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Online adaptive radiotherapy: Clinical utility, challenges and perspectives
Morgan Michalet1, Jeppe Friborg2, Ivan Richter Vogelius2
1Department of Radiation Oncology, CHU de Nîmes, Université of Montpellier-Nîmes, France; University Federation of Radiation Oncology of Mediterranean Occitanie, Montpellier, France; Inserm U1194, Montpellier Cancer Research Institute (IRCM), University of Montpellier, Montpellier, France.
Online adaptive radiotherapy (oART) offers daily treatment adjustments for improved cancer care. While showing promise in reducing side effects and enhancing tumor targeting, challenges in workflow and treatment time need addressing.
Area of Science:
- Radiation Oncology
- Medical Physics
Background:
- Online adaptive radiotherapy (oART) allows for daily adjustments to radiation plans based on patient anatomy changes during treatment.
- This adaptive approach aims to improve treatment accuracy and minimize toxicity compared to traditional static radiotherapy.
- Current evidence on oART's clinical utility and implementation is rapidly evolving.
Purpose of the Study:
- To review and synthesize the existing evidence on the clinical utility of oART.
- To identify the challenges associated with implementing oART in clinical practice.
- To explore future directions and potential advancements in oART.
Main Methods:
- A comprehensive literature search was conducted on PubMed, covering studies from 2014 to June 2025.
- The review included studies reporting dosimetric and clinical outcomes for oART across various tumor sites.
- Data were extracted on treatment delivery systems (MR- or CT-guided), outcomes, and implementation factors.
Main Results:
- oART consistently demonstrated improved target coverage and reduced dose to organs at risk across multiple cancer types.
- Clinical benefits observed include enhanced gastrointestinal tolerance in pancreatic cancer and improved genitourinary outcomes in prostate cancer.
- Early positive results were also noted for head and neck and thoracic tumors, though widespread adoption is hindered by workflow complexity and resource demands.
Conclusions:
- oART represents a significant advancement in precision radiotherapy, enabling daily adaptation to patient anatomy.
- While dosimetric benefits are clear, large-scale trials are needed to confirm survival and toxicity advantages.
- Integration of AI, radiomics, and further research are crucial for optimizing oART's clinical application and cost-effectiveness.
