External beam radiotherapy otherwise known as teletherapy, is the most frequently used form of radiotherapy. The patient sits or lies on a couch and an external source of X-rays is pointed at a particular part of the body. The radiation interacts with tissues and is absorbed, damaging the DNA of the exposed cells.

Conventionally, the energy of diagnostic and therapeutic gamma- and X-rays is expressed in kilovolts or megavolts (kV or MV), whilst the energy of therapeutic electrons is expressed in terms of megaelectronvolts (MeV). In the first case, this voltage is the maximum electric potential used by a linear accelerator to produce the photon beam. The beam is made up of a spectrum of energies: the maximum energy is approximately equal to the beam's maximum electric potential times the electron charge. Thus a 1 MV beam will produce photons of no more than about 1 MeV. The mean X-ray energy is only about 1/3 of the maximum energy. Beam quality and hardness may be improved by special filters, which improve the homogeneity of the X-ray spectrum.

In the medical field, useful X-rays are produced when electrons are accelerated to a high energy. Some examples of X-ray energies used in medicine are:

• diagnostic X-rays - 20 to 50 kV
• superficial X-rays - 50 to 200 kV
• orthovoltage X-rays - 200 to 500 kV
• supervoltage X-rays - 500 to 1000 kV
• megavoltage X-rays - 1 to 25 MV

Of these energy ranges, megavoltage X-rays are by far most common in radiotherapy. Orthovoltage X-rays do have limited applications, and the other energy ranges are not typically used clinically.

Medically useful X-rays can also be derived from a radioactive source such as cobalt-60, iridium-192, caesium-137 or radium-226 (which is no longer used clinically). Such X-rays, derived from radioactive decay, are more or less monochromatic and are properly termed gamma rays. The usual energy range is in the 300 keV to 1.5 MeV range, and is specific to the isotope.

Therapeutic radiation is mainly generated in the radiotherapy department using the following equipment:

1. Orthovoltage units. These are also known as "deep" and "superficial" machines depending on their energy range. Orthovoltage units have essentially the same design as diagnostic X-ray machines. These machines are generally limited to less than 600 kV.
2. Linear accelerators ("linacs") which produce megavoltage X-rays. Commercially available medical linacs produce X-rays and electrons with an energy range from 4 MeV up to around 25 MeV. The X-rays themselves are produced by the rapid deceleration of electrons in a target material, typically a tungsten alloy, which produces an X-ray spectrum via bremsstrahlung radiation. The shape and intensity of the beam produced by a linac may be modified or collimated by a variety of means. Thus, conventional, conformal, intensity-modulated, tomographic, and stereotactic radiotherapy are all produced by specially modified linear accelerators.
3. Cobalt units which produce stable, dichromatic beams of 1.17 and 1.33 MeV, resulting in an average beam energy of 1.25 MeV. The role of the cobalt unit has partly been replaced by the linear accelerator, which can generate higher energy radiation. Cobalt treatment still has a useful role to play in certain applications and is still in widespread use worldwide, since the machinery is relatively reliable and simple to maintain compared to the modern linear accelerator.

Radiation oncology