Omission of breast RT for HER2+ with path CR

[Krukenberg]

---

Members do not see this ad.

Cohort study just opened at KU. Patients choose either SOC or omission of RT and both groups are followed prospectively. Depending on results could serve as a precursor to a ph3. I guess I’m glad it’s a rad onc running it but I suspect local recurrences will be unacceptable.

Researcher Investigates Eliminating Radiation for HER2-Positive Breast Cancer

 

[medgator]

What's the rationale in H2N patients? The drugs have gotten so good with pCR rates that rt can be skipped?

Agree.... this is not the same population as those ER+ node- pts who get to skip it

 

[Palex80]

Here it is:
Omission of Radiation in Patients With Her-2 Positive Breast Cancer - Full Text View - ClinicalTrials.gov

I don't like one thing already: why put as a primary endpoint "biopsy positive her-2 positive tumor in the same breast". What if it's a Her-2 negative recurrence?

 

[Radiator20]

I wonder how interpretable the results are going to be given that patients are choosing their treatment arm...

 

[metallica81788]

I'm all for hypofractionation and such to optimize cost/convenience/toxicities when evidence is there, but now we're designing trials to eliminate our modality entirely? What are we doing as a field?

 

[scarbrtj]

but now we're designing trials to eliminate our modality entirely

"We" that have tenure I suppose.

 

[scarbrtj]

All who saw the first HER2 data in NEJM etc and gifted with the least bit of prophecy could hear in the back of their minds one of Eli Glatstein's famous quotes: "We're always just one really good drug away from being out of the radiation business in any given disease."

 

[medgator]

All who saw the first HER2 data in NEJM etc and gifted with the least bit of prophecy could hear in the back of their minds one of Eli Glatstein's famous quotes: "We're always just one really good drug away from being out of the radiation business in any given disease."

Hasn't that been a (failed) prophecy for decades?

This isn't gleevec in all likelihood

 

[DebtRising]

I'm all for hypofractionation and such to optimize cost/convenience/toxicities when evidence is there, but now we're designing trials to eliminate our modality entirely? What are we doing as a field?

There is nothing inherently wrong with designing trials to omit radiation if the benefit is perceived to be low. HER2 positive disease with its high distant failure rate may be that disease in breast. If its the right thing to ask, it's the right thing to ask, and better to have us be stewards of those questions then outside specialties.

But what you describe is very real frustration. It is wrong to keep asking questions about cutting back radiation usage, both in terms of indications and fraction number, while ASTRO, ABR, ACGME, SCAROP pump out 50% more residents than they did ~8 years ago and endorse this. That is morally reprehensible to increase training slots of 5-year cycles when very clearly the field is being winnowed down.

But if you think any of those leaders care about the future of those souls coming in now, think again. The free market will eventually determine a solution, but only after potential hundreds of people with fairly high intelligence, years of training, and obligate 'buy in' of ~$140-340K just in medical education [not including compounding for debt] suffer the consequences of not being able to use what they were trained to do for jobs that never existed, because 'it was no one's problem' to chaperone if people being trained for 5 years after medical school actually had positions for said training.

 

[scarbrtj]

Hasn't that been a (failed) prophecy for decades?

This isn't gleevec in all likelihood

Certain lymphomas. Stage I seminoma. Certain CNS tumors. Now breast. IMHO!

 

[medgator]

Certain lymphomas. Stage I seminoma. Certain CNS tumors. Now breast. IMHO!

Yes but those are different situations. Chemo can cure stage IV testicular cancers and sterilize blood tumors.

I just don't see the jump to solid tumors happening outside of older patients with less aggressive disease (Hughes study you cited). There was in fact a difference in recurrence rates even then, without rt, it's just that it wasn't felt to be clinically significant

 

[evilbooyaa]

Going to have significant differences in baseline characteristics if patients can choose what group they want to be treated on. Should really just be a single arm large phase II for the people that want to be guinea pigs and omit radiation in this scenario.

I mean Her2+ breast cancer that starts off lymph node negative (which is the inclusion criteria) is relatively rare in my experience, but from a world-wide oncologic perspective it's not an inherently bad question to ask. The issues of continued decrease in RT usage is going to happen regardless of whether rad oncs run the trials or not. At least now the publication will have a Rad Onc as the first author and can hopefully not make outlandish claims (like the hughes trial suggesting that radiation shouldn't be offered to women over the age of 70)