Specific requirements for translation of biological research into clinical radiation oncology

Models for Translational Proton Radiobiology-From Bench to Bedside and Back

The number of proton therapy centers worldwide are increasing steadily, with more than two million cancer patients treated so far. Despite this development, pending questions on proton radiobiology still call for basic and translational preclinical research. Open issues are the on-going discussion on an energy-dependent varying proton RBE (relative biological effectiveness), a better characterization of normal tissue side effects and combination treatments with drugs originally developed for photon therapy. At the same time, novel possibilities arise, such as radioimmunotherapy, and new proton therapy schemata, such as FLASH irradiation and proton mini-beams. The study of those aspects demands for radiobiological models at different stages along the translational chain, allowing the investigation of mechanisms from the molecular level to whole organisms. Focusing on the challenges and specifics of proton research, this review summarizes the different available models, ranging from in vitro systems to animal studies of increasing complexity as well as complementing in silico approaches.

Role of radiation oncology in modern multidisciplinary cancer treatment

Cancer care is moving from a disease‐focused management toward a patient‐centered tailored approach. Multidisciplinary management that aims to define individual, optimal treatment strategies through shared decision making between healthcare professionals and patient is a fundamental aspect of high‐quality cancer care and often includes radiation oncology. Advances in technology and radiobiological research allow to deliver ever more tailored radiation treatments in an ever easier and faster way, thus improving the efficacy, safety, and accessibility of radiation therapy. While these changes are improving quality of cancer care, they are also enormously increasing complexity of decision making, thus challenging the ability to deliver quality affordable cancer care. In this review, we provide an updated outline of the role of radiation oncology in the modern multidisciplinary treatment of cancer. Particularly, we focus on the way some developments in key areas of cancer management are challenging multidisciplinary cancer care in the different clinical settings of early, locally advanced, and metastatic disease, thus highlighting some priority areas of research.

Technology-driven research for radiotherapy innovation

Technology has a pivotal role in the continuous development of radiotherapy. The long road toward modern ‘high‐tech’ radiation oncology has been studded with discoveries and technological innovations that resulted from the interaction of various disciplines. In the last decades, a dramatic technology‐driven revolution has hugely improved the capability of accurately and safely delivering complex‐shaped dose distributions. This has contributed to many clinical improvements, such as the successful management of lung cancer and oligometastatic disease through stereotactic body radiotherapy. Technology‐driven research is an active and lively field with promising potential in several domains, including image guidance, adaptive radiotherapy, integration of artificial intelligence, heavy‐particle therapy, and ‘flash’ ultra‐high dose‐rate radiotherapy. The evolution toward personalized Oncology will deeply influence technology‐driven research, aiming to integrate predictive models and omics analyses into fast and efficient solutions to deliver the best treatment for each single patient. Personalized radiation oncology will need affordable technological solutions for middle‐/low‐income countries, as these are expected to experience the highest increase of cancer incidence and mortality. Moreover, technology solutions for automation of commissioning, quality assurance, safety tests, image segmentation, and plan optimization will be required. Although a large fraction of cancer patients receive radiotherapy, this is certainly not reflected in the worldwide budget for radiotherapy research. Differently from the pharmaceutical companies‐driven research, resources for research in radiotherapy are highly limited to equipment vendors, who can, in turn, initiate a limited number of collaborations with academic research centers. Thus, enhancement of investments in technology‐driven radiotherapy research via public funds, national governments, and the European Union would have a crucial societal impact. It would allow for radiotherapy to further strengthen its role as a highly effective and cost‐efficient cancer treatment modality, and it could facilitate a rapid and equalitarian large‐scale transfer of technology to clinic, with direct impact on patient care.