Rad Onc Twitter

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$1000 Dr. Kendi learned this while speaking at ASTRO.

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NotMattSpraker said:
$1000 Dr. Kendi learned this while speaking at ASTRO.

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www.dailymail.co.uk

Kendi's Antiracist Research Center will lay off up to TWENTY staff

Woke activist Ibram X. Kendi's Antiracist Research Center at Boston University had laid off up to twenty members off staff.
www.dailymail.co.uk

nypost.com

Like other ‘antiracist’ activists, Ibram X. Kendi proves he’s only in it for himself

The real measure of an individual’s character isn’t what he portrays to the public but how he treats people in private. Truly righteous people treat others with respect and dignity when there is no…
nypost.com nypost.com
 
I realize why Musk changed the name of Twitter to “X”… I mistakenly clicked on the wrong “X” to close the window but went directly to the sign in page. Of course I have no desire to sign up but smart marketing technique!
 
Is this the end of SLNB?

I swear, someone needs to get AI to do Dr. Evil and radiation oncology...

"Its the end of radiation (evil laugh).... (looks around gleefully, then confusion as rita whispers in his ear)... No.. no.. ... I mean.. surgery! Its the end of Surgery.. "
 
BobbyHeenan said:
CALBG study as I recall around 25-30% had no sentinel node or axilla eval. Never saw increased rates of relapse in their no xrt arm even in that subset as I recall.
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Yes in elderly women omitting SLNB was already a common place thing and was in Choose Wisely for breast surgeons, but considering omission of SLNB in patients < 65yo is the thing of interest here... which 2/3rd were on this trial, including 17-19% below the age of 50.

I imagine breast surgeons will have the same response as rad oncs - need 10 year data....
 
evilbooyaa said:
Yes in elderly women omitting SLNB was already a common place thing and was in Choose Wisely for breast surgeons, but considering omission of SLNB in patients < 65yo is the thing of interest here... which 2/3rd were on this trial, including 17-19% below the age of 50.

I imagine breast surgeons will have the same response as rad oncs - need 10 year data....
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I guess the younger pts will always get xrt and oncotype can predict systemic disease
 
Palex80 said:
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Lets really parse what a study like this means.

It means only what it says. That in a group of woman with <2cm breast CA and negative axilla on u/s, sentinel lymph node biopsy did not demonstrably change distant disease free progression over 5 years for the whole cohort.

For the actual graph, follow the link:


Only 97 women had a positive node. The most important question to me is: for those with a positive sentinel node, does subsequent choice of therapy change to the point where outcomes are different? This trial not only doesn't answer this question, but is a bit specious with its analysis.

Correction: Actually their conclusion is fine, just vague. In patients where pathologic info isn't going to change treatment recommendations.
But...how often does nodal burden not change your treatment recommendation?
 
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evilbooyaa said:
Yes in elderly women omitting SLNB was already a common place thing and was in Choose Wisely for breast surgeons, but considering omission of SLNB in patients < 65yo is the thing of interest here... which 2/3rd were on this trial, including 17-19% below the age of 50.

I imagine breast surgeons will have the same response as rad oncs - need 10 year data....
Click to expand...

Yeah, given the difference in oncotype thresholds for chemo for node + and node - cohort....if it's me or my wife and they're in good enough shape for chemo then I'd want that SLNB.
 
Our trends are all the same. Maximalist with molecular medicine, minimalist with physical intervention.

I know that SLN bx carries some risk of lymphedema and other toxicity, but I wonder how the final actual cost of SLN bx compares to Onocotype-DX itself.
 
BobbyHeenan said:
Yeah, given the difference in oncotype thresholds for chemo for node + and node - cohort....if it's me or my wife and they're in good enough shape for chemo then I'd want that SLNB.
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Threshold in NCCN is the same for pN0 and pN1. Institutional preference?
 
evilbooyaa said:
Yes in elderly women omitting SLNB was already a common place thing and was in Choose Wisely for breast surgeons, but considering omission of SLNB in patients < 65yo is the thing of interest here... which 2/3rd were on this trial, including 17-19% below the age of 50.

I imagine breast surgeons will have the same response as rad oncs - need 10 year data....
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They have actually been surprisingly open to reducing their foot print or at least that’s what I’ve noticed where i practice.
 
grenz said:
Threshold in NCCN is the same for pN0 and pN1. Institutional preference?
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might just be my mistake.

I know the print outs/order sets from the company make you specify node negative or 1-3 nodes.
The scores may be the same, but is threshhold to give chemo lower if in the 1-3 node category?
 
Fpg1245 said:
They have actually been surprisingly open to reducing their foot print or at least that’s what I’ve noticed where i practice.
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Absolutely my experience. A good breast surgeon is the head of the "breast center". Still driving patient from biopsy forward, directing breast tumor board, running MDC. Lots of culture of accreditation in breast (NSABP etc) and lots of community interaction by breast surgeons. Just a different site all around, where surgeons lead while reducing their operative footprint.

If anything, my concern is extreme avoidance of axillary dissection and mastectomy by surgeons.

I'm guessing lumpectomy alone must be pretty damn straight forward by surgical standards.
 
communitydoc13 said:
But...how often does nodal burden not change your treatment recommendation?
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It should *not* change your tx approach... ESPECIALLY for a rad onc... way more often than it does!

If you ever do RNI... or even "high tangents" (pfft)... for early low risk breast with a positive SLN... you're doing it wrong! I said it.
 
communitydoc13 said:
Absolutely my experience. A good breast surgeon is the head of the "breast center". Still driving patient from biopsy forward, directing breast tumor board, running MDC. Lots of culture of accreditation in breast (NSABP etc) and lots of community interaction by breast surgeons. Just a different site all around, where surgeons lead while reducing their operative footprint.

If anything, my concern is extreme avoidance of axillary dissection and mastectomy by surgeons.

I'm guessing lumpectomy alone must be pretty damn straight forward by surgical standards.
Click to expand...

Same with me. We brought in a good surg onc that wanted to focus on breast and she's been amazing.
 
TheWallnerus said:
It should *not* change your tx approach... ESPECIALLY for a rad onc... way more often than it does!

If you ever do RNI... or even "high tangents" (pfft)... for early low risk breast with a positive SLN... you're doing it wrong! I said it.
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Meh. All tangents are high tangents. I see little downside to it in healthy women. If someone has issues, might as well do PBI, and make that the defacto standard if we're gonna say its because we want to do the least harm.

Please pass the mustard.
 
TheWallnerus said:
It should *not* change your tx approach... ESPECIALLY for a rad onc... way more often than it does!

If you ever do RNI... or even "high tangents" (pfft)... for early low risk breast with a positive SLN... you're doing it wrong! I said it.
Click to expand...

I don't know.

False signal in thousands of patients? Magic? Every woman in the analysis with clinically positive nodes? Such a disparate population relative to today that not even a limiting case to give us insight?

A case!

58 year old woman shows up with ER+/PR-, Her2 negative Ki-67 30-40% cT1c(1cm)N0 (including dedicated axillary U/S) disease.

Do you want the SLN bx?

If SLN bx reveals 6mm deposit in one node with focal ECE...you still not adjusting your field?
 
sirspamalot said:
And on the topic of fraction shaming, I'm thinking of printing up some t-shirts for the next ASTRO/ACRO meeting like

"Don't fraction shame me bro" or something..
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It isn’t even worth the effort.
My copy of the RJ goes from the delivery bin to my desk into the garbage.
Buying a ticket to San Diego to tell them how I feel makes it seem like they’ve won
 
TheWallnerus said:
It should *not* change your tx approach... ESPECIALLY for a rad onc... way more often than it does!

If you ever do RNI... or even "high tangents" (pfft)... for early low risk breast with a positive SLN... you're doing it wrong! I said it.
Click to expand...
the dude your opinion GIF


Your opinion is not *wrong* in the same way that treating RNI is not *wrong*. 50% of pts on Z11 got breast alone w/o high tangents or RNI.

I guess I took the bait to get you back on your omission of all RNI in any pN1 breast for all time, ever, soap box.
 
evilbooyaa said:
the dude your opinion GIF


Your opinion is not *wrong* in the same way that treating RNI is not *wrong*. 50% of pts on Z11 got breast alone w/o high tangents or RNI.

I guess I took the bait to get you back on your omission of all RNI in any pN1 breast for all time, ever, soap box.
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I had one low risk small breasted woman insist that we do "partial breast" so I did what she asked (ended up treating 80% of the breast anyway) and she was happy.

Breast radonc: The most emasculating for experienced radonc decision making evah
 
evilbooyaa said:
the dude your opinion GIF


Your opinion is not *wrong* in the same way that treating RNI is not *wrong*. 50% of pts on Z11 got breast alone w/o high tangents or RNI.

I guess I took the bait to get you back on your omission of all RNI in any pN1 breast for all time, ever, soap box.
Click to expand...
Don’t we have a separate thread about all this (breast is the worst ahem). I’m here for the social media rubbernecking!
 
communitydoc13 said:
Absolutely my experience. A good breast surgeon is the head of the "breast center". Still driving patient from biopsy forward, directing breast tumor board, running MDC. Lots of culture of accreditation in breast (NSABP etc) and lots of community interaction by breast surgeons. Just a different site all around, where surgeons lead while reducing their operative footprint.

If anything, my concern is extreme avoidance of axillary dissection and mastectomy by surgeons.

I'm guessing lumpectomy alone must be pretty damn straight forward by surgical standards.
Click to expand...
A lot of those boomer surgeons had to retire to make this so. But not before embarrassing themselves, and by proxy the junior surgeons at the time, by insisting on mastectomies for everyone.
 
communitydoc13 said:
A case!

58 year old woman shows up with ER+/PR-, Her2 negative Ki-67 30-40% cT1c(1cm)N0 (including dedicated axillary U/S) disease.

Do you want the SLN bx?

If SLN bx reveals 6mm deposit in one node with focal ECE...you still not adjusting your field?
Click to expand...
Honest answer: 15 fx of partial breast opposed tangent IMRT beams. This will have ~99% 5y LC and significantly lower side effects than whole breast/partial axillary treatment (of whatever sort), and based on "apples to orange" comparisons versus contemporary whole breast RT data, better LC (this, I know, is a counterintuitive, but true, statement).

I would love to do 5 fractions of 5.2 Gy each of partial breast, but I would bankrupt the house.

2023-09-22 12_36_12-Untitled-1_ @ 200 % (CMYK_Preview).png
 
TheWallnerus said:
5y data: 😒
10y data: 😛

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IIRC... the worse cosmesis with 5 day BID APBI was not seen in the initial publications, then came out with the 10 year follow up. Toxicity is the main reason I'd wait for 10 year data before treating the entire breast in 5 fractions. No one doubts all other outcomes will be the same.

That... and we already have an excellent 5 fraction protocol with 10 year follow up for early stage breast cancers. Which also has less acute + late toxicity and better cosmesis. (Livi)

This might be good for those handful of patients with higher risk histology you just don't feel great about partial breast.
 
dieABRdie said:
IIRC... the worse cosmesis with 5 day BID APBI was not seen in the initial publications, then came out with the 10 year follow up. Toxicity is the main reason I'd wait for 10 year data before treating the entire breast in 5 fractions. No one doubts all other outcomes will be the same.

That... and we already have an excellent 5 fraction protocol with 10 year follow up for early stage breast cancers. Which also has less acute + late toxicity and better cosmesis. (Livi)

This might be good for those handful of patients with higher risk histology you just don't feel great about partial breast.
Click to expand...
5x5.2 would be even better than Livi though. IMPORT-LOW and FAST-Forward were designed to be taken together so that's why 5x5.2 (instead of 5x6 Gy) is the UK standard. (It's also usually 2-field IMRT vs VMAT/multifield.)

And.... 10x3.85Gy bid was just a regimen made by a radiobiological know-nothing.
 
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