SEER based Breast Cancer Mortality advantage for XRT in DCIS. Believe it?

[Mandelin Rain]

http://jco.ascopubs.org/content/early/2016/01/28/JCO.2015.65.1869.full.pdf

Not sure how I feel about it. But useful for tumor boards nonetheless.

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[medgator]

It was only found in a specific subgroup which would make sense. I saw a young pt with an axillary recurrence today 2 years out from mastectomy for multifocal high grade ER- dcis. No nodes were sampled at the time.

It certainly should give pause to those in the oncology community who don't take dcis seriously/don't think it's cancer

http://mobile.nytimes.com/blogs/wel...s-to-cancer-detection-and-treatment/?referer=

 

[Gfunk6]

For those of us (me) who are too lazy to download the full article, could someone please quote the absolute magnitude of benefit in the high-risk sub-group?

 

[Mandelin Rain]

I can't directly attach the whisker plots for whatever reason, but the PDF is hyperlinked above. You literally just have to click it. The absolute magnitude of Breast Cancer Mortality in the higher-risk groups is 2-3% at 10 years and 0.5% in a lower-risk group. Reminder that the survival benefit of Herceptin in HER2+ patients is what? About 3%?

I think the most important issue was that overall mortality wasn't worse with the XRT population. The cardiac and second malignancy events were actually higher in the non-XRT arm. This is likely (in large-part) selection bias given the methodology, but it is reassuring nonetheless.

 

[Damn_Daniel]

It's only a full .PDF if you subscribe to JCO.
It's something, but, I'd be hard pressed to say that I really think there's a survival benefit. It's a lot like low risk prostate cancer - we are over treating many to cure the few that may have disease that will present itself as aggressive down the road. Anyone using OncoType to make RT decisions? There isn't great prospective data, but you'd have to presume it will pan out, as it did for invasive disease.

Even with a full discussion, I find it very hard to convince women to omit RT. I think since I give 16 fractions to almost everyone, the commitment seems short enough for them to almost always want treatment.

 

[medgator]

It's only a full .PDF if you subscribe to JCO.
It's something, but, I'd be hard pressed to say that I really think there's a survival benefit. It's a lot like low risk prostate cancer - we are over treating many to cure the few that may have disease that will present itself as aggressive down the road. Anyone using OncoType to make RT decisions? There isn't great prospective data, but you'd have to presume it will pan out, as it did for invasive disease.

Even with a full discussion, I find it very hard to convince women to omit RT. I think since I give 16 fractions to almost everyone, the commitment seems short enough for them to almost always want treatment.

I don't offer that to younger women and I almost always add a boost unless it's grade 1.

 

[Damn_Daniel]

What's the rationale for not offering it to younger women?

Younger women were included on every hypofractionation trial. And MDACC recent randomized trial showed less toxicity and better QOL with hypofractionation, and included women 40 and up. START B showed a survival benefit for HF. There is unpublished combined data set that shows that the benefit for HF is highest in the younger age group (will be published soon).

So, you offer younger women a more toxic treatment that gives them possibly worse survival, worse quality of life, takes longer, and costs the system more money? Interesting approach. I tend to offer the less toxic treatment that offers them a possibly higher chance of survival and provides greater QOL. That's just me, though.

 

[Burt Radnolds]

DD, there is extensive prior discussion on breast hypofractionation on the board. Since you seem to be dredging up a bunch of old threads yourself as you continue your borderline trollish rampage through the forum, I'm surprised you haven't read it yet. I completely agree with you that there is a mounting pile of data that suggests not only equivalence, but superiority to hypofractionation for most people. It's amazing the sort of subconscious rationalization that occurs in order to hold on to those 6 week treatment courses. The day of reckoning will come though. I can't wait to see the usage rates of 3-4 week vs 5-6 weeks when/if bundled payments are implemented. Many eyes will be opened to the wonders of hypofractionation.

 

[medgator]

Where is the 20 year data? What about in higher grade ER- disease? Even astro doesn't endorse hypofx at all under the age of 50.

And an OS benefit for hypofx in DCIS? There is nothing "borderline" about that trolling

 

[Damn_Daniel]

You want 20 year data for hypofractionation? Hahahahaha. And then that shows benefit, and then we need 25 year data? When does it stop? Sheesh ...

ASTRO Guidelines actual text: "It is important to note that this guideline should not be interpreted to prohibit or oppose the use of HF-WBI for patients not meeting all the criteria listed but rather that the evidence was not sufficient to reach consensus for such patients." They never made an "endorsement"; that's not how the guidelines were to be interpreted, even though community physicians didn't read the whole paper and decided that anyone not meeting that criteria should never be offered hypo-fractionation, and despite the fact that the guidelines are 6 years old and even the authors don't follow them. The lead author, in fact, treats almost every single stage I/II/node negative patient with hypofractionation. We really should focus on the more up to date consensus guidelines. The most recent NCCN guidelines (2016) says it is "preferred" for stage I/II and does not mention age. The ACR Appropriateness Criteria for DCIS (2015) says that for even young woman, HF is given an "8"

As far as grade, there was an update that showed no difference in outcome based on grade, and the conclusion that all N0 patients can safely be treated with HF.

And, sorry for lack of clarity. No, not a OS benefit for DCIS. But there is for invasive.

I just don't get where the age thing comes from. All the trials included younger patients. They may be the ones that even benefit the most. Less side effects. Possibly more effective. Cheaper. More convenient.

 

[Gfunk6]

If ASTRO wants to encourage HF across the board then they should push for case-base reimbursement. Oh, wait, that means that all the proton centers in academic centers will go bankrupt!

Hypocrisy in its purest form. They want to put on the public face of "value driven medicine" while still benefitting from the proton/CME/board certification fees for life boondoggle.

 

[Damn_Daniel]

If ASTRO wants to encourage HF across the board then they should push for case-base reimbursement. Oh, wait, that means that all the proton centers in academic centers will go bankrupt!

Hypocrisy in its purest form. They want to put on the public face of "value driven medicine" while still benefitting from the proton/CME/board certification fees for life boondoggle.

Yup. ASTRO doesn't really have our interests at heart. My boy just published this showing that we are going to have a huge surplus, yet the powers that be continue to churn out more rad oncs. What a fiasco! We can fight back. The internists revolted and they won. But, unfortunately, our specialty is composed mostly of weenies.

 

[seper]

Wow, quite a study. Thanks. Any specific criticisms?
Prostate cancer situation is such a bummer.
Pure economics seem to suggest inevitable drop in average mid-career salary, correct?

 

[medgator]

You want 20 year data for hypofractionation? Hahahahaha. And then that shows benefit, and then we need 25 year data? When does it stop? Sheesh ...

ASTRO Guidelines actual text: "It is important to note that this guideline should not be interpreted to prohibit or oppose the use of HF-WBI for patients not meeting all the criteria listed but rather that the evidence was not sufficient to reach consensus for such patients." They never made an "endorsement"; that's not how the guidelines were to be interpreted, even though community physicians didn't read the whole paper and decided that anyone not meeting that criteria should never be offered hypo-fractionation, and despite the fact that the guidelines are 6 years old and even the authors don't follow them. The lead author, in fact, treats almost every single stage I/II/node negative patient with hypofractionation. We really should focus on the more up to date consensus guidelines. The most recent NCCN guidelines (2016) says it is "preferred" for stage I/II and does not mention age. The ACR Appropriateness Criteria for DCIS (2015) says that for even young woman, HF is given an "8"

As far as grade, there was an update that showed no difference in outcome based on grade, and the conclusion that all N0 patients can safely be treated with HF.

And, sorry for lack of clarity. No, not a OS benefit for DCIS. But there is for invasive.

I just don't get where the age thing comes from. All the trials included younger patients. They may be the ones that even benefit the most. Less side effects. Possibly more effective. Cheaper. More convenient.

FTR, I've offered hypo-Fx to my older patients with DCIS. Not doing it in my 50 y/o ER- G3 DCIS until I see more data. I know people who do it after chemo as well. Not doing that either until we see data on that and/or an update to the guidelines. Why take the risk in the community in someone getting adriamycin?

 

[medgator]

The ACR Appropriateness Criteria for DCIS (2015) says that for even young woman, HF is given an "8"

I was wondering why you didn't give out the ACR appropriateness score for conventional fractionation.... now I know why, because it was a "9" in a 55 y/o F with DCIS. In 41 y/o F Hypo-fractionation gets a "7" while conventional gets a "9"
http://www.acr.org/~/media/ACR/Documents/AppCriteria/Oncology/DuctalCarciniomaInSitu.pdf

Even in a 78 y/o F, hypo-fractions gets the SAME score as convetional at an "8"

Troll fail.

 

[Damn_Daniel]

Do you know how the ACR appropriateness rating system works? Do you know how 7 is different from 9? I'm intimately aware of the rating systems (I had an "American Pie" like incident with a copy of the Oncology journal; oh, and professionally I'm involved).

7, 8, 9 mean "usually appropriate and the treatment is indicated in the specified clinical scenarios at a favorable risk-benefit ratio for patients." If you read the text of how the ratings are given and what they mean, within each category (usually appropriate, may be appropriate, usually not appropriate), each treatment/imaging modality is considered equal. When there is a numerical difference, it does not mean superiority within a specific category. Technically, it means that there was more variance in opinions. Literally, it mean that there was some loudmouth community yahoo that was upset that there are less fractions being delivered, and because of that, the group just had to say, "Yes, we all know it's completely appropriate, but let's just appease this cat, because the rest of us want to go for lunch." As we all know, lunch is a big part of these discussions, and knowing that, they created the "ratings within the ratings" system. It revolutionized the ACR Appropriateness Criteria meetings, and the incidence of lunch delays went down tremendously.

This is similar to a discussion that went on in the 80s and 90s... B06 showed that lumpectomy + RT = mastectomy for invasive cancer. Surgeons literally did the same type of logic that's being used above for DCIS - "There is not enough data to suggest that mastectomy = lumpectomy + RT, and so DCIS should be treated with mastectomy." The rates of mastectomy for DCIS remained much higher than for IDC. The radiation oncologists, being in the reality based world, didn't listen to those people, and they wrote B17 that compared BCS+RT vs BCS alone. The same type of person that delays lunch and drags down a completely appropriate treatment to a 7 shouted "You're committing malpractice! DCIS IS DIFFERENT!! We need to treat with mastectomy!" Anyway, we know how that turned out. Yes, there is no prospective evidence that mastectomy = BCS +RT for DCIS. No, there is no reason to treat a less aggressive disease with more aggressive treatment.

But, yeah. Let's wait for the HF trial that never comes and give patients non-invasive disease double the treatment. Oh, wait it did come. MDACC did the trial. And it showed better QOL to deliver HF.

 

[xrt123]

Long time reader. First time poster. DD is straight dabbing on haters.

 

[Damn_Daniel]

11% on Whelan had chemo. >20% on START A/B (large trials), a similar number on Royal Marsden Trial. In all trials, this was stratified. None of the trials showed a difference in side effects or efficacy based on that variable. It's not good science to pick and choose like this, and using that same example leads to some funny examples ...

On RTOG 9111, only 20% of the patients were women (similar to # of patients in the above trials that had chemo). Are we saying that because only 20% of patients were women, that is too low numbers (even though it was stratified), so it's unlikely that women with locally advanced laryngeal cancer benefit from chemo?

On Stupp trial, upon further analysis, patients with STR rather than GTR did not benefit from Temodar. I think you'd be hard pressed to find an oncologist that would withhold Temodar for a patient with an STR.

 

[thesauce]

It's only a full .PDF if you subscribe to JCO.
It's something, but, I'd be hard pressed to say that I really think there's a survival benefit. It's a lot like low risk prostate cancer - we are over treating many to cure the few that may have disease that will present itself as aggressive down the road. Anyone using OncoType to make RT decisions? There isn't great prospective data, but you'd have to presume it will pan out, as it did for invasive disease.

Even with a full discussion, I find it very hard to convince women to omit RT. I think since I give 16 fractions to almost everyone, the commitment seems short enough for them to almost always want treatment.

If you believe the EBCTCG data about adjuvant XRT after lumpectomy improving survival for invasive cancers, it would HAVE to be the case in DCIS as well, simply because adjuvant XRT decreases the subsequent incidence of invasive disease. You just have to have large enough numbers to see it.

 

[scarbrtj]

Yup. ASTRO doesn't really have our interests at heart. My boy just published this showing that we are going to have a huge surplus, yet the powers that be continue to churn out more rad oncs. What a fiasco! We can fight back. The internists revolted and they won. But, unfortunately, our specialty is composed mostly of weenies.

I just saw some ABR data regarding number of first-time written exam test takers. It was around 130 in 2004 and around 190 last year; which to me means about a 50% increase in the number of rad oncs being churned out in the US just in the last 10 years. Fifty percent! Yikes. I guess on the upside this probably will only translate mathematically into just a 33% drop in professional reimbursement.