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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.
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.
Röntgen's X-rays were used against cancer within a year of their discovery, and the Curies' radium became brachytherapy. Cobalt units and then linear accelerators (1950s) delivered higher energies deeper; CT planning in the 1980s let beams be shaped to the tumour in three dimensions. Radioactive iodine for thyroid cancer, from the 1940s, was the first targeted radiotherapy and a preview of the radiopharmaceutical field.
Intensity-modulated and image-guided radiotherapy shaped dose around organs and checked position daily, cutting late toxicity in prostate and head and neck cancer. Stereotactic body radiotherapy ablated early lung cancers and oligometastases in one to five sessions. Large trials proved that fewer, larger fractions match conventional courses: CHHiP in prostate cancer and FAST-Forward (2020), which delivered breast radiotherapy in five sessions over one week. CONVERT settled the small-cell lung schedule debate. Treatment planning software became the real product.
PACIFIC made a year of durvalumab after chemoradiation the standard in stage III lung cancer; KEYNOTE-A18 added pembrolizumab to curative chemoradiation for cervical cancer with a survival gain; LAURA gave osimertinib after chemoradiation in EGFR-mutant lung cancer; INTERLACE showed that six weeks of cheap chemotherapy before cervical chemoradiation cuts deaths. The failures were as instructive: adding a PD-L1 blocker to head and neck chemoradiation did not help (JAVELIN HN 100), a promising radiosensitiser made things worse (TrilynX), and de-escalating radiation for HPV-positive throat cancer fell short (NRG-HN002 and HN005).
Protons stop inside the tumour rather than passing through, which matters most in children and near critical organs; the Christie opened the UK's first NHS proton centre and compact single-room systems are spreading. Carbon ions kill radioresistant tumours and are available at a handful of centres, with North America's first being built at Mayo Clinic Florida. MR-linacs image soft tissue during treatment and adapt the plan daily; PET-guided systems track the tumour by its own emissions. AI auto-contouring now saves hours per plan in hundreds of centres. Clinical proton dose is still reported at RBE 1.1; whether LET-weighted RBE plus tissue alpha/beta can pick the adults who benefit versus IMRT is untested in the randomised trials now running.
Single-fraction radiotherapy relieves bone pain as well as ten fractions and is still under-used. ESTIMABL2 showed that most low-risk thyroid cancers can skip radioactive iodine after surgery. ACNS0331 tested lower doses and smaller fields in children with medulloblastoma to reduce cognitive harm. MRI surveillance is replacing prophylactic brain irradiation in small-cell lung cancer. In overloaded systems, one-week hypofractionated courses are the single largest capacity gain available.
FLASH radiotherapy delivers a full dose in under a second and, in animals, spares normal tissue while killing tumour; the first human trials of FLASH protons have been run and dedicated electron machines are being built. Very-high-energy electrons and proton arcs are routes to deep FLASH. Upright treatment chairs could cut the cost of particle therapy; boron neutron capture therapy, approved in Japan for head and neck cancer, needs compact neutron sources; lattice radiotherapy deliberately doses a large tumour unevenly. Each is limited by engineering and dosimetry rather than biology.
Radiation releases tumour antigens and can switch on the innate immune alarm, or switch it off, depending on dose and fractionation; trials are trying to find the schedule that primes rather than suppresses. Systemic radiation is the radiopharmaceutical roadmap: radioligands, radio-antibodies and alpha emitters that deliver dose to every metastasis, increasingly combined with DNA-repair inhibitors. The two fields are converging on the same question: how to kill the last cell wherever it is.
Radiotherapy cures a large share of all cured patients and receives a small share of research funding. Most of the world's population lacks access to a working linear accelerator, and where machines exist they are idle for want of physicists and maintenance. Pooled procurement of machines and service, contracts that pay for uptime rather than hardware, remote planning hubs and remote quality assurance, and low-cost brachytherapy for cervical cancer in every regional centre are the proposals that would change that.
Every era's records, trial outcomes and papers, and every watch item, as JSON.
Probability ranges are named estimates that the claim is borne out on roughly a five-year horizon. They are meant to be argued with: propose a revision with your name and reasoning via a pull request to src/data/confidence.ts.
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One trial page, one roadmap page and one idea page on OnCo cite this paper by its DOI; this record gives the citation a page of its own so a reader can follow it without leaving OnCo. Read the abstract above alongside the citing pages listed under Related; the record was created automatically from the Europe PMC entry and its figures have not been checked by hand.
Two technology pages, two bottleneck pages and one roadmap page on OnCo cite this paper by its DOI; this record gives the citation a page of its own so a reader can follow it without leaving OnCo. Read the abstract above alongside the citing pages listed under Related; the record was created automatically from the Europe PMC entry and its figures have not been checked by hand.
The standard of care in limited-stage small-cell lung cancer from 1999 until ADRIATIC added immunotherapy in 2024, and a rare example of a curative gain in a disease that has had almost none.
The origin of short-course preoperative radiotherapy, still the standard schedule across northern Europe and the backbone of the RAPIDO regimen 24 years later.
Shares Leo Cancer Care, P-Cure, Mevion Medical Systems, RefleXion Medical.
Shares Mevion Medical Systems, IBA (Ion Beam Applications), Relative biological effectiveness (RBE), Use LET, RBE and alpha/beta to decide when protons beat IMRT.
Shares Leo Cancer Care, P-Cure, Mevion Medical Systems, Proton arc therapy.
Shares Relative biological effectiveness (RBE), Use LET, RBE and alpha/beta to decide when protons beat IMRT, Linear energy transfer (LET), Hypofractionation (fewer, larger radiotherapy doses).
Shares Mevion Medical Systems, IBA (Ion Beam Applications), FLASH radiotherapy, Varian (Siemens Healthineers).
Shares Proton arc therapy, Relative biological effectiveness (RBE), Use LET, RBE and alpha/beta to decide when protons beat IMRT, Linear energy transfer (LET).
Shares Proton arc therapy, Relative biological effectiveness (RBE), Use LET, RBE and alpha/beta to decide when protons beat IMRT, Linear energy transfer (LET).
Shares Elekta, Varian (Siemens Healthineers), Brachytherapy, Not enough oncologists, nurses, pathologists, physicists.