but they may not always apply well to real-world patients. This is because patient characteristics are an important factor in radiation treatment outcomes. Different patients have different backgrounds, such as age, sex, frailty, and comorbidities. In addition, patients’ sociodemographic factors are also very important in radiotherapy decision-making. For example, insurance coverage, financial situation, and distance from the treatment center can all influence whether a patient receives radiotherapy or a specific dose schedule.

As for dose and schedule in radiotherapy, the authors mainly reviewed breast cancer and prostate cancer studies, comparing hypofractionation (higher doses over fewer treatment sessions) and standard fractionation (lower doses given once a day over several weeks). The authors reviewed clinical data from multiple countries, including India, Canada, Denmark, China, Australia, and England, and concluded that higher-dose schedules can achieve similar outcomes to standard schedules, while also saving patients time and money and reducing healthcare system resource use.

Finally, the authors reviewed new technologies in radiotherapy, such as intensity-modulated radiotherapy (IMRT), magnetic resonance imaging (MRI)-guided radiotherapy, stereotactic ablative body radiotherapy (SABR), and proton/charged-particle therapy. Older radiation therapy uses CT scans to locate the tumor and delivers high-energy X-rays from a few fixed directions. Although effective, it exposes more nearby healthy tissue to radiation compared with newer techniques. Unlike older radiation therapy, MRI uses live MRI imaging to help target a tumor more accurately while treatment is happening, IMRT uses computer-guided radiation beams from multiple directions to target the tumor more precisely and better protect nearby healthy tissue. SABR uses highly precise imaging and delivers a few high-dose treatments instead of many smaller ones. Proton and charged-particle therapy use tiny, charged particles instead of X-rays. These particles stop more precisely at the tumor, reducing radiation exposure to surrounding healthy tissues.

Understanding different types of radiotherapy, clinical trial evidence on dose schedules, and new technologies can help doctors, patients, and healthcare systems make more appropriate treatment decisions. It can help avoid both over-treatment (therapeutic enthusiasm) and under-treatment (therapeutic nihilism) and improve both survival and quality of life.

Although newer technologies are more precise and better at protecting healthy tissues, the equipment is expensive, and many low-income countries or regions cannot afford them. For patients in those areas, traditional radiotherapy may still be the only available option.

References

Vinod SK, Merie R, Harden S. Quality of decision making in radiation oncology. Clin Oncol (R Coll Radiol). 2025;38:103523. doi:10.1016/j.clon.2024.02.001