A National Center for Pediatric Radiotherapy in Israel

Ory Haisraely, MD, MPH

Department of Radiation Oncology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel

Introduction

Pediatric radiotherapy combines a small patient population with an unusually broad spectrum of diseases, treatment protocols, and developmental considerations. The International Paediatric Radiation Oncology Society (PROS) has identified rarity, histologic diversity, and complex multimodal treatment as defining challenges of the specialty [1]. Distributing these cases among otherwise capable departments can leave each team with limited repeated experience of a particular diagnosis. For Israel, the challenge is to sustain collective expertise across the treatment pathway. A national pediatric radiotherapy center, connected to regional pediatric oncology services, offers a coherent response. The development of proton therapy provides an opportunity to establish that clinical structure alongside the new technology.

National demand

Published Israeli registry data provide a historical context for the scale and diversity of childhood cancer. Among 4,255 children and adolescents aged 0–19 years diagnosed during 1998–2007, the age-adjusted incidence was 172.4 per million; leukemia, lymphoma, and central nervous system tumors accounted for 22%, 20.2%, and 17.4%, respectively [2]. These proportions describe all cancer diagnoses, not the radiotherapy population. In an Egyptian single-center cohort of 13,305 pediatric patients, 4,390 (33%) received at least one radiotherapy course, with utilization varying substantially by diagnosis and stage [3]. This provides a capacity benchmark, rather than an Israel-specific utilization estimate.

For Israeli service planning, we propose a provisional demand envelope of approximately 170–210 children aged 0–19 years requiring radiotherapy annually by 2030, increasing to 185–230 by 2035 and 200–250 by 2040. They exclude international referrals. Reirradiation and multiple courses in the same child would generate additional treatment workload, which should be recorded separately from unique-patient counts.

The provisional 2030 service mix anticipates approximately 51 brain/CNS cases, 37 lymphoma cases, and 15 cases each of neuroblastoma and rhabdomyosarcoma annually. Additional planning lines comprise approximately 11 other soft-tissue sarcomas, seven Wilms/renal tumors, seven Ewing sarcomas, six leukemia/TBI cases, five intracranial germ-cell tumors, and three osteosarcomas. Their clinical implication is that several technically demanding indications would remain in single digits nationally each year. Concentrating those cases would provide more repeated disease-specific experience and opportunities for expert review. A prospective national registry should validate both demand and diagnostic distribution.

Clinical requirements

Recommendations developed by the European Society for Paediatric Oncology (SIOPE), the European Society for Radiotherapy and Oncology (ESTRO), PROS, and Childhood Cancer International–Europe define pediatric radiotherapy as an organized multidisciplinary service. Janssens and colleagues recommend the availability of at least two radiation oncologists knowledgeable about pediatric tumors, explicitly addressing continuity during weekends and holiday periods [4]. A national service should build on this standard with protected clinical time, sustained pediatric experience, and routine peer review. These arrangements would support both reliable coverage and the exchange of informed opinions.

Planning extends well beyond choosing a machine or producing a conformal dose distribution. The radiation oncologist must interpret diagnostic and postoperative imaging, treatment response, and protocol-specific indications in collaboration with pediatric oncologists, surgeons, and radiologists. Immobilization, anesthesia when required, specialist physics, dosimetry, and preparation by play or child-life specialists must function as a coordinated pathway. The British review of pediatric radiotherapy describes precisely this integration and emphasizes early radiation oncology involvement when radiotherapy may form part of treatment [5]. Expertise therefore belongs to a team whose members repeatedly work together.

Normal-tissue protection also requires developmental judgment. Pediatric Normal Tissue Effects in the Clinic (PENTEC) evaluates radiation dose–volume effects in the context of age, tissue development, other therapies, and patient factors [6]. The implications are organ-specific. For example, SIOPE guidance on vertebral irradiation addresses how dose gradients across growing vertebrae may contribute to asymmetric growth and spinal deformity [7]. A plan with apparently attractive dose sparing can therefore require reconsideration when growth is taken into account. Concentrating experience would support informed peer review of these decisions and international consultation for exceptionally rare presentations.

Evidence for concentration

A systematic review by Knops and colleagues found evidence of better outcomes with higher volume or specialized care in several pediatric oncology settings [8]. In a population-based European study of 4,415 children from six countries, treatment in higher-volume hospitals was associated with better five-year survival after adjustment for age, sex, and diagnostic group [9]. These observational findings concern childhood cancer care overall; they cannot establish a causal benefit or a pediatric radiotherapy volume threshold. They nevertheless provide a sound reason to examine how concentration could strengthen a small national service.

Radiotherapy-specific evidence demonstrates the value of expert review. QUARTET, the European program for quality and excellence in pediatric radiotherapy and imaging, reported 254 completed reviews across six trials. Initially submitted plans had a rejection rate of 39.8%, most commonly because of target-volume delineation. Prospective review enabled correction of 92% of unacceptable variations before treatment [10]. These trial-based findings give specialist discussion and independent contour review a concrete role in service design: preventing protocol deviations before a child receives radiotherapy.

A subsequent survey of 121 centers in 31 SIOPE-affiliated countries found that higher pediatric radiotherapy volume was associated with better general organization scores [11]. Although this survey did not evaluate patient outcomes, it reinforces the organizational dimension of expertise. A national center should therefore combine repeated clinical experience with explicit standards, prospective review, and outcome assessment.

European experience

European models distinguish between where expertise is concentrated and where care is delivered. In the Netherlands, pediatric oncology was brought together at the Princess Máxima Center, while regional shared-care relationships preserved care closer to home [12]. A review of pediatric surgical oncology emphasizes the organizational effort, stakeholder agreement, and country-specific circumstances required for centralization [13]. This experience supports a national center whose regional partners have a substantive role in the child’s care.

France illustrates a different scale of concentration. Its 2025 pediatric radiotherapy guidance describes approximately 800 children treated annually across 15 specialized centers, supported by common guidance and intercenter discussion [14]. The British review describes a national proton referral process and two proton centers, within an evolving pediatric radiotherapy network [5]. These arrangements reflect different populations and existing services. Their center counts should not be transferred directly to Israel; their shared commitment to designated expertise, coordinated referral, and multidisciplinary review is more instructive.

A Swedish model proposed in 2006 offered a complementary approach: assessment and planning at regional clinics, joint discussion through information-supported conferences, and delivery at a central proton facility [15]. More recently, the European Reference Network for Pediatric Cancers (ERN PaedCan) has demonstrated the feasibility of virtual multidisciplinary boards for children with central nervous system tumors [16]. These networks provide access to additional expert opinions across institutions and countries. Their value is greatest when consultation is integrated with the experienced team responsible for daily treatment.

The wider policy literature reaches beyond equipment and referral counts. A review covering 41 European countries examined how national cancer plans address children, adolescents, and young adults, including specialized care, research, and coordination [17]. The implication for Israel is that centralization should be embedded in a national pediatric cancer pathway. Geography, caseload, existing expertise, and the capacity of regional partners should determine the balance between central treatment and shared care.

The proton opportunity

The potential of proton therapy to reduce normal-tissue exposure is particularly consequential for children’s development and long-term health [5]. Realizing that benefit requires careful clinical selection and execution. In a nonrandomized longitudinal comparison of 79 children treated for medulloblastoma, proton therapy was associated with more favorable trajectories in several intellectual domains than photon therapy [18]. These findings support a clinically important benefit in a specific setting, while the choice of modality remains dependent on diagnosis, anatomy, and the comparative treatment plans.

Protons also introduce planning considerations that require specialist physics and clinical oversight. The ESTRO consensus developed within the European Particle Therapy Network addresses robustness evaluation under uncertainties in range, positioning, and anatomy [19]. Pediatric expertise remains necessary to define the appropriate target and acceptable tradeoffs before technical optimization begins. Moreover, as children move from photon to proton treatment, pediatric experience in photon-only departments may diminish, an organizational issue highlighted in the British review [5]. A national program should sustain expertise in both modalities and select between them on clinical grounds.

The Israeli discussion of proton access provides a timely setting for this broader clinical proposal [20]. Investment in a proton facility should include a durable pediatric team, prospective plan review, training, and long-term follow-up. These functions merit national coordination regardless of the eventual configuration of proton facilities. The relevant opportunity is to build a service capable of selecting and delivering the most appropriate radiotherapy for each child.

Implications for Israel

Israel’s relatively compact geography makes a national center with regional partners a plausible service model. Its feasibility would depend on addressing the burdens of daily treatment, repeated anesthesia, and separation from home. Transport and accommodation support, timely referral, and regional provision of supportive care and follow-up should accompany concentration of treatment. Regional branches should have defined clinical responsibilities and direct access to the national team.

Israel already has a relevant organizational analogy in the National Unit of Orthopedic Oncology at Tel Aviv Sourasky Medical Center, identified in a recent publication on advanced surgical technologies [21]. This provides a precedent for organizing expertise in a rare, technically demanding field around a nationally oriented specialist unit. A pediatric radiotherapy center could adopt that principle while developing its own referral network, clinical standards, and outcome evaluation.

We propose concentrating most pediatric radiotherapy planning and delivery in a national center, with particular priority for rare diagnoses and complex treatments. Regional pediatric oncology teams should participate in case discussions and retain responsibility for appropriate local care. Selected regional radiotherapy delivery could be considered where expertise, infrastructure, and shared quality assurance support it. National peer review should bring several informed perspectives to consequential decisions, while international reference networks provide additional consultation for exceptional cases. Referral processes should enable prompt shared decisions and should be evaluated for delays and barriers to access.

The center’s performance should be assessed through a national dataset linking diagnosis, treatment, plan review, disease control, late effects, and patient access. Staffing and treatment capacity should follow a verified assessment of Israeli demand, including anesthesia requirements and modality selection. Ongoing evaluation would allow capacity, referral arrangements, and regional responsibilities to evolve with patient needs.

Conclusion

The strongest argument for a national pediatric radiotherapy center is the need to sustain collective expertise in rare, complex diseases throughout a child’s treatment and survivorship. European experience supports concentration of specialist knowledge alongside meaningful regional participation, while leaving the precise configuration to each health system. Israel’s emerging proton program creates an opportunity to establish this structure. Its success should be judged by the quality, continuity, and accessibility of pediatric care.

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