- Joined
- Oct 19, 2004
- Messages
- 536
- Reaction score
- 833
Makes sense to me.I would love to get a good argument going as to whether 26 Gy in 5 fractions partial breast is valid for all 50+ yos with T1N0 favorable risk breast cancer.
Makes sense to me.I would love to get a good argument going as to whether 26 Gy in 5 fractions partial breast is valid for all 50+ yos with T1N0 favorable risk breast cancer.
I wouldn't do PBI in TNBC.Does hormonal status play a role in your decision making whole vs partial?
Some women who refuse (or find out they can't tolerate) endocrine therapy may (?) benefit from whole breast..
is PBI billed as SBRT?
If not, say goodbye to radonc financial survival... 33 to 16 to 5 to 0.
#thisisthewayto0
From a wRVU stand point 5 fx imrt is not all that different from 3 week 3DI don’t treat breast, but if I did, I would offer partial breast 15 x 266 to these women solely for financial
I thought 3D actually had more rvus? Anyway, I don’t need the rvus, if the clinic is routinely finishing by 1-2, hospital wont keep me as FTE and techs won’t get their 40 hrs.From a wRVU stand point 5 fx imrt is not all that different from 3 week 3D
but the hospital know they can replace me very quickly, probably with someone smarter and cheaper.
So we're clear, I don't recommend anyone do anything without understanding their own situation and speaking with appropriate professional advisors.Yeah so…won’t be doing that until that’s a thing. I remember asking about it with fellow colleagues and was immediately accused of being a fraudster so good luck with that.
Oh my. That's silly! You're not silly 26/5 is *not* a made up scheme.I prefer 30/5 rather than making up a fractionation scheme like 26/5 PBI
0 is the new 5.SCENE
Group of angry finger pointing radoncs, mostly academics, clustered and shouting at each other.. fraction shaming galore..
"I'll give 15, instead of 16"
"I'll see your 15, and lower it to 6"
"I can beat your six, and counter with a FIVE!"
"I see your FIVE, and counter with ONE!" with chest thrusted forward spoketh the proud lone radonc.. glaring at the others...
BUT
Distinguished Medonc proudly steps forward and speaketh:
"Gentlemen, no need to outdo each other. We've arrived, now take your filthy photons and kindly exit the building. We won't be needing your services. Good day sirs."
And so, in the great book of Breast Radiation Oncology, it was written.
END SCENE
is PBI billed as SBRT?
If not, say goodbye to radonc financial survival... 33 to 16 to 5 to 0.
#thisisthewayto0
ps. I chuckled at the one person who disliked this post. Hey, it ain't me fraction shaming and promoting nonsense. Spend that downvote on something where its deserved bro.
26/5 is not made-up but 26/5 PBI is made-up and unstudied. When we have so much randomized data in early stage breast, I don't feel a need to go off the beaten path in terms of dosing.Oh my. That's silly! You're not silly 26/5 is *not* a made up scheme.
Also, I'd just like to point out... about 10 or so more years ago, we considered 15-16 fractions "accelerated." Interesting how yesterday's "accelerated" is today's "standard."
NEVER FORGET.
View attachment 377500
common sense says that if 26/5 ok for whole breast then it’s ok for apbi doesn’t it? But then again, I tried arguing the same type of common sense logic with my breast attendings in 2011 about hypofrac and dcis and they looked at me like I was crazy.
I personably do 30/5 when possible but have low threshold to lower to 26/5 with smaller breast volumes, close to nipple or skin or other scenarios where I want to reduce chances of toxicity.
You say the outcomes are good with 30/5, but has it been compared to 40/15 whole breast the way that IMPORT-LOW was (twice including DBCG)?26/5 is not made-up but 26/5 PBI is made-up and unstudied. When we have so much randomized data in early stage breast, I don't feel a need to go off the beaten path in terms of dosing.
We have no confirmatory data that confirms that 26/5 to PBI volumes is oncologically equivalent to 26/5 WBI. It's overwhelmingly likely to be fine and I wouldn't hold up a case in chart rounds for doing it. But, unless someone has data that 26/5 PBI is less toxic and just as effective as 30/5 PBI I see no reason to go less than 30/5. Extrapolating IMPORT-low (which had bigger expansions than Florence regimen) across different fractionation schemes is, again, not unreasonable, but not necessary given we have such good data (IMO) from 30/5.
I think looking at cases individually and turning edges down to 26/5 if struggling with constraints is not unreasonable.
I don't like 26/5 WBI because it IS more toxic in certain domains, buried in the supplement, and glossed over by the UK authors as their goal is simply to reduce fractions because of the limitations of their own health system in regards to throughput of patients. It's not a huge difference, but it is LATE toxicity which is increased with 26/5 which I'm not OK with for my patients. Which is probably why UK ROs want to 26/5 PBI, knowing that 26/5 WBI is more toxic despite the conclusions of the UK study.
Hmm.You say the outcomes are good with 30/5, but has it been compared to 40/15 whole breast the way that IMPORT-LOW was (twice including DBCG)?
You should write a disapproving letter to the Royal College of Radiologists and/or His Majesty.26/5 is not made-up but 26/5 PBI is made-up and unstudied
You need data... you need to RUN A LARGE MULTI-INSTITUTIONAL TRIAL OF A THOUSAND WOMEN FOLLOWED FOR 10+ YEARS?... that 26 Gy is less toxic than 30 Gy?But, unless someone has data that 26/5 PBI is less toxic and just as effective as 30/5 PBI
ALARADo we expect 30/5 APBI to be worse than 26/5 APBI for local control?
Of course not.
It is a little bit better. Whether this is demonstrated in individual trials or not, I am sure that if we could run a trial on an infinite number of patients, there would be a few less recurrences in the 30 Gy arm.
Is the cosmetic outcome good? Yes, it is very good. Hard to improve on actually.
Is the lumpectomy bed hard? Yes, the lumpectomy bed gets hard after Livi.
So why are we dose de-escalating here? To reduce fibrosis at the lumpectomy bed? Not sure that is a good enough reason. Are we saving resources? Not really.
We are saving photons.
I get that. But among the rationale for smaller treatment volumes in other disease sites is the corresponding ability to dose escalate for improved local control.ALARA
I think it's important to remember in discussions like this: it's OK to shame an idea, but never a person. I love everyone!#fractionshame #volumeshame
Sorry, hard pass for me.. literally.
I think it's important to remember in discussions like this: it's OK to shame an idea, but never a person. I love everyone!
Ideas:
1) There is zero data supporting the use of breast boost for breast hypofrac in general.
2) PBI is proven less toxic than whole breast.
3) "Shaming" the UK breast data because they have socialized medicine doesn't make a good argument against the data.
Eventually, I do foresee 5 fraction being the upper limit fractions allowed by insurance companies for early stage low risk breast cancer (almost all payors have a 21 fraction limit now... in the UK, about 80-90% of all breast cases are treated w/ 5 fx now). I could even see 5 fraction being the upper limit for all stages once the UK 5 fraction nodal data comes out, long-term. Insurance companies setting fraction limits will settle a lot of these arguments. I was upbraided by telephone by my residency PD around 2005 when she heard I had been doing a lot of 16 fraction breast treatments in practice... I felt the shame!
In the wrong direction it sounded like.... 16 instead of 25-28Hold the phone...your residency program director called you to fraction-shame you after you graduated? HahahahahahahahaHAHAHAHAHA what a field we are in.
1) There is zero data supporting the use of breast boost for breast hypofrac in general.
I would argue there is some randomized partial breast irradiation data that indicate doses lower than 30 gy in 5 fractions may decrease toxicity while maintaining high tumor control.26/5 is not made-up but 26/5 PBI is made-up and unstudied. When we have so much randomized data in early stage breast, I don't feel a need to go off the beaten path in terms of dosing.
We have no confirmatory data that confirms that 26/5 to PBI volumes is oncologically equivalent to 26/5 WBI. It's overwhelmingly likely to be fine and I wouldn't hold up a case in chart rounds for doing it. But, unless someone has data that 26/5 PBI is less toxic and just as effective as 30/5 PBI I see no reason to go less than 30/5. Extrapolating IMPORT-low (which had bigger expansions than Florence regimen) across different fractionation schemes is, again, not unreasonable, but not necessary given we have such good data (IMO) from 30/5.
I think looking at cases individually and turning edges down to 26/5 if struggling with constraints is not unreasonable.
I don't like 26/5 WBI because it IS more toxic in certain domains, buried in the supplement, and glossed over by the UK authors as their goal is simply to reduce fractions because of the limitations of their own health system in regards to throughput of patients. It's not a huge difference, but it is LATE toxicity which is increased with 26/5 which I'm not OK with for my patients. Which is probably why UK ROs want to 26/5 PBI, knowing that 26/5 WBI is more toxic despite the conclusions of the UK study.
"In the old days" we were fraction shamed for doing too few fractions. Believe it or not.In the wrong direction it sounded like.... 16 instead of 25-28
This is exactly true re: boost for hypofrac. Which is why I never boost 40 Gy in 15 fx whole breast, or partial breast. And here we have data, e.g., no extrapolation needed. The benefit of boost in START was a stone cold zero, something rather striking like an HR of 1.000 in "thousands" of women iirc....there's zero data for 26/5 PBI but you're arguing it's reasonable based on oncologic principles. Which I agree with! But why would the same not be true for extrapolating a local control benefit for boost with hypofx?
Great to see, I was not aware of this. Relevant data in this space.I would argue there is some randomized partial breast irradiation data that indicate doses lower than 30 gy in 5 fractions may decrease toxicity while maintaining high tumor control.
There is a phase II randomized controlled trial with 281 patietns that compared 27.5 Gy in 5 fractions to 30 Gy in 5 fractions. There was a trend to better cosmetic outcomes with 27.5 Gy. There were no local failures in either arm. Abstract attached below
I agree a full publication would be nice. I believe that the abstact is almost two years old, so hopefully they will get a full publication out in the near future.Great to see, I was not aware of this. Relevant data in this space.
A full publication would be nice.
Do we think 3-5 non-coplanar 3D (or IMRT) equal in toxicity risk to VMAT PBI as per Florence?
Great to see, I was not aware of this. Relevant data in this space.
A full publication would be nice.
Do we think 3-5 non-coplanar 3D (or IMRT) equal in toxicity risk to VMAT PBI as per Florence?
The heart (mean and max <1 Gy for most) and lung DVH generally can't be beat with a two-field partial breast IMRT tangent vs VMAT. Just sayin'.I agree a full publication would be nice. I believe that the abstact is almost two years old, so hopefully they will get a full publication out in the near future.
Thats a good point. I am curious how many patients where treated with 3D vs IMRT. I would likely guess that 3-5 non-coplanar IMRT would have very similar toxicity to VMAT. I am not sure about 3-5 non-coplanar 3D, my gut instinct is that the toxicity would likely be a little worse than VMAT.
Good point. I was thinking of skin toxicity when I replied. I am sure that two-filed partial breast IMRT tangent lowers heart dose and lung dose compared to VMAT, but I bet it is only slightly lower. I looked through a few of my 27.5 Gy partial breast patietns and as long as the tumor was not left sided and medial the mean heart dose was less than 1 Gy.The heart (mean and max <1 Gy for most) and lung DVH generally can't be beat with a two-field partial breast IMRT tangent vs VMAT. Just sayin'.
View attachment 377511
Multi field or VMAT (acute, maybe even late) skin tox would be better vs two field tangent IMRT. Agree.Good point. I was thinking of skin toxicity when I replied. I am sure that two-filed partial breast IMRT tangent lowers heart dose and lung dose compared to VMAT, but I bet it is only slightly lower. I looked through a few of my 27.5 Gy partial breast patietns and as long as the tumor was not left sided and medial the mean heart dose was less than 1 Gy.