This patient will be receiving Kadcyla as adjuvant treatment, something to keep in mind.
with/without axilla dissection?
It’s right sided, I’d go with comprehensive.
pubmed.ncbi.nlm.nih.gov
That was the point, I was trying to adress. If she gets axillary dissection and comes back clear, I would leave axilla alone. Otherwise, I would treat.
Fair enough. So high tangents vs ax dissection+wbrt vs rni. Standard breast.
Turns out Dr. Beriwal reads this and called me out .. @evilbooyaa right - ITCs post chemo portend worse outcome.
That depends... You can use Z11 data for that, but the population of premenopausal ER-PR- patients in Z11 was small...
Well, if Dr beriwal says rni, which I surmise he is, then rni it is.
Mad respect for this man.
Certainly a "modern" fascination with RNI. The overall survival in breast cancer is going up, up, up. This is not due to the advent of irradiating much, much, much huger volumes of normal female tissue than we did ~10 years ago.
Yes, I have even gotten push back from a breast surgeon and med oncs.
As a group, with all the surgeons, MedOncs, and RadOnc in my community: cN1 --> ypN0 will buy you PMRT until B51 results (and is positive). While we've discussed the nuances of this in tumor board etc, I fortunately haven't encountered anyone in my referral chain making this statement (yet).
Or did she really have ITC and this is a reflection of poor response to nact?
Just FLASH the whole breast and get on with it. Hell, FLASH both breasts. Wouldn’t that be wild
I couldn't agree more. It's maddening.
Radiation for almost any cancer via local or locoregional RT will improve DFS. There was even a measurable (super small) DFS benefit to PMRT in T1N0 breast cancer in the EBCTCGs eg. If you don’t have thousands of patients, and look in a more modern era, the DFS benefit will be there but be statistically insignificant (DEFINE_ME). If you go back a quarter century and enroll thousands of patients, the benefit becomes statistically significant (https://www.nejm.org/doi/full/10.1056/nejmoa1415369). OS benefits of ENI are never robustly shown. The med oncs seem to be having a discussion about “Should we chase DFS benefit without OS benefit.” This doesn’t seem to bother rad oncs re ENI in breast? These large studies with thousands of patients also recorded toxicity outcomes, most of which were also statistically significantly different.
It doesn't take much for me to offer re-irradiation of the breast/chest wall especially if there's a couple years in between. Lot's of (low-quality) data out there.
yes, there were many years. I feel pretty good about offering it in a case that was discussed recently, but will be the first time I re-RT if the patient ends up coming to me.
perfect, thanks. I neglected to mention that in my particular patient, she was cT3N1 at presentation, but I was mostly curious about the general experience of rad oncs out there with respect to surgeons advising patients as if B-51 showed no benefit to RNI when ypN0.
Definitely have a handful of pts who refuse endocrine therapy upfront that end up getting sent to me for RT. It really brings home the point to me they many of these cooperative group rad onc PIs have no clue about patient preferences and concerns in the real world when they try to create these RT omission trials in favor of endocrine therapy
I agree with 5 fx breast RT instead of anti-estrogen therapy so much. But OTOH, what is weird and unexpected (to me) is that ~40% of all older women get RT alone already? And only ~10% get hormone therapy alone?? And the differences don't vary by age as much as one might expect. Also hidden in this data is the fact that we know when someone gets RT that the RT compliance rate is ~100%, however when someone is "taking" hormone therapy (for 5 years) compliance rates are less than 100%. Finally, this article will do exactly zero to change any practice pattern anywhere.
The way cancer care in my system is set up, I would say the vast majority of patients receiving lumpectomy in my catchment area come to me for consult. It is surprising to me how many women have refused endocrine therapy, are willing to talk to MedOnc but haven't decided if they'll do it, or are planning to "try it out" but aren't sure if they'll continue it for 5 years.
A few of the pts i end up treating refuse to even see a MO. Definitely was eye opening compared to how i saw things in residency
I scrolled through the posts here. Didn't see any mentions as to this. Somewhat notable/remarkable that w/ 2y median (1-55 mos) followup, not a single cN+/ypN0 patient... with or without RNI... had regional nodal failure. It certainly makes a long row to hoe for PMRT by itself.
Would def use IMRT, although my bet is a static field "slightly askew mohawk" static field arrangement of 7-9 beams will be better than a coplanar VMAT. Sometimes you can't aim an arc in the tumor plane (this tumor seems planar in shape but again its plane is "askew mohawk") without also rotating the couch simultaneously as the gantry moves. Who knows when we will get that function, but it would be nice. I would do 37.5/15 to 50/20. You should get <20% of dose to optic n/retina and a very good brain DVH. This is one of those mets that will need to be "cured" or else cause the patient really bad QOL down the road.
wait and see what systemic therapy does, or just go ahead and start?
