# Coverage-with-evidence registries for MR-guided and adaptive radiotherapy

Source: https://onco.cc/ideas/idea-fund-adaptive-radiotherapy-evidence/  
OnCo record `idea-fund-adaptive-radiotherapy-evidence` (Idea). Data CC BY-NC 4.0, attribute "Data from OnCo (onco.cc)"; commercial use needs a licence.

## TL;DR

Radiotherapy machines that adapt to the tumour each day cost far more than standard ones and their benefit is unproven. Payers would fund them only within registries and trials that measure whether they help.

## Summary

Payers reimburse MR-linac and daily adaptive radiotherapy at a premium only for patients enrolled in an international registry with standard outcome and toxicity capture (building on the MR-Linac Consortium's MOMENTUM study) or in randomised comparisons for indications where a benefit is plausible (pancreatic, prostate, oligometastatic, bladder). The registry has pre-specified analysis plans and triggers for randomised trials. Adaptive radiotherapy has strong dosimetric rationale but the clinical benefit over conventional image-guided radiotherapy is unquantified, and the technology is diffusing on the strength of physics rather than outcomes.

## Fields

- Kind: Idea
- Last checked: 2026-09-08
- Hypothesis: Coverage-with-evidence generates outcome and toxicity data on more than 90% of adaptive radiotherapy patients in participating systems and produces at least two randomised comparisons with definitive results within five years.
- Rationale: MOMENTUM has shown that an international MR-linac registry is feasible; the proton experience shows what happens without payment leverage. Adaptive radiotherapy is the next expensive technology where evidence should precede diffusion.
- Proposed test: Implement the conditional payment in two health systems and compare registry completeness and trial launch against systems reimbursing unconditionally.
- Maturity: being-tested-at-scale
- Actor: payer

## Sources

- Bottleneck evidence (Surgery and radiotherapy cure most, get least): Sullivan et al., Global cancer surgery (Lancet Oncology Commission 2015): https://doi.org/10.1016/S1470-2045(15)00223-5

## Connected records

- ideas: [A regulatory pathway for new radiotherapy techniques modelled on drug development](https://onco.cc/ideas/idea-fund-radiotherapy-innovation-pathway/), [An independent evaluation unit for surgical robots and AI, paid on evidence](https://onco.cc/ideas/idea-fund-surgical-ai-robotics-evaluation/), [Pooled coverage-with-evidence for proton therapy across all centres](https://onco.cc/ideas/idea-fund-proton-coverage-with-evidence/)
- cancers: [Bladder & urothelial cancer](https://onco.cc/cancers/urothelial/), [Locally advanced unresectable pancreatic ductal adenocarcinoma](https://onco.cc/cancers/locally-advanced-pdac/), [Pancreatic ductal adenocarcinoma](https://onco.cc/cancers/pancreatic/), [Prostate cancer](https://onco.cc/cancers/prostate/)
- technologies: [IMRT / IGRT (modern external beam)](https://onco.cc/technologies/imrt-igrt/), [MR-guided adaptive radiotherapy](https://onco.cc/technologies/mr-linac/), [SBRT / SABR (stereotactic radiotherapy)](https://onco.cc/technologies/sbrt/)
- companies: [Elekta](https://onco.cc/companies/elekta/), [RefleXion Medical](https://onco.cc/companies/reflexion/), [Varian (Siemens Healthineers)](https://onco.cc/companies/varian/)
- bottlenecks: [Surgery and radiotherapy cure most, get least](https://onco.cc/bottlenecks/b-surgery-radiation-innovation/), [Weak real-world evidence and registries](https://onco.cc/bottlenecks/b-real-world-evidence/)
- key papers: [Global cancer surgery: delivering safe, affordable, and timely cancer surgery](https://onco.cc/key-papers/paper-sullivan-lancet-oncol/)

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