Authors' objectives: The objective of this review is to assess the effectiveness, safety, cost effectiveness, and organisational impact of online adaptive radiotherapy (oART) using the Varian Ethos system for the treatment of cancer patients.

Authors' results and conclusions: Efficacy/ effectiveness There was moderate quality evidence showing that online adaptive radiotherapy (oART) may improve target coverage while reducing normal tissue exposure, palpable by superior dosimetric benefits in many observational studies. However, additional clinical data is needed to fully evaluate its clinical impact especially in term of clinical goal such as tumour control and organ toxicity. Across the evidence retrieved, oART is feasible to be done in clinical setting with treatment time reported ranging 13.9 – 34.5 minutes. Safety There was limited evidence reporting on safety aspect of online adaptive radiotherapy. Ethos therapy by Varian has received 510(k) clearance from U.S Food and Drug Administration (FDA) and CE mark in February 2023. Organisational issues Organisational issue highlighted in implementing online adaptive radiotherapy (oART) includes; 1) increased time required per treatment session, 2) requires a highly skilled multidisciplinary team with additional staff training, 3) careful patient selection, 4) compatibility issue with existing infrastructure or system, 5) additional infrastructure needed 6) risk of algorithm bias in Artificial Intelligence (AI)-driven plan generation. Economic implication There was no retrievable evidence on the cost or cost-effectiveness of online adaptive radiotherapy using Ethos therapy in cancer population. However, there was one study in United States concluded that incremental cost per additional adaptive fraction is $103.58. Conclusion There is moderate quality of evidence from observational studies showing that online adaptive radiotherapy (oART) improves short-term dosimetric outcomes, such as target coverage and organ sparing, in patients with head and neck, lung, bone metastases, and pelvic cancer. However, adaptive treatment time requires an additional 13 to 34 minutes for plan re-optimization based on the patient’s anatomy of the day. In terms of safety, there is limited evidence available on the safety aspects of oART. Regarding cost and cost-effectiveness, no retrievable evidence exists on the economic impact of using Ethos therapy for cancer treatment. From an organizational perspective, implementing oART necessitates a multidisciplinary team with additional training in editing and validating AI-driven contouring. Considerations must also be given to ensuring interoperability for seamless integration into the existing healthcare ecosystem.

Authors' methods: A systematic search was conducted on the following databases with restriction on English and Human. The Ovid interface: Ovid MEDLINE(R) and Epub Ahead of Print, In-Process, In-Data-Review & Other Non-Indexed Citations and Daily 1946 to July 2024. Searches were also run in PubMed databases. Google was used to search for additional web-based materials and information. The last search was conducted on 15th July 2024.

Project Status: Completed

URL for project: https://www.moh.gov.my/index.php/database_stores/store_view_page/30/421

Year Published: 2024

URL for published report: https://www.moh.gov.my/index.php/database_stores/store_view_page/30/421

English language abstract: An English language summary is available

Publication Type: Mini HTA

Country: Malaysia

Organisation Name: Malaysian Health Technology Assessment

Contact Address: Malaysian Health Technology Assessment Section, Ministry of Health Malaysia, Federal Government Administrative Centre, Level 4, Block E1, Parcel E, 62590 Putrajaya Malaysia Tel: +603 8883 1229

Contact Name: htamalaysia@moh.gov.my

Contact Email: htamalaysia@moh.gov.my

Copyright: Malaysian Health Technology Assessment Section (MaHTAS)