The shortage of well-trained personnel to deliver cancer care and conduct research remains a major obstacle to reducing disparities in cancer survival between high-income countries and low-income and middle-income countr...The shortage of well-trained personnel to deliver cancer care and conduct research remains a major obstacle to reducing disparities in cancer survival between high-income countries and low-income and middle-income countries (LMICs). This Commission set out to provide actionable guidance for strengthening the global cancer workforce with an emphasis on reducing these disparities. To better understand the extent of the rising global cancer burden and the resulting workforce needs, we modelled the current and future global landscape of 17 common cancers and 18 workforce personnel types. Among the modelled cancers, diagnosed incidence rates are projected to increase globally, especially in LMICs, driven by growing and ageing populations and changing risk factors. Crucially, we estimate that one in three cancers go undiagnosed worldwide, with more than 60% of cancers remaining undiagnosed in parts of Africa. We find that, among the diagnosed cancers in LMICs, late-stage presentation and a lack of essential treatments and qualified health professionals contribute to poor survival. According to our modelling, in 2050, 5-year net survival is projected to remain lowest in Africa (34%) and Asia (39%), while reaching beyond 60% in high-income settings. The global cancer workforce shortage is projected to reach about 100 million in 2050, with the largest shortages being for nurses (65 million) and diagnostic (radiology and pathology) specialists (16 million), especially in Africa and Asia. Comprehensive workforce scale-up of all personnel types is projected to avert 170 million cancer deaths and yield net economic benefits of US$120 trillion between 2030 and 2050, translating to a global return on investment of $4 per $1 invested. Focusing primarily on examples from sub-Saharan Africa and Latin America, we examine key obstacles to workforce development and retention in LMICs and propose pragmatic actions to address the workforce crisis. These actions include establishment of workforce and cancer registries; the creation of cross-sector and international partnerships to improve access to education and research training programmes as well as diagnostics, therapeutics, and equipment; and implementation of task-shifting, digital health, and artificial intelligence solutions, which could improve workforce productivity, further strengthening the case for investing in the cancer workforce. TRANSLATIONS: For the Spanish, Portuguese, French, Chinese (Mandarin), Arabic and Russian translations of the abstract see Supplementary Materials section.
BACKGROUND: Around 57 000 people are diagnosed with breast cancer annually in the UK. Radiotherapy can improve local control and survival, but it can also cause long-term side-effects. UK hypofractionation trials have de...BACKGROUND: Around 57 000 people are diagnosed with breast cancer annually in the UK. Radiotherapy can improve local control and survival, but it can also cause long-term side-effects. UK hypofractionation trials have defined dose constraints for heart and lung, reducing heart exposure and treatment burden in a research setting. However, real-world data on heart and lung doses remain scarce. In 2022, the National Health Service (NHS) in England procured a cloud-based radiation dosimetry repository (ProKnow). Using this resource, we aimed to characterise heart and lung doses in routine breast radiotherapy, quantify variation between centres, inform national guidance, and support quality improvement. METHODS: On Dec 11, 2024, NHS England invited all 49 NHS radiotherapy centres in England to upload anonymised radiotherapy plans to ProKnow. Plan upload was stratified by laterality; breast, chest wall, or partial-breast only (26 Gy in five fractions); breast or chest wall and axilla (40 Gy in 15 fractions); and breast or chest wall and axilla and internal mammary chain (40 Gy in 15 fractions). Use of field-based versus volumetric-modulated arc therapy was recorded. Dose-volume heart and lung metrics were analysed against national scorecards derived from UK trials. FINDINGS: Between Dec 11, 2024, and April 24, 2025, 48 of 49 centres participated, contributing 30 582 plans. 27 368 were harvested for analysis, of which 26 236 (95·9%) were analysable. For breast, chest wall, or partial-breast-only treatments, 10 012 (99·8%) of 10 031 left-sided cases and 6961 (99·9%) of 6962 right-sided cases achieved mean heart doses (MHD) below 2 Gy (median MHD 0·57 Gy [IQR 0·43-0·74; left] and 0·25 Gy [0·18-0·36; right]). For nodal plans including internal mammary chain, median MHDs were 3·3 Gy (IQR 2·3-4·5; left) and 2·3 Gy (1·1-3·7; right). 2405 (98·3%) of 2446 plans met the 6 Gy constraint. 8697 (92·1%) of 9448 left-sided breast, chest wall, or partial-breast plans met the optimal lung dose constraint (volume of ipsilateral lung receiving >7·8 Gy being ≤15%) and 1155 (96·0%) of 1203 left-sided nodal-internal mammary chain plans met the mandatory lung dose constraint (volume of lung receiving >17 Gy being ≤35%). Volumetric-modulated arc therapy was used in 65 (0·3%) of 21 119 breast-only plans, 276 (10·5%) of 2638 nodal-non-internal mammary chain plans, and 1738 (70·1%) of 2479 internal mammary chain plans. Volumetric-modulated arc therapy delivered superior target volume coverage but higher MHDs compared to field-based techniques. INTERPRETATION: This breast radiotherapy dosimetry audit shows the feasibility of high-quality large-scale, real-world dosimetric collection and evaluation across the NHS in England. Heart and lung doses predominantly met constraints and were comparable to international benchmarks. However, dosimetric variation existed between centres, particularly in volumetric-modulated arc therapy planning, identifying opportunities for quality improvement. FUNDING: NHS England.
BACKGROUND: Stereotactic ablative body radiotherapy (SABR) is a non-invasive therapy for inoperable primary renal cell carcinoma. However, long-term prospective clinical trial data are scarce. We aimed to use pooled data...BACKGROUND: Stereotactic ablative body radiotherapy (SABR) is a non-invasive therapy for inoperable primary renal cell carcinoma. However, long-term prospective clinical trial data are scarce. We aimed to use pooled data from two clinical trials (FASTRACK and FASTRACK II) to evaluate activity and safety of SABR in the long term. METHODS: In this pooled analysis, we used data from FASTRACK, a single-institutional, phase 1, prospective clinical trial conducted at the Peter MacCallum Cancer Centre (Melbourne, VIC, Australia), and FASTRACK II, an international, non-randomised, phase 2 clinical trial conducted in seven academic hospitals in Australia and one in the Netherlands. The treatment protocol, inclusion and exclusion criteria, and dose constraints were the same in both trials. Patients had primary renal cell carcinoma and were deemed medically inoperable or high-risk for surgery, were aged 18 years or older, had an Eastern Cooperative Oncology Group performance status of 2 or less, tumours of 10 cm or less in maximal dimension, and N0-N1 disease. Tumours 4 cm or smaller in FASTRACK II and smaller than 5 cm in FASTRACK received a single fraction of 26 Gy and larger tumours received 42 Gy in three fractions 48 h apart. Local control (freedom from local progression) was the primary endpoint, assessed using Response Evaluation Criteria in Solid Tumours (version 1.1) criteria. The analyses were conducted only in patients who commenced protocol treatment. Safety was evaluated with the Common Terminology Criteria for Adverse Events in participants who started protocol treatment. A patient representative was involved in the study design and conduct of FASTRACK II. Both trials were registered with ClinicalTrials.gov (FASTRACK: NCT01676428; FASTRACK II: NCT02613819) and are both completed. FINDINGS: 108 patients were enrolled between June 28, 2012, and Oct 17, 2014 (FASTRACK), and between July 28, 2016, and Feb 27, 2020 (FASTRACK II). Five patients did not receive treatment (one opted for surgery, three did not meet dose constraints and were withdrawn, and one died before treatment). Median age was 76·9 years (IQR 70·0-81·9). 74 (72%) of 103 patients analysed were male and 29 (28%) were female. Race and ethnicity data were not collected. The median follow-up was 5·0 years (IQR 2·3-6·0). Local control at 1 year was 100%, at 3 years was 98% (89-100), and at 5 years was 98% (89-100), with local progression occurring in only one patient who had both local and distant progression at 28 months. Eight (8%) patients had grade 3 adverse events: abdominal or flank pain (four [4%] patients), nausea or vomiting (two [2%]), colonic obstruction (two [2%]), fatigue (one [1%]), and colitis or diarrhoea (one [1%]). All grade 3 or worse adverse events occurred within 2 years of SABR delivery. No grade 4 adverse events or treatment-related deaths were reported. INTERPRETATION: This pooled analysis from two clinical trials of SABR in patients with larger primary kidney tumours unsuitable for surgery supports evidence of long-term local control and low rate of severe adverse events. These results support further investigation through a randomised trial comparing SABR with surgery in select operable patients. FUNDING: None.
BACKGROUND: Stereotactic ablative body radiotherapy (SABR) is an emerging, non-invasive alternative for primary renal cell carcinoma. We aimed to provide the final long-term trial outcomes of TransTasman Radiation Oncolo...BACKGROUND: Stereotactic ablative body radiotherapy (SABR) is an emerging, non-invasive alternative for primary renal cell carcinoma. We aimed to provide the final long-term trial outcomes of TransTasman Radiation Oncology Group (TROG) 15.03 FASTRACK II, the first phase 2 trial investigating SABR for primary renal cell carcinoma to our knowledge. METHODS: FASTRACK II was a non-randomised, phase 2 study conducted in eight hospitals in Australia and the Netherlands by TROG and the Australian and New Zealand Urogenital and Prostate (ANZUP) Cancer Trials Group. Here, we report the final pre-planned follow-up results. Adult patients (aged ≥18 years) with histologically confirmed primary renal cell carcinoma, who were medically inoperable, high risk, or declined surgery, had an Eastern Cooperative Oncology Group performance status of 2 or less, had tumours 10 cm or less in size, and had N0-N1 disease were included. Patients underwent either a single fraction SABR of 26 Gy for tumours 4 cm or less in maximum diameter, or 42 Gy in three fractions delivered 48 h apart for tumours more than 4 cm in maximum diameter. The primary outcome was freedom from local progression to assess local control after SABR evaluated with the Response Evaluation Criteria in Solid Tumours. The primary endpoint and safety were evaluated in the intention-to-treat population. A patient representative was involved in the study design and conduct. The trial was registered with ClinicalTrials.gov (NCT02613819) and is closed to enrolment. FINDINGS: Between July 28, 2016, and Feb 27, 2020, 71 patients were enrolled and one withdrew consent before treatment. Median follow-up was 62 months (IQR 60-72), median age was 77 years (70-82). 49 (70%) of 70 patients were male and 21 (30%) were female. Race and ethnicity data were not collected. The median tumour size was 46 mm (37-55), with 24 (34%) patients with T1a disease, 39 (56%) with T1b disease, six (9%) with T2a disease, and one (1%) with T3a disease. One patient (1%) had nodal involvement (N1). SABR resulted in 100% local control at 36 months, 60 months, and 84 months. Seven (10%) patients had at least one grade 3 adverse event within 9 months of SABR that was designated possibly, probably, or definitely related to treatment: nausea and vomiting (three [4%] events); abdominal, flank, or tumour pain (four [6%]); colonic obstruction (two [3%]); and diarrhoea (one [1%]). No new long-term safety signals, grade 4 events, or treatment-related deaths were noted. INTERPRETATION: Long-term follow-up supports the safety and local control of SABR for non-surgical patients with renal cell carcinoma, with no observed local recurrences or cancer-related deaths in this cohort, which had predominantly T1b disease or higher. FUNDING: The Cancer Australia Priority-driven Collaborative Cancer Research Scheme and Varian.
BACKGROUND: FAST-Forward aimed to identify a 1-week adjuvant radiotherapy schedule for early-stage breast cancer that was as safe and efficacious as the standard 3-week schedule of 40 Gy in 15 fractions over 3 weeks. Pri...BACKGROUND: FAST-Forward aimed to identify a 1-week adjuvant radiotherapy schedule for early-stage breast cancer that was as safe and efficacious as the standard 3-week schedule of 40 Gy in 15 fractions over 3 weeks. Primary analysis showed non-inferiority of 5-year ipsilateral breast recurrence for 26 Gy and 27 Gy in five fractions over 1 week, with 26 Gy also having similar results to 40 Gy for normal tissue effects. Here, we report 10-year outcomes of the FAST-Forward trial and 5-year efficacy outcomes of a substudy assessing the approach in patients requiring axillary treatment. METHODS: FAST-Forward is a multicentre, open-label, non-inferiority, phase 3, randomised controlled trial done at 97 hospitals (47 radiotherapy centres and 50 referring hospitals) in the UK. Patients aged 18 years or older with invasive carcinoma of the breast (pT1-3, pN0-1, M0) after breast conservation surgery or mastectomy were eligible. We randomly allocated patients (in a 1:1:1 ratio with random permuted blocks, stratified by radiotherapy centre) to either 40 Gy in 15 fractions (over 3 weeks), 27 Gy in five fractions (over 1 week), or 26 Gy in five fractions (over 1 week) to the whole breast or chest wall. Allocation was not masked because of the nature of the intervention. The primary endpoint was non-inferiority of ipsilateral breast recurrence at 5 years. Here, we report the planned 10-year analysis assessed in the intention-to-treat population (all participants who were randomly assigned and consented for use of data). We also report a planned intention-to-treat analysis of a subsequent substudy assessing 5-year efficacy of the same schedules in patients meeting the study criteria but requiring axillary treatment. The clinical trial was registered with ISRCTN (ISRCTN19906132); the main trial is complete, follow-up of the substudy cohort is ongoing. FINDINGS: Between Nov 24, 2011, and June 19, 2014, 4110 participants were enrolled in the main FAST-Forward trial. 23 withdrew consent for data use and were excluded and 4087 participants were included in the intention-to-treat population for this 10-year analysis. Participants were randomly assigned to 40 Gy (n=1358), 27 Gy (n=1362), or 26 Gy (n=1367). Median follow-up was 10·1 years (IQR 10·0-10·2). Ipsilateral breast recurrence was reported for 116 participants (45 in the 40 Gy group, 41 in the 27 Gy group, and 30 in the 26 Gy group), with 10-year cumulative incidence of 3·6% (95% CI 2·7-4·9) for the 40 Gy group, 2·9% (2·1-4·0) for the 27 Gy group, and 2·1% (1·5-3·1) for the 26 Gy group. 10-year clinician-reported moderate or marked breast or chest wall effects occurred in 100 (13·1%) of 765 participants in the 40 Gy group, 157 (19·3%) of 814 in the 27 Gy group, and 111 (14·4%) of 770 in the 26 Gy group. Between April 11, 2016, and Oct 2, 2018, 469 participants enrolled in the nodal substudy, 466 of which were included in intention-to-treat analyses. Median follow-up was 7·0 years (IQR 6·2-7·1) and 32 locoregional recurrences were reported. INTERPRETATION: Long-term follow-up confirms that 26 Gy in five fractions over 1 week is safe and efficacious for adjuvant radiotherapy to the breast or chest wall, supporting its use as a standard of care. Efficacy data for this schedule in the axillary nodal radiotherapy setting are reassuring; however, sample size limits precision of estimation for this subgroup on its own. FUNDING: UK National Institute for Health and Care Research.
BACKGROUND: Radiotherapy volumes for patients with glioblastoma have remained unchanged for decades and result in large volumes of irradiated brain. We aimed to show the safety of a small-margin, MRI-guided adaptive radi...BACKGROUND: Radiotherapy volumes for patients with glioblastoma have remained unchanged for decades and result in large volumes of irradiated brain. We aimed to show the safety of a small-margin, MRI-guided adaptive radiotherapy approach for glioblastoma. METHODS: This single-arm, phase 2 trial was done at Sunnybrook Health Sciences Centre, Toronto, ON, Canada, and included patients with pathologically confirmed glioblastoma and planned for concurrent daily chemoradiotherapy up to 60 Gy in 30 daily fractions over 6 weeks (long course) or 40 Gy in 15 daily fractions over 3 weeks (short course). Eligible patients were adults (≥18 years) with an expected life expectancy greater than 12 weeks and an Eastern Cooperative Oncology performance status less than or equal to 2. A 5 mm clinical target volume (CTV) was applied, with the allowance of associated T2-weighted fluid-attenuated inversion recovery hyperintense regions in a personalised way at the discretion of the treating physician. All patients were treated with 1·5 T MRI-guided linear accelerator (MR-Linac) incorporating weekly gadolinium-enhanced online adaptive fractions. The primary outcome was the risk of marginal failure powered for non-inferiority with a margin of 10% compared with a historical control. All patients were included in the primary and safety analyses. This study is registered with ClinicalTrials.gov, NCT04726397. FINDINGS: Between April 28, 2021, and May 12, 2023, 109 patients were assessed for eligibility and 98 were enrolled and received treatment on the UNITED protocol with 59 [60%] patients receiving long-course radiotherapy and 39 [40%] receiving short-course radiotherapy. Median follow-up was 14·2 months (IQR 8·9-19·7). 53 (54%) of 98 patients were male and 45 (46%) were female. The observed risk of marginal failure was 4% (95% CI 0-8). The most common grade 3-4 adverse events were lymphopenia (eight [11%] of 72 patients without baseline lymphopenia) and thrombocytopenia (four [4%] of 98 patients). Serious adverse events occurred in one (1%) patient due to febrile neutropenia and there were no treatment-related deaths. INTERPRETATION: MRI-guided adaptation for glioblastoma enables margin de-escalation and resulted in a low rate of marginal failure. A randomised trial comparing this technique to a standard large-margin radiotherapy approach will establish whether toxicity and quality-of-life improvements can be realised. FUNDING: None.
Laimer G, Johnston EW, Overduin CG
… +70 more, Paolucci I, Ahmed M, Arellano RS, Beermann M, Beyer LP, Breen DJ, Burgmans MC, Calandri M, Chern MC, Crocetti L, van Dam RM, Denys A, Edwin B, Filippiadis D, Fong Y, Fotiadis N, Freedman J, Fretland ÅA, Gimenez M, Garcia RG, Grasso RF, Helmberger TK, Hendriks P, Iezzi R, Jenniskens SF, Kupferthaler A, Lachenmayer A, Lee FT, Lee JM, van der Lei S, van der Leij C, Liang P, Lin CC, Luerken L, Maglione M, Mahnken A, McWilliams JP, Menezes M, Narayanan G, Orsi F, Pereira PL, Pua U, Puijk RS, Rhim H, Rilling WS, Ruiter SJS, Ryan AG, Schullian P, Shyn PB, Siriwardena AK, Smits MLJ, Sofocleous CT, Solbiati L, Sotirchos V, Stättner S, van Strijen M, Syversveen T, Tinguely P, Tselikas L, Vauthey JN, Vogl TJ, Wah TM, White SB, Wiggermann P, Wood BJ, van der Meulen J, Goldberg SN, Meijerink MR, Odisio BC, Bale R
Thermal ablation offers a safer, less invasive, and more cost-effective curative-intent treatment for selected patients with primary and metastatic liver tumours than surgery; when done with appropriate technique, ablati...Thermal ablation offers a safer, less invasive, and more cost-effective curative-intent treatment for selected patients with primary and metastatic liver tumours than surgery; when done with appropriate technique, ablation can deliver similar oncological outcomes. However, effectiveness in routine practice varies because structured training, planning, and procedural governance remain scarce. These international multidisciplinary, multi-society guidelines-formally endorsed by the European Society of Surgical Oncology, the Cardiovascular and Interventional Radiological Society of Europe, and the Society of Interventional Oncology-define key domains contributing to procedural difficulty and practice variation in liver tumour thermal ablation. A Delphi consensus initiative held in Innsbruck, Austria, engaged 72 experts across three iterative rounds of scoring across 135 statements grouped into five domains: credentialing, indications, approach, procedural factors, and safety measures. Consensus was achieved for 94 (70%) of 135 statements. The least invasive route-typically percutaneous-should be prioritised, and margin adequacy was reaffirmed as the principal technical goal. Procedural difficulty was considered context-dependent, shaped by tumour factors, institutional infrastructure, and operator experience. Organ displacement techniques were endorsed to maintain safety and expand treatable indications. Complex ablations should be done by experienced operators (more than 100 previous cases), with programmes underpinned by structured training, multidisciplinary team participation, and routine audit. Future efforts should develop and validate practical tools such as difficulty scoring systems, standardised procedural reporting templates, and comprehensive training curricula to improve consistency, standardisation, and clinical outcomes globally.
Paolucci I, Overduin CG, Johnston EW
… +70 more, Laimer G, Ahmed M, Arellano RS, Beerman M, Beyer LP, Breen DJ, Burgmans MC, Calandri M, Chern MC, Crocetti L, van Dam RM, Denys A, Edwin B, Filippiadis D, Fong Y, Fotiadis N, Freedman J, Fretland ÅA, Gimenez M, Garcia RG, Grasso RF, Helmberger TK, Hendriks P, Iezzi R, Jenniskens SF, Kupferthaler A, Lachenmayer A, Lee FT, Lee JM, van der Lei S, van der Leij C, Liang P, Lin CC, Luerken L, Maglione M, Mahnken A, McWilliams JP, Menezes M, Narayanan G, Orsi F, Pereira PL, Pua U, Puijk RS, Rhim H, Rilling WS, Ruiter SJS, Ryan AG, Schullian P, Shyn PB, Siriwardena AK, Smits MLJ, Sofocleous CT, Solbiati L, Sotirchos V, Stättner S, van Strijen M, Syversveen T, Tinguely P, Tselikas L, Vauthey JN, Vogl TJ, Wah TM, White SB, Wiggermann P, Wood BJ, van der Meulen J, Goldberg SN, Meijerink MR, Bale R, Odisio BC
This multisociety, multidisciplinary consensus-formally endorsed by the European Society of Surgical Oncology, the Cardiovascular and Interventional Radiological Society of Europe, and the Society of Interventional Oncol...This multisociety, multidisciplinary consensus-formally endorsed by the European Society of Surgical Oncology, the Cardiovascular and Interventional Radiological Society of Europe, and the Society of Interventional Oncology-was developed to standardise the assessment of ablation margins in liver tumour thermal ablation. A modified Delphi process, consisting of two online surveys and a hybrid (online and in-person meeting in Innsbruk) consensus meeting of 72 experts from North America, South America, Europe, and Asia. Formal consensus was reached for 150 (75%) of 199 statements. Strong agreement was observed between interventional and surgical oncologists, with only 12 (6%) of 199 statements showing significantly different ratings. Participants agreed that ablation margins should be assessed and documented for every treated tumour. Margins should be assessed quantitatively in three dimensions, with contrast-enhanced CT or MRI, preferably intraprocedurally with ablation confirmation software. Ablation margins should be categorised as A0 (tumour completely covered with sufficient margin), A1 (tumour completely covered but insufficient margin), or A2 (portion of tumour remains unablated). This effort is, to our knowledge, the first international consensus initiative to define best-practice recommendations for margin assessment in liver tumour thermal ablation to standardise practices, aiming to improve and promote uniform outcomes.