Clinical practice, barriers to implementation, and priorities for equitable access of Stereotactic Body Radiation Therapy: An analysis of the global status by the ESTRO SBRT Focus Group

Ciro Franzese^{1

2}, Stephanie Tanadini-Lang³, Dirk Verellen⁴, Lisa Wiersema⁵, Juliane Hörner-Rieber⁶, Alejandra Méndez Romero⁷, David Pasquier^{8

9}, Anna Bruynzeel¹⁰, Judit Boda-Heggemann^{11

12}, Tom Depuydt¹³, Patrik Sibolt¹⁴, Najma Douir¹⁵, Łukasz Kuncman^{16

17}, Casper Beijst¹⁸, Harley Stephens¹⁹, Carolina de la Pinta²⁰, Francesco Cuccia²¹, Maaike Milder⁷, Luca Nicosia²², Hiroshi Onishi²³, Alexander V Louie²⁴, Arjun Sahgal²⁴, Simon S Lo²⁵, Ben J Slotman¹⁰, Matthias Guckenberger³, Marta Scorsetti^{1

2}

Affiliations

¹ Department of Biomedical Sciences, Humanitas University, Milan, Italy.
² IRCCS Humanitas Research Hospital, Dept of Radiotherapy and Radiosurgery, Milan, Italy.
³ Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Zurich, Switzerland.
⁴ Department of Radiation Oncology, Iridium Network, Wilrijk (Antwerp), Belgium, Integrated Personalised and Precision Oncology Network, University Antwerp, Antwerp, Belgium.
⁵ Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, the Netherlands.
⁶ Department of Radiation Oncology, Duesseldorf University Hospital, Duesseldorf, Germany.
⁷ Department of Radiotherapy, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, the Netherlands.
⁸ Academic Department of Radiation Oncology, Centre Oscar-Lambret, Lille, France.
⁹ Lille University, CRIStAL CNRS UMR, 9189 Lille, France.
¹⁰ Department of Radiation Oncology, Amsterdam UMC, Vrije Universiteit, Amsterdam, Netherlands, Cancer Center Amsterdam, Amsterdam, Netherlands.
¹¹ Department of Radiation Oncology, University Medical Center Mannheim, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany.
¹² DKFZ-Hector Cancer Institute, University Medical Center Mannheim, Mannheim, Germany.
¹³ University Hospitals Leuven, Radiation Oncology, Belgium.
¹⁴ Department of Oncology, Copenhagen University Hospital - Herlev and Gentofte, Copenhagen, Denmark.
¹⁵ Department of Radiation Oncology, Gustave Roussy, Université Paris-Saclay, Villejuif, France.
¹⁶ Department of Radiotherapy, Medical University of Lodz, Łódź, Poland.
¹⁷ Department of External Beam Radiotherapy, Copernicus Memorial Hospital in Lodz Comprehensive Cancer Center and Traumatology, Łódź, Poland.
¹⁸ Department of Radiotherapy, Utrecht University and University Medical Center Utrecht, Utrecht, the Netherlands.
¹⁹ University Hospitals Bristol and Weston, United Kingdom.
²⁰ Radiation Oncology, Ramón y Cajal University Hospital, Madrid. Biomarkers and Therapeutic Targets Group, IRYCIS, Madrid, Spain.
²¹ Radiation Oncology, ARNAS Civico Hospital, Palermo, Italy.
²² Advanced Radiation Oncology Department, IRCCS Sacro Cuore Don Calabria Hospital, Cancer Care Center, Verona, Italy.
²³ Department of Radiology, University of Yamanashi, Yamanashi, Japan.
²⁴ Department of Radiation Oncology, Sunnybrook Health Science Centre, University of Toronto, Ontario, Canada.
²⁵ Department of Radiation Oncology and Department of Neurological Surgery, University of Washington and Fred Hutchinson Cancer Center, Seattle, Washington, USA.

PMID: 41502557
PMCID: PMC12771324
DOI: 10.1016/j.ctro.2025.101096

Clinical practice, barriers to implementation, and priorities for equitable access of Stereotactic Body Radiation Therapy: An analysis of the global status by the ESTRO SBRT Focus Group

Ciro Franzese et al. Clin Transl Radiat Oncol. 2025.

. 2025 Dec 14:57:101096.

doi: 10.1016/j.ctro.2025.101096. eCollection 2026 Mar.

Authors

Affiliations

¹ Department of Biomedical Sciences, Humanitas University, Milan, Italy.
² IRCCS Humanitas Research Hospital, Dept of Radiotherapy and Radiosurgery, Milan, Italy.
³ Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Zurich, Switzerland.
⁴ Department of Radiation Oncology, Iridium Network, Wilrijk (Antwerp), Belgium, Integrated Personalised and Precision Oncology Network, University Antwerp, Antwerp, Belgium.
⁵ Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, the Netherlands.
⁶ Department of Radiation Oncology, Duesseldorf University Hospital, Duesseldorf, Germany.
⁷ Department of Radiotherapy, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, the Netherlands.
⁸ Academic Department of Radiation Oncology, Centre Oscar-Lambret, Lille, France.
⁹ Lille University, CRIStAL CNRS UMR, 9189 Lille, France.
¹⁰ Department of Radiation Oncology, Amsterdam UMC, Vrije Universiteit, Amsterdam, Netherlands, Cancer Center Amsterdam, Amsterdam, Netherlands.
¹¹ Department of Radiation Oncology, University Medical Center Mannheim, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany.
¹² DKFZ-Hector Cancer Institute, University Medical Center Mannheim, Mannheim, Germany.
¹³ University Hospitals Leuven, Radiation Oncology, Belgium.
¹⁴ Department of Oncology, Copenhagen University Hospital - Herlev and Gentofte, Copenhagen, Denmark.
¹⁵ Department of Radiation Oncology, Gustave Roussy, Université Paris-Saclay, Villejuif, France.
¹⁶ Department of Radiotherapy, Medical University of Lodz, Łódź, Poland.
¹⁷ Department of External Beam Radiotherapy, Copernicus Memorial Hospital in Lodz Comprehensive Cancer Center and Traumatology, Łódź, Poland.
¹⁸ Department of Radiotherapy, Utrecht University and University Medical Center Utrecht, Utrecht, the Netherlands.
¹⁹ University Hospitals Bristol and Weston, United Kingdom.
²⁰ Radiation Oncology, Ramón y Cajal University Hospital, Madrid. Biomarkers and Therapeutic Targets Group, IRYCIS, Madrid, Spain.
²¹ Radiation Oncology, ARNAS Civico Hospital, Palermo, Italy.
²² Advanced Radiation Oncology Department, IRCCS Sacro Cuore Don Calabria Hospital, Cancer Care Center, Verona, Italy.
²³ Department of Radiology, University of Yamanashi, Yamanashi, Japan.
²⁴ Department of Radiation Oncology, Sunnybrook Health Science Centre, University of Toronto, Ontario, Canada.
²⁵ Department of Radiation Oncology and Department of Neurological Surgery, University of Washington and Fred Hutchinson Cancer Center, Seattle, Washington, USA.

PMID: 41502557
PMCID: PMC12771324
DOI: 10.1016/j.ctro.2025.101096

Abstract

Background: Stereotactic Body Radiation Therapy (SBRT) has become an established treatment for several primary and metastatic malignancies; however, considerable heterogeneity remains in its definition, clinical indications, and technical delivery.

Methods: In May 2025, the SBRT Focus Group of the European Society for Radiotherapy and Oncology (ESTRO), in collaboration with International Stereotactic Radiosurgery Society (ISRS), the Radiosurgery Society (RSS), and the Japanese Society for Radiation Oncology (JASTRO), conducted a global survey. A 44-item questionnaire explored SBRT indications, technical aspects, dose/fractionation, and barriers to implementation. Descriptive statistics summarized the responses.

Results: Overall, 289 professionals from 59 countries participated. Routine use of SBRT was reported by 96.6 % of respondents, with lung, bone, liver and prostate as the most frequent indications. Pancreatic tumor (48.4 %), renal cell carcinoma (46.4 %), and ventricular tachycardia (12.4 %) represented emerging indications. C-arm linacs (89.2 %) and in-room Cone beam CT (CBCT) (92.0 %) were the dominant technologies. Motion management relied mainly on 4D-CT internal target volume (ITV) (88.9 %) and deep inspiration breath-hold (DIBH) (57.8 %). Fractionation was consistent for lung and prostate but heterogeneous for liver, and pancreas. Only 3.5 % reported routine use of online adaptive SBRT, while 61.5 % reported artificial intelligence (AI) use, mainly for organs-at-risk delineation. Key barriers included limited clinical trial funding (35.2 %), high equipment costs (34.2 %), insufficient reimbursement (27.7 %), and workforce shortages (33.9 %).

Conclusions: This ESTRO international survey provides the first global overview of SBRT practices. It demonstrates broad adoption but also substantial variability, highlighting the need for consensus guidelines, greater trial access, and expanded education to harmonize SBRT delivery and ensure equitable care worldwide.

Keywords: Ablative radiotherapy; Advanced radiotherapy; Radiation oncology; SABR; SBRT; Stereotactic body radiation therapy; Stereotactic radiotherapy.

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Conflict of interest statement

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Figures

**Fig. 1**
Distribution of the most frequently reported SBRT indications.

**Fig. 2**
Technical platforms and planning approaches for SBRT.

See this image and copyright information in PMC

References

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Clinical practice, barriers to implementation, and priorities for equitable access of Stereotactic Body Radiation Therapy: An analysis of the global status by the ESTRO SBRT Focus Group

Affiliations

Clinical practice, barriers to implementation, and priorities for equitable access of Stereotactic Body Radiation Therapy: An analysis of the global status by the ESTRO SBRT Focus Group

Authors

Affiliations

Abstract

Conflict of interest statement

Figures

References

LinkOut - more resources

Full Text Sources