Is upright radiotherapy medically and financially better?

Upright radiotherapy is not new. It has been practiced for specialized treatments such as boron neutron capture therapy, light ion therapy, and even photon therapy before isocentric C-arm gantries became standardized more than 60 years ago. Today, radiotherapy treatment planning relies on CT and/or MRI systems which were typically designed only for recumbent positioning, however, lately CT and MRI scanners that can scan patients in the upright position have been developed. In recent years there is growing evidence that there are some medical benefits for treating some sites with the patient in the upright position. The existing literature describing the medical appropriateness is reviewed. Original work examining the impact to prostate radiotherapy in the upright direction is reported as is the effectiveness of repurposing conventional patient immobilization for upright radiotherapy. The financial benefits for treating with a fixed horizontal beam direction for external beam particle and photon therapy is also examined. So, is upright radiotherapy medically and financially better? The hypothesis is reasonable but it will require regulatory approval and early adopters to confirm the medical and cost effectiveness of the approach.