Breast IMRT Choosing Wisely... We Knew Ye

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Im just saying i would not do this, data free area. FAST FW looks fairly straightforward with likely achievable constraints with FIF and higher energy photons. Or do IMRT if you want.
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Ray D. Ayshun said:
Anybody doing APBI on triple negatives who met Livi inclusion criteria?
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Long story short, I *recommend* APBI for anyone who meets suitable criteria. I am willing to offer it for a cautionary patient (ER-) if that is the only 'cautionary' factor. So a T2N0 TNBC, no I'm not recommending APBI.

An absence of evidence is not an evidence of absence (of no difference).
 
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evilbooyaa said:
Long story short, I *recommend* APBI for anyone who meets suitable criteria. I am willing to offer it for a cautionary patient (ER-) if that is the only 'cautionary' factor. So a T2N0 TNBC, no I'm not recommending APBI.

An absence of evidence is not an evidence of absence (of no difference).
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Okay, but I’m sure you have some sort of rationale, right ?

I think for me APBI with VMAT is one of the best things we have for breast preservation and cosmetic outcome.

I am just curious where the notion comes from that this distribution of recurrences is different in TN vs other histologies.

A few were included in Florence, but I think that chirag agrees with you about not offering, but nobody has given a plausible biological reason why.
 
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RealSimulD said:
Okay, but I’m sure you have some sort of rationale, right ?

I think for me APBI with VMAT is one of the best things we have for breast preservation and cosmetic outcome.

I am just curious where the notion comes from that this distribution of recurrences is different in TN vs other histologies.

A few were included in Florence, but I think that chirag agrees with you about not offering, but nobody has given a plausible biological reason why.
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Tnbc is treated completely differently from a systemic tx standpoint both adjuvantly and neoadj. It's a different disease altogether. We consider pmrt in tnbc pts where we would not in an equivalent ER+ one.

Why would that paradigm not exist loco-regionally as well?
 
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If there is a benefit I would guess it’s from more coverage of lymphovas channels, partial nodes, etc

High risk node negative benefited from regional nodal radiation to same degree as node positive in ma20 subset analysis

(No, I’m not arguing for Comprehensive nodal coverage)
 
medgator said:
Tnbc is treated completely differently from a systemic tx standpoint both adjuvantly and neoadj. It's a different disease altogether. We consider pmrt in tnbc pts where we would not in an equivalent ER+ one.

Why would that paradigm not exist loco-regionally as well?
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The entire premise of PBI from the beginning is that 80% of recurrences happen within 2cm of cavity, this is from follow up recurrence data and surgical specimen data.

Are you saying that TNBC recurs more often away from the cavity? If you believe so, treat the whole breast - by all means. I’ve seen nothing in literature that suggests this.

If 80% of recurrences are within 2cm of cavity, it doesn’t matter if baseline risk is 20% IBTR or 5% the RT will do the same thing
 
I see a clinical trial with Simul’s name on it!

Kinda related question but are we now skipping APBI and going to Fast Foward? I just got comfortable offering APBI! Breast is literally the worst!
 
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RadOncDoc21 said:
I see a clinical trial with Simul’s name on it!

Kinda related question but are we now skipping APBI and going to Fast Foward? I just got comfortable offering APBI! Breast is literally the worst!
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Lol. I just don’t get treating different volumes in this scenario, but happy to review any available data.

I don’t like 5 fx whole breast.
 
RadOncDoc21 said:
I see a clinical trial with Simul’s name on it!

Kinda related question but are we now skipping APBI and going to Fast Foward? I just got comfortable offering APBI! Breast is literally the worst!
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Anti PBI peeps would say, B39 and recent PBI metanalysis confirms “inferiority” of PBI (by 1pct or less lol) so WBRT remains “king”. Don’t at me.
 
Ray D. Ayshun said:
Yeah, got chemo. My bigger concern is body habitus and toxicity with WBRT. She met inclusion criteria, but virtually none were TN.
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She got chemo?

1665438530513.png
 
RealSimulD said:
Okay, but I’m sure you have some sort of rationale, right ?

I think for me APBI with VMAT is one of the best things we have for breast preservation and cosmetic outcome.

I am just curious where the notion comes from that this distribution of recurrences is different in TN vs other histologies.

A few were included in Florence, but I think that chirag agrees with you about not offering, but nobody has given a plausible biological reason why.
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I... really don't. We know that TNBC recurs more frequently, both locally, and distantly. In terms of local recurrences, do they happen at more than 2cm away? No, I do not, but is there evidence that says local recurrence rates are super reasonable with APBI?

Idk, I find myself not *routinely* extrapolating a lot on breast. Maybe I'm part of the problem with that sort of boomer mentality. Sure, if I had a motivated patient who lived far and had heard about APBI then I'd do shared decision making where we talk about the controversy and come up with a plan we can both be comfortable with. But routinely offering APBI to TNBC patients... I just don't know.

I do very minimal breast, and there's oodles of Rad Oncs out there who do nothing but breast. I'd like to think I'm a pretty smart person, but do I think I'm smarter than ALL the breast rad oncs who write the guidelines, who say being ER- for APBI makes you cautionary?

I'm not saying it's wrong to offer it for TNBC. I'm just saying it's a data-free zone, we know these patients have more aggressive disease, and I'm not comfortable de-escalating therapy in a patient with worse prognosis.

However, the words of Dan Spratt from mednet (Albeit for prostate cancer patients) do echo in my head - is it worth punishing the patient simply because they have something that is a poor prognostic factor, even if it's not predictive of a response to therapy?
 
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Also, APBI should not be used in neoadjuvant chemotherapy cases (which is a lot of TNBC) and frequently the seroma becomes indiscernable if patients receive extended adjuvant chemotherapy (seen in the rest of TNBC). You'd be talking about doing APBI on a patient with TNBC who wasn't getting chemo, and squeezing it after their surgery but before their adjuvant therapy.
 
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thecarbonionangle said:
Anti PBI peeps would say, B39 and recent PBI metanalysis confirms “inferiority” of PBI (by 1pct or less lol) so WBRT remains “king”. Don’t at me.
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I feel like we just added another “discussion topic” regarding breast RT. So what should I tell the 65 y/o luminal A, ER/PR+ patient now? Mast vs lump… RT vs no RT… whole breast vs PBI…five fraction whole breast vs APBI… boost vs no boost.

Let’s not forget the the patient with a micromet in which we now open up the door on RNI vs Tangents, then thee hypofx vs standard vs boost vs no boost vs concomitant vs sequential… just goes on and on and on!
 
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evilbooyaa said:
I... really don't. We know that TNBC recurs more frequently, both locally, and distantly. In terms of local recurrences, do they happen at more than 2cm away? No, I do not, but is there evidence that says local recurrence rates are super reasonable with APBI?

Idk, I find myself not *routinely* extrapolating a lot on breast. Maybe I'm part of the problem with that sort of boomer mentality. Sure, if I had a motivated patient who lived far and had heard about APBI then I'd do shared decision making where we talk about the controversy and come up with a plan we can both be comfortable with. But routinely offering APBI to TNBC patients... I just don't know.

I do very minimal breast, and there's oodles of Rad Oncs out there who do nothing but breast. I'd like to think I'm a pretty smart person, but do I think I'm smarter than ALL the breast rad oncs who write the guidelines, who say being ER- for APBI makes you cautionary?

I'm not saying it's wrong to offer it for TNBC. I'm just saying it's a data-free zone, we know these patients have more aggressive disease, and I'm not comfortable de-escalating therapy in a patient with worse prognosis.

However, the words of Dan Spratt from mednet (Albeit for prostate cancer patients) do echo in my head - is it worth punishing the patient simply because they have something that is a poor prognostic factor, even if it's not predictive of a response to therapy?
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Good answer!

Everyone says not to, but no one has much biological rationale.

We know they fail distantly. We know they have higher IBTR without RT. And small number did okay on Florence study.

I am am extrapolater for sure (memantine with glioma, HF for DCIS before gator made it cool, etc).

Definitely not saying any one should or shouldn’t, but the Og Astro PBI guidelines are actually not very good. Read their references. They were just guessing. And they guessed pretty wrong, bc people treated unsuitable patients, wrote em up, and they did just fine.
 
RadOncDoc21 said:
I feel like we just added another “discussion topic” regarding breast RT. So what should I tell the 65 y/o luminal A, ER/PR+ patient now? Mast vs lump… RT vs no RT… whole breast vs PBI…five fraction whole breast vs APBI… boost vs no boost.

Let’s not forget the the patient with a micromet in which we now open up the door on RNI vs Tangents, then thee hypofx vs standard vs boost vs no boost vs concomitant vs sequential… just goes on and on and on!
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You might need to start blocking ur breast consults for 2-3 hour spots brotha! Lots of discuss, so lil time!
 
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thecarbonionangle said:
You might need to start blocking ur breast consults for 2-3 hour spots brotha! Lots of discuss, so lil time!
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Lol, normally I would just hypofx and boost everyone but I’ve been getting the stank eye lately from my snooty peers who “specialize in breast.”

N+ would give standard RNI. Of course some caveats but to me this should be it. Only offer the other fancy stuff if patient requests fancier items. I can’t discuss every single trial that has ever existed in breast!

Prostate cancer consults are catching up to also being ridiculously longer then they need to be, especially now that proton ads are popping up everywhere. I normally squash the proton question with your insurance won’t cover it vs data. It’s getting to the point where trials and data points are nebulously done and arguments can be made to support anything based on awful trial designs.

Don’t mind me, just my weekly Monday rant…
 
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I’ve much more paternalistic these days.

I disagree with complete “shared decision making”. It was foisted upon the medical world and everyone takes it as gospel. Yes, we want to avoid decision regret, but I’m the doctor, and that’s that.

Makes for faster consultation and happier patients!
 
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RealSimulD said:
I’ve much more paternalistic these days.

I disagree with complete “shared decision making”. It was foisted upon the medical world and everyone takes it as gospel. Yes, we want to avoid decision regret, but I’m the doctor, and that’s that.

Makes for faster consultation and happier patients!
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I too have grown tired of confusing the **** out of people who simply don't want their cancer to come back.
 
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evilbooyaa said:
Also, APBI should not be used in neoadjuvant chemotherapy cases (which is a lot of TNBC) and frequently the seroma becomes indiscernable if patients receive extended adjuvant chemotherapy (seen in the rest of TNBC). You'd be talking about doing APBI on a patient with TNBC who wasn't getting chemo, and squeezing it after their surgery but before their adjuvant therapy.
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This is a salient point re: APBI. I am lucky to have surgeons that place clips... but if you can't accurately define the cavity you shouldn't be doing partial breast.
 
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I agree. I think ultimately patients want a recommendation. When you present them with every choice most give you a blank look and basically ask “what would you do doc”. Tell them what you think.

If i treated breast i would follow royal college UK guidelines, where hypofrac is standard for even RNI, so 40.05/15 or 42.56/16 plus or minus boost. Save 5 fx schemes for special situations or elderly. I am not opposed if you wanna offer 5 fx to all but you must recommend something. Patients want decisiveness. I follow KISS philosophy.
 
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thecarbonionangle said:
I agree. I think ultimately patients want a recommendation. When you present them with every choice most give you a blank look and basically ask “what would you do doc”. Tell them what you think.

If i treated breast i would follow royal college UK guidelines, where hypofrac is standard for even RNI, so 40.05/15 or 42.56/16 plus or minus boost. Save 5 fx schemes for special situations or elderly. I am not opposed if you wanna offer 5 fx to all but you must recommend something. Patients want decisiveness. I follow KISS philosophy.
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I will make a bold statement and say that 99% of practicing rad oncs know how to treat breast cancer. There is nothing special about it. Same goes with pretty much all disease sites except when you start going into things like head and neck, GI and the weird stuff like skin and if we ever get to see lymphomas again. For some strange reason, we like to complicate the hell out of everything and judge anyone who gives more then 5 fractions to anything.
 
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RadOncDoc21 said:
I will make a bold statement and say that 99% of practicing rad oncs know how to treat breast cancer. There is nothing special about it. Same goes with pretty much all disease sites except when you start going into things like head and neck, GI and the weird stuff like skin and if we ever get to see lymphomas again. For some strange reason, we like to complicate the hell out of everything and judge anyone who gives more then 5 fractions to anything.
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Eh. I think when I see some folks practicing, they don’t have any logic / worldview guiding their decisions.

It’s not number of fractions. It’s not having consistency and that’s when I think without firm way of looking at disease can lead to errors - since no unified theory.
 
RealSimulD said:
I’ve much more paternalistic these days.

I disagree with complete “shared decision making”. It was foisted upon the medical world and everyone takes it as gospel. Yes, we want to avoid decision regret, but I’m the doctor, and that’s that.

Makes for faster consultation and happier patients!
Click to expand...

I like to share the history of how the different options came about, very clearly state my recommendation at the top, then compare some alternatives pros/cons. This is still shared decision making because patients who have a very strong opinion about their treatment will tell you at the end. I've had two cases where this strategy landed me at UK Fast Forward. They were adamant about 5 days of treatment but weren't "eligible" for APBI per ASTRO. As silly as it may be, it's still a published guideline, and if I were giving APBI to someone in the cautionary or unsuitable category I will make sure they know about that.

I really like 15-16 fractions +/- boost as standard with reserving 5 WBRT or APBI for special situations per @thecarbonionangle. I think my "algorithm" is basically landing there.
 
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thecarbonionangle said:
I agree. I think ultimately patients want a recommendation. When you present them with every choice most give you a blank look and basically ask “what would you do doc”. Tell them what you think.

If i treated breast i would follow royal college UK guidelines, where hypofrac is standard for even RNI, so 40.05/15 or 42.56/16 plus or minus boost. Save 5 fx schemes for special situations or elderly. I am not opposed if you wanna offer 5 fx to all but you must recommend something. Patients want decisiveness. I follow KISS philosophy.
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Anyone who can fit omission criteria get 5 fx APBI.

Everyone else Whelan dosing.

If treating nodes, either / or. Data supports RNI with HF based on OG studies. But within standard of care to do 5 weeks. Just pick one. For inflammatory, would do conventional or consider BID if young/residual dz after chemo.

N0 or i+ - no nodes
N1mic - high tangents
1-3 macro mets- scv/level 3 ax. Include IMN if medial
4 or more - scv/full ax/IMN

Lump Boost - under 60, rare exceptions. If boost, drop to 15 fx for breast and 5 fx boost
CW boost - t4 or margin issue and it is localizable

This gets you like 98% of the way there

Neoadjuvant is way more to type but pretty much go with pre chemo staging. Rare circumstances will omit if pCR.
 
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RealSimulD said:
Anyone who can fit omission criteria get 5 fx APBI.

Everyone else Whelan dosing.

If treating nodes, either / or. Data supports RNI with HF based on OG studies. But within standard of care to do 5 weeks. Just pick one. For inflammatory, would do conventional or consider BID if young/residual dz after chemo.

N0 or i+ - no nodes
N1mic - high tangents
1-3 macro mets- scv/level 3 ax. Include IMN if medial
4 or more - scv/full ax/IMN

Lump Boost - under 60, rare exceptions. If boost, drop to 15 fx for breast and 5 fx boost
CW boost - t4 or margin issue and it is localizable

This gets you like 98% of the way there

Neoadjuvant is way more to type but pretty much go with pre chemo staging. Rare circumstances will omit if pCR.
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This should be a sticky and made into a breast cancer rad onc commandment!
 
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RealSimulD said:
Anyone who can fit omission criteria get 5 fx APBI.

Everyone else Whelan dosing.

If treating nodes, either / or. Data supports RNI with HF based on OG studies. But within standard of care to do 5 weeks. Just pick one. For inflammatory, would do conventional or consider BID if young/residual dz after chemo.

N0 or i+ - no nodes
N1mic - high tangents
1-3 macro mets- scv/level 3 ax. Include IMN if medial
4 or more - scv/full ax/IMN

Lump Boost - under 60, rare exceptions. If boost, drop to 15 fx for breast and 5 fx boost
CW boost - t4 or margin issue and it is localizable

This gets you like 98% of the way there

Neoadjuvant is way more to type but pretty much go with pre chemo staging. Rare circumstances will omit if pCR.
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You aren’t allowed to make breast this simple :)
 
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metallica81788 said:
Don't let the breast cancer experts tell you it isn't that simple!

That is a much more eloquent way of explaining essentially how I practice as well. They just want you to think breast is hard.
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I refuse to believe there is such a “thing” anymore as a radiation breast or prostate cancer “expert”. It’s like describing a surgeon who claims to be an expert at placing ports.
 
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I essentially do what simul does as well. However, there are cases where anatomy makes me wanna do something more conformal, which prompted my question. I also agree with what medgator and evil said regarding the biology of tn disease, and, if nothing else, gut feeling that what applies to er+ cancer doesn't necessarily apply to tn.
 
RickyScott said:
I refuse to believe there is such a “thing” anymore as a radiation breast or prostate cancer “expert”. It’s like describing a surgeon who claims to be an expert at placing ports.
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wild how two prostate RT experts or two breast RT experts will almost never give perfectly concordant recommendations even in routine cases
 
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Kind of a tangent, but have tried my first few 15 fraction breast IMRT plans and the plans look amazing. Kind of mind boggling that it isn't considered standard of care at this point, and I feel lied to for the last decade, haha. Thanks for your work pushing for these changes Simul et al.

Also agree, ASTRO consensus on APBI are severely outdated, they have things that make people cautionary that have ZERO to do with local recurrence. For example, if you have a margin of 2 mm, not 3 mm. So you're telling me, that in the year 2022, we honestly believe that if the surgical margin is "only" 2mm, they need WHOLE BREAST radiation? Same for ER- (Agree with Simul). Sometimes you have to use our doctor training in common sense because there is never going to be a randomized phase III trial comparing APBI to whole breast in ER- vs ER+ breast cancer.
 
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RealSimulD said:
Anyone who can fit omission criteria get 5 fx APBI.

Everyone else Whelan dosing.

If treating nodes, either / or. Data supports RNI with HF based on OG studies. But within standard of care to do 5 weeks. Just pick one. For inflammatory, would do conventional or consider BID if young/residual dz after chemo.

N0 or i+ - no nodes
N1mic - high tangents
1-3 macro mets- scv/level 3 ax. Include IMN if medial
4 or more - scv/full ax/IMN

Lump Boost - under 60, rare exceptions. If boost, drop to 15 fx for breast and 5 fx boost
CW boost - t4 or margin issue and it is localizable

This gets you like 98% of the way there

Neoadjuvant is way more to type but pretty much go with pre chemo staging. Rare circumstances will omit if pCR.
Click to expand...

I'd modify
Lump boost - Under 60, drop to 15 fraction and do IMRT with SIB boost. (OR 10 fractions, 5 fraction whole breast followed by 5 fraction boost)

I keep joking with people in real life, but in 5 years we'll be treating EVERYTHING in 5 fractions.
 
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I would agree with 15 fr SIB. Import High abstract data is promising, and I think there is more to come at ASTO
 
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taserlaser said:
I would agree with 15 fr SIB. Import High abstract data is promising, and I think there is more to come at ASTO
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Breast boost local control p0rn. Just what we need more of in breast oncology. I kid. Not really. Rad oncs will be running breast boost trials a thousand years from now.
Sheldor said:
Kind of a tangent, but have tried my first few 15 fraction breast IMRT plans and the plans look amazing. Kind of mind boggling that it isn't considered standard of care at this point
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"Kind of a tangent..."

We can all now agree it's standard of care. The Choosing Wisely has been jettisoned, and NCCN says to use it. We need to fight against the notion that it is NOT standard of care even in this dingy corner of the 'net.
 
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TheWallnerus said:
wild how two prostate RT experts or two breast RT experts will almost never give perfectly concordant recommendations even in routine cases
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Also wild that some “breast experts” virtue signal that they are authentic “experts” by insisting on 3d.
 
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TheWallnerus said:
Breast boost local control p0rn. Just what we need more of in breast oncology. I kid. Not really. Rad oncs will be running breast boost trials a thousand years from now.

"Kind of a tangent..."

We can all now agree it's standard of care. The Choosing Wisely has been jettisoned, and NCCN says to use it. We need to fight against the notion that it is NOT standard of care even in this dingy corner of the 'net.
Click to expand...

Which payers are refusing IMRT for whole breast? Do we have a list? I have only used it on cases where I can't do DIBH on left breast or the patient specifically requests it. Or on 5 fraction where I deliver an SIB to the lumpectomy cavity. Conceptually, I agree with 15 fraction with SIB but would like to know which patients I shouldn't even bother with, This is one where the fight is not worth it, but if it's allowed I like to do it.
 
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Moonbeams said:
Which payers are refusing IMRT for whole breast? Do we have a list? I have only used it on cases where I can't do DIBH on left breast or the patient specifically requests it. Or on 5 fraction where I deliver an SIB to the lumpectomy cavity. Conceptually, I agree with 15 fraction with SIB but would like to know which patients I shouldn't even bother with, This is one where the fight is not worth it, but if it's allowed I like to do it.
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What's this regimen/what's it based upon? Sounds like genesis may have something ongoing involving 28 fx, noble folk they are. Presumably 50.4 to the breast, 56 to the cavity. I may have misunderstood when I heard that though.
 
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Moonbeams said:
Which payers are refusing IMRT for whole breast? Do we have a list? I have only used it on cases where I can't do DIBH on left breast or the patient specifically requests it. Or on 5 fraction where I deliver an SIB to the lumpectomy cavity. Conceptually, I agree with 15 fraction with SIB but would like to know which patients I shouldn't even bother with, This is one where the fight is not worth it, but if it's allowed I like to do it.
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Medicare allows IMRT for whole breast since the code first appeared
 
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Are commercial insurances approving IMRT? Medicare advantage approving it or are you doing this on medicare?
 
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Is anyone who is using it willing to let a brotha know the dose constraints ?
 
Ray D. Ayshun said:
You're using it, or would like to?
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I do an SIB in 5 fraction based on basically nothing. This is a phase 3 trial based on phase 1 data. 3.2 Gy SIB in 15 fractions. So yeah, I'd like to. Also I loathe sequential boosts personally.
 
RealSimulD said:
Is anyone who is using it willing to let a brotha know the dose constraints ?
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It's in the appendix (VII) of the protocol I linked. Yay, a publicly available protocol because it's old as dirt at this point.
 
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