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

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.

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.

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.
What would test it
Implement the conditional payment in two health systems and compare registry completeness and trial launch against systems reimbursing unconditionally.
Maturity
being tested at scale
Who has to act
payer
Cost to try
Medium ($1M to $50M)
Years to first evidence
4
Bottlenecks it attacks

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