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Hypofractionation & Ultra-hypofractionation

 

Hypofractionation and Ultra-hypofractionation

 

Chairs: 

  • Beate Timmermann, Radiation Oncologist, West German Proton Therapy Center Essen, Germany
  • Agata Rembielak, Radiation Oncologist, The Christie NHS Foundation Trust and The University of Manchester, Manchester, United Kingdom
  • Sofia Rivera, Radiation Oncologist, Institut Gustave Roussy, France

 

Speakers: 

  • Marianne Aznar, Medical Phycisist, University of Manchester and  The Christie NH, United Kingdom
  • Dorota Gabrys, Radiation Oncologist, MSC National Research Institute of Oncology, Poland
  • Mateusz Spałek, Radiation Oncologist, Maria Sklodowska-Curie National Research Institute of Oncology, Poland
  • Miet Vandemaele, Radiation Oncologist, Ugent, Belgium

 

Description: 

This theme is jointly organised by the ESTRO Breast Focus Group and the Skin & Soft Tissue Focus Group. It consists of five interactive sessions, each lasting 1-2 hours, with a focus on radiobiological, clinical, technical, and implementation aspects of hypo- and ultrahypofractionation, including brachytherapy. In order to prepare for the live workshop, a survey on hypo- and ultrahypofractionation will be distributed to partcipants before the workshop. In addition, participants will be invited to draft potential projects on hypo- and ultrahypofractionation to be discussed during the workshop.

 

Deliverables:

  • Recommendations on the type/frequency of PROMs, side effect and QoL tools in hypo- and ultrahypofractionation
  • White Paper:
    • Benefits and limitations of hypo- and ultrahypofractionation
    • Strategies for reimbursement, adoption, and international harmonisation
  • Educational material:
    • Introductory radiobiology lectures
    • Radiobiological exercises on hypo- and ultrahypofractionation schedules linked to tumour control and side effects

 

Disease sites of interest

  • Any disease site that is currently using or consider using hypo- and ultrahypofractionation

 

Outcomes:

  • Enhanced collaboration between physicians, clinicians, RTTs and other health care professionals involved in radiotherapy
  • Opportunities for funding and support to advance future trials

 

Target Audience:

Clinicians radiation oncologists/clinical oncologists/medical oncologist/, early-career professionals, researchers interested in hypo- and ultrahypofractionation

 

Why Attend?

  • Gain a multidisciplinary perspective on hypo-/ultrahypofractionation

  • Learn from leading experts across Europe

  • Contribute to shaping future practice, guidelines, and collaborative projects

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Detailed programme

Session 1: Radiobiology (120 mins)

 

Topics

  • Basics of Radiobiology: A Pre-recorded Introduction
  • Hypofractionation & Ultrahypofractionation: Setting the Stage, Clinical Implications in EBRT and Brachytherapy
  • Interactive Hands-on Live Dose Calculations: Exploring Fraction Size and Tissue Effects

Generate deliverables (60’):

  • Establishing BED/EQD2 table recommendation for clinical scenarios
  • Benefits and limitations of hypo- and ultrahypofractionation in radiobiology
  • Strategies for reimbursement/availability, adoption and international harmonisation in radiobiology

 

Overview
This session covers the basic radiobiology principles relevant to hypo- and ultrahypofractionated radiotherapy. As a homework, a prerecorded lecture on radiobiology basics will be provided. To start the session, a live introduction to the clinical context will presented. Interactive dose calculations will demonstrate the impact of fraction size and treatment time on tumor control and normal tissue effects, with a special focus on brachytherapy schedules.

 

Learning Outcomes

By the end of this session, participants will be able to:

  1. Explain key radiobiology concepts related to fractionation.
  2. Compare different fractionation schedules using biologically effective dose (BED).
  3. Understand how fraction size and treatment time affect tissue responses.
  4. Apply radiobiological models to clinical scenarios, including brachytherapy.

 

Teaching Points

  • Linear-quadratic model and its clinical relevance
  • Effect of fraction size on tumor and normal tissue response
  • Importance of treatment time (daily vs. weekly fractions)
  • Integration of brachytherapy into hypo/ultrahypofractionation
  • Practical exercises using BED/EQD2 calculations

 

Session 2: Medical Physics & Technology (120 mins)

 

Topics:

  • Cutting-Edge Technologies in Hypofractionation: SBRT, FLASH, Protons, Brachytherapy & Dosimetric Challenges
  • Interactive subgroup session (groups assigned by speakers: SBRT, FLASH, protons, brachytherapy): Technological strengths and limits of each technology used for Hypo- and Ultrahypofractionation
  • Generate deliverables:
    • Presentation of subgroup findings
    • Benefits and limitations of cutting-edge technologies for hypo- and ultrahypofractionation
    • Strategies for reimbursement/availability, adoption, and international harmonisation

 

Overview

This session focuses on the incorporation of cutting-edge technologies such as FLASH, Proton therapy, SBRT radiotherapy and brachytherapy into hypo- and ultrahypofractionated treatment schedules. It also addresses dosimetric challenges that arise with these approaches. The latter interactive part of the session explores additional challenges like availability, required resources, and standardization.

 

Learning Outcomes

By the end of this session, participants will be able to:

  1. Describe advanced radiotherapy technologies applicable to hypo/ ultrahypofractionation, including SBRT, FLASH, proton therapy and brachytherapy.
  2. Identify key dosimetric challenges when implementing these technologies.
  3. Understand    the    biological    constraints    of    hypo- and ultrahypofractionation          versus conventional fractionation.
  4. Evaluate how these limitations affect clinical decision-making and treatment planning.
  5. Understand issues with availability and limitation in resources.

 

Teaching Points

  • Overview of FLASH radiotherapy and its potential benefits and challenges
  • Role and integration of brachytherapy in hypo/ultrahypofractionated regimens
  • Dosimetric complexities in advanced treatment delivery (e.g., dose heterogeneity, quality assurance)
  • Biological compensation limits in hypo/ultrahypofractionation compared to standard fractionation
  • Impact of these (among other) limitations on normal tissue tolerance and tumor control
  • Clinical implications for treatment planning and outcome optimization

 

 

Session 3: Cosmesis, PROMs & Clinical Outcomes (60 min)

 

Topics:

  • Current PROMs & Cosmesis Scales: Usage, Limitations, and Future Needs
  • Developing QoL tools & patients involvement
  • Whole group discussion on deliverables:
    • The role of brachytherapy’s in optimizing cosmetic and fucntional outcomes
    • Benefits and limitations of PROMS as primary or secondary outcome in trials
    • Delivering PROMS in stretched health care resources
    • International harmonisation, language, cultural differences in PROMs

 

Overview

This session covers the assessment tools used to evaluate cosmesis and side effects in patients undergoing hypo- and ultrahypofractionated radiotherapy. It reviews current patient- reported outcome measures (PROMs), including their frequency of use and the need for updates, with a special focus on the EORTC Quality of Life Group (QLG) initiatives. The session will also interactively highlight the role of brachytherapy in achieving favorable aesthetic outcomes.

 

Learning Outcomes

By the end of this session, participants will be able to:

  1. Identify validated tools for assessing cosmesis and treatment-related side effects.
  2. Understand current PROMs and lack of widely accepted cosmesis scales, including their clinical application and limitations
  3. Recognize the importance of updating assessment tools to better capture patient outcomes.
  4. Describe the contribution of brachytherapy to cosmetic results in hypo-/ultrahypofractionated treatments.

 

Teaching Points

  • Overview of common cosmesis and side effect evaluation tools
  • Current PROMs and cosmesis scales, with emphasis on EORTC QLG frameworks
  • Frequency and timing of assessments in clinical practice
  • Challenges and opportunities in updating and developing new assessment tools
  • Impact of brachytherapy on aesthetic outcomes compared to external beam radiotherapy
  • Integration of patient-reported outcomes in clinical decision-making and research

 

Session 4: Quality Indicators & Clinical Implementation (120 min)

 

Topics:

  • Quality Indicators in Clinical Radiotherapy and Defining Minimal Quality Indicator Datasets Across Tumour Sites: A Global Perspective (including Low-Middle Income Countres (LMIC) and “green radiotehrapy“
  • Quality assurance in hypo- and ultrahypofractionation
  •  Generate deliverables discussion:
    • How to introduce quality specific indicators in clinical practice
    • What is minimal requirements and what is “nice to have” in quality indicators?
    • Is current QA ready and fit for hypo- and ultrahypofractionation?
    • Can there be a pan-European standard for quality indicators and QA?

 

Overview

This session highlights the importance of quality indicators (QIs) in clinical radiotherapy. It further discusses proposals for establishing minimal QI datasets across different tumour sites to improve treatment consistency and outcomes. In addition, implementation in LMICs, and environmentally sustainable (“green”) radiotherapy practices that reduce patient travel and treatment times will be tackled. From the physics point of view, QA prerequisites for hypo- and ultrahypofractionation will be covered.

 

Learning Outcomes

By the end of this session, participants will be able to:

  1. Explain the role and importance of quality indicators in radiotherapy practice.
  2. Identify key quality indicators relevant to multiple tumour sites.
  3. Appreciate the need for standardized minimal QI datasets to support clinical practice and research.
  4. Acknowledge impact of hypo- and ultrahypofractionation for LMIC and “green” RT.
  5. Understands challenges for physics QA measures in hypo- and ultrahypofractionation.

 

Teaching Points

  • Definition and clinical relevance of quality indicators (QIs) in radiotherapy
  • Overview of hypofractionation QI harmonisation project: aims and impact
  • Examples of proposed minimal QI datasets for various tumour types
  • Role of QIs in quality assurance, benchmarking, and improving patient outcomes
  • Challenges in developing and implementing standardized QIs
  • Future directions for QI research and international collaboration
  • Potential role of hypo- and ultrahypofractionation in LMIC and “green” RT
  • QA measure to take into account when doing hypo and ultrahypofractionation

 

Session 5: Unmet Needs and Future Directions (90 min)

 

Topics:

  • Holistic perspective on quality in clinical radiation oncology with emphasis on hypo- and ultrahypofractionation
  • Gaps and challenges in trials on hypo- and ultrahypofractionation
  • General discussion:
    • Ideas and experiences from the participants on developing and delivering clinical trials in hypofractionation
    • Presentation and discussion on projects around hypo- and ultrahypofractionation submitted by participants (group feedback and brainstorming exercise) by participants

 

Overview

In this wrap-up session, general aspects of quality in RT and scientific challenges with regard to hypo- and ultrahypofractionation will be highlighted. The interactive part of the session invites participants and ESTRO Focus Groups (FGs) / Working Groups (WGs) to present and discuss ongoing or planned projects related to hypo- and ultrahypofractionation. Through group feedback and brainstorming, key unmet needs will be further elaborated.

 

Learning Outcomes

By the end of this session, participants will be able to:

  1. Share and critically evaluate current and proposed projects related to hypo- and ultrahypofractionation.
  2. Identify major gaps in clinical QA, clinical trials and research for hypo- and ultrahypofractionation.
  3. Discuss challenges and opportunities for implementing hypo- and ultrahypofractionation.

 

Teaching Points

  • Overview of participant-submitted and ESTRO FG/WG projects on hypo- and ultrahypofractionation
  • Identification of unmet clinical and research needs, including trial gaps
  • Consider various levels of clinical QA
  • Collaborative brainstorming to prioritize future research and implementation strategies
  • Encouraging multi-disciplinary and international cooperation for advancing hypo- and ultrahypofractionation