Head and Neck Cancer Adaptive Radiation Therapy (ART): Conceptual Considerations for the Informed Clinician

For nearly 2 decades, adaptive radiation therapy (ART) has been proposed as a method to account for changes in head and neck tumor and normal tissue to enhance therapeutic ratios. While technical advances in imaging, planning and delivery have allowed greater capacity for ART delivery, and a series of dosimetric explorations have consistently shown capacity for improvement, there remains a paucity of clinical trials demonstrating the utility of ART. Furthermore, while ad hoc implementation of head and neck ART is reported, systematic full-scale head and neck ART remains an as yet unreached reality. To some degree, this lack of scalability may be related to not only the complexity of ART, but also variability in the nomenclature and descriptions of what is encompassed by ART. Consequently, we present an overview of the history, current status, and recommendations for the future of ART, with an eye toward improving the clarity and description of head and neck ART for interested clinicians, noting practical considerations for implementation of an ART program or clinical trial. Process level considerations for ART are noted, reminding the reader that, paraphrasing the writer Elbert Hubbard, "Art is not a thing, it is a way."