Advances have been made in unravelling the molecular chains of cause and effect that determine cellular responses to radiotherapy, including cell cycle arrest, DNA repair and apoptosis. To begin with, cells must have mechanisms that enable them to sense DNA damage. Little was known about this until recently, when a DNA-protein kinase (DNA-PK) system for detecting radiation-induced strand breaks was described. The ataxia telangiectasia (ATM) gene has amino acid sequence similarities to DNA-PK, raising the possibility that the ATM protein also functions in some way as a sensor of DNA damage. However, just knowing the DNA damage is present is not enough. Signals must be transmitted via afferent biochemical pathways to proteins, such as p53, that determine which cellular responses are activated. The responses include cell cycle arrest, apoptosis and DNA repair, all of which relate closely to loss of clonogenic capacity and the outcome of treatment in our patients.