# Radiotherapy roadmap: X-rays → shaped beams → fewer fractions, particles and FLASH

Source: https://onco.cc/roadmaps/radiation-roadmap/  
OnCo record `radiation-roadmap` (Roadmap). Data CC BY-NC 4.0, attribute "Data from OnCo (onco.cc)"; commercial use needs a licence.

## TL;DR

Radiotherapy cures more people than any drug and has reinvented itself every decade: from crude X-ray fields to beams shaped by computer, delivered in days instead of weeks, and now in fractions of a second. Its future is precision, fewer visits, and combination with drugs that make radiation work better.

## Summary

External beam radiotherapy moved from two-dimensional fields to three-dimensional conformal plans, intensity modulation, daily image guidance and stereotactic delivery that ablates a tumour in one to five sessions. Large randomised trials showed that fewer, larger fractions are as effective and as safe in breast and prostate cancer, cutting a course from weeks to days; protons and carbon ions spare tissue behind the tumour; MR-linacs adapt the plan to the anatomy of the day.

The present decade is about combination and de-escalation. Immunotherapy after chemoradiation is standard in stage III lung cancer (PACIFIC) and locally advanced cervical cancer (KEYNOTE-A18), and a targeted pill after chemoradiation in EGFR-mutant lung cancer (LAURA); several attempts to add drugs to head and neck chemoradiation failed, and de-escalation for HPV-positive throat cancer fell short. Single-fraction palliative treatment, skipping radioactive iodine in low-risk thyroid cancer and lower doses in children's brain tumours are the de-escalation wins.

Ahead are FLASH radiotherapy, which delivers the whole dose in under a second and spares normal tissue in animals, very-high-energy electrons, proton arcs, upright treatment, AI planning and radiation as an immune primer. The pace is set by the underfunding of radiotherapy research relative to drugs, and by the machines, physicists and technicians that most of the world does not have.

## Fields

- Kind: Roadmap
- Last checked: 2026-09-10

## Sources

- FAST-Forward: five-fraction breast radiotherapy (Lancet 2020): https://doi.org/10.1016/S0140-6736(20)30932-6
- PACIFIC (NEJM 2017): https://www.nejm.org/doi/full/10.1056/NEJMoa1709937
- Lancet Oncology Commission: expanding global access to radiotherapy (2015): https://doi.org/10.1016/S1470-2045(15)00222-3

## Connected records

- roadmaps: [Devices and physical therapies roadmap: heat and light → electric fields and focused sound → drug-releasing implants](https://onco.cc/roadmaps/devices-roadmap/), [Global access and affordability roadmap: essential medicines and generics → biosimilars and frugal trials → reliance, pooling and homegrown innovation](https://onco.cc/roadmaps/global-access-roadmap/), [Lung cancer roadmap: from Doll and Hill and the naming of tobacco, through the cytotoxic plateau, computed tomography screening, EGFR and ALK, immunotherapy by PD-L1, the perioperative trials and PACIFIC, to DLL3 in small-cell disease and a 2032 registry watch](https://onco.cc/roadmaps/lung-cancer-evidence-roadmap/), [Lymphoma roadmap: from a jaw tumour in Uganda and the first human cancer virus to gene-expression subtypes, PET-adapted chemotherapy, CAR-T cells, bispecific antibodies and the genetics-directed trials now recruiting](https://onco.cc/roadmaps/lymphoma-roadmap/), [Radical oncology: what could change the war by 2035](https://onco.cc/roadmaps/frontier-2035/), [Radiopharmaceutical roadmap: iodine → lutetium → actinium](https://onco.cc/roadmaps/radiopharma-roadmap/)
- ideas: [A Gavi-style pooled purchaser for radiotherapy equipment and service](https://onco.cc/ideas/idea-acc-pooled-procurement-radiotherapy/), [ctHPV-DNA-adapted de-escalation of chemoradiation](https://onco.cc/ideas/idea-cthpv-adapted-deescalation/), [Low-cost cobalt-60 brachytherapy for cervical cancer in every regional centre](https://onco.cc/ideas/idea-acc-frugal-hdr-brachytherapy/), [Make one-week radiotherapy the default in overloaded systems](https://onco.cc/ideas/idea-acc-hypofractionation-default-lmic/), [One medical physicist covering many radiotherapy machines through remote quality assurance](https://onco.cc/ideas/idea-acc-remote-medical-physics-qa/), [Pay for radiotherapy machine uptime, not for the machine](https://onco.cc/ideas/idea-acc-linac-uptime-contracts/), [Pick the radiation dose that switches the immune alarm on, not off](https://onco.cc/ideas/idea-bio2-radiotherapy-sting-fractionation/), [Round-the-clock remote treatment-planning hubs for clinics without physicists](https://onco.cc/ideas/idea-acc-remote-planning-hubs/), [Single-fraction radiotherapy as the default for painful bone metastases](https://onco.cc/ideas/idea-acc-single-fraction-palliative-radiotherapy-default/), [Use LET, RBE and alpha/beta to decide when protons beat IMRT](https://onco.cc/ideas/idea-bio2-let-rbe-ab-selects-protons/)
- fronts: [Radiation Therapy](https://onco.cc/fronts/radiation/)
- technologies: [Acupuncture for dry mouth after head and neck radiotherapy](https://onco.cc/technologies/acupuncture-xerostomia/), [AI auto-contouring and adaptive planning](https://onco.cc/technologies/auto-contouring-ai/), [Boron neutron capture therapy](https://onco.cc/technologies/bnct/), [Brachytherapy](https://onco.cc/technologies/brachytherapy/), [Carbon-ion therapy](https://onco.cc/technologies/carbon-ion/), [FLASH radiotherapy](https://onco.cc/technologies/flash-rt/), [Hyperbaric oxygen for late radiation injury](https://onco.cc/technologies/hyperbaric-oxygen-radiation-injury/), [Hyperthermia](https://onco.cc/technologies/hyperthermia/), [IMRT / IGRT (modern external beam)](https://onco.cc/technologies/imrt-igrt/), [Intraoperative radiotherapy (IORT)](https://onco.cc/technologies/intraoperative-radiotherapy/), [Lattice and GRID radiotherapy](https://onco.cc/technologies/lattice-radiotherapy/), [MR-guided adaptive radiotherapy](https://onco.cc/technologies/mr-linac/), [Palliative radiotherapy](https://onco.cc/technologies/palliative-radiotherapy/), [Prophylactic cranial irradiation vs MRI surveillance](https://onco.cc/technologies/prophylactic-cranial-irradiation/), [Proton arc therapy](https://onco.cc/technologies/proton-arc-therapy/), [Proton therapy](https://onco.cc/technologies/proton-therapy/), [Radio-antibody & radio-ADC](https://onco.cc/technologies/radioimmunotherapy/), [Radiodynamic therapy and radiosensitising nanoparticles](https://onco.cc/technologies/radiodynamic-therapy/), [Radioligand plus DNA-repair inhibitor combinations](https://onco.cc/technologies/radionuclide-parp-combination/), [Radiotherapy treatment planning and QA software](https://onco.cc/technologies/treatment-planning-systems/), [SBRT / SABR (stereotactic radiotherapy)](https://onco.cc/technologies/sbrt/), [Targeted alpha therapy](https://onco.cc/technologies/targeted-alpha-therapy/), [Very-high-energy electron therapy](https://onco.cc/technologies/vhee-radiotherapy/)
- drugs: [Amifostine](https://onco.cc/drugs/amifostine/), [Durvalumab](https://onco.cc/drugs/durvalumab/), [Radioactive iodine (I-131)](https://onco.cc/drugs/radioactive-iodine/), [Temozolomide](https://onco.cc/drugs/temozolomide/)
- companies: [Elekta](https://onco.cc/companies/elekta/), [IBA (Ion Beam Applications)](https://onco.cc/companies/iba/), [Leo Cancer Care](https://onco.cc/companies/leo-cancer-care/), [Limbus AI](https://onco.cc/companies/limbus-ai/), [Mevion Medical Systems](https://onco.cc/companies/mevion/), [Neutron Therapeutics](https://onco.cc/companies/neutron-therapeutics/), [NRG Oncology](https://onco.cc/companies/nrg-oncology/), [P-Cure](https://onco.cc/companies/p-cure/), [RaySearch Laboratories](https://onco.cc/companies/raysearch/), [RefleXion Medical](https://onco.cc/companies/reflexion/), [TAE Life Sciences](https://onco.cc/companies/tae-life-sciences/), [TheraPanacea](https://onco.cc/companies/therapanacea/), [THERYQ](https://onco.cc/companies/theryq/), [Varian (Siemens Healthineers)](https://onco.cc/companies/varian/)
- institutions: [Institut Curie](https://onco.cc/institutions/institut-curie/), [Massachusetts General Hospital Cancer Center](https://onco.cc/institutions/mgh/), [Mayo Clinic Comprehensive Cancer Center in Florida](https://onco.cc/institutions/mayo-clinic-florida/), [The Christie NHS Foundation Trust](https://onco.cc/institutions/the-christie/)
- terms: [Hypofractionation (fewer, larger radiotherapy doses)](https://onco.cc/terms/hypofractionation/), [Linear energy transfer (LET)](https://onco.cc/terms/linear-energy-transfer/), [Relative biological effectiveness (RBE)](https://onco.cc/terms/relative-biological-effectiveness/)
- trials: [COG ACNS0331](https://onco.cc/trials/acns0331/), [CONVERT](https://onco.cc/trials/convert/), [CROSS](https://onco.cc/trials/cross/), [EORTC 26981 / NCIC CE.3 (Stupp trial)](https://onco.cc/trials/eortc-26981/), [ESTIMABL2](https://onco.cc/trials/estimabl2/), [INTERLACE](https://onco.cc/trials/interlace/), [JAVELIN Head and Neck 100](https://onco.cc/trials/javelin-hn-100/), [KEYNOTE-A18 / ENGOT-cx11 / GOG-3047](https://onco.cc/trials/keynote-a18/), [LAURA](https://onco.cc/trials/laura/), [NRG-HN002 & NRG-HN005 (HPV+ de-escalation)](https://onco.cc/trials/nrg-hn002-hn005/), [PACIFIC](https://onco.cc/trials/pacific/), [PORTEC-3](https://onco.cc/trials/portec-3/), [TrilynX](https://onco.cc/trials/trilynx/)
- bottlenecks: [Most of the world has almost no cancer care](https://onco.cc/bottlenecks/b-global-access/), [Not enough oncologists, nurses, pathologists, physicists](https://onco.cc/bottlenecks/b-workforce/), [Surgery and radiotherapy cure most, get least](https://onco.cc/bottlenecks/b-surgery-radiation-innovation/), [Trial design, endpoints and cost](https://onco.cc/bottlenecks/b-trial-design/)
- key papers: [Expanding global access to radiotherapy](https://onco.cc/key-papers/paper-atun-lancet-oncol/), [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/), [Improved survival with preoperative radiotherapy in resectable rectal cancer (Swedish Rectal Cancer Trial)](https://onco.cc/key-papers/paper-swedish-rectal-cancer-trial-preoperative-radiotherapy-nejm-1997/), [Twice-daily compared with once-daily thoracic radiotherapy in limited small-cell lung cancer treated concurrently with cisplatin and etoposide](https://onco.cc/key-papers/paper-turrisi-twice-daily-thoracic-radiotherapy-limited-sclc-nejm-1999/)

---
JSON: https://onco.cc/api/v1/entities/radiation-roadmap.json