# From fractionation to financials: economic and clinical implications of hypofractionation in German outpatient radiotherapy practice

## TL;DR

This study compares the economic benefits of hypofractionation versus normofractionation in radiotherapy for breast and prostate cancer in Germany, finding hypofractionation more efficient and cost-effective.

## Contribution

The study introduces a detailed economic analysis of hypofractionation in the German outpatient radiotherapy context, emphasizing its efficiency and financial sustainability.

## Key findings

- Hypofractionation yields higher economic efficiency due to increased patient throughput and reduced staff-time per treatment.
- Over 10 years, hypofractionation breast cancer treatments generated significantly higher revenue per linear accelerator compared to normofractionation.
- A one-time investment in hypofractionation can be quickly amortized, showing substantial efficiency gains without expanding machine capacity.

## Abstract

Thie study aimed to examine the economic implications of different radiotherapy fractionation schemes, specifically normofractionation (NF) and hypofractionation (HF), for breast and prostate cancer in the outpatient setting of the German healthcare system. In times of workforce shortages, limited machine availability, and rising patient numbers, the study aims to identify which fractionation approach offers the highest value in terms of efficiency and economic sustainability, aligning with a value-based healthcare framework.

Economic models were developed using German reimbursement data (EBM), treatment costs, machine usage, and realistic patient volumes. Three breast cancer fractionation schemes (conventional NF with 30 fractions, i.e., 25 fractions to the whole breast +5 boost fractions), NF with simultaneous integrated boost (SIB) comprising 28 fractions, and HF with 20 fractions (15 fractions to the whole breast +5 boost fractions) as well as two prostate cancer regimens (39 × 2.0 Gy versus 20 × 3.0 Gy) were compared. A standardized clinic setup with two linear accelerators and defined full-time staff was assumed. Analyses included cost, break-even points, contribution margins, and personnel needs in both scenarios (HF and NF).

Despite lower reimbursement per case, HF regimens yielded significantly higher economic efficiency due to increased patient throughput and reduced staff-time per treatment. Over 10 years, the total revenue per linear accelerator for HF breast cancer treatments reached approximately € 56.9 million, compared to € 40.2 million and € 46.6 million for the two NF approaches. A one-time investment of € 50,000 for implementing HF (e.g., for software, training, and workflow optimization) could be amortized within a few days, depending on the scenario. Simulation models further demonstrated substantial efficiency gains under hypofractionation without the need to expand machine capacity—an important strategy amidst staffing shortages and increasing demand.

When supported by efficient clinic organization and sufficient patient volume, HF offers clear economic advantages over traditional fractionation schemes. However, for widespread implementation, structural reform of the current outpatient reimbursement system is desirable.

The online version of this article (10.1007/s00066-025-02484-y) contains supplementary material, which is available to authorized users.