By Maria Dimopoulos, Assistant Professor, Radiation Oncology, Icahn School of Medicine at Mount Sinai
A Foundation Built in Image
For more than a century, advances in medical thinking and cancer care have evolved in tandem, creating modern oncology. From x-ray detection to computed tomography (CT) and the modern linear accelerator, these new techniques have changed the way tumors are detected and targeted. Cancer treatment is now scaled to millimeters, allowing doctors to use tighter margins while better preserving healthy tissue.
In my opinion in radiation oncology, the most important change today is not a single way of thinking or treatment, but how these technologies come together. Cross-modality imaging combines multiple techniques, such as CT, magnetic resonance (MR), and positron emission tomography (PET), to provide a comprehensive understanding of diseases by combining anatomical, functional, and biological information. Combining these imaging modalities with radiation therapy enables precise, flexible, and real-time treatment.
Theranostics is expanding the role of imaging further. By combining therapeutics and diagnostics with radiopharmaceuticals that target specific molecular features of the disease, theranostics directly links imaging findings to targeted therapies based on tumor biology. For patients, this can mean improved accuracy, fewer side effects, and increasingly individualized care.
Advanced imaging not only tells us where the tumor is, but also how it behaves and responds.
From perception to adaptation
Adaptive radiotherapy shows how imaging shapes the treatment, not just informs it. This treatment modality alters the patient’s treatment plan in response to anatomical or biological changes during radiation therapy. MR-guided radiation therapy is an example. MR-linear accelerators combine real-time MRI with radiation therapy delivery, allowing continuous visualization of the tumor and on-the-table adjustments as the anatomy changes. Our technology allows treatment plans to evolve with the patient, improving accuracy while sparing healthy tissue. This highlights a broader shift in oncology. Imaging techniques such as PET-CT and PET-MR are no longer prescribed but are increasingly integrated into the way we define disease and guide treatment. Advanced imaging not only tells us where the tumor is, but also how it behaves and responds.
For patients, this can mean tighter margins, and fewer side effects. In some cases, flexible methods support hypofractionation, reducing the number of medical visits and the burden of travel, time off work, and care.
Accuracy of Daily Practice and Movement Management
In daily practice, a diverse offering of imaging techniques remains fundamental to the delivery of safe and effective treatment. Image-guided radiation therapy, including cone-beam CT, allows us to confirm positioning before each treatment, ensuring accuracy and consistency.
Imaging also improves the treatment experience for patients. Motion control techniques such as respiratory gating and surface-directed radiation therapy allow radiation oncology teams to respond to natural motion, including breathing, during treatment.
For patients, this can mean relying on traditional prevention, where treatment is more tolerable without compromising accuracy. Innovation in radiation oncology is not only about accuracy, but also about the patient experience.
Accelerating Care with AI and Automation
Artificial Intelligence (AI) and automation are increasingly embedded in the imaging workflow, supporting clinical decision-making while preserving expert judgment. Automated and knowledge-based planning tools reduce the time required to produce high-quality treatment plans.
As cross-modality imaging advances, AI will continue to play an important role in integrating complex data into clinically actionable insights. Its value is in improving our ability to interpret information, reduce variability, and deliver consistent care. In this case, efficiency and personalization are aligned.
Imaging Across the Care Continuum
Thinking now extends to the entire cancer care journey, from diagnosis and staging to treatment planning, response assessment, and follow-up. These developments create opportunities for integrated and patient-centered care. Advanced Practice Radiation Therapists (APRTs), an emerging role in radiation oncology, play an important role in completing these procedures under the direction of a radiation oncologist. APRTs may serve as clinical experts and liaisons between imaging, treatment teams, and inpatient care, ensuring that imaging information informs decisions and supports directed care. For patients, this can mean fewer unnecessary scans, clearer communication, and information navigating a complex system.
Theranostics and the Future of Radiation Oncology
Innovation in radiation oncology continues to advance with the rise of theranostics. In this way, diagnostic imaging and radiation therapy are combined with radiopharmaceuticals that target specific molecular features of the disease, allowing doctors to visualize and treat cancer based on its biology. This represents a shift from cancer treatment based primarily on location to integrating biology as a central driver of care. While integration into general practice is emerging, early detection is showing its potential to refine treatment choices, guide adaptive strategies, and improve response assessment.
Radiation oncology has long been a highly specialized specialty. Its continued development will depend on how imaging, radiation therapy delivery, and emerging therapies are integrated. As theranostic principles become more focused, imaging will not simply guide treatment; will increasingly change individualized treatment plans.
The Future of Patient-Centered Radiation Oncology
Advanced imaging is a defining feature of modern radiation oncology, enabling precision, flexibility, and integration across the continuum of care. The convergence of imaging and theranostics is reshaping the way care is delivered and experienced. As imaging informs all phases of care and radiation therapy becomes increasingly personalized, we’re not just improving outcomes, we’re redefining what patient-centered care looks like.
