Rad Onc Twitter

[OTN]

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How does this get thumbs down. IMPORT LOW and Livi are very mature, thousands of patients, etc. There’s as much clinical indication to irradiate elbow as there is uninvolved breast in women who are PBI appropriate (and we know what we’d say about a rad onc who was irradiating elbow for a breast cancer case). PBI pays just as well as whole breast too 😉 maybe even more depending on the insurance guideline.

First, I'd like to start with the caveat that I love Livi and do it as much as I possibly can.

"Misadministration" is far too strong of a word here, as it has a legal definition in radiation oncology, and treating with a different volume and fractionation scheme than what the original twitter OP would prefer isn't it. It's also not even close to a tragedy, and with the difficulty we have in the media when it comes to radiation already, this kind of hyperbole isn't helpful.

Also, what about a perfectly healthy woman who underwent an oncoplastic lumpectomy who is older than 70 and would benefit from whole breast RT? Would it be misadministration and tragic to give her 15 or 16 fractions of whole breast RT?

 

[NotMattSpraker]

My dad would call this talking out both sides of your mouth. And ASTRO is great at it.

I oppose it primarily because I dont think legislating fixed income and unchecked power for a medical society is a good idea. It seems like an especially bad idea for a society that is highly opaque and loaded with COI like ASTRO.

Given that physicians seem to be ever more vocal about regulatory capture in medicine, it's shocking to me that so many people are okay with it.

 

[RickyScott]

I oppose it primarily because I dont think legislating fixed income and unchecked power for a medical society is a good idea. It seems like an especially bad idea for a society that is highly opaque and loaded with COI like ASTRO.

Given that physicians seem to be ever more vocal about regulatory capture in medicine, it's shocking to me that so many people are okay with it.

Exactly- why would anyone want to empower such a bad actor.

 

[mheat3]

Misadministration" is far too strong of a word here, as it has a legal definition in radiation oncology, and treating with a different volume and fractionation scheme than what the original twitter OP would prefer isn't it. It's also not even close to a tragedy, and with the difficulty we have in the media when it comes to radiation already, this kind of hyperbole isn't helpful.

Also, what about a perfectly healthy woman who underwent an oncoplastic lumpectomy who is older than 70 and would benefit from whole breast RT?

This is also why I down voted the post. PBI is excellent and I utilize it often but the language used in the tweet doesn't match reality IMO.

 

[TheWallnerus]

Misadministration" is far too strong of a word here, as it has a legal definition in radiation oncology, and treating with a different volume and fractionation scheme than what the original twitter OP would prefer isn't

This is also why I down voted the post. PBI is excellent and I utilize it often but the language used in the tweet doesn't match reality IMO.

70yo stage one ER positive low risk patient with identifiable surgical bed gets whole breast RT. How is that not a misadministration. Wouldn’t ENI be a misadministration? If so, then whole breast would be too. (Ignore fractionation, just talking treatment volumes.)

 

[communitydoc13]

70yo stage one ER positive low risk patient with identifiable surgical bed gets whole breast RT. How is that not a misadministration. Wouldn’t ENI be a misadministration? If so, then whole breast would be too. (Ignore fractionation, just talking treatment volumes.)

The patient hardly benefits from XRT at all (~10 local control benefit over lifetime without cancer specific survival benefit).

So... the question is difference in toxicity. WBRT typically has a simpler beam arrangement and may even have lower heart dose. The relative impact on second malignancy risk is unknown. WBRT likely has a marginal positive impact on in breast recurrence and causes more breast shrinkage than APBI. WBRT can also be given in 5 fractions if desired.

Added risk of lymphedema? Close to nil in the arm the way most of us give it. Perhaps some in breast, although not high and APBI results in a hard cavity in a soft breast.

ENI typically a longer course in the US. Definite added risk of lymphedema. Marked increase in integral dose, lung dose and at times heart dose depending on the case. In my mind, ENI is a bigger jump from WBRT than WBRT is from APBI.

The best aspect of APBI is the cosmesis. (Less breast shrinkage with a firm surgical cavity and sometimes focal impact on breast contour). That's it. It's not mind blowing. I use it all the time. It is psychologically appealing to many patients, however.

 

[RadOncMegatron]

70yo stage one ER positive low risk patient with identifiable surgical bed gets whole breast RT. How is that not a misadministration. Wouldn’t ENI be a misadministration? If so, then whole breast would be too. (Ignore fractionation, just talking treatment volumes.)

I think the word “misadministration” is the problem here. The line where misadministration vs bad clinical judgment is blurry here. PBI (which most of us would do) but if you had to use a retired locums in a pinch would it be “misadministration” if they gave whole breast?

Misadministration in my experience has been used for treating the wrong site, wrong side, wrong patient, or wrong dose not in cases like this one.

 

[alwaysbeIMRTing]

70yo stage one ER positive low risk patient with identifiable surgical bed gets whole breast RT. How is that not a misadministration. Wouldn’t ENI be a misadministration? If so, then whole breast would be too. (Ignore fractionation, just talking treatment volumes.)

For a stage I low risk patient, whole breast RT is in the NCCN guidelines (I just checked, it's the first recommendation).
ENI is not.

Sounds like you have a beef with NCCN.

Misadministration implies that you meant to give partial breast RT and gave full breast RT instead. I agree, that would be naughty.

Final thought: There is room between PBI and traditional whole breast wire-to-wire. If you use the AI contours of the breast, you get a beautiful geometric shape that's not aggressively grabbing the lateral and medial tails. With a VMAT plan, to this not-entirely-whole-breast (you could call it partial and not be a liar), you get excellent homogeneity and can meet the BED3 Livi constraints no problem (excepting the uninvolved breast). Outcome is excellent.

 

[Ray D. Ayshun]

Fraction shaming has transitioned to volume shaming. Back to my 20 met SRS thread, has treatment of asymptomatic brain mets ever shown a benefit worth talking about (outside of PCI)?

 

[alwaysbeIMRTing]

Fraction shaming has transitioned to volume shaming. Back to my 20 met SRS thread, has treatment of asymptomatic brain mets ever shown a benefit worth talking about?

There is a survival benefit in small cell carcinoma based on PCI data (treatment of subclinical asymptomatic disease).

 

[Ray D. Ayshun]

There is a survival benefit in small cell carcinoma based on PCI data (treatment of subclinical asymptomatic disease).

Haha, sorry, updated as you were posting. One of the diseases we wouldn't do 20 met srs in.

 

[TheWallnerus]

This is a great discussion. I didn't know I'd be having it but I would have thought the PBI question was settled (way more so than which fraction regimen to use... 5 vs 15 vs 16 vs plus/minus boosts). It's good to push at the edges sometimes by contrapositive reasoning. That is, if partial breast is not indicated in a given case, then whole breast RT is not a misadmin. But if the opposite is true... that is to say partial breast is indicated... then whole breast would be a misadmin. One could use this form of logic speciously in a great many ways, but in this instance based on that tweet, it is hard to refute that when PBI is indicated whole breast would be a misadmin because the wrong site is being treated.

The patient hardly benefits from XRT at all (~10 local control benefit over lifetime without cancer specific survival benefit).

But they do benefit. When PBI is indicated, there is no benefit for any measure for whole breast.

WBRT typically has a simpler beam arrangement and may even have lower heart dose.

The word "typically" is doing the work in this sentence. Partial breast can be just as simple as a whole breast arrangement and if so would always have equal or less heart dose.

WBRT likely has a marginal positive impact on in breast recurrence

In IMPORT LOW the ~5y LC was twice as a better with PBI. Depending on the lens, there is even a trend w/ better LC with PBI. I'm not saying that there's better LC w/ PBI... but I can't say that whole breast has even a "marginal positive impact."

The best aspect of APBI is the cosmesis. (Less breast shrinkage with a firm surgical cavity and sometimes focal impact on breast contour). That's it.

"That's it"... not really. Also toxicities.

Sounds like you have a beef with NCCN.

Well now that you mention it I do. You probably do too. NCCN breast guidelines don't endorse IGRT except if DIBH is being used. They don't want us to "alwaysbeIMRTing" unless 30 Gy/5 fx is being used where 26 Gy/5 fx is probably the ideal 5 fraction PBI dose and whole breast IMRT vs 3D is the most studied IMRT question in our field and made IMRT proven to be best; but, again, IMRT is barely mentioned in the guidelines. Now throw in outdated rec's regarding axillary staging...

... and endorsing ENI for say a cT1N1/ypN0 patient...
the NCCN guidelines are very problematic. They do "endorse" PBI. Does that mean if a treatment is endorsed and you do the thing that's not quote-unquote endorsed it's a misadmin? IDK.

But ASTRO guidelines do say PBI is preferred over whole breast.

Misadministration implies that you meant to give partial breast RT and gave full breast RT instead. I agree, that would be naughty.

When PBI is indicated (e.g. a 70yo T1N0 ER+ patient), shouldn't PBI "meant" to be given? I suppose that's the core question.

Fraction shaming has transitioned to volume shaming.

Absolutely 🙂 Can you imagine being in a tumor board 15y ago and someone doing dog leg fields on a stage one seminoma? Much shaming.

Or partial breast external beam RT on a 70yo lady with stage one ER+ breast in the same tumor board 15y ago?! Extreme volume shaming.

 

[Ray D. Ayshun]

This is a great discussion. I didn't know I'd be having it but I would have thought the PBI question was settled (way more so than which fraction regimen to use... 5 vs 15 vs 16 vs plus/minus boosts). It's good to push at the edges sometimes by contrapositive reasoning. That is, if partial breast is not indicated in a given case, then whole breast RT is not a misadmin. But if the opposite is true... that is to say partial breast is indicated... then whole breast would be a misadmin. One could use this form of logic speciously in a great many ways, but in this instance based on that tweet, it is hard to refute that when PBI is indicated whole breast would be a misadmin because the wrong site is being treated.

But they do benefit. When PBI is indicated, there is no benefit for any measure for whole breast.

The word "typically" is doing the work in this sentence. Partial breast can be just as simple as a whole breast arrangement and if so would always have equal or less heart dose.
View attachment 405404

In IMPORT LOW the ~5y LC was twice as a better with PBI. Depending on the lens, there is even a trend w/ better LC with PBI. I'm not saying that there's better LC w/ PBI... but I can't say that whole breast has even a "marginal positive impact."
View attachment 405405

"That's it"... not really. Also toxicities.
View attachment 405406

Well now that you mention it I do. You probably do too. NCCN breast guidelines don't endorse IGRT except if DIBH is being used. They don't want us to "alwaysbeIMRTing" unless 30 Gy/5 fx is being used where 26 Gy/5 fx is probably the ideal 5 fraction PBI dose and whole breast IMRT vs 3D is the most studied IMRT question in our field and made IMRT proven to be best; but, again, IMRT is barely mentioned in the guidelines. Now throw in outdated rec's regarding axillary staging...

... and endorsing ENI for say a cT1N1/ypN0 patient...
the NCCN guidelines are very problematic. They do "endorse" PBI. Does that mean if a treatment is endorsed and you do the thing that's not quote-unquote endorsed it's a misadmin? IDK.

But ASTRO guidelines do say PBI is preferred over whole breast.

When PBI is indicated (e.g. a 70yo T1N0 ER+ patient), shouldn't PBI "meant" to be given? I suppose that's the core question.

Absolutely 🙂 Can you imagine being in a tumor board 15y ago and someone doing dog leg fields on a stage one seminoma? Much shaming.

Or partial breast external beam RT on a 70yo lady with stage one ER+ breast?! Extreme volume shaming.

TBH, I do everything you're saying wrt breast. I love import lo. import hi too, but we can't seem to do breast imrt here.

 

[alwaysbeIMRTing]

I can't have a beef with the NCCN as much as I would like to because ASTRO is currently occupying 100% of that real estate in my prefrontal cortex.

 

[communitydoc13]

This is a great discussion. I didn't know I'd be having it but I would have thought the PBI question was settled (way more so than which fraction regimen to use... 5 vs 15 vs 16 vs plus/minus boosts). It's good to push at the edges sometimes by contrapositive reasoning. That is, if partial breast is not indicated in a given case, then whole breast RT is not a misadmin. But if the opposite is true... that is to say partial breast is indicated... then whole breast would be a misadmin. One could use this form of logic speciously in a great many ways, but in this instance based on that tweet, it is hard to refute that when PBI is indicated whole breast would be a misadmin because the wrong site is being treated.

But they do benefit. When PBI is indicated, there is no benefit for any measure for whole breast.

The word "typically" is doing the work in this sentence. Partial breast can be just as simple as a whole breast arrangement and if so would always have equal or less heart dose.
View attachment 405404

In IMPORT LOW the ~5y LC was twice as a better with PBI. Depending on the lens, there is even a trend w/ better LC with PBI. I'm not saying that there's better LC w/ PBI... but I can't say that whole breast has even a "marginal positive impact."
View attachment 405405

"That's it"... not really. Also toxicities.
View attachment 405406

Well now that you mention it I do. You probably do too. NCCN breast guidelines don't endorse IGRT except if DIBH is being used. They don't want us to "alwaysbeIMRTing" unless 30 Gy/5 fx is being used where 26 Gy/5 fx is probably the ideal 5 fraction PBI dose and whole breast IMRT vs 3D is the most studied IMRT question in our field and made IMRT proven to be best; but, again, IMRT is barely mentioned in the guidelines. Now throw in outdated rec's regarding axillary staging...

... and endorsing ENI for say a cT1N1/ypN0 patient...
the NCCN guidelines are very problematic. They do "endorse" PBI. Does that mean if a treatment is endorsed and you do the thing that's not quote-unquote endorsed it's a misadmin? IDK.

But ASTRO guidelines do say PBI is preferred over whole breast.

When PBI is indicated (e.g. a 70yo T1N0 ER+ patient), shouldn't PBI "meant" to be given? I suppose that's the core question.

Absolutely 🙂 Can you imagine being in a tumor board 15y ago and someone doing dog leg fields on a stage one seminoma? Much shaming.

Or partial breast external beam RT on a 70yo lady with stage one ER+ breast in the same tumor board 15y ago?! Extreme volume shaming.

Agree with most of your post. I should have included breast firmness and acute toxicity with cosmesis. Add those together and you get the difference relative to contemporary WBRT IMO. None of us should be putting traditional marks on and treating at block edge without blocking heart or tailoring to minimize lung dose.

IMPORT LOW is great. This is not what most of us do as you are aware re APBI. 5 fractions is a big selling point. As @alwaysbeIMRTing posted above, you can fudge from WBRT to IMPORT LOW on a case-to-case basis...I think this is fine (don't treat the heart at all...really).

The local failure graph comparing across trials is just dumb and you have posted before. You know this and I don't know why you spoil your good arguments with it. Livi did a comparative trial fer crying out loud. In-breast recurrence was higher in the APBI arm as you would expect (3.7 vs 2.5%). We should not believe better local control with therapeutic de-escalation unless we have a really good reason to believe.

Agree with all above. It's the misadministration thing in the tweet. Fine to be an APBI evangelist given how we practice in the US.

Addendum: Complicating things of course are dose reduction and peculiarities with "discovering" local recurrence. Would you consider someone who gave 36 Gy WBRT with exquisite heart sparing to be in the wrong (the winning arm by gross recurrence with equivalent toxicity reporting in IMPORT-LOW).

Addendum II: Apologies about the snark regarding the cross-trial comparison graphic. It is valuable in many ways, I understand that, just not as comparator regarding outcomes mediated by our intervention. There is a lot of historical stuff that is not applicable at all anymore. Remember the old "for every 4 local recurrences we prevent, we prevent one breast cancer death" adage. Not remotely believable for this population of course.

 

[drowsy12]

The patient hardly benefits from XRT at all (~10 local control benefit over lifetime without cancer specific survival benefit).

So... the question is difference in toxicity. WBRT typically has a simpler beam arrangement and may even have lower heart dose. The relative impact on second malignancy risk is unknown. WBRT likely has a marginal positive impact on in breast recurrence and causes more breast shrinkage than APBI. WBRT can also be given in 5 fractions if desired.

Added risk of lymphedema? Close to nil in the arm the way most of us give it. Perhaps some in breast, although not high and APBI results in a hard cavity in a soft breast.

ENI typically a longer course in the US. Definite added risk of lymphedema. Marked increase in integral dose, lung dose and at times heart dose depending on the case. In my mind, ENI is a bigger jump from WBRT than WBRT is from APBI.

The best aspect of APBI is the cosmesis. (Less breast shrinkage with a firm surgical cavity and sometimes focal impact on breast contour). That's it. It's not mind blowing. I use it all the time. It is psychologically appealing to many patients, however.

Not just cosmesis. The acute tox is different also. Florence patients hardly get any dermatitis

I think the language in the tweet was strong. But it makes basic sense to me not to treat more tissue than we need to. You don’t need protons to spare. Just treat less!

 

[pikachu]

Not just cosmesis. The acute tox is different also. Florence patients hardly get any dermatitis

I think the language in the tweet was strong. But it makes basic sense to me not to treat more tissue than we need to. You don’t need protons to spare. Just treat less!

This statement contains entirely too much common sense to continue to exist in rad onc. please reconsider

 

[medgator]

Haha, sorry, updated as you were posting. One of the diseases we wouldn't do 20 met srs in.

Some CNS nuts would