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Man comprehension is difficult out there in MO!

Anyway - no - the way breast cancer studies work haven't changed since the 70s. Not one study has shown a difference in the 10 year update. I don't know how else to keep saying this.
LOL. We are constantly learning new information. There clearly are risks that go beyond 10 years and trial patients aren't community patients. "No differences" eh? Your 'outcome' of low risk patients having few differences in recurrence (local failures) outcome proves the obvious we already knew. What we didn't know was but f'd around and found out was: ultra short course may be acceptable but as noted, may have consequences with regards to side effects. Maybe we already knew that was coming from our old skool APBI trial.

Anyway:

I don't care for the personal attack(s) you're waging and find your holier-than-thou attitude pretty unpleasant. I'll say it again: I suggest we move on.

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Not one study has shown a difference in the 10 year update. I don't know how else to keep saying this.
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There clearly are risks that go beyond 10 years
One of the nice features of the Kaplan-Meier analysis, which is non-parametric, is that the "risk rate" is assumed to be proportional (and reliably proportional between randomized groups as well) over time... even beyond 10 years. To be more clear, results at <10y are highly predictive of results even with longer follow-up; this will be associated with how "strong" the originally witnessed statistical (in)significance was however.

EkchPnd.png
 
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You do things a completely reasonable way, that's not my completely reasonable way of doing it?

Embarrassed Shame GIF
 
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LOL. We are constantly learning new information. There clearly are risks that go beyond 10 years and trial patients aren't community patients. "No differences" eh? Your 'outcome' of low risk patients having few differences in recurrence (local failures) outcome proves the obvious we already knew. What we didn't know was but f'd around and found out was: ultra short course may be acceptable but as noted, may have consequences with regards to side effects. Maybe we already knew that was coming from our old skool APBI trial.

Anyway:

I don't care for the personal attack(s) you're waging and find your holier-than-thou attitude pretty unpleasant. I'll say it again: I suggest we move on.
Not holier than thou and I apologize that it appears that way.

Saying that you need 10 year follow up for breast is just a way to delay the inevitable, inexorable decline of not only indications, but fractions, which unfortunately hurts us all. It seemed okay to do this in the past - to wait for 10 years. But, every single study shows the exact same thing and the 5 year toxicity outcomes, if they are equal in both arms, will be equal at 10 years. If recurrences are lower at 5 years, they will be lower at 10 years.

The 26/5 whole breast data at the 5 year mark - it already shows potential problems with cosmesis. So, I don't use it. If, like the other studies, did not show a problem, then I would use it - like IMPORT or Livi. For me - personally speaking - if a treatment is equal in terms of cure / toxicity, choose the shorter one - because its good for patients and sometimes is lower cost. I have very little concern about the cost at this point because the US health care system is sofa king broken that me choosing a shorter course won't fix the problems. But, people have lives and if they can get back at it quicker, I'm on board. This forum has led me to reconsider conventional for prostate - I would say I have evolved on this point. It has a different time course for the toxicity (earlier) and a different intensity (higher). Not in all patients. So, I understand why people do it.
 
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You do things a completely reasonable way, that's not my completely reasonable way of doing it?

Embarrassed Shame GIF
It's not what people choose to do, it's the rationale.

Whelan originally came out with 5 year data and basically 0% of America touched it. Then 10 year came out. I presented the data as a PGY5 at our faculty meeting and man people were resisting. The data over the last decade has still not shown optimal uptake of the shorter treatment. I took over for a fella who up to 2021 - 99% received 60.4 in 33 Fx. What are people waiting for? If 5 isn't enough, 10 isn't enough, then what is?

15-16 +/- 4-5 is fine and works were well, but not evidence based (Wallnerus has pointed out that Whelan had no boost; with 6.7% recurrence at 10 years, boost doesn't help much, but most people do it. APBI had 5 year f/u and of course it was ignored. At 10 years, it is still barely making up a few percent of overall breast treatment, even though the toxicity outcomes are stunning.

5 years outcome for escalation / boost even with toxicity is routinely accepted. 5 year outcome for de-escalation for whatever reason needs 10-15-million year follow up.
 
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What I am saying is - if the 5 year results show efficacy and same toxicity, friends, it's not changing at 10 years.
I agree with the toxicity part. Timelines to toxicity are pretty well tabulated in the FAST work out of UK actually. Most toxicity evident within 1-2 years. Telangiectasias continue to get worse over time. Breast hardness continues to get worse over time. Shrinkage happens within year I believe (a nice pearl to tell your patients).

Regarding efficacy, there is some danger here. There is a spike in recurrences after cessation of endocrine therapy.
 
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If only there was artificially unbiased way of intelligently determining the best volume, dose, and fractionation for breast cancer, then we could all happily starve together.
Something that money-grubbing community guys have been clamoring for for a very long time. Which likely won't happen any time soon
 
Why would anal cancer cells a/b be lower than 10? Squamous cell, concern for fast repopulation, etc. etc. A/b 10 seems appropriate.

I doubt that anal cancer repopulates like H&N cancer. Think of all the split course regimes we used to wirk with. No reports of tumor regrowth during the pause.
Then think about how anal cancer often slowly regresses after completion of treatment, not like esophageal cancer which can be in CR by the end of treatment sometimes.
 
I agree with the toxicity part. Timelines to toxicity are pretty well tabulated in the FAST work out of UK actually. Most toxicity evident within 1-2 years. Telangiectasias continue to get worse over time. Breast hardness continues to get worse over time. Shrinkage happens within year I believe (a nice pearl to tell your patients).

Regarding efficacy, there is some danger here. There is a spike in recurrences after cessation of endocrine therapy.
I have seen no evidence connecting post ET recurrences linked with dose/fx. Is there something specific you’re referring to?
 
I have seen no evidence connecting post ET recurrences linked with dose/fx. Is there something specific you’re referring to?
Not at all, and I agree with you. I was thinking of XRT omission trials. I’m pretty sure all of our dose regimens are more than enough for the vast majority of patients.
 
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It's not what people choose to do, it's the rationale.

Whelan originally came out with 5 year data and basically 0% of America touched it. Then 10 year came out. I presented the data as a PGY5 at our faculty meeting and man people were resisting. The data over the last decade has still not shown optimal uptake of the shorter treatment. I took over for a fella who up to 2021 - 99% received 60.4 in 33 Fx. What are people waiting for? If 5 isn't enough, 10 isn't enough, then what is?

15-16 +/- 4-5 is fine and works were well, but not evidence based (Wallnerus has pointed out that Whelan had no boost; with 6.7% recurrence at 10 years, boost doesn't help much, but most people do it. APBI had 5 year f/u and of course it was ignored. At 10 years, it is still barely making up a few percent of overall breast treatment, even though the toxicity outcomes are stunning.

5 years outcome for escalation / boost even with toxicity is routinely accepted. 5 year outcome for de-escalation for whatever reason needs 10-15-million year follow up.
BIG 3–07/TROG 07.01 did 2x2 for DCIS looking at conventional vs hypo and boost vs no boost. So there's that data for the hypo + boost paradigm. I haven't heard anyone question the benefit of boost purely on a conventional vs hypo basis.

@TheWallnerus Help me with my stats interpretation. From the PRIME II update, they had this gem:

1684415360017.png


If you generously assume a HR of the benefit of endocrine therapy from baseline of 0.5, then going from no adjuvant to → endocrine, takes you down HR 0.5. If you then stop endocrine therapy and your HR relative to the new 0.5 baseline is 4.66, doesn't that mean your risk is more than double what it would have been if you never started endocrine at all?

Haven't seen anybody discuss this yet, and they don't show the data that they are talking about here. The CI goes below 2, but that's a wide range, and while we talk a lot about poor compliance I haven't seen anything about starting and stopping being worse than never starting at all. Thoughts?

I cannot wait for the modern APBI vs AI trials to report. None of my patients want to take anti-estrogens.
 
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Whelan is about to open up RAPID2, 26 Gy whole breast vs 26 Gy partial breast.

the original draft protocol mandated a very poor conformity index so that partial breast was not like Florence but more like import low. Sigh. That’s been changed fortunately. There is still quibbling over margins but looks like it will be 2.5 cm = ctv + ptv

one would think we had enough data to walk from 26 Gy whole breast to 26 Gy partial, but alas, some will not be convinced.
 
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Whelan is about to open up RAPID2, 26 Gy whole breast vs 26 Gy partial breast.

the original draft protocol mandated a very poor conformity index so that partial breast was not like Florence but more like import low. Sigh. That’s been changed fortunately. There is still quibbling over margins but looks like it will be 2.5 cm = ctv + ptv

one would think we had enough data to walk from 26 Gy whole breast to 26 Gy partial, but alas, some will not be convinced.
Adherence to protocols to the letter is one of the silliest things RadOncs do.

“But Whelan didn’t have DCIS”

Illogical
 
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Whelan is about to open up RAPID2, 26 Gy whole breast vs 26 Gy partial breast.

the original draft protocol mandated a very poor conformity index so that partial breast was not like Florence but more like import low. Sigh. That’s been changed fortunately. There is still quibbling over margins but looks like it will be 2.5 cm = ctv + ptv

one would think we had enough data to walk from 26 Gy whole breast to 26 Gy partial, but alas, some will not be convinced.

If people were gonna adopt it, it would have happened already.
 
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Whelan is about to open up RAPID2, 26 Gy whole breast vs 26 Gy partial breast.

the original draft protocol mandated a very poor conformity index so that partial breast was not like Florence but more like import low. Sigh. That’s been changed fortunately. There is still quibbling over margins but looks like it will be 2.5 cm = ctv + ptv

one would think we had enough data to walk from 26 Gy whole breast to 26 Gy partial, but alas, some will not be convinced.

Why are they comparing partial breast RT to a known inferior whole breast treatment? Are the academics really just accepting that it's ok that cosmesis in the long-term is harmed so we can offer ten fewer radiation treatments? When did that become ok? Do they tell their patients that's the trade-off?
 
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Because if you're in academics, you need something, anything to keep those papers rollin and these are some of the highest profile topics one can hype.
 
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Because if you're in academics, you need something, anything to keep those papers rollin and these are some of the highest profile topics one can hype.
Yep. Everyone on this board is already thinking too hard about this. If only we had new drugs to give.
 
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Why are they comparing partial breast RT to a known inferior whole breast treatment? Are the academics really just accepting that it's ok that cosmesis in the long-term is harmed so we can offer ten fewer radiation treatments? When did that become ok? Do they tell their patients that's the trade-off?
100%

This is a useless study.

Other than philosophically, what is the hesitation with 30 Gy / 5 APBI - like why drop to 26/5? Use the 30 Gy volume as boost, 26/5 to larger area and use IGRT.

They do so well - data supports this, personal outcomes support this.
 
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Why don't we just skip design and let ChatGPT just handle everything period.

Between that and AI commercials (see: "Pizza Nuggets"), the nightmare will become reality.
 
Here's how breast consult goes...

1) Inquire in open fashion what patient has heard about radiation from other providers

2) Inquire if number of treatments has been discussed by other providers

3) Enter this number in prescription and head to simulator
 
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Here's how breast consult goes...

1) Inquire in open fashion what patient has heard about radiation from other providers

2) Inquire if number of treatments has been discussed by other providers

3) Enter this number in prescription and head to simulator

It should be make clear to referring that treating is decided on a case by case basis.
 
It should be make clear to referring that treating is decided on a case by case basis.
Was a joke. I have pretty reasonable referrings who trust my discretion. However, some have their biases and patients on occasion can come in with strong preconceived notions. I always lay out the options and my general rec, but if someone they trust has already planted certain seeds, and the plan is within a reasonable standard of care (there are often several options with general equipoise), it can be best for all parties and the patients psyche to just go with the flow.
 
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It's so embarrassing how our field has just been dictated by others what WE should do
And the patients believe the other specialties (my cancer doctor said) oftentimes over us, the radiation people

But we cannot bite the hand that feeds and it takes oftentimes years to change habits
 
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Adherence to protocols to the letter is one of the silliest things RadOncs do.

“But Whelan didn’t have DCIS”

Illogical
Oh I remember those evidence driven idiots who made a point of treating invasive but not dcis in 16 fractions despite the practice pattern in the rest of the world. Just trying to signal that they are smarter than you.
 
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Here's how breast consult goes...

1) Inquire in open fashion what patient has heard about radiation from other providers

2) Inquire if number of treatments has been discussed by other providers

3) Enter this number in prescription and head to simulator
Not far off. lol.

I love it when they come in thinking they're getting 6 weeks. "Well, I've got some good news for you."

I hate it when they come in thinking it's radiation or hormonal therapy, one or the other. "Oh boy. Here we go."
 
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Thankfully, working in a rural area means:

a. patients dont push for treatments one way or another
b. are generally very respectful of physician directives

exception: when they are affluent/educated enough to go to the big city and are told to do something, they push hard by saying "but big bad center says do this" which most of the time is correct, but occasionally..
 
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Thankfully, working in a rural area means:

a. patients dont push for treatments one way or another
b. are generally very respectful of physician directives

exception: when they are affluent/educated enough to go to the big city and are told to do something, they push hard by saying "but big bad center says do this" which most of the time is correct, but occasionally..

Then go to a big center. I hate those people. They can spend a few days at a hotel and get their 3 fx whatever. Enjoy paying out of pocket for that ****.
 
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Thankfully, working in a rural area means:

a. patients dont push for treatments one way or another
b. are generally very respectful of physician directives

exception: when they are affluent/educated enough to go to the big city and are told to do something, they push hard by saying "but big bad center says do this" which most of the time is correct, but occasionally..
I love treating my rural patients. I have a clinic in the "city" but the rural patients are the best.

None of the 1.5 hour prostate consults that end with "well, sounds good, we'll see what *insert 3-4 other huge academic centers i'm also going to but failed to tell anyone until now* say and I'll let you know what I want to do.

Got it, brother.
 
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1.5 hour consults?

kill me now barney stinson GIF
The longest consult of all time.

Favorable intermediate risk prostate cancer. I considered blocking 2 hours for this specific risk classification of prostate cancer.

If, you really go through a variety of options that each have pros/cons.

Bonus points if you do both LDR and HDR brachy at your institution.
 
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How much information do we think patients are retaining in the 100th minute of a consult?

Are there snack breaks?
 
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The longest consult of all time.

Favorable intermediate risk prostate cancer. I considered blocking 2 hours for this specific risk classification of prostate cancer.

If, you really go through a variety of options that each have pros/cons.

Bonus points if you do both LDR and HDR brachy at your institution.
Extra bonus points if you do space oar, space oar vue, and barrigel. Extra extra if you have a cousin in Japan who does Carbon ion therapy.
 
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LOL. 2 hours. in 20 years, I've had maybe 1 or 2 with 10 family members asking 50 questions for a borderline terminal patient etc.

It’s either the ones who have low risk disease or the ones on deaths door that ask the most questions.

Then again I have seen IO given to a dead person once.
 
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The longest consult of all time.

Favorable intermediate risk prostate cancer. I considered blocking 2 hours for this specific risk classification of prostate cancer.

If, you really go through a variety of options that each have pros/cons.

Bonus points if you do both LDR and HDR brachy at your institution.
TMI
 
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The longest consult of all time.

Favorable intermediate risk prostate cancer. I considered blocking 2 hours for this specific risk classification of prostate cancer.

If, you really go through a variety of options that each have pros/cons.

Bonus points if you do both LDR and HDR brachy at your institution.
Many of my patients after any explanation longer than 5 minutes
“Doc, I don’t mean to interrupt but just tell me what I should do”
 
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Man im just glad i dont treat prostate or breast. Truly da worst! Have you guys ever had a prostate consult so long the patient has to go pee midway (AUA >15) so you thinking standard frac, maybe “go slow” at 1.8!, and you think we haven’t even started treating you and you already gotta pee midway? This is gonna be fun!
 
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The longest consult of all time.

Favorable intermediate risk prostate cancer. I considered blocking 2 hours for this specific risk classification of prostate cancer.
The money shot consult for established GU chairs at prestige institutions. 2 hours with a rich man and potential benefactor.

Outcomes are good. A life (a rich one) is believed to have been saved (but probably not really).

Private research dollars, endowed faculty positions and sometimes buildings are obtained.
 
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Man im just glad i dont treat prostate or breast. Truly da worst! Have you guys ever had a prostate consult so long the patient has to go pee midway (AUA >15) so you thinking standard frac, maybe “go slow” at 1.8!, and you think we haven’t even started treating you and you already gotta pee midway? This is gonna be fun!
I have a lot of breast consults where *I* need to go pee midway. Lol
 
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The money shot consult for established GU chairs at prestige institutions. 2 hours with a rich man and potential benefactor.

Outcomes are good. A life (a rich one) is believed to have been saved (but probably not really).

Private research dollars, endowed faculty positions and sometimes buildings are obtained.
We have one late career GU doc with an insane ‘research fund’. Well connected with local politicians, and just rakes in the cash.
 
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The longest consult of all time.

Favorable intermediate risk prostate cancer. I considered blocking 2 hours for this specific risk classification of prostate cancer.

If, you really go through a variety of options that each have pros/cons.

Bonus points if you do both LDR and HDR brachy at your institution.

Yup.

I have spent more time on average with fav int risk good urine function/low AUA symptom score patients than head and necks over the years. Especially if they are engineers, accountants, or architects.

This is patient driven though often. I don't think it's helpful or plan to go through that much. But that above subset (engineers, etc) want to know everything.
 
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Yup.

I have spent more time on average with fav int risk good urine function/low AUA symptom score patients than head and necks over the years. Especially if they are engineers, accountants, or architects.

This is patient driven though often. I don't think it's helpful or plan to go through that much. But that above subset (engineers, etc) want to know everything.

Engineers are the worst patients
 
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