Lymphoma: (HD or NHL)- role of RT in real life

[ramsesthenice]

Just goes to show for what is a "rare" cancer. Only about 13K cervical ca cases/year in the U.S. Assume 75% are brachy candidates. So about 10K new cerv brachy pts a year for the entire country. This would yield about 2 cervical cancer patients per rad onc per year in the U.S. So if you're seeing 6 unique a month, or 72 a year, that means you see roughly 30 times more cervical cancer patients than the "average" rad onc. There's *significant* variation in case loads and case makeup from rad onc to rad onc in the U.S. Emphasis on significant. This is what happens in oversupply!

That and there are only 2 sites in our midwestern state that do T&Os and I am the only one that does interstitial. Half of these people do their EBRT at other centers. Also, I should clarify, 6-8 unique GYN patients get implanted. Most are cervical, but probably a third are either vaginal primary or cuff recurrences. Might have oversold the number of cervical patients a bit in my first post.

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[RickyScott]

Just goes to show for what is a "rare" cancer. Only about 13K cervical ca cases/year in the U.S. Assume 75% are brachy candidates. So about 10K new cerv brachy pts a year for the entire country. This would yield about 2 cervical cancer patients per rad onc per year in the U.S. So if you're seeing 6 unique a month, or 72 a year, that means you see roughly 30 times more cervical cancer patients than the "average" rad onc. There's *significant* variation in case loads and case makeup from rad onc to rad onc in the U.S. Emphasis on significant. This is what happens in oversupply!

As always, you are too generous! with the 75%. my guess would be close to 50 if evaluated by aggressive gyn onc. I see abt one cervix per year and promptly refer them out.

 

[medgator]

Just goes to show for what is a "rare" cancer. Only about 13K cervical ca cases/year in the U.S. Assume 75% are brachy candidates. So about 10K new cerv brachy pts a year for the entire country. This would yield about 2 cervical cancer patients per rad onc per year in the U.S. So if you're seeing 6 unique a month, or 72 a year, that means you see roughly 30 times more cervical cancer patients than the "average" rad onc. There's *significant* variation in case loads and case makeup from rad onc to rad onc in the U.S. Emphasis on significant. This is what happens in oversupply!

Sending it out whenever i get it these days to the nearby larger center with in house brachy OR suite and MRI next to the dept...

No need for both me and the pt to suffer with my suboptimal rarely used Point A dose plan, even if it is done with a ct sim.

 

[ramsesthenice]

Sending it out whenever i get it these days to the nearby larger center with in house brachy OR suite and MRI next to the dept...

No need for both me and the pt to suffer with my suboptimal rarely used Point A dose plan, even if it is done with a ct sim.

I don't think i would mess with it at most community centers either. We have an OR brachy suite with in suite CT and the MRI is in the next room. More than that, we have dedicated physics and therapy support for brachy. We implanted a lady with a huge cuff recurrence with 6 interstitial needles using a hybrid applicator under general anesthesia this morning. I used both CT (for needle recon) and MRI (for target definition). Implant started at 7:58 and device removed at 11:08. Since everything was in house I was able to squeeze a consult and follow up in during that time. That only works if everyone is very familiar with their roles and does them frequently. Can quickly turn into a resource sink if only performing once in a while.

 

[evilbooyaa]

Ha. The MRgRT crowd seems set to eliminate T&O from cervical ca e.g. I seem to recall some data where people had found that EBRT is no substitute for brachy, but this is special EBRT from a linac that works with an MRI so I guess that's different.

Cervical cancer treatment world first at The Christie

Cervical cancer treatment world first at The Christie A Stockport woman is set to become the first ever patient in the world to be entirely treated for cervical cancer using a state-of-art radiotherapy treatment at The Christie NHS Foundation Trust.Karen Hall, 57, will be treated using the MR-gui...

www.pharmiweb.com

Coming back to add that seminoma is a perfect prototype/template on how RT disappears... roughly:
Treat very large area→treat smaller area→treat even smaller area→dose reduce→RT elimination vs systemics (or observation)

Pretty sure that Christie is just saying they do MRI-linac followed by MRI guided brachytherapy. Thought I saw a different post that suggested that it was the first patient being treated solely with MRI guidance. I think that press reslease is just poorly worded.

 

[OTN]

I don't think i would mess with it at most community centers either. We have an OR brachy suite with in suite CT and the MRI is in the next room. More than that, we have dedicated physics and therapy support for brachy. We implanted a lady with a huge cuff recurrence with 6 interstitial needles using a hybrid applicator under general anesthesia this morning. I used both CT (for needle recon) and MRI (for target definition). Implant started at 7:58 and device removed at 11:08. Since everything was in house I was able to squeeze a consult and follow up in during that time. That only works if everyone is very familiar with their roles and does them frequently. Can quickly turn into a resource sink if only performing once in a while.

My partner at our community practice does a ton of T+O and interstitial brachy. She does it in the OR across the street, and the patients are then transported to our center. Works pretty well, though she's been able to dial it in over the last 12 years, which helps.

 

[ramsesthenice]

My partner at our community practice does a ton of T+O and interstitial brachy. She does it in the OR across the street, and the patients are then transported to our center. Works pretty well, though she's been able to dial it in over the last 12 years, which helps.

There are some very high volume community centers. Academic or private, they key is you need to have adequate volume and efficient work flow. As scar pointed out, there are just not enough patients to justify the effort at most places. The physician is just one piece. I am very comfortable but if you put me in a center where therapy and physics have no experience there is no way I would put in the time and effort required to get everyone up to speed to do it 1-2x per year. To me, its like drywall. I HATE paying someone to do something I am capable of doing. But lets face it, I can spend a whole weekend doing something I rarely do or pay someone who does this professionally to do it better in an hour or 2.

 

[Mandelin Rain]

I'm seeing a IIA tomorrow who is being treated per H10 exactly.

2 cycles ABVD>PET(neg)>1 more cycle + 30Gy.

It's like seeing bigfoot.

 

[medgator]

I'm seeing a IIA tomorrow who is being treated per H10 exactly.

2 cycles ABVD>PET(neg)>1 more cycle + 30Gy.

It's like seeing bigfoot.

Loch ness lymphoma monster

 

[Palex80]

I'm seeing a IIA tomorrow who is being treated per H10 exactly.

2 cycles ABVD>PET(neg)>1 more cycle + 30Gy.

It's like seeing bigfoot.

Wait... Is that a favorable or unfavorable stage IIA? I am confused...

 

[RadOncDoc21]

Wait... Is that a favorable or unfavorable stage IIA? I am confused...

I’m going to guess unfavorable since 30 Gy. It’s been like 5 yrs since I’ve seen one so I def could be wrong.

 

[Mandelin Rain]

Wait... Is that a favorable or unfavorable stage IIA? I am confused...

3 nodal sites

 

[Palex80]

3 nodal sites

All good then!

 

[Neuronix]

Pretty sure that Christie is just saying they do MRI-linac followed by MRI guided brachytherapy. Thought I saw a different post that suggested that it was the first patient being treated solely with MRI guidance. I think that press reslease is just poorly worded.

We've been doing some cases with MRI-linac and MRI guided brachytherapy for years.

 

[Krukenberg]

We've been doing some cases with MRI-linac and MRI guided brachytherapy for years.

Recently heard that one of the MD Anderson affiliate hospitals (non-academic) is getting an MR-linac. Have the suits figured out a business case for the MR-linac?

 

[Neuronix]

Recently heard that one of the MD Anderson affiliate hospitals (non-academic) is getting an MR-linac. Have the suits figured out a business case for the MR-linac?

A number of private places are installing them now. I'm regularly getting calls from non-academics these days, and certainly Viewray is trying to highlight the non-academic places that have bought them. We'd like to put a second MRI-Linac in a satellite.

 

[evilbooyaa]

We've been doing some cases with MRI-linac and MRI guided brachytherapy for years.

First case in the UK treated with MRI + MRI

 

[Krukenberg]

A number of private places are installing them now. I'm regularly getting calls from non-academics these days, and certainly Viewray is trying to highlight the non-academic places that have bought them. We'd like to put a second MRI-Linac in a satellite.

Wow surprised to hear that. What’s the business case? My understanding is it demands a lot of physician time to be doing adaptive treatment

 

[Neuronix]

Wow surprised to hear that. What’s the business case? My understanding is it demands a lot of physician time to be doing adaptive treatment

Honestly, I don't know. I've already written how I feel about it giving me as the doc more professional work RVUs when doing SBRT. It also allows me to treat SBRT with high quality based on excellent motion management and soft tissue contrast and setup every day without need for fiducials (and frankly fiducial based setups of moving targets with respiratory management is complicated too).

How the company appeases the private practice guys (like the ones in this forum who pile on me every time MRI-linac gets mentioned), I have no idea. In the conversations I have, other docs don't really really ask me about how to make the financials work.

I do think a large part of this is halo effect and keeping up with the competition. It's the same thing in proton in my opinion, which is far more costly than MRI-linac.

 

[medgator]

Wow surprised to hear that. What’s the business case? My understanding is it demands a lot of physician time to be doing adaptive treatment

Could be private groups staffing loaded hospitals with an endowment too big to know what to do with it

 

[evilbooyaa]

Wow surprised to hear that. What’s the business case? My understanding is it demands a lot of physician time to be doing adaptive treatment

I mean in some situations it is a better treatment. Not all PPs cut corners just for the finances. Yes it's unlikely to be the only Linac at a facility, but if you have a workhorse and want something to use for advertising against the competition in the area (or to keep up with the competition in the area) and can't spring for protons, MRI-linac isn't unreasonable...

Although, I do not know what the cost of one of those things is.

 

[RickyScott]

I mean in some situations it is a better treatment. Not all PPs cut corners just for the finances. Yes it's unlikely to be the only Linac at a facility, but if you have a workhorse and want something to use for advertising against the competition in the area (or to keep up with the competition in the area) and can't spring for protons, MRI-linac isn't unreasonable...

Although, I do not know what the cost of one of those things is.

I think the machine is over 7 million and need a larger vault than typical for linac.

 

[Palex80]

There is definetely a role for MRI-linacs. The way I see it however, you can only justify buying one if you are:
a) in a large academic center with multiple linacs - if you are at MD Anderson you are always going to have enough pancreatic or cervical cancer to treat with that machine.
b) in a network of private practices and have a firm committment to get referrals from your partners for certain treatments - see a) (but probably tougher to achieve).
c) in the excellent position to have a very high case-load of "special indications", which may arise from the fact that other competing specialities are not well established in the area you practice - this is basically the case if you do not have a thoracic surgeon that can do sublobar VATS and get referrals for peripheral NSCLC (although only a fraction of those patients will probably experience a clinical nenefit by being treated on an MRI Linac, treating them with CBCT-IGRT will result in larger volumes, but probably not much more toxicity), another example would be if you do not have eager interventional radiologists that perform RFA in liver metastasis and get many referrals for liver SBRT (an MRI Linac will make liver SBRT a lot easier).

If you look at the published times of patients on the couch for MRI gated treated, for example in SBRT of peripheral NSCLC, you will see that the times are significantly longer than those with CBCT-IGRT. One potential benefit is that you can cut down the number of fractions with an MRI Linac, but still I am not convinced that a business model actually works out (e.g. treatment with an MRI Linac is profitable), you will need both more physician (wo)manpower to operate it and higher investment costs. I also presume that with growing complexity the machine may also be more prone to downtime and may requite more QA.

 

[fiji128]

Not to beat a dead horse but noticed this in JCO today.

To improve curability and limit long-term adverse effects for newly diagnosed early-stage (ES), unfavorable-risk Hodgkin lymphoma.
METHODS

In this multicenter study with four sequential cohorts, patients received four cycles of brentuximab vedotin (BV) and doxorubicin, vinblastine, and dacarbazine (AVD). If positron emission tomography (PET)-4–negative, patients received 30-Gy involved-site radiotherapy in cohort 1, 20-Gy involved-site radiotherapy in cohort 2, 30-Gy consolidation-volume radiotherapy in cohort 3, and no radiotherapy in cohort 4. Eligible patients had ES, unfavorable-risk disease. Bulk disease defined by Memorial Sloan Kettering criteria (> 7 cm in maximal transverse or coronal diameter on computed tomography) was not required for cohorts 1 and 2 but was for cohorts 3 and 4. The primary end point was to evaluate safety for cohort 1 and to evaluate complete response rate by PET for cohorts 2-4.
RESULTS

Of the 117 patients enrolled, 116 completed chemotherapy, with the median age of 32 years: 50% men, 98% stage II, 86% Memorial Sloan Kettering–defined disease bulk, 27% traditional bulk (> 10 cm), 52% elevated erythrocyte sedimentation rate, 21% extranodal involvement, and 56% > 2 involved lymph node sites. The complete response rate in cohorts 1-4 was 93%, 100%, 93%, and 97%, respectively. With median follow-up of 3.8 years (5.9, 4.5, 2.5, and 2.2 years for cohorts 1-4), the overall 2-year progression-free and overall survival were 94% and 99%, respectively. In cohorts 1-4, the 2-year progression-free survival was 93%, 97%, 90%, and 97%, respectively. Adverse events included neutropenia (44%), febrile neutropenia (8%), and peripheral neuropathy (54%), which was largely reversible.
CONCLUSION

BV + AVD × four cycles is a highly active and well-tolerated treatment program for ES, unfavorable-risk Hodgkin lymphoma, including bulky disease. The efficacy of BV + AVD supports the safe reduction or elimination of consolidative radiation among PET-4–negative patients.

https://ascopubs.org/doi/full/10.1200/JCO.21.00108

 

[TheWallnerus]

Not to beat a dead horse but noticed this in JCO today.

To improve curability and limit long-term adverse effects for newly diagnosed early-stage (ES), unfavorable-risk Hodgkin lymphoma.
METHODS

In this multicenter study with four sequential cohorts, patients received four cycles of brentuximab vedotin (BV) and doxorubicin, vinblastine, and dacarbazine (AVD). If positron emission tomography (PET)-4–negative, patients received 30-Gy involved-site radiotherapy in cohort 1, 20-Gy involved-site radiotherapy in cohort 2, 30-Gy consolidation-volume radiotherapy in cohort 3, and no radiotherapy in cohort 4. Eligible patients had ES, unfavorable-risk disease. Bulk disease defined by Memorial Sloan Kettering criteria (> 7 cm in maximal transverse or coronal diameter on computed tomography) was not required for cohorts 1 and 2 but was for cohorts 3 and 4. The primary end point was to evaluate safety for cohort 1 and to evaluate complete response rate by PET for cohorts 2-4.
RESULTS

Of the 117 patients enrolled, 116 completed chemotherapy, with the median age of 32 years: 50% men, 98% stage II, 86% Memorial Sloan Kettering–defined disease bulk, 27% traditional bulk (> 10 cm), 52% elevated erythrocyte sedimentation rate, 21% extranodal involvement, and 56% > 2 involved lymph node sites. The complete response rate in cohorts 1-4 was 93%, 100%, 93%, and 97%, respectively. With median follow-up of 3.8 years (5.9, 4.5, 2.5, and 2.2 years for cohorts 1-4), the overall 2-year progression-free and overall survival were 94% and 99%, respectively. In cohorts 1-4, the 2-year progression-free survival was 93%, 97%, 90%, and 97%, respectively. Adverse events included neutropenia (44%), febrile neutropenia (8%), and peripheral neuropathy (54%), which was largely reversible.
CONCLUSION

BV + AVD × four cycles is a highly active and well-tolerated treatment program for ES, unfavorable-risk Hodgkin lymphoma, including bulky disease. The efficacy of BV + AVD supports the safe reduction or elimination of consolidative radiation among PET-4–negative patients.

https://ascopubs.org/doi/full/10.1200/JCO.21.00108

“Nice.” - local med onc

 

[Mandelin Rain]

4 armed, 100 patient trial is wild.

 

[Ray D. Ayshun]

Seems inevitable, though weird trial. Thought hd17 already kinda answered this.

 

[fiji128]

At what point does the lymphoma section get omitted from the oral boards? Or does it remain as a vestigial organ like testicular and peds?

 

[Palex80]

At what point does the lymphoma section get omitted from the oral boards? Or does it remain as a vestigial organ like testicular and peds?

 

[TheWallnerus]

Meanwhile…

Role of radiotherapy to bulky sites of advanced Hodgkin lymphoma treated with ABVD: final results of FIL HD0801 trial - PubMed

The role of consolidation radiotherapy (RT) for bulky lesions is controversial in patients with advanced-stage Hodgkin lymphoma who achieve complete metabolic response (CMR) after doxorubicin, bleomycin, vinblastine, dacarbazine (ABVD)-based chemotherapy. We present the final results of the...

pubmed.ncbi.nlm.nih.gov

 

[thecarbonionangle]

Meanwhile…

Role of radiotherapy to bulky sites of advanced Hodgkin lymphoma treated with ABVD: final results of FIL HD0801 trial - PubMed

The role of consolidation radiotherapy (RT) for bulky lesions is controversial in patients with advanced-stage Hodgkin lymphoma who achieve complete metabolic response (CMR) after doxorubicin, bleomycin, vinblastine, dacarbazine (ABVD)-based chemotherapy. We present the final results of the...

pubmed.ncbi.nlm.nih.gov

“However, the sample size was under-powered to detect a benefit of 10% or less, keeping open the question on potential, more limited, role of RT in this setting.”

Crap study but will still be used to avoid that big bad radiation. ABVD has no toxicities you know!

 

[Gfunk6]

View attachment 340504

We'll always have prostate.

 

[Lamount]

Meanwhile…

Role of radiotherapy to bulky sites of advanced Hodgkin lymphoma treated with ABVD: final results of FIL HD0801 trial - PubMed

The role of consolidation radiotherapy (RT) for bulky lesions is controversial in patients with advanced-stage Hodgkin lymphoma who achieve complete metabolic response (CMR) after doxorubicin, bleomycin, vinblastine, dacarbazine (ABVD)-based chemotherapy. We present the final results of the...

pubmed.ncbi.nlm.nih.gov

I'm not gonna lie... I don't know if I have ever encountered this specific circumstance. DLBCL all the time, but not HD

 

[gmsquid]

Really? 2 year EFS in a 110 patient Hodgkins trial with a 20% benefit? Who let this trial design happen. The time point, the sample size, the estimated benefit. Ludicrous.

This is why physicians need to understand statistics. We practice bad medicine because we don’t

 

[Palex80]

Really? 2 year EFS in a 110 patient Hodgkins trial with a 20% benefit? Who let this trial design happen. The time point, the sample size, the estimated benefit. Ludicrous.

This is why physicians need to understand statistics. We practice bad medicine because we don’t

 

[ramsesthenice]

This is why physicians need to understand statistics. We practice bad medicine because we don’t

They understand it fine. They knew how many patients they could get and asked a statistician to make it work. The shame should be on their PRMC and IRB for letting the trial proceed and then on the journal to publish it. There are at least 3-4 levels of failure here ☹️

 

[thesauce]

Can't remember the last time I got an HD referral... Do see a decent amount of NHL though... Usually early stage low grade, or high grade with combined therapy for cure or consolidation

Shocked that you are seeing these referrals.

The medoncs here seem to make up whatever explanation they can to avoid RT. It is not data driven at all and does not follow NCCN.

 

[TheWallnerus]

Shocked that you are seeing these referrals.

The medoncs here seem to make up whatever explanation they can to avoid RT. It is not data driven at all and does not follow NCCN.

Sad/provocative...

The decrease in RT utilization in NHL over the last two decades has been associated with an almost doubling of NHL survival.

"We are one drug away from being out of the lymphoma game."
- said to me by Eli Glatstein in 2000

 

[medgator]

Shocked that you are seeing these referrals.

The medoncs here seem to make up whatever explanation they can to avoid RT. It is not data driven at all and does not follow NCCN.

Oh, they try stuff sometimes... definitely have gotten a few low grade NHLs/MALTS that have seen rituxan or benda first and then invariably fail locally.

 

[fiji128]

We are just not players in lymphoma anymore. We get sent some patient when a med onc sees fit. The med oncs own these patients and they don't care what we have to say.

I think a lot of this comes from the way RT was given in pre IFRT/ISRT 2D/3D era. I've seen a few patients that were treated in the 1980's as young adults and they will tell you how much the RT really messed them up with long term side effects. This is why med oncs will do anything to not send these patients to us. I'm not saying the treatment delivered was wrong for the time but this is were the extreme anti RT bias is coming from.

At this point in time, I really wonder what a radiation lymphoma service looks like a top institution these days. What percent of stage I/II lymphomas even get RT anymore as comparted to 20 years ago? It's just not a battle we are going to win.

 

[Lamount]

We are just not players in lymphoma anymore. We get sent some patient when a med onc sees fit. The med oncs own these patients and they don't care what we have to say.

I think a lot of this comes from the way RT was given in pre IFRT/ISRT 2D/3D era. I've seen a few patients that were treated in the 1980's as young adults and they will tell you how much the RT really messed them up with long term side effects. This is why med oncs will do anything to not send these patients to us. I'm not saying the treatment delivered was wrong for the time but this is were the extreme anti RT bias is coming from.

At this point in time, I really wonder what a radiation lymphoma service looks like a top institution these days. What percent of stage I/II lymphomas even get RT anymore as comparted to 20 years ago? It's just not a battle we are going to win.

I see a fair amount of lymphoma in my practice -in all honesty, probably a little more than I would like. I know this isn't the case in many places...

It's funny that RT is seen as more toxic because when I see patients who have had upfront chemo, I usually tell them that the hard part is over. I will say something like "I am going to tell you a bunch of potential side effects, but my most frequent complaint is actually 'Hey Doc, are you sure this is working because I don't feel ANYTHING'"

 

[fiji128]

Ya treating patients with modern techniques and doses is super non toxic compared to the chemo but I still rarely get the consults.

 

[thesauce]

Sad/provocative...

The decrease in RT utilization in NHL over the last two decades has been associated with an almost doubling of NHL survival.

"We are one drug away from being out of the lymphoma game."
- said to me by Eli Glatstein in 2000

But you can’t possibly be making the point that it was because of the reduced RT that this is happening? Yes survival is improving in this cancer and many many others. The systemic therapy is getting better and so is the RT. And in most cases you do not have to choose

 

[TheWallnerus]

But you can’t possibly be making the point that it was because of the reduced RT that this is happening? Yes survival is improving in this cancer and many many others. The systemic therapy is getting better and so is the RT. And in most cases you do not have to choose

I can possibly be making the point. You have a reduction of RT utilization by half in a disease. And survival for that disease doubles. It’s associative. Is it it causative? At the very least, trending toward elimination of RT from NHL would not seem to affect overall population NHL survival negatively. That the RT is getting better… do you mean by irradiating smaller areas, ie ISRT vs IFRT etc?

Thus
Q = k * V^-1

Where Q is quality of the RT (as Q gets bigger the RT gets better) and V is volume irradiated. Q approaches infinity as V approaches zero!

 

[jondunn]

That’s asinine.

Survival in metastatic NSCLC has vastly lmproved in the last ten years. Also in the last ten years there has been a exponential growth in lung cancers being treated with an MR Linac.


I guess there’s an association!

 

[medgator]

That’s asinine.

Survival in metastatic NSCLC has vastly lmproved in the last ten years. Also in the last ten years there has been a exponential growth in lung cancers being treated with an MR Linac.


I guess there’s an association!

How much of the country is seeing NSCLC treated with an MR Linac? At least pick a strawman that makes sense.

 

[jondunn]

How much of the country is seeing NSCLC treated with an MR Linac? At least pick a strawman that makes sense.

sort of the point. I could also say that TikTok has soared in popularity over the last 5 years. i guess that's also associated with an increase in survival for metastatic NSCLC patients.

making any sort of judgement on an 'association' is quite spurious and the person who posted that is fully aware of this.


this idea is about 100 times worse than the worst of the worst NCDB survival versus radiation papers.

 

[TheWallnerus]

sort of the point. I could also say that TikTok has soared in popularity over the last 5 years. i guess that's also associated with an increase in survival for metastatic NSCLC patients.

making any sort of judgement on an 'association' is quite spurious and the person who posted that is fully aware of this.


this idea is about 100 times worse than the worst of the worst NCDB survival versus radiation papers.

Associations... are controversial... I will grant you that. Which are real; which are not? I will say that receipt of RT being associated with worse survival is a signal we have seen in a few other settings so it's not spurious to ponder it when you see the signal in other places. I have not seen MR-Linacs associated with increased survival. Yet.

Smoking is associated with lung cancer
USPSTF screening recommendations are associated with decreased prostate cancer survival
Surgery is associated with better survival vs RT in high risk prostate cancer
Mastectomy is associated with worse survival versus BCS+RT

 

[Lamount]

I can possibly be making the point. You have a reduction of RT utilization by half in a disease. And survival for that disease doubles. It’s associative. Is it it causative? At the very least, trending toward elimination of RT from NHL would not seem to affect overall population NHL survival negatively. That the RT is getting better… do you mean by irradiating smaller areas, ie ISRT vs IFRT etc?

Thus
Q = k * V^-1

Where Q is quality of the RT (as Q gets bigger the RT gets better) and V is volume irradiated. Q approaches infinity as V approaches zero!

One can draw a similar conclusion showing that having a normal BMI is harmful for NHL patients. The BMI of patients with NHL today is more likely to be in the "overweight" or "obese" range than it was 40 years ago (as is the case for non-NHL patients as well). Survival has gone up over that same 40 years.

At the very least, eating a box of cookies every night would not seem to affect the overall population of NHL survival negatively... right?

 

[TheWallnerus]

One can draw a similar conclusion showing that having a normal BMI is harmful for NHL patients. The BMI of patients with NHL today is more likely to be in the "overweight" or "obese" range than it was 40 years ago (as is the case for non-NHL patients as well). Survival has gone up over that same 40 years.

You're not wrong.