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Shared decision making is a great answer. I should have said that!I would participate in shared decision making with the patient regarding pros/cons of B51 data in terms of treating WBI alone vs WBI + RNI
Of course not an "equal comparison to thinking of outcomes between omission of RT vs delivering RT," just simply throwing it in the mix as an amuse bouche of the temporality of 5 vs 10 y outcomes in terms of significance vs insignificanceComparing Rabinovitch's slide which is a discussion of comparing one RT regimen to another is not an equal comparison to thinking of outcomes between omission of RT vs delivering RT
Again I think I'm being unintentionally misunderstood (imagine that!). There are differences in the "instantaneous recurrence rate" of 5 and 10y data in every breast cancer trial I can think of. But this is not my point. My point is that the positivity or negativity of a breast cancer, or any, trial's actuarial (i.e. logrank or Cox hazards, from the KM curves) outcomes rarely change with 10y median followup vs 5y median followup. CALGB was positive/statistically significant at 5y for LRR, and with the 10y update it was still significant; overall survival was not significant at 5y, and it was still not significant at the 10y update. Same exact story for PRIME. (Including other metrics like distant DFS, etc.: everything negative at 5y was still negative at 10y.) So negative actuarial results rarely become positive over time, especially if we are talking 5 vs 10 years. It is uncommon—yet more likely—that positive results become negative over time. E.g., in the "Upfront Outback," any of the positive results at 5 years (say, significantly more distant recurrences if radiation happened before chemo and more local recurrences if chemo happened before radiation) disappeared at 10 years.See PRIME and CALGB for pretty significant differences in numerical risks of recurrence between 5 and 10-year data.
So about one of the least controversial things I can ever say around here would be, should be: on the basis of the 5y results from B51 (and biostats principles and assumptions), there is a <<5% chance that the 10y update will show a significant benefit of RNI for LRR, distant DFS, or OS.
I wanted to say this, but thought "quit while ahead."RT to a TNBC cN1 patient --> ypN0 after NAC is actively killing them.
This is the kind of thinking Antonin Scalia would have lovedB51 protocol states that clinical nodal involvement may be assessed by mri, pet, ct, etc. please see section 5.2.5 of the protocol. Under ineligibility criteria please see section 5.3.4
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