The radiation oncology community will gather in Boston from September 26 through September 30 for the 2026 ASTRO Annual Meeting. The meeting’s theme, “Data to Dialogue: Communicating Radiotherapy’s Value to Patients and Policymakers,” could not be more timely. ASTRO 2026 Annual Meeting
Radiation oncology must communicate its value, but value cannot be discussed only in terms of clinical efficacy. The harder conversation involves the cost of producing that value, the infrastructure required to sustain it and whether the current delivery model can survive the next five years.
For more than a decade, the industry has described its instability as a reimbursement problem. Reimbursement matters, but it does not fully explain what is happening. Radiation oncology is confronting the failure of an operating model built around conventional fractionation, high technical revenue and operating margins large enough to absorb escalating capital, software, labor and service-contract costs.
The 2027 Medicare proposals did not create this crisis. They revealed how little financial protection remains.
ASTRO 2026 should therefore involve more than presentations about new technology, reimbursement advocacy and access. Attendees should ask direct questions of vendors, professional leaders, health systems and themselves.
Are We Discussing Access Without Discussing Economics?
A 2026 national analysis reported that 68.5 percent of United States counties, representing approximately 50.8 million people, did not contain a radiation oncology practice site in 2025. Rural sites had 44 percent higher odds of disappearing than urban sites, while freestanding facilities had 56 percent higher odds of closing than hospital-affiliated locations.
Those findings deserve attention, but documenting where facilities disappeared does not explain why they disappeared.
At ASTRO, we should ask whether access discussions account for population density, cancer incidence, travel time, payer mix, equipment age, treatment volume, hospital financial performance and capital replacement requirements.
County boundaries are not healthcare markets. A county without a linear accelerator does not necessarily represent a population without reasonable access. Conversely, a county containing a facility may still have poor access because of staffing shortages, limited capacity, insurance restrictions or deteriorating infrastructure.
The national map of radiation oncology facilities is also a map of capital. Investment flows toward markets with population growth, commercial insurance, strong referrals and sufficient volume. It retreats from markets with declining populations, heavy government-payer dependence, workforce shortages and financially distressed hospitals.
Access disappears after economic sustainability has already disappeared.
What Are Vendors Doing to Preserve Community Radiation Oncology?
The exhibit hall will showcase remarkable technology. It will also provide an opportunity to ask difficult questions.
What is the vendor’s plan for a rural program treating eight to ten patients per day? Does the company offer a lower-cost platform designed for that market? Will it provide a service agreement tied to actual utilization? Can the equipment remain clinically supportable for longer than the traditional replacement cycle? What are the annual escalation provisions? What happens to software costs after the initial purchase?
For years, the United States was the cash cow of radiation oncology. Hospitals purchased increasingly expensive machines, imaging systems, planning platforms and point solutions while reimbursement supported the investment. The industry now appears increasingly focused on global markets that are still expanding capacity.
That may be a rational business decision, but vendors should not simultaneously claim to prioritize American access while maintaining pricing that makes community access impossible.
A commitment to access must appear in acquisition prices, maintenance agreements, financing structures, interoperability and measurable operating value.
Does This Technology Reduce the Total Cost of Care?
Every artificial intelligence, software and automation vendor should be asked the same question: What work does this product eliminate?
A product that adds another interface, queue, dashboard, subscription or manual reconciliation process may increase complexity even if it performs one task well. Radiation oncology cannot afford another generation of point solutions that create hidden labor costs downstream.
Health systems should ask vendors to quantify implementation expenses, integration requirements, ongoing staffing needs, cybersecurity obligations and measurable productivity improvement. They should also ask who retains accountability when an algorithm produces a recommendation and whether the technology supports transparent clinical and legal governance.
Innovation should reduce administrative burden, improve capacity or lower total cost. If it does none of those things, it may be interesting technology without being a sustainable investment.
What Happens to Radiation Oncology if 340B Economics Change?
This may be the most important question asked in Boston.
CMS has proposed paying for certain 340B-acquired drugs more closely to hospital-reported acquisition costs beginning in 2027. Most discussion will focus on infusion, medical oncology and pharmacy. However, revenue generated through 340B often supports the broader cancer enterprise.
Radiation oncology does not need to administer a 340B drug to depend indirectly on 340B economics.
If pharmacy and infusion contribution margins decline, health systems will reassess the complete cancer portfolio. A radiation oncology program operating near breakeven may become vulnerable even when its clinical performance remains excellent.
Executives should ask whether their organizations have modeled the effect of proposed 340B changes on radiation oncology capital, staffing and satellite locations. They should know whether a planned linear accelerator replacement depends on margin generated elsewhere in the cancer program.
The first sign of trouble may not be a closure. It may be a delayed replacement, reduced hours, a hiring freeze or a decision not to replace a retiring physician. Those decisions begin the consolidation process long before the public recognizes an access problem.
What Is the Real Breakeven Volume?
Bridge Oncology’s total-cost analysis modeled a representative program with approximately $5.19 million in annual costs and a breakeven point near 400 patients. At 500 patients, the modeled margin was approximately 19.6 percent. At 300 patients, it fell to approximately negative 34 percent.
The exact number will differ for every organization, but the underlying principle remains. Radiation oncology is volume-dependent because most of its costs are fixed.
Attendees should ask whether their organizations know the fully allocated cost per treatment course, breakeven volume by location, machine utilization, five-year capital requirements and margin by disease site and payer.
A department can report a positive operating margin today and remain economically unsustainable if it cannot finance its next equipment replacement.
Are We Normalizing the Warning Signs?
The Deepwater Oncology analysis offers a useful lesson. Complex systems rarely fail because of one reckless decision. They fail after leaders normalize warning signs, accept incremental compromises and interpret contradictory information in ways that allow operations to continue.
Radiation oncology has normalized denials, peer-to-peer reviews, authorization delays, missed starts, workforce shortages, aging equipment and shrinking margins. Each issue is treated as isolated operational friction. Together, they describe a delivery system under mounting pressure.
At ASTRO, leaders should ask which warning signs their organizations have accepted as normal. They should also ask what specific threshold would cause them to stop, reassess and redesign the model.
Waiting for a machine failure, physician departure or payer disruption is not strategic planning.
Can ROCR Solve a Total-Cost Problem?
Episode-based payment may stabilize selected practices, but ROCR does not lower equipment prices, renegotiate service contracts, eliminate duplicative software, solve workforce shortages or fund capital replacement.
Payment reform without cost reform resets the pressure gauge. It does not repair the underlying system.
The question for professional leaders is whether advocacy will address the total cost of delivering radiation therapy or continue focusing primarily on how much Medicare pays. Fair reimbursement remains essential, but additional payment without operating accountability will eventually be consumed by the same cost structure.
What Are We Prepared to Change?
This question connects the three books in The Accountable Oncology Trilogy. Not About Access explains that access is the visible result of failed economics. Beyond Payment argues that reimbursement alone cannot repair a fragmented cancer enterprise. Built to Last asks whether organizations will redesign oncology deliberately or allow financial pressure to redesign it through consolidation.
ASTRO 2026 should be a turning point.
Professional societies must address cost and capacity. Vendors must address pricing. Hospitals must address utilization and capital discipline. Physicians must recognize that evidence-based efficiency changes historical revenue. Policymakers must understand that reducing margin in one part of oncology can destabilize another.
Radiation oncology remains clinically valuable. That does not guarantee that every program will survive.
The old model cannot be restored. The choice is now between deliberate transformation and unmanaged consolidation.
When the community arrives in Boston, the most important question will not be what new technology radiation oncology can buy.
It will be whether the industry is finally prepared to build an operating model it can afford.