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The aim of IMRT is to eradicate all cancerous cells by irradiating the tumor with a prescribed dose while simultaneously sparing, as much as possible, the neighboring tissues and organs. The optimal choice of beam irradiation directions\u2014beam angle optimization (BAO)\u2014can play an important role in IMRT treatment planning by improving organ sparing and tumor coverage, increasing the treatment plan quality. Typically, the BAO search is guided by the optimal value of the fluence map optimization (FMO)\u2014the problem of obtaining the most appropriate radiation intensities for each beam direction. In this paper, a new score to guide the BAO search is introduced and embedded in a parallel multistart derivative\u2010free optimization framework that is detailed for the extremely challenging continuous BAO problem. For the set of 10 clinical nasopharyngeal tumor cases considered, treatment plans obtained for optimized beam directions clearly outperform the benchmark treatment plans obtained considering equidistant beam directions typically used in clinical practice. Furthermore, treatment plans obtained considering the proposed score clearly improve the quality of the plans resulting from the use of the optimal value of the FMO problem to guide the BAO search.<\/jats:p>","DOI":"10.1111\/itor.12587","type":"journal-article","created":{"date-parts":[[2018,8,22]],"date-time":"2018-08-22T15:27:01Z","timestamp":1534951621000},"page":"908-928","update-policy":"http:\/\/dx.doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":20,"title":["Beam angle optimization in IMRT: are we really optimizing what matters?"],"prefix":"10.1111","volume":"26","author":[{"ORCID":"http:\/\/orcid.org\/0000-0002-5981-4469","authenticated-orcid":false,"given":"Humberto","family":"Rocha","sequence":"first","affiliation":[{"name":"FEUC and CeBER Av. Dias da Silva 165 3004\u2010512 Coimbra Portugal"},{"name":"INESCC, Rua Silvio Lima 3030\u2010290 Coimbra Portugal"}]},{"given":"Joana Matos","family":"Dias","sequence":"additional","affiliation":[{"name":"FEUC and CeBER Av. Dias da Silva 165 3004\u2010512 Coimbra Portugal"},{"name":"INESCC, Rua Silvio Lima 3030\u2010290 Coimbra Portugal"}]},{"given":"Tiago","family":"Ventura","sequence":"additional","affiliation":[{"name":"IPOC\u2010FG, EPE Av. Bissaya Barreto 98 3000\u2010075 Coimbra Portugal"}]},{"given":"Br\u00edgida da Costa","family":"Ferreira","sequence":"additional","affiliation":[{"name":"ESS.PP Rua Valente Perfeito 322 4400\u2010330 Vila Nova de Gaia Portugal"},{"name":"I3N.UA, Departamento de Fisica Universidade de Aveiro 3810\u2010193 Aveiro Portugal"}]},{"given":"Maria do Carmo","family":"Lopes","sequence":"additional","affiliation":[{"name":"IPOC\u2010FG, EPE Av. 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