Breast WBI Fractionation discussion

[scarbrtj]

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Med students have already figured this out. Rad Onc is now one of the least competitive specialty in medicine based on US MDs to available spots.

The shocking part is the total lack of an appropriate response by "leadership."

Meanwhile I get a noticed on Twitter from Mayo clinic that they can now do breast RT in 3 fractions! (It wasn't disclosed how that is a huge benefit for their hospital system if they can keep patients in Rochester for treatment). If KO is really advocating for this, why not decrease your residency complement by 50% to reflect this new future?

Forget where I read it but something like only a third of American Stage I br Ca patients getting hypofrac. People don’t realize how profound a full shift from std frac in breast to, say, 5 fx schedules will be. Much less 3 fx. Breast is rad onc bread and butter. It (post lump RT vs MRM) caught stride in the 1990s and to some extent we are still riding that wave. Six weeks to 5 fx is huge. Like going from telegraphy to iPhone. Pony express to jet. Except the change is happening overnight, or can or should. ASTRO and leadership totally head in sand about this.

 

[OTN]

Forget where I read it but something like only a third of American Stage I br Ca patients getting hypofrac. People don’t realize how profound a full shift from std frac in breast to, say, 5 fx schedules will be. Much less 3 fx. Breast is rad onc bread and butter. It (post lump RT vs MRM) caught stride in the 1990s and to some extent we are still riding that wave. Six weeks to 5 fx is huge. Like going from telegraphy to iPhone. Pony express to jet. Except the change is happening overnight, or can or should. ASTRO and leadership totally head in sand about this.

I think there's still an argument for 16 fractions +/- boost for cosmetic reasons. While we haven't seen it yet, based on the available data we do have thus far, I would be willing to bet UK/Canadian hypofx would win out over 3 or 5 fx breast RT. It's why I'm very confident continuing to offer 16+5 rather than trying to move to 5 fx total.

Edit: When it comes to Mayo, let's keep in mind that Rochester, Scottsdale, and Jacksonville all have residents. I would argue that Scottsdale and Jacksonville should not exist at all as training programs.

 

[thecarbonionangle]

I think there's still an argument for 16 fractions +/- boost for cosmetic reasons. While we haven't seen it yet, based on the available data we do have thus far, I would be willing to bet UK/Canadian hypofx would win out over 3 or 5 fx breast RT. It's why I'm very confident continuing to offer 16+5 rather than trying to move to 5 fx total.

Edit: When it comes to Mayo, let's keep in mind that Rochester, Scottsdale, and Jacksonville all have residents. I would argue that Scottsdale and Jacksonville should not exist at all as training programs.

The Italian update looked pretty pretty pretty good, as Larry David would say

 

[OTN]

The Italian update looked pretty pretty pretty good, as Larry David would say

True- however, the breast surgeons in my group will never perform a non-oncoplastic lumpectomy. Given that every fellowship-trained breast surgeon I've ever worked with only does oncoplastic lumpectomies, and given that the patient-driven market is moving towards fellowship-trained breast surgeons for breast cancer surgery (at least in my neck of the woods it is), the Italian-style APBI won't be applicable to the majority of my patients.

 

[Ray D. Ayshun]

I think there's still an argument for 16 fractions +/- boost for cosmetic reasons. While we haven't seen it yet, based on the available data we do have thus far, I would be willing to bet UK/Canadian hypofx would win out over 3 or 5 fx breast RT. It's why I'm very confident continuing to offer 16+5 rather than trying to move to 5 fx total.

Edit: When it comes to Mayo, let's keep in mind that Rochester, Scottsdale, and Jacksonville all have residents. I would argue that Scottsdale and Jacksonville should not exist at all as training programs.

Is there a 16+5 vs 15+5 debate? (serious question). I do 16 if no boost, and 15 if i'm doing a 5 fx boost.

 

[thecarbonionangle]

Is there a 16+5 vs 15+5 debate? (serious question). I do 16 if no boost, and 15 if i'm doing a 5 fx boost.

Yes serious contentious debate. Both excellent but both sides dug in heels.

 

[RadOncDoc21]

Is there a 16+5 vs 15+5 debate? (serious question). I do 16 if no boost, and 15 if i'm doing a 5 fx boost.

That one extra fraction can be the difference between life and death in this rad onc world we live in. I was a 15 + 5, now I have switched over to 16 + 5 because I need to feed my family!

 

[evilbooyaa]

Is there a 16+5 vs 15+5 debate? (serious question). I do 16 if no boost, and 15 if i'm doing a 5 fx boost.

I will throw my hat in the ring as a 16 + 4 fx (250cGy/fx) booster (if boost is necessary), as a 3rd arm that we can all fight over. Never understood 2.66Gy/fx for whole breast and then slowing down on the boost at 2Gy/day. Could probably even do 3.33/fx if really needed to get done in 19 (say started on a Tuesday).

Same number of OTVs too, so you're not missing out on billing.

 

[Ray D. Ayshun]

That one extra fraction can be the difference between life and death in this rad onc world we live in. I was a 15 + 5, now I have switched over to 16 + 5 because I need to feed my family!

No extra prof fees really. If you could do 15 + 8, would be a boon.

 

[RadOncDoc21]

No extra prof fees really. If you could do 15 + 8, would be a boon.

Man, no wonder I’m still poor!

 

[Burt Radnolds]

I replicate START (15+5) as it had the most compelling evidence for improved cosmesis with zero detriment towards local control (slightly favored hypofx actually). I actually don't understand how anyone could given 16 over 15 after closely reviewing START.

 

[Gfunk6]

I replicate START (15+5) as it had the most compelling evidence for improved cosmesis with zero detriment towards local control (slightly favored hypofx actually). I actually don't understand how anyone could given 16 over 15 after closely reviewing START.

One more fraction = more money

It ain't rocket science

 

[scarbrtj]

I replicate START (15+5) as it had the most compelling evidence for improved cosmesis with zero detriment towards local control (slightly favored hypofx actually). I actually don't understand how anyone could given 16 over 15 after closely reviewing START.

If you wanna follow this line of logic (which I don’t agree with), then if you closely review START I don’t understand how anyone could use 15 instead of 13. Or why you would ever use a boost.

 

[fiji128]

I’ve been doing 40.05 in 15 fractions +/- 10 Gy in 4 fractions boost for years. Zero issues. Won’t go lower until evicore makes me.

 

[theradiator]

I’ve been doing 40.05 in 15 fractions +/- 10 Gy in 4 fractions boost for years. Zero issues. Won’t go lower until evicore makes me.

42.56 + 10 Gy in 5 fraction boost consistent with NCCN guidelines. 40 Gy + 10 Gy in 4 fractions also NCCN approved. Nothing really to argue about here!

 

[Gfunk6]

28 fractions? No. 25 fractions? No. 16 fractions? No. 15 fractions? No. 5 fractions? No. 1 fraction?

No whammy, no whammy, no whammy, STOP!

It's all just a race to zero.

 

[Ray D. Ayshun]

28 fractions? No. 25 fractions? No. 16 fractions? No. 15 fractions? No. 5 fractions? No. 1 fraction?

No whammy, no whammy, no whammy, STOP!

It's all just a race to zero.

When I'm giving 2 gy x 2 for an indolent lymphoma bc it's evidence-based, deep down, I know I should be giving 4 Gy x 1, or even something crazy like 5 gy x 1. Of course, there's reassortment and all...

 

[DebtRising]

Whenever I’m feeling down, I read this board and immediately cheer up. Not about my future of course, but the moment feels better.

 

[Burt Radnolds]

If you wanna follow this line of logic (which I don’t agree with), then if you closely review START I don’t understand how anyone could use 15 instead of 13. Or why you would ever use a boost.

I was mostly baiting and you took it, let's roll with it! I omit boost all the time depending on risk factors. START showed better cosmesis and was a much bigger trial rather than Whelan which was smaller and just showed equivalence. I know which one I would want. Do you know what START stands for? UK STAndardization of breast RadioTherapy. Do you know what national standard came out of the several fractionations they used? 40.05/15. All seems pretty logical to me.

 

[RadOncDoc21]

This sounds like my weekly breast tumor board debates between my rad onc competitors. We all know all fractionations lead to similar outcomes, yet we fight and in the end we all lose. I wonder what the equivalent arguments would be amongst surgeons.

 

[fiji128]

This sounds like my weekly breast tumor board debates between my rad onc competitors. We all know all fractionations lead to similar outcomes, yet we fight and in the end we all lose. I wonder what the equivalent arguments would be amongst surgeons.

The best brand of scalpel to use?

 

[kimplera]

This sounds like my weekly breast tumor board debates between my rad onc competitors. We all know all fractionations lead to similar outcomes, yet we fight and in the end we all lose. I wonder what the equivalent arguments would be amongst surgeons.

vicryl vs nylon vs silk - the difference is everyone still gets surgery
perhaps the trials we really should have run are tomotherapy vs. truebeam vs. oncor - then the winner is radiation

 

[RadOncDoc21]

vicryl vs nylon vs silk - the difference is everyone still gets surgery
perhaps the trials we really should have run are tomotherapy vs. truebeam vs. oncor - then the winner is radiation

See! This is the leadership we all desperately need!

 

[Burt Radnolds]

This sounds like my weekly breast tumor board debates between my rad onc competitors. We all know all fractionations lead to similar outcomes, yet we fight and in the end we all lose. I wonder what the equivalent arguments would be amongst surgeons.

We lose by looking for the best outcomes for our patients? Man I've been doing this all wrong! Totally agree though that this is hair splitting, but getting in a clinical debate seemed more fun that the usual wallowing in despair of our collective plight, even if me and scarb are just going through the motions of a debate we've had 3 or 4 times already.

 

[RadOncDoc21]

We lose by looking for the best outcomes for our patients? Man I've been doing this all wrong! Totally agree though that this is hair splitting, but getting in a clinical debate seemed more fun that the usual wallowing in despair of our collective plight, even if me and scarb are just going through the motions of a debate we've had 3 or 4 times already.

The argument goes I can do what you do but in less treatments with similar/slightly better results(insert my favorite study). The counter argument is you can do better then me with more but similar/slightly better results (insert your favorite study). All the other docs listen to us argue while in the background we are losing the war regarding applying these results to patients as we continue to “improve” upon those studies that all give similar/slightly better results (insert new academic study) stating we don’t even need radiation (med onc smiles).

 

[scarbrtj]

The argument goes I can do what you do but in less treatments with similar/slightly better results(insert my favorite study). The counter argument is you can do better then me with more but similar/slightly better results (insert your favorite study). All the other docs listen to us argue while in the background we are losing the war regarding applying these results to patients as we continue to “improve” upon those studies that all give similar/slightly better results (insert new academic study) stating we don’t even need radiation (med onc smiles).

 

[scarbrtj]

Listening to the great podcast “You’re Wrong About...” today the girl and the guy offhandedly observed that in academia you give a lot in hopes of being the tiny percent that get a little. Oh my how much we have given to fraction reduction in breast cancer. I want to do a trial where post lumpectomy I apply a single drop of Tc-99m to the nipple and report a 5y LC of 99%. Radioisotopes allow a 77470 charge, I have heard.

 

[Ray D. Ayshun]

Listening to the great podcast “You’re Wrong About...” today the girl and the guy offhandedly observed that in academia you give a lot in hopes of being the tiny percent that get a little. Oh my how much we have given to fraction reduction in breast cancer. I want to do a trial where post lumpectomy I apply a single drop of Tc-99m to the nipple and report a 5y LC of 99%. Radioisotopes allow a 77470 charge, I have heard.

Imagining this makes me laugh

 

[RSAOaky]

28 fractions? No. 25 fractions? No. 16 fractions? No. 15 fractions? No. 5 fractions? No. 1 fraction?

No whammy, no whammy, no whammy, STOP!

It's all just a race to zero.

As I have said before, academics realized long ago that a far easier path to academic success was to ask questions we already know the answer to. Is 8 divided by 8 equal to 4 divided by 4? "ASTRO Plenary: Radiation Oncologists Confirm Math." This is great for our patients, sure, but the problem is the amount of time and effort expended on this that could be better used asking new or remotely interesting questions, which would probably be better for our patients. Just look at omission of radiation in the elderly. I don't know about you guys, but all but my most voluptuous patients tolerate 15 fractions of whole breast treatment phenomenally well so why do we put all of this effort into convincing ourselves and our patients that a 50% reduction in local recurrence is not clinically meaningful to someone? We're willing to do a whole lot more to people for a whole lot less and our medical oncology colleagues wouldn't even think twice about it.

 

[RadOncDoc21]

As I have said before, academics realized long ago that a far easier path to academic success was to ask questions we already know the answer to. Is 8 divided by 8 equal to 4 divided by 4? "ASTRO Plenary: Radiation Oncologists Confirm Math." This is great for our patients, sure, but the problem is the amount of time and effort expended on this that could be better used asking new or remotely interesting questions, which would probably be better for our patients. Just look at omission of radiation in the elderly. I don't know about you guys, but all but my most voluptuous patients tolerate 15 fractions of whole breast treatment phenomenally well so why do we put all of this effort into convincing ourselves and our patients that a 50% reduction in local recurrence is not clinically meaningful to someone? We're willing to do a whole lot more to people for a whole lot less and our medical oncology colleagues wouldn't even think twice about it.

Right and now that ship has sunk even if patients really want treatment, we won’t get the opportunity to even discuss treatment with them even though there is a benefit. Imagine if med onc couldn’t flaunt their 3% decrease in PFS benefit for their 100k drug?

 

[scarbrtj]

"ASTRO Plenary: Radiation Oncologists Confirm Math."

On BEDs, rad oncs love to confirm math; but re: supply/demand, pretty hit and miss. (Linear quadratic tho... still undisproven.) So as much as I'd like to see this in a plenary, more likely to be "Radiation Oncologists Pick and Choose Which Maths to Confirm."

 

[RadOncDoc21]

On BEDs, rad oncs love to confirm math; but re: supply/demand, pretty hit and miss. (Linear quadratic tho... still undisproven.) So as much as I'd like to see this in a plenary, more likely to be "Radiation Oncologists Pick and Choose Which Maths to Confirm."

 

[evilbooyaa]

I have moved an off-topic branching into its own thread to avoid cluttering the other thread. Carry on.

 

[Mandelin Rain]

If you prescribe 16 and I prescribe 15, you are a money hungry, malicious charlatan.

(I prescribe 16, though boost in 4 if needed)

 

[evilbooyaa]

This 16 vs 15 discussion is all for naught as we're all gonna be prescribing 5 in daily fractions for WBI once 10-year data from fast-forward come out anyways

 

[scarbrtj]

This 16 vs 15 discussion is all for naught as we're all gonna be prescribing 5 in daily fractions for WBI once 10-year data from fast-forward come out anyways

I'm just gonna tote my linac-on-wheels into the O.R. and out-compete the 5 fraction guys with 1 fx. It'll all pay the same under APM anyways.

 

[Burt Radnolds]

So for real though, all joking and potshots and smirking aside, can someone tell me an evidence based reason for 16 over 15? I've given my reasons for 15, and I'm willing to hear counterpoints, but have not actually heard anyone defend their viewpoint other than "this is what I do".

 

[Mandelin Rain]

So for real though, all joking and potshots and smirking aside, can someone tell me an evidence based reason for 16 over 15? I've given my reasons for 15, and I'm willing to hear counterpoints, but have not actually heard anyone defend their viewpoint other than "this is what I do".

I smell randomized trial......

 

[evilbooyaa]

So for real though, all joking and potshots and smirking aside, can someone tell me an evidence based reason for 16 over 15? I've given my reasons for 15, and I'm willing to hear counterpoints, but have not actually heard anyone defend their viewpoint other than "this is what I do".

Because they haven't been directly compared to one another? The BED of 2.66 x 16 is closer to 50/2 than 2.67 x 15.

I like Canadians more than I like the British. Canadians have given us Palma and the Toronto Raptors. UK has given us Jayant Vaidya and Brexit.

I find myself thinking that folks in the UK are driven by a perverse interest to minimize number of fractions at all costs, so as to the cut the costs to their failing NHS system, and they want us all to be on their level of dissatisfaction of lives as doctors. Beyond START, there's FAST and now FAST FORWARD.

Canadians seem to be less so in that vein, and more interested in expanding indications for radiation or more technical forms of RT (see Palma, Arjun Sahgal, etc), while the Brits just seem to be less, and less, and less. To the point where they seem less interested in the science and more towards pushing the agenda to fewest treatments possible (see the cosmesis data from FAST-FORWARD 5-year data)

 

[Mandelin Rain]

The first big (and clear i.e. no A/B 4 arms behemoth) randomized trial reported was the Whelan trial and he came to America and pimped it to anyone who'd listen. We started doing it. It worked. Patients did well. There was no reason to change.

The (much) better question is, "why would anyone care if their colleague is doing 15 or 16 fractions?"

 

[Burt Radnolds]

Because they haven't been directly compared to one another? The BED of 2.66 x 16 is closer to 50/2 than 2.67 x 15.

I like Canadians more than I like the British. Canadians have given us Palma and the Toronto Raptors. UK has given us Jayant Vaidya and Brexit.

I find myself thinking that folks in the UK are driven by a perverse interest to minimize number of fractions at all costs, so as to the cut the costs to their failing NHS system, and they want us all to be on their level of dissatisfaction of lives as doctors. Beyond START, there's FAST and now FAST FORWARD.

Canadians seem to be less so in that vein, and more interested in expanding indications for radiation or more technical forms of RT (see Palma, Arjun Sahgal, etc), while the Brits just seem to be less, and less, and less. To the point where they seem less interested in the science and more towards pushing the agenda to fewest treatments possible (see the cosmesis data from FAST-FORWARD 5-year data)

The first big (and clear i.e. no A/B 4 arms behemoth) randomized trial reported was the Whelan trial and he came to America and pimped it to anyone who'd listen. We started doing it. It worked. Patients did well. There was no reason to change.

The (much) better question is, "why would anyone care if their colleague is doing 15 or 16 fractions?"

Whelan did it first, so that is best. The British scientists are bad people who hate radiation. Ok, got it. Convinced me.

Both are standards of care, I have plenty of colleagues that use 16 and I believe them to take perfectly good care of their patients. Not sure why people are so offended about such a simple question.

evilbooyaa: In regards to BED, I disagree that 4256/16 is necessarily closer to 50/2, depends what a/b you use. Local control did not suffer in START and actually favored hypofx crudely.

I would never advocate for a completely asinine trial such as 15 vs 16, but still am left to decipher them to the best of my ability. I guess caring about such small details is below you?

There is a such thing as normal tissue complication probability curves. FAST FORWARD proved that a very small difference in dose in whole breast can greatly impact cosmesis. Given START was only one that showed significantly improved cosmesis, I posit that we are seeing a similar phenomenon between it and Whelan, but cannot prove that without a trial.

I know, I know, all makes too much sense but does not fit with what you do and might lose you a fraction, just go back to the drive bys and snide remarks and ignore the rest.

 

[Mandelin Rain]

I guess caring about such small details is below you?

No, but caring about THAT small detail is indeed below me.

 

[Burt Radnolds]

No, but caring about THAT small detail is indeed below me.

Lol, dude, hope you got what you needed from the internet today. I know these are some tough times.

 

[evilbooyaa]

START showed improved cosmesis? Citation for that statement? I was not aware of HypoFx showing improved cosmesis in anything besides retrospective studies or in well selected patients (like larger breasted women, like in that MDACC trial I think?)

Not sure what scenario you would think that 2.67 x 15 is closer in BED to 2 x 25 than 2.66 x 16, but here's the evidence that you are incorrect.

50/2:

42.56/16:

40.05/15:

I agree with Mandelin Rain that trying to make 16 vs 15 an issue is more representative of you as a person than it is of me as a person. There is zero monetary advantage of me doing 16 vs 15, unless it's a left breast and I get to charge for one extra daily kV. If Evicore told me I was only authorized for 15, I'd be like 'whatev' and move on with my life. I boost most of my ladies, and I still get them done in 20 treatments. Maybe you can get yours done in 19 if you did 15 + 4fx boost?

 

[scarbrtj]

So for real though, all joking and potshots and smirking aside, can someone tell me an evidence based reason for 16 over 15?

There is no evidence-based reason for 16 over 15.

There is no evidence-based reason for 15 over 16.

Far more interesting to me, though, is: you start with START to support 15. Fine. Boosting in START was nebulous (some got it, some didn't, was different center to center, no pre-spec reasons for doing so on the trial, etc.), and it had almost exactly HR=1.0000 effect on LC in START. START post-hoc analyses also suggested that treatment elongation harmed LC, somewhat impugning the treatment-elongating boost. Without extrapolating from standard fractionation, is there any evidence-based reason to boost after 15 fractions of whole breast?

 

[Mandelin Rain]

I agree with Mandelin Rain that trying to make 16 vs 15 an issue is more representative of you as a person than it is of me as a person.

Bingo!

 

[Mandelin Rain]

There is no evidence-based reason for 16 over 15.

There is no evidence-based reason for 15 over 16.

I smell randomized trial....

 

[scarbrtj]

I smell randomized trial....

The statistician in me thinks we will need ~5000 patients in each arm followed 10y for LC or cosmesis questions, inferiority or equivalence questions, to hope to get p<0.05 satisfaction.

 

[scarbrtj]

START showed improved cosmesis?

I believe in START-A, the *****13 fraction to 39 Gy****** arm had improved cosmesis.

Monkey needs to be using 13 fractions instead of 15 as I previously hinted 🙂

 

[Palex80]

True- however, the breast surgeons in my group will never perform a non-oncoplastic lumpectomy. Given that every fellowship-trained breast surgeon I've ever worked with only does oncoplastic lumpectomies, and given that the patient-driven market is moving towards fellowship-trained breast surgeons for breast cancer surgery (at least in my neck of the woods it is), the Italian-style APBI won't be applicable to the majority of my patients.

Who says that?

I have heard this argument over and over again, yet I have not seen any data after oncoplastic surgery pointing out:

a) worse cosmetic outcomes when performing hypofractionated EBRT
b) worse cosmetic outcomes when performing external beam partial breast RT
c) worse local control when performing external beam partial breast RT

Oncoplastic surgery is not supposed to move the tumor bed within the breast, making it unidentifiable for postoperative external beam partial breast RT. And if it does, it's the job of your surgeon to clip that tumor bed.