First of all, I really respect the passion. I used to have that.
Secondly, I don’t see the breast swelling thing. That said, I am having a nice afternoon glass of wine with a bunch of lobbyists. Even so, to my eyes, it appears 40/15 has about a 200%+ risk of breast swelling versus 26/5 and about a 20% risk of more breast pain (patient reported). I certainly can stand to be corrected.
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Oh sure. It’s “telling” like how I mentioned earlier if there was a study showing 48 tire psi gave me a tenth of a miles per gallon better gas mileage than 47 psi.
Mostly agree.
Why ignore the second half of the table? Why ignore 'moderate' breast swelling which is 10x more likely numerically in 26Gy? Or phrased differently, why ignore that 87% of women receiving 40/15 will have NO breast swelling, as opposed to only 82% of those getting 26/5? Meaning 5% of women are sensing, on their own, that they are having breast swelling - why? So they can come in for 5 days instead of 15?
Why ignore statistically significant differences? I posted the whole table above? Why push a difference in 'marked' in either of those metrics, which you and I BOTH know are NOT statistically significant in favor of 26/5? Why purposefully be obtuse about the difference between numerically different and statistically different (understanding that there is a third metric, clinically significant) results?
When you say 'I don't see' do you mean that your anecdotal clinical practice overrules what was seen in a randomized trial of > 900 patients across the two relevant arms? Or that, if you crop half the table above, you don't see how the data supports my position? If the former, are you following these patients to 5 years to evaluate for the LATE toxicities? Or are you sending them back to their PCP/breast surgeon meaning you have no idea of the toxicities you are subjecting women to just because you want to.... I don't know, see them for 2 less OTVs? Compete with other Rad Onc facilities as to who can do the least amount of radiation treatments feasible?
In regards to the PSI comment you've made twice now - hell yeah if there was an advantage of 1/10th of a MPG of being a 48 PSI over 47 PSI I would certainly think it reasonable to maintain it. While I personally might not, I would completely understand someone who ensures their car tire's PSI is up to best recommended number. That's partially where recommended PSIs for tires/cars come from - are you saying you don't check your car tire's PSI ever? Or when the TPMS sensor goes off, you just ignore it, because, well, who cares about it?
That being said, glad we can agree on something, ANYTHING, in breast cancer. Contentious topic to say the least.
Idk if anyone was saying that you should be paternalistic and decide everything for the patient. Your main argument was on physician evaluation with most of the things listed being close to a significant p value, and some being a significant p value. The patients however did not seem to notice these same issues themselves and between the courses they were largely equal, even favoring the 5 fractions in a lot of the categories. The marked swelling was higher in the 40 gy regimen, but I assume you misspoke, there was a 0.5% risk of marked breast swelling in the 26Gy arm.
Another thing that was almost significant was the local control of the tumor, favoring the shorter fractionation, HR ~ 0.66, p nearing 0.05. That's a pretty bad toxicity, not killing the cancer. But I guess subjective. It's a breast trial, very small absolute differences can lead to a statistical significance, as many people have noted above. What is also statistically significant is the cost of treatment (nearly twice as expensive?), the length of treatment (thrice as long?), etc.
So, better tumor control (maybe), cheaper, more convenient, and patient's barely notice a difference in cosmetic toxicity (maybe about 2% higher in breast swelling, but almost significant in breast not smaller per patient report... coincidence?!?! IDK, probably.)
But at the end of the day treat your patients however you want. Interesting discussion between you two.
My entire post was my main argument. That includes both physician AND patient associated evaluations of their own situation. There is not a single toxicity, physician or patient preferenced, where the 5 fx regimen is favored in a statistically significant manner. Continuing to say 'well numerically it was better' is not appropriate and not a real discussion of what we should be talkign about with patients.
Again, fixating on only 'marked' swelling (when we know there is no statistically significant difference between 0.5 and 1.1) and ignoring moderate, and all the other things that the trialists ACTUALLY DID, hence why there is a statistically significant difference in patient related toxicity that is in favor of 40/15, is purposefully being obtuse. It is reading a trial and making a conclusion that is literally the opposite of the data. Seriously, I linked the whole table. Please read it. But if you do and you still can't see that there is no scenario where 40/15 is MORE toxic by either physician or patient preference compared to 26/5 , then we really can't continue this conversation in good faith.
Numerically improved LR - where is the p-value for HR 0.66? CI 0.38 - 1.16 - is this the graph you're referencing that supports your belief that 26/5 maybe has significantly improved LR rates to 40/15?
Might need to get your eyes checked.
Prioritizing 26/5 over 40/15 in WBI pts means that a Rad Onc is thinking about the following things, at absolute minimum (if you say all physician assessed toxicities are useless because a UK physician identified them - NEWSFLASH - UK health system is incentivized to say 'everything is fine'!), more than the patient in front of them:
1. The cost to the country of the treatment (IMO, bad)
2. The burden on the patient of coming in for more treatments (Good)
3. Wanting a lower risk of acute dermatitis maybe? Would like to see data p-values on this - I'm not sure how one gets 'better' than G1 dermatitis from 40/15...(Good). Although, acute side effects resolve.
4. Accepting a higher rate of late side effects like breast swelling (Bad). Late side effects do not improve.
Reasonable people can disagree, but I know what I would want for the women in my family who 'needed' WBI. And it wouldn't be 26/5. Can Wallnerus and Curb honestly say the same?
