{"entity":{"id":"idea-cost-hypofractionation-payment","kind":"idea","name":"Pay for a course of radiotherapy, not for each fraction","aka":[],"tldr":"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.","asOf":"2026-09-10","links":[{"label":"Brunt et al., Lancet 2020: FAST-Forward","url":"https://doi.org/10.1016/S0140-6736(20)30932-6"}],"tags":[],"related":[],"cancers":["breast-hr-positive","prostate"],"sections":["radiation"],"technologies":["imrt-igrt","sbrt"],"targets":[],"drugs":[],"companies":[],"institutions":["astro"],"pathways":[],"terms":[],"trials":[],"people":[],"bottlenecks":["b-surgery-radiation-innovation","b-incentive-misalignment","b-knowledge-diffusion"],"keyPapers":["paper-murray-brunt-lancet"],"journals":[],"dependsOn":[],"notes":[],"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.","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","cost":"small","horizonYears":2},"route":"/ideas/idea-cost-hypofractionation-payment/","neighbours":{"cancer":[{"id":"breast-hr-positive","kind":"cancer","name":"HR-positive / HER2-negative breast cancer","route":"/cancers/breast-hr-positive/"},{"id":"prostate","kind":"cancer","name":"Prostate cancer","route":"/cancers/prostate/"}],"section":[{"id":"radiation","kind":"section","name":"Radiation Therapy","route":"/fronts/radiation/"}],"technology":[{"id":"imrt-igrt","kind":"technology","name":"IMRT / IGRT (modern external beam)","route":"/technologies/imrt-igrt/"},{"id":"sbrt","kind":"technology","name":"SBRT / SABR (stereotactic radiotherapy)","route":"/technologies/sbrt/"}],"institution":[{"id":"astro","kind":"institution","name":"American Society for Radiation Oncology","route":"/institutions/astro/"}],"bottleneck":[{"id":"b-incentive-misalignment","kind":"bottleneck","name":"Incentives reward me-too drugs and marginal gains","route":"/bottlenecks/b-incentive-misalignment/"},{"id":"b-knowledge-diffusion","kind":"bottleneck","name":"Knowledge reaches practice too slowly","route":"/bottlenecks/b-knowledge-diffusion/"},{"id":"b-surgery-radiation-innovation","kind":"bottleneck","name":"Surgery and radiotherapy cure most, get least","route":"/bottlenecks/b-surgery-radiation-innovation/"}],"paper":[{"id":"paper-murray-brunt-lancet","kind":"paper","name":"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","route":"/key-papers/paper-murray-brunt-lancet/"}]}}