Online adaptive radiotherapy: International strategies for AI-enabled workflow efficiency and radiation therapist-led delivery for sustainable practice.

Online adaptive radiotherapy (oART) represents a significant advancement in personalised radiation cancer treatment, offering improved daily dose to targets and optimised organ exposures with reduced toxicity. Implementation remains challenging due to resource intensiveness, workflow complexity and workforce limitations. This article presents international insights on optimising oART delivery with a focus on practice development and workforce transformation. Strategies are explored to improve workflow efficiency, integration of artificial intelligence (AI) and the role of both therapeutic radiographers and radiation therapists (RTTs) in leading adaptive workflows. Credentialing frameworks for RTTs are examined as a mechanism to support sustainable oART delivery and reduce clinician console time. The discussion synthesises practical innovations from across multiple international healthcare systems, highlighting reproducible models for efficiency, workforce training and AI integration. These insights aim to guide global efforts in scaling oART delivery through efficient and collaborative practice models that align with safe, accessible patient-centred care.