a b s t r a c tBackground and purpose: The impact of differences in the distribution of major cancer sites and stages at diagnosis among 4 European countries on the optimal utilization proportion (OUP) of patients who should receive external beam radiotherapy was assessed within the framework of the ESTRO-HERO project. Materials and methods: Data from Australian Collaboration for Cancer Outcomes Research and Evaluation (CCORE) were used. Population based stages at diagnosis from the cancer registries of Belgium, Slovenia, the Greater Poland region of Poland, and The Netherlands were used to assess the OUP for each country. A sensitivity analysis was carried out. Results: The overall OUP by country varied from the lowest of 48.3% in Australia to the highest of 53.4% in Poland; among European countries the variation was limited to 3%. Cancer site specific OUPs showed differences according to the variability in stage at diagnosis across countries. The most important impact on the OUP by country was due to changes in relative frequency of tumours rather than stage at diagnosis. Conclusions: This methodology can be adapted using European data, thus facilitating the planning of resources required to cope with the demand for radiotherapy in Europe, taking into account the national variability in cancer incidence.Ó 2015 Elsevier Ireland Ltd. All rights reserved. Radiotherapy and Oncology xxx (2015) xxx-xxx Radiotherapy is a key therapeutic approach in the multimodality treatment of cancer. The investment required to set up a radiotherapy facility, the time elapsed from the initial decision until the equipment is fully operational and the need for training highly skilled multi-professional teams are factors that have made the planning of radiotherapy a matter of discussion from a cancer policy making perspective. In order to proceed with such projects, the estimation of demand for radiotherapy is an essential component.Classically, the demand for radiotherapy has been estimated as a percentage of the incident cancer cases with an adjustment for re-treatment rates [1][2][3]. Traditionally the '50%' estimate of incident cases benefitting from radiotherapy was the 'ad hoc' approach. However, this heuristic method has been replaced by three new approaches to the estimation of demand [4-9]:1) an analysis of the utilization of radiotherapy in 'optimal' regions; 2) a criterion-based approach carried out for specific indications, and 3) an evidence-based evaluation of clinical guidelines, including all tumour sites with incidence of more than of 1%.These approaches were reviewed within the framework of the QUARTS project [10]. The third approach was selected as being http://dx