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As a consequence of daily image guidance in the world of radiotherapy, we have expanded our knowledge regarding the everchanging human anatomy. It can be a struggle to handle this knowledge, because while the margins can be reduced, the target and organs at risk should ideally remain static intra- and inter-fractional during the entire treatment course. As we are all human beings, and especially when treating in the pelvic region, this is nearly impossible. Some of the strategies to cope with this could be having a Library of Plans to choose from or using real-time adaptation.

The patients spend more time on the couch when they are treated with online adaptive radiotherapy, and they have to get something in return. In the first part of this debate, I will do my best to provide the evidence, based on the advantages found in both literature and experience, that the real-time adaptation strategy is indeed the way going forward.