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Practical Radiation Oncology associate section editor, Sandra Meyers, PhD of University of California, San Diego, hosts a conversation on online adaptive radiotherapy, or the use of imaging to adapt radiation treatments to the anatomy observed each day. Lauren Henke, MD of University Hospitals Cleveland Medical Center and Bin Cai, PhD of UT Southwestern Medical Center discuss their clinical experience with both cone-beam CT and MR-based online adaptive radiotherapy. Benefits and challenges of online adaptive compared to conventional radiotherapy are discussed, as well as strategies for success when implementing this technologically.