ESTRO 2026 Congress Report
Report by the ESTRO Positioning and Immobilisation Focus Group
The 2026 Congress of the European Society for Radiotherapy and Oncology (ESTRO) was held in Stockholm, Sweden, from 15–19 May 2026, bringing together radiation oncology professionals, Radiation Therapists (RTTs), medical physicists, clinicians, researchers, industry representatives, and patient advocates from around the world. Under the theme “Innovating Radiation Oncology, Together,” the congress highlighted the importance of collaboration, technological innovation, patient-centred care, and multidisciplinary teamwork in shaping the future of radiation oncology.
Adaptive Radiotherapy: From Offline to Real-time
Teaching lecture
This year, the Positioning and Immobilisation Journey focused strongly on Adaptive Radiotherapy (ART). Across four full days of scientific and educational sessions, participants had the opportunity to explore adaptive radiotherapy from different professional perspectives. The programme demonstrated how essential teamwork is in modern radiation oncology and emphasised that every member of the multidisciplinary team plays a critical role in delivering safe, precise, and personalised treatments.
One of the most interesting sessions attended was the teaching lecture entitled “Adaptive Radiotherapy: From Offline to Real-Time,” chaired by Denis Dudas and presented by Lotte Wilke, medical physicist at the University Hospital Zurich, Switzerland.
The lecture provided a comprehensive overview of the evolution of adaptive radiotherapy. Adaptive RT initially developed as an offline strategy designed to address systematic anatomical changes occurring over several treatment fractions. Over time, the field evolved toward online adaptive radiotherapy, capable of responding to day-to-day anatomical variability. Looking ahead, adaptive radiotherapy is now progressing toward real-time adaptation, where organ motion and anatomical changes can be monitored continuously during treatment delivery.
In the first part of the presentation, Lotte Wilke explained the workflow of adaptive radiotherapy and discussed the impact of treatment adaptation on clinical outcomes. She described how anatomical changes during a treatment course can influence dose distribution and potentially affect tumour control as well as toxicity to organs at risk. Through adaptive approaches, treatment plans can be adjusted to better reflect the patient’s anatomy, improving precision and treatment quality.
The second part of the lecture focused on online adaptive radiotherapy. This approach considers daily anatomical variations, including organ filling and positional changes. Compared to offline ART, online adaptation requires a different and more complex workflow because the patient remains on the treatment couch while imaging, contour adaptation, plan optimisation, and quality assurance are performed. Therefore, efficiency and speed are essential, with the aim of completing the adaptive workflow within minutes. Different strategies and technologies for online adaptive treatment were presented, demonstrating how centres are implementing these techniques in clinical practice.
An important topic discussed during the session was whether there is sufficient clinical evidence supporting improved outcomes with adaptive radiotherapy. The presentation highlighted emerging evidence showing that adaptive techniques can lead to better target coverage, improved treatment accuracy, and reduced toxicity for patients. These benefits are particularly relevant for tumour sites affected by significant anatomical changes or organ motion.
The final part of the lecture explored the future direction of real-time adaptive radiotherapy. Real-time ART aims to continuously monitor organ motion during treatment delivery, such as lung, liver, or cardiac movement, and to adapt or gate the radiation beam accordingly. This represents a major technological advancement with the potential to further improve treatment precision while protecting surrounding healthy tissues.
Overall, the ESTRO 2026 Congress successfully demonstrated how adaptive radiotherapy is transforming radiation oncology. The Positioning and Immobilisation Journey provided valuable insights into the technological, clinical, and collaborative aspects of ART, reinforcing the importance of multidisciplinary teamwork in delivering innovative and patient-centred cancer care.
Ghizela Ana Maria Salagean, PhD
Expert in Medical Physics
TopMed Medical Centre
ESTRO –Positioning and Immobilisation FG
Anamaria.salagean.21@gmail.com
LinkedIn LinkedIn Ghizela Ana Maria Salagean - PhD
Patient experience and quality of life: from technical precision to personalised care
The RTT mini-oral session “Accuracy, adaptation and patient experience,” chaired by Orla McKivitt (Ireland) and William Kinnaird (UK), brought together presentations spanning the entire radiotherapy pathway, from treatment preparation and positioning reproducibility to survivorship and long-term quality of life. While the topics ranged from liver stereotactic body radiotherapy (SBRT) setup accuracy to treatment-related sexual dysfunction and prehabilitation, a common message emerged throughout the session: optimising radiotherapy requires more than technical precision alone. Increasingly, RTT-led research is focusing on how preparation, adaptation, communication and supportive care influence patient outcomes before, during and after treatment.
The session opened with a presentation by Nicola Iosca (Italy) examining whether body mass index (BMI) influences the reproducibility of abdominal compression during liver SBRT. Although mean translational and rotational setup errors were similar between BMI groups, patients with higher BMI demonstrated significantly greater setup variability and more frequent translational shifts exceeding 1 cm. These findings suggest that while abdominal compression remains an effective motion management strategy, reproducibility may be reduced in patients with higher BMI, supporting a more personalised approach to immobilisation and motion management.
This theme of individualised preparation continued in the presentation by Sophie Boisbouvier (France), who reported results from the multicentre phase III ETADAPT trial. The study investigated whether therapeutic patient education combining dietary counselling and adapted physical activity could improve rectal reproducibility during prostate radiotherapy. Surprisingly, the intervention did not reduce repositioning rates. However, repositioning rates were substantially lower than anticipated in both study groups. The investigators suggested that providing structured oral and written information to all patients, including those receiving standard care, may itself have improved preparation and reduced variability. The findings raise important questions about how the benefits of patient education should be evaluated and whether technical endpoints alone adequately capture its value.
The focus then shifted towards patient experience and quality of life. Rebecca Shakir (UK) presented outcomes from a radiographer-led Macmillan radiotherapy late-effects service established in Oxford. Since its launch in September 2024, the service has received more than 140 referrals, with most patients managed directly by radiographers. Seventy per cent of patients reported improvements in health-related quality of life, while patients consistently highlighted the value of having time to discuss symptoms and receive clear explanations regarding radiotherapy-related late effects. Particularly compelling were the patient-reported outcomes and testimonials presented during the session, illustrating both the clinical and personal impact of dedicated survivorship support. The study demonstrated the expanding contribution of advanced practice radiographers in multidisciplinary survivorship care.
Technological innovation and its impact on patient experience were explored in two subsequent presentations. Alex Price (USA) investigated whether accelerated cone-beam computed tomography (CBCT) acquisition using higher gantry rotation speeds increased patient anxiety. Despite concerns that faster machine movements might be distressing, anxiety levels remained low throughout the study and decreased over time, suggesting that familiarity with the imaging process plays a greater role than machine speed itself.
Similarly, Celina Mandy Höhne (Germany) compared patient-reported experiences during daily CBCT-based online adaptive radiotherapy and conventional image-guided radiotherapy (IGRT) for prostate cancer. Although adaptive workflows increased treatment session duration by approximately 16 minutes, overall patient satisfaction remained high, with no significant differences observed between treatment approaches. Together, these studies provide reassuring evidence that increasingly sophisticated radiotherapy technologies can be implemented without compromising patient experience.
One of the most thought-provoking presentations of the session was delivered by William Kinnaird (UK), who explored treatment-related sexual dysfunction in men with advanced prostate cancer. Through qualitative interviews, participants described profound effects on relationships, identity, self-confidence and emotional well-being. Many felt that healthcare services prioritised oncological outcomes while offering insufficient support for quality-of-life concerns. The patient quotations presented during the session vividly illustrated the emotional burden associated with treatment-related sexual dysfunction and the need for more holistic care approaches. Notably, patients who adapted their expectations and redefined intimacy appeared to cope more successfully than those focused solely on restoring previous sexual function.
The session concluded with Nisha Bhudia (UK) presenting a pilot study evaluating a multimodal prehabilitation programme for prostate cancer patients before radiotherapy. Combining education, exercise, psychological support and peer interaction, the programme significantly reduced anxiety levels. Patients identified increased knowledge, peer support and improved understanding of treatment as key contributors to reduced distress and greater confidence before treatment initiation.
Taken together, the presentations highlighted an important evolution in RTT-led research. While accurate positioning, immobilisation and image guidance remain fundamental to high-quality radiotherapy, equal attention is increasingly being directed towards outcomes that matter most to patients. Whether through personalised preparation strategies, patient education, adaptive treatment workflows, survivorship services or psychosocial support, the studies collectively demonstrated that the future of radiotherapy lies not only in delivering treatment more precisely, but also in supporting patients more effectively across the entire radiotherapy journey.
Siret Kivistik MSc, doctoral researcher
Quality manager RTT, Tartu University Hospital
Principal Lecturer, Tartu Applied Health Sciences University
Estonia
Patient Positioning in the Year 2026: Updates in Positioning and Immobilisation
Symposium Report
The ESTRO congress 2026 was held in Stockholm from 15 to 19 May 2026, bringing together radiation oncology professionals, RTTs, physicists, clinicians, researchers, industry experts, and patients from across the world. The congress theme, “Innovating Radiation Oncology, Together,” highlighted collaboration, technological advancement, patient-centred care, and multidisciplinary innovation in shaping the future of radiation oncology.
One of the well-attended symposium sessions was “Patient Positioning in the Year 2026: Updates in Positioning and Immobilisation.” Chaired by Jenna Dean and Mirjam Mast, the symposium attracted significant attention because patient positioning and immobilisation remain fundamental components of precision radiotherapy. With advancements in patient preparation, proton therapy, motion management technologies and patient positioning, the symposium highlighted how radiotherapy practice is moving toward more personalised and patient-centred treatment approaches.
A key message throughout the symposium was the importance of patient preparation, positioning and immobilisation to optimise and personalise the treatment accuracy and improve patient experience. Speakers emphasised holistic and patient-centred care approaches, balancing treatment precision with patient comfort, emotional well-being, and shared decision-making.
The audience response was positive and interactive. Participants appreciated the practical clinical relevance of the topics presented, especially discussions around personalised immobilisation, motion management, and reducing unnecessary patient preparation burdens.
The first presentation, “Should We Continue Rectal Preparation for Prostate Cancer Radiotherapy?” was delivered by Sophie Alexander. The presentation questioned the continued necessity of strict rectal preparation protocols in the era of advanced IGRT. Clinical findings demonstrated acceptable prostate motion management without strict preparation while improving patient comfort and reducing treatment burden. It showed the differences between patients, even when they followed the preparation protocols, and found that the rectal volume was more consistent without following the preparation protocols. The presentation stressed the importance of personalised preparation strategies rather than applying the same protocol to every patient.
The second lecture, “P&I National Guidelines in Proton Therapy,” was presented by Malin Kügele. The session focused on the importance of standardised positioning and immobilisation protocols in proton therapy due to the sensitivity of proton beams to anatomical variations and setup uncertainties. The workflow optimisation, quality assurance, and multidisciplinary collaboration were discussed to ensure safe and precise proton therapy delivery for each individual patient. Finally, the future of the slit collimator for using small grids was highlighted as well. This refers to spatially fractionated radiation therapy (SFRT) and microbeam radiation therapy (MBRT). Instead of a continuous uniform field, these systems use multi-slit collimators to divide the beam into an array of micro-beams or "grids," delivering high peak doses separated by low valley doses.
In the third presentation, “Immobilisation and Mobile Tumours Treatment: A Challenging Paradox…?” Christel Abdel Massih explored the balance between respiratory motion management and patient experience in thoracic and abdominal tumours. Advanced motion management techniques, including the Mechanically Assisted Non-Invasive Ventilation (MANIV) approach, were discussed along with workflow adaptation, staff training and experience, and patient feedback. The gain of using MANIV in the treatment of these patients is the decrease in the tumour movement and the improvement of the quality of the CBCT images for position verification.
The final presentation, “One Size Doesn’t Fit All: Personalising Immobilisation and Margins in Head & Neck Radiation Therapy,” was presented by Roisin O Maolalai. Findings from the OPEN trial demonstrated that open-face masks achieved comparable treatment accuracy while significantly improving patient comfort and reducing distress during treatment. The presentation also highlighted the role of SGRT in personalised radiotherapy and the potential for personalised margin reduction in selected patients. The OPEN trial revealed that 30% of the patients were lying stable during their treatment in the OPEN trial. When you see the motion better with SGRT, you can begin personalising immobilisation and margins. Patient feedback further emphasised the importance of communication, emotional support, and shared decision-making throughout the treatment process. Roisin stated that the future lies in understanding which patient needs which level of immobilisation and which margin. In addition, the patient needs to be involved in this.
Overall, the symposium highlighted the rapid evolution of patient positioning and immobilisation techniques in radiation oncology. Advances in patient preparation, immobilisation, motion management, and personalised treatment approaches continue to improve treatment precision, workflow efficiency and patient experience. The symposium strongly reflected the ESTRO 2026 theme, “Innovating Radiation Oncology, Together,” by promoting innovation, collaboration, and patient-centred advancements in modern radiotherapy practice. The session gave the participants some food for thought to bring back to their departments.
This house believes that online adaptive radiotherapy demands a major overhaul of RTT educational programmes
Debate Session Report
This engaging debate session at ESTRO 2026 focused on the evolving role of RTTs in the era of online adaptive radiotherapy (oART). Chaired by Rita Simoes and Sophie Boisbouvier, the session featured both clinical and educational perspectives presented for and against the motion. Four international experts presented contrasting perspectives on whether RTT educational programmes require a complete transformation or gradual adaptation to meet future clinical demands. The debate generated significant discussion among attendees and highlighted the growing importance of adaptive radiotherapy in modern cancer care.
Claudio Votta – For the Motion (Clinical Perspective)
Claudio Votta opened the debate with the clinical perspective supporting the motion. He explained that the rapid implementation of online adaptive radiotherapy is fundamentally changing radiotherapy workflows and significantly expanding the responsibilities of RTTs. He highlighted that RTTs are increasingly required to perform advanced image assessment, adaptive workflow management, contour review, and real-time decision-making during treatment delivery.
He stressed that future RTTs will need greater autonomy and deeper technical and clinical expertise to manage adaptive radiotherapy safely and efficiently. Claudio Votta advocated for major educational reform that incorporates advanced imaging, AI-assisted adaptive workflows, online treatment adaptation, and multidisciplinary clinical training into RTT educational programmes. According to him, the future of precision radiotherapy demands more specialised and comprehensive RTT education. This should be started in time to prevent us from falling too far behind with this education.
Helen McNair – Against the Motion (Clinical Perspective)
Helen McNair presented the clinical argument against the motion and emphasised that online adaptive radiotherapy should be considered an evolution rather than a complete transformation of RTT practice. She explained that radiotherapy has continuously evolved over many decades through technological progress, role extension, and clinical adaptation. She highlighted that the core principles of radiotherapy — including patient preparation, immobilisation, imaging, contouring, planning, verification, and treatment delivery — remain fundamentally unchanged despite advances in adaptive technologies.
She strongly advocated for continuing professional development (CPD), mentorship, experiential learning, and competency-based education rather than completely redesigning RTT educational programmes. According to Helen McNair, existing ESTRO core curricula already provide strong foundations for RTT practice, and adaptive radiotherapy skills can be successfully integrated through focused expansion of current educational systems.
Rianne de Jong – For the Motion (Educational Rebuttal)
Rianne de Jong delivered the educational rebuttal in support of the motion. She emphasised that online adaptive radiotherapy is rapidly transforming the professional identity of RTTs and creating new educational demands. She highlighted that RTTs are now expected to develop advanced competencies in adaptive planning, image interpretation, contour evaluation, AI-supported technologies, and clinical decision-making.
According to Rianne de Jong, these evolving responsibilities require structured educational reform and updated academic curricula to ensure RTTs are adequately prepared for future adaptive radiotherapy practice. She stressed the importance of specialised competency-based education, simulation training, and integration of adaptive radiotherapy concepts into formal RTT educational programmes to maintain high standards of patient care and treatment safety.
Winnie Li – Against the Motion (Educational Rebuttal)
Winnie Li presented the educational rebuttal against the motion and supported targeted adaptation within existing RTT educational frameworks rather than a complete overhaul. She highlighted that current RTT education already provides strong clinical and technical foundations that can be enhanced through specialised training, mentorship, and continuous professional development.
She emphasised the importance of competency-based learning, interdisciplinary collaboration, practical clinical experience, and departmental training in helping RTTs adapt to online adaptive radiotherapy. Winnie Li explained that collaboration between academic institutions, clinical departments, and professional societies is essential for supporting RTT professional growth while maintaining flexibility within educational systems. She reinforced that gradual adaptation and continuous learning are more practical and sustainable approaches for the future of RTT education. “Undergraduate education introduces the oART. Postgraduate and clinical education focus on hands-on training, credentialing and local protocol mastery”.
Debate Outcome and Audience Voting
The debate generated excellent audience participation and discussion throughout the session. Before the debate, audience voting showed strong support for the motion, with 71% voting in favour and 29% against. However, after hearing the arguments from all four expert speakers, the final voting results changed significantly. Post-debate voting showed that 56% of participants voted against the motion, while 44% remained in favour.
The outcome demonstrated the strong impact of the arguments presented by Helen McNair and Winnie Li, who successfully convinced many attendees that targeted educational adaptation and CPD within existing RTT educational frameworks may be more practical and sustainable than implementing a complete educational overhaul. Overall, the debate highlighted the rapidly evolving role of RTTs and the importance of balancing innovation, education, and professional development in the future era of adaptive radiotherapy.
“Adaptive radiotherapy is not just transforming technology — it is reshaping the future role, responsibility, and continuous learning journey of RTTs worldwide.”
