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Hypofractionation of radiotherapy

Hypofractionation of radiotherapy

What changed?

  • During the COVID-19 pandemic, a number of national and international cancer organisations and research associations, including the American Society for Radiation Oncology (ASTRO) and the European Society for Radiotherapy and Oncology (ESTRO), recommended that hypofractionated or short-course regimens be used where appropriate, to limit patient volumes in clinics and reduce risk to staff, and that increased use of hypofractionation be employed where possible for cancer patients with suspected or confirmed COVID-19.1,2,3,4
  • The use of hypofractionated schedules increased in Australia and internationally for selected cancers, such as head and neck cancers, non-melanoma skin cancers and breast cancers.5,6,7

Impact of change

  • There is evidence to suggest that, for select patients and cancers, hypofractionation of radiotherapy is not inferior to standard fractionation in terms of local and distant recurrence, cosmetic outcomes and overall survival;8 is not associated with increased toxicity;9 may result in improved quality of life for patients; and may be more appropriate compared to conventional radiotherapy.7,10
  • Reducing the number of required clinic visits can minimise patient exposure to sources of infection and counteracts the increased pressure on the healthcare system during the pandemic.11,12
  • There is unwarranted variation in the use of hypofractionation for several reasons and country-based differences, including availability of schedules, differences in training of health professionals, funding models and willingness to adopt new models.7,10 The nature and extent of such variations during the COVID-19 pandemic is unclear.10

How can high-value changes be embedded or enhanced?

The following strategies were identified in Australian and international literature and by leading Australian cancer experts and consumers. This list is provided to prompt considerations and future strategies to support high-value cancer care in the Recovery phases of the COVID-19 pandemic.

These strategies are listed at the system-, service-, practitioner-, and patient-levels and are intended to be used by a range of cancer control stakeholders across Australia to support high-value cancer care and improve outcomes for people with cancer.

System-level strategies

  • Undertaking an economic evaluation to determine cost-effectiveness of the use of hypofractionation of radiotherapy compared to standard fractionation, in order to support the safe and appropriate use of hypofractionated radiotherapy and help minimise unwarranted variation in practice.10
  • Reviewing approaches to support increased uptake of hypofractionation in the delivery of radiotherapy, where appropriate for the patient.7

Service-level strategies

  • Developing and distributing tumour-specific, evidence-based and validated guidance and recommendations for the use of hypofractionated radiotherapy, including information on patient eligibility, standardised dose and fractionation schedules, and safety and toxicity concerns. Best-practice recommendations should be shared formally and via electronic means;13 this may require further research.10

Practitioner-level strategies

  • Educating and training health professionals on the appropriate use of hypofractionated radiotherapy to minimise unwarranted variations in practice.7,14

Patient-level strategies

  • Increasing adoption of the use of patient-reported outcome measures to evaluate the use of hypofractionated radiotherapy in terms of patient quality of life, with a focus on safety and toxicity.10,15



[1] American Society for Radiation Oncology (ASTRO). COVID-19 Recommendations and Information. Accessed: June 2020;

[2] Gasparri ML, Gentilini OD, Lueftner D et al. Changes in breast cancer management during the Corona Virus Disease 19 pandemic: An international survey of the European Breast Cancer Research Association of Surgical Trialists (EUBREAST). Breast. 2020;52:110-5.

[3] Slotman BJ, Lievens Y, Poortmans P et al. Effect of COVID-19 pandemic on practice in European radiation oncology centers. Radiother Oncol. 2020. doi:10.1016/j.radonc.2020.06.007.

[4] Veness MJ. Hypofractionated radiotherapy in patients with non‐melanoma skin cancer in the post COVID‐19 era: Time to reconsider its role for most patients. 2020 May 27;10.1111/1754-9485.13070

[5] Nagar H and Formenti SC. Cancer and COVID-19 — potentially deleterious effects of delaying radiotherapy. Nat Rev Clin Oncol. 2020; 17:322-4.

[6] Achard V, Tsoutsou P and Zilli T. Radiotherapy in the time of the Coronavirus pandemic: when less is better. Int J Radiat. 2020. doi: 10.1016/j.ijrobp.2020.03.008

[7] Cancer Australia. Influencing best practice in breast cancer. Accessed: May 2020;

[8] Faivre-Finn C, Fenwick JD, Franks KN, et al. Reduced Fractionation in Lung Cancer Patients Treated with Curative-intent Radiotherapy during the COVID-19 Pandemic. Clin Oncol (R Coll Radiol). 2020 May 13. doi: 10.1016/j.clon.2020.05.001

[9] National cancer expert or consumer participant, Cancer Australia COVID-19 Recovery and cancer roundtable. Meeting minutes unpublished. 30 July 2020.

[10] Al-Rashdan A, Roumeliotis M, Quirk S et al. Adapting Radiation Therapy Treatments for Patients with Breast Cancer During the COVID-19 Pandemic: Hypo-Fractionation and Accelerated Partial Breast Irradiation to Address World Health Organization Recommendations. Adv Radiat Oncol. 2020 Apr 2. doi: 10.1016/j.adro.2020.03.011

[11] Larrea L, Lopez E, Antonini P, et al. COVID-19: hypofractionation in the Radiation Oncology Department during the ‘state of alarm’: first 100 patients in a private hospital in Spain. Ecancermedicalscience. 2020; 14: 1052.

[12] Chandra R and Thomas Jr CR. What is our threshold: Departmental planning for radiation oncology’s future in the time of COVID-19. 2020; 149:46-7.

[13] Thomson DJ, Palma D, Guckenerger M. Practice recommendations for risk-adapted head and neck cancer radiotherapy during the COVID-19 pandemic: an ASTRO-ESTRO consensus statement. 2020 Apr 14;107(4):618-627.

[14] Marandino L, Necchi A, Aglietta M, Di Maio M. COVID-19 Emergency and the Need to Speed Up the Adoption of Electronic Patient-Reported Outcomes in Cancer Clinical Practice. J Oncol Pract. 2020; 16(6):295-8.