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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."Illogical?
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."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.
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.)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.
Don't practice like the Brits unless you have to. NHS not a destination for medical tourism.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.
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.Don't practice like the Brits unless you have to. NHS not a destination for medical tourism.
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.And yet, in terms of breast hypofractionation, almost all the good usable data for this comes from the Brits
Guns don't kill people, people kill people. Statistical tools are likewise not misleading!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.
Telling. (not the wife thing, the omission thing).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.
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.)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.
How about a trial of 26 Gy/5fx partial breast/no hormone vs no RT/hormonesIf they're that low risk, how about surgery + hormones then and radiation be gone
Worst?! You can't spell B-R-E-A-S-T without B-E-S-T.Another spinoff to the breast is the worst conversation!
Breast is the..Worst?! You can't spell B-R-E-A-S-T without B-E-S-T.
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 had early stage breast patients who got denied by the boomer attending wanting to do 25Fx in a large breasted patient
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.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.
Why would anal cancer cells a/b be lower than 10? Squamous cell, concern for fast repopulation, etc. etc. A/b 10 seems appropriate.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?
IMPORT-LOW…
So hot in quality and evidence
So cold in the heart and mind of the American MD
Are you arguing against partial breast irradiation? And you think endocrine compliance has something to do with risk of IBTR that would be non-equal between the two groups?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).
I will dance on the head of a pin and quibble with the pneumonitis rate numbers; can be more like 4% vs 2%. Clinically insignificant? The number needed to harm w/ breast ENI is arguably smaller (about 40) than the number needed to treat for a DFS w/ ENI (about 100)... an inconvenient truth! But I say all that to also say the ~1% vs ~1% local recurrence rates with whole vs partial breast RT in low risk breast cancer, in IMPORT-LOW, must thus be termed clinically insignificant too.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.
"An argument without merit!" (!)6 year follow up is not the be all end all for breast cancer. LRR risk doesn't dissipate with time in breast
For those paying attention, or for Anglophiles, or both, IMPORT-LOW is, now, really 26 Gy/5 fx. Which should offer lower toxicity than 30/5.Nothing wrong with IMPORT-LOW, but nothing wrong with Livi et al. Different strokes for different folks.
Not unreasonable to do but no clinical data on 26/5 partial breast in terms of 'establishing a standard'. Is it enough dose in the PBI setting compared to the same dose for WBI? We know how sensitive LC rates are to even slight differences in total RT dose across a 5fx regimen...For those paying attention, or for Anglophiles, or both, IMPORT-LOW is, now, really 26 Gy/5 fx. Which should offer lower toxicity than 30/5.
5 years not being long enough for breast is the boomerest RO thing ever
I do. No age restriction. That doesn't even make biological sense.Tell it to your 40 yo high risk patient.
How about 5Fx whole breast is more toxic than 15-16Fx whole breast based on the supplemental data that was buried by the UK folks because they're perversely incentivized to limit number of treatments despite the potential downsides, similar to as is seen in prostate cancer?
PS - my standard is 3 weeks for all whole breasts, so ya can't "OK boomer" me!
Two sets of cultists on either side, what are those of in the middle like me and OTN supposed to do?
I am here to learn. Explain please why dose/fraction would change outcomes in 40 vs 65 year old? Data please, as this is "common sense"If you don't understand the difference between a high risk 40yo patient and a 65 yo ER+ low risk patient, its you who is lacking common sense.
@TheWallnerus you will never succeed in life until you start to think like a Med OncHow about a trial of 26 Gy/5fx partial breast/no hormone vs no RT/hormones vs 5 years of weekly pembrolizumab
At the level of evidence to which I think you're hinting, we will never get that "standard." So we have it now, or we don't. You/we decide!Not unreasonable to do but no clinical data on 26/5 partial breast in terms of 'establishing a standard'.
WellSlide are cool. References are better. One thing isn't necessarily another. And breast cancer goes way past 10 years if we're talking about high risk 40 year olds.
Cherry picking low risk patients and hollering about marginally improved cosmetic outcomes, ok dokey.
Meanwhile, I like my job. If you're hypo everything, then I would think you do nothing but 5 fraction rectal, 1 fraction bone mets, and whenever possible, no radiation at all where the benefit is so marginal as to be in doubt.
Try me! @elementaryschooleconomics @TheWallnerus and @NotMattSpraker have changed my practice.No, you're not hear to learn. You're hear to espouse your one sided holy grail views based on 6 year follow up data without regard to the potential for long term risk to patients who may be at high risk not only for local recurrence but distal failure as well.
I do. No age restriction. That doesn't even make biological sense.
So, I hear you, but that is in terms of follow up for recurrence. None of the studies have shown a change after 5 year mark AFTER the treatment.
ER+ breast cancer comes back forever. It's almost like looking at 5 year outcomes for prostate cancer.
Age also matters enormously for ER+ breast CA. Utility of genomic studies limited in younger patients for a number of reasons (including menstrual modulation of genomic profiles).
Man comprehension is difficult out there in MO!Because treatment hasn't changed for breast cancer since the 1970's? So nothing will change?
It must have felt so good to write that sentence, and yet, here we are.
Dude... I am the expert. You are the expert.Regardless, the experts agree that 16 fx is just fine,