Anyone at SA Breast?

[Bequerel]

I’m getting live texts and screen shots from my breast MO who’s at the conference. IDEA just presented 5 year data and she’s asking if we can quit radiating all low risk er+ patients over 50 now???? I said hell no, way to early of a follow up period and we do apbi on all these patients now anyway so why take away something that lowers LRR and has virtually no side effects, especially when there’s a real question about AI compliance. This is why I have been doing APBI from day 1. I knew this day was coming and APBI will be the way I keep these patients from having RT omitted at our center. Also, said wait for EUROPA to be presented and we just do APBI with no AI lol.

Also, RTOG 1304 was just presented and, not surprising, there’s no diff in arms, so no PMRT for these ypN0 patients now.

Hold on tight!

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[metallica81788]

The day of reckoning hath come

 

[BobbyHeenan]

If EUROPA shows a detriment to omitting AI and using APBI instead the field is going to continue to lose breast patients.

Luckily, APBI is an absolute breeze and has minimal side effects, so I don't feel like I'm doing much harm if we over-treat some of these cases.

I continue to be amazed at how bad QOL is with AI and we should be taking aim at figuring out a way to eliminate that, though there's always that concern that breast cancer is so sneaky hiding out (see those old bone marrow biopsy studies) and that AI is suppressing it.

 

[TheWallnerus]

I’m getting live texts and screen shots from my breast MO who’s at the conference. IDEA just presented 5 year data and she’s asking if we can quit radiating all low risk er+ patients over 50 now???? I said hell no, way to early of a follow up period and we do apbi on all these patients now anyway so why take away something that lowers LRR and has virtually no side effects, especially when there’s a real question about AI compliance. This is why I have been doing APBI from day 1. I knew this day was coming and APBI will be the way I keep these patients from having RT omitted at our center. Also, said wait for EUROPA to be presented and we just do APBI with no AI lol.

Also, RTOG 1304 was just presented and, not surprising, there’s no diff in arms, so no PMRT for these ypN0 patients now.

Hold on tight!

Best be doing 5 fraction APBI imho!

 

[deleted1111261]

36% compliance of ET at 30 months per SABCS

 

[metallica81788]

36% compliance of ET at 30 months per SABCS

Not surprising. If my [low risk] patients are hesitant about either XRT or AI at consult, I will pull out numbers like this.

 

[grenz]

If EUROPA shows a detriment to omitting AI and using APBI instead the field is going to continue to lose breast patients.

Luckily, APBI is an absolute breeze and has minimal side effects, so I don't feel like I'm doing much harm if we over-treat some of these cases.

I continue to be amazed at how bad QOL is with AI and we should be taking aim at figuring out a way to eliminate that, though there's always that concern that breast cancer is so sneaky hiding out (see those old bone marrow biopsy studies) and that AI is suppressing it.

I think there’s a strong rationale for the EUROPA concept for DCIS, because the effect of AI is purely local. But for invasive I worry more since a surprising % of these patients have occult metastatic disease.

 

[NotMattSpraker]

If EUROPA shows a detriment to omitting AI and using APBI instead the field is going to continue to lose breast patients.

I am so fascinated by EUROPA because of the cultural impact. This above is definitely true. If EUROPA shows no determinant, very interested to see what all these omission rad oncs will say about it.

 

[grenz]

I am so fascinated by EUROPA because of the cultural impact. This above is definitely true. If EUROPA shows no determinant, very interested to see what all these omission rad oncs will say about it.

I’m becoming increasingly skeptical that med oncs will place any weight on it. To them the point of the AI is to prevent/stave off distant recurrence, so it’s not like the RT is replacing that function. Again, I think DCIS is a different story and APBI could very reasonably replace AI.

 

[NotMattSpraker]

I’m becoming increasingly skeptical that med oncs will place any weight on it. To them the point of the AI is to prevent/stave off distant recurrence, so it’s not like the RT is replacing that function. Again, I think DCIS is a different story and APBI could very reasonably replace AI.

It's not about one replacing for the other. For me, it's about scientifically de-escalating therapy like a reasonable person, not someone with extreme bias, career aspirations, and/or stock in gene signature companies.

Every patient asks me in clinic "do I really need 5 years of AI?"

I dont know, few of my colleagues have been brave enough to ask.

If they ask "do I really need radiation?", I say gather round fam, we have 2175 studies go through.

 

[BobbyHeenan]

36% compliance of ET at 30 months per SABCS

Can you send me that link? I need tha tin my back pocket for discussion.

I suspect compliance on trial is wwaaayyy better than community compliance as well (or maybe that's what you're quoting here).

 

[BobbyHeenan]

It's not about one replacing for the other. For me, it's about scientifically de-escalating therapy like a reasonable person, not someone with extreme bias, career aspirations, and/or stock in gene signature companies.

Every patient asks me in clinic "do I really need 5 years of AI?"

I dont know, few of my colleagues have been brave enough to ask.

If they ask "do I really need radiation?", I say gather round fam, we have 2175 studies go through.

Same.

I would feel a lot better about harming the QoL if we were stone cold clear the AI improved survival or breast conservation/organ preservation in these super favorable patients. It may very well do that, but it's a disservice to patients that no one ever did this trial before and in the US there's seemingly minimal interest in it.

My practice has been to more "aggressively" push APBI in the older favorable patients that express concern over AI or have pre-existing bothersome joint issues....after a long time in the game with a heavy breast practice you get a sense of who will be on that AI for years and who will not....and there's a lot in that "not" camp.

 

[BobbyHeenan]

I’m becoming increasingly skeptical that med oncs will place any weight on it. To them the point of the AI is to prevent/stave off distant recurrence, so it’s not like the RT is replacing that function. Again, I think DCIS is a different story and APBI could very reasonably replace AI.

YOu may be right, but it depends on how busy the med onc is. THough with that said in my experience they punt the AI mgmt off to a mid level...but I have heard them bitch about managing AI issues not being fun while they're much more enthusiastic for actually giving say keynote chemo or TCHP than spending a lot of time on AI stuff.

 

[NotMattSpraker]

Same.

I would feel a lot better about harming the QoL if we were stone cold clear the AI improved survival or breast conservation/organ preservation in these super favorable patients. It may very well do that, but it's a disservice to patients that no one ever did this trial before and in the US there's seemingly minimal interest in it.

My practice has been to more "aggressively" push APBI in the older favorable patients that express concern over AI or have pre-existing bothersome joint issues....after a long time in the game with a heavy breast practice you get a sense of who will be on that AI for years and who will not....and there's a lot in that "not" camp.

You know weirdly I have a hard time omitting in practice. My medical oncologists dont push AI super hard and clearly recognize the compliance issue. My surgeons know how to read papers and think recurrence is a bad thing and still appropriately view radiation as good "insurance".

I honestly wonder how these conversations go in omission forward academic centers. What do these women say when you tell them they will have a 10x chance of recurrence and having to do the whole biopsy --> surgery thing again?

The only time that conversation goes well for me is when the patient is very old and has already decided to minimize all her care for all conditions. They usually aren't wanting AI either.

Edit: I should just add that this conversation is always discussing APBI as radiation, not WBRT or longer course.

 

[medgator]

You know weirdly I have a hard time omitting in practice. My medical oncologists dont push AI super hard and clearly recognize the compliance issue. My surgeons know how to read papers and think recurrence is a bad thing and still appropriately view radiation as good "insurance".

 

[metallica81788]

I honestly wonder how these conversations go in omission forward academic centers. What do these women say when you tell them they will have a 10x chance of recurrence and having to do the whole biopsy --> surgery thing again?

Where I trained, there was no conversation. If patient met the CALGB criteria, the attending told them they don't need radiation. Zero choice. This was a few years before Florence or right at the very beginning.

Didn't realize how crazy it was at the time, was just happy didn't have other sim to deal with.

 

[TheWallnerus]

The above is why I think academics should have been all in on 5 fraction breast as much as possible going way back in time (even 5fx ENI). It would have totally blunted any omission arguments. “It’s just 5 days and less side effects than the old days.” I always saw this “omission fever” about to happen, and now we may be caught with our pants down a bit from a workforce AND existential standpoint.

 

[taserlaser]

Can you send me that link? I need tha tin my back pocket for discussion.

I suspect compliance on trial is wwaaayyy better than community compliance as well (or maybe that's what you're quoting here).

Compliance on Lumina I think was over double than what we see usually in the community (85% or something like that). And we had a few patients enrolled onto that trial.

 

[taserlaser]

Also re EUROPA- I think we would see something similar to this. RT + ET and RT alone do equally as good

https://www.thegreenjournal.com/article/S0167-8140(20)30789-1/pdf

 

[OTN]

Also re EUROPA- I think we would see something similar to this. RT + ET and RT alone do equally as good

https://www.thegreenjournal.com/article/S0167-8140(20)30789-1/pdf

RT- especially Livi protocol - is so, so well tolerated compared with AI, I think we'll be moving towards surgery + RT rather than surgery + AI for these patients once this all shakes out.

 

[Fpg1245]

It was a foolish move really because it doesn’t matter. 0 is better than 5. The repeated omission trials will continue. If a patient doesn’t need something then it doesn’t matter how far you reduce it.

There was a post years ago I think from the UK that basically said the quiet part out loud.
25–15–5–>0. That’s been the goal from the very beginning.

 

[TheWallnerus]

It was a foolish move really because it doesn’t matter. 0 is better than 5. The repeated omission trials will continue. If a patient doesn’t need something then it doesn’t matter how far you reduce it.

There was a post years ago I think from the UK that basically said the quiet part out loud.
25–15–5–>0. That’s been the goal from the very beginning.

Classic old thread on here:

Breast WBI Fractionation discussion

Med students have already figured this out. Rad Onc is now one of the least competitive specialty in medicine based on US MDs to available spots. The shocking part is the total lack of an appropriate response by "leadership." Meanwhile I get a noticed on Twitter from Mayo clinic that they can...

forums.studentdoctor.net

 

[NotMattSpraker]

It was a foolish move really because it doesn’t matter. 0 is better than 5. The repeated omission trials will continue. If a patient doesn’t need something then it doesn’t matter how far you reduce it.

There was a post years ago I think from the UK that basically said the quiet part out loud.
25–15–5–>0. That’s been the goal from the very beginning.

If someone genuinely thinks omission of radiation for all patients is the goal, they should go back to medical school or maybe college. The existence of BR007 should be confirmation that we really struggle to "comfortably" omit radiation in even the hypothesized lowest risk patients.

Maybe the quiet part is really: this entire conversation is more a reflection of our toxic culture around the workforce discussion than a scientific discussion of optimal clinical management of breast cancer.

 

[OTN]

It was a foolish move really because it doesn’t matter. 0 is better than 5. The repeated omission trials will continue. If a patient doesn’t need something then it doesn’t matter how far you reduce it.

There was a post years ago I think from the UK that basically said the quiet part out loud.
25–15–5–>0. That’s been the goal from the very beginning.

But 5 is better than 0 + AI, it's not just 5 > 0

 

[Fpg1245]

If someone genuinely thinks omission of radiation for all patients is the goal, they should go back to medical school or maybe college. The existence of BR007 should be confirmation that we really struggle to "comfortably" omit radiation in even the hypothesized lowest risk patients.

Maybe the quiet part is really: this entire conversation is more a reflection of our toxic culture around the workforce discussion than a scientific discussion of optimal clinical management of breast cancer.

Some real winners on this forum for sure. Oh all those heroic academics “struggling” to get rid of radiation - what a joke.

Yeah man. The “struggle” is real. You run a similar trial enough times or set the non inferiority thresholds just right and bam: you've eliminated 40-60 percent of volume at most centers.

I can’t tell you how many patients and referring shoved the nejm trial in my face that came out earlier this year. Even patients on treat!

Also you have it backwards, the toxic culture is ultimately a failure of the so called “imaginative” class in academia that is entrusted with the future of the field to study anything other than elimination.

Haha!! Dude I would gladly turn back the clock and do it all over again if it meant I could be spared the sheer stupidity, lack of imagination, and utterly unbearable personalities in your typical mega hospital “academic” rad onc Dept.

Honestly, you won’t need much more than a college education to run a rad onc facility in the future.

The optimal care of breast patients is one thing. When you continually harp on the same strategy over and over again I question the judgement and interests of the investigators.

 

[Palex80]

Concerning the results of RTOG1304, it will be interesting to see if they are driven by the Her2positive subgroup of patients or omission of RNI can be safely practiced in the TNBC cohort too. Numbers will be likely too low to draw safe conclusions. I did not see any mention of subgroup analysis, was that presented?

 

[TheWallnerus]

Concerning the results of RTOG1304, it will be interesting to see if they are driven by the Her2positive subgroup of patients or omission of RNI can be safely practiced in the TNBC cohort too. Numbers will be likely too low to draw safe conclusions. I did not see any mention of subgroup analysis, was that presented?

They’d better get ready to bribe a statistician for a significant subgroup analysis from this data

 

[Palex80]

They’d better get ready to bribe a statistician for a significant subgroup analysis from this data

Indeed. I read the full protocol, and patients were stratified according to histology too.

 

[HolySmokes]

"We don't have 10 year data, we can't draw any conclusions yet"
"All the ER+ patients are still on AI, we can't draw any conclusions yet"
"We don't have subgroup analyses for individual histologies, we can't draw any conclusions yet"

Don't mind me I'm just practicing my excuses for how to keep my breast practice alive...
I get there will be criticisms of this trial but imo where there's smoke there's fire. This absolutely seems like a dagger for RNI in ypN0 patients.

 

[deleted1111261]

It should be a dagger, but there are always excuses. This is not omission. This is a real question that needed answering. Bummer the chips fell as they did.

What about if no pCR in breast? Still skip CW RT if nodes ypN0?

 

[Palex80]

What about if no pCR in breast? Still skip CW RT if nodes ypN0?

pCR to the breast was also a stratification factor, according to the protocol.

https://med.uc.edu/docs/default-source/cancercenter/all-protocols/breast/nsabp_b51_randomized-phase-iii-clinical-trial-evaluating-post-mastectomy-chestwall.pdf

15.3 Stratification and randomization Assignment of treatments to patients will be balanced with respect to type of breast surgery (mastectomy, lumpectomy), hormone receptor status (ER-positive and/or PgR-positive, ER- and PgR-negative), HER2 status (negative, positive), adjuvant chemotherapy (yes, no), and pCR in breast (yes, no) using a biased-coin minimization algorithm

 

[communitydoc13]

It should be a dagger

It's done. The absolute risk in the non-XRT arm is enough.

Even when XRT provides a remarkable relative control benefit, it will be (appropriately) omitted when the absolute benefit is getting into the single digits with some variability related to the morbidity of the XRT.

Given the morbidity of comprehensive nodal and CW XRT, the absolute risk here without XRT means that most docs are not going going to recommend it.

 

[OTN]

I sent the B-51 data to our breast surgeons and told them the good news: we don't have to treat RNI in patients who have a pCR to chemo.

I'll also tell them that, given the real-world adherence rates to AI and the negligible SE profile of Livi protocol APBI, I think it's still smart to offer post-lumpectomy RT even for our patients who would have been eligible for the IDEA trial, and I expect EUROPA to confirm that strategy.

Being honest, up front, and proactive about the results of B-51 gives us a better chance of having referring docs listen to us when it comes to other trials/issues in breast cancer.

 

[thesauce]

The above is why I think academics should have been all in on 5 fraction breast as much as possible going way back in time (even 5fx ENI). It would have totally blunted any omission arguments. “It’s just 5 days and less side effects than the old days.” I always saw this “omission fever” about to happen, and now we may be caught with our pants down a bit from a workforce AND existential standpoint.

It wouldn’t matter at all. Medoncs are hell-bent on omission of RT. If we did a single fraction with no side effects, they would still write endless papers about the need to omit it.

 

[deleted1111261]

It wouldn’t matter at all. Medoncs are hell-bent on omission of RT. If we did a single fraction with no side effects, they would still write endless papers about the need to omit it.

I am more scared of our own doing it than medonc.

 

[Linaculous]

Indeed. I read the full protocol, and patients were stratified according to histology too.

Ask and you shall receive

 

[fiji128]

Breast, our number one indication for RT fractions, is slipping away. We will be left with only locally advanced type cases. By 2030 we might be seeing about 20% of the curative intent cases that would've been seen 2010. From 25 to 15 to 5 to 0. Of course training positions will be up about 70% in over that same time frame.

 

[Palex80]

View attachment 379614

View attachment 379615
Ask and you shall receive

Wow, thank you!

Weird stuff!!! In TNBC tumors RNI even appears to have a detrimental effect!
Some unexplained immunosuppressive phenomenon perhaps?

 

[communitydoc13]

Wow, thank you!

Weird stuff!!! In TNBC tumors RNI even appears to have a detrimental effect!
Some unexplained immunosuppressive phenomenon perhaps?

Our first guess with numbers this low has to be random effects.

The age 50-59 cohort...makes no sense.

Probably all rando, rando, rando...doesn't matter, the worst cohort has about a 10% risk of distant recurrence...hard to improve on this.

They are already doing de-escalation systemic trials with no adjuvant IO if pcR after neoadjuvant chemo-immunotherapy.

We are part of the de-escalation.

 

[RadOncDoc21]

Something told me to not come in here. I’ve had a disdain for breast and am the originator of the “breast is the worst” mantra but yet here I am reading all this nonsense! When will I learn to look away?

 

[TheWallnerus]

Breast, our number one indication for RT fractions, is slipping away.

We’ve become a good country music lyric

Something told me to not come in here

HAPPY FRIDAY.

 

[TheWallnerus]

It's done. The absolute risk in the non-XRT arm is enough. Given the morbidity of comprehensive nodal and CW XRT, the absolute risk here without XRT means that most docs are not going going to recommend it.

I really could have never predicted this.

 

[communitydoc13]

I really could have never predicted this.

Way to ruin a good "Three Dog Night" post.

 

[TheWallnerus]

"We don't have 10 year data, we can't draw any conclusions yet"
"All the ER+ patients are still on AI, we can't draw any conclusions yet"
"We don't have subgroup analyses for individual histologies, we can't draw any conclusions yet"

Don't mind me I'm just practicing my excuses for how to keep my breast practice alive...
I get there will be criticisms of this trial but imo where there's smoke there's fire. This absolutely seems like a dagger for RNI in ypN0 patients.

It should be a dagger, but there are always excuses. This is not omission. This is a real question that needed answering. Bummer the chips fell as they did.

What about if no pCR in breast? Still skip CW RT if nodes ypN0?

I believe N0i+ and mol+ were included as ypN0 too

Would absolutely not do post MRM XRT on a cT1-3N1 patient with complete nodal response and residual tumor in the removed breast

 

[BobbyHeenan]

I believe N0i+ and mol+ were included as ypN0 too

Would absolutely not do post MRM XRT on a cT1-3N1 patient with complete nodal response and residual tumor in the removed breast

Agree for older patients. Maybe for ER+ younger would still consider (?need longer follow up?).

Next question is do they need surgery? Anyone want to run a clinical CR post chemo (with repeat biopsy) radiation vs surgery trial?

 

[NotMattSpraker]

Here you go Eliminating breast surgery for invasive breast cancer in exceptional responders to neoadjuvant systemic therapy: a multicentre, single-arm, phase 2 trial - PubMed

How do I get in the exceptional responders trials group? I bet they have the most cheery clinics!

 

[evilbooyaa]

View attachment 379614

View attachment 379615
Ask and you shall receive

ER/PR/Her2- should get RNI! They're the most common type of breast CA! positive interaction P-value!

ALL IS NOT LOST

 

[Mandelin Rain]

I've been offering Livi partial breast protocol to women with <5mm margin, who were excluded from the protocol. Just wondering how much of an outlier I am.

 

[Surf Rx]

I've been offering Livi partial breast protocol to women with <5mm margin, who were excluded from the protocol. Just wondering how much of an outlier I am.

Same. No tumor on ink and otherwise a good apbi candidate gets Livi.

 

[communitydoc13]

I've been offering Livi partial breast protocol to women with <5mm margin, who were excluded from the protocol. Just wondering how much of an outlier I am.

I'm confident you are not an outlier. Most surgeons I have worked with are not aspiring to 5mm margins. We have the XRT avoidance trials to reference in terms of a limiting case regarding risk to patient.

Most guidelines do not recommend 5mm margins for APBI candidacy.