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; Stephanie Tanadini-Lang; Dirk Verellen; Lisa Wiersema; Juliane Hörner-Rieber; Alejandra Méndez Romero; David Pasquier; Anna Bruynzeel; Judit Boda-Heggemann; Tom Depuydt; Patrik Sibolt; Najma Douir; Łukasz Kuncman; Casper Beijst; Harley Stephens; Carolina de la Pinta; Francesco Cuccia; Maaike Milder; Luca Nicosia; Hiroshi Onishi; Alexander V. Louie; Arjun Sahgal; Simon S. Lo; Ben J. Slotman; Matthias Guckenberger; Marta Scorsetti

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^*
, Stephanie Tanadini-Lang
, Dirk Verellen
, Lisa Wiersema
, Juliane Hörner-Rieber
, Alejandra Méndez Romero
, David Pasquier
, Anna Bruynzeel
, Judit Boda-Heggemann
, Tom Depuydt
, Patrik Sibolt
, Najma Douir
, Łukasz Kuncman
, Casper Beijst
, Harley Stephens
, Carolina de la Pinta
, Francesco Cuccia
, Maaike Milder
, Luca Nicosia
, Hiroshi Onishi

Alexander V. Louie, Arjun Sahgal, Simon S. Lo, Ben J. Slotman, Matthias Guckenberger, Marta Scorsetti

^*Corresponding author for this work

Radiotherapy

Research output: Contribution to journal › Article › Academic › peer-review

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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.

Original language	English
Article number	101096
Journal	Clinical and Translational Radiation Oncology
Volume	57
DOIs	https://doi.org/10.1016/j.ctro.2025.101096
Publication status	Published - Mar 2026

Bibliographical note

Publisher Copyright:
© 2025 The Author(s)

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Clinical practice, barriers to implementation, and priorities for equitable access of Stereotactic Body Radiation TherapyFinal published version, 2.72 MBLicence: CC BY-NC-ND

Cite this

Franzese, C., Tanadini-Lang, S., Verellen, D., Wiersema, L., Hörner-Rieber, J., Romero, A. M., Pasquier, D., Bruynzeel, A., Boda-Heggemann, J., Depuydt, T., Sibolt, P., Douir, N., Kuncman, Ł., Beijst, C., Stephens, H., de la Pinta, C., Cuccia, F., Milder, M., Nicosia, L., ... Scorsetti, M. (2026). 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. Clinical and Translational Radiation Oncology, 57, Article 101096. https://doi.org/10.1016/j.ctro.2025.101096

@article{e5874ccb6aac4e4da8089c118d635485,

title = "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",

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.",

author = "Ciro Franzese and Stephanie Tanadini-Lang and Dirk Verellen and Lisa Wiersema and Juliane H{\"o}rner-Rieber and Romero, \{Alejandra M{\'e}ndez\} and David Pasquier and Anna Bruynzeel and Judit Boda-Heggemann and Tom Depuydt and Patrik Sibolt and Najma Douir and {\L}ukasz Kuncman and Casper Beijst and Harley Stephens and \{de la Pinta\}, Carolina and Francesco Cuccia and Maaike Milder and Luca Nicosia and Hiroshi Onishi and Louie, \{Alexander V.\} and Arjun Sahgal and Lo, \{Simon S.\} and Slotman, \{Ben J.\} and Matthias Guckenberger and Marta Scorsetti",

note = "Publisher Copyright: {\textcopyright} 2025 The Author(s)",

year = "2026",

month = mar,

doi = "10.1016/j.ctro.2025.101096",

language = "English",

volume = "57",

journal = "Clinical and Translational Radiation Oncology",

issn = "2405-6308",

publisher = "Elsevier Ireland Ltd",

}

Franzese, C, Tanadini-Lang, S, Verellen, D, Wiersema, L, Hörner-Rieber, J, Romero, AM, Pasquier, D, Bruynzeel, A, Boda-Heggemann, J, Depuydt, T, Sibolt, P, Douir, N, Kuncman, Ł, Beijst, C, Stephens, H, de la Pinta, C, Cuccia, F, Milder, M, Nicosia, L, Onishi, H, Louie, AV, Sahgal, A, Lo, SS, Slotman, BJ, Guckenberger, M & Scorsetti, M 2026, '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', Clinical and Translational Radiation Oncology, vol. 57, 101096. https://doi.org/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. / Franzese, Ciro; Tanadini-Lang, Stephanie; Verellen, Dirk et al.
In: Clinical and Translational Radiation Oncology, Vol. 57, 101096, 03.2026.

Research output: Contribution to journal › Article › Academic › peer-review

TY - JOUR

T1 - Clinical practice, barriers to implementation, and priorities for equitable access of Stereotactic Body Radiation Therapy

T2 - An analysis of the global status by the ESTRO SBRT Focus Group

AU - Franzese, Ciro

AU - Tanadini-Lang, Stephanie

AU - Verellen, Dirk

AU - Wiersema, Lisa

AU - Hörner-Rieber, Juliane

AU - Romero, Alejandra Méndez

AU - Pasquier, David

AU - Bruynzeel, Anna

AU - Boda-Heggemann, Judit

AU - Depuydt, Tom

AU - Sibolt, Patrik

AU - Douir, Najma

AU - Kuncman, Łukasz

AU - Beijst, Casper

AU - Stephens, Harley

AU - de la Pinta, Carolina

AU - Cuccia, Francesco

AU - Milder, Maaike

AU - Nicosia, Luca

AU - Onishi, Hiroshi

AU - Louie, Alexander V.

AU - Sahgal, Arjun

AU - Lo, Simon S.

AU - Slotman, Ben J.

AU - Guckenberger, Matthias

AU - Scorsetti, Marta

PY - 2026/3

Y1 - 2026/3

N2 - 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.

AB - 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.

UR - https://www.scopus.com/pages/publications/105025127734

U2 - 10.1016/j.ctro.2025.101096

DO - 10.1016/j.ctro.2025.101096

M3 - Article

AN - SCOPUS:105025127734

SN - 2405-6308

VL - 57

JO - Clinical and Translational Radiation Oncology

JF - Clinical and Translational Radiation Oncology

M1 - 101096

ER -

Franzese C, Tanadini-Lang S, Verellen D, Wiersema L, Hörner-Rieber J, Romero AM et al. 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. Clinical and Translational Radiation Oncology. 2026 Mar;57:101096. 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

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