Rad Onc Twitter

[Palex80]

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Anal cancer on it's way to become the next 5 fractions indication.

5 x 4 Gy for ENI
5 x 5 Gy for cN+
5 x 6 Gy for primary and call it a day?

 

[medgator]

Anal cancer on it's way to become the next 5 fractions indication.

5 x 4 Gy for ENI
5 x 5 Gy for cN+
5 x 6 Gy for primary and call it a day?

28 to 23 fractions? 5 fractions didn't work out so well in rectal. Anything organ preserving like anal or h&n will continue to get long-course chemoRT imo

 

[radoncftw]

28 to 23 fractions? 5 fractions didn't work out so well in rectal. Anything organ preserving like anal or h&n will continue to get long-course chemoRT imo

I think the 5 fraction regimen is here to stay. May be some areas where long-course is a better option, but most patients will probably do fine with 5 fraction. RAPIDO wasn't designed to compare LC + SC. Prior studies that were show equivalence.

 

[Palex80]

5 x 6 Gy gives a BED of 48 Gy (a/b=10 Gy)
28 x 1.8 Gy gives a BED of 59.5 Gy (a/b=10 Gy)

a/b for anal cancer cells is however perhaps lower than 10 Gy?

 

[communitydoc13]

Coming soon by all insurances and they wouldnt be “wrong”:

Standard non IBC RNI without a needed boost: we will only cover 15

Standard non IBC which requires a standard boost: we will only cover 16

APBI candidate: we will cover 5

Non RNI, not APBI: we will cover 5 WBRT

We were wrong. We use the wrong tools. Would you want to offer 5 fraction whole breast to a 45-55 y/o after reading the appendices to the five fraction whole breast trials?

5 fraction is a bit worse that 13-16 fraction for long term cosmetic and fibrotic outcomes.

I love APBI for the right patient. However, have you felt the lumpectomy bed 2 years out from XRT in these patients? Cosmesis is good for APBI because of volumes alone.

Like many things, we have used EBM tools to advance the field to shorter, more convenient care that is in some ways a little bit worse, but is much easier to consolidate in a few large centers.

Meanwhile, in my experience, academics with captive metastatic patients are the most likely to offer prolonged or expensive palliative radiation.

Whatever, I have adopted moderate hypofractionation for many things as it is now national standard of care.

Why are we not seeing articles like, "The radiation oncologist as comprehensive solid tumor oncologist in rural America: accounting for distribution of care crises by expanding the scope of practice of available board certified physicians"

 

[TheWallnerus]

5 x 6 Gy gives a BED of 48 Gy (a/b=10 Gy)
28 x 1.8 Gy gives a BED of 59.5 Gy (a/b=10 Gy)

a/b for anal cancer cells is however perhaps lower than 10 Gy?

You didn’t correct for time 🙂

 

[OTN]

50.4 Gy is worse for cosmesis than UK/Canadian
5 fraction whole breast is worse for cosmesis than UK/Canadian
5 fraction partial breast is not worse for cosmesis than UK/Canadian

For my patients who get non-oncoplastic lumpectomies and are eligible for APBI, I treat with Livi APBI. If they cared about cosmesis enough to get an oncoplastic lumpectomy, then UK/Canadian it is. If they don't care about cosmesis, didn't get an oncoplastic lumpectomy, and aren't eligible for partial breast RT, then 5-fraction whole breast. I haven't seen any of the latter yet, but that's probably because the vast majority of the lumpectomies I see are oncoplastic.

 

[grenz]

50.4 Gy is worse for cosmesis than UK/Canadian
5 fraction whole breast is worse for cosmesis than UK/Canadian
5 fraction partial breast is not worse for cosmesis than UK/Canadian

For my patients who get non-oncoplastic lumpectomies and are eligible for APBI, I treat with Livi APBI. If they cared about cosmesis enough to get an oncoplastic lumpectomy, then UK/Canadian it is. If they don't care about cosmesis, didn't get an oncoplastic lumpectomy, and aren't eligible for partial breast RT, then 5-fraction whole breast. I haven't seen any of the latter yet, but that's probably because the vast majority of the lumpectomies I see are oncoplastic.

Something that isn’t talked about much is Livi’s control arm was conventional frac. So unless I missed something, we don’t know for sure how it compares to UK/canadian

 

[Palex80]

Something that isn’t talked about much is Livi’s control arm was conventional frac. So unless I missed something, we don’t know for sure how it compares to UK/canadian

Indeed, and there was also a 10Gy-boost in the conventional arm.

To me, the Livi regime was more of a way to prove that APBI is safe in terms of toxicity and without an excessive risk for recurrences, as long as you picked the patients right.

One can always argue to do IMPORT-LOW (40/2.66) partial breast, if one is not confident with the Livi regime.

Or, as TheWallnerus will likely agree, simply do FAST-FORWARD to a partial breast volume.
If FAST-FORWARD to the whole breast is non-inferior to START-B to the whole breast, then FAST-FORWARD to a partial breast volume will certainly not be inferior to START-B to the whole breast in terms of cosmesis. Only caveat here is the boost. FAST-FORWARD is one week, but some patients got a boost (delivered in 5 fractions with 2 Gy each). How to compensate for that (provided you want to give the boost)?

 

[sirspamalot]

Round these parts everyone gets 4256/16 unless there is RNI, then regular. Or some other compelling factor.

1, uno, un, echad, etc.. patient demanded APBI with EBRT and so it was done.

Choosing Wisely..or going insane/broke. What'll it be folks?

 

[grenz]

Indeed, and there was also a 10Gy-boost in the conventional arm.

To me, the Livi regime was more of a way to prove that APBI is safe in terms of toxicity and without an excessive risk for recurrences, as long as you picked the patients right.

One can always argue to do IMPORT-LOW (40/2.66) partial breast, if one is not confident with the Livi regime.

Or, as TheWallnerus will likely agree, simply do FAST-FORWARD to a partial breast volume.
If FAST-FORWARD to the whole breast is non-inferior to START-B to the whole breast, then FAST-FORWARD to a partial breast volume will certainly not be inferior to START-B to the whole breast in terms of cosmesis. Only caveat here is the boost. FAST-FORWARD is one week, but some patients got a boost (delivered in 5 fractions with 2 Gy each). How to compensate for that (provided you want to give the boost)?

Since the publication of the DBCG trial, I’ve come around to the thinking that IMPORT-LOW has the best evidence of any PBI regimen, including Livi. I don’t use PBI a lot but when I do, it’s three weeks of two or three fields

 

[TheWallnerus]

Since the publication of the DBCG trial, I’ve come around to the thinking that IMPORT-LOW has the best evidence of any PBI regimen, including Livi. I don’t use PBI a lot but when I do, it’s three weeks of two or three fields

IMPORT-LOW…

So hot in quality and evidence

So cold in the heart and mind of the American MD

 

[sirspamalot]

negative ghostrider, the RVU's are low

 

[Ray D. Ayshun]

IMPORT-LOW…

So hot in quality and evidence

So cold in the heart and mind of the American MD

i do import all the time. to some degree i do it with every breast i treat inasmuch as i dont have my tangents blasting through from wire to wire.

 

[thecarbonionangle]

i do import all the time. to some degree i do it with every breast i treat inasmuch as i dont have my tangents blasting through from wire to wire.

This is how i would look at it, basically tells you it is ok to “cheat” a bit

 

[communitydoc13]

IMPORT-LOW…

So hot in quality and evidence

So cold in the heart and mind of the American MD

It's barely partial breast. It's a treat most of the breast protocol, which is what we all do anyway (except for some old folks, who really take 3 cm lung bites and 2 cm inferior margins on their tangents).

 

[sirspamalot]

It's barely partial breast. It's a treat most of the breast protocol, which is what we all do anyway (except for some old folks, who really take 3 cm lung bites and 2 cm inferior margins on their tangents).

 

[grenz]

It's barely partial breast. It's a treat most of the breast protocol, which is what we all do anyway (except for some old folks, who really take 3 cm lung bites and 2 cm inferior margins on their tangents).

It’s enough that it improves cosmesis. Regardless, it definitely has the strongest data behind ir

 

[communitydoc13]

It’s enough that it improves cosmesis. Regardless, it definitely has the strongest data behind ir

Agree. I was just responding to @TheWallnerus regarding why it isn’t exciting to us as a group.

 

[metallica81788]

Isn't the reimbursement for 5fx PBI with IMRT and daily CBCT about the same as 15fx 3D?
I guess only difference is the wRVUs for those two extra OTVs

Import low is not partial breast. Especially if you've seen these seromas out in the community; it's pretty much worthless for most
Florence or 15/16fx or nodes

 

[sirspamalot]

Breast tangents in 16 fx works fine, RNI gets the full monty. IDGAF what the overseas data says: if my patient gets arm edema, and it goes there, then I will get slaughtered in front of jury. It is what it is... hypofrac for RNI is not the USA community standard. If you're going to do it, I hope its for SLN patients only... because round these parts some patients are still getting axillary dissections. Its not like I get to dictate what happens before they get here and neither do you.

APBI? Nah. Think of your patient population. Will they really take their pill every day for 5 years? And if they're high risk otherwise? Just think of it as prophylaxis. For small breasts with big cavity margins its still whole breast anyway.

16fx (rarely boost) is basically where the line is drawn for average patients. Perhaps if you have 40+ on treatment and the linac folks are wilting..

 

[TheWallnerus]

Agree. I was just responding to @TheWallnerus regarding why it isn’t exciting to us as a group.

Isn't the reimbursement for 5fx PBI with IMRT and daily CBCT about the same as 15fx 3D?
I guess only difference is the wRVUs for those two extra OTVs

Import low is not partial breast. Especially if you've seen these seromas out in the community; it's pretty much worthless for most
Florence or 15/16fx or nodes

Breast tangents in 16 fx works fine, RNI gets the full monty. IDGAF what the overseas data says: if my patient gets arm edema, and it goes there, then I will get slaughtered in front of jury. It is what it is... hypofrac for RNI is not the USA standard.

APBI if you have a Contura, or a highly educated well taken care of (top 5%) type patient, otherwise, esp in my population who won't reliably take their pillz, why is everyone so worked up about 60+ year old breasts? Just think of it as prophylaxis and all is well.

16fx (rarely boost) is as far as Imma gunna go. If I was incredibly busy (40+ on tx) I'd start seriously thinking about 5 fx... it ain't. gonna. happen.

16 fractions is a way to pay fealty to thine overlords for an extra fraction, whereas 15 fractions works just as well clinically (and offers equal wRVUs to the MD serfs) and would ipso facto offer less side effects than 16 fractions/more dose.

Discuss!

 

[sirspamalot]

I can't wait for the 16 v 15 randomized trial to be published. Why, it will get an oral presentation and put someone on track to be a Department Chair surely.

 

[Mandelin Rain]

I can't wait for the 16 v 15 randomized trial to be published. Why, it will get an oral presentation and put someone on track to be a Department Chair surely.

We got a 26 vs 27 Gy study (with a stat sig difference)

 

[TheWallnerus]

It's barely partial breast. It's a treat most of the breast protocol,

I would call this not true! IMPORT-LOW volumes can prevent hundreds of cc's of normal tissue from seeing any RT at all versus standard tangents, and sometimes 0 cc of lung getting any dose (besides scatter); the latter is typically not achievable with standard tangents. If I had a boob, and a lung, I'd love to get ~0 Gy to my lung during boob RT if possible.

Also keep in mind what IMPORT stands for: intensity modulated partial organ radiotherapy. This trial gives excellent "cover" in my opinion to use IMRT to give 15 fractions of breast RT.

 

[sirspamalot]

Yes. But.. there are caveats littered like a Ukranian Minefield in Bahkrut with regards to that study.
'
Excellent discussion here: Expert Discussion: Hypofractionated Radiation Therapy – Standard for All Indications?

I stand by my original statement (tongue in cheek one was obviously for fun).

 

[TheWallnerus]

Yes. But.. there are caveats littered like a Ukranian Minefield in Bahkrut with regards to that study.
'
Excellent discussion here: Expert Discussion: Hypofractionated Radiation Therapy – Standard for All Indications?

I stand by my original statement (tongue in cheek one was obviously for fun).

We can quibble, now, over whether hypofx is standard for all breast RT indications. As we all know, it is the standard for many rad oncs elsewhere on the planet:

It is as plain as the tusks coming out of my mouth that one day in the not distant future insurance companies will place 15 fractions as the upper limit of fractions for all breast cancer RT patients... and 5 fractions some years after that if FAST-Forward nodal substudy is good.

 

[sirspamalot]

I would call this not true! IMPORT-LOW volumes can prevent hundreds of cc's of normal tissue from seeing any RT at all versus standard tangents, and sometimes 0 cc of lung getting any dose (besides scatter); the latter is typically not achievable with standard tangents. If I had a boob, and a lung, I'd love to get ~0 Gy to my lung during boob RT if possible.

Also keep in mind what IMPORT stands for: intensity modulated partial organ radiotherapy. This trial gives excellent "cover" in my opinion to use IMRT to give 15 fractions of breast RT.

Yes in this highly favorable subset of g1/2 ER+ PR+ patients ( ~90% on trial) who were on a trial and likely therefore religiously taking their endocrine therapy.. seems like it'd be good.

For those not in most favored status.. and who won't take their pillz reliably.. are you still willing to do this regimen?

I've treated breast tangents standard and then mod hypo over a long career. In healthy patients who are not competitive triatheletes (I've never had one) lung damage appears to be irrelevant.

 

[sirspamalot]

When Evilcore/Insurance and the RCS solely determine my patients care, I hope I will be in retirement..

 

[TheWallnerus]

Yes in this highly favorable subset of g1/2 ER+ PR+ patients ( ~90% on trial) who were on a trial and likely therefore religiously taking their endocrine therapy.. seems like it'd be good.

For those not in most favored status.. and who won't take their pillz reliably.. are you still willing to do this regimen?

I've treated breast tangents standard and then mod hypo over a long career. In healthy patients who are not competitive triatheletes (I've never had one) lung damage appears to be irrelevant.

In many Shakespearean plays a character often exclaims "ALARUM!"

"ALARA!" for ~6 years now. So yes totally willing. Peering into the mind of the patient to gauge future endocrine compliance seems illogical, on the basis of RT data we have, on which to base breast PTV decisions for low risk breast cancer.

 

[sirspamalot]

Illogical?

 

[TheWallnerus]

Illogical?

Yes, sure, illogical. We know there's about a 10-20% non-compliance rate for endocrine therapy for breast cancer patients. It would be illogical to think that somehow all the non-compliance was distributed all Maxwell's Demon-like into either 1) the whole breast RT group (trend toward more LR vs IMPORT) or 2) the IMPORT group (trend toward less LR vs whole breast). Almost certainly, thanks to the power of randomization, the non-compliance reached entropy between the groups. Finally, thinking Fisherian, "variations in the style of locoregional therapy will never affect OS in breast cancer."

 

[sirspamalot]

Yes, sure, illogical. We know there's about a 10-20% non-compliance rate for endocrine therapy for breast cancer patients. It would be illogical to think that somehow all the non-compliance was distributed all Maxwell's Demon-like into either 1) the whole breast RT group (trend toward more LR vs IMPORT) or 2) the IMPORT group (trend toward less LR vs whole breast). Almost certainly, thanks to the power of randomization, the non-compliance reached entropy between the groups.

Lol 20% noncompliance rate. Also, define "noncompliance" cause its not just "i missed a pill once last week, but otherwise I did great in the last xx months" versus "I take them every other day, it really helps keep my hot flashes in check. Also, sometimes I just skip a few days."


Bro, where do you practice? I think you made my point for me.

 

[TheWallnerus]

Lol 20% noncompliance rate. Also, define "noncompliance" cause its not just "i missed a pill once last week, but otherwise I did great in the last xx months" versus "I take them every other day, it really helps keep my hot flashes in check. Also, sometimes I just skip a few days."


Bro, where do you practice? I think you made my point for me.

Imagine a 50-100% endocrine non-compliance rate for each group in the curves above... does endocrine non-compliance affect LR in terms of breast PTVwhole (recurrence 1.5% @7y) vs breast PTVpartial (recurrence 1.2% @7y)? The higher the non-compliance, one becomes more compelled to assume that the raw number of non-adherers is higher, but still equal, in the two different PTV groups (giving a better potential effect of non-compliance on the LR). And, AT WORST, if Maxwell's Demon did put all the endocrine non-adherers in the IMPORT group, non-adherence had no effect on LR... and/or made LR statistically insignificantly less likely. (EDIT: I should also make the point that if the Demon put all the non-adherers in the whole breast group, non-compliance also likewise had no effect on LR.)

 

[communitydoc13]

We can quibble, now, over whether hypofx is standard for all breast RT indications. As we all know, it is the standard for many rad oncs elsewhere on the planet:

It is as plain as the tusks coming out of my mouth that one day in the not distant future insurance companies will place 15 fractions as the upper limit of fractions for all breast cancer RT patients... and 5 fractions some years after that if FAST-Forward nodal substudy is good.

Don't practice like the Brits unless you have to. NHS not a destination for medical tourism.

 

[Fpg1245]

Don't practice like the Brits unless you have to. NHS not a destination for medical tourism.

No need to follow them over a cliff.

 

[TheWallnerus]

Don't practice like the Brits unless you have to. NHS not a destination for medical tourism.

And yet, in terms of breast hypofractionation, almost all the good usable data for this comes from the Brits... and was originated by the Brits for sure. The Brits "discovered" the alpha/beta for breast cancer and the normal tissue of the breast/ribs/chest wall and so on. START, IMPORT, FAST-Forward, etc. All the feelings of "it's safe to hypofractionate breast" for tumor control and side effects come from Britain. Like when Gene Wilder told Marty Feldman "Damn your eyes!" and Marty Feldman said "Too late!"... it's too late for us NOT to practice like the Brits. We already are.

 

[communitydoc13]

And yet, in terms of breast hypofractionation, almost all the good usable data for this comes from the Brits

All true, and their trials are well done IMO. But the statistical tools are misleading and the motivation is clear. This is the NHS. They are very transparent in their published appendices. In terms of EBM, Brits far far far ahead of us.

It is reasonable and in general cost effective to hypofractionate anything. I would not be going beyond moderate hypofractionation for my wife's whole breast.

 

[TheWallnerus]

All true, and their trials are well done IMO. But the statistical tools are misleading and the motivation is clear. This is the NHS. They are very transparent in their published appendices. In terms of EBM, Brits far far far ahead of us.

It is reasonable and in general cost effective to hypofractionate anything. I would not be going beyond moderate hypofractionation for my wife's whole breast.

Guns don't kill people, people kill people. Statistical tools are likewise not misleading!

And given that stage I breast cancer is the most common presentation of breast cancer, I likely would not use any sort of fractionation schedule on my wife's whole breast. Of course, I don't have a wife.

 

[communitydoc13]

Guns don't kill people, people kill people. Statistical tools are likewise not misleading!

And given that stage I breast cancer is the most common presentation of breast cancer, I likely would not use any sort of fractionation schedule on my wife's whole breast. Of course, I don't have a wife.

Telling. (not the wife thing, the omission thing).

Fair regarding the guns analogy. Often there isn't an appropriate gun for the job. Toxicity is tough to study well. Rare bad toxicity is not conducive to p-value type work, and common lower grade toxicity has enormous variance in assessment.

 

[sirspamalot]

My RVU's bring all the admins to the yard..

 

[TheWallnerus]

Telling. (not the wife thing, the omission thing).

Fair regarding the guns analogy. Often there isn't an appropriate gun for the job. Toxicity is tough to study well. Rare bad toxicity is not conducive to p-value type work, and common lower grade toxicity has enormous variance in assessment.

I would not omit radiation... I just almost never irradiate whole breast for low risk stage I anymore. (And stage 0 or stage I is the majority of what we all see, natch.)

"Rare bad toxicity is not conducive to p-value type work"...
Have to mention: the most significant p-values in MA20 and EORTC 22922 (p<0.001 ranges eg) were for lung toxicity from ENI... not for improved DFS and certainly not improved OS.

 

[RadOncDoc21]

Another spinoff to the breast is the worst conversation!

 

[sirspamalot]

If they're that low risk, how about surgery + hormones then and radiation be gone

 

[TheWallnerus]

If they're that low risk, how about surgery + hormones then and radiation be gone

How about a trial of 26 Gy/5fx partial breast/no hormone vs no RT/hormones

 

[TheWallnerus]

Another spinoff to the breast is the worst conversation!

Worst?! You can't spell B-R-E-A-S-T without B-E-S-T.

 

[sirspamalot]

Worst?! You can't spell B-R-E-A-S-T without B-E-S-T.

Breast is the..

 

[evilbooyaa]

Coming soon by all insurances and they wouldnt be “wrong”:

Standard non IBC RNI without a needed boost: we will only cover 15

Standard non IBC which requires a standard boost: we will only cover 16

APBI candidate: we will cover 5

Non RNI, not APBI: we will cover 5 WBRT

15Fx for RNI seems fine based on updated data. I felt it was 'too early' as a resident but there aren't really any new safety signals I'm aware of. Glad I don't treat breast...

APBI billed as SBRT for 5Fx? Sounds good to me for appropriate candidates. Win-win. That being said, people that are 'candidates' for APBI are much more than the inclusion criteria for the trials - are there clips? Seroma? % of breast filled by the seroma is too big? Unable to create a safe plan due to anatomy?

27/5 Fx WBRT is worse than 16 in terms of toxicity (buried in the supplement section). I would fight for 16Fx WBRT to be an option compared to 5Fx WBRT the same way I fight for conventional prostate to still be an option compared to mod hypo.

Even at end of residency (like 4-5 years ago) we had early stage breast patients who got denied by the boomer attending wanting to do 25Fx in a large breasted patient

 

[sirspamalot]

we had early stage breast patients who got denied by the boomer attending wanting to do 25Fx in a large breasted patient

 

[communitydoc13]

Have to mention: the most significant p-values in MA20 and EORTC 22922 (p<0.001 ranges eg) were for lung toxicity from ENI... not for improved DFS and certainly not improved OS.

Have to reply that you may be making my point. 11 vs 2 patients with grade 2 pneumonitis in arms with 900 patients. 1% vs 0%. That p-value should not be lauded and the added risk may be clinically insignificant.