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.
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?
You didn’t correct for time 🙂
Indeed, and there was also a 10Gy-boost in the conventional arm.
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…
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
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
Agree. I was just responding to @TheWallnerus regarding why it isn’t exciting to us as a group.
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.
We got a 26 vs 27 Gy study (with a stat sig difference)
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.
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:
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.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.
In many Shakespearean plays a character often exclaims "ALARUM!"
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.
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.
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.
Guns don't kill people, people kill people. Statistical tools are likewise not misleading!
Telling. (not the wife thing, the omission thing).
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.)
How about a trial of 26 Gy/5fx partial breast/no hormone vs no RT/hormones
Worst?! You can't spell B-R-E-A-S-T without B-E-S-T.
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.
