ESTRO 2026 Congress Report I Interdisciplinary Track

The ESTRO 2026 symposium, “The Role of Clinical Audits in Driving Performance in Radiotherapy,” held on Saturday 16 May, highlighted the increasingly important role of clinical audit in improving quality, safety, consistency, and accountability across radiotherapy services. Drawing on national experiences from Belgium, Australia, Denmark, and the UK, the session demonstrated how structured audit programmes can drive measurable improvements in patient care while fostering collaboration, transparency, and continuous learning.

A key message throughout the symposium was that clinical audits are far more than regulatory exercises. Instead, they are becoming essential tools for strengthening clinical governance, reducing unwarranted variation, and embedding a culture of quality improvement within radiotherapy departments, which are being positively received. Several speakers emphasised that peer review and benchmarking are particularly valuable in identifying variability in practice—especially contouring variability, an issue that, as highlighted during the discussions, has existed since the era of 2D radiotherapy and remains highly relevant in today’s advanced treatment techniques.

Aude Vaandering presented Belgium’s national B-QUATRO programme, a peer-review audit framework adapted from the IAEA QUATRO model. Supported through the Belgian National Cancer Plan, the programme has now completed two nationwide audit cycles across all radiotherapy departments, with a third cycle underway. Vaandering described how B-QUATRO evaluates departmental workflows, infrastructure, organisational structures, and quality governance through multidisciplinary collaboration rather than inspection's focus on ‘quality improvement, not regulation’. The audits have generated tangible improvements at both local and national levels, including the identification of RTT training needs and the strengthening of initiatives such as QMRT.be and PRISMA-RT. Importantly, the programme has also promoted cultural change within radiotherapy services by improving teamwork, encouraging openness, and strengthening collaboration between centres.

Kate Francis outlined the work of the Australian Clinical Dosimetry Service (ACDS), which delivers independent dosimetric audits across Australia and New Zealand. Her presentation highlighted the importance of independent verification in ensuring treatment accuracy as radiotherapy technologies continue to evolve ‘where clinical risk of error is high’. Since 2011, the ACDS has completed more than 1,400 audits covering techniques from conventional 3DCRT to advanced SABR, SRS, adaptive radiotherapy, and motion-management workflows. Approximately 10% of audits identified out-of-tolerance results, revealing issues throughout the radiotherapy pathway, from image guidance errors to planning and beam modelling problems. Francis demonstrated how independent audits not only identify potential hazards but also drive remediation, process improvement, and safer clinical practice. The resulting audit data has additionally contributed to more than 30 peer-reviewed publications influencing international medical physics practice.

Christian Rønn Hansen from Denmark focused on the role of quality assurance groups, standardisation, and data-driven audits in reducing variability in radiotherapy practice. Drawing on his extensive experience within the DAHANCA QA group and his work in head and neck radiotherapy, Hansen highlighted contouring variability as one of the most persistent challenges in radiation oncology. Despite advances in imaging, automation, and treatment delivery, variability in delineation continues to significantly influence treatment quality and outcomes. His discussion emphasised the value of ‘audit methodologies’ such as collaborative audits, benchmarking exercises, and shared learning in improving consistency across centres. He also explored how emerging technologies such as automated planning, AI-supported workflows, and NTCP modelling may support future quality assurance strategies while still requiring robust independent oversight.

Joanna Dodkins concluded the symposium with an overview of the UK’s National Cancer Audit Collaborating Centre (NATCAN) and the National Prostate Cancer Audit (NPCA). Using linked national datasets, the NPCA enables benchmarking of radiotherapy outcomes and treatment-related side effects across approximately 50 radiotherapy centres in England and Wales. Transparent reporting and risk-adjusted analyses have helped identify both positive and negative outliers, therefore ‘driving quality improvement activity’ and shared learning opportunities. The audit has also generated important evidence supporting IMRT and hypofractionated treatments while identifying drivers of variation, including contouring practice, image guidance, dosimetry, and bowel and bladder preparation protocols.

Overall, the symposium provided compelling evidence that well-designed clinical audits are powerful drivers of excellence in radiotherapy. Through benchmarking, peer review, transparent reporting, and shared learning, audit programmes are helping departments improve safety, reduce variability, and strengthen confidence in increasingly complex radiotherapy technologies.

Maeve Kearney

Assistant Professor

Discipline of Radiation Therapy, Trinity College Dublin, Ireland

Email mkearne@tcd.ie

LinkedIn: https://www.linkedin.com/in/maeve-kearney