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. 2026 Oct 2;62:101308. doi: 10.1016/j.ctro.2026.101308

Advancing brachytherapy: The GEC-ESTRO strategic vision

Frank-André Siebert a,⁎, Christian Kirisits b, Peter Niehoff c, Andrea Slocker d, Vratislav Strnad e,f, Alina Sturdza b, Luca Tagliaferri g, Jean-Michel Hannoun-Levi h
PMCID: PMC13670387  PMID: 42889952

Abstract

Introduction

Brachytherapy (BT) is an established and highly effective component of modern radiotherapy, offering a favourable therapeutic ratio for several tumor sites. Despite technological advances and strong clinical evidence, its use has declined in some countries. The GEC-ESTRO Committee of ESTRO therefore initiated a strategic process to promote and strengthen BT within European radiation oncology.

Methods

The BT Think Tank (B3T), established in September 2024, comprised eight European BT specialists supported by ESTRO staff. Through structured discussions, topic prioritisation and feedback from the GEC-ESTRO Committee, key barriers to the wider implementation and promotion of BT were identified and strategic actions developed.

Results

Five major areas were identified: communication, scientific research, training, reimbursement and technical development. Communication was ranked as the highest priority. Particular emphasis was placed on improving communication with patients, referring and non-BT specialists, other scientific societies, industry and healthcare stakeholders. To implement this strategy, five communication work packages were established addressing patients, other scientific societies, social media, industry, and healthcare administration/insurance. Specific milestones and activities were defined through 2028. In parallel, ongoing initiatives address clinical research, including prospective trials and real-world evidence, structured training programmes such as the EuroBT Fellowship, reimbursement analyses, and evaluation of technical developments.

Conclusion

The GEC-ESTRO strategic vision aims to reposition BT as an integral component of personalised, value-based radiotherapy within the overarching strategy of ESTRO. Strengthening communication and interdisciplinary collaboration, alongside continued investment in research, training and advocacy, is essential to ensure that BT is considered as a treatment option for appropriate patients and remains accessible in the future.

Keywords: Brachytherapy, Radiation Oncology, Education and Training, Future of Brachytherapy

Highlights

  • •

    The GEC-ESTRO Brachytherapy Think Tank developed a strategic vision to advance brachytherapy in European radiation oncology.

  • •

    Five key priorities were identified: communication, research, training, reimbursement and technical development.

  • •

    Communication was ranked as the highest priority, addressing patients, professionals, societies, industry and healthcare stakeholders.

  • •

    The strategy aims to strengthen BT as an integral component of personalised, value-based radiotherapy within ESTRO.

1. Introduction

In 2025, the European Society for Radiotherapy and Oncology (ESTRO) published a strategy paper setting out strategic objectives for ESTRO based on three main pillars [1]: membership and advocacy, training, and research. Important outlined aspects of the ESTRO vision are to proactive and strategically approach partnerships to create content (A), increase collaboration with National Societies (B), grow of ESTRO membership (C), signpost ESTRO content and increase of engagement (D), and increase advocacy for radiation oncology at the level of the European Union (E).

The Groupe Européen de Curiethérapie (GEC)-ESTRO is one of the standing Committees of ESTRO. The GEC-ESTRO Committee coordinates and supervises all activities within the brachytherapy (BT) field in ESTRO in collaboration with other ESTRO bodies. Given that BT is a transversal and multidisciplinary specialised field within radiation oncology with distinct requirements, a more focused and dedicated strategic vision for BT needs to be further developed within the overarching ESTRO strategy. This would complement and reinforce the broader ESTRO strategy, making it even stronger.

In BT, also called Interventional Radiotherapy, tumors are typically treated with sealed sources placed in or close to the tumor or tumor bed in order to destroy the cancer cells. Due to the small size of the sources, mostly a few millimetres long and below one millimetre in diameter, the dose distribution of a BT source is dominated by the inverse square law [2]. This results in a very localized but inhomogeneous dose distribution with steep dose gradients, allowing delivery of high doses to the target whilst sparing organs at risk.

In many tumor sites, there is clear evidence that BT delivers an improved therapeutic ratio. This applies, for example, to BT for cervical cancer [3], [4], [5], for prostate cancer [6], [7], [8] or for breast cancer [9], [10]. In a large meta-analysis of over 50,000 patients, Grimm et al. [6] demonstrated that BT is one of the preferred treatment options for localized prostate cancer in low, intermediate and high-risk patients. In addition to highlighting the biological tumor-free survival for localized prostate cancer, studies have also demonstrated very good overall survival after BT [7]. New international guidelines recommend BT as a boost modality for favourable/unfavourable intermediate and high-risk prostate cancer patients [8]. For low-risk breast cancer, the GEC-ESTRO phase 3 randomized trial comparing accelerated partial breast irradiation using multi catheter interstitial BT versus whole-breast irradiation showed non-inferior local control, disease-free survival and overall survival after a median follow-up of 5 years [9]. For local recurrence occurring in a pre-irradiated area, BT plays also a key role in locations where more aggressive surgical techniques, often quite mutilating, would be required [10].

The application of BT has changed very much during the last three decades. The use of stepping source technologies with an afterloading system allows the implementation of intensity-modulated techniques, optimizing the dose outside the target to avoid excessive dose to organs at risk, and giving the opportunity to deliver a simultaneous integrated boost inside the target based on the biological characteristics of the tumor. Additionally, anatomical implants can be performed using information gained at surgery, enabling tumors to be covered through intensity modulation [11]. Image-guided techniques using 3D imaging such as CT, MRI or ultrasound are standard [12]. It should also be emphasised that adaptive treatment planning has been successfully implemented in BT for decades, mainly in prostate and gynaecological treatments [13]. New dose calculation algorithms are available [14], [15] and with the establishment of dose-response relationships from large patient cohorts, e.g. for gynaecological radiotherapy [16], [17] there is upcoming evidence for personalised patient treatment planning rather than a general approach in which the dose is the same for all patients [18]. Due to the highly localized dose distribution and the high-dose regions within the tumor tissue, the combination of BT and immunotherapy is particularly promising and will be an area of future exploration, mainly with regard to checkpoint inhibitors [19]. Some patients will benefit from this combination, whereas others – for example, in gynaecology – already reach the same therapeutic outcome through a well-conducted chemoradiotherapy, including BT with combined intracavitary and interstitial applicators [20]. There are some shortcomings however: BT is often invasive requiring anaesthesia (general, spinal or local) and, in some cases, patients need to be hospitalized for several days. The logistics are crucial as it requires a complex infrastructure including a dedicated, well-trained team for the implant, and in some cases the implant process is time consuming. Moreover, the development of BT has had to progressively adapt to major changes, including the widespread adoption of high-dose-rate techniques since the 1980s, the discontinuation of low-dose-rate Iridium-192 in 2014, and more recently the phasing out of pulsed-dose-rate techniques. Considering both the available scientific evidence but also the intrinsic limitations of the technique and the patient's expectations, it is essential to adopt a personalised approach to define, on a case-by-case basis, the most appropriate patient centred and value based therapeutic strategy, taking into account the full spectrum of radiotherapy techniques that can be offered.

In recent years, use of BT appeared to be in decline in some countries [21], [22]; however, in a number of regions worldwide, its use and implementation have increased [21], [22], [23], [24], [25]. Given the advantages of this unique technology resulting in a very good outcome for many patients, the GEC-ESTRO Committee considers that it is of paramount importance to preserve and promote BT both for training and practice in Europe and beyond.

2. Brachytherapy Think Tank: current status and perspectives

A representative group, called BT Think Tank (B3T), was established in September 2024 with the aim of developing a strategic vision for the future of European BT. The B3T consists of eight European BT specialists, most members of the GEC-ESTRO Committee, six of them radiation oncologists and two medical physicists. This group was professionally supported by ESTRO administrative staff and met regularly online to discuss and develop modalities for BT promotion. Topics were collected in discussion rounds and allotted in groups. A priority ranking was conducted and subtopics defined where relevant. The results of the B3T were regularly reported to the GEC-ESTRO Committee and feedback considered.

In the first B3T discussions, the following strategic questions were identified:

  • •

    Why brachytherapy is not used more often?

  • •

    How can we raise awareness of BT among non-BT practitioners in the clinics and among patients?

During the discussion, it became apparent that the GEC-ESTRO and BT community largely functions within its own sphere. This means that discussions, meetings, and conference programs are generally shaped primarily by members of this community. The BT specialization in Europe has its roots in the GEC-ESTRO Committee. While this is important and necessary, it seems crucial to promote more interdisciplinary interaction outside our GEC-ESTRO/BT community. This counts for interaction within ESTRO, e.g. to other standing Committees or Focus Groups, and outside ESTRO. In the B3T, the main topics to promote BT identified were: communication, scientific research, training, reimbursement, and technical aspects. The most important strategic points are shown in Fig. 1; communication with sub-topics.

Fig. 1.

Fig. 1

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The five most important strategic points for brachytherapy. Communication was considered by far the most important point.

3. Communication

Communication was ranked first in the promotion of BT. Specifically, communication with patients is of high importance, e.g. by applying shared decision making [26]. Ideally, patients should be made aware of BT prior to their discussion with their attending specialist. BT, as part of radiotherapy, is multidisciplinary and a transversal irradiation process, which involves non-radiation oncology specialities like gynaecology, urology, dermatology, breast and head and neck surgeons. The multidisciplinary facet of BT is more accentuated in comparison to EBRT due to collaboration in the operating room between surgeons, physicists, radiation oncologists, radiotherapy technologists, and nursing staff, in other words a dedicated and well-trained team is essential. Therefore, promoting BT at other societies' congresses and activities will be one of our main priorities.

Communication patterns have changed significantly overall in recent years. To reach many people in different target groups (patients, radiotherapy professionals, referring physicians) social media communication must be up to date and improved. Moreover, many patients referred to BT departments are relatively young and accustomed to using the internet and social media to search for information. Providing accurate and up-to-date information is essential to prevent misunderstanding, anxiety and unfounded fears.

Also, communication to the BT related industry must be enhanced and it is expected that will be mutually beneficial. The industry can learn first-hand about the needs of the BT community and offer the appropriate products. A recently conducted survey among the GEC-ESTRO workshop participants explored the needs of the BT users pertinent to industry. Most participants considered it a priority to develop new tools which optimize workflow and relatively simple software solutions like patient-specific treatment planning support that integrates calculation of equivalent dose in 2 Gy fractions (EQ.D2) in the treatment planning system. Additionally, greater interchangeability of applicators and treatment planning systems between vendors was suggested. On the other hand, while physicians and physicists continuously develop innovations and improvements to enhance implant accuracy, industry partners must navigate lengthy and costly processes to bring these technological advances to market.

In order to implement these points, four working packages (WPs) were initially established: WP Patients, WP Other Scientific Societies, WP Social media, WP (Pharma) Industry. At a later timepoint a WP Healthcare administration / insurance companies will be created. These WPs are also depicted in Fig. 1.

3.1. Scientific research

Scientific research for BT is primarily required in the context of clinical studies. In a review manuscript Chen et al. [27] showed that the overall number of BT trials is increasing over time from 2010 onwards, showing there is still scientific interest in BT. However, based on “level of evidence” philosophy, more trials are needed, e.g. comparative trials with EBRT or surgery or single arm phase 2 studies for rare entities with lower incidence. In these trials technical novelties can be woven in, like the use of in cone-beam CT in-room-imaging [28], model-based dose calculation algorithms [14], [15] or modern in-vivo dosimetry solutions [29]. GEC-ESTRO is aware of the needs of clinical trials involving BT and has already started several studies in the clinical working groups. A remarkable one is a prospective phase II trial evaluating 16 Gy single fraction interstitial breast trial, started in 2025. CITRuS is a PROMS trial investigating quality of life of bowel cancer patients including those treated with contact BT; BRAVO is a prospective study in the treatment of nasal vestibule focusing on dose optimization and treatment technique. Following the successful EMBRACE I and II studies in gynaecological BT, the gynaecological community is focusing now on EMBRACE III, EMBRAVE and Retro COSMOS trials. Another aspect is the definition of new treatment sites for BT or salvage BT as a reirradiation strategy for a variety of recurrent tumors [10]. However, it is important to acknowledge that the concept of the level of evidence may be interpreted differently depending on the clinical context. For instance, in cervical cancer, although no randomized trial has ever directly compared an external beam radiotherapy boost with a BT boost, BT remains an essential component of the standard treatment strategy. In this setting, the level of evidence may be considered relatively low according to traditional evidence hierarchies, while the strength of recommendation remains extremely high. Conversely, in high-risk prostate cancer, several randomized trials and meta-analyses have demonstrated the benefit of a BT boost. Despite this higher level of evidence, the corresponding recommendations are still not consistently implemented in routine clinical practice.

These observations suggest that BT, owing to its exceptionally strong biological, physical, and dosimetric rationale, allowing the delivery of very high doses to the target volume while minimizing exposure to surrounding organs at risk, may represent a particular therapeutic paradigm in which the absolute requirement for phase III randomized trials comparing BT with alternative external irradiation techniques deserves reconsideration.

In this context, large real-world data cohorts, registry-based studies, and synthetic control cohorts may provide valuable complementary evidence and help answer clinically relevant questions when randomization is either methodologically challenging or ethically and practically unfeasible [30].

3.2. Brachytherapy training

BT training peer education remains of high importance. Results of surveys have shown the need for BT training but also a high level of interest of the trainees [31], [32]. To reflect this, GEC-ESTRO started the EuroBT Fellowship in 2023, to train radiotherapy trainees in European centers of excellence for 6 to 24 months [33].

3.3. Reimbursement

Reimbursement is a challenging topic to solve. It can change as result of other steps. To get an overview on this complex topic, the Brachy-HERO working group has started a survey with subsequent analysis on the data in Europe on reimbursement of a simple BT technique; adjuvant vaginal vault treatment. Preliminary results were presented at the GEC-ESTRO workshop in Belgrade in November 2025 and will be submitted to a peer-review journal.

3.4. Technical developments

Several important technical improvements have developed a lot over recent years; several have already entered routine clinical practice, others are still in planning [34]. To name the new and important technical developments are outside of the scope of this vision paper. The BRAPHYQS working group of GEC-ESTRO is regularly evaluating the need for further developments in BT physics.

Although research, training, reimbursement and technical development are important, they are already in the focus of the GEC-ESTRO committee. Therefore, no immediate action is required – unlike the topic of communication. Milestones have been defined for this topic for each WP:

  • •

    WP Patients (WP1): establish contact to patient groups and invite them to the Brachy-HERO WG.

  • •

    WP Other Scientific Societies (WP2): Contact these societies and invite them to GEC-ESTRO workshops for joined tracks and submit abstracts to their scientific meetings, starting with societies where links already exist. A joint track with a society in a related field is planned for the GEC-ESTRO Workshop in autumn 2026.

  • •

    WP Social media (WP3): establish a social media group within GEC-ESTRO to prepare social media contents (younger members should be involved).

  • •

    WP (Pharma) Industry (WP4): establish greater contact with potential new industry partners (start-ups, non-BT industry, pharmaceutical industry) and deepen contact with existing partners.

  • •

    WP Healthcare administration/Insurance companies (WP5): establish contact at different European national bodies and at EU level.

The timelines for the five WPs on communication are illustrated in Fig. 2. The beginning of the arrows indicates the start of a WP. It is expected that all work packages will continue after 2028. The black dots show a milestone for the WP, described earlier.

Fig. 2.

Fig. 2

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Timeline of the aspects to promote brachytherapy in the future. Black dots indicate milestones of a WP.

4. Discussion and conclusion

As part of the ESTRO vision, the GEC-ESTRO B3T was established to promote and revitalise BT and secure its future. The main challenges were identified, with the topic”Communication“labelled as most important. In addition, five communication WPs were presented with initial approaches implemented and milestones defined. The good results and potential of BT, as outlined earlier in this manuscript, simply need to be made better known outside the sphere of BT.

Today, social media is an important part of daily life for many people [35]. Several multimedia platforms offer free photo or video sharing which can be used to deliver information about medical procedures and techniques. Radiotherapy and particularly BT can use these to their advantage. GEC-ESTRO can reliably notify the general public and patients via these digital social media channels. However, this should be done with care, as social media information may not always be reliable. The social media appearance of GEC-ESTRO must be reputable and fact-based. To ensure this, the professional social media channels of ESTRO should be used.

In 2012 Valentini et al. [36] presented ESTRO's vision for the year 2030. One of the key aspects was that every cancer patient has access to state-of-the-art radiation therapy. This counts as well for GEC-ESTRO as integral part of ESTRO, maybe even more so, due to the highly interdisciplinary approach in BT. The strategic vision presented by GEC-ESTRO also fits well with the ESTRO strategy paper by Kirby et al. [1] and elaborates on it with regard BT in Europe. GEC-ESTRO opted for a proactive approach to building partnerships with other parts of ESTRO, the industry and patients (A). There are plans to step up cooperation with other societies (B), and this has already been implemented in WP2. It is also to be hoped that the European vision for GEC-ESTRO outlined here will attract new members to ESTRO (C) and that this will undoubtedly bring ESTRO's work more into the spotlight and boost engagement (D). ESTRO's aim of strengthening advocacy at EU level has already been partially achieved for BT; in particular, contacts with patient groups and activities involving health authorities and insurance companies at EU level are planned (WP5). However, contact with the bodies of the European Commission is the responsibility of ESTRO and is maintained by GEC-ESTRO in close cooperation with other ESTRO bodies, such as the Professions and Partnerships (P&P) Council.

The main aims of the GEC ESTRO strategic vision are to ensure that BT is considered, from the outset, among radiotherapy options for every patient with a solid tumor, in order to provide a value based and personalised approach, and that every patient with cancer should be informed about BT before the first medical consultation. Indeed, a patient who is well informed about all relevant treatment options, including BT, prior to consulting with their treating physician will be better able to understand the situation and make an informed decision.

GEC-ESTRO's place within the wider ESTRO family sends a clear message: BT belongs at the heart of radiation oncology and is one of key components of the fight against cancer.

The presented strategic vision is endorsed by the ESTRO P&P Council, the CEO of ESTRO, and the GEC-ESTRO Committee.

CRediT authorship contribution statement

Frank-André Siebert: Writing – review & editing, Investigation. Christian Kirisits: Writing – review & editing, Investigation. Peter Niehoff: Writing – review & editing, Investigation. Andrea Slocker: Writing – review & editing, Investigation. Vratislav Strnad: Writing – review & editing, Investigation. Alina Sturdza: Writing – review & editing, Investigation. Luca Tagliaferri: Writing – review & editing, Investigation. Jean-Michel Hannoun-Levi: Writing – review & editing, Investigation.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Acknowledgements

Catharine Clark, Alessandro Cortese, Matthias Guckenberger, Vilma Jahja, Barbara Jereczek-Fossa, Alexandra Stewart.

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