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winstonfoot5

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Never good for RO when you are on front page of WSJ and an original article in the latest NEJM (but good for patients?)

www.wsj.com

More Women With Breast Cancer Could Skip Harsh Radiation, Study Says

Deaths were nearly equal whether women received radiation in addition to surgery and hormone therapy, a study showed.
www.wsj.com www.wsj.com
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winstonfoot5 said:
Never good for RO when you are on front page of WSJ and an original article in the latest NEJM (but good for patients?)

www.wsj.com

More Women With Breast Cancer Could Skip Harsh Radiation, Study Says

Deaths were nearly equal whether women received radiation in addition to surgery and hormone therapy, a study showed.
www.wsj.com www.wsj.com
Click to expand...

I noticed this yesterday as well. Clearly all the data and the narrative is going in one direction. 30 fractions to 15 fractions to 5 fractions (or less) to 0 fractions over the course of about 10 years. Low risk stage IA breast will become our next lymphoma. It would be great if Astro and NRG (its the same people at both orgs) had our backs and was aggressively looking at Sx + AI or RT but their attention seems to be elsewhere these days.
 
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From nejm, "The risk–benefit ratio of irradiation and endocrine therapy in older patients with low-risk, ER-positive disease has become more nuanced, with hypofractionated dose schedules, accelerated partial breast irradiation, and improved delivery techniques. Given the limitations of partial-breast irradiation (which demands localization of the treatment site and associated quality assurance) as compared with whole-breast irradiation, we concur with the view that adjuvant endocrine therapy without irradiation is the principal competitor to whole-breast irradiation. For patients who do not receive irradiation and do have subsequent development of local recurrence, the option of further breast-conserving therapy and irradiation is available, so recurrence does not necessarily mean loss of the breast."

If you can effectively salvage those 10% of patients who will have a LF down the road and save the other 90% of patients from a treatment they derive no benefit from with no determinant in terms of survival why would this be considered an unreasonable approach?
 
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EUROPA can't be published soon enough. #droptheAI
 
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fiji128 said:
From nejm, "The risk–benefit ratio of irradiation and endocrine therapy in older patients with low-risk, ER-positive disease has become more nuanced, with hypofractionated dose schedules, accelerated partial breast irradiation, and improved delivery techniques. Given the limitations of partial-breast irradiation (which demands localization of the treatment site and associated quality assurance) as compared with whole-breast irradiation, we concur with the view that adjuvant endocrine therapy without irradiation is the principal competitor to whole-breast irradiation. For patients who do not receive irradiation and do have subsequent development of local recurrence, the option of further breast-conserving therapy and irradiation is available, so recurrence does not necessarily mean loss of the breast."

If you can effectively salvage those 10% of patients who will have a LF down the road and save the other 90% of patients from a treatment they derive no benefit from with no determinant in terms of survival why would this be considered an unreasonable approach?
Click to expand...
Bsabp 6 had equal survival amongst all arms. You can say same thing for any patient undergoing BCS+RT, I suppose. IBTR can be salvaged.

Now, my thinking has been BCS + RT is a cosmetic treatment, and that aesthetics plays a role. Otherwise, just do mastectomy. In modern era, with a fellowship trained surgeon and FiF whole or VMAT partial breast radiation, you get a great result and highest local control right off the bat.

Reducing IBTR maximally, while having best aesthetic outcome is optimal.
 
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RealSimulD said:
Bsabp 6 had equal survival amongst all arms. You can say same thing for any patient undergoing BCS+RT, I suppose. IBTR can be salvaged.

Now, my thinking has been BCS + RT is a cosmetic treatment, and that aesthetics plays a role. Otherwise, just do mastectomy. In modern era, with a fellowship trained surgeon and FiF whole or VMAT partial breast radiation, you get a great result and highest local control right off the bat.

Reducing IBTR maximally, while having best aesthetic outcome is optimal.
Click to expand...

In my experience ladies that have local recurrence don't opt for attempt at ongonig breast conservation therapy. They've HAD IT/FED UP with mammograms, stress, etc. THey choose mastectomies. So this fantasy land of we'll just salvage with another lump + XRT when it comes back in theory/oncologically is fine...but in reality is not.

I remain convinced that a HUGE chunk of breast radiation oncologists don't actually see long term follow up patients, especially as it relates to AI management.
 
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1676556139668.png


1676556188733.png

1676556301439.png




AND SO ON AND SO FORTH.

STOP BEING RACIST, WSJ.
 
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fiji128 said:
From nejm, "The risk–benefit ratio of irradiation and endocrine therapy in older patients with low-risk, ER-positive disease has become more nuanced, with hypofractionated dose schedules, accelerated partial breast irradiation, and improved delivery techniques. Given the limitations of partial-breast irradiation (which demands localization of the treatment site and associated quality assurance) as compared with whole-breast irradiation, we concur with the view that adjuvant endocrine therapy without irradiation is the principal competitor to whole-breast irradiation. For patients who do not receive irradiation and do have subsequent development of local recurrence, the option of further breast-conserving therapy and irradiation is available, so recurrence does not necessarily mean loss of the breast."

If you can effectively salvage those 10% of patients who will have a LF down the road and save the other 90% of patients from a treatment they derive no benefit from with no determinant in terms of survival why would this be considered an unreasonable approach?
Click to expand...
Definitely not unreasonable. In fact it’s very reasonable if the option is 5+ week non IMRT whole breast. But as we all know any woman who’s a candidate for skipping RT is a candidate for partial breast 26 Gy/5fx. It’s very tough to get major side effects or have to spend a lot on gas for that treatment.
 
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fiji128 said:
From nejm, "The risk–benefit ratio of irradiation and endocrine therapy in older patients with low-risk, ER-positive disease has become more nuanced, with hypofractionated dose schedules, accelerated partial breast irradiation, and improved delivery techniques. Given the limitations of partial-breast irradiation (which demands localization of the treatment site and associated quality assurance) as compared with whole-breast irradiation, we concur with the view that adjuvant endocrine therapy without irradiation is the principal competitor to whole-breast irradiation. For patients who do not receive irradiation and do have subsequent development of local recurrence, the option of further breast-conserving therapy and irradiation is available, so recurrence does not necessarily mean loss of the breast."

If you can effectively salvage those 10% of patients who will have a LF down the road and save the other 90% of patients from a treatment they derive no benefit from with no determinant in terms of survival why would this be considered an unreasonable approach?
Click to expand...

Most radiation oncologists I talk to consider that a reasonable approach and include it in their discussion. However, the patient perspective is conspicuously absent here. "Effective salvage" includes another biopsy, another surgery at least, and potentially more therapy. Why is it considered a reasonable approach to imply that none of these women should receive radiotherapy?

In my clinic, here is the discussion I give for a 67 year old fit woman with an ER low, Ki67 low 1.5 cm N0 IDC. These women are often a couple weeks past diagnosis and surgery, sore, and anxious. They don't want hormone therapy or radiotherapy, "why do I need this when the disease is out?".

So I share the options. Do nothing, not recommended, we discuss old B-trial data. Next, hormone therapy alone, 8-10% risk of recurrence in your life time. If it recurs, we can likely fix it with surgery, radiation, and hormone therapy. If you stop hormone therapy, the risk goes up. Alternatively, radiotherapy for 5 days per Florence for a recurrence risk of <1% (I will start using this number). This carries a very low but non-zero risk of acute and late toxicity. I close by discussion radiotherapy alone and how there is limited data, in part due to investigator bias against radiation.

Genuinely as yourself what you would pick.

It is very patient uncentered to deny patients this discussion by emphasizing we are "over treating" 90% of patients.

It is shockingly hypocritical for a medical oncologist - a doctor that makes a living off adjuvant therapy in unselected populations - to suggest that.
 
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NotMattSpraker said:
Most radiation oncologists I talk to consider that a reasonable approach and include it in their discussion. However, the patient perspective is conspicuously absent here. "Effective salvage" includes another biopsy, another surgery at least, and potentially more therapy. Why is it considered a reasonable approach to imply that none of these women should receive radiotherapy?

In my clinic, here is the discussion I give for a 67 year old fit woman with an ER low, Ki67 low 1.5 cm N0 IDC. These women are often a couple weeks past diagnosis and surgery, sore, and anxious. They don't want hormone therapy or radiotherapy, "why do I need this when the disease is out?".

So I share the options. Do nothing, not recommended, we discuss old B-trial data. Next, hormone therapy alone, 8-10% risk of recurrence in your life time. If it recurs, we can likely fix it with surgery, radiation, and hormone therapy. If you stop hormone therapy, the risk goes up. Alternatively, radiotherapy for 5 days per Florence for a recurrence risk of <1% (I will start using this number). This carries a very low but non-zero risk of acute and late toxicity. I close by discussion radiotherapy alone and how there is limited data, in part due to investigator bias against radiation.

Genuinely as yourself what you would pick.

It is very patient uncentered to deny patients this discussion by emphasizing we are "over treating" 90% of patients.

It is shockingly hypocritical for a medical oncologist - a doctor that makes a living off adjuvant therapy in unselected populations - to suggest that.
Click to expand...

What is the 10 year LF rate where giving adjuvant RT stops making sense? Is it 5% at 10 years? 3% at 10 years? It will always make sense b/c that's how I make my living?

I imagine in the not too distant future it will be the surgeons and medical oncologist who will be the ones making this decision for us.
 
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fiji128 said:
What is the 10 year LF rate where giving adjuvant RT stops making sense? Is it 5% at 10 years? 3% at 10 years? It will always make sense b/c that's how I make my living?

I imagine in the not too distant future it will be the surgeons and medical oncologist who will be the ones making this decision for us.
Click to expand...

Are you an oncologist or an epidemiologist? We don't make decisions about therapeutic pathways in this way in my clinic and I would suggest that you don't either.

If someone has a 3% risk at 10 years, I would discuss with my surgeon that I would not recommend radiotherapy but I would be more than happy to talk to the patient about the recommendation. She would tell the patient. Most would cancel their appointment with me, but some don't.
 
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NotMattSpraker said:
Most radiation oncologists I talk to consider that a reasonable approach and include it in their discussion. However, the patient perspective is conspicuously absent here. "Effective salvage" includes another biopsy, another surgery at least, and potentially more therapy. Why is it considered a reasonable approach to imply that none of these women should receive radiotherapy?

In my clinic, here is the discussion I give for a 67 year old fit woman with an ER low, Ki67 low 1.5 cm N0 IDC. These women are often a couple weeks past diagnosis and surgery, sore, and anxious. They don't want hormone therapy or radiotherapy, "why do I need this when the disease is out?".

So I share the options. Do nothing, not recommended, we discuss old B-trial data. Next, hormone therapy alone, 8-10% risk of recurrence in your life time. If it recurs, we can likely fix it with surgery, radiation, and hormone therapy. If you stop hormone therapy, the risk goes up. Alternatively, radiotherapy for 5 days per Florence for a recurrence risk of <1% (I will start using this number). This carries a very low but non-zero risk of acute and late toxicity. I close by discussion radiotherapy alone and how there is limited data, in part due to investigator bias against radiation.

Genuinely as yourself what you would pick.

It is very patient uncentered to deny patients this discussion by emphasizing we are "over treating" 90% of patients.

It is shockingly hypocritical for a medical oncologist - a doctor that makes a living off adjuvant therapy in unselected populations - to suggest that.
Click to expand...

fiji128 said:
What is the 10 year LF rate where giving adjuvant RT stops making sense? Is it 5% at 10 years? 3% at 10 years? It will always make sense b/c that's how I make my living?

I imagine in the not too distant future it will be the surgeons and medical oncologist who will be the ones making this decision for us.
Click to expand...
Two excellent but obviously somewhat incompatible “cultures of thought” at play here. Indeed I do think the surgeons and med oncs will make the decisions. This is why I think it’s imperative to go five fraction on all these ladies ASAP and also imperative in my opinion to lower the dose as reasonably allowable and not use 30 Gy but instead use 26 Gy. And also never to do whole breast. 26 partial breast has noticeably less acute and late side effects in clinic versus 30… the med oncs and surgeons are “at risk” of noticing our late side effects. (Eventually we will prob have good data on single fraction and need to be prepared to use that if robustly validated.)
 
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I do adjuvant RT in a ton of breast patient's and will continue to do so at this time. I am obviously not talking about any individual cases but rather the overall trend and narratives that I am seeing in the literature and what that may mean for us down the road. There is no need for name calling and stating who the "real" oncologist are.

When something like the above is published in the NEJM people will pay attention. NRG is running a low risk breast trial that is likely could be positive as well if it can accrue. From BR007, "Framing this HR as differences in EFS for IBTR, this is equivalent to declaring any EFS value in the No RT group ≥ 91.57% at 10 years of average follow-up being equivalent to that of the RT group (assuming that the EFS RT group was about 95.57%)." What rate of LF will be tolerated by surgeons and med oncs with no RT is a very valid question.
 
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fiji128 said:
I do adjuvant RT in a ton of breast patient's and will continue to do so at this time. I am obviously not talking about any individual cases but rather the overall trend and narratives that I am seeing in the literature and what that may mean for us down the road. There is no need for name calling and stating who the "real" oncologist are.

When something like the above is published in the NEJM people will pay attention. NRG is running a low risk breast trial that is likely could be positive as well if it can accrue. From BR007, "Framing this HR as differences in EFS for IBTR, this is equivalent to declaring any EFS value in the No RT group ≥ 91.57% at 10 years of average follow-up being equivalent to that of the RT group (assuming that the EFS RT group was about 95.57%)." What rate of LF will be tolerated by surgeons and med oncs with no RT is a very valid question.
Click to expand...
You’re on the right track.

Unfortunately.

We have had great data on 3 week regimens for breast since around 2003-5 timeframe iirc. But this data was ignored for the LONGEST time in America. I do feel this is coming back to bite us. The chickens are coming home to roost. We needed to show value (to patients and payors) with hypofx in breast way back when. This would have made RT omission much more of a gauche topic outside rad onc. We were not smart. ASTRO was not smart! I was doing 16 fx breast IMRT on all Stage I since around 2006 at a cheaper or equal cost to that of 33 fraction 3D breast with multiple sims, plans, and cone downs. Yet per ASTRO I was wrong and venal.
 
Another breast radiation discussion- not going to lie, I skipped through the discussion because breast is the worst as we already know. I just wanted to comment on the word “harsh” in the title. If there isn’t a bias opinion, I don’t know what is.

I think what’s “harsh” is 5-10 years of hormonal therapy or “harsh” surgery/anesthesia for a local recurrence. Slightly pigmented skin that usually goes away isn’t “harsh” in my own biased opinion.
 
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What were the salvage mastectomy rates in the NEJM study?
That was the reason to disregard the previous generation of omission studies.
 
sirspamalot said:
Upton Sinclair has entered the chat.

“It is difficult to get a man to understand something, when his salary depends on his not understanding it.”​

Click to expand...
Gator, someone stealing your line that you took from Mr. Sinclair!
 
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Wait so this is CALGB study just in a slightly younger population, no? What possible utility do the results of this study have for anyone's clinical decision making? Why on earth are people still wasting time and resources on the same questions again and again and again? We know that adding RT to ER cuts a low chance of local recurrence down even more, without affecting overall survival (we've known this since B21). We know that giving both RT and hormone therapy reduces local recurrence to a greater extent than giving either treatment on its own. We know that while local recurrence risk goes down with age it's never zero and that age alone should not be a reason to offer or deny any therapy. So what is the point of all this? We have the information we need, let's tell our patients the risks and let them make their own decisions about their risk tolerance vs acceptance of potential side effects. Breast is the worst!
 
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pikachu said:
Wait so this is CALGB study just in a slightly younger population, no? What possible utility do the results of this study have for anyone's clinical decision making? Why on earth are people still wasting time and resources on the same questions again and again and again? We know that adding RT to ER cuts a low chance of local recurrence down even more, without affecting overall survival (we've known this since B21). We know that giving both RT and hormone therapy reduces local recurrence to a greater extent than giving either treatment on its own. We know that while local recurrence risk goes down with age it's never zero and that age alone should not be a reason to offer or deny any therapy. So what is the point of all this? We have the information we need, let's tell our patients the risks and let them make their own decisions about their risk tolerance vs acceptance of potential side effects. Breast is the worst!
Click to expand...
What is the ethical way to let patients make their own decisions about this. AFAIK, every patient makes their own decision about radiation after talking to me. I definitely tip the scales though. I tell these women the probability of a bad outcome is higher if they skip 5 fractions of RT. And I wonder if I should rephrase this and if so how.
 
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"hey, it could be worse. I could be asking you to do 16 like the rest of the chumps on SDN!"

administrators have entered the chat (...remember that pelvic sensation I mentioned previously?)
 
TheWallnerus said:
What is the ethical way to let patients make their own decisions about this. AFAIK, every patient makes their own decision about radiation after talking to me. I definitely tip the scales though. I tell these women the probability of a bad outcome is higher if they skip 5 fractions of RT. And I wonder if I should rephrase this and if so how.
Click to expand...
I don't know, I think we underestimate the emotional (and by this I mean not strictly risk-benefit-based) factors that influence the patients' decisions, most of which won't necessarily be influenced by our discussions , and can operate in all sorts of idiosyncratic ways (not just for early stage breast cancer). The anxious ones Want Everything, I Want The Cancer Gone, damn the torpedoes, give them 6 months of chemo for a 2% survival benefit plus All the Radiation (and are you sure 5 treatments are just as good as 35). The patient whose great-aunt Flora's neighbor's sister had skin burns from RT 30 years ago doesn't want anything to do with us even if she has higher risk disease. And then I think there is a lot of 'discounting' future risks for present inconvenience. I'm not even going to get into the ones who Did Their Own Research. I tell them the numbers, tell them the side effects, tell them to call me if they want treatment, and a lot of them do. Some of them don't and that's fine too!
 
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pikachu said:
I don't know, I think we underestimate the emotional (and by this I mean not strictly risk-benefit-based) factors that influence the patients' decisions, most of which won't necessarily be influenced by our discussions , and can operate in all sorts of idiosyncratic ways (not just for early stage breast cancer). The anxious ones Want Everything, I Want The Cancer Gone, damn the torpedoes, give them 6 months of chemo for a 2% survival benefit plus All the Radiation (and are you sure 5 treatments are just as good as 35). The patient whose great-aunt Flora's neighbor's sister had skin burns from RT 30 years ago doesn't want anything to do with us even if she has higher risk disease. And then I think there is a lot of 'discounting' future risks for present inconvenience. I'm not even going to get into the ones who Did Their Own Research. I tell them the numbers, tell them the side effects, tell them to call me if they want treatment, and a lot of them do. Some of them don't and that's fine too!
Click to expand...
This post resonates with my soul.
 
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fiji128 said:
I do adjuvant RT in a ton of breast patient's and will continue to do so at this time. I am obviously not talking about any individual cases but rather the overall trend and narratives that I am seeing in the literature and what that may mean for us down the road. There is no need for name calling and stating who the "real" oncologist are.

When something like the above is published in the NEJM people will pay attention. NRG is running a low risk breast trial that is likely could be positive as well if it can accrue. From BR007, "Framing this HR as differences in EFS for IBTR, this is equivalent to declaring any EFS value in the No RT group ≥ 91.57% at 10 years of average follow-up being equivalent to that of the RT group (assuming that the EFS RT group was about 95.57%)." What rate of LF will be tolerated by surgeons and med oncs with no RT is a very valid question.
Click to expand...

Apologies for the poor choice of words, I dont mean to imply you are not a real oncologist. It is a valid question. I just think its less important than what rate of LF a patient is willing to tolerate with no RT.

We probably agree that the message from NEJM, NRG, WSJ, etc. is to de-escalate by omitting RT. I am worried that clinics will de-escalate by omitting the RT referral, not the treatment. This is a population health maneuver (epidemiologist) not a patient centered maneuver (oncologist). It is not valid for you to decide for another clinic's doctor and patient whether they should have a treatment that offers clear benefit just because you value the benefit a certain way.

To grossly simplify, the same data would support a campaign to patients... "ask your doctor, do you REALLY need RT (and HT)?"

Very different than "Hey everyone, you probably dont need that RT"
 
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TheWallnerus said:
What is the ethical way to let patients make their own decisions about this. AFAIK, every patient makes their own decision about radiation after talking to me. I definitely tip the scales though. I tell these women the probability of a bad outcome is higher if they skip 5 fractions of RT. And I wonder if I should rephrase this and if so how.
Click to expand...

I present both sets of data and usually make a joke about my obvious bias since I do radiation. Usually gets a laugh and it's kind of nice to reassure people that all choices include very high chances of "cure".

Probably the best way is to have every patient see both a medical and radiation oncologist who are slightly biased toward omission and inclusion of radiotherapy respectively. That medical oncologist should definitely share adherence data and outcomes for non-adherent patients without radiation. That is often left out of this conversation.
 
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NotMattSpraker said:
I present both sets of data and usually make a joke about my obvious bias since I do radiation. Usually gets a laugh and it's kind of nice to reassure people that all choices include very high chances of "cure".

Probably the best way is to have every patient see both a medical and radiation oncologist who are slightly biased toward omission and inclusion of radiotherapy respectively. That medical oncologist should definitely share adherence data and outcomes for non-adherent patients without radiation. That is often left out of this conversation.
Click to expand...
Also long term AEs of ai therapy and how that play into real world compliance
 
TheWallnerus said:
What is the ethical way to let patients make their own decisions about this. AFAIK, every patient makes their own decision about radiation after talking to me. I definitely tip the scales though. I tell these women the probability of a bad outcome is higher if they skip 5 fractions of RT. And I wonder if I should rephrase this and if so how.
Click to expand...
 
I have still never had a patient choose hormone therapy over RT in 5 years as a practicing rad onc
 
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When I did med onc I had more than ten women in a span of two months say they would commit suicide if they had to be on Tam/AI any longer
 
RT does what it’s supposed to do - lower IBTR. Never said it improves survival.

“They are what we thought they are!”

 
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evilbooyaa said:
It's literally just CALGB but in pts up to 5 years younger. Why are everyone's panties in a bunch (again)?
Click to expand...

To me it is the strong language in the conclusion of the paper and the newspaper headlines.

Concern is surgeons or med onc will feel comfortably omitting radiation without a consult. "you don't need radiation, it is safe to omit" is basically what the authors state.
 
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Had a patient bring up this article today. I stood strong and defended “harsh radiation” therapy… thank you media!
 
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RadOncDoc21 said:
Had a patient bring up this article today. I stood strong and defended “harsh radiation” therapy… thank you media!
Click to expand...
In school when a kid was alleged to have cooties I was very cautious to be friends with them. Even if the kid did make a case about actually not having cooties. Slowly I could maybe eventually be friends with the kid, but always in the back of my mind: COULD POSSIBLY have cooties.
 
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RadOncDoc21 said:
Had a patient bring up this article today. I stood strong and defended “harsh radiation” therapy… thank you media!
Click to expand...

I found the editorial in the nejm regarding this trial far more infuriating than the actual trial or the wsj piece.
 
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fiji128 said:
Because?
Click to expand...

It plays into the stupidity that there is a subgroup out there that we just discovered can do without radiation. It also gives a nod to the ongoing biomarker grift as well.
 
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Fpg1245 said:
It plays into the stupidity that there is a subgroup out there that we just discovered can do without radiation. It also gives a nod to the ongoing biomarker grift as well.
Click to expand...
Bird users pushing biomarkers should probably be putting coi disclosure in their tweets as well
 
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medgator said:
Bird users pushing biomarkers should probably be putting coi disclosure in their tweets as well
Click to expand...
Good point. They practically want a copy of your freaking tax returns when you publish in a no nothing journal with a negative impact factor. But you can spout off nonsense and plug for your biomarker test on TikTok or Twitter free of such problems like coi.
 
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