A look at upright radiotherapy research so far

Tracy Underwood, Head of Translational Research at Leo Cancer Care, recently delivered a webinar titled “A look at upright radiotherapy research so far”. The session provided a clear, well-structured overview of the rapidly expanding body of research exploring upright radiotherapy across multiple tumor sites and clinical indications.

A strength of this overview was the way research from diverse academic and clinical centers was synthesized and explained. By bringing together patient-reported experiences, physiological studies, and early clinical data, the session demonstrated how upright radiotherapy has evolved from a theoretical concept into a growing, evidence-based field.

Why upright radiotherapy, and why now?

The discussion opened with an introduction to upright radiotherapy and the factors driving renewed interest in this approach. A key driver is the increasing cost and complexity of advanced radiotherapy, particularly heavy particle therapy, which relies on large rotating gantries. The significant infrastructure, cost, and resource demands of these systems mean that particle therapy remains inaccessible to many patients who could benefit from it.

Upright radiotherapy offers a potential route to more compact, flexible, and accessible treatment delivery. Reference was made to The Lancet Oncology Commission “The Human Crisis in Cancer Care” [1], which highlights how fragmented systems and a lack of human connection negatively impact cancer treatment for our patients. This framing reinforced the idea that innovation in radiotherapy must improve not only technical outcomes, but also patient comfort, dignity and overall experience.

Head and neck cancer: patient experience and clinical feasibility

Research into head and neck cancer has provided some of the earliest insights into the potential of upright radiotherapy. Qualitative work from Sheffield Hallam University (as yet unpublished) explored patient experience of supine radiotherapy through online focus groups with people who had lived experience of treatment. Participants described significant discomfort related to swallowing thick oral secretions, nausea, and breathing difficulties.

These patient-reported findings were supported by clinical experience from Russia, where upright proton therapy has been used for head and neck cancers with fast setup times [2,3]. Additional clinical data from Hadassah Medical Centre in Israel demonstrated setup accuracy comparable to supine treatments [4], while the Shanghai Proton and Heavy Ion Center has successfully delivered treatments using a combination of upright and supine postures to achieve favorable beam angles, again with comparable accuracy [5].

Breast cancer: comfort, positioning, and internal anatomy

Breast cancer research has similarly highlighted potential benefits from upright positioning. Work from Sheffield Hallam University examined patient experience of supine positioning. Many patients reported difficulty and vulnerability in the supine position, particularly following surgery. When introduced to an upright treatment posture, feedback was largely positive, with many patients preferring the upright position for comfort and reduced feelings of exposure [6]. This aligns with a French study reporting a 78% patient preference for upright breast treatment [7].

Alongside patient experience, multiple studies have focused on technical feasibility. Studies using specialist radiotherapy bras demonstrated effective lifting of the breast, reducing skin folds and the potential for skin toxicity. A recent study from Dr Gordon Sands has also demonstrated promising photon beam access in the upright position, addressing a key feasibility concern [8].

It was reported that an ongoing MRI-based study conducted by Leo Cancer Care, the University of Nottingham and University College London is investigating the position of the breasts relative to the heart, upright versus supine, with different arm positions and bra use. The aim is that this data will advance our understanding and optimization of upright breast radiotherapy.

Lung, liver, and the role of gravity

Physiology and organ motion represent a critical area of upright radiotherapy research. Research from Keio University, involving hundreds of volunteers scanned upright and supine, showed an average 10% increase in lung volume in the upright position [9].

Spirometry studies (as yet unpublished) from Dr Anthony Criscuolo and Sophie Boisbouvier have demonstrated reduced airway obstruction for upright radiotherapy postures, making breathing easier. This is an important finding for patients with lung tumors or existing respiratory conditions. The feasibility of deep inspiration breath-hold in upright positions has also been demonstrated by these groups.

Further motion studies, including work by PhD student Timothy Lo, found that diaphragm and blood vessel motion was reduced upright, in the majority of cases. Similar findings have been published by Yusuke Nomura et al, highlighting reduced liver and diaphragm motion upright [9].

Particularly for relatively heavy organs such as the liver, it has been reported that it can take up to 35 minutes for anatomy to settle after a patient is positioned supine, with positional changes exceeding 5mm for many participants [10].

Pelvic cancers: stability, dignity, and reproducibility

Pelvic indications have also been explored, with a strong focus on patient comfort and reproducibility. Sheffield Hallam University has led qualitative research involving patients with a prostate cancer diagnosis [11]. Focus groups highlighted fear and anxiety related to bladder filling, discomfort lying flat, embarrassment, and difficulty getting on and off the treatment couch. Over half of the participants said they would have preferred upright treatment, noting potential benefits such as improved communication with treatment radiographers.

These findings were supported by earlier work from Sophie Boisbouvier, which showed high comfort levels for upright positioning, interfractional reproducibility around 1 mm, and intrafractional motion within 3 mm for the majority of patients [12].

Additional physiological research from Niek Schreuder demonstrated increased pelvic organ stability upright, regardless of bladder filling, and greater separation between organs: factors that may help to reduce dose to healthy tissue [13].

Emerging work has also explored how existing technologies might translate to upright workflows. Gordon Sands and MVision successfully applied an auto-segmentation model for the male pelvis, trained only on supine MRI data, to upright MRI datasets, achieving credible contours in around 80% of cases [14].

Looking forward

Taken together, this body of research highlights upright radiotherapy as a credible, patient-centered approach with growing evidence across multiple tumor sites. While the research to date is encouraging, the webinar also underscored the importance of continued data collection, larger clinical studies, and ongoing collaboration to fully validate and optimize upright treatment pathways.

As this field continues to evolve, sustained research momentum will be essential to ensure upright radiotherapy can realize its potential; improving access, enhancing patient experience, and supporting future innovation in radiotherapy.

References

[1] Rodin G. et al. (2025) The human crisis in cancer: a Lancet Oncology Commission
https://doi.org/10.1016/S1470-2045(25)00530-3
[2] Balakin V.E. et al. (2018) Clinical Application of New Immobilization System in Seated Position for Proton Therapy
https://doi.org/10.18502/ken.v3i2.1790
[3] Gordon K. et al. (2024) Upright proton therapy for esthesioneuroblastoma: a single-institution experience
https://doi.org/10.3389/fonc.2024.1348291
[4] Feldman J. et al. (2024) Study of upright patient positioning reproducibility in image-guided proton therapy for head and neck cancers
https://doi.org/10.1016/j.radonc.2024.110572 ScienceDirect
[5] Sun J. et al. (2025) Comparative analysis of residual setup errors in head and neck patients from upright versus supine radiotherapy postures
https://doi.org/10.1002/mp.17824
[6] Ulman J. et al. (2025) Exploring patient perceptions of the current breast radiotherapy pathway and a future upright radiotherapy solution
https://doi.org/10.1016/j.radi.2025.103157
[7] Boisbouvier S. & Underwood T. et al. (2023) Upright patient positioning for gantry-free breast radiotherapy: feasibility tests using a robotic chair and specialised bras
https://doi.org/10.3389/fonc.2023.1250678

[8] Nomura Y. et al. (2025) Comparison of supine and upright postures for liver respiratory motion management in radiotherapy
https://doi.org/10.1002/mp.18111
[9] Yamada Y. et al. (2020) Comparison of inspiratory and expiratory lung and lobe volumes among supine, standing, and sitting positions using conventional and upright CT
https://doi.org/10.1038/s41598-020-73240-8
[10] von Siebenthal M. et al. (2007) Systematic errors in respiratory gating due to intrafraction deformations of the liver
https://doi.org/10.1118/1.2767053
[11] Underwood T.S.A. et al. (2024) Patient perspectives on upright radiotherapy
https://www.thegreenjournal.com/article/S0167-8140(24)01570-6/abstract
[12] Boisbouvier S. et al. (2022) Upright patient positioning for pelvic radiotherapy treatments
https://doi.org/10.1016/j.tipsro.2022.11.003
[13] Schreuder A. et al. (2023) Anatomical changes in the male pelvis between the supine and upright positions — a feasibility study for prostate treatments in the upright position
https://doi.org/10.1002/acm2.14099
[14] MVision AI (Industry article) Breaking new ground: MVision AI contour for upright MRI scans