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August 7, 2017. Rad oncs love to talk about fractionation. No, not the art of fractionation seduction...the art of dividing up a cumulative radiation dose into smaller daily treatments. A dose of 2 Gray (Gy) once per day is generally considered “standard” fractionation. Anything else (e.g., lower doses over more treatments, higher doses over less treatments, or >1 treatment per day) is usually lumped together as “altered” fractionation. There is now an update to the original MARCH meta-analysis comparing various fractionation schemes for H&N cancer first published in 2005: This new and improved report includes double the number of patients, 17 new trials, and no interest for 36 months. MARCH 2.0 (as well call it) demonstrates, when giving radiation without chemo, altered fractionation improves 5 year overall survival over standard fractionation by 3.1%, which seems mainly driven by the 8.1% improvement seen with hyper- (twice-daily) fractionation. The only thing keeping this from being groundbreaking is that we’ve known better disease control is seen with hyperfractionation since RTOG 9003 reported circa 2000, with a survival benefit demonstrated by its long term outcomes in 2014. So, even if it’s not technically news, this update on a huge dataset should serve as a huge reminder to at least consider altered fractionation for your H&N patients who are non-chemo candidates.