Evidence-based indications for proton therapy in adults determined using the GRADE approach

Proton therapy (PT) offers dosimetric advantages over conventional X-ray-based radiotherapy (XRT), aiming to reduce toxicity and better spare healthy tissues. The Agency for Health Quality and Assessment of Catalonia (AQuAS), commissioned by the Spanish Ministry of Health, conducted a Health Technology Assessment to evaluate the safety and clinical effectiveness of PT for cancer indications not yet approved for PT in Spain. This article summarizes the main findings regarding PT's safety and clinical performance in adults compared with XRT.

The assessment was based on a systematic review of primary studies published between 2012 and 2024, following Cochrane methodological standards, PRISMA guidelines, and the GRADE approach. Eligibility criteria were defined using the PICO-DT framework, focusing on adult cancer patients, comparative study designs, and primary outcomes including serious adverse events, mortality, overall survival, and progression-free survival. Risk of bias was evaluated with RoB 2.0 and ROBINS-I depending on study design. Searches covered major biomedical databases.

Of 6958 records screened, 76 were included (five randomized trials and 71 observational studies) across 16 tumour types. Overall, evidence certainty was low or very low, limited by few randomized trials, methodological concerns, and heterogeneity. For some indications, including leptomeningeal metastases, lung cancer, and anal cancer, evidence suggests that PT may be equivalent or superior to XRT, although certainty remains limited.

PT shows variable, cancer-specific results and does not consistently outperform XRT. Some indications appear promising, but substantial evidence gaps persist, emphasizing the need for high-quality comparative studies and systematic clinical data collection.