LUMINA Discussion

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winstonfoot5

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radoncle said:
All while articles like this are being published:

Radiation, a mainstay of cancer treatment, begins a fade-out

www.statnews.com

Radiation, a mainstay of cancer treatment, begins a fade-out

“There are situations now on an individual patient basis where radiation may not be needed.”
www.statnews.com www.statnews.com
Click to expand...
LUMINA in this weeks NEJM:
Omitting Radiotherapy after Breast-Conserving Surgery in Luminal A Breast Cancer

Prepare for the subsequent clickbait (for example):
Some early-stage, low-risk breast cancer patients may not need radiotherapy after surgery
www.news-medical.net

Some early-stage, low-risk breast cancer patients may not need radiotherapy after surgery

Some women with early-stage, low-risk breast cancer may not need radiotherapy after breast conserving surgery according to new research led by McMaster University, BC Cancer, Hamilton Heath Sciences, and the University of British Columbia.
www.news-medical.net www.news-medical.net

Is it time to buy the dip?
 
winstonfoot5 said:
LUMINA in this weeks NEJM:
Omitting Radiotherapy after Breast-Conserving Surgery in Luminal A Breast Cancer

Prepare for the subsequent clickbait (for example):
Some early-stage, low-risk breast cancer patients may not need radiotherapy after surgery
www.news-medical.net

Some early-stage, low-risk breast cancer patients may not need radiotherapy after surgery

Some women with early-stage, low-risk breast cancer may not need radiotherapy after breast conserving surgery according to new research led by McMaster University, BC Cancer, Hamilton Heath Sciences, and the University of British Columbia.
www.news-medical.net www.news-medical.net

Is it time to buy the dip?
Click to expand...
I think it’s time to turn the ship around… my proposal is to lean into it by showing the world how important radiation is by allowing local recurrences to rise and we go full in on salvage radiation therapy.

We’ve lost being able to come in the front door with upfront definitive radiation in almost all disease sites. Let the “cool kids” mess up and we wait to be the “hero.”
 
RadOncDoc21 said:
I think it’s time to turn the ship around… my proposal is to lean into it by showing the world how important radiation is by allowing local recurrences to rise and we go full in on salvage radiation therapy.

We’ve lost being able to come in the front door with upfront definitive radiation in almost all disease sites. Let the “cool kids” mess up and we wait to be the “hero.”
Click to expand...

Nonsense, vast majority will never suffer a local recurrence. 1/50 chance at 5 years. Like it has been pointed out many times previously the trajectory is 30 fx in 2010 to 15 fx in 2017 to 5 fx in 2023 to 0 fx by 2030. That is where the narrative is heading weather you like it our not. When LF rates are so low this basically becomes the next lymphoma.

If it were me personally I would definitely do the RT over 5 years of AI every time but our "academic leadership" seems very uninterested in this question.
 
fiji128 said:
Nonsense, vast majority will never suffer a local recurrence. 1/50 chance at 5 years. Like it has been pointed out many times previously the trajectory is 30 fx in 2010 to 15 fx in 2017 to 5 fx in 2023 to 0 fx by 2030. That is where the narrative is heading weather you like it our not. When LF rates are so low this basically becomes the next lymphoma.

If it were me personally I would definitely do the RT over 5 years of AI every time but our "academic leadership" seems very uninterested in this question.
Click to expand...
I mean yes, for breast it’s pretty much off the table, but again who knows… maybe there will be more local failures in the future. I guess right now, what’s the other option… we’re not going to win the AI vs RT war.
 
Honestly, discussion of LUMINA probably deserves it's own thread separate from expansion talk. Potential sea change if widely adopted. I'll let the mods determine if that's appropriate.
 
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This why I’ve been aggressive with APBI for past 3 years. Our approach for all these patients is for them to get the protection from recurrence with basically no side effects with APBI and try an AI. If lucky enough to not have side effects from AI then stay on it, but if they have side effects even after switching up meds..then just stop because theyve had APBI. Hopefully the EUROPA trial ends up supporting APBI alone for these patients. LUMINA results are not surprising, but no medonc here is looking to eliminate radiotherapy because APBI is such a winner.
 
Mandelin Rain said:
What's the ROCR case rate on 0 fractions?
Click to expand...
Not reimbursement per se, but you get to sht on and stick a dagger in your colleagues, which is so much more valuable than mere rvus. Lets say you are the number 2 breast radonc in Cleveland, and you want to diminish Chirag Shah. Tell the pts that you have a test that will get them out of toxic xrt!
 
RickyScott said:
Not reimbursement per se, but you get to sht on and stick a dagger in your colleagues, which is so much more valuable than mere rvus. Lets say you are the number 2 breast radonc in Cleveland, and you want to diminish Chirag Shah. Tell the pts that you have a test that will get them out of toxic xrt!
Click to expand...
Canadians neutralized test by basing study on already reported IHC factors. No need for expensive assay. Just look at the path report.
 
Continuing to train people, sometimes bright people, in a medical field that continues to have less and less roll in helping society is the greatest illustration of generational greed I can think of. Great show. The use cases for radiation continue to shrink, but residency classes sure don’t. Thank God at least US grads got the message, but it’s disheartening to know our leaders think of us as human fodder to lubricate the second half of their careers.

Radiation will be used less and less in breast cancer. It’s used less in rectal cancer. Breast has a significantly higher volume due to its incidence. That’s how it will be, and it’s good for society. It would be fine for us if not for the greed of our chairs and big private practice.
 
I've been fairly aggressive about this in tumor board at both my current practice and prior practice, if anyone so much as breathes the concept of skipping XRT.

It's pretty interesting to see the disconnect between the literature/Ivory Tower narrative of the last decade, and my personal experience in non-urban, community-based settings.

1) By now, everyone is familiar with how relatively easy the 5-15 fraction regimens are, compared to the stories from the 1980s/1990s.

2) Someone asks about omission, either a patient has been on the internet too much, or something like LUMINA hits the mainstream medical media platforms

3) "Look, at the end of the day, if it was my Mom, or if it was me, I would do the radiation without question. You've probably never seen an early stage breast patient quit radiation in the past few years, right?"

[usually a surgeon says "I don't think so" to my question]

"It almost never happens. Now, lemme ask you [insert MedOnc name], how many of your breast patients make it the whole 5 years? Or, of the patients who make it the whole 5 years, how often are you dealing with switching regimens because of side effects, blood clots, women telling you they're miserable? I'll go out on a limb here and say you probably don't get the 95% adherence rates we saw in JAMA, right?"

[scattered chuckles because I ask the JAMA question in a clearly comedic tone of voice]

And then I don't hear about omission again until the next random publication makes the rounds.

Normal, reasonable people, who live in the real world with the rest of us, basically don't consider the "5-15 radiation treatments or 5 years of a pill that commonly has side effects" an actual question.

In the real world, it's "we need to make sure this breast patient gets radiation because we can't guarantee she'll tolerate half a decade of pills".
 
Mandelin Rain said:
What's the ROCR case rate on 0 fractions?
Click to expand...

Bequerel said:
This why I’ve been aggressive with APBI for past 3 years. Our approach for all these patients is for them to get the protection from recurrence with basically no side effects with APBI and try an AI. If lucky enough to not have side effects from AI then stay on it, but if they have side effects even after switching up meds..then just stop because theyve had APBI. Hopefully the EUROPA trial ends up supporting APBI alone for these patients. LUMINA results are not surprising, but no medonc here is looking to eliminate radiotherapy because APBI is such a winner.
Click to expand...
This is the way IMHO. Rx: 26 Gy/5 fx "mini-tangent" IMPORT (intensity modulated partial organ RT) for favorable/low risk risk breast cancers. It is ridiculously well tolerated and bad-side-effect free.
elementaryschooleconomics said:
1) By now, everyone is familiar with how relatively easy the 5-15 fraction regimens are, compared to the stories from the 1980s/1990s
Click to expand...
Is *everyone* familiar with 5-15? I am not sure it's even scientifically fair to say "5 to 15" anymore... and especially from a patient-centered viewpoint, 5 is *a lot* different than 15. As you know, I have a wide-ranging, all-seeing perch from which to view fractionation patterns across the US. From this admittedly anecdotal spot, I see five-fraction being used in ~1% of all five-fraction-able women. I wager $1 million it's not greater than 5%. In the UK it's at ~90% now.
 
DebtRising said:
Continuing to train people, sometimes bright people, in a medical field that continues to have less and less roll in helping society is the greatest illustration of generational greed I can think of. Great show. The use cases for radiation continue to shrink, but residency classes sure don’t. Thank God at least US grads got the message, but it’s disheartening to know our leaders think of us as human fodder to lubricate the second half of their careers.

Radiation will be used less and less in breast cancer. It’s used less in rectal cancer. Breast has a significantly higher volume due to its incidence. That’s how it will be, and it’s good for society. It would be fine for us if not for the greed of our chairs and big private practice.
Click to expand...
Sad to hear about rectal cancer in your neck of the woods. Radiation utilization is almost 100% tied to surgery utilization now. Places that dont practice selective omission of surgery will lose half of their former volume. In my neck of the woods, we offer patients who are potential prospect patients chemo and surgery or TNT with the possibility of no surgery and so far 100% have opted for the chance to avoid surgery. The only group that is really affected for me is earlyish high rectal tumors near the RS junction. They don’t like to watch them due to concerns that a recurrence may act more like a true sigmoid cancer with respect to mesenteric nodal drainage (I’m not totally sold on this but I’m not going to push their otherwise amazing support for this small group of people). I’ll maybe lose 10% of my rectal patients over this.

But I am keenly aware of what is out there. I had an R01 involving rectal cancer get discussed this summer. Amazing scores from 2/3 reviewers (as in all 1s and a couple of 2s). The third killed it largely because they argued with prospect, it will be impossible to accrue to a radiation trial in rectal cancer anymore ☹️. Will be interesting to see how the NCCN view things. Will TNT stay the preferred SOC? In my mind, it should. Avid supporters of Prospect ignore one potential consideration. RAPIDO suggested that TNT has better distant disease control than the German regimen but prospect only showed equivalence between chemo/surgery and the German paradigm. This at least suggests the TNT may still be superior and that it wasn’t just earlier chemo that contributed to the benefit. Lots of caveats but still, it can’t be completely discounted.
 
TheWallnerus said:


This is the way IMHO. Rx: 26 Gy/5 fx "mini-tangent" IMPORT (intensity modulated partial organ RT) for favorable/low risk risk breast cancers. It is ridiculously well tolerated and bad-side-effect free.

Is *everyone* familiar with 5-15? I am not sure it's even scientifically fair to say "5 to 15" anymore... and especially from a patient-centered viewpoint, 5 is *a lot* different than 15. As you know, I have a wide-ranging, all-seeing perch from which to view fractionation patterns across the US. From this admittedly anecdotal spot, I see five-fraction being used in ~1% of all five-fraction-able women. I wager $1 million it's not greater than 5%. In the UK it's at ~90% now.
Click to expand...

I would absolutely agree.

And to be clear, 15 dominates my personal practice. It's my default and my favorite.

Why? Because I consider it "the most conservative". For actually precisely some of the critiques leveled at the omission trials, which is long-term follow-up data.

My next favorite is the original FAST once-weekly regimen.

I get the impression, that in America, people went from "Canadian fractionation" to Florence APBI but just to plug FAST - if you have patients with transportation or mobility issues, once weekly treatments are the way to go.

Because I want to and because I can, I've used every "acceptable" breast regimen in existence to this point.

All are easier than 5 years of pills.

(Note: I still have never used conventional fractionation on intact breast s/p lumpectomy. That's my version of omission. I omit an extra few weeks.)
 
Neuronix said:
Plus a good chunk of those will go to mastectomy and reconstruction, never having radiation in that event either.
Click to expand...
A lot of the 70+ yr olds will just die from other causes, having never failed locally or having stopped follow up scans in old age.
 
I really hope EUROPA trial shows no difference in any failure metrics. I have faith that if they're tracking any QoL metrics the XRT is going to knock it out of the park vs. the AI.

I see all my breast patients yearly....I cannot emphasize enough how much quality of life detriment an AI is to a large chunk of patients. I would guess upwards of 50% are not liking that pill AT ALL. Switching regimens, chasing hot flashes with SSRI's or gabapentin, recurrent UTI's, vaginal dryness issues, joint aches.

I would guess the rad oncs on these trials don't follow their patients long term and discuss AI's with them.

26 to 30 Gy in 5 APBI IMRT is an absolute walk in the park. Cosmesis is fantastic. Easiest regimen I give to any curative patient I swear. Flexibility to treat QOD or daily or 3 fractions/week.
 
Last edited:
RickyScott said:
A lot of the 70+ yr olds will just die from other causes, having never failed locally or having stopped follow up scans in old age.
Click to expand...
I disagree. This was the assumption of the Hughes trial. Recurrence is only about 10% at 10 yrs though.
 
madchemist89 said:
I disagree. This was the assumption of the Hughes trial. Recurrence is only about 10% at 10 yrs though.
Click to expand...

Yes. In theory if you're still getting regular mammograms at 70 you're probably slightly more healthy than an "average" 70 year old.

However, your years are limited (versus an average 50 year old), so why waste them on an AI if you don't have to? *prays to EUROPA gods for a good outcome for RT*
 
BobbyHeenan said:
I really hope EUROPA trial shows no difference in any failure metrics. I have faith that if they're tracking any QoL metrics the XRT is going to knock it out of the park vs. the AI.

I see all my breast patients yearly....I cannot emphasize enough how much quality of life detriment an AI is to a large chunk of patients. I would guess upwards of 50% are not liking that pill AT ALL. Switching regimens, chasing hot flashes with SSRI's or gabapentin, recurrent UTI's, vaginal dryness issues, joint aches.

I would guess the rad oncs on these trials don't follow their patients long term and discuss AI's with them.

26 to 30 Gy in 5 APBI IMRT is an absolute walk in the park. Cosmesis is fantastic. Easiest regimen I give to any curative patient I swear. Flexibility to treat QOD or daily or 3 fractions/week.
Click to expand...

You do realize if there is no difference then that will be what is emphasized in the headline as the primary endpoint. No one except us will care about the QOL.
 
Fpg1245 said:
You do realize if there is no difference then that will be what is emphasized in the headline as the primary endpoint. No one except us will care about the QOL.
Click to expand...

As long as I am present at multi disciplinary tumor board I'll speak up about it.

Med onc's in my experience don't love dealing with AI stuff either. I don't think they will push for AI's the way they would say rectal chemo intensification or immunotherapy.
 
Fpg1245 said:
You do realize if there is no difference then that will be what is emphasized in the headline as the primary endpoint. No one except us will care about the QOL.
Click to expand...
Bingo. As a normal tissue guy, I have to call out the blatant hypocrisy. Everyone pays lip service to QOL when it suits their narrative but are extremely fast to look the other way when it doesn’t. It’s disgusting.
 
BobbyHeenan said:
As long as I am present at multi disciplinary tumor board I'll speak up about it.

Med onc's in my experience don't love dealing with AI stuff either. I don't think they will push for AI's the way they would say rectal chemo intensification or immunotherapy.
Click to expand...
ramsesthenice said:
Bingo. As a normal tissue guy, I have to call out the blatant hypocrisy. Everyone pays lip service to QOL when it suits their narrative but are extremely fast to look the other way when it doesn’t. It’s disgusting.
Click to expand...

Tumor board is one thing. Public perception drives health policy a lot of times.

Values change to fit whatever narrative the dominant group wants to push
 
Obviously, cross-trial analysis is not great, but here is a subset of SWOG S1007 (low-risk, node positive). Younger median age. Obviously a somewhat worse prognosis give N+.

Results Of 4871 female patients (median [range] age, 57 [18-87] years) with radiotherapy forms, 3947 (81.0%) reported radiotherapy receipt. Of 3852 patients who received radiotherapy and had complete information on targets, 2274 (59.0%) received RNI. With a median follow-up of 6.1 years, the cumulative incidence of LRR by 5 years was 0.85% among patients who received breast-conserving surgery and radiotherapy with RNI; 0.55% after breast-conserving surgery with radiotherapy without RNI; 0.11% after mastectomy with postmastectomy radiotherapy; and 1.7% after mastectomy without radiotherapy. Similarly low LRR was observed within the group assigned to endocrine therapy without chemotherapy. The rate of IDFS did not differ by RNI receipt (premenopausal: hazard ratio
, 1.03; 95% CI, 0.74-1.43; P = .87; postmenopausal: HR, 0.85; 95% CI, 0.68-1.07; P = .16).


Two things:
1. RNI probably adds nothing. Not sure if anyone has ever made that case on this site.
2. Radiation works VERY well in breast cancer. Would be a shame if we were the modality eliminated to de-escalate.
 
Mandelin Rain said:
Obviously, cross-trial analysis is not great, but here is a subset of SWOG S1007 (low-risk, node positive). Younger median age. Obviously a somewhat worse prognosis give N+.

Results Of 4871 female patients (median [range] age, 57 [18-87] years) with radiotherapy forms, 3947 (81.0%) reported radiotherapy receipt. Of 3852 patients who received radiotherapy and had complete information on targets, 2274 (59.0%) received RNI. With a median follow-up of 6.1 years, the cumulative incidence of LRR by 5 years was 0.85% among patients who received breast-conserving surgery and radiotherapy with RNI; 0.55% after breast-conserving surgery with radiotherapy without RNI; 0.11% after mastectomy with postmastectomy radiotherapy; and 1.7% after mastectomy without radiotherapy. Similarly low LRR was observed within the group assigned to endocrine therapy without chemotherapy. The rate of IDFS did not differ by RNI receipt (premenopausal: hazard ratio
, 1.03; 95% CI, 0.74-1.43; P = .87; postmenopausal: HR, 0.85; 95% CI, 0.68-1.07; P = .16).


Two things:
1. RNI probably adds nothing. Not sure if anyone has ever made that case on this site.
2. Radiation works VERY well in breast cancer. Would be a shame if we were the modality eliminated to de-escalate.
Click to expand...
In order to justify protons, centers insist on RNI including Imn for sketchy indications like 1 small ax node. Anyone who has done um work would recognize this. Simul?
 
Last edited:
Mandelin Rain said:
Obviously, cross-trial analysis is not great, but here is a subset of SWOG S1007 (low-risk, node positive). Younger median age. Obviously a somewhat worse prognosis give N+.

Results Of 4871 female patients (median [range] age, 57 [18-87] years) with radiotherapy forms, 3947 (81.0%) reported radiotherapy receipt. Of 3852 patients who received radiotherapy and had complete information on targets, 2274 (59.0%) received RNI. With a median follow-up of 6.1 years, the cumulative incidence of LRR by 5 years was 0.85% among patients who received breast-conserving surgery and radiotherapy with RNI; 0.55% after breast-conserving surgery with radiotherapy without RNI; 0.11% after mastectomy with postmastectomy radiotherapy; and 1.7% after mastectomy without radiotherapy. Similarly low LRR was observed within the group assigned to endocrine therapy without chemotherapy. The rate of IDFS did not differ by RNI receipt (premenopausal: hazard ratio
, 1.03; 95% CI, 0.74-1.43; P = .87; postmenopausal: HR, 0.85; 95% CI, 0.68-1.07; P = .16).


Two things:
1. RNI probably adds nothing. Not sure if anyone has ever made that case on this site.
2. Radiation works VERY well in breast cancer. Would be a shame if we were the modality eliminated to de-escalate.
Click to expand...

I mean how were they doing the RT. High tangent vs true RNI?
 
Fpg1245 said:
I mean how were they doing the RT. High tangent vs true RNI?
Click to expand...
jamanetwork.com

Radiotherapy Use and Locoregional Recurrence Incidence in Patients in SWOG S1007 Trial

This secondary analysis of a clinical trial investigates how often patients with favorable-risk, node-positive breast cancer receive regional nodal irradiation, incidence and predictors of locoregional recurrence rates, and associations between locoregional therapy and disease-free survival.
jamanetwork.com jamanetwork.com

I'm not going to dig into the minutia of any of this, but sounds like addition of SCF field was the primary definition.

We described radiotherapy receipt among patients with available radiotherapy forms and defined RNI based on an indication of treatment targets that included at least the supraclavicular region. In addition to this study’s primary definition of RNI with its focus on the supraclavicular region, we described radiotherapy receipt to the internal mammary and axillary regions and performed a sensitivity analysis that considered an alternative definition of RNI that included targeting of any of these nodal regions
 
BobbyHeenan said:
I really hope EUROPA trial shows no difference in any failure metrics. I have faith that if they're tracking any QoL metrics the XRT is going to knock it out of the park vs. the AI.
Click to expand...
this is a risk and potential criticism of EUROPA that we need to grapple with. Meta-analyses have shown that AI has better breast cancer mortality and distance recurrence than tamoxifen, which was thought to be equivalent to RT on B21 and other trials. If there is no difference on EUROPA then a criticism could be it wasn’t adequately powered. If there is a difference then obviously RT alone is dead
 
grenz said:
this is a risk and potential criticism of EUROPA that we need to grapple with. Meta-analyses have shown that AI has better breast cancer mortality and distance recurrence than tamoxifen, which was thought to be equivalent to RT on B21 and other trials. If there is no difference on EUROPA then a criticism could be it wasn’t adequately powered. If there is a difference then obviously RT alone is dead
Click to expand...
Also ai prevent new cancers in contralateral breast, which develop at rate of 1%/yr. Trial results could easily be spun as higher rate of 2nd breast cancer with xrt alone.
 
RickyScott said:
Also ai prevent new cancers in contralateral breast, which develop at rate of 1%/yr. Trial results could easily be spun as higher rate of 2nd breast cancer with xrt alone.
Click to expand...
grenz said:
Meta-analyses have shown that AI has better breast cancer mortality and distance recurrence than tamoxifen, which was thought to be equivalent to RT on B21 and other trials.
Click to expand...
They are complementary interventions. Endocrine therapy does impact LR in a more defined way than XRT impacts distant progression (XRT certainly impacts late distant recurrences in high risk patients, but this is not the question here). The best narrative that we can hope for is that XRT in the right population makes it "reasonable" to not pursue endocrine therapy in certain patients after a mutual decision type process.

BobbyHeenan said:
Med onc's in my experience don't love dealing with AI stuff either.
Click to expand...
We need to take over the AIs. Medonc's schedules are busy, but often extremely low value IMO. They now give lots of therapies that require q6week f/u for years (this will have to change). Given the demography of breast cancer, those q6 mos breast cancer f/u's for low risk breast cancer can really eat into their schedules.

Our schedules are getting lighter.
 
communitydoc13 said:
They are complementary interventions. Endocrine therapy does impact LR in a more defined way than XRT impacts distant progression (XRT certainly impacts late distant recurrences in high risk patients, but this is not the question here). The best narrative that we can hope for is that XRT in the right population makes it "reasonable" to not pursue endocrine therapy in certain patients after a mutual decision type process.


We need to take over the AIs. Medonc's schedules are busy, but often extremely low value IMO. They now give lots of therapies that require q6week f/u for years (this will have to change). Given the demography of breast cancer, those q6 mos breast cancer f/u's for low risk breast cancer can really eat into their schedules.

Our schedules are getting lighter.
Click to expand...
Can I get the med onc supporting staff also? Would love to have a MA much less a nurse or PA who could do more then tell the patient “please ask the doctor what you asked me”
 
Mandelin Rain said:
1. RNI probably adds nothing. Not sure if anyone has ever made that case on this site.
Click to expand...
max von sydow priest GIF
 
LUMINA is a nothing-burger for my clinical practice because of APBI. AI and TAM suck something awful. Of course this will negatively impact referral patterns in some practice environments.

I’m not surprised that Fei Fei Liu is on the study. She is one of those morally bankrupt FASTRO, pro-expansion, pro-cheap labor, job-market-A’OK.


They reassure students of rad onc’s job market durability with one side of their mouth, while consulting with LUMINA on what’s an acceptable risk of local recurrence with the other side of their mouth.
 
Last edited:
yesmaster said:
LUMINA is a nothing-burger for my clinical practice because of APBI. AI and TAM suck something awful. Of course this will negatively impact referral patterns in some practice environments.

I’m not surprised that Fei Fei Liu is on the study. She is one of those morally bankrupt FASTRO, pro-expansion, pro-cheap labor, job-market-A’OK.


They reassure students of rad onc’s job market durability with one side of their mouth, while consulting with LUMINA on what’s an acceptable risk of local recurrence with the other side of their mouth.
Click to expand...
Fei fei wrote that letter to med school deans complaining that medstudents were misled by sdn and avoiding the field!
 
I still do not understand why the Canadians have anything to do with the US society. Liu and Dawson, why exactly? They do not for the most part let us work there and give preference to their own. Why cant’t we do the same? And it is super annoying to me to have a Canadian lecturing us about job market in the US. The amount of warm body loving, cheap labour espousing people in our “leadership” is sickening. People have zero shame.
 
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