Anyone at SA Breast?

[evilbooyaa]

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.

Florence group is offering APBI to those w/ < 5mm margin, supported by ABS and ASTRO. I would do no tumor on ink for invasive dz

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[Mandelin Rain]

Yeah. I caught a side eyed look during a peer review about it. I didn't think anyone was holding that margin as a hard cutoff.

 

[taserlaser]

RAPID2 which is randomizing 26 Gy whole breast vs 26 Gy APBI is no tumour on ink iirc

 

[SneakyBooger]

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.

RAD ONC's are hell-bent on omission of RT...

 

[Ray D. Ayshun]

So are people waiting on Rapid2 results, or are there many doing 26/5 PBI now? I can't tell, but think wallnerus is.

 

[TheWallnerus]

So are people waiting on Rapid2 results, or are there many doing 26/5 PBI now? I can't tell, but think wallnerus is.

“People,” sure. People, countries, etc.

One plus one equals two, and FAST FORWARD plus IMPORT LOW equals 26/5 PBI.

RAPID2 is practically guaranteed not to give us answers we don’t already know. Hadn’t heard of it!

Loading…

www.clinicaloncologyonline.net

 

[Ray D. Ayshun]

“People,” sure. People, countries, etc.

One plus one equals two, and FAST FORWARD plus IMPORT LOW equals 26/5 PBI.

RAPID2 is practically guaranteed not to give us answers we don’t already know. Hadn’t heard of it!

Loading…

www.clinicaloncologyonline.net

I understand all the extrapolations etc, and Dr Parikh has a great mednet article. The rejoinder of course is that there's a trial giving 30/5 in this context. I'm not wondering if it makes sense, but how commonly it's being done.

 

[Bequerel]

This reminds me of the argument 15 years ago about hypofrac and Dcis. Makes me want to bang my head against the wall. Common sense

 

[Ray D. Ayshun]

This reminds me of the argument 15 years ago about hypofrac and Dcis. Makes me want to bang my head against the wall. Common sense

Seems different. 26/5 makes perfect sense. 30/5 was the trial.

 

[Bequerel]

Seems different. 26/5 makes perfect sense. 30/5 was the trial.

If 26/5 ok for whole breast why wouldn’t it be ok for part of the breast? If 40/15 ok for cancer why not ok for pre-cancer? Just reminded me of same argument. Besides, I think we all know that women who qualify for apbi might really be ok with 0 Gy, which makes the argument of 26 Vs 30 that much more silly to me.

 

[TheWallnerus]

If 26/5 ok for whole breast why wouldn’t it be ok for part of the breast? If 40/15 ok for cancer why not ok for pre-cancer? Just reminded me of same argument. Besides, I think we all know that women who qualify for apbi might really be ok with 0 Gy, which makes the argument of 26 Vs 30 that much more silly to me.

If the I-like-30 thinkers of these above thoughts would give as much thought to the lowering of late effect risk with going from 30/5 to 26/5 (which is probably a significant lowering) as they do in thinking of the improvement in LC with 30/5 vs 26/5 (which is probably no improvement at all), those thinkers might more strongly consider liking 26/5, I have always thought.

 

[drowsy12]

Sure maybe 26 better than 30 for toxicity, but let's not lose the forest for the trees. the Livi regimen is excellent and very well tolerated with awesome long term data. I do 30/5 and I have zero interest in switching. The point and biggest reduction in toxicity is going from whole to partial.

whatever people want to do - Livi or IMPORT-Low, or 26/5, just do partial if you can.

 

[Bequerel]

If you’re getting toxicity with 30/5 then you’re doing something wrong and should probably lower to 26/5 because you’re probably treating too big of a volumes or not cropping off skin or cw enough. I plan on 30/5 but have very low threshold to drop to 26/5 when anatomy isn’t cooperating

 

[drowsy12]

should also consider the fact that 26/5 whole breast vs 30/5 whole breast is more likely to show a fibrosis difference than to a small cute Livi style modern volume. volume matters, obviously.

 

[TheWallnerus]

Sure maybe 26 better than 30 for toxicity

The word “maybe” is doing A LOT of work in this sentence, and it has never read Hall or internalized some of the FAST Forward findings.

 

[drowsy12]

The word “maybe” is doing A LOT of work in this sentence, and it has never read Hall or internalized some of the FAST Forward findings.

Volume matters dude

 

[TheWallnerus]

Volume matters dude

Oh of course. But like in Boyle’s law, you can’t just look at volume independently.

 

[drowsy12]

Volume matters dude

As does radiation technique. Read the methods section of each and tell me you can’t see a difference

I don’t think your approach is wrong or crazy at all, 26/5 is fine, but to ignore those other factors is not accurate

10 year published data and personal experience among those of us who do 30/5 is pretty telling

 

[communitydoc13]

If you’re getting toxicity with 30/5 then you’re doing something wrong and should probably lower to 26/5 because you’re probably treating too big of a volumes or not cropping off skin or cw enough.

Is this true?

My experience with Livi is outstanding cosmesis (as in very hard to tell that XRT administered at all), however there is fibrosis at the lumpectomy bed, a little more symptomatic fat necrosis, and maybe a few more patient's complaining of tenderness in the lumpectomy cavity over the first year post-treatment. That cavity is qualitatively firmer relative to whole breast treatment (probably because fibrotic changes are limited to a portion of breast and not uniform within the breast).

it has never read Hall or internalized some of the FAST Forward findings

Toxicity/local control are complementary things. 30 is undoubtedly a little better in terms of local control from first principles (although maybe not clinically significant in our present partial breast population). 26 is undoubtedly a little better in terms of toxicity (although maybe not clinically significant for small volume lumpectomy patients).

 

[Ray D. Ayshun]

My apologies, this went the way I thought it would

 

[TheWallnerus]

As does radiation technique. Read the methods section of each and tell me you can’t see a difference

I don’t think your approach is wrong or crazy at all, 26/5 is fine, but to ignore those other factors is not accurate

10 year published data and personal experience among those of us who do 30/5 is pretty telling

You need to read the methods section of IMPORT LOW for 26/5 PBI. From there, comparing that IMRT approach with the Livi IMRT approach gets complicated, nuanced, etc.

 

[BobbyHeenan]

Is this true?

My experience with Livi is outstanding cosmesis (as in very hard to tell that XRT administered at all), however there is fibrosis at the lumpectomy bed, a little more symptomatic fat necrosis, and maybe a few more patient's complaining of tenderness in the lumpectomy cavity over the first year post-treatment. That cavity is qualitatively firmer relative to whole breast treatment (probably because fibrotic changes are limited to a portion of breast and not uniform within the breast).


Toxicity/local control are complementary things. 30 is undoubtedly a little better in terms of local control from first principles (although maybe not clinically significant in our present partial breast population). 26 is undoubtedly a little better in terms of toxicity (although maybe not clinically significant for small volume lumpectomy patients).

I have seen less fat necrosis and toxicity than whole breast. I've been doing Livi now maybe 3-5 years and it is truly remarkable how much better these patients have done both in terms of acute and late toxicity in my experience.

With that said, we have a new breast surgeon who is absolutely fantastic and places clips in a small lumpectomy cavity and her cavities are smaller/wounds are better than I've seen previously.

 

[OTN]

I've seen almost zero side effects in either the short- or long-ish term with Livi. Only 1 pt with very mild erythema overlying the cavity. No fat necrosis or tenderness.

26 in 5 to the whole breast is more toxic than either 30 in 5 partial breast with Livi or compared to whole breast with UK/Canadian hypofractionation, so I do not offer it.

 

[TheWallnerus]

I've seen almost zero side effects in either the short- or long-ish term with Livi. Only 1 pt with very mild erythema overlying the cavity. No fat necrosis or tenderness.

26 in 5 to the whole breast is more toxic than either 30 in 5 partial breast with Livi or compared to whole breast with UK/Canadian hypofractionation, so I do not offer it.

I never offer 26/5 whole breast either.

 

[evilbooyaa]

We don't have data that 26/5 PBI is equally oncolgically effective to 30/5 PBI. Changing variable like volume requiring a clinical trial. Changing dose/fractionation from 50/25 to 40/15 to 26/5 WBI required a clinical trial.
Why do people think changing from 40/15 PBI or 30/5 PBI (both 'standard options') to 26/5 PBI would not require a clinical trial?

 

[TheWallnerus]

We don't have data that 26/5 PBI is equally oncolgically effective to 30/5 PBI. Changing variable like volume requiring a clinical trial. Changing dose/fractionation from 50/25 to 40/15 to 26/5 WBI required a clinical trial.
Why do people think changing from 40/15 PBI or 30/5 PBI (both 'standard options') to 26/5 PBI would not require a clinical trial?

This is scientific obtusity my friend.
We have two particular things enormously well-established relevant to your concerns. Those are (when the patient is properly selected):
1) 26 Gy in 5 fractions is oncologically equivalent to 40 Gy in 15 fractions.
2) Partial breast RT is oncologically equivalent to whole breast RT.
Thus, if you can walk and chew gum, you can put number one and number two together to arrive at: 26/5 PBI is well-established. F. Scott Fitzgerald said “The test of a first-rate intelligence is the ability to hold two opposing ideas in mind at the same time and still retain the ability to function." You don't even need a first-rate intelligence to hold these two (non-opposing) ideas in mind at the same time.

And... 26/5 is given credence as an option in the ASTRO PBI guidelines out this month.

 

[evilbooyaa]

This is scientific obtusity my friend.
We have two particular things enormously well-established relevant to your concerns. Those are (when the patient is properly selected):
1) 26 Gy in 5 fractions is oncologically equivalent to 40 Gy in 15 fractions.
2) Partial breast RT is oncologically equivalent to whole breast RT.
Thus, if you can walk and chew gum, you can put number one and number two together to arrive at: 26/5 PBI is well-established. F. Scott Fitzgerald said “The test of a first-rate intelligence is the ability to hold two opposing ideas in mind at the same time and still retain the ability to function." You don't even need a first-rate intelligence to hold these two (non-opposing) ideas in mind at the same time.

And... 26/5 is given credence as an option in the ASTRO PBI guidelines out this month.

1) add 'in patients receiving whole breast irradiation'
2) add 'at the doses of 40/15 and 30/5 for PBI'.

To claim 26/5 PBI is well-established is putting politicking above evidence base. Given how excellent 30/5 PBI performs toxicity wise (I will say that I notice some late chronic firmness that I wouldn't otherwise have seen in a 40/15 patient not receiving boost over the lumpectomy cavity), I see no reason to gamble with my patient's oncologic control and drop the dose, using PBI, without prospective data on equivalent oncologic control.

 

[TheWallnerus]

1) add 'in patients receiving whole breast irradiation'
2) add 'at the doses of 40/15 and 30/5 for PBI'.

To claim 26/5 PBI is well-established is putting politicking above evidence base. Given how excellent 30/5 PBI performs toxicity wise (I will say that I notice some late chronic firmness that I wouldn't otherwise have seen in a 40/15 patient not receiving boost over the lumpectomy cavity), I see no reason to gamble with my patient's oncologic control and drop the dose, using PBI, without prospective data on equivalent oncologic control.

“Drop the dose.” You know you can drop the dose from 40/15 to 26/5 and oncologic outcomes are same. Or you can drop the dose (Livi trial) from 50/25 to 30/5. Also, in your head here, you’re comparing 40/15 and 30/5 outcomes. Which have never been compared directly. Politicking for thee but none for me? To use the verb “gamble” re: using 26/5 PBI instead of 30/5 PBI (or 40/15 PBI) is… a little weird. Is it a gamble to omit the RT for many of these women?

But I am not a breast expert. Your argument is with them, and much of the planet, not with me!

 

[MidwestRadOnc]

This is scientific obtusity my friend.
We have two particular things enormously well-established relevant to your concerns. Those are (when the patient is properly selected):
1) 26 Gy in 5 fractions is oncologically equivalent to 40 Gy in 15 fractions.
2) Partial breast RT is oncologically equivalent to whole breast RT.
Thus, if you can walk and chew gum, you can put number one and number two together to arrive at: 26/5 PBI is well-established. F. Scott Fitzgerald said “The test of a first-rate intelligence is the ability to hold two opposing ideas in mind at the same time and still retain the ability to function." You don't even need a first-rate intelligence to hold these two (non-opposing) ideas in mind at the same time.

And... 26/5 is given credence as an option in the ASTRO PBI guidelines out this month.

Clearly you have never tried to argue with an Evicore reviewer/obstructer (aszholes!).
If your exact scenario is not tested on a phase 3 trial, then it's experimental and denied.
And if it is, well then here's this other trial that's kind of similar which showed something different, so there is conflicting data, so it's denied.

So you wind up not being allowed to treat the whole breast to 26/5 with IMRT but you are allowed to treat the partial breast to 30/5 with IMRT. And you are told by an evicore aszhole with a straight face that "this is experimental and we don't know if it's safe." Are they checking to make sure you have defined your volume according to the partial breast trials? Of course not.

 

[evilbooyaa]

“Drop the dose.” You know you can drop the dose from 40/15 to 26/5 and oncologic outcomes are same. Or you can drop the dose (Livi trial) from 50/25 to 30/5. Also, in your head here, you’re comparing 40/15 and 30/5 outcomes. Which have never been compared directly. Politicking for thee but none for me? To use the verb “gamble” re: using 26/5 PBI instead of 30/5 PBI (or 40/15 PBI) is… a little weird. Is it a gamble to omit the RT for many of these women?

But I am not a breast expert. Your argument is with them, and much of the planet, not with me!

View attachment 383353
View attachment 383354

I'm not directly comparing 40/15 to 30/5. Just stating we have multiple trials where the experimental arm was those regimens, which confirmed non-inferiority.

All I'm asking for is a trial where 26/5 PBI is the experimental arm and demonstrates non-inferiority.
I look forward to references 60 and 61 being published in the part you noted.

Clearly you have never tried to argue with an Evicore reviewer/obstructer (aszholes!).
If your exact scenario is not tested on a phase 3 trial, then it's experimental and denied.
And if it is, well then here's this other trial that's kind of similar which showed something different, so there is conflicting data, so it's denied.

So you wind up not being allowed to treat the whole breast to 26/5 with IMRT but you are allowed to treat the partial breast to 30/5 with IMRT. And you are told by an evicore aszhole with a straight face that "this is experimental and we don't know if it's safe." Are they checking to make sure you have defined your volume according to the partial breast trials? Of course not.

??? When would Evicore ever give 2 ****s whether you are doing 30/5 IMRT PBI vs 26/5 IMRT PBI? Just say you're doing 30Gy and give most of it 26. They care about # of Fx, NOT the amount of Gy.

 

[MidwestRadOnc]

??? When would Evicore ever give 2 ****s whether you are doing 30/5 IMRT PBI vs 26/5 IMRT PBI? Just say you're doing 30Gy and give most of it 26. They care about # of Fx, NOT the amount of Gy.

The difference is whole breast vs. partial breast. They will pay for 5 fraction IMRT partial breast but not IMRT whole breast.
Evil liars. P2P? No, you're not my peer. You are practicing medicine across state lines for a corporation without seeing the patient, which last I checked was illegal.

“Politicking for thee but none for me?

Comparing across trials for thee (evicore), but none for me (any doctor with a soul).

 

[evilbooyaa]

The difference is whole breast vs. partial breast. They will pay for 5 fraction IMRT partial breast but not IMRT whole breast.
Evil liars. P2P? No, you're not my peer. You are practicing medicine across state lines for a corporation without seeing the patient, which last I checked was illegal.



Comparing across trials for thee (evicore), but none for me (any doctor with a soul).

Ah, my apologies, misread your post.

Just do 30/5 PBI in those patients. Hell, just say you're doing 5fx PBI even if you're going to do 26/5 WBI. There's no CPT code that denotes whether a RO is covering a partial breast volume or a whole breast volume. There's no evaluation. Get approval for 5fx IMRT through whatever means and then do whatever you want.

Better yet, swing for the fences and request 5Fx SBRT (not to open ANOTHER can of worms when it comes to breast, the worst, indefinitely) for the 30/5 you plan to give the patient.

 

[MidwestRadOnc]

Better yet, swing for the fences and request 5Fx SBRT (not to open ANOTHER can of worms when it comes to breast, the worst, indefinitely) for the 30/5 you plan to give the patient.

I'm going to take a wild guess that evicore is going to tell you to pound sand for trying to bill 5 fraction SBRT breast. Anyone been successful at that?

 

[evilbooyaa]

I'm going to take a wild guess that evicore is going to tell you to pound sand for trying to bill 5 fraction SBRT breast. Anyone been successful at that?

When it gets denied I don't do the p2p, just re-submit as 5Fx IMRT which then gets approved, but you'll miss 100% of the shots you don't take.

 

[TheWallnerus]

So you wind up not being allowed to treat the whole breast to 26/5 with IMRT but you are allowed to treat the partial breast to 30/5 with IMRT.

Just to be clear, I am saying do 26/5 PBI instead of 30/5 PBI. (Evicore pays for 26 or 30 gray, they don't care as long as it's PBI.) Thirty gray PBI is a plot by the thirty gray PBI companies to sell more thirty gray PBI.

Just do 30/5 PBI in those patients. Hell, just say you're doing 5fx PBI even if you're going to do 26/5 WBI. There's no CPT code that denotes whether a RO is covering a partial breast volume or a whole breast volume. There's no evaluation. Get approval for 5fx IMRT through whatever means and then do whatever you want.

There is no randomized data to support your approach here. But mystifyingly it is the correct approach. You might even be saying that whatever works for whole breast works for partial breast. Wink.

I'm going to take a wild guess that evicore is going to tell you to pound sand for trying to bill 5 fraction SBRT breast. Anyone been successful at that?

Never.

 

[RadOncDoc21]

Anybody hear of surgeons using cryoablation for early stage breast cancers? I’m seeing it creep in more in my neck of the woods. Any good data to say it’s feasible or is it for marketing?

 

[BobbyHeenan]

Anybody hear of surgeons using cryoablation for early stage breast cancers? I’m seeing it creep in more in my neck of the woods. Any good data to say it’s feasible or is it for marketing?

THere was a radiology group in my area enrolling some patients as definitive cryo followed by XRT then AI for older luminal A patients about 5-8 years ago in my area. I treated one patient that was sent to me post cryo. She did fine, but had firm, minimally sore cryo frozen ball of tissue in the "cavity" as I recall.

They quit enrolling patients about 5 years ago, I haven't seen it used again in my area.

 

[medgator]

Anybody hear of surgeons using cryoablation for early stage breast cancers? I’m seeing it creep in more in my neck of the woods. Any good data to say it’s feasible or is it for marketing?

Yes. Not CMS approved iirc. I don't get the point of it. I think patients pay cash. Same shysters often do PEM (positron emission mammography) scans as well (which CMS doesn't pay for either I don't think).

Honestly sounds like something shady IRs would do so it's surprising to see surgeons getting into it at all

 

[evilbooyaa]

There is no randomized data to support your approach here. But mystifyingly it is the correct approach. You might even be saying that whatever works for whole breast works for partial breast. Wink.

I have no qualms about bending the truth or lying by omission when it comes to an insurance company approving a treatment so at the end of the day I can do what I think is best for the patient.

 

[medgator]

I have no qualms about bending the truth or lying by omission when it comes to an insurance company approving a treatment so at the end of the day I can do what I think is best for the patient.

They would do no less to you or the pt, and likely much worse

 

[TheWallnerus]

I have no qualms about bending the truth or lying by omission when it comes to an insurance company approving a treatment so at the end of the day I can do what I think is best for the patient.

I was being rascally when saying there's no randomized data to support your approach.

All I'm asking for is a trial where 26/5 PBI is the experimental arm and demonstrates non-inferiority.

Imagine that a 30 Gy PBI dose offers 99% LC at 10y and a 26 Gy dose 98% LC at 10y. Imagine you want to run a non-inferiority trial to exclude a 2% or more LC difference at 10y between these groups. My back of envelope calcs say you're going to need a ~5000 patient trial with median 10y followup to get the answer you want. Which for all intents and purposes means you will side-eye the world's 26 Gy PBI users as local relapse gamblers for the rest of your career!

 

[MidwestRadOnc]

I was being rascally when saying there's no randomized data to support your approach.

View attachment 383416
Imagine that a 30 Gy PBI dose offers 99% LC at 10y and a 26 Gy dose 98% LC at 10y. Imagine you want to run a non-inferiority trial to exclude a 2% or more LC difference at 10y between these groups. My back of envelope calcs say you're going to need a ~5000 patient trial with median 10y followup to get the answer you want. Which for all intents and purposes means you will side-eye the world's 26 Gy PBI users as local relapse gamblers for the rest of your career!

Are you arguing that 26 Gy should be used because it’s less toxic or more effective? I’m genuinely confused.

 

[Mandelin Rain]

My guess is he thinks for most cases, radiation to the breast doesn't do anything so you might as well minimize the dose and volume. For the 10% that radiation to the breast does matter, 26Gy APBI is almost certainly good enough based on the cumulative knowledge of multiple trials with multiple recipes.

 

[TheWallnerus]

Are you arguing that 26 Gy should be used because it’s less toxic or more effective? I’m genuinely confused.

I am arguing that 26 Gy is a standard PBI dose.

It's difficult to make a convincing case that 26 Gy is apt to show better toxicity outcomes versus 30 Gy. It's impossible to make a convincing case it would have worse toxicity outcomes.

It's difficult to make a convincing case that 30 Gy is apt to show better LC outcomes versus 26 Gy.* It's impossible to make a convincing case it would have worse LC outcomes.

Improvements in LC via RT in essentially every single trial (excluding meta-analyses, granted) iirc came with no improvements in OS, but some worsened toxicity.

So, all the above means we arrive at this fact: 26 Gy is a standard PBI dose.

* in one hypofx breast RT study of 2000 women, an increased RT dose to the tumor cavity was associated with a perfectly zero increased chance of LC:

 

[evilbooyaa]

I am arguing that 26 Gy is a standard PBI dose.

It's difficult to make a convincing case that 26 Gy is apt to show better toxicity outcomes versus 30 Gy. It's impossible to make a convincing case it would have worse toxicity outcomes.

It's difficult to make a convincing case that 30 Gy is apt to show better LC outcomes versus 26 Gy.* It's impossible to make a convincing case it would have worse LC outcomes.

Improvements in LC via RT in essentially every single trial (excluding meta-analyses, granted) iirc came with no improvements in OS, but some worsened toxicity.

So, all the above means: 26 Gy is a standard PBI dose.

* in one hypofx breast RT study of 2000 women, an increased RT dose to the tumor cavity was associated with a perfectly zero increased chance of LC:

View attachment 383420

Boost use was non-randomized and thus the patients who needed the boost got it, and those who didn't, didn't.

Randomized trials have confirmed benefit of boost in improving LC when necessary, at expense of increased toxicity. Regardless, 26 vs 30Gy is less than what a boost dose would be even for PBI.

Fine if you (and folks) want to do it, even fine calling it a standard option, but no reason to get away from what the trials actually did. Thus, I, personally, will never see an indication for 26Gy in 5 fx based on current evidence base. Again, look forward to the ongoing trials evaluating this.

 

[MidwestRadOnc]

How do you reconcile the EORTC boost data?

What you are really talking about is giving a boosted dose to the cavity alone (30/5) with nothing to the rest of the breast (similar to giving 50 gy in 20 fractions as is common) vs. giving just the standard adjuvant dose to the cavity alone (26/5).

Your rationale makes sense but why risk having to explain that to a jury when 30/5 is so well tolerated?

BED2 30/5 = 120 gy
BED2 40/15 + 10/5 = 113 gy
BED2 26/5 = 93.6 gy
BED2 40/15 = 93.4 gy

Edit: I guess the logical question is, at what age would you give 30/5 instead of 26/5, and is there an age where you would you switch to whole breast plus boost?

 

[TheWallnerus]

Boost use was non-randomized and thus the patients who needed the boost got it, and those who didn't, didn't.

I love this argument. It's a deus ex machina.

How do you reconcile the EORTC boost data?

There is no data from any hypofractionated RT breast trial that shows a boost improved LC. I think I'm right about this, but haven't checked in a few years. I think IMPORT-HIGH was compelling data too.

Your rationale makes sense but why risk having to explain that to a jury when 30/5 is so well tolerated?

This old saw? I think we lose credibility if we try to hypothesize that any rad onc is going to ever have to explain to a jury why a local relapse happened after 26 Gy versus 30 Gy. It would be legally impossible to prove a malpractice here, for starters (as 26 Gy/5 fx is a recognized standard of care dose, and 26/5 PBI is a recognized standard of care too).

 

[MidwestRadOnc]

I love this argument. It's a deus ex machina.


There is no data from any hypofractionated RT breast trial that shows a boost improved LC. I think I'm right about this, but haven't checked in a few years. I think IMPORT-HIGH was compelling data too.


This old saw? I think we lose credibility if we try to hypothesize that any rad onc is going to ever have to explain to a jury why a local relapse happened after 26 Gy versus 30 Gy. It would be legally impossible to prove a malpractice here, for starters (as 26 Gy/5 fx is a recognized standard of care dose, and 26/5 PBI is a recognized standard of care too).

Are there any guidelines that lists 26/5 PBI as an option? Or this dose and volume in a randomized trial? I agree and it would be a non issue if it were true.

Just asking a question, is there ANY T1-T2 N0 patient you would not give 26/5 to?

30 years old?
Triple negative?
Assuming multi focal would still get whole breast, but you’ve said you don’t do 26/5 whole breast?

 

[TheWallnerus]

Are there any guidelines that lists 26/5 PBI as an option?

Just asking a question, is there ANY T1-T2 N0 patient you would not give 26/5 to?

30 years old?
Triple negative?
Assuming multi focal would still get whole breast, but you’ve said you don’t do 26/5 whole breast?

None of these would match the recent ASTRO PBI guidelines (which again do mention 26/5 as an option). I would follow those. Better for jury explanations.

I love 40/15 as a whole breast dose. (Do we need an argument of 42.5/16 vs 40/15 whole breast?) But this is probably traditionalist of me.

Eventually, we will have data that 26/5 is the standard dose even for ENI. What will all us Americans do then?

 

[evilbooyaa]

Eventually, we will have data that 26/5 is the standard dose even for ENI. What will all us Americans do then?

Pontificate. Strongly. With lots of firm beliefs held in dogma.

The more things change, the more they stay the same.

I bow out of this discussion - Wallnerus, you do you, and I will do me. We can co-exist and sing Kumbaya.

Until the next time... when we re-hash this discussion for the (n-1)th time.