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They likely included some dcis too in some of those trials, but let's be honest, neither included significant numbers if either, yet dcis is treated as a "conditional" recommendation while chemo is not. There is plenty of single institution data to support it in dcis.
Ok so you can't explain why they decided to treat dcis and chemo differently.
Yes, data is generally nice when coming up with recommendations and guidelines.
Whole breast hypofractionation is a slam dunk. It is equally efficacious, less toxic, more cost effective, and less burdensome to patients. The data is compelling and there isn't a sniff of increased toxicity or worse outcomes compared to conventional fractionation in any situation.
I have lots of problems with lots of things in our specialty, but these guidelines are perfect.
You mean the guidelines that gave a "conditional recommendation" to hypo-fx DCIS despite the fact that DCIS is pre-malignant and is the exact same thing it was 20+ years ago in those trials, but a "strong recommendation" to hypo-fx patients based on data for chemo that no one uses anymore?
Welllllllllllll.... not exactly. But, the transition to ~2.65 Gy per day from <=2 Gy per day seems OK cancer-wise and even side-effects wise (w/ caveats). But hypofractionation via the use of >3 Gy a day has been shown to have more side effects. Is this an all-or-nothing situation (ie is toxicity not different from 1.8 Gy all the way to 3 Gy), or is toxicity a continuum? Everything I know about radiobiology suggests the latter versus the former. But the word on high has been given. All hail the word on high. Nevermind that Whelan's and START A/B don't meet the non-inferiority trial "guidelines" (read their stats sections) for late side effects as sample sizes have always been calc'd so as not to miss a local control difference. To detect small differences in late side effects in a non-inferiority trial would have taken more patients. Thus another unpopular but perniciously skeptical way of viewing the "hypofractionation guidelines" based on Whelan/START B is: we don't have solid non-inferiority statistical evidence that the side effects of new treatments are not worse than old ones, but the manifestly good economic/logistical effects and non-inferiority of cancer outcomes mean we should ignore the small possibility of worse side effects. I don't have boobs so I guess I'm OK with this.
I can not recall formal ASTRO guidelines re: fractionations, doses, etc. pre-2000. "Guidelinemania" is a relatively recent rad onc affectation. Guidelines can be cudgels which, if not used by our colleagues, certainly can be used that way by the insurance companies or the government. Guidelines in radiation oncology right now are en vogue not because they are a boon to patient care in the traditional sense IMHO. Re: the breast guidelines, e.g., we can not convincingly say that in using hypofx cancer outcomes are better (they're not worse) or side effects are better (again, they seem not worse). So what is the motive for publishing guidelines then. We aren't harming (via toxicity or oncologically) patients by using the standard treatment that has been in place for decades (in America). I am left with nothing but linear quadratic mathematics and my own biases, and now mildly shade-throwing guidelines, in thinking that 45/25 would be less side-effecty than 42.5/16. But economically and logistically the hypofractionation treatments hold promise, so that alone seems to be motivation enough to come out and trumpet a guideline. And plus too, it's breast... I must've missed the ASTRO guideline for hypofractionating Stage I/II smoking-associated glottic cancers but maybe they'll get around to it one day. In the meantime, if you want to hypofractionate glottic CA, I guess you have to read some studies and employ your own *gasp* clinical judgment.
One might, but then immediately, he/she would be "fraction-shamed" and called out for being a "greedy" PP'er from the bitter self-loathing peanut gallery that seems to enjoy trolling the SDN RO forum
Totally with you there. But, again, I believe in the spirit of intellectual honesty you have to look at the late effects data from START (shoulder data, yes of course they were expressly looking at ENI there but sometimes we glance the axilla with WBI etc etc) and Whelan's trial re: gr3 worse LC and say that your statement of "The data is compelling and there isn't a sniff of increased toxicity or worse outcomes compared to conventional fractionation in any situation" is not 100% true. Or is false. Either one. And in that same spirit of honesty I do not think we can make the case that standard fx has been overturned even w/ START's good cosmesis data.
"They" being Whelan/the Canadian group?
The big difference in LC seen at 10 years they published in NEJM in 2010 vanished with 12 years' data they published in 2014. Neat. I can click on the link but can't get full text to see how they explain that in their discussion section. But, my fears are assuaged and I can now discount all the previous data from their previous reports. Or, as MDACCRules might say... My fears are assuaged and I can now discount all the previous data from their previous reports! Ay yay yay!
Actual reimbursement rates paid to insurance companies are typically hidden by nondiscloure agreements at large centers.
The data is proprietary to the insurance company and not available to the public, unfortunately. It needs to be known how excessively expensive hospital-based radiation is, but APMs with case-based reimbursement might help solve the problem for us, as long as site-based payment parity is included.
You think negative data against NIH/NCI centers is going to make it in to the JCO?
They finally figured out that ship sailed a decade later than everyone else, it seems.
You think negative data against NIH/NCI centers is going to make it in to the JCO?
