Mastectomy Scar Boost

[dieABRdie]

Where I trained we boosted everyone.... period.

Then when studying for oral boards just now I realized most major trials for PMRT did not boost.

One of those times you realize the "experts" that trained you might not actually know what they are doing.....


What do people do here? I'm probably going to drop it unless there's a reason to be worried about the scar (close/positive margin)

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[RADONC4285]

Where I trained we boosted everyone.... period.

Then when studying for oral boards just now I realized most major trials for PMRT did not boost.

One of those times you realize the "experts" that trained you might not actually know what they are doing.....


What do people do here? I'm probably going to drop it unless there's a reason to be worried about the scar (close/positive margin)

same here. Where i trained everyone got a boost, but there is really no good evidence for it. My philosophy is not to boost unless it's inflammatory or there is a really convincing reason. Same for bolus, unless there is skin involvement, there is no need to bolus. In fact, EORTC guidelines published recently recommend against routine bolus. Adds tox for no benefit

 

[Ray D. Ayshun]

Yeah, I don't boost PMRT. I'm not aware of it ever having been shown to make a difference. I do boost inflammatory, or will when I see one...

 

[elementaryschooleconomics]

As soon as I left residency I stopped doing a routine scar boost.

After the Consensus Guidelines dropped in the Green Journal a few weeks ago, I will likely abandon routine bolus as well. Currently just waiting to see the inevitable response papers and Twitter battles before making a final call on that...

 

[TheWallnerus]

Scar failure was invented by the boost companies to sell more scar boost.

After the Consensus Guidelines dropped in the Green Journal a few weeks ago, I will likely abandon routine bolus as well.

This, and a little RO-APM'ing; scar boost we hardly knew ye

 

[elementaryschooleconomics]

Scar failure was invented by the boost companies to sell more scar boost.


This, and a little RO-APM'ing; scar boost we hardly knew ye

There was only a little grumbling by my therapists about my lack of scar boosting (when I explained why to one of them once, she goes "well, I just know that if it was ME on that table, I'd definitely ask for one...", but they've moved on).

The bolus thing, on the other hand, is going to ruffle a lot of feathers. I have been bringing up that ESTRO paper a lot to try to short circuit the headaches that it will cause me. I don't know why I bother, the headaches are coming no matter what.

 

[deleted1111261]

There is no evidence for using it routinely.

But, makes oncologic sense for + margin, T4 disease, I'd still do it.

Same with bolus. But, will be hard to change practice. People love thinking we need to be complicated for things, when we don't really need to. "BREAST IS THE WORST!"

 

[madchemist89]

Im not routinely boosting. I've been gentle bolusing but I might stop that too soon.

 

[TheWallnerus]

There was only a little grumbling by my therapists about my lack of scar boosting (when I explained why to one of them once, she goes "well, I just know that if it was ME on that table, I'd definitely ask for one...", but they've moved on).

Therapists and deodorant advice to breast patients. I will say no more.

 

[Palex80]

I have to confess that I did not boost a sarcoma surgical scar last week.

 

[RADONC4285]

There was only a little grumbling by my therapists about my lack of scar boosting (when I explained why to one of them once, she goes "well, I just know that if it was ME on that table, I'd definitely ask for one...", but they've moved on).

The bolus thing, on the other hand, is going to ruffle a lot of feathers. I have been bringing up that ESTRO paper a lot to try to short circuit the headaches that it will cause me. I don't know why I bother, the headaches are coming no matter what.

tbh, it's strange the therapists will question you about this stuff. It's one thing to bring up something that's being done differently. I appreciate that. It's a good way to make sure nothing was missed. But to still question your decision after you explained is ridiculous. You're the doctor making the decisions

 

[elementaryschooleconomics]

tbh, it's strange the therapists will question you about this stuff. It's one thing to bring up something that's being done differently. I appreciate that. It's a good way to make sure nothing was missed. But to still question your decision after you explained is ridiculous. You're the doctor making the decisions

I suspect novels could be written about RadOnc and RTT interactions...

 

[DrZap]

I do for T4, inflammatory, or close margins, definitely more cases where I omit the boost than give it

 

[temujim]

tbh, it's strange the therapists will question you about this stuff. It's one thing to bring up something that's being done differently. I appreciate that. It's a good way to make sure nothing was missed. But to still question your decision after you explained is ridiculous. You're the doctor making the decisions

Doctors come and go. Some therapists are forever.

 

[evilbooyaa]

No routine use of scar boost OR bolus on any of my PMRT patients. Inflammatory, yes. Close skin margin, yes. Dermal involvement at any point, yes.

 

[fiji128]

Agree with the above T4 dz especially inflammatory. Clinical or pathological skin involvement or positive margin. From a practical stand point this means it’s rarely done.

 

[taserlaser]

Rarely ever boost in our dept, 16 fr routine. Inflammatory yes. Positive margin boosts even are controversial here, since ‘where is the evidence’ and ‘how do you know what’s where the positive margin was’. Have shifted away from bolus pre green journal recommendations, primarily on the BC data. Skin involvement/dermal lvi get bolus, no boost.

 

[dieABRdie]

Thank you everyone for confirming what I suspected all through residency.... my attendings are actually *****s.

Henceforth... I will no longer boost or bolus unless the above mentioned clinical indications are present.

Despite being a cesspool of negativity (which I participate in regularly)… this forum has been a tremendous help with real world advice as I began my practice..

 

[elementaryschooleconomics]

Thank you everyone for confirming what I suspected all through residency.... my attendings are actually *****s.

Henceforth... I will no longer boost or bolus unless the above mentioned clinical indications are present.

Despite being a cesspool of negativity (which I participate in regularly)… this forum has been a tremendous help with real world advice as I began my practice..

While I love ragging on my residency institution, I do understand how this happens.

RadOnc was born in academia, and it attracts certain personalities. Namely, people who, on average, care about intangible accolades and their reputation amongst their peers to a significant degree (gross generalization, I know). Departments develop a culture and practice patterns, and institutional inertia is incredibly powerful. Medicine is also inherently conservative. Thus, new trials and evidence are published, but people might be slow to adopt novel or different data if senior leaders ("the cool kids") don't adopt it themselves. Going against dogma is very difficult to do in many academic environments, and Radiation Oncology, being so small, seems to suffer from this Mean Girls clique syndrome more than other specialties.

Basically, the nail that sticks out gets hammered down.

So, practice patterns change at a glacier pace. Enter: medical students and residents, who must pass through these environments. We're taught "this is the one and true correct way", and don't have the perspective (or power) to challenge these things.

It's why breast patients are told not to wear deodorant, or why head and neck patients are only prescribed Silvadene very reluctantly at the very end of a treatment course, if at all. I can immediately think of at least four therapeutic schemes that the culture of my residency institution told me was the "correct" way to treat, which I eventually came to learn was just "like, their opinion, man", and other institutions did something else - and their patients seem to do fine.

It is what it is. I assume every specialty has variations of this? I mean...I hope they do.

 

[evilbooyaa]

While I love ragging on my residency institution, I do understand how this happens.

RadOnc was born in academia, and it attracts certain personalities. Namely, people who, on average, care about intangible accolades and their reputation amongst their peers to a significant degree (gross generalization, I know). Departments develop a culture and practice patterns, and institutional inertia is incredibly powerful. Medicine is also inherently conservative. Thus, new trials and evidence are published, but people might be slow to adopt novel or different data if senior leaders ("the cool kids") don't adopt it themselves. Going against dogma is very difficult to do in many academic environments, and Radiation Oncology, being so small, seems to suffer from this Mean Girls clique syndrome more than other specialties.

Basically, the nail that sticks out gets hammered down.

So, practice patterns change at a glacier pace. Enter: medical students and residents, who must pass through these environments. We're taught "this is the one and true correct way", and don't have the perspective (or power) to challenge these things.

It's why breast patients are told not to wear deodorant, or why head and neck patients are only prescribed Silvadene very reluctantly at the very end of a treatment course, if at all. I can immediately think of at least four therapeutic schemes that the culture of my residency institution told me was the "correct" way to treat, which I eventually came to learn was just "like, their opinion, man", and other institutions did something else - and their patients seem to do fine.

It is what it is. I assume every specialty has variations of this? I mean...I hope they do.

In regards to the bolded: I always try to instill in trainees that although I do things X way, there are multiple other viable ways to treat, and that a lot of Rad Onc is not 'right' and 'wrong' but simply personal preference and lots of grey rather than mostly black and white

 

[elementaryschooleconomics]

In regards to the bolded: I always try to instill in trainees that although I do things X way, there are multiple other viable ways to treat, and that a lot of Rad Onc is not 'right' and 'wrong' but simply personal preference and lots of grey rather than mostly black and white

I'm so happy you're in a position to teach that concept. So many of my attendings had iron-clad convictions that their way was the right (and only) way, and anyone who did anything else was clearly wrong.

However, there was one attending who was always quick to admit when they weren't sure about something and frequently acknowledged that the way we were treating someone was not the only way we could do it. I was fortunate to spend a lot of time with that person and it had a very strong influence on how I perceive the practice of Radiation Oncology.

Recognizing that we can't always be right, or that an alternative approach might have equal or better outcomes, is the reason we're no longer practicing bloodletting to balance the four humours.

 

[RadOncDoc21]

There is no evidence for using it routinely.

But, makes oncologic sense for + margin, T4 disease, I'd still do it.

Same with bolus. But, will be hard to change practice. People love thinking we need to be complicated for things, when we don't really need to. "BREAST IS THE WORST!"

 

[deleted1111261]

I think an example of this - and I am guilty of this - was when Georgetown started an aggressive Cyber/SBRT prostate program. Their marketing was really irritating to me, they were killing it with patients in the DMV, but most of us in the area were pretty pissed about it.

We could have had a more curious mindset, we could have called the Collins’ brothers, really looked at their outcomes (which are good) and offered it to our own patients with their guidance, we would have benefited our local patients with a new treatment instead of decrying them as “experimental”.

There is a story of an interaction with a prominent UPMC Rad Onc being told by a prominent MDACC Gyn Rad Onc being told that cervical cancer IMRT was “malpractice”, to their face. And that sort of commentary occurs .. all .. the .. time. We really need to learn from each other and utilize best practices.

 

[thecarbonionangle]

People like PE are perfect example of what is wrong with the field, sitting at top gobbling opportunities preventing any sort of change at all based on dogma. Disgusting.

 

[TheWallnerus]

There is a story of an interaction with a prominent UPMC Rad Onc being told by a prominent MDACC Gyn Rad Onc being told that cervical cancer IMRT was “malpractice”, to their face.

Haha. Definitely a real cadre of cervical-GYN-IMRT-is-malpractice folks in academia for many years. They tended to be late-stage boomer, or early senior citizen, in my experience. IMRT is (for some) rad onc's Moby Dick. He piled upon IMRT the sum of all the general rage and hate felt by his whole race from Adam down; and then, as if his chest had been a mortar, he burst his hot heart's shell upon it.

 

[jondunn]

People like PE are perfect example of what is wrong with the field, sitting at top gobbling opportunities preventing any sort of change at all based on dogma. Disgusting.

I mean this was true in like 2010. pick a better example than PE now in 2021, girl lol

 

[medgator]

I mean this was true in like 2010. pick a better example than PE now in 2021, girl lol

Accurate

 

[theradiator]

Great topic that gives insight into the field of radiation oncology's treating philosophy.

Let's acknowledge that those old randomized PMRT trials were performed before widespread breast reconstructions. Breast reconstructions were routinely adopted by plastic surgeons without randomized controlled trials.

We now routinely perform presurgical MRI - adopted without randomized trials - that would potentially address the unknown target issue. (Projected circumferential margin width/positivity now routinely reported on rectal MRI)

Marked increase in nipple sparing and skin sparing that would logically increase the frequency and relevance of close anterior margins - also widely adopted without randomized data.

Is it safe to conclude that boosting makes sense if deemed high risk for local failure after only 50 Gy? And, if there are data that a boost slightly increases toxicity related to fibrosis or breast implant complications, it is non-randomized.

 

[fiji128]

same here. Where i trained everyone got a boost, but there is really no good evidence for it. My philosophy is not to boost unless it's inflammatory or there is a really convincing reason. Same for bolus, unless there is skin involvement, there is no need to bolus. In fact, EORTC guidelines published recently recommend against routine bolus. Adds tox for no benefit

Does some one have a link to these EORTC guidelines, can't seem to find them. Thanks.

 

[TheWallnerus]

Does some one have a link to these EORTC guidelines, can't seem to find them. Thanks.

I think this is it. (Companion.)

Bolus use (or non-use) is known to be much more associated with the country in which a patient is treated versus any tumor or patient associated factors. The previous "guidelines" which I considered prevailing were ASCO's which were always mute on the indications for bolus in PMRT.

 

[BobbyHeenan]

I have slowly backed away from the bolus and boost over the last decade. I'm now a lot more selective...things like margins, tumor biology, location in regard to skin, reconstruction plans, etc. go into decision making now.

Where I trained everyone got bolus until they were bright red and everyone was boosted...no matter what.

 

[TheWallnerus]

Where I trained everyone got bolus until they were bright red and everyone was boosted...no matter what.

Multifactorial reasons afoot, but definitely in my training there was an undercurrent in my attendings' minds that as surgeons were "de-escalating" surgery it was 1) bad/risky and 2) up to rad oncs to rescue patients from locoregional recurrences. Ergo, once skin-sparing mastectomy became a thing, the learned breast rad oncs (with feelings, not data) said... by way of action... "surgeons risky, we smart." I think we saw these sentiments rear their head again with Z0011.

 

[TheWallnerus]

For historical interest, a top US breast rad onc reviewed another rad onc's breast cases in the recent past because a colleague of the latter's was irate that the rad onc wouldn't always use bolus. Here's what the well known rad onc breast doc said:

 

[BobbyHeenan]

For historical interest, a top US breast rad onc reviewed another rad onc's breast cases in the recent past because a colleague of the latter's was irate that the rad onc wouldn't always use bolus. Here's what the well known rad onc breast doc said:

Can't say I've ever said "your skin isn't red enough, let's add some fractions."

 

[Mandelin Rain]

Skin as a target always seemed a bit odd to me in "most" post mastectomy cases. Like we're out here sparing skin in lumpectomy cases, but a woman with the same exact T1cN1 cancer who opted for mastectomy needs her skin falling off to be adequately treated?

 

[OTN]

I only bolus for inflammatory disease or frank skin involvement. Recent data demonstrated there's no need to routinely boost all breast ca pts s/p mastectomy.

 

[evilbooyaa]

For historical interest, a top US breast rad onc reviewed another rad onc's breast cases in the recent past because a colleague of the latter's was irate that the rad onc wouldn't always use bolus. Here's what the well known rad onc breast doc said:

Bolusing a reconstructed breast with your PMRT in the absence of postive margin, skin involvement, or inflammatory should be tantamount to malpractice.

Whoever wrote these words is a moran.

 

[Mandelin Rain]

I think that's a bit hyperbolic, but yeah, I don't do it anymore (did it 100% of time in residency).

 

[TheWallnerus]

Bolusing a reconstructed breast with your PMRT in the absence of postive margin, skin involvement, or inflammatory should be tantamount to malpractice.

Whoever wrote these words is a moran.

And yet he’s a “leader”

 

[metallica81788]

I self identify as a "leader" and "expert in the field"

 

[RickyScott]

And yet he’s a “leader”

The real issue here are self righteous execrable p-- who weaponize minor differences in practice to injure a colleague, often with ulterior motives . Have seen this play out before and several "leaders" (chairs) known for it. Very poisonous since radonc is a black box to other specialties and most administrators.

 

[medgator]

Bolusing a reconstructed breast with your PMRT in the absence of postive margin, skin involvement, or inflammatory should be tantamount to malpractice.

Whoever wrote these words is a moran.

Agree but using the m word seems a bit over the top imo....

 

[deleted1111261]

Maybe it was Dr. Moran? There are quite a few that a RadOncs

 

[evilbooyaa]

Agree but using the m word seems a bit over the top imo....

Last part was a bit tongue in cheek, given the ******* nature (IMO) of the 'expert opinion'... most notably the one that says 'just add more fractions until that G2-3 dermatitis develops'

 

[TheWallnerus]

Maybe it was Dr. Moran? There are quite a few that a RadOncs

 

[elementaryschooleconomics]

Look, the only thing that matters is there's no tumor on the ink of those signs.