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w00tz said:
I am very skeptical of 25/5, especially for NOM. Based on what we know/believe about BED and alpha/beta, LC has significantly higher BED than SC. If SC does prove to be equivalent to LC for in NOM for big T3 tumors, I will have an existential crisis and throw my Hall book in a dumpster fire.
Click to expand...


I understand the sentiment, but the data is the data.

Alpha beta doesn’t seem to be telling the whole story
 
jondunn said:
I understand the sentiment, but the data is the data.

Alpha beta doesn’t seem to be telling the whole story
Click to expand...
I would marry alpha beta if I could! It always tells the whole story, if you use the right alpha beta. The BED of 25/5 is bigger than 50.4/28... with the right alpha beta.*† (And sometimes all the cells in the same tumor refuse to tell the same alpha beta story.)

* and time correction factors
† α/β≤~3.8 (with ~0.5 per day BED-lessening correction factor), α/β≤~1.3 (with no time correction)
 
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TheWallnerus said:
I would marry alpha beta if I could! It always tells the whole story, if you use the right alpha beta. The BED of 25/5 is bigger than 50.4/28... with the right alpha beta.* (And sometimes all the cells in the same tumor refuse to tell the same alpha beta story.)

* and time correction factors
Click to expand...
And maybe short course is less immunosuppressive
 
As a not very common user of 25/5, the Wash U study is interesting to me.

RAPIDO told me that TNT is probably better than ChemoRT/SC RT alone --> Surgery --> Chemo in an unselected population.

I agree with @elementaryschooleconomics that trying to get non-academic CRS on TNT can be a struggle on it's own.

Historically, my concern with watch and wait was whether LC was better than SC. I'd be intersted in seeing OPRA results compared to this Wash U paper.

@OTN , It's not the highest quality data to suggest that short course for non-op management is MANDATORY, but it does provide data (at least to me) that it's a reasonable tx paradigm.

As APM approaches closer and closer for the general population, we should all be ready to be willing to pivot to a shorter, equal fractionation. Not mandatory, but an option.
 
I've been using short course TNT for just about everyone with locally advanced rectal cancer, including W&W since 2014... helps that my job has a Polish med onc; so he's totally on-board! But I do support the equipoise that we don't know for sure in the W&W setting the SC-TNT vs the LC-TNT.

The alpha/beta arguments and the non-statistically significant difference in local control are boomer arguments! That Hall textbook is about as relevant as the decay curve of a Co-60 teletherapy unit by now; and should be limited to the ABR board hazing only! And to not offer a patient 4 weeks of their life back for a numerical difference in local control that has a p=.10 is also silly.

The better argument for long course rectal cancer chemoradiation is the lack of W&W data; and lack of integration of SC-TNT with the rest of your treatment team (med onc, surgery).

Has anyone tried the FOLFOXIRI -> long course in the French study? I don't have the cajones to do it for locally advanced rectal cancer; but have seen some young patients with metastatic disease with a good response who have been referred in for the radiation...
 
GI_RadOnc said:
The alpha/beta arguments and the non-statistically significant difference in local control are boomer arguments! That Hall textbook is about as relevant as the decay curve of a Co-60 teletherapy unit by now; and should be limited to the ABR board hazing only! And to not offer a patient 4 weeks of their life back for a numerical difference in local control that has a p=.10 is also silly.
Click to expand...
I have a dream,

that one day future residents will practice in a specialty,

where they are not tested on their ability to memorize and regurgitate irrelevant trivia,

but on their ability to practice compassionate and and effective medicine.
 
GI_RadOnc said:
I've been using short course TNT for just about everyone with locally advanced rectal cancer, including W&W since 2014... helps that my job has a Polish med onc; so he's totally on-board! But I do support the equipoise that we don't know for sure in the W&W setting the SC-TNT vs the LC-TNT.

The alpha/beta arguments and the non-statistically significant difference in local control are boomer arguments! That Hall textbook is about as relevant as the decay curve of a Co-60 teletherapy unit by now; and should be limited to the ABR board hazing only! And to not offer a patient 4 weeks of their life back for a numerical difference in local control that has a p=.10 is also silly.

The better argument for long course rectal cancer chemoradiation is the lack of W&W data; and lack of integration of SC-TNT with the rest of your treatment team (med onc, surgery).

Has anyone tried the FOLFOXIRI -> long course in the French study? I don't have the cajones to do it for locally advanced rectal cancer; but have seen some young patients with metastatic disease with a good response who have been referred in for the radiation...
Click to expand...
Is that Prodige?
 
The issue I have with 5 x 5 in w&w is that sometimes it works, and in this setting, that's good enough, because there's always surgery. Not much pressure to do any more than work every now and then. Is 54-56 gy plus xeloda more likely to cure rectal cancer than 5x5? I'll do a side bet for a really expensive bourbon at the next astro I attend.
 
Ray D. Ayshun said:
The issue I have with 5 x 5 in w&w is that sometimes it works, and in this setting, that's good enough, because there's always surgery. Not much pressure to do any more than work every now and then. Is 54-56 gy plus xeloda more likely to cure rectal cancer than 5x5? I'll do a side bet for a really expensive bourbon at the next astro I attend.
Click to expand...

Sometimes it works? Why do you say sometimes?

Your baseline belief is that 25/5 is ‘less than’ in terms of efficacy. As long as you have that bias, the rest of the conversation is hard to have
 
elementaryschooleconomics said:
I have a dream,

that one day future residents will practice in a specialty,

where they are not tested on their ability to memorize and regurgitate irrelevant trivia,

but on their ability to practice compassionate and and effective medicine.
Click to expand...
..so if you don’t rate, just overcompensate …
 
jondunn said:
Sometimes it works? Why do you say sometimes?

Your baseline belief is that 25/5 is ‘less than’ in terms of efficacy. As long as you have that bias, the rest of the conversation is hard to have
Click to expand...
Because sometimes it does. Sometimes long course dose too. Only an rct will determine which does it better, and one rct hints that a lower dose long course regimen (50.4 vs 54-56) is slightly better at controlling residual microscopic disease than short course. The idea that a five fx regimen thats barely more aggressive than a 5 fx palliative regimen would be used in the definitive setting seems weird. I'll trust the data, and buy the bourbon, if I'm wrong.
 
Ray D. Ayshun said:
Because sometimes it does. Sometimes long course dose too. Only an rct will determine which does it better, and one rct hints that a lower dose long course regimen (50.4 vs 54-56) is slightly better at controlling residual microscopic disease than short course. The idea that a five fx regimen thats barely more aggressive than a 5 fx palliative regimen would be used in the definitive setting seems weird. I'll trust the data, and buy the bourbon, if I'm wrong.
Click to expand...
This is mood affiliation in action. The pCr rate in rapido trial is impressive, amongst highest reported. As the honorable alligator asks, is it the chemotherapy or the SCRT? I answer - “yes”.

Give it a try. But beware the pelvic and abdominal spasms in week 1-2 after treatment. We have a handout made for this, with some people pre writing RXs

It’s not bad to do LCRT, I’m not judging anybody. I think the problem, personally, is this is an advance for patients but we get punished to do it. This is a big problem in RO, in general.
 
sometimes I think about what I would/will want as a patient. changes from time to time. how I feel right now:

I would actively demand/want 5 fraction partial breast

would want prostate sbrt

I would lean towards wanting 25/5 but would be fine with either. 5.5 weeks is a long time to deal with the worsening acute toxicity, having to be on the table with it, etc

I would be fine with any of 1,5,or 10 fraction for my bone mets. would prob pick 5, but that's not data based, just a little bit of wishful thinking.

I would prefer 54/3 or 50/5 over 34/1 for my stage 1 lung cancer.
 
RealSimulD said:
This is mood affiliation in action. The pCr rate in rapido trial is impressive, amongst highest reported. As the honorable alligator asks, is it the chemotherapy or the SCRT? I answer - “yes”.

Give it a try. But beware the pelvic and abdominal spasms in week 1-2 after treatment. We have a handout made for this, with some people pre writing RXs

It’s not bad to do LCRT, I’m not judging anybody. I think the problem, personally, is this is an advance for patients but we get punished to do it. This is a big problem in RO, in general.
Click to expand...
Pcr in SC double lc, 27% vs 13%, yet somehow trending towards worse lrf, or equivalent... In any case, using the results of a trial comparing the short course regimen to a long course regimen nobody uses in the definitive setting doesn't seem right.
 
jondunn said:
sometimes I think about what I would/will want as a patient. changes from time to time. how I feel right now:

I would actively demand/want 5 fraction partial breast

would want prostate sbrt

I would lean towards wanting 25/5 but would be fine with either. 5.5 weeks is a long time to deal with the worsening acute toxicity, having to be on the table with it, etc

I would be fine with any of 1,5,or 10 fraction for my bone mets. would prob pick 5, but that's not data based, just a little bit of wishful thinking.

I would prefer 54/3 or 50/5 over 34/1 for my stage 1 lung cancer.
Click to expand...
If you can spare the anus, there is not much toxicity to rectal xrt, especially with imrt.
 
GI_RadOnc said:
Has anyone tried the FOLFOXIRI -> long course in the French study? I don't have the cajones to do it for locally advanced rectal cancer; but have seen some young patients with metastatic disease with a good response who have been referred in for the radiation...
Click to expand...

I have a local Med Onc who is doing FOLFOXIRI exclusively in his N+ rectals before I see them. They have happened to be those I would consider for W&W (anal involvement or ultra low likely requiring APR) anyways so I haven't had any qualms about long course. Part of the battle is managing expectations of the med oncs and surgeons one works with.

I do 5 x 5 routinely for metastatic folks going for surgery to avoid delays in effective systemic therapy. I used to worry about offering it to those who weren't going for surgery. The Wash U trial gives me some reassurance that it's not unreasonable with minimal even G2 persistence of side effects (although I would've liked to see incidence of G2 toxicity as well).
 
GI_RadOnc said:
I've been using short course TNT for just about everyone with locally advanced rectal cancer, including W&W since 2014... helps that my job has a Polish med onc; so he's totally on-board! But I do support the equipoise that we don't know for sure in the W&W setting the SC-TNT vs the LC-TNT.

The alpha/beta arguments and the non-statistically significant difference in local control are boomer arguments! That Hall textbook is about as relevant as the decay curve of a Co-60 teletherapy unit by now; and should be limited to the ABR board hazing only! And to not offer a patient 4 weeks of their life back for a numerical difference in local control that has a p=.10 is also silly.

The better argument for long course rectal cancer chemoradiation is the lack of W&W data; and lack of integration of SC-TNT with the rest of your treatment team (med onc, surgery).

Has anyone tried the FOLFOXIRI -> long course in the French study? I don't have the cajones to do it for locally advanced rectal cancer; but have seen some young patients with metastatic disease with a good response who have been referred in for the radiation...
Click to expand...
I must be a millennial boomer, because I live by a/b to extrapolate constraints when doing 8-15 fx hypofx… let’s me get in as much dose as I can safely.
 
Are we back to arguing about fractions again? The only number I care about are the number of graduating residents… 25/5 sounds like a good number!

I’m regards to rectal cancers… I’m definitely seeing a lot less these days and expect it to be due to TNT, and when they say TNT it usually means no RT despite the acronym having “total” in the name. Another site bites the dust!
 
RadOncDoc21 said:
Are we back to arguing about fractions again? The only number I care about are the number of graduating residents… 25/5 sounds like a good number!

I’m regards to rectal cancers… I’m definitely seeing a lot less these days and expect it to be due to TNT, and when they say TNT it usually means no RT despite the acronym having “total” in the name. Another site bites the dust!
Click to expand...
A lot of times our medoncs image pt after chemo and if good response, no xrt. Again absolute benefit of xrt is single digit if any.
 
RadOncDoc21 said:
Are we back to arguing about fractions again? The only number I care about are the number of graduating residents… 25/5 sounds like a good number!

I’m regards to rectal cancers… I’m definitely seeing a lot less these days and expect it to be due to TNT, and when they say TNT it usually means no RT despite the acronym having “total” in the name. Another site bites the dust!
Click to expand...
Chemo alone without RT?
 
RadOncDoc21 said:
Are we back to arguing about fractions again? The only number I care about are the number of graduating residents… 25/5 sounds like a good number!

I’m regards to rectal cancers… I’m definitely seeing a lot less these days and expect it to be due to TNT, and when they say TNT it usually means no RT despite the acronym having “total” in the name. Another site bites the dust!
Click to expand...
RickyScott said:
A lot of times our medoncs image pt after chemo and if good response, no xrt. Again absolute benefit of xrt is single digit if any.
Click to expand...

Off-protocol I am not seeing anyone routinely advocating for this...
 
For those using SC-RT, do you still use it when external iliacs or inguinals need to be treated? Or do you use LC-CRT for those situations?
 
RickyScott said:
I would feel embarrassed if I had to quote the actual local benefit of rectal xrt to a patient or at tumor board.
Click to expand...
It's slightly higher than the DFS benefit seen with Taxanes in breast cancer, yet ... you'd have to torture and maim a medonc not to give it.

I'm also "over" skipping RT on 70 year old women w/stage I breast cancer. If you can get a mammo, if you get a dx mammo, if you can get an US, if you can get a biopsy, if you can get a wire and lumpectomy + SLN bx (b/c not everyone Choosing Wisely), if you can even consider taking a pill for 5 years, you can most certainly do 5-15 fractions of RT to bring recurrence from 10% to 2%.
 
metview said:
For those using SC-RT, do you still use it when external iliacs or inguinals need to be treated? Or do you use LC-CRT for those situations?
Click to expand...
Yes, RAPIDO allowed for it. I don't think people are finding much toxicity. Personal communication from MDACC is that they tend to do long course in these situations. I've done it once. No issues.
 
RealSimulD said:
This is mood affiliation in action. The pCr rate in rapido trial is impressive, amongst highest reported. As the honorable alligator asks, is it the chemotherapy or the SCRT? I answer - “yes”.

Give it a try. But beware the pelvic and abdominal spasms in week 1-2 after treatment. We have a handout made for this, with some people pre writing RXs

It’s not bad to do LCRT, I’m not judging anybody. I think the problem, personally, is this is an advance for patients but we get punished to do it. This is a big problem in RO, in general.
Click to expand...
What do you prescribe for spasms?
 
RealSimulD said:
It's slightly higher than the DFS benefit seen with Taxanes in breast cancer, yet ... you'd have to torture and maim a medonc not to give it.
Click to expand...
I am not sure about that.
journals.plos.org

Adjuvant Chemotherapy, with or without Taxanes, in Early or Operable Breast Cancer: A Meta-Analysis of 19 Randomized Trials with 30698 Patients

Background Taxanes have been extensively used as adjuvant chemotherapy for the treatment of early or operable breast cancer, particularly in high risk, node-negative breast cancer. Previous studies, however, have reported inconsistent findings regarding their clinical efficacy and safety. We...
journals.plos.org journals.plos.org

In the era of neoadjuvant chemo (FOLFOX/FOLFOXIRI), neoadjuvant RT for rectal cancer adds very little.

Two possible study designs:

1. Redo the MRC rectal cancer trial, this time with neoadjuvant chemo,
pubmed.ncbi.nlm.nih.gov

Preoperative radiotherapy versus selective postoperative chemoradiotherapy in patients with rectal cancer (MRC CR07 and NCIC-CTG C016): a multicentre, randomised trial - PubMed

Taken with results from other randomised trials, our findings provide convincing and consistent evidence that short-course preoperative radiotherapy is an effective treatment for patients with operable rectal cancer.
pubmed.ncbi.nlm.nih.gov pubmed.ncbi.nlm.nih.gov
All patients get neoadjuvant chemo, half get 5 x 5 Gy preoperatively, the other half only get postoperative CRT if R1-resected.
Now, I know that postoperative CRT is not as well tolerated or effective as preoperative, but how many patients do you think will require any. Probably very few...

2. Ommit RT based on MRI/PET-response
All patients get new neoadjuvant chemo, those responding well don't get neoadjuvant RT. Those who don't respond well, get neoadjuvant RT.
 
Last edited:
Palex80 said:
I am not sure about that.
journals.plos.org

Adjuvant Chemotherapy, with or without Taxanes, in Early or Operable Breast Cancer: A Meta-Analysis of 19 Randomized Trials with 30698 Patients

Background Taxanes have been extensively used as adjuvant chemotherapy for the treatment of early or operable breast cancer, particularly in high risk, node-negative breast cancer. Previous studies, however, have reported inconsistent findings regarding their clinical efficacy and safety. We...
journals.plos.org journals.plos.org

In the era of neoadjuvant chemo (FOLFOX/FOLFOXIRI), neoadjuvant RT for rectal cancer adds very little.

Two possible study designs:

1. Redo the MRC rectal cancer trial, this time with neoadjuvant chemo,
pubmed.ncbi.nlm.nih.gov

Preoperative radiotherapy versus selective postoperative chemoradiotherapy in patients with rectal cancer (MRC CR07 and NCIC-CTG C016): a multicentre, randomised trial - PubMed

Taken with results from other randomised trials, our findings provide convincing and consistent evidence that short-course preoperative radiotherapy is an effective treatment for patients with operable rectal cancer.
pubmed.ncbi.nlm.nih.gov pubmed.ncbi.nlm.nih.gov
All patients get neoadjuvant chemo, half get 5 x 5 Gy preoperatively, the other half only get postoperative CRT if R1-resected.
Now, I know that postoperative CRT is not as well tolerated or effective als preoperative, but how many patients do you think will require any. Probably very few...

2. Ommit RT based on MRI/PET-response
All patients get new neoadjuvant chemo, those responding well don't get neoadjuvant RT. Those who don't respond well, get neoadjuvant RT.
Click to expand...
Yep, this is what’s being done out there folks and if there are med oncs dictating cancer care in your area, they now have another disease site they get to manage without us and can determine when to get us involved. Rectal cancer just became the new pancreatic cancer.

I know there are a lot of people who have cordial colleagues and a healthy relationship but just know all it takes is a subtle change in practice to have a significant impact. I had a a colorectal surgeon who would send to me directly, after he left, the general surgeons will now only send directly to the med oncs because they’re idiots and don’t understand oncology.

I feel like I’m the owner of a blockbuster franchise in 2001 and I’m hearing stories about a new company called Netflix!

I will make one last analogy. As we continue to argue about fractions, volumes, dose, etc, there is a real dangerous threat looming. Med oncs and insurance companies don’t care about any of that and are ready to wipe us out. So while many can afford the luxury of choosing a fractionation, there are some rad oncs who are casualties in being involved in treating GI cancers.
I feel like I’m trying to warn you guys that there are “white walkers” beyond our walls and they smell blood!
 
Last edited:
Palex80 said:
I am not sure about that.
journals.plos.org

Adjuvant Chemotherapy, with or without Taxanes, in Early or Operable Breast Cancer: A Meta-Analysis of 19 Randomized Trials with 30698 Patients

Background Taxanes have been extensively used as adjuvant chemotherapy for the treatment of early or operable breast cancer, particularly in high risk, node-negative breast cancer. Previous studies, however, have reported inconsistent findings regarding their clinical efficacy and safety. We...
journals.plos.org journals.plos.org

In the era of neoadjuvant chemo (FOLFOX/FOLFOXIRI), neoadjuvant RT for rectal cancer adds very little.

Two possible study designs:

1. Redo the MRC rectal cancer trial, this time with neoadjuvant chemo,
pubmed.ncbi.nlm.nih.gov

Preoperative radiotherapy versus selective postoperative chemoradiotherapy in patients with rectal cancer (MRC CR07 and NCIC-CTG C016): a multicentre, randomised trial - PubMed

Taken with results from other randomised trials, our findings provide convincing and consistent evidence that short-course preoperative radiotherapy is an effective treatment for patients with operable rectal cancer.
pubmed.ncbi.nlm.nih.gov pubmed.ncbi.nlm.nih.gov
All patients get neoadjuvant chemo, half get 5 x 5 Gy preoperatively, the other half only get postoperative CRT if R1-resected.
Now, I know that postoperative CRT is not as well tolerated or effective als preoperative, but how many patients do you think will require any. Probably very few...

2. Ommit RT based on MRI/PET-response
All patients get new neoadjuvant chemo, those responding well don't get neoadjuvant RT. Those who don't respond well, get neoadjuvant RT.
Click to expand...
Agreed, xrt has local absolute benefit of around 5% compared with nothing in setting of TME, but chemo, especially folfox will significantly “eat into” this 5%.
 
Last edited:
RadOncDoc21 said:
Yep, this is what’s being done out there folks and if there are med oncs dictating cancer care in your area, they now have another disease site they get to manage without us and can determine when to get us involved. Rectal cancer just became the new pancreatic cancer.
Click to expand...
Still getting panc referrals as well.... What happens when they aren't Whipple candidates??
 
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jondunn said:
I get those referrals too, after they have been on FOLFIRINOX for some time and haven’t metted out, usually like 3-6 months
Click to expand...
Yup. Usually this scenario, or... chemo till progression. If local only, chemo RT. If metastatic, more chemo.
 
Palex80 said:
I see the reactions, but I have not cured a pancreatic cancer patient yet in my career without surgery using SBRT or chemorads or whatever.
Click to expand...
No it’s just sad in general, kinda like GBM’s without surgery. Are there some who live, of course but we all know and have seen what usually happens. Unless you treat at Cancer Treatment Centers of America where “all they treat is cancer…” that’s all I treat also.
 
Palex80 said:
I see the reactions, but I have not cured a pancreatic cancer patient yet in my career without surgery using SBRT or chemorads or whatever.
Click to expand...

You're right. The data shows very clearly that 5 year survival is basically 0% without curative-intent surgery in pancreas cancer.

Quality SBRT/chemorads likely gets you local and symptom control. Whether there's a population where you can improve survival is an open question.
 
Palex80 said:
In the era of neoadjuvant chemo (FOLFOX/FOLFOXIRI), neoadjuvant RT for rectal cancer adds very little.
Click to expand...
RickyScott said:
Agreed, xrt has local absolute benefit of around 5% compared with nothing in setting of TME, but we know chemo, especially folfox will significantly “eat into” this 5%.
Click to expand...
The benefit of neo RT LC in rectal cancer is double digit, like 10 or 11 (binary notation).

RadOncDoc21 said:
I feel like I’m the owner of a blockbuster franchise in 2001 and I’m hearing stories about a new company called Netflix!
Click to expand...
quTbpPv.jpg
 
Palex80 said:
I am not sure about that.
journals.plos.org

Adjuvant Chemotherapy, with or without Taxanes, in Early or Operable Breast Cancer: A Meta-Analysis of 19 Randomized Trials with 30698 Patients

Background Taxanes have been extensively used as adjuvant chemotherapy for the treatment of early or operable breast cancer, particularly in high risk, node-negative breast cancer. Previous studies, however, have reported inconsistent findings regarding their clinical efficacy and safety. We...
journals.plos.org journals.plos.org
Click to expand...
Not arguing relatively small benefit of XRT here, but I'll let you estimate an "absolute benefit" of a 17% HR in early stage breast CA when accounting for additional therapy available today. I'm guessing absolute benefit is quite small.

In addition, this meta-analysis has a great plot:

image

Always look at what the largest trials tell you.
 
communitydoc13 said:
Not arguing relatively small benefit of XRT here, but I'll let you estimate an "absolute benefit" of a 17% HR in early stage breast CA when accounting for additional therapy available today. I'm guessing absolute benefit is quite small.

In addition, this meta-analysis has a great plot:

image

Always look at what the largest trials tell you.
Click to expand...
The two largest studies were negative.
E2197 was a negative study.
UKTACT was a negative study.
When you put it all together, there may be a benefit. However, they don’t speak to the patient like that. There is no “choosing wisely” to hold off on the T, because may be marginal benefit. I’m not saying I’m anti Taxane, I’m just saying the neuropathy is no joke, it’s minimized by MO, the benefit is so so, and yet it’s is a defined “standard of care”.
 
Ray D. Ayshun said:
Pcr in SC double lc, 27% vs 13%, yet somehow trending towards worse lrf, or equivalent... In any case, using the results of a trial comparing the short course regimen to a long course regimen nobody uses in the definitive setting doesn't seem right.
Click to expand...
“Trending” isn’t good stats. It’s a 2.7% difference and it’s not SS. I don’t think anyone but those holding on to long course is looking at that number. Respectfully…

If we see something non-significant supporting what we already believe, then we evaluate it in a way that supports what we believe. If something goes against what we believe, we muster all of our critical / analytical skills to say why that data is wrong.

Facts -

Two short course vs LCRT trials show no efficacy difference

Acute toxicity is lower with short course
One study shows worse outcomes with distal disease (other study did not show this, nor did RAPIDO)

RAPIDO has excellent outcomes with the intervention arm and is equivalent or better in almost all outcomes

If you’ve never done one or the other before and are starting anew as a RadOnc, I think most people would probably do SCRT. But, I may be wrong.

Say if SCRT was better and we knew with 100% certainty. It still sucks taking 20-23 fractions off. If we get paid substantially different for the treatment, of course our analysis is going to be somewhat flawed. Our getting a massive haircut to do new things is going to throw a wrench into things. I hate that we have to even think that way.

In this case, I think at the very least, we can say it’s 50/50, but practice pattern don’t support that. I think 90+ % people do LCRT.

If everyone at every center rapidly changed to short course everything, it would be an absolute nightmare. So, people have to hold the line.
 
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