APBI - 26 Gy?

[Ray D. Ayshun]

I get that. But among the rationale for smaller treatment volumes in other disease sites is the corresponding ability to dose escalate for improved local control.

We have all this boost data that impacts local control. I'm not a big booster fwiw.

Is a (potentially) softer lumpectomy bed worth a 0.5% to 2% difference in recurrence?

I don't know.

Well the nice thing about VMAT PBI is you can actually dose escalate while not changing the prescription dose. The dirty secret we never really talk about are the absurd coverage constraints in breast, even on trial. I think the IMN constraint that's acceptable is like 80-90% to 90%. I imagine when these trials are designed, investigators are saying, "meh, it's breast." VMAT PBI would allow you to actually cover the whole volume with 98%+ of the script. You could try this with 3D as well of course, just seems easier to pull off with VMAT without massive hotspots.

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[communitydoc13]

I would argue there is some randomized partial breast irradiation data that indicate doses lower than 30 gy in 5 fractions may decrease toxicity while maintaining high tumor control.

There is a phase II randomized controlled trial with 281 patietns that compared 27.5 Gy in 5 fractions to 30 Gy in 5 fractions. There was a trend to better cosmetic outcomes with 27.5 Gy. There were no local failures in either arm. Abstract attached below

Interesting result. The photographic assessment is equivalent (unlike for the 5 fraction whole breast trials). Definitely would want to know if patients and assessors were blinded to intervention (If not, it pretty much kills the validity of the non-photographic toxicity assessment).

 

[TheWallnerus]

"Less dose gives less toxicity" would have been the easiest thing to agree on in rad onc. I woulda thunk.

 

[metallica81788]

In this time this discussion has been going, I've met and consented four patients for 30/5 PBI

Not even joking

 

[sirspamalot]

For post-op melanoma

Say what?

 

[sirspamalot]

In this time this discussion has been going, I've met and consented four patients for 30/5 PBI

Not even joking

 

[evilbooyaa]

The heart (mean and max <1 Gy for most) and lung DVH generally can't be beat with a two-field partial breast IMRT tangent vs VMAT. Just sayin'.

View attachment 377511

That is not where the concern for late toxicity comes from. If you see from 26/5 it's about breast cosmesis changes which amongst PBI prescriptions would be a matter of homogeneity in the breast. Also why IMRT WBI is better than 3D WBI - the homogeneity is what's driving improvements.

 

[evilbooyaa]

Good point. I was thinking of skin toxicity when I replied. I am sure that two-filed partial breast IMRT tangent lowers heart dose and lung dose compared to VMAT, but I bet it is only slightly lower. I looked through a few of my 27.5 Gy partial breast patietns and as long as the tumor was not left sided and medial the mean heart dose was less than 1 Gy.

Again, depends on the physician and the dosimetrist. Certainly seen VMAT plans where the heart is so poorly optimized it's like MHD of 4 for R-sided or MHD 8 for L-sided. Simul has posted about his side hustle rejecting IMRT for breast when people are doing it the wrong way.

 

[OTN]

In this time this discussion has been going, I've met and consented four patients for 30/5 PBI

Not even joking

3 for me

 

[TheWallnerus]

Willingness to do a lot of 5 fraction breast is probably tied to how busy a doctor or center is. If you’re very busy the lost revenue doesn’t hurt much. But for a small non-busy center, five fraction breast will be a revenue killer that’s too much. Which is probably why still less than 1% of all breast RT patients in the US are five fraction (and the majority of RT centers in America are small low volume centers).

 

[sirspamalot]

"In the old days" we were fraction shamed for doing too few fractions. Believe it or not.

Old days eh.. you mean grease pencils on films circa..

ps. You guys know about Revanced, hopefully..

 

[communitydoc13]

"Less dose gives less toxicity" would have been the easiest thing to agree on in rad onc. I woulda thunk.

Yeah, 26/5 is fine.

The British trials are notable in that local control is exceptionally good no matter what you do. You wouldn't expect 26/5 to be equivalent to even 40/20 for most a/b and you wouldn't expect time factors to be significant for low risk, post-operative breast cancer. In Fast-Forward they had to exclude the lowest risk patients (mostly who we are talking about) after 2013 to try to drive up the total numbers of events. That a large trial with fairly liberal inclusion criteria would demonstrate such remarkably low recurrence rates (as compared to 90s era boost trials) is well...telling.

It's almost like breast cancer in the modern era isn't even the same disease as it was in the 80s/90s. Sorta like prostate cancer.

Some enterprising academic undoubtedly working on the ~20 Gy/3 fxn trial now...and intra-op probably really is OK. We undoubtedly continue to overtreat breast (and prostate).

We need to go all in on eliminating surgery in the very elderly. (Even a good 80 year old get's beat up from surgery).

Definitive radiotherapy with stereotactic or IMRT boost with or without radiosensitization strategy for operable breast cancer patients who refuse surgery

Abstract. For breast cancer (BC) patients who refused surgery, we developed a definitive treatment employing modern sophisticated radiation techniques. Thirty-e

academic.oup.com

Hail @TheWallnerus.

 

[TheWallnerus]

It's almost like breast cancer in the modern era isn't even the same disease as it was in the 80s/90s

Key point.

 

[evilbooyaa]

Willingness to do a lot of 5 fraction breast is probably tied to how busy a doctor or center is. If you’re very busy the lost revenue doesn’t hurt much. But for a small non-busy center, five fraction breast will be a revenue killer that’s too much. Which is probably why still less than 1% of all breast RT patients in the US are five fraction (and the majority of RT centers in America are small low volume centers).

5Fx VMAT about equal to 15Fx 3D

We need to go all in on eliminating surgery in the very elderly. (Even a good 80 year old get's beat up from surgery).

Definitive radiotherapy with stereotactic or IMRT boost with or without radiosensitization strategy for operable breast cancer patients who refuse surgery

Abstract. For breast cancer (BC) patients who refused surgery, we developed a definitive treatment employing modern sophisticated radiation techniques. Thirty-e

academic.oup.com

Hail @TheWallnerus.

Raise you: https://www.redjournal.org/article/S0360-3016(23)07908-7/fulltext

 

[TheWallnerus]

5Fx VMAT about equal to 15Fx 3D



Raise you: https://www.redjournal.org/article/S0360-3016(23)07908-7/fulltext

The last time I did back of envelope guesses on this a 3D breast (21 fraction admittedly, which is what most folks actually wind up doing) nets about twice that of 5 fraction IMRT breast

 

[drowsy12]

but why would you change the calculus for no reason?

The comparison is 15 fraction 3D vs 5 fraction IMRT. Those are the standard approaches one would be considering for an APBI candidate

I agree with the multiples who have said this already - and I’m fairly sure chirag shah published this as well - but yeah 15 fx 3D not too dissimilar from 5 fx Livi IMRT

 

[HolySmokes]

This is exactly true re: boost for hypofrac. Which is why I never boost 40 Gy in 15 fx whole breast, or partial breast. And here we have data, e.g., no extrapolation needed. The benefit of boost in START was a stone cold zero, something rather striking like an HR of 1.000 in "thousands" of women iirc.

You'll have to point me to this data because for the life of me I have never heard this and can't seem to find it within the START trial results. I see stratification based on boost between arms but no comparison within the hypofx arm of boost vs. not. And would that not potentially be confounded by higher risk patients being more likely to receive boosts since it was non-randomized?

 

[Burt Radnolds]

You'll have to point me to this data because for the life of me I have never heard this and can't seem to find it within the START trial results. I see stratification based on boost between arms but no comparison within the hypofx arm of boost vs. not. And would that not potentially be confounded by higher risk patients being more likely to receive boosts since it was non-randomized?

https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(22)01246-6/fulltext

Unequivocal evidence that boost still lowers local recurrence in the setting of hypofractionation (at least for DCIS).

 

[TheWallnerus]

You'll have to point me to this data because for the life of me I have never heard this and can't seem to find it within the START trial results. I see stratification based on boost between arms but no comparison within the hypofx arm of boost vs. not. And would that not potentially be confounded by higher risk patients being more likely to receive boosts since it was non-randomized?

@Palex80 once told me that the reason the LF rate was exactly similar between boost and no boost in START is that the treating physicians were exactly perfect in choosing whom to boost!

 

[TheWallnerus]

You'll have to point me to this data because for the life of me I have never heard this and can't seem to find it within the START trial results. I see stratification based on boost between arms but no comparison within the hypofx arm of boost vs. not. And would that not potentially be confounded by higher risk patients being more likely to receive boosts since it was non-randomized?

See Figure 4

 

[sirspamalot]

https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(22)01246-6/fulltext

Unequivocal evidence that boost still lowers local recurrence in the setting of hypofractionation (at least for DCIS).

And how much lowered recurrence value was the boost in the hypofrac group versus induration again?

 

[Burt Radnolds]

And how much lowered recurrence value was the boost in the hypofrac group versus induration again?

Yes, we all know boost increases toxicity as well. Thanks for pointing it out though. It's an informed decision to make with patients.

 

[Burt Radnolds]

And how much lowered recurrence value was the boost in the hypofrac group versus induration again?

A more thorough answer to your seemingly non serious question.

My point is not to convince anyone to boost. It is to rebut the repeated claim that there is ZERO EVIDENCE that boost adds anything in the setting of hypofractionation by presenting level 1 evidence.

I often omit boost in the setting of whole breast radiation, but sometimes choose to give it.

 

[TheWallnerus]

A more thorough answer to your seemingly non serious question.

My point is not to convince anyone to boost. It is to rebut the repeated claim that there is ZERO EVIDENCE that boost adds anything in the setting of hypofractionation by presenting level 1 evidence.

I often omit boost in the setting of whole breast radiation, but sometimes choose to give it.

View attachment 377537

View attachment 377538

This is OK data. But… it’s just DCIS, right. Which (paradoxically) can have higher LR rates than invasive disease. And paradoxically may even be more radioresistant. Even in the “old days” pound for pound there were trends with more LF with lumpectomy vs mastectomy in DCIS. Those trends were “never” seen in invasive. A 5y LF of ~7% (92.7% LC at 5y for no boost) is also “never” seen in modern times for low risk early stage invasive disease. For example, without a boost, the 5y LF rate for partial breast alone in IMPORT LOW was less than one percent. Food for arguing thought.

 

[Palex80]

@Palex80 once told me that the reason the LF rate was exactly similar between boost and no boost in START is that the treating physicians were exactly perfect in choosing whom to boost!

 

[communitydoc13]

A 5y LF of ~7% (92.7% LC at 5y for no boost) is also “never” seen in modern times for low risk early stage invasive disease. For example, without a boost, the 5y LF rate for partial breast alone in IMPORT LOW was less than one percent.

The DCIS trial was non-low risk, overwhelmingly with comedonecrosis and overwhelmingly without endocrine treatment.

This is a group of patients that we would not typically consider for APBI and should consider for boost (after discussing pros/cons with patients). The boost is not a life saver (nor is the radiation in general).

 

[sirspamalot]

Seriously though, specifically for hypofrac only, what is the value of boost vs. side effect hazard increase?

I don't ever (unless focally positive margins or something similar) do a boost with hypofrac, haven't had a single in-quadrant failure, regardless of histology.. at least, that I am aware of...

 

[evilbooyaa]

Seriously though, specifically for hypofrac only, what is the value of boost vs. side effect hazard increase?

I don't ever (unless focally positive margins or something similar) do a boost with hypofrac, haven't had a single in-quadrant failure, regardless of histology.. at least, that I am aware of...

How's your f/u game with your breast cancer patients? Most Rad Oncs don't actually follow their follow-ups. Easy to say you've never had a recurrence when they don't see you after 3 months post-RT. 100% LC. This is why we have to rely on big data sets rather than personal anecdotes.

The last time I did back of envelope guesses on this a 3D breast (21 fraction admittedly, which is what most folks actually wind up doing) nets about twice that of 5 fraction IMRT breastView attachment 377523View attachment 377524

New CT Sim for a boost plan for 3D certainly is a variation in practice nationally but in most patients is NOT necessary, IMO.
And I'm mostly talking about the professional component for MDs which is what most employed folks will care about, so the huge discrepancy between the number of treatments is somewhat minimized. Mostly the increased OTV charges. Agree that comparing 21 vs 5 is not really a fair comparison unless one indiscriminately boosts all breast cancer patients.

You'll have to point me to this data because for the life of me I have never heard this and can't seem to find it within the START trial results. I see stratification based on boost between arms but no comparison within the hypofx arm of boost vs. not. And would that not potentially be confounded by higher risk patients being more likely to receive boosts since it was non-randomized?

Yes to the bolded. Physician's decision on when to boost suggests one of two things with the graph Wallnerus showed - either boost has ZERO value (which flies directly in the face of other prospective randomized data like TROG for DCIS and older studies in IDC) or the tumor/patient characteristics we use to determine need for a boost are pretty good as previously noted by Palex. Taking a trial that had non-randomized boost usage and saying it trumps randomized data showing better LR with boost is poor logic, IMO.

 

[sirspamalot]

What is your recommendation re boost for a patient offered hypofrac for: g2 IDC 2mm+ margins for inv/DCIS +/+, stage IIA but with (focal) LVSI here after chemo.. (hi risk genetically)

I don't think a boost is needed -

The role of the radiation therapy breast boost in the 2020s

Given that most local relapses of breast cancer occur proximal to the original location of the primary, the delivery of additional radiation dose to breast tissue that contained the original primary cancer (known as a “boost”) has been ...

www.ncbi.nlm.nih.gov

I think for a women over 50 with no path risk factors and getting hypofrac.. no need. Also, if you are gonna do a boost, ideally with electrons vs. photons, the data would suggest lowers risk of side effects.

 

[evilbooyaa]

Assuming your pt is over age of 50 and ER/PR+ and negative margins (I am in agreement of no ink on tumor for IDC), no boost.

If G3 or TNBC or < 50 I would boost. LVSI honestly doesn't change my recommendation but I'm not sure how evidence based that is.

Boost with electron is fine based on the location and anatomy. Again an individualized decision.

 

[TheWallnerus]

New CT Sim for a boost plan for 3D certainly is a variation in practice nationally but in most patients is NOT necessary, IMO.
And I'm mostly talking about the professional component for MDs which is what most employed folks will care about, so the huge discrepancy between the number of treatments is somewhat minimized. Mostly the increased OTV charges. Agree that comparing 21 vs 5 is not really a fair comparison unless one indiscriminately boosts all breast cancer patients

Alright fair enough

Straight 15 fraction 3D: $7137.85 (no IGRT allowed)
5 fraction IMRT: $5529.72

I’ll have to calc wRVUs later

 

[RadOncDoc21]

Damn you breast!

 

[TheWallnerus]

Taking a trial that had non-randomized boost usage and saying it trumps randomized data showing better LR with boost is poor logic, IMO.

That would be poor logic to say non randomized data trumps randomized data. I agree! Notice I didn’t really say that though (hope I didn’t). I’ve merely only ever said there is no randomized data supporting use of a boost in hypofrac (for invasive disease, to be clear). I have also said: aren’t the (non randomized obv) post-hoc comparisons for boost data in hypofrac underwhelming. To ever argue for a boost in hypofrac, you’ve got to use extrapolation. Yet extrapolation seems to be invidious to you when the Royal College of Radiologists use extrapolation to say 26/5 partial breast is standard (wink).

 

[SneakyBooger]

That would be poor logic to say non randomized data trumps randomized data. I agree! Notice I didn’t really say that though (hope I didn’t). I’ve merely only ever said there is no randomized data supporting use of a boost in hypofrac (for invasive disease, to be clear). I have also said: aren’t the (non randomized obv) post-hoc comparisons for boost data in hypofrac underwhelming. To ever argue for a boost in hypofrac, you’ve got to use extrapolation. Yet extrapolation seems to be invidious to you when the Royal College of Radiologists use extrapolation to say 26/5 partial breast is standard (wink).

Oh, how I do absolutely adore extrapolation when it suits me!

And fire come down from the heavens if it does not! 👹👹👹

 

[TheWallnerus]

either boost has ZERO value (which flies directly in the face of other prospective randomized data like TROG for DCIS and older studies in IDC) or the tumor/patient characteristics we use to determine need for a boost are pretty good as previously noted by Palex. Taking a trial that had non-randomized boost usage and saying it trumps randomized data showing better LR with boost is poor logic, IMO.

That would be poor logic to say non randomized data trumps randomized data. I agree! Notice I didn’t really say that though (hope I didn’t). I’ve merely only ever said there is no randomized data supporting use of a boost in hypofrac (for invasive disease, to be clear). I have also said: aren’t the (non randomized obv) post-hoc comparisons for boost data in hypofrac underwhelming. To ever argue for a boost in hypofrac, you’ve got to use extrapolation. Yet extrapolation seems to be invidious to you when the Royal College of Radiologists use extrapolation to say 26/5 partial breast is standard (wink).

Also, woe betide me (I may be losing a step), I totally forgot to mention the recent IMPORT HIGH. (Agree this discussion still needs confined to low risk early stage.)

Keep IMPORT-HIGH in mind and look at the other hypofrac data, including no effect of boost on LC in post-hoc START analyses. NB: At 10y, IMPORT LOW local failure is now 2.8%.

 

[Burt Radnolds]

Also, woe betide me (I may be losing a step), I totally forgot to mention the recent IMPORT HIGH. (Agree this discussion still needs confined to low risk early stage.)

View attachment 377577

View attachment 377578

Keep IMPORT-HIGH in mind and look at the other hypofrac data, including no effect of boost on LC in post-hoc START analyses. NB: At 10y, IMPORT LOW local failure is now 2.8%.

View attachment 377579

What are you saying IMPORT High is telling us? All 3 arms received a boost of different flavors. Local recurrence was very low. Toxicity was reasonable. Arm 3 overdid it on the boost and had increased toxicity without improved local control.

In the times I choose to boost, I do like use an import high arm 2 or rtog 1005 approach. Sometimes I just push for ~95/95 coverage or around 4560 cGy to boost target. Also allows you to boost deep cavities with less integral dose to surrounding breast than you would with sequential photon boost crushing through already irradiated breast.

We can agree to disagree on START B. The UK has very algorithmic medicine pathways and gave boosts to the patients most likely to benefit (high grade, young, etc). You choose to see no effect, I choose to see appropriate/expected effect of intervention. Neither of us can prove the other wrong IMO.

 

[Burt Radnolds]

Also as to the original question, I use 26Gy apbi not infrequently. I usually choose 26, 28.5 or 30Gy depending on clinical situation / risk factors/ anatomy. Sometimes do SIB to 30 and 26 to larger volume. Sometimes tinker with CTV with larger volume to 26 in borderline partial breast candidate. Probably (definitely) overcomplicating things, gotta keep it interesting somehow!

 

[TheWallnerus]

In the times I choose to boost, I do like use an import high arm 2 or rtog 1005 approach

Very interesting to prioritize LC, and from this three (control, arm 1/2) arm randomized trial to favor arm 2. Admittedly there was no statistical significance associated with higher boost BED and LC, so again all the data (from hypofrac invasive world) says: choose whatever boost regimen you want, or don’t boost, it doesn’t matter (statistically speaking). But, still, interesting choice to use the boostiest regimen with the worstiest local control.

 

[Ray D. Ayshun]

What'd I miss? We have consensus?

 

[Burt Radnolds]

Very interesting to prioritize LC, and from this three (control, arm 1/2) arm randomized trial to favor arm 2. Admittedly there was no statistical significance associated with higher boost BED and LC, so again all the data (from hypofrac invasive world) says: choose whatever boost regimen you want, or don’t boost, it doesn’t matter (statistically speaking). But, still, interesting choice to use the boostiest regimen with the worstiest local control.

I was referring to using the overall second arm of the trial (experimental arm 1), arguably the least boosty (and also what rtog 1005 used). I can see how you interpreted me saying arm 2 (intended as experimental arm 1) as meaning experimental arm 2 though. (Now I'm confusing myself). However I did later clarify that I usually shoot for ~4560 to cover the cavity which is way less than the boostiest 53gy arm, but per protocol of both import high experimental arm 1 and rtog 1005 experimental arm as its 95/95 coverage of 4800.

Pretty sure everyone else stopped paying attention a long time ago. I'll shut up now!

 

[evilbooyaa]

I was referring to using the overall second arm of the trial (experimental arm 1), arguably the least boosty (and also what rtog 1005 used). I can see how you interpreted me saying arm 2 (intended as experimental arm 1) as meaning experimental arm 2 though. (Now I'm confusing myself). However I did later clarify that I usually shoot for ~4560 to cover the cavity which is way less than the boostiest 53gy arm, but per protocol of both import high experimental arm 1 and rtog 1005 experimental arm as its 95/95 coverage of 4800.

Pretty sure everyone else stopped paying attention a long time ago. I'll shut up now!

True for 99% of breast RT discussions both in SDN and real world

 

[taserlaser]

Very interesting to prioritize LC, and from this three (control, arm 1/2) arm randomized trial to favor arm 2. Admittedly there was no statistical significance associated with higher boost BED and LC, so again all the data (from hypofrac invasive world) says: choose whatever boost regimen you want, or don’t boost, it doesn’t matter (statistically speaking). But, still, interesting choice to use the boostiest regimen with the worstiest local control.

Yes, it is peculiar to see that on the high dose boost arm. Same thing that was seen at 27 Gy vs 26 Gy on UK-FF, though difference is small. I have to assume it is spurious on UK-FF, but there may be something else unexplained that we are seeing. Would be curious on others speculations on that.

 

[sirspamalot]

both in SDN and real world

They are one and the same I say.. come at me bruh..

 

[communitydoc13]

the boostiest regimen with the worstiest local control

Yes, it is peculiar to see that on the high dose boost arm.

numbers are so low...of course our first thought needs to be just rando stuff.

However, if this were real signal, why would this be?

I have always contended that exams post XRT are difficult and the more hypo (or boostier) you get, the more meaningless the exam for local recurrence. If you feel a few Livi protocol breasts 6 mos to a year out...you inevitably say to yourself, "well, the breast looks damn good" while palpating a pretty hard treatment area.

Maybe the boostiest protocol just caused the fibrosis that cued the process of looking hard for a local recurrence?

The discordance between actual numbers of recurrences and detected recurrences may itself muddy things tremendously. Of course, for luminal A type patients, a recurrence could take ages to become clinically significant.

Regardless of all this nonsense, very few women are dying of the breast cancer. What we do is not impacting mortality for the low risk breast patient, and the tradeoffs between local control and fibrosis make all sorts of options reasonable.

I wish my job stimulated me to think about more clinically significant things. I can only imagine being a breast only radonc attending.

 

[SneakyBooger]

I am not even going down the rabbit hole of boost in this post as it deserves its own thread, IM_O

50 in 25 there will be local recurrences
45 in 25 there will be local recurrences
30 in 5 there will be local recurrences
26 in 5 there will be local recurrences

If we base our decision solely on local recurrence we should recommend mastectomy (according to my breast surgeons).
And there will be local recurrences.

 

[sirspamalot]

So if local recurrences are really "about the same" for all flavors of radiation, then the least 'injurious' form should be used.

PBI reduces volume, but may cause more induration. Whole breast hypofrac and delete the boost, and you're good.

Whole breast has a very very long track record.

Imma finna do what imma already doin, as the kids say.

 

[TheWallnerus]

So if local recurrences are really "about the same" for all flavors of radiation, then the least 'injurious' form should be used.
PBI reduces volume, but may cause more induration.

"Less dose gives less toxicity" would have been the easiest thing to agree on in rad onc. I woulda thunk.

"Treating much less volume to the same dose gives less toxicity" woulda been the second easiest thing to agree on in rad onc. I woulda thunk.

 

[TheWallnerus]

If we base our decision solely on local recurrence we should recommend mastectomy (according to my breast surgeons).
And there will be local recurrences.

Can't really speak to the local recurrence issue (lump/XRT vs MRM); the rates are just too darn close.

But mastectomy will have inferior survival

1. Effect of Breast Conservation Therapy vs Mastectomy on Disease-Specific Survival for Early-Stage Breast Cancer
2. ECCO 2017: Some Patients With Early-Stage Breast Cancer May Benefit More From Breast-Conserving Therapy Than Mastectomy
3. Breast conserving therapy and mastectomy revisited: Breast cancer-specific survival and the influence of prognostic factors in 129,692 patients
4. Andrew Seidman, MD, and Sabine Seisling, PhD, on Early-Stage Breast Cancer Outcomes: Breast-Conserving Therapy vs Mastectomy
5. Overall survival according to type of surgery in young (≤40 years) early breast cancer patients: A systematic meta-analysis comparing breast-conserving surgery versus mastectomy.
6. Noninferior Outcome After Breast-Conserving Treatment Compared to Mastectomy in Breast Cancer Patients With Four or More Positive Lymph Nodes

 

[taserlaser]

Can't really speak to the local recurrence issue (lump/XRT vs MRM); the rates are just too darn close.

But mastectomy will have inferior survival

1. Effect of Breast Conservation Therapy vs Mastectomy on Disease-Specific Survival for Early-Stage Breast Cancer
2. ECCO 2017: Some Patients With Early-Stage Breast Cancer May Benefit More From Breast-Conserving Therapy Than Mastectomy
3. Breast conserving therapy and mastectomy revisited: Breast cancer-specific survival and the influence of prognostic factors in 129,692 patients
4. Andrew Seidman, MD, and Sabine Seisling, PhD, on Early-Stage Breast Cancer Outcomes: Breast-Conserving Therapy vs Mastectomy
5. Overall survival according to type of surgery in young (≤40 years) early breast cancer patients: A systematic meta-analysis comparing breast-conserving surgery versus mastectomy.
6. Noninferior Outcome After Breast-Conserving Treatment Compared to Mastectomy in Breast Cancer Patients With Four or More Positive Lymph Nodes

This is a nice list of papers highlighting this observation. When I have learners and surgical residents with me, they are often surprised when we discuss this data.

 

[evilbooyaa]

Can't really speak to the local recurrence issue (lump/XRT vs MRM); the rates are just too darn close.

But mastectomy will have inferior survival

1. Effect of Breast Conservation Therapy vs Mastectomy on Disease-Specific Survival for Early-Stage Breast Cancer
2. ECCO 2017: Some Patients With Early-Stage Breast Cancer May Benefit More From Breast-Conserving Therapy Than Mastectomy
3. Breast conserving therapy and mastectomy revisited: Breast cancer-specific survival and the influence of prognostic factors in 129,692 patients
4. Andrew Seidman, MD, and Sabine Seisling, PhD, on Early-Stage Breast Cancer Outcomes: Breast-Conserving Therapy vs Mastectomy
5. Overall survival according to type of surgery in young (≤40 years) early breast cancer patients: A systematic meta-analysis comparing breast-conserving surgery versus mastectomy.
6. Noninferior Outcome After Breast-Conserving Treatment Compared to Mastectomy in Breast Cancer Patients With Four or More Positive Lymph Nodes

The magic of non-purposeful RT dose to the axilla?

So if local recurrences are really "about the same" for all flavors of radiation, then the least 'injurious' form should be used.

PBI reduces volume, but may cause more induration. Whole breast hypofrac and delete the boost, and you're good.

Whole breast has a very very long track record.

Imma finna do what imma already doin, as the kids say.

The cosmetic outcome with PBI compared to WBI favors PBI in every trial using a regimen that is NOT 38.5 in 10 fractions BID.
40/15 PBI and 30/5 PBI both have less acute AND late toxicity than WBI regimens they were compared to.
26/5 PBI we have no prospective data for but presumably would cause less toxicity than 26/5 WBI.

Your internal justification to avoid learning how to do PBI is wrong. If you're gonna act like a boomer RO and ignore new techniques/data that would benefit patients, then go ahead and just own it. Lord knows there are enough ROs nationwide who feel similarly.