APBI - 26 Gy?

[sirspamalot]

The magic of non-purposeful RT dose to the axilla?



The cosmetic outcome with PBI compared to WBI favors PBI in every trial using a regimen that is NOT 38.5 in 10 fractions BID.
40/15 PBI and 30/5 PBI both have less acute AND late toxicity than WBI regimens they were compared to.
26/5 PBI we have no prospective data for but presumably would cause less toxicity than 26/5 WBI.

Your internal justification to avoid learning how to do PBI is wrong. If you're gonna act like a boomer RO and ignore new techniques/data that would benefit patients, then go ahead and just own it. Lord knows there are enough ROs nationwide who feel similarly.

Yeah, so if you want to #fractionshame #volumeshame by all means, you do that.

My 55+ yo patients have done great with hypofrac whole breast no boost, and particularly for those who are ER+, and may not tolerate endocrine therapy, I see no need to change.

I'd appreciate it if you wouldn't assume I'm a boomer, or for that matter, feel this discussion warrants a personal attack.

If we can misgrade GU toxicity in prostate, I'm sure we can do the same for breast (see post elsewhere). "Are you happy with your treatment" is the bottom line, and nearly all women who get hypofrac whole breast are pleased.

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[TheWallnerus]

The magic of non-purposeful RT dose to the axilla?



The cosmetic outcome with PBI compared to WBI favors PBI in every trial using a regimen that is NOT 38.5 in 10 fractions BID.
40/15 PBI and 30/5 PBI both have less acute AND late toxicity than WBI regimens they were compared to.
26/5 PBI we have no prospective data for but presumably would cause less toxicity than 26/5 WBI.

Your internal justification to avoid learning how to do PBI is wrong. If you're gonna act like a boomer RO and ignore new techniques/data that would benefit patients, then go ahead and just own it. Lord knows there are enough ROs nationwide who feel similarly.

Haha re: non purposeful axillary RT. “Happy dosimetric accidents” if Bob Ross were a rad onc.

This is like a religious discussion in breast. Local recurrences are hell. Nodal RT achieves salvation; do you believe?

We can all guarantee SirSpam knows how to do PBI. It’s called a mini tangent or a photon boost. He’s a very if it ain’t broke don’t fix it guy. Which one can respect… to a point!

 

[TheWallnerus]

My 55+ yo patients have done great with hypofrac whole breast no boost,

They will do even better without the whole breast at all. It’s proven.

 

[evilbooyaa]

Yeah, so if you want to #fractionshame #volumeshame by all means, you do that.

My 55+ yo patients have done great with hypofrac whole breast no boost, and particularly for those who are ER+, and may not tolerate endocrine therapy, I see no need to change.

I'd appreciate it if you wouldn't assume I'm a boomer, or for that matter, feel this discussion warrants a personal attack.

If we can misgrade GU toxicity in prostate, I'm sure we can do the same for breast (see post elsewhere). "Are you happy with your treatment" is the bottom line, and nearly all women who get hypofrac whole breast are pleased.

Not calling you a boomer, saying that you are acting like one. Boomer (especially in RO) is a mindset less than it is an age. Like being resistant to change for things that are wins across the board for patients (used to be 50/25 WBI vs 40-42.6/15-16, now I believe it's this, where treatments are just as effective but not as toxic). If you're uncomfortable with the fractionation scheme of 30/5 then consider giving 40/15 PBI a try. It's the same WBI plan just treating less of the breast. Less toxicity. Same LR. Start with just the 'suitable' patients and don't offer it for cautionary if you want.

Your personal experience (again, how's your f/u game been across all the breast cancer pts you've treated?) does not, IMO, trump published randomized data over thousands of patients.

I'm not routinely interested in fraction shaming, because vast majority of the time, less fractions means some trade off somewhere in terms of side effects.

I suppose I am 'volume' shaming - you treating gyn cases with 3D techniques?

 

[deleted1111261]

@evilbooyaa - one caution of the Livi study w the toxicity

The control arm treated in a way you or I would never treat, old school 2D to isocenter. Even actual wedges.

If you seen how this looks (I caught the tail end) and compare it to 42/16 with V105 minimized and out of sensitive areas, it’s vastly different.

I think APBI is superior for a variety of reasons, but the difference in toxicity seen in Livi should be put in context

 

[evilbooyaa]

@evilbooyaa - one caution of the Livi study w the toxicity

The control arm treated in a way you or I would never treat, old school 2D to isocenter. Even actual wedges.

If you seen how this looks (I caught the tail end) and compare it to 42/16 with V105 minimized and out of sensitive areas, it’s vastly different.

I think APBI is superior for a variety of reasons, but the difference in toxicity seen in Livi should be put in context

Fair enough. I think I'm parital to 30/5 because I think it eliminates the "why not 5Fx" discussion and I've had > 0% success billing it as SBRT, and not feeling like I have to use mini-tangents as I would for 40/15 and have to deal with insurance challenges for 15Fx IMRT....

But yes, maybe not the best comparator arm....

 

[drowsy12]

I don't think the comparator arm is a major issue. We have seen that treating less tissue is good. the story checks out across multiple trials. but fair point