Upright pediatric radiotherapy: building the evidence for a new approach

A new peer-reviewed paper has brought together international expertise to explore an important question for the future of pediatric cancer care: could radiotherapy be safely and effectively delivered to children in an upright position?

Published in Technical Innovations & Patient Support in Radiation Oncology, “Upright positioning in pediatric radiotherapy: rationale, safety considerations and a research roadmap” examines the rationale for treating children upright, the clinical and safety considerations involved, and the research needed to support its wider adoption.

Importantly, this is not simply a discussion about whether upright treatment is technically possible. The paper considers how it could be implemented in a way that is safe, evidence-led and centered around the individual needs of children and their families.

A multidisciplinary approach to a complex question

The paper was developed by the Upright Radiotherapy Pediatric Task Group, an international, multi-institutional and multidisciplinary collaboration bringing together expertise from radiation oncology, medical physics, radiation therapy, pediatric anesthesia and industry.

That breadth of expertise is particularly important.

Pediatric radiotherapy is about far more than the delivery of radiation. Treatment teams must consider a child’s age and development, their ability to understand and cooperate with treatment, immobilization, anxiety, anesthesia requirements, communication and the experience of their parents or caregivers.

Exploring a different treatment position therefore requires input from all the professionals involved in safely supporting that child through their treatment. Rather than looking at upright radiotherapy from a single perspective, the Task Group has created a framework that considers the entire pathway, from imaging and treatment planning to positioning, anesthesia, emergency procedures and the child’s experience.

Why consider upright treatment for children?

For most children receiving radiotherapy today, treatment involves lying on a treatment couch. For some, particularly younger children, remaining still in this position and coping with the treatment environment can be challenging. As a result, some children require sedation or general anesthesia for repeated radiotherapy appointments.

The paper explores the potential for upright positioning to provide another option for selected children, particularly where distress, limited cooperation or repeated general anesthesia may create additional challenges. It draws upon historical experience with seated radiotherapy, developments in upright imaging and treatment technology, and evidence from wider pediatric healthcare suggesting seated positioning can improve the tolerability of some procedures.

The authors are careful not to suggest that upright treatment should replace conventional supine radiotherapy for every child. Instead, they describe it as a potential extension of child-centered care, providing another treatment option where clinically appropriate.

Designing treatment around the child

One of the strongest themes throughout the paper is that technology alone is not enough. Successful upright pediatric radiotherapy requires careful consideration of age-appropriate immobilization, imaging and treatment-planning accuracy, positioning reproducibility, movement during treatment and anatomical changes associated with gravity. The treatment experience matters too.

Audiovisual distraction, education, preparation and other child-centered strategies are identified as important components of awake upright treatment. Creating an environment in which children understand what is happening, feel supported and are able to remain comfortable and still is an important part of making treatment possible.

For children who do require sedation or anesthesia, the paper establishes additional requirements. These include clear visibility and access to the airway, appropriate monitoring, sufficient space for the anesthesia team, emergency release mechanisms and the ability to rapidly move a child into a rescue position if required.

Crucially, the authors argue that these should be considered fundamental design and commissioning requirements rather than adaptations made later.

From possibility to evidence

The publication also acknowledges the work still to be done. Pediatric-specific evidence for upright radiotherapy remains limited. The Task Group therefore sets out a research roadmap including further anatomical and phantom validation, assessment of imaging and dosimetric accuracy, testing of emergency workflows and prospective clinical studies.

Future studies should investigate not only whether children can be positioned accurately and reproducibly, but also treatment duration, anesthesia use, acute safety and the experiences of children and their caregivers. This is an important distinction.

The question is no longer simply, “Can we treat children upright?”

Increasingly, the questions are: For which children could upright treatment be beneficial? How do we deliver it safely and reproducibly? And what evidence do we need to establish best practice?

What this means for Leo Cancer Care

For Leo Cancer Care, this publication represents an important milestone. For years, we have believed that pediatric radiotherapy should be part of the conversation around upright treatment. Children have been central to our thinking about how treatment environments could be designed differently, not simply around the technology required to deliver radiation, but around the person receiving it.

This paper provides independent, peer-reviewed support for exploring that possibility while establishing something equally important: a clear framework for how the radiotherapy community can investigate it responsibly.

And the evidence is beginning to move beyond theory. Upright pediatric radiotherapy is now entering clinical practice, providing an opportunity to combine the framework described within this publication with real-world clinical experience. That experience can help the community understand where upright treatment works well, where challenges remain and what further research is needed. We do not believe upright positioning will be the right approach for every child, nor should it be. What matters is having options.

For selected children, upright radiotherapy could provide another way to approach treatment, one that may support comfort, cooperation and a more child-centered experience while maintaining the rigorous standards of safety and accuracy that pediatric radiotherapy demands.

The publication of this research is therefore not the end of the conversation. It provides a foundation for the next stage: gathering evidence, sharing clinical experience and continuing to work across disciplines and institutions to understand what upright radiotherapy could offer children and their families.

Read the full paper here: Upright positioning in pediatric radiotherapy: rationale, safety considerations and a research roadmap, published in Technical Innovations & Patient Support in Radiation Oncology.