# Pay for a course of radiotherapy, not for each fraction

Source: https://onco.cc/ideas/idea-cost-hypofractionation-payment/  
OnCo record `idea-cost-hypofractionation-payment` (Idea). Data CC BY-NC 4.0, attribute "Data from OnCo (onco.cc)"; commercial use needs a licence.

## TL;DR

One week of breast radiotherapy in five doses works as well as three weeks in fifteen, but clinics paid per dose lose money by switching; paying one price per course removes the penalty.

## Summary

FAST-Forward (Lancet 2020) showed 26 Gy in five fractions over one week was non-inferior to 40 Gy in fifteen fractions for local recurrence after breast surgery. Prostate, rectal, lung and palliative bone regimens have similar evidence. Fee-for-fraction payment makes the shorter course a revenue loss for the centre. Medicare's Radiation Oncology Model proposed episode payments; a simpler per-course rate for the common sites would align the incentive with the evidence.

## Fields

- Kind: Idea
- Last checked: 2026-09-10
- Hypothesis: Per-course payment will raise the share of eligible breast and prostate patients treated with five or fewer fractions to above 70% within two years, with lower total cost and equal control rates.
- Rationale: Where payment is per patient rather than per fraction (the NHS, Canadian provinces) ultra-hypofractionation became standard within a few years of the trials.
- Proposed test: A payer pilot with per-course payment in selected regions, comparing fraction numbers, costs, patient travel and local control against fee-for-fraction regions.
- Maturity: being-tested-at-scale
- Actor: payer

## Sources

- Brunt et al., Lancet 2020: FAST-Forward: https://doi.org/10.1016/S0140-6736(20)30932-6

## Connected records

- cancers: [HR-positive / HER2-negative breast cancer](https://onco.cc/cancers/breast-hr-positive/), [Prostate cancer](https://onco.cc/cancers/prostate/)
- fronts: [Radiation Therapy](https://onco.cc/fronts/radiation/)
- technologies: [IMRT / IGRT (modern external beam)](https://onco.cc/technologies/imrt-igrt/), [SBRT / SABR (stereotactic radiotherapy)](https://onco.cc/technologies/sbrt/)
- institutions: [American Society for Radiation Oncology](https://onco.cc/institutions/astro/)
- bottlenecks: [Incentives reward me-too drugs and marginal gains](https://onco.cc/bottlenecks/b-incentive-misalignment/), [Knowledge reaches practice too slowly](https://onco.cc/bottlenecks/b-knowledge-diffusion/), [Surgery and radiotherapy cure most, get least](https://onco.cc/bottlenecks/b-surgery-radiation-innovation/)
- key papers: [Hypofractionated breast radiotherapy for 1 week versus 3 weeks (FAST-Forward): 5-year efficacy and late normal tissue effects results from a multicentre, non-inferiority, randomised, phase 3 trial](https://onco.cc/key-papers/paper-murray-brunt-lancet/)

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