Breast Cancer&nbsp;&nbsp;&nbsp;

Does radiation therapy (ex. to the breast) in patients with CDK4 mutations increase the risk of developing melanoma?

What is your approach to a patient with incidentally found DCIS or invasive disease after a breast reduction?

Generally, the margins are uncertain in this scenario and re-excision is usually not possible.

In light of the NSABP B-51 data presented at SABCS, will you defer RNI in all patients with negative nodes after chemotherapy?

Are there any subgroups that would still benefit from RNI?

For a young female (<40) with HR-/HER2+ cT1-2N1, ypT1aN0 s/p mastectomy with SLNB, would you offer PMRT?

Would you feel confident in omission for residual disease in the breast and only 1 LN removed during SLNB, which is the same node that was biopsied up...

Would you consider partial breast irradiation in patients who otherwise meet PBI guidelines who have a pathogenic variant of CHEK2 or other moderate penetrance gene?

Do you recommend additional nodal boost in patients with suspicious internal mammary nodes that respond completely after neoadjuvant chemotherapy?

This boost would be in addition to the standard regional nodal irradiation delivered post-op.

Would you recommend hypofractionated PMRT with a positive deep margin?

How would you dose?

Do you recommend post-mastectomy RT for a premenopausal woman with ER/PR+ Her2 negative breast cancer and Li-Fraumeni syndrome with RCBII and residual disease in multiple LNs following neoadjuvant chemotherapy?

For patients between 40-49 years old who undergo lumpectomy, how do you choose between offering PBI per the updated PBI guidelines or boosting based on boost guidelines?

Would you recommend PMRT to a clinically node positive (biopsy proven axillary node and indeterminate single IMN node) BRCA positive patient with multiple medical co-morbidities including scleroderma and ILD who is treated with neoadjuvant chemotherapy (NAC) and mastectomy who converts to ypT0/ypN0?

For a small focally positive DCIS margin in the setting of invasive disease and negative invasive margins, not undergoing re-excision, what boost dose would you use?

What if positive margin is felt to be from a DCIS skip lesion (initial DCIS margins widely negative but small focus DCIS found in additional tissue wi...

Would you consider PMRT in patients with clinically node negative breast cancer found to have micrometastatic nodal disease after neoadjuvant chemotherapy?

Would it matter if the patient did or did not have a pathologic CR in the breast?

What is the appropriate approach to manage a patient with triple-negative, locally advanced breast cancer (LN+) who progresses on neoadjuvant chemo-immunotherapy (KEYNOTE-522 regimen)?

Do you recommend self-breast exams to your patients with history of breast cancer in addition to imaging surveillance?

Would you recommend MRI post surgery and pre-irradiation for patients with extensive DCIS and close margins and how would it impact your management?

Does pathologic complete response impact your selection criteria for tumor bed boost of breast cancer patients' status post neoadjuvant chemotherapy and breast-conserving surgery?

What are your top takeaways in Breast Cancer from ESMO 2024?

What are your top takeaways in Breast Cancer from ASTRO 2024?

Do you prefer IMRT to 3D for partial breast treatment?

Isn't there a tradeoff of increased lung dose?

Under what circumstances would you pursue completion ALND in a patient with multiple positive sentinel nodes after breast-conserving surgery?

How would you approach an isolated supraclavicular nodal recurrence involving the skin in a patient who has received standard chest wall and nodal radiation therapy?

Disease is not responding to systemic therapy.

What are the advantages/disadvantages of using static IMRT vs VMAT when treating breast cancer?

Would you expect a difference in skin reaction?

When do you recommend endocrine therapy for chemoprevention in women with high-risk benign breast lesions?

When utilizing hypofractionated radiotherapy in the post mastectomy setting, are the nodal regions dose painted to a different dose or the same dose as the chest wall/reconstructed breast?

When treating nodes in the post mastectomy setting, what dose/coverage do you find acceptable to the nodal regions versus to the chest wall/reconstruc...

How are you clinically incorporating the data presented from RT Charm at ASTRO 2024?

Are you routinely offering a 16-fraction course of hypofractionated PMRT for patients undergoing breast reconstruction versus a traditional 25-fractio...

With the presentation of HypoG-01 phase III UNICANCER trial at ESMO 2024, should hypofractionated radiotherapy be the standard across the board for breast cancer?

What is your preferred sequencing of adjuvant chemotherapy and PMRT for node + breast cancer?

Patient with pT2 N2a (6/9 LN+, 5 with macromets, 1 with focal ENE) ER/PR+, Her2- s/p mastectomy. Is there compelling reason to start PMRT prior...

In patients with history of prior axillary surgery, subsequently with breast cancer recurrence, and sentinel lymph nodes mapped to internal mammary area (but were not biopsied), do you offer post-mastectomy radiation to cover the IMNs?

If no enlarged lymph nodes on imaging, and no other high risk features. Would your opinion change if the patient has had prior breast radiation?

How do you choose between ALND and RNI in the setting of LYMPHA or S-Lympha surgery?

Given the very low lymphedema rates associated with these procedures, does it impact your choice for axillary management?

Do you hold endocrine therapy during adjuvant breast radiotherapy?

How would you treat a patient with HER2 positive CNS only progression on fam-trastuzumab which had previously progressed on tucatinib/capecitabine/trastuzumab, and has failed both SRS and WBRT?

Should PMRT be offered for ypN0(i+) disease if only 1-2 nodes were removed in the post-chemotherapy SLNB and there is no plan for a completion AxLND?

Should the answer differ for cN1 luminal disease vs. cN0 TNBC?

When should the dissected axilla (levels I-II) be included when delivering RNI?

Would you use adjuvant hypofractionation (15-20 fractions) after BCT with negative margins for a patient with malignant phyllodes tumor?

In the post-mastectomy setting, are there situations where only the regional nodes or targeted nodal basis are covered?

How should ECE influence radiotherapy in breast cancer? For T1-2 patients with N1 disease after sentinel node biopsy alone and upfront mastectomy (gr...

How would you treat a young breast cancer patient with limited nodal involvement and an isolated sternal oligometastasis at diagnosis?

Would you treat with curative intent (neoadjuvant chemotherapy, surgery, and radiation to include the sternum)?

For primary angiosarcoma of the breast following mastectomy, what would your targets be for adjuvant radiation therapy?

Would you cover the chest wall alone or would it be chest wall plus regional nodes? Patient factors: no prior radiation therapy

If a patient has multiple PET-avid level 3, supraclavicular, or IMN nodes that are small and would have been considered negative by size criteria with traditional imaging, that are no longer positive on PET after chemotherapy, would you try to boost these nodes?

How would you manage a patient with micrometastatic node positive tumor post mastectomy (no neoadjuvant chemotherapy)?

For instance, would you incorporate use of Oncotype DX in this patient population to guide decision making on the use of regional nodal irradiation?

How would you approach radiation for an elderly patient with pT2N1 TNBC s/p MRM and ALND who refused chemo-immunotherapy?

The patient is an elderly female with a good KPS who presented with a cT2N1 triple-negative breast cancer. The patient refused chemotherapy and immun...

Would you omit radiation for an elderly woman with bilateral breast cancers (both early-stage disease and ER+/PR+/HER2 negative) who otherwise meets the criteria for endocrine therapy alone?

What pentoxifylline and vitamin E dose do you typically use for both the prevention and treatment of radiation-associated fibrosis after breast RT?

Would you consider APBI using the Florence regimen in patients with preexisting breast implants?

How do you advise patients on cardiotoxicity when they are expected to receive a low mean heart dose and low cardiac substructure doses with their radiation plan?

Such as breast plans with < 200 cGy mean heart dose

What is your preferred method of surveillance after mastectomy?

For example, when would you recommend clinical exam for surveillance versus imaging with MRI, CT or PET?

In which scenarios do you stage breast cancer using CT and nuclear bone scans versus PET-CT?

Do you recommend axillary dissection for women with ER+ breast cancer and low risk Oncotype or Mammaprint if single node positive with only 1-2 SLN removed, to ensure <4 nodes positive?

Do you consider chest wall constraints when treating with 5-fraction APBI?

Have the breast surgeons at your institution adopted the SOUND trial into their clinical practice?

The SOUND trial looked at sentinel node versus observation in patients of any age with breast cancer up to 2 cm and a negative preoperative axillary u...

Would you recommend PMRT for multifocal IDC with extensive LVI and 1 SLN with ITCs?

In cT4aN0 triple negative breast cancer would you still recommend PMRT if pCR, ypT0N0(sn), after neoadj chemo is achieved?

Would prior RT (>30 years ago in this case) to the breast or ATM mutation alter your recommendations?

What percentage of your breast cancer patients do you plan using IMRT vs 3D?

Are you comfortable combining palliative radiotherapy with capivasertib/fulvestrant?

Any pitfalls to be aware of?

Would you offer APBI to a patient with very large breast anatomy and a small lumpectomy cavity after an oncoplastic closure?

In what circumstances would you offer or avoid APBI in a woman with an oncoplastic closure after lumpectomy?

Do you start systemic therapy for patients with previously localized HR+ breast cancer developing solitary bone metastasis which is now triple negative if there are no other sites of disease after metastasis-directed radiation?

8 Answers available

What evidence supports the use of high tangents for pN1mic breast cancer?

In my experience, high tangents are commonly used for patients with pN1mic disease, and occasionally for higher risk patients with pN0 disease. The re...

In a patient with cardiac comorbidities, who meets ASTRO APBI criteria other than a positive margin, would you offer APBI in an attempt to reduce cardiac dose?

In patients with HER-2 positive breast cancer on pertuzumab/trastuzumab with newly developed asymptomatic brain metastases only, do you wait 3 weeks after administration of the targeted therapy to deliver SRS?

What hotspot and heterogeneity metrics do you utilize when delivering PMRT to a patient who has had breast reconstruction?

How do you use 105%, 107% and max dose metrics differently compared with non-reconstructed cases?

When using FAST Forward, how important is it for the treatment to be delivered Monday through Friday in one week as opposed to spanning a weekend?

Do you recommend re-excision of a unifocal positive anterior margin at skin after lumpectomy in a patient with otherwise low risk breast cancer features?

Can adjuvant radiation therapy compensate for the potential increased local recurrence risk?

Would you recommend BCS and adjuvant radiation for early stage multicentric breast cancer?

What would you consider when thinking about your boost?

Would you consider once weekly radiation with a simultaneous integrated boost for a patient with node negative breast cancer with a positive margin for whom reexcision is not an option?

Due to multiple complicating factors including travel distance of ~1 hour each way, this patient (mid-60s) refuses to come any more often than 2 days ...

Are there additional risks associated with PMRT for a patient with prior lympho-venous bypass surgery?

If a patient is found to have 2 lymph nodes positive with ECE s/p mastectomy, axillary dissection, tissue reconstruction, and lympho-venous bypa...

What is the earliest you would start postmastectomy radiation after adjuvant chemotherapy for a patient with breast cancer?

Any concern for increased risk of radiation recall?

Under what circumstances would you offer PMRT in a patient with DCIS?

When treating APBI with the Florence regimen, are you using daily or every other day fractionation?

When do you consider the addition of concurrent pembrolizumab to breast irradiation?

Would you consider administering Keytruda (pembrolizumab) concurrently with radiation therapy for the treatment of a patient with an ER-negative, PR-n...

What group of patients is suitable for breast radiation using high tangents?

Z0011 population, cN0 with 1-2 SLN involvement with a low likelihood for additional non SLN metastases?

How does the recently published SOUND Trial affect your approach to breast RT?

The SOUND (Sentinel Node vs Observation After Axillary Ultra-Sound) trial was a prospective noninferiority phase 3 randomized clinical trial suggestin...

Do you prefer to use the FAST or FAST-Forward regimen when treating stage I breast cancer with an ultra-hypofractionated approach?

If treating a patient with prior breast augmentation with whole breast radiation, would you alter your field setup?

For standard tangential radiation would you pull the field edge forward to avoid radiation dose to the entire implant?

What volumes would you cover in a young patient with otherwise low risk breast cancer in whom the sentinel node failed to map and ALND was not performed?

Would your recommendation change if the patient had a high Oncotype and received adjuvant chemotherapy?

What is the current criteria for sentinel node biopsy over a full axillary lymph node dissection in a patient with breast cancer?

What are the current criteria in 2023 for selection to complete sentinel node biopsy or skipping of sentinel node biopsy specific to age, grade, clini...

Would you consider PBI plus covering the regional lymph nodes for a LN+ breast cancer in the remnant of the axillary tail?

If a patient had a stage I contralateral breast cancer and received bilateral mastectomies with implant reconstruction 2 decades ago and now has ...

What is the current paradigm for breast cancer diagnosed with isolated metastases prior to initial treatment?

Is there a role for loco-regional treatment in this scenario? If a young patient with ER/PR positive cT2N2M1 IDC presents with a single bone metastasi...

What dose constraints do you use for the left anterior descending artery (LAD) for breast radiation?

Is there data to support those constraints?

In a clinically node negative early stage breast cancer patient who underwent neoadjuvant systemic therapy, would surgical finding of fibrosis suspicious for treatment effect in sentinel nodes impact your RT decision?

When doing a tumor bed boost following whole breast irradiation, what do you typically use for CTV and PTV margin for photon and electron plans?

Do you offer adjuvant radiation therapy for a breast cancer patient with dermatomyositis?

If so, what dose-fractionation do you utilize? What other factors do you take into consideration?

How do you approach the discussion of omission vs. inclusion of adjuvant radiation in patients with low to intermediate-grade DCIS?

For additional reading, see JCO OGR (11/2021) by Drs. @Warren and @Bellon reviewing the landscape of adjuvant treatment after lumpectomy for DCIS and ...

What is your approach to a tumor bed boost in early stage breast cancer patients with micrometastasis?

Would you do a tumor bed boost in the absence of other risk factors?

Do young, early-stage breast cancer patients with pCR to chemoimmunotherapy still benefit from PMRT?

If a patient in her 30s with a cT2N0 triple negative breast cancer has a pathologic complete response (pCR) after chemo/immunotherapy at the time of m...

Would you offer PMRT when the only indication is a focally positive margin?

Would you ever considering de-escalating therapy in any way for women with inflammatory breast cancer who had a complete pathologic response after surgery?

Would you ever consider any of the following? Discontinue the bolus after brisk reaction Moderate hypofractionation to the chest wall instead of c...

How do you incorporate DCISionRT testing in the setting of close (<2 mm) or positive DCIS margins?

When offering palliative radiation for breast cancer, what dose/fractionation do you prefer and in what subset of patients do you believe derive the most benefit?

Would you omit post-lumpectomy radiotherapy for high clinical risk, but low molecular risk DCIS?

The patient had a high-grade DCIS with necrosis, but a 0.9 DCSionRT score

Would you consider omission of radiotherapy in patients 70 years and older with invasive ductal carcinoma who had initially positive lumpectomy margins, but had no residual disease upon re-excision?

Would you consider radiation omission for a patient with a Stage I breast cancer with an elevated Oncotype Dx?

The patient is an otherwise healthy patient in her 60s with an ER-positive, PR-positive, HER2 negative grade 3 pT1N0 invasive ductal carcinoma followi...

Would you ever offer a simultaneous integrated boost to the lumpectomy cavity with 5 fraction ultra-hypofractionated whole breast radiotherapy (2600 cGy in 5 fractions)?

If so, what dose would you utilize for the SIB? When utilizing a boost with ultra-hypofractionated whole breast RT, would you favor adding a single fr...

Why do we tend to boost grade 3 DCIS, but not grade 1 invasive disease?

Would you offer reirradiation for a patient who had prior MammoSite PBI?

The patient had ER/PR positive, early-stage recurrent disease superficial to the prior RT site involving the nipple and dermis without ulceration, tot...

When offering APBI, if a patient has invasive ductal carcinoma and DCIS, do they need to fill suitability criteria for both, or does the DCIS criteria only apply to pure DCIS?

Would you recommend removal of pec muscle for a positive microscopic deep margin post mastectomy?

Would you recommend this for a focally +, diffusely +, grossly + margin? What would you expect local recurrence rate for diffusely (+) microscopic mar...

Do you routinely perform mammograms for women that underwent nipple-sparing mastectomy with reconstruction after a breast cancer diagnosis?

How does treatment management change with a positive intramammary lymph node in the setting of a negative axilla, with the inclusion of these as N1 node in the AJCC 8th edition?

Is there a rationale for treating medically inoperable stage I-III breast cancer patients with RT alone?

My understanding is that if someone isn’t medically operable, the default is to offer systemic therapy palliatively because breast cancer is tho...

How do you respond to a patient who asks "Why do I still need breast radiation after chemotherapy if chemotherapy treats the whole body?"

This patient had a T1N0, ER/PR negative, HER2 negative breast cancer

Would you consider omitting PMRT in cT3N0 triple negative breast cancer with a pCR?

In a young patient <30 years old with large pre-chemotherapy, multifocal disease with pCR following mastectomy, would you consider extrapolating th...

Have you seen any increased dermatologic toxicity with whole breast or chest wall radiation if patients have received recent or concurrent pembrolizumab?

Would you start any treatment for radiation pneumonitis if there is a large area of consolidation in the irradiated lung field but the patient is asymptomatic?

Would you consider pentoxifylline and vitamin E to mitigate fibrosis?

Is post-mastectomy chest wall radiotherapy indicated for DCIS with very close (<1 mm) or positive margins?

Would you offer a patient with “good-risk” DCIS and an elevated DCISionRT score APBI or WBI?

Good risk DCIS as per RTOG 9804

How would you manage a premenopausal patient with HER-2 positive DCIS in the setting of a prior HER-2 positive contralateral breast cancer?

The patient had a prior right-sided ER+ HER2-ve breast cancer, treated with neoadjuvant chemotherapy, MRM with ALND, and PMRT They recently developed...

What fields would you treat for a postmastectomy patient with a single suspected small IMN node on MRI but no other criteria for PMRT and a negative SNB?

Do you offer APBI to patients who do not have surgical clips but a visible seroma?

What skin care regimen do you prefer during radiation for patients with inflammatory breast cancer?

Are there any skin care products you would avoid in this population?

How would you manage a patient presenting with recurrent cT4 breast cancer?

In a patient who had a wide local excision and radiotherapy 10 years ago and now recurs with cT4 disease, would you repeat radiation after neoadjuvant...

What treatment would you recommend for DCIS incidentally found in pathologic specimen following breast reduction surgery?

How does age, grade, hormone receptors play into your decision?

Can post-lumpectomy radiation be omitted for ER/PR(+) low-volume (2 mm) low-int DCIS, with > 2 mm margins in a post-menopausal patient who will be taking tamoxifen?

Would you offer PMRT for a small focus of invasive disease in a background of extensive DCIS?

Would postmastectomy radiotherapy ever be indicated in a young patient with close margins and a massive (14 cm) DCIS breast tumor interspersed with le...

Would you offer partial breast radiation for bilateral DCIS?

Assume each lesion would have been suitable for partial breast radiation

Is it safe to irradiate a patient with Cowden syndrome?

In an asymptomatic patient, would this be safe?Is there any reason to withhold radiation such as in the case of T1N0 breast cancer advising the patien...

How does the extent of DCIS influence eligibility for APBI for invasive breast cancer?

For example, if a patient is otherwise a candidate for APBI with a 1.5 cm primary tumor but has 2 cm of associated DCIS would the patient be ineligibl...

What is your treatment approach in patients with early breast cancer with axillary soft tissue involvement, with or without concurrent lymph node involvement?

In a patient with otherwise favorable DCIS and a focally positive margin who refuses reexcision, is APBI an appropriate treatment option?

For a young patient with advanced TNBC with a single lung nodule status post NAC, not amenable to biopsy, would you consider SBRT to the lesion?

Would you still treat the chest wall with standard dose and give the patient the benefit of the doubt in the absence of pathological confirmation of m...

Do you still recommend SBRT for oligometastatic and oligoprogressive breast cancer after the abstracts of the BR002 and CURB, respectively?

NRG-BR002 (Chmura et al., JCO 2022) CURB (Tsai et al., IJROBP 2022)

Would you offer definitive local therapy to a patient with ER/PR+, Her2 neg breast cancer with oligometastatic disease that responded well to CDK 4/6 inhibitor +AI, despite NRG-BR002 results?

Young healthy patient, ER/PR positive HER2 negative right breast cancer with a synchronous single site of oligometastatic disease in the right 4th rib...

Do you ever treat patients with phyllodes tumor of the breast with adjuvant radiation?

Do your post-operative treatment recommendations differ for benign vs. malignant phyllodes tumors of the breast? Is phyllodes tumor size ever a crite...

Is there a role for radiation therapy for florid LCIS managed with lumpectomy?

In the setting of recurrent breast cancer localized to the chest wall (no prior RT), do you allow concurrent abemaciclib or Enhertu with post-operative comprehensive chest wall irradiation?

When evaluating for PMRT in patients who did not receive neoadjuvant chemotherapy and are found to be pN0, do you utilize clinical T-staging, or pathologic T-staging?

For example, if preoperative imaging indicates T3 disease (non-mass enhancement extending over 5cm) but final pathology s/p mastectomy shows multiple ...

Do you always use a bolus when treating with postmastectomy radiotherapy?

I trained at a place where use of a bolus for chest wall irradiation PMRT was standard practice, but this is not so at my practice right now. Assuming...

Can the SIB regimen from RTOG 1005 be extrapolated to all patients requiring whole breast irradiation?

Do you use SIB regimen (40/48 Gy) per RTOG 1005 for whole breast radiation in scenarios not included on trial? For example: a patient who has received...

How would you approach a cT4 cN2 (22 cm in size) TNBC that shrank to 9 cm with KN-522 regimen but remains inoperable at the end of treatment?

Both sets of CT scans pre and post- chemoimmunotherapy show no evidence of distant mets.

Do you offer APBI to patients with close margins?

In prior ASTRO guidelines, it was mentioned as a cautionary group for IDC but not in the 2023 updated guidelines.

What are your top takeaways from SABCS 2023?

Do you omit APBI for lobular histology?

Based on Mill et al. paper showing increased IBTR rates with ILC vs IDC (Mills et al., PMID 34516030)

Does a genetic predisposition to cancer affect your recommendations regarding breast conservation and radiation?

If a patient has a genetic mutation, but not necessarily the classic ones where we avoid radiation (ATM, BRCA, p53, etc.), does this change your treat...

Would you do APBI for encapsulated papillary carcinoma with negative margins and no surgical axillary assessment?

How do you address the axilla in an incidentally found T1bNx invasive breast cancer with extensive DCIS on bilateral prophylactic mastectomy in BRCA-2 mutated woman?

The patient is in her 40s with a BRCA-2 mutation and underwent bilateral prophylactic nipple-sparing, skin-sparing mastectomy. No sentinel nodes were ...

When evaluating margin status to consider APBI for early stage invasive breast cancer, given the specification for at least 2 mm margins, do you look at the DCIS margin or only the invasive margin?

Additionally, when evaluating margin status for APBI IMRT 30 Gy in 5 fractions which specifies at least 5 mm margins, do you look at the DCIS margin o...

How do you explain the risks and benefits of palliative radiation therapy to patients with fungating breast masses?

Patients are understandably concerned about the risks and benefits of radiation to an oozing, bleeding, and ulcerated breast.

How do you reconcile the differences between 2022 ABS APBI recommendations and 2023 ASTRO APBI recommendations?

ABS APBI guidelines are much more permissive relative to the newer ASTRO Guidelines.

How would you manage a patient with a negative axillary ultrasound but no sentinel lymph node evaluation at the time of lumpectomy for early-stage breast cancer?

Would you change your recommendations for APBI vs whole-breast RT for this reason?

For a patient receiving postmastectomy IMRT to chest wall with expander and regional nodes including IMN, what constraint would you use for dose to the contralateral chest wall/implant if the patient also had a mastectomy and reconstruction on that side?

NSABP B-51 recommends V3<10% or a variation acceptable of V5<10% for contralateral breast. Is there a limit needed for contralateral chest wall/...

How do you approach an early stage breast cancer patient s/p BCS in which ECE is found on a positive sentinel node?

Do you advocate for completion ALND? If so, would you radiate the dissected axilla?

Is it acceptable to give hypofractionated breast radiation in a patient who is being treated for rheumatoid arthritis with Actemra, methotrexate and leucovorin?

Is there a subset of patients with Paget's disease of the breast in whom you would omit radiation after a central lumpectomy?

Would you especially consider RT omission in the setting of low-grade, small-volume disease with no underlying DCIS or invasive disease component on p...

How would you treat a patient with p16 (-) neck lymph node metastasis of an unknown primary, considering their history of prior supraclavicular and chest wall irradiation?

Do you recommend omitting radiation therapy in young women with favorable DCIS?

How would you approach a young woman (under the age of 50) with DCIS with favorable disease (ER+, low grade, small size <5mm, negative margins)?

For which patients, if any, do you typically order additional imaging workup for staging in early-stage breast cancer?

How do you treat encapsulated papillary carcinoma of the breast after lumpectomy with negative margins?

Do you recommend observation, APBI, whole breast or whole breast with low axilla treatment?

What is your preferred PMRT dose/fractionation for patients with implant reconstruction?

Did your treatment inclinations change with the results of the recent FABREC trial (NCT03422003) presented at ASTRO?

Would you consider eliminating PMRT to the chest wall in select cases of T3N0 breast cancer?

Would you consider eliminating radiation to the chest wall in a patient greater than 50 years of age with a T3N0M0 grade 2, ER+/PR+ Her2 negative inva...

Would you consider a FAST-forward fractionation for a cT1a IDC with DCIS that was found to be pTis on lumpectomy specimen?

I.e., the IDC was completely removed during biopsy, but DCIS was present on post-lumpectomy specimen with close anterior margin

How do you approach breast RT in a patient with a recent history of ipsilateral thoracic irradiation?

A female in her 60's was simultaneously diagnosed with stage I triple-negative left breast cancer and stage I NSCLC of the left lung. The patient had...

What are the current indications for proton beam therapy in the treatment of breast cancer?

In which particular patient cases or clinical scenarios would you consider preferentially treating a patient with protons over photons?

What are your thoughts on the relevance of sentinel lymph node biopsy before the onset of neoadjuvant chemotherapy for HER2+ or triple negative cT2+N0M0 breast cancer patients?

Nodal staging changes radiation fields, but given increasing pertinent null findings of a positive SLNBx with regards to outcomes, I wonder if ypN0 is...

To obtain insurance approval for DIBH when treating left breast cancers, are there particular dose constraints to sites that you employ?

What total heart dose and LAD dose do you typically utilize to justify the DIBH technique?

Would you recommend PMRT for T2N0(i+) breast cancer?

If a patient was noted to have poorly differentiated histology with two tumor foci in the breast, positive LVSI, and isolated tumor cells in 1/3 senti...

How would you approach a patient that did not have preoperative axillary imaging and was found to have macromets on sentinel node biopsy, and on radiation planning scan has abnormal appearing nodes?

The patient is a female in her 50s with luminal B pT1b pN1(sn) invasive ductal carcinoma with 2/2 nodes, 5 mm ECE, and extensive LVI. No preoperative ...

Do you use traditional bony landmarks or contoured nodal volumes when designing breast and supraclavicular treatment fields?

For example, would you consider treating part of the humeral head if required to adequately cover the axillary nodal volume CTV/PTV?

In what clinical scenario, if any, would you consider APBI appropriate treatment for a patient with triple-negative breast cancer?

Would you consider APBI for an ER/PR/HER2 negative pT1-2 N0 with pathologic complete response after neoadjuvant chemotherapy? Would the presence...

Would you offer PMRT to ER/PR+ patients with synchronous bone metastasis?

In what scenarios do the benefits of local control with PMRT outweigh the risks? How would systemic therapy and/or the number of bone metastases impa...

Is morphea, cutaneous scleroderma, with no organ involvement a contraindication for radiation in early stage breast cancer as part of breast conservation therapy?

Do you ever treat a recurrent breast cancer with RNI alone rather than chest wall and RNI?

A patient presents with clinically node-positive cT2 grade 3 invasive breast cancer in the upper outer quadrant. The patient had breast RT to 50 Gy wi...

In the era of hypofractionation for breast cancer, how would you re-irradiate for these cases if recurrence develops years later?

What constraints would you use for ribs, lungs, and heart?

What dose volume constraints do you use for APBI using the Livi regimen for rib, contralateral breast and lung?

Is there any situation where hypofractionation of post-mastectomy radiation (CW and regional nodes) is absolutely contraindicated?

How would you manage a left sided triple negative breast cancer with a concurrent left sided locally advanced non-small cell lung cancer?

The left breast cancer is an ER-negative, PR-negative, HER2-negative cT2N0 invasive ductal carcinoma, while the left lung primary is a cT2N1 squamous ...

Do you offer APBI for patients with invasive disease if there is high grade DCIS present in the lumpectomy specimen?

If a patient has a small luminal A invasive tumor resected to negative margins with admixed high-grade DCIS, does the high-grade DCIS component influe...

What rates of breast (not arm) lymphedema would you quote to patients post-lumpectomy and adjuvant radiation?

What prophylactic strategies you use to mitigate the risk?

When do you offer a boost for patients receiving 5 fraction whole breast radiation as per UK FAST Forward?

What dose and fractionation do you use?

Do you ever consider local therapy to oligometastatic hormone-receptor positive breast cancer?

Would you offer adjuvant radiotherapy to a young patient with microinvasive lobular carcinoma (< 1 mm) in a background of LCIS?

If a patient is <50 years old, would this change your recommendation?

Would you cover regional nodes in an early-stage breast cancer with a non-mapping sentinel lymph node?

The patient is an otherwise healthy female in her 70s with an ER-positive, PR-negative, HER2-negative grade 3 invasive ductal carcinoma. Lumpectomy r...

How long after surgery would you no longer offer PMRT for a patient who had pCR after neoadjuvant chemotherapy for stage IIB HER2+ breast cancer?

The patient was treated with neoadjuvant chemotherapy and had mastectomy with SLNBx about 6 months prior to being referred for adjuvant radiation.

What do you do when the dose constraints for heart and/or lung do not pass at all in a whole breast treatment planning?

If the dose to these OARs deviates from goal by a significant margin, how do you approach changing the treatment plan, accordingly?

Can PMRT be avoided in patients with 1-3 + nodes if they achieve a pCR after neoadjuvant chemotherapy?

When treating breast cancer patients with RNI, how often do you include internal mammary nodes?

For women with non-autologous breast reconstruction who require PMRT, is it better to radiate an implant or an expander?

Can you safely proceed with breast irradiation during treatment with immunotherapy?

For a node positive, triple negative patient that underwent neoadjuvant chemotherapy followed by breast conservation with a complete pathologic respon...

What criteria do you use to determine the utility of DIBH for breast cancer patients?

What criteria do you use to determine the utility of using DIBH for planning after free breathing and DIBH CT scans? Do you typically create a ...

When do you add a third field for IMPORT-LOW style partial breast irradiation?

The IMPORT-LOW and DBCG trials of 40 Gy in 15 fraction PBI utilized mini-tangents, which simplify planning but increase breast V40 Gy.The paper by Tho...

Do the results of the GEPAR trials indicate that PMRT based on pre-neoadjuvant chemo risk factors, irrelevant of pCR, should be the standard of care until NSABP B-51 is completed?

The GEPAR trials presented at ASCO 2015 showed increased LRR with the omission of RT in patients who had a pCR after neoadjuvant chemotherapy.

Is it reasonable to offer APBI in an obese patients with large breasts and N1mi disease?

For a patient with an ER-positive, pT1c breast cancer who otherwise meets criteria for APBI, but has a BMI of 50 with pendulous breasts and N1mi disea...

How does one interpret the LUMINA trial in the FLORENCE APBI ERA?

While I am encouraged by the results of the LUMINA trial with respect to identifying patients who are less likely to benefit from radiation therapy wh...

Would you have a patient temporarily discontinue methotrexate while receiving a FAST or FAST FORWARD regimen for breast irradiation?

The patient is on a dose of 22 mg of methotrexate weekly for severe rheumatoid arthritis. If you would discontinue the methotrexate, how long would y...

In a patient with local recurrence of breast cancer after mastectomy, how would you sequence adjuvant treatment after wide local resection?

Assuming the patient had no prior radiation and has no evidence of metastatic disease, would you start with adjuvant radiotherapy or adjuvant systemic...

Would you hesitate to give breast radiation to a patient with prior near-fatal Stevens Johnson medication reaction?

Might a prior SJ incident pre-dispose to SJ reaction to radiation? Would you be more or less apt to treat with RT for grade 2 DCIS with refusal of pr...

How would you treat a patient with a prior history of an early-stage breast cancer who now has a 5 cm tumor in this ipsilateral breast with nodal involvement?

If a patient had a partial mastectomy and radiation therapy 10 years ago and now has a large ipslateral breast cancer (different ER/PR/Her 2 markers n...

How do we reconcile what appears to be a more aggressive surgical resection for DCIS than for invasive disease?

NCCN suggests 2 - 4mm margins in DCIS, and no tumor on ink with invasive disease.

What is your strategy for managing radiation dermatitis in breast cancer in the prophylactic, erythema/dry desquamation, and moist desquamation stages?

What agents have you found helpful? What agents have been proven to be effective/non-effective?

Would you use bolus in patients s/p mastectomy and reconstruction if they had dermal involvement?

Would you offer PMRT to a young patient with a remote history of mantle/lung RT for Hodgkins lymphoma and a left cT0N1 triple positive breast cancer with a complete response after neoadjuvant chemotherapy?

The patient is less than 35 years old, and received 21 Gy to the mantle and 10.5 Gy to the lungs >15 years ago as part of treatment for Hodgkins ly...

Are there any potential benefits to irradiating the partial breast with an MR-linac over conventional linac?

Is PMRT considered the standard of care in women with 1-3 positive axillary lymph nodes?

Did the EBCTCG meta-analysis change your practice?

Is it acceptable to offer 26 Gy in 5 fractions for APBI rather than whole-breast RT?

For patients who are otherwise eligible for CALGB 9343 and candidates for APBI who choose to proceed with partial breast RT, are you offering 26 Gy in...

How would you manage a ER/PR positive, HER2-negative grade 2 T3N0 invasive breast cancer s/p adjuvant chemotherapy who had post-operative complications with reconstruction?

The patient is a woman in her 30s with a grade 2 T3N0 ER/PR+ Her2- invasive ductal carcinoma who was treated with mastectomy (margin negative, but LVI...

Is it safe to give radiation for early stage breast cancer in a kidney transplant patient who is on Tacrolimus & Cellcept?

For path CR after neoadjuvant chemotherapy in breast cancer with sentinel node (2-3 nodes) negative but >4 nodes positive on initial PET, do you boost the nodes not assessed by sentinel node?

Do biomarkers impact your decision-making? If you were to boost, what dose would you use?

What is your IGRT strategy for prone breast radiation?

Do you use CBCT or kV images? Do you match to the breast or the chest wall?

Would you offer RNI for young patient with cT3N0 triple negative breast cancer that had progression of disease during neoadjuvant chemotherapy, followed by mastectomy and sentinel node biopsy?

The patient had 0/2 sentinel lymph nodes involved, and mastectomy revealed pT3 disease with negative margins

In what setting is PMRT indicated for T1-2N0 breast cancer?

Is there a practical way to quanitfy risk of LRR in patients with T1-2 N0 with multiple high risk factors in such as multifocal disease, high grade, L...

What are your top takeaways in Breast Cancer from ASCO 2023?

Can radiation to the breast be given in the setting of prior radiation for Hodgkin's lymphoma?

How would you approach post-operative radiation in a patient with ER/PR negative Her2 positive, T1c N0 breast cancer originating in the ectopic mammary tissue close to the axilla, treated wide excision followed by APT regimen (weekly paclitaxel plus trastuzumab with trastuzumab for one year)?

Would you recommend PMRT using a hypofractionated course to the chest wall and nodes?

Would you recommend this if we were treating level I/II?

What dose/fractionation would you use for a patient with unresectable, ER+/PR+/HER2 negative breast cancer who declines chemotherapy and progresses locally after receiving endocrine therapy with abemaciclib?

The patient has locally advanced disease with chest wall invasion and extensive axillary/IMN lymphadenopathy

Is a completion axillary dissection required for a patient with clinical N+ disease who had a complete clinical response in the axilla to neoadjuvant systemic therapy but is found to ypN+ disease on sentinel node biopsy?

Is axillary radiotherapy an acceptable alternative?

Do you offer adjuvant radiotherapy for completely resected breast fibromatosis after lumpectomy?

Would you offer ultrahypofractionated 5 fraction breast radiation to a patient with lupus?

What are best practices for oncologists during the national platinum shortage?

Please specify how your institution is allocating resources now or will be soon.

13 Answers available

If CBCT is not an option, what is your preferred IGRT strategy for prone breast patients?

Do you offer ultra-hypofractionated 5-fraction whole breast RT after oncoplastic rearrangement?

Are there any concerns about increased acute or late toxicity in the context of more extensive surgery?

How do you approach the discussion with a patient who is seeking proton therapy for early stage breast cancer?

What is your approach to try to persuade her that photons would be a better option?

What radiation would you offer for isolated nodal recurrence in a patient who received APBI for breast cancer about 2 years ago after ALND?

How does residual DCIS after neoadjuvant chemotherapy impact prognosis if there is a CR of the invasive disease?

Is it time to re-evaluate the timing of radiation and chemotherapy with the adoption of hypofractionated courses of radiation for breast cancer?

Historically, chemotherapy has been delivered prior to radiation for breast cancer patients requiring it. With the acceptance of shorter cour...

How would you approach an elderly patient with locally advanced breast cancer and co-morbidities, who strongly refuses surgery but is willing to consider radiation?

Are there any accruing trials in the U.S. evaluating selective use of radiation after mastectomy in early stage breast cancer?

I have yet to see results from the SUPREMO trial investigating this question in Europe. There is the EXPERT trial, NCT02889874 based in Australia/New...

If using protons instead of photons, does the use of protons impact your recommendation for using hypofractionation in breast cancer?

Is it ethical to still prescribe conventionally-fractionated treatments for breast cancer, prostate cancer, and osseous metastatic disease for patients that do not have contraindications to hypofractionation?

What do you consider valid reasons to deliver 39 or more fractions for prostate cancers, 25 or more fractions for breast cancers or 10 or more fractio...

What dose and fractionation regimen would you use for a patient with DCIS with multiple close margins unable to undergo re-excision, who has a history of photosensitivity (polymorphous light eruption)?

Would you consider APBI so that less tissue is irradiated or do whole breast (hypofractionation vs conventional fractionation)?

Would you offer re-irradiation for a patient with a left sided medial DIEP flap recurrence with a history of prior whole breast radiation 25 years ago?

The patient is in her 70s and had a prior breast recurrence 10 years ago treated with mastectomy and reconstruction; this most recent recurrence has t...

What is your adjuvant radiation approach for a patient that declines chemotherapy for an occult primary TNBC after ALND only, with 1-2 non-bulky nodes positive, no ENE?

Patient with multiple comorbidities (childhood CNS cancer survivor, stroke with residual deficits).

Would presence of DIEP flap reconstruction impact your decision to proceed with a BID approach to PMRT for inflammatory breast cancer?

How would you manage a patient with a prior history of an ER+/PR+ breast cancer s/p mastectomy who develops nodal recurrence 2 years after surgery?

The patient did not have radiation previously, but now has recurrent disease in Axillary levels 1-3, supraclavicular nodes, and IMN in the first inter...

How do you decide whether to offer partial breast radiation to T2 tumors that are 2-3cm in size?

The ASTRO consensus lists 2-3cm size as cautionary, while the ABS consensus lists 3cm or less as suitable, though acknowledges that most patients incl...

How well does left chest wall electron chest wall RT compare with IMRT with with respect to heart and lung radiation doses?

Is there any reason that this is not commonly done, apart from lack of RNI coverage?

How would you approach a non-healing wound following lumpectomy for recurrent disease in a patient who underwent breast conservation therapy with radiation 10 years prior?

The patient had lumpectomy with standard radiotherapy to 50 Gy whole breast, followed by 10 Gy boost 11 years ago, and was recently found to have a sm...

Would you treat with post-mastectomy radiotherapy in patients with early-stage (T1-T2), node-negative, hormone-positive disease if the only risk factor for recurrence was a focally positive anterior margin?

In a patient with a history of prior BCS+RT for early stage breast cancer who is now s/p repeat lumpectomy for a low risk in-breast recurrence, what dose/fractionation regimens are appropriate for reirradiation?

Patient is refusing BID dosing as per RTOG 1014.

What dose constraints for lung would you use in a patient with breast cancer requiring regional nodal irradiation who had significant pneumonitis during systemic therapy?

Patient developed pembrolizumab-related pneumonitis after ddAC followed by Taxol/Keytruda - what thresholds/constraints would you prioritize with rega...

When do you use IMRT in breast radiotherapy?

Do you also use DIBH in these cases?

Does the presence of perineural invasion in early-stage breast cancer post-lumpectomy affect the decision regarding partial breast vs whole breast radiation?

Or would it change your decision on a boost in WBRT if negative surgical margins?

Would you offer partial breast irradiation for women with G2 4cm DCIS with close margins of 1mm but a very large breast size?

Why do the available guidelines restrict APBI to patients with lesion size <3cm? Is this purely from higher rates of necrosis noted in older brachy...

Do you treat the optional radcomp posterior lymph node field for patients with breast cancer?

If so, are there any patient/pathology selection factors? What technique do you utilize?

Should BED or EQD2 be used when deciding on a fractionation scheme for breast cancer radiation, and should tumor or normal tissue be prioritized in this consideration?

Are there any resources comparing whichever value is more relevant for the various breast fractionation schedules (FAST, FAST-Forward, Canadian, UK, 3...

What dose of consolidative EBRT do you use after IORT for breast?

In which situations do you consider post-mastectomy radiation therapy when the patient has a localized node-positive breast cancer with a complete nodal response and minimal residual disease in the breast post-neoadjuvant chemotherapy?

Is there any role for RT in the management of florid LCIS after mastectomy?

If a patient is found to have florid LCIS with with a 1 cm positive inferior margin s/p sentinel node biopsy (0/2 nodes involved) and mastectomy, is t...

Are there any indications to boost the axilla for women with locally advanced breast cancer who do not have clear gross residual/undissected axillary disease?

For example, a heavy burden of nodal disease with diffuse ECE? Would you treat the axilla higher than 45-50 Gy? What would you use for a boost dose?

Are apocrine type TNBC breast cancers less sensitive to radiation?

Do your radiation treatment recommendations change if a breast cancer patient does not complete a full course of neoadjuvant chemotherapy?

Do you follow the breast NCCN guidelines to decide adjuvant radiation recommendations if a patient treated with neoadjuvant chemotherapy stops the che...

How do you approach brain SRS for patients currently receiving Trastuzumab deruxtecan with progressive brain lesions?

Is there a certain amount of time that you prefer to have elapsed after the last infusion before delivering SRS? Do you avoid all subsequent Trastuzum...

What do you quote as the recurrence risk without radiation for patients that undergo neoadjuvant systemic therapy followed by lumpectomy and are found to have a complete pathologic response?

Patients will frequently ask why they need treatment when there is no cancer left on the pathology specimen.

What additional pathologic or clinical features might sway you to recommend PMRT specifically for a very young patient with pT1 sentinel node negative breast cancer?

Would you consider RNI in a patient with axillary recurrence after lumpectomy, whole breast RT and cavity boost 10 years ago?

The patient is now s/p neoadjuvant chemotherapy, mastectomy, and ALND for their ipsilateral recurrence, and pathology showing residual disease (ypT0N2...

For postmastectomy patients who have >2 sentinel nodes involved, would you recommend a completion axillary dissection or proceed with PMRT?

How do you counsel patients who want breast augmentation following breast conserving surgery and whole breast radiation?

Would you offer FAST-Forward for a metastatic breast cancer patient with breast implants needing palliation of symptomatic breast lesions?

Would you deliver post-operative axillary radiation for breast cancer patients who have contralateral axillary disease s/p ALND?

If so, would you also include the breast?

Is there role for partial breast radiation in a small <1cm low to intermediate grade DCIS with widely negative margins?

Would you offer APBI if the DCIS was ER-?

How does the performance of a LYMPHA procedure affect the timing and planning of post-mastectomy radiation?

Does Oncotype score affect your decision to do regional nodal irradiation in a patient with early-stage breast cancer?

If a patient with early-stage breast cancer s/p lumpectomy is noted to have 1/3 SLNs positive for ITCs (and no other negative prognostic factors) woul...

How would you manage the axilla of a patient with a recurrent ipsilateral breast cancer treated with lumpectomy, sentinel node biopsy, and IORT?

The patient is a woman in her 60s with a history of a grade 1 ER-positive, HER2 negative pT1bN0 invasive ductal carcinoma treated with lumpectomy, who...

In a patient who is planned for WBRT for multiple brain metastases but also needs breast palliation, do you favor breast radiation over palliative mastectomy?

Would you radiate concurrently with WBRT? How would you dose/fractionate in this situation?

How do you counsel a patient with early stage breast cancer, planned for breast conserving surgery, who wants implants at the time of surgery or soon thereafter?

Do you have recommendations on timing of her implant placement with respect to radiation therapy?

Based on data from CREATE-X/JBCRG-04, would you consider adjuvant capecitabine in breast cancer patients treated with neoadjuvant chemotherapy who do not achieve a pCR?

Masuda et al. NEJM 2017 If so, how do you sequence it with adjuvant radiotherapy?

How does the potential for a patient to accept or forego adjuvant tamoxifen factor into your recommendations on adjuvant RT for DCIS?

Are there specific patient populations in which you may feel comfortable with a patient selecting only one adjuvant therapy approach (tamoxifen vs RT)...

How would the development of pneumonitis from pembrolizumab after treatment as per Keynote 522 alter your PMRT recommendations?

The patient was a >70-year-old with right-sided cT3N1M0, ypT0N0 TNBC s/p NAC pembro/taxol x 4 cycles followed by mastectomy w SLN (0/4); post-opera...

Is a FAST regimen reasonable for re-treating a patient with PBI after prior whole breast radiation ten years ago?

Is a FAST regimen reasonable in this circumstance, or should a more gentle fractionation (either the RTOG re-treatment regimen, IMPORT-LOW, or 45Gy in...

Would you consider radiation omission in an elderly patient with a 2 mm focus of invasive ductal carcinoma in a background of high-grade DCIS?

For a > 70-year-old female patient with 2 mm of ER+ PR+ HER2- grade 1 invasive ductal carcinoma in background of 1 cm of grade 3 DCIS, would you re...

Would you boost a resected axilla if extra-nodal extension is found in a patient with breast cancer?

What are your volumes? What if the lymph node area was not clipped?

Would you offer whole-breast RT to a BRCA-positive patient who has multifocal recurrent disease after APBI?

The patient is BRCA2 positive and previously received 30 Gy in 5 fraction APBI to the right breast for an ER/PR+ pT2N0 IDC. She then developed multifo...

If using hyperthermia in breast reirradiation, what type of protocol do you follow?

How would you treat bilateral synchronous breast cancer with single bony metastatic disease on imaging when one is ER+ HER2 neg and other is TNBC?

What are the current timing recommendations for initiating radiation after lumpectomy?

The prior recommendations were between 6-12 months, but also were based on chemotherapy after surgery.

What is your approach to young healthy women with locally advanced breast cancer and biopsy-proven low cervical lymph nodes?

Would you treat this as a locally advanced breast cancer and offer surgery, radiation, and systemic therapy? Does your management change depending on ...

Does a pathologic complete response in the breast and axilla change your radiation recommendations?

In a woman with high-grade, clinically node positive invasive ductal carcinoma who receives neoadjuvant chemotherapy and breast conserving surgery, wo...

How would you counsel a patient with extragenital lichens sclerosis on the acute and long term risks of post-lumpectomy radiotherapy?

Assume a mild but diffuse case of lichens sclerosis with involvement of the ipsilateral breast. If node negative disease, would you recommend she unde...

How does pathological skin involvement (i.e. nipple, epidermis) but not clinical skin involvement change your recommendations regarding PMRT in the absence of other risk factors?

Does that change if they received a skin sparing mastectomy?

How do you approach the treatment of breast cancer with enlarged but indeterminate breast nodes?

For a cT2 triple negative breast cancer with indeterminate enlarged breast nodes s/p negative biopsies, and indeterminate findings on both MRI and PET...

Do you routinely boost the lumpectomy cavity for HER2-positive breast cancer in the absence of other risk factors?

Is it reasonable to use hypofractionation in breast cancer patients with non-active connective tissue disorders?

Is there any reason to hold fulvestrant during SBRT to an oligoprogressive nodule?

If a patient with endometrial stromal sarcoma managed with fulverstrant has a single oligoprogressive lung nodule, is there any contraindication to tr...

How does your treatment of lymph nodes change for a breast cancer with limited (<2mm) vs more extensive ECE?

What total dose do you use for a close and positive breast cancer margin that cannot be re-excised?

For conventional fractionation, should one increase total dose above 60 Gy for either close or positive margin (invasive or DCIS). What about for acce...

Would you consider partial breast reirradiation in an otherwise healthy elderly patient with a distant history of BCS+RT, now with a clinical stage I triple negative IDC?

Patient is declining mastectomy.

How do you approach the use of IMRT/VMAT boost for grossly involved internal mammary nodes in breast cancer patients?

If electrons are unable to be used, or if the patient's anatomy precludes use of electron treatment, what is your general approach to using IMRT in th...

How do you treat the chest wall after mastectomy with an expander?

Would you consider hypofractionation? If so,what dose? Would you consider a boost if there were close margins?

Would you treat a male breast cancer patient with post-mastectomy radiotherapy for a single positive sentinel lymph node and a low Oncotype?

Is there an effective treatment for severe radiation fibrosis of the skin after radiotherapy to the breast or other areas?

I have heard of long-term pentoxifylline and Vitamin E daily combination that can prevent and even reverse radiation fibrosis (Delanian et al., PMID 1...

What margins (CTV and PTV) do you use for boosting breast lumpectomy cavity?

When do you hold radiation for moist desqumation to recover when treating breast cancer?

How significant does the moist desquamation need to be? Does the length of tretment remaining ( i.e. 1 v. 3 weeks) or use of medication effect your de...

In your experience, is a bra worn during radiation treatment for large-breasted patients ever beneficial?

Is a bra that can be worn during treatment and indexed ever advisable for patients with large breasts who are otherwise unable to do prone treatment? ...

For a postmenopausal patient with a pT2N0 breast cancer s/p BCS+SNB who qualifies for MA20, how do you decide between RNI, high tangents, and standard whole breast RT?

How would you modify this based on endopredict or RT-PCR?

Would you treat a Stage I ER/PR positive HER2 negative breast cancer differently if it is associated with Lynch syndrome?

How are you using predictive tests such as DCISionRT (PreludeDx) or OncotypeDX DCIS in the management of DCIS?

What advantages/disadvantages are there between assays or over traditional clinical pathologic factors? What other concerns do you have?For additional...

Would you consider regional nodal irradiation for a patient who refused initial adjuvant breast RT who now presents with locally recurrent multifocal breast cancer s/p lumpectomy with positive margins and no nodal evaluation?

Do you treat synchronous bilateral breast cancers with RT simultaneously or sequentially?

What is your rationale for your approach? Does your treatment in any way depend on stage, extent of RT, and/or dose to OARs?

What volumes would you treat and what dose constraints do you use for breast and lymphatic re-irradiation?

In a patient who had BCS and adjuvant radiation to the breast and regional nodes, now several years later with extensive axillary recurrence s/p axill...

What is the ideal interval to wait after surgery before starting external beam PBI treatment?

Would you consider definitive radiation to a medically inoperable patient with left sided early stage breast cancer?

Patient has declined endocrine therapy and is unfit for systemic therapy.

How would you manage young female patients with a phyllodes tumor of the breast s/p excision with a positive margin at the posterior fascia?

The patient was in her 30s with a 2.8 cm benign phyllodes tumor with positive margin at the posterior fascia. Surgical resection is not considered ide...

How do you manage triple negative primary squamous cell carcinoma of the breast?

What pathological factors do you use to consider treatment of the axillary level I/II after an axillary dissection?

How do you define an “adequate” axillary dissection, (i.e., would 8 lymph nodes dissection instead of 10 be “adequate”), or ch...

Is there any data for prophylactic use of lymphedema sleeves during breast radiation?

Why is it recommended that patients not apply moisturizer in the radiation field immediately prior to daily treatment?

Is there any evidence to support the theory that this may cause worse skin reaction?

Is it safe to give radiation to a breast cancer patient with discoid lupus?

The patient has notable lip lesions from her discoid lupus erythematosus

On a field-in-field breast tangent plan do you have a minimum MU you accept for a subfield?

Would you offer PMRT to a pre-menopausal patient with early stage breast cancer, favorable biology, and an axillary dissection showing pN1a disease?

If you are unable to meet V50% dose constraint for partial breast irradiation, do you revert to whole breast treatment?

In patients with small breasts and large lumpectomy cavities, is there a benefit to switching to whole breast if you can produce a very homogenous par...

How do you manage early stage breast cancer patients with suspicious internal mammary nodes on imaging?

If a patient has T2N0 disease without LVSI, but has a ~4 mm IMN node in the 4th or 5th intercostal space, would you be inclined to include the IMN cha...

How do you manage a patient with early stage small cell carcinoma of the breast?

How do you sequence radiation and capecitabine in breast cancer patients receiving adjuvant capecitabine for residual disease after neoadjuvant chemotherapy?

It is not clear from CREATE-X whether radiation was before or after capecitabine. Is there a preferred approach?

How do you manage severe fibrosis/contracture and breast/axilla pain in a patient with a history of breast radiation who cannot tolerate trental?

Patient had significant GI side effects with Trental. (This particular case involved a second course of radiation for a secondary lung cancer 30+ year...

How do you explain fleeting, post-RT breast pain to patients, and what do you recommend as management?

10 Answers available

What volumes would you cover for cT3N0, ypT2N0 breast cancer s/p neoadjuvant chemotherapy and lumpectomy/SLNB?

If the patient were of young age with high grade and ER+ disease without LVI, do these factors sway you one way or another?

When treating an intact whole breast with hypofractionated radiation, how do you approach boost dosing in the case of a close margin?

In a setting of standard fractionation, we would sometimes consider going to 66Gy total dose to the boost cavity, so how would you "translate" this to...

What is your opinion on IORT for breast with electron brachytherapy?

We have a lot of push from our surgeons to do IORT, do you use the ASTRO APBI criteria? Do you treat off-protocol? Do you use Xoft or Intrabeam?

What early stage breast cancer patients would you give IOeRT?

With newly published long-term data of single fraction IOeRT (Intraoperative electron Radiation Therapy) for breast cancer on the ELIOT trial, does th...

Do you include the entire seroma in your lumpectomy cavity volume for PBI when it extends far beyond surgical clips?

What fractionation would you offer to a young pre-menopausal woman with early stage ER+/HER2- breast cancer who received adjuvant chemotherapy and is highly interested in maximizing breast cosmesis?

Assume no contraindications to hypofractionation.

Is APBI appropriate in post menopausal women with small, triple negative breast cancers excised with negative margins?

Do you need to hold Humira (adalimumab) during radiation for breast cancer in a patient with psoriatic arthritis?

Would you offer adjuvant radiation in a woman with solitary plasmacytoma of the breast who underwent lumpectomy with clear surgical margins?

Do you consider clinically node negative patients who have been on neoadjuvant endocrine therapy eligible for omission of axillary dissection if their sentinel node is positive?

What if the duration of neoadjuvant therapy has been less than 6 months?

How do you approach a breast cancer with noninflammatory skin invasion (T4b)?

If negative margins can be obtained, would you consider breast conversation therapy? If so, would you recommend bolus placement over lumpectomy scar?I...

What is the best treatment for radiation recall skin reaction of the breast?

If a patient develops a new erythematous macular rash in the exact area of the prior radiation portal months following completion of RT without new me...

Is central lumpectomy always required for Paget's disease of the breast?

The NCCN Breast guidelines specify that for a patient with Paget's disease of the NAC with a positive full-thickness skin biopsy of involved NAC but a...

Is ultra-hypofractionation to the whole breast an appropriate adjuvant radiation treatment for Paget's localized to the nipple, status post central lumpectomy?

Are there any contraindications to BCS and adjuvant radiotherapy in patients with BARD1 mutation?

Would you give palliative breast RT to a patient receiving weekly paclitaxel for rapidly progressing metastatic disease?

If a patient has a painful breast lesion in the setting of rapidly progressing systemic disease treated with weekly taxol (60 mg/m2), would you feel c...

What type of IGRT do you use for external beam partial breast irradiation?

Would you offer post-lumpectomy RT in a young adult with DCIS, who received bilateral whole lung radiation for Wilms Tumor as a child?

In a breast cancer patient treated with neoadjuvant endocrine therapy, how would the presence of a lymph node micrometastasis influence your recommendations regarding radiation therapy?

Would ypN1mi after neoadjuvant endocrine therapy cause you to recommend postmastectomy radiation? Or regional nodal coverage after breast conservation...

Would you treat comprehensive nodes in an ER+/PR+/HER2+ breast cancer with an initial biopsied node showing atypia and then pCR (0/2 SLN) on lumpectomy?

Would you offer hypofractionated PMRT to a pathologic T2N1a BRCA positive patient?

The patient is a young female with a pT2N1a ER/PR positive, Her-2 positive invasive ductal carcinoma of the upper inner quadrant of the right breast s...

How would you deliver whole breast radiotherapy in someone who cannot raise their ipsilateral arm above their head due to recent shoulder replacement surgery?

When is postmastectomy radiation therapy indicated for a de-novo occurrence of cancer in the chest wall after mastectomy without prior malignancy, such as in a patient who had prophylactic mastectomy?

Do you have particular recommendations for management of a nipple piercing during adjuvant breast radiation?

What dose constraints do you use for OARs when treating with breast IMRT?

Are you able to achieve the contralateral breast and lung V5 constraints from current protocols?

Do you offer adjuvant radiation for low grade spindle cell neoplasm of the breast after lumpectomy?

What are your top takeaways in Breast Cancer from ASCO 2022?

What were your “top 3” presentations/studies coming out of the meeting this year and how will it impact your own clinical practice? ...

12 Answers available

Would the presence of a close but negative pleomorphic LCIS surgical margin impact your decision for APBI in a patient who is otherwise a favorable candidate?

What is the appropriate timeline to start post mastectomy chest wall/regional nodal XRT (+/- reconstruction) after surgery?

What if Medical Oncology wants to give more systemic therapy and further delay XRT start date?What should we be telling the Breast/Plastic surgeon/Med...

How would you approach a morbidly obese patient with early stage favorable breast cancer who is premenopausal?

Would you consider APBI despite younger age?

What is the soonest you can start adjuvant whole breast radiation after surgery?

Do you typically aim to wait a certain amount of time to allow for healing? The range seems to be 4-6 weeks but 4 seems a bit early with potential ser...

How would you manage an elderly female patient with a remote history of synchronous bilateral invasive ductal carcinoma with a new triple-negative recurrence in the left breast and axilla with extension to the contralateral breast?

The patient had been treated with conventional fractionation to bilateral breasts in the past as treatment for her synchronous IDC.She is currently in...

When do you consider it too late after lumpectomy to offer adjuvant whole breast radiotherapy?

In a patient not receiving adjuvant chemotherapy who has a delayed consultation due to complications/personal issues, etc, is there a time delay ...

How do you typically screen for lymphedema in breast cancer patients following RT?

What role or experience is there for noninvasive bioimpedance spectroscopy (BIS) devices (SOZO)?

At what heart dose would you prospectively refer a patient to cardiology due to anticipated long term risks?

If a patient had prior breast conserving treatment and now has inflammatory breast disease, would you prophylactical send the patient to a cardiologis...

Is your decision to hypofractionate or boost altered by surgeon's plans for DIEP reconstruction after radiotherapy?

Would you ever offer pre-operative radiotherapy in carefully selected patients before primary oncologic surgery off-trial, based on this Lancet Oncolo...

How would you treat low grade primary breast Leiomyosarcoma following lumpectomy?

Less than 2cm in size and closest margin is 0.6mm. Would you consider re-excision or mastectomy? Would you offer radiotherapy?

Would you offer PMRT to a perimenopausal female with a single positive LN with microscopic ENE who has otherwise low risk features?

What is the maximum electron energy you would consider using for a breast lumpectomy boost?

Is there a certain energy beyond which you feel the acute or late toxicity to the skin/breast warrants a switch to photon techniques?

For invasive ductal carcinoma with micropapillary features s/p lumpectomy, is bolus needed when treated with adjuvant whole-breast RT?

In what clinical circumstances would bolus be indicated for this histology?

Are there any whole breast RT techniques or modifications to optimize cosmesis for patients who had prior breast augmentation?

How do you modify your adjuvant whole breast RT design (e.g., CTV_WB per RTOG 1005 volume-based or field-based approach) for patients with *prior* cos...

Do you routinely perform a breast boost after whole breast radiation?

If the patient has invasive breast carcinoma and close margins with no other risk factors for local recurrence, would you utilize a cavity boost?

How do you approach the decision to boost patients diagnosed with DCIS?

What factors do you consider?Is your thought process at all different from your approach to boost with IDC? Do you apply TROG 7.01 data (age <...

What resection margins are required for DCIS with a component of invasive disease?

What resection margins are required for pure DCIS with adjuvant RT? What resection margins are required for pure DCIS without RT? For additi...

For external-beam partial breast irradiation, if the CTV lies close to the skin surface, do you apply bolus?

Due to the use of 1-1.5 cm CTV expansions on the surgical bed, the CTV for PBI often closely approaches the skin surface. In such cases, do you apply ...

For a patient with breast cancer s/p lumpectomy found to have a heterozygous RAD50 mutation, is adjuvant radiation appropriate therapy or would you recommend completion mastectomy?

Is there any role for post-mastectomy radiation in the setting of N1mic axillary disease?

What if it was found on SLNB and no axillary dissection was performed? Any risk factors that would make you consider RNI vs CW only vs observation?

Would you consider eliminating post lumpectomy RT in a premenopausal patient with pCR after chemotherapy for a cT1cN0 triple negative breast cancer?

Is there data that shows that late side effects change from 5 year follow up to 10 year follow up when comparing iso-effective doses of conventional and hypofractionation for breast cancer?

If patient has multicentric triple negative breast cancer with complete radiographic response post chemo, is BCS feasible?

If pCR in lumpectomies would you boost both sites?

Would you offer reirradiation after resection of locally recurrent triple negative breast cancer only 6 months after completion of postmastectomy radiation?

Would you recommend PMRT for stage IIA (pT1c pN1a) ER+/HER2- grade 2 IDC in an elderly patient with a single positive non-sentinel lymph node?

How would you approach management? If a low oncotype score was obtained, would this change your management?

Would you offer PMRT to an ER/PR+, Her-2 negative cT3 tumor treated with neoadjuvant chemotherapy, but with a minimal treatment response?

The tumor was initially 5.5 cm in size. Mastectomy and ALND revealed a grade 2, ER/PR positive HER-2 negative tumor with negative surgical marg...

Is there an indication for bolus in whole breast RT for early-stage invasive ductal carcinoma with micropapillary features?

If a patient presents with ER/PR positive, HER-2 negative pT1cN1 invasive ductal carcinoma with micropapillary features s/p lumpectomy, how would you ...

Would you offer RT for a patient with early stage breast cancer with a focally positive margin who was lost to follow up for over a year after surgery?

Does the presence of an ATM mutation impact your fractionation regimen for a woman with breast cancer?

Would you omit radiation in ER/PR negative DCIS patients who are otherwise low risk?

What additional benefit does radiation offer for a patient <65 years old with T1aN0 ER+ invasive carcinoma (tubular histology) of the breast?

How would you approach a patient with invasive breast cancer and DCIS s/p mastectomy and immediate reconstruction with a negative invasive margin, but a close DCIS margins?

The patient is not amenable to re-resection. What pathologic features and/or margin status would preclude the need for additional irradiation?

What treatment planning challenges do you consider when treating a woman with synchronous bilateral breast cancers?

For example, what is the minimal acceptable distance between the medial tangents?

How do you manage lengthy unplanned breaks during radiation therapy for breast cancer?

For example, a two week break halfway through a course of hypofractionation for early stage breast cancer.

Would you hold abemaciclib during adjuvant chest wall/axillary radiation after mastectomy?

Is active rheumatoid arthritis (RA) a contraindication to hypofractionated breast irradiation?

How does a diagnosis of active RA inform your treatment approach for patients with breast cancer, if at all?

Does the presence of DCIS in conjunction with invasive breast cancer require consideration of adjuvant RT where invasive disease alone may allow for omission?

Were patients with mixed histology included in the omission trials?

Would you offer PMRT to a young woman with high-grade neuroendocrine carcinoma of the breast?

The patient was treated with neoadjuvant cisplatin/etoposide followed by mastectomy and SLNB with a 4 cm primary and negative nodes. LVI was noted on ...

How do you decide upon a preferred dose/fractionation scheme for breast RT?

What is you decision making process in terms of the various hypofractionated regimens for WBRT supported by different trials? When do you favor APBI?...

When treating whole breast, how do you minimize contralateral breast dose without sacrificing coverage and lung/heart dose?

What constraints do you use for the contralateral breast and what will you accept?

Is it reasonable to use hypofractionation in early stage male breast cancer s/p lumpectomy?

What clinical and pathologic features - if any - would necessitate conventional fractionation?

When would you utilize hypofractionated partial breast irradiation (40 Gy/15 fxs)?

This is one of the available options in the NRG-BR007 DEBRA trial

For patients with small, early stage breast cancers that undergo cryoablation, do you ever offer adjuvant radiation?

What would be the indications for doing so? Would you proceed with APBI, or hypofractionated whole breast RT?

How would you treat an early-stage ER/PR+ Her-2 negative breast cancer s/p lumpectomy in an elderly patient who had sentinel node biopsy omission?

Given the CALGB 9343 trial, as well as the recent "Choosing Wisely" recommendation (https://www.choosingwisely.org/clinician-lists/sso-sentinel-node-b...

How do you approach adjuvant comprehensive breast or chest wall RT for locally advanced breast cancer on a CDK 4/6 inhibitor?

Do you allow pre-RT treatment with the CDK 4/6i and hold during RT, vs. allow concurrent with breast/chest wall RT, vs. delay starting CDK 4/6i until ...

What daily/weekly imaging (MV/KV/CBCT) do you use when treating regional nodes in breast cancer?

Does availability of surface imaging (visionRT) reduce your use of imaging for setup?

Would you offer postmastectomy re-irradiation in a patient with locally advanced, ER-/Her2+ disease with pathologic complete response after neoadjuvant chemo?

Prior treatment with ipsilateral breast RT was >10 years ago

What is your preferred IGRT approach when treating with ultra-hypofractionation for breast cancer?

Do you approve ports daily or less often? Do you ever use CBCT?

How would you treat cT3N1 ER/PR (-), Her2 (+) breast cancer who had mastectomy + ALND with a pCR in the nodes but ypT1 disease in the breast?

The patient has tissue expanders in place and is receiving ado-trastuzumab emtansine. Would you treat with PMRT? If so, would you target the CW and R...

Would you treat regional lymph nodes in an elderly patient with a triple negative pT2 IDC of the UOQ of the left breast s/p lumpectomy with N0 sentinel node biopsy, but was clinically node negative?

The tumor was 3.2 cm; post-op margins were negative, but <0.1 mm. The patient has excellent performance status. She will not be receiving sys...

Do you routinely offer PMRT for T3N0 breast cancer?

Although these patients are included in the Danish trials, Taghian et al. & Floyd et al. both showed ~ 7% LRR in this group of patients witho...

When would you add an extra radiation dose to compensate for treatment breaks?

Apart from H&N SCC, are there times where adding an extra dose of radiation due to a tx break is appropriate? Is there a decent equatio...

How does implant breast reconstruction/augmentation at the time of lumpectomy affect your adjuvant radiotherapy approach?

Do the same concerns as post-mastectomy radiation of implants apply?There are some small case series' (https://www.ncbi.nlm.nih.gov/pubmed/21346535 DO...

In a patient who had a prior CABG with internal mammary grafting who now requires comprehensive RNI, what landmarks would you use to contour the IMN volume?

For patients with triple negative breast cancer who are planned to receive adjuvant pembrolizumab, would you recommend pembrolizumab be held until radiation is complete?

For patients who were not neoadjuvantly on pembrolizumab, is it safe to initiate it concurrently with radiation?

Would you consider PMRT in a patient < 40 y.o with a with an ER/PR(+) Her 2(-) pT1, cN0 breast cancer patient, LVSI positive, who did not have sentinel lymph node biopsy?

MRI pre-op did not reveal suspicious lymph nodes. Margins were negative upon mastectomy.

How would you design chest wall boost in a patient who underwent mastectomy with a Wise-pattern incision?

Our breast surgeons are increasingly using Wise-pattern mastectomy for improved cosmetic outcomes. Expanding the scars by 2 cm, especially along the i...

In a patient with a remote history of mantle field radiation, is there any contraindication to whole breast irradiation for early stage breast cancer?

Would you prefer APBI or mastectomy in this situation?

What is the appropriate management of breast cancer patients with axillary nodal involvement based on imaging (MRI or ultrasound) but negative axillary nodal involvement based on physical exam?

If biopsy is not feasible, should these patient be treated as cN+ with neoadjuvant chemotherapy or as cN0 with upfront surgery with axillary sent...

What is the best approach to treat a triple-negative inflammatory breast cancer with pCR following preoperative chemotherapy and a prior history of ipsilateral breast irradiation?

The patient was treated for left breast DCIS 5 years ago to a dose of 5040 cGy with a lumpectomy boost dose of 1600 cGy with conventional fractionatio...

Can I treat breast nodal volumes with hypofractionation?

With the recently reported START (A and B) trial data from the UK, in which patients were allowed to receive hypfractionated doses to nodal regions, i...

What risk/pathologic factors merit PMRT for a patient with recurrent breast cancer and a prior history of ipsilateral breast irradiation?

If the patient has evidence of axillary lymphadenopathy on imaging, would that change your approach to treatment? Would response to neoadjuvant...

Is reirradiation in the setting of DCIS of the breast ever appropriate?

If yes, do you have an age cutoff and/or surgical margin cutoff?

In a patient s/p lumpectomy+RT for an early stage breast cancer, who later has recurrent disease requiring mastectomy and PMRT, under what circumstances would you recommend a boost?

For patients with DCIS on biopsy but invasive disease in lumpectomy, are there any circumstances in which you would not recommend returning for a SNB?

For example, if the lumpectomy specimen had low risk/low volume invasive disease?

In a patient with favorable risk pT1N0(mic/i+) breast cancer and favorable anatomy, would you use IMPORT-LOW style PBI while incorporating the high axilla?

The patient is pT1c ER+/PR+/HER2- grade 1 IDC, LVSI-, N0(i+) with an upper outer cavity and a ~29cm breast separation If the cavity location is such ...

What would be your approach for a patient with triple negative metastatic breast cancer with oligo-progressive disease in the axilla alone?

The lymph node is 4 cm and is the only site that is growing on her current systemic therapy regimen.

For women who have difficulty healing after a mastectomy but need adjuvant radiation therapy, is there an amount of time for which you would abandon plans for radiation?

At what timepoint after surgery does prospective adjuvant radiation no longer become beneficial?

How do you manage residual hyperpigmentation after breast irradiation?

If this is bothersome to the patient, are there any topic ointments or medications that can help if used?

Would you offer APBI in patients with a high Oncotype who are otherwise considered “suitable” per ASTRO guidelines?

What if the patient is refusing chemotherapy?

Should we be performing sentinel lymph node biopsies for HR+ patients ≥70 years of age?

In light of updated monarchE trial data, it seems a SLNB would help delineate adjuvant treatment options in this population. However, Choosing Wisely ...

Will the recent publication of the KROG 08-06 trial change your practice in node positive breast cancer patients?

In which node positive patients will you omit the IMC when treating regional nodes?

Would you recommend adjuvant radiation to the chest wall and/or regional lymphatics after a resected chest wall recurrence?

Assume no nodal involvement.

What are the indications for PMRT in an ER/PR(+) Her-2(-) patient with a complete pathologic response in the nodes after neoadjuvant chemo, but with residual disease in the breast?

How would you approach the treatment of an elderly patient with dementia, with multifocal pT1b IDC s/p lumpectomy, with extensive DCIS, and medial margin positive for DCIS?

Would you favor re-excision? If re-excision and surgery are not an option, would you proceed with radiation or observation? If the patient had prior ...

Would you hypofractionate breast cancer patients with >25 cm separation?

Do you boost when employing this regimen?

How would you manage a patient with early-stage invasive ductal carcinoma with associated low-grade DCIS who was found to have ADH at the tumor margin on post-op pathology?

Would you recommend a re-excision? Is radiation without re-excision appropriate; if so, should a boost be given?

Are there any breast ca patients for whom you would offer PMRT if they were cN0 and ypN0?

For example, if they were triple negative or had a poor response to neoadjuvant chemotherapy in the breast?

What dose can you give the axilla after 5040 cGy of prior radiation?

Does anyone have experience re-treating the axilla and what dose/fractionation would you recommend?

Is whole body phototherapy for skin disorders a contraindication to chest wall or breast radiation?

If so, how long after phototherapy (eg. NB-UVB) is it safe to proceed with RT? See: Systemic review of phototherapy for pruritic skin disorders

How much do you deflate a tissue expander prior to beginning post-mastectomy irradiation?

Do you deflate to a specific volume?

Would you omit a boost in a patient with an indication if a very large (>200cc) post-op seroma obscures the actual tumor bed?

If using boost, how would you define the tumor bed? Would you consider resimulation for target localization? If so, what is the maximum interval of t...

Would you offer radiation to an elderly patient with cT2N1 triple negative breast cancer, whose lumpectomy and ALND showed a complete response to neoadjuvant chemotherapy?

Is the competing risk of a distant recurrence too high to justify doing radiation?

Would you offer the UK FAST Forward regimen to a patient with prior breast augmentation?

Is there data to guide you? Is there any reason to believe that there is an increased risk of complications in patients with prior breast implant from...

Is a close (<1mm) posterior margin an indication for lumpectomy cavity boost in a patient with early stage breast cancer when dissection was carried down to the pectoral fascia?

What do you consider is an acceptable surgical margin for invasive breast cancer?

No tumor at ink? 1-2mm?

For a young patient who had a prior pCR to neoadjuvant therapy, would you consider systemic therapy after local resection and radiation of an isolated brain metastatic recurrence of triple negative breast cancer?

CNS recurrence occurred within two years of prior neoadjuvant therapy

Is there any reason to stop mesalamine in a patient with UC undergoing breast/regional nodal radiation?

Would you consider PMRT for non-mass like enhancement >5cm on breast MRI that resolves with NAC and has a pCR?

Do you offer partial breast radiation in the absence of surgical clips?

If yes, how do you modify your margins? How can you change the minds of community surgeons who refuse to place them citing patient discomfort and for...

Should one perform a sentinel node biopsy in a clinically negative axilla prior to neoadjuvant chemotherapy?

NSABP B51 and B52 specifically prohibit this.

How would you treat a locally advanced breast cancer who had prior radiation to the contralateral breast over 10 years ago?

Would your recommendation change if patient had complete response to neoadjuvant chemotherapy in breast and axillary nodes? Please include informatio...

In what circumstances would you recommend using DIBH in patients with breast cancer during an electron boost?

What technique, total dose, and fractionation do you use for DCIS following lumpectomy with <2 mm negative margins which are not re-excised?

The recently published SSO/ASTRO/ASCO consensus guideline on DCIS states that "a 2 mm margin minimizes the risk of IBTR compared with smalle...

Are CHEK2 mutations a contraindication for breast conservation therapy with lumpectomy + RT?

Should patients with moderate penetrance pathogenic variants be managed similar to BRCA patients and consider risk reducing contralateral mastectomy?&...

What plan parameters do you prioritize in 3D conformal breast treatment planning?

What normalization do you choose, what is your preferred target volume coverage, and how do you assess for homogeneity and heterogeneity?

How would you approach an early stage node negative breast cancer s/p BCS with a history of severe chest wall burns?

Does the presence of a BRCA 1/2 mutation affect your recommendation for post-mastectomy RT in patients with pT1-2, N0 disease?

How do you use higher photon energies in your treatment of breast cancer with tangent fields?

Would you use 10x and 15x in your fields?

In patients with breast cancer, do you use bolus when boosting a chest wall scar or flap with electrons?

Does skin reaction at the time of starting the boost guide the decision to bolus?

What is your approach to the management of hot flashes in a patient who wants to use herbal medicine?

Do you allow patients with breast cancer on tamoxifen to use black cohosh?

When do you add an adjuvant bone-modifying agent in patients with history of localized breast cancer?

Is there any role for denosumab? How do you counsel patients regarding the benefit of bisphosphonates on breast cancer outcomes?

In the era of neoadjuvant chemotherapy, how reliable is biopsy for assessment of LVI to make decisions about PMRT?

Is there often discordance with LVI status in biopsy vs. mastectomy such that biopsy resulting as LVI negative is not reliable to decide on PMRT indic...

Is it safe for a patient to breastfeed during their course of EBRT?

Does the answer change on proximity/distance from breast (i.e. what if pelvis or lower extremity?)

Which patients with breast cancer do you treat with deep inspiration breath hold (DIBH)?

Do you do any type of assessment to see if they would likely benefit from, or be able to tolerate, treatment with DIBH versus free-breathing?

How do you approach breast conserving therapy in a woman who has formed bothersome keloids after prior surgeries?

Is there any alteration in approach from the medical, surgical, or radiation oncology perspective that can mitigate the risk of forming keloids withou...

Do you ever treat regional lymph nodes for malignant phyllodes tumor of the breast?

In what situations would you want to include regional nodes? Particular tumor size?

How would you re-irradiate a breast recurrence in a patient treated with prior whole breast radiotherapy?

Assume patient has refused surgery and additional systemic therapy.

For breast patients that are clinically node negative based on ultrasound and axial imaging, is axillary radiation an acceptable alternative to axillary dissection in a setting where a sentinel lymph node fails to map?

Is it necessary to hold azathioprine in a Crohn's patient receiving breast radiation?

Given that azathioprine increases skin sensitivity preferentially to UVA radiation, is it safe to continue or do you counsel any increased risk of ski...

Would you consider APBI in a patient <50 years of age?

Assume patient is otherwise a suitable candidate.

How do you approach axillary radiation in a patient with breast cancer who did not have a sentinel node biopsy?

If she is over 70 and has favorable enough breast cancer to forego a sentinel node biopsy, is it reasonable to assume she does not need to have her ax...

When would you recommend postmastectomy radiation to a male, status post mastectomy with 1/1 sentinel nodes with ITCs?

What is your approach for PMRT when the patient has a DIEP flap?

For a breast cancer patient treated with a mastectomy who has clear indications for post-mastectomy radiation therapy, what do you consider to be the longest acceptable delay prior to initiating PMRT following surgery?

Is there a time frame for when you may not offer post-mastectomy radiation therapy to a patient who may otherwise benefit from treatment in a typical ...

What target volume and dose would you boost for inflammatory breast cancer with prepectoral saline implant?

How would you treat a biopsy proven isolated left-sided internal mammary node recurrence 20 years after mastectomy and chemotherapy for left breast cancer?

No prior radiation. No evidence of chest wall, axillary, or supraclavicular disease.

What is your preferred IGRT strategy when treating breast cancer using IMRT?

How would you approach a radiation-induced angiosarcoma of the breast after mastectomy with negative margins?

For APBI, do you prefer a brachytherapy or external beam technique?

What specific technique (i.e. interstitial vs intracavitary, 3DCRT vs IMRT) do you prefer? What do you consider to be the pros and cons with each appr...

Do you offer ultra-hypofractionated 5-fraction RT regimens for DCIS s/p lumpectomy?

These patients were not included in FAST or FAST-Forward. Can we extrapolate to the treatment of high grade DCIS?

How does a close DCIS margin factor into surgical and radiation decision making for Stage I invasive ductal carcinoma after breast conserving surgery?

Do you use no tumor on ink for margin even if DCIS is the component close to the margin?

Does apocrine differentiation/AR positivity alter your radiation recommendations for triple negative breast cancer?

Chemotherapy is often de-escalated and omitted in this setting. Would you also consider de-escalating radiation and treating like more favorable histo...

Would you consider ultra-hypofractionated 5 fraction regional nodal radiation in a node + breast cancer who otherwise wouldn't tolerate 16 fractions of RT?

Are there any recommendations on ways to reduce capsulitis in patient with implants receiving adjuvant whole breast radiation?

Is it ever appropriate to de-escalate regional nodal coverage in PMRT for patients with localized inflammatory breast cancer (IBC)?

Historically, IBC is traditionally treated with trimodality therapy to include PMRT with comprehensive regional nodal irradiation (RNI). However, give...

Would you add dose/fractions to a post-mastectomy patient who had a two week break due to being COVID-19 positive?

Do you offer partial breast irradiation to woman with a germline variant of unknown significance (VUS) who otherwise fall into the "suitable" ASTRO category?

In breast cancer patients with a positive margin on permanent tissue but not on frozen, do you recommend re-excision or just proceed with radiation?

Given the difficulty in identifying the location of the positive margin, would you push to re-excise?

For a chest wall scar boost with a very long scar that requires 2 electron fields, how do you do that clinical setup?

Do you match on skin? What maximum hot spot do you accept? Do you do matchline shifts to feather out the hot spot and if so, how do you do that?

What treatment would you offer for a patient with unresectable triple negative breast CA who remains unresectable after completion of dd AC-T?

Presuming that imaging does not show distant metastatic disease, what would you offer? What about if the patient were PD-L1 negative?

In what situations do you routinely use posterior axillary boost (PAB) for breast cancer radiotherapy?

What is the best evidence available for the benefit of PAB in disease control?

Given favorable UK FAST Forward data for whole breast, would you consider this daily 1 week fractionation scheme when treating with partial breast approach?

As opposed to the every other day Florence regimen. Would you use mini tangents, 3D conformal, IMRT?

How do you account for hot/cold spots generated by a metallic port used to inflate tissue expander in breast reconstruction?

Do you need the expander to be removed?

How would you counsel a young female patient who refuses to use contraception during radiotherapy?

Would your counseling change if she reported a history of unplanned pregnancy? Is there any wording or waiver you might be able to use warning her of ...

Does microscopic ENE warrant post-mastectomy radiotherapy if all other factors are low risk?

For example, in a patient with T1 disease and 1/1 node involved with a micromet and focal ENE. Would your recommendation change if the patient were r...

For patients who are incidentally found to have pT1a invasive breast cancer on excision for presumed atypia/DCIS without a sentinel lymph node biopsy, will you irradiate without the SLNB being performed?

How does patient age, grade, histology (IDC vs. ILC) and ER status affect your recommendations

For a breast plan utilizing a medial electron patch for comprehensive nodal coverage, do you have a limit for hot spot at the electron photon match?

Is it appropriate to use hypofractionation to treat breast cancer when the patient is receiving concurrent TDM-1 (Kadcyla)?

Do you request lumpectomy cavity markers to be placed at time of surgery to guide planning?

Do you find such markers such as biozorb to be more helpful than delineating the seroma and/or clips on CT? When is this useful? During ...

Would a finding of isolated tumor cells on SNB impact your decision to offer omission of radiation in a patient with breast cancer who is otherwise a candidate?

Are there any situations where you would not offer SBRT for an oligometastatic bone lesion from breast cancer?

Is the dose fractionation used in BR-001 (10Gyx3) appropriate for all osseous locations, for example humeral head metastases?

Would you offer adjuvant radiation to a woman with a history of mastectomy and reconstruction for DCIS (no prior RT) who develops a cT1cN0 new primary IDC in the chest wall?

The IDC was felt to be a new primary arising from residual breast tissue given it was over 10 years from her initial DCIS.

Would you go back and do an axillary lymph node dissection if a sentinel lymph node biopsy showed a single lymph node with extracapsular extension?

i.e. 1/1 node with ECE

Should special precautions be taken patients with Ehlers-Danlos syndrome receiving radiation therapy?

Would you have reservations in treating patients with breast, GI, or pelvic malignancies with radiation alone or concurrent chemoradiation?

What image guidance do you utilize for photon breast boost?

Why are skin reactions better with hypofx breast RT vs standard fx breast RT?

How would you approach a triple negative carcinoma of the axilla with unknown primary and a CR after neoadj chemo followed by ALND?

Would you offer RT to the axilla? Would you treat the breast?

Would you omit IMN coverage in cN1 TNBC with a CR after neoadjuvant chemo?

While we are waiting for results from B51, could we omit internal mammary radiation in triple negative, cT1N1 breast cancet pts who have a complete pa...

If a patient has a history of lumpectomy and adjuvant radiation, and then develops an in-breast recurrence s/p mastectomy with breast only disease and no nodal disease, would you re-irradiate the chest wall?

Would you include the regional nodes?

Would you omit RNI in a patient with locally advanced TNBC with N1 disease who has an ALND and is found to have a pCR in the nodes?

What treatment fields do you use for N1mi breast cancer after lumpectomy/SLNB?

Comprehensice RNI? High tangents? Whole breast only? Does ER/PR/Her2 status influence your decision?

Do you recommend IM biopsy in the initial staging of breast cancer patients with suspicious IM nodes on imaging?

For early stage TNBC without nodal disease, is a prone breast setup contraindicated due to concerns of suboptimal chest wall coverage?

How would you approach patients who have undergone nipple sparing mastectomies with close or positive margins at the nipple areola complex?

This is assuming they have other indications requiring post mastectomy radiation therapy.

What ratio of lumpectomy cavity volume to normal breast tissue do you consider reasonable for treating a patient with APBI?

For example, if partial breast RT results in the prescription dose to 80% of the breast, is that reasonable? 50% of the breast?

Would you give post-mastectomy radiation for a T2N1 triple negative BRCA 2+ patient who had a complete response from neoadjuvant chemo?

How would you manage a patient with an early stage ER+ cancer of the accessory breast tissue in the axilla with clear margins and negative sentinel lymph nodes?

Would you consider/favor APBI given the negative normal breast if you can meet the brachial plexus constraints?

Is pre-treatment nodal ultrasound evaluation necessary if a patient undergoes upfront PET/CT for staging?

For locally advanced breast cancer, to what dose do you treat undissected clinically positive level III axilla, SCV or IM nodes?

We sometimes find highly suspicious LNs by CT, PET or MRI in the undissected regional lymphatics, and surgeons may not be willing to perform another o...

If patient had a significant treatment break during breast/chest wall radiation, would you consider boosting?

If the patient had at treatment break not due to radiation toxicity, for >2 weeks, and had to complete the remaining course, would you consider any...

How do you counsel patients with NF1 diagnosed with breast cancer regarding breast radiation?

Is breast conservation absolutely contraindicated? What is the true increase in risk of secondary malignancy? Is there a good reference?

Are you offering hypofractionated comprehensive nodal irradiation following neoadjuvant chemotherapy for patients with locally advanced breast cancer in the setting of COVID-19?

Would you consider nodal irradiation alone (not irradiating chest wall) in an otherwise early stage breast cancer, cN0 patient but has a positive node from a SLN bx who is status post mastectomy?

Can APBI be integrated with oncoplastics?

Since oncoplasty is becoming more common at the time of lumpectomy, is it possible to do APBI with an HDR device like SAVI in these patients?

How do you apply the concept of a lumpectomy bed boost in the setting of oncoplastic surgery?

After multiple adjacent tissue transfers it is difficult to define a "tumor bed" with oncoplastic surgery. Surgical clips are often useful ...

For a young patient with high grade pT1N0 medially located breast cancer, under what circumstances would you include the IMN in your treatment fields?

Would you recommend axillary dissection for a patient with cT1N1 triple negative metaplastic breast cancer?

Should hydroxychloroquine be stopped prior to standard or hypofractionated breast treatment?

In light of the AMAROS trial, how do you decide between ALND vs. axillary RT?

In particular, I have a patient who underwent lumpectomy for a T3 tumor with positive margins and 1/2 SLN+. She is now scheduled for mastectomy ...

8 Answers available

What is your practice for the use of bolus in patients with breast cancer who had mastectomy and expander placement?

What technique/schedule/material?

In the setting of recurrent breast cancer after breast radiation, who receives a mastectomy and is found to have positive axillary nodes, under what circumstances would you give radiation to the chest wall and nodes vs the nodes only?

Should axillary imaging be routinely performed in all patients with a new diagnosis of breast cancer?

How do you approach management of a young inflammatory breast cancer patient after a CR to neoadj chemo but refuses surgery?

What lung constraints do you use for early stage breast hypofractionation?

Do you avoid adding high energy photons (with associated neutrons) for younger breast cancer patients, out of concern for secondary malignancy risk?

For a patient otherwise suitable for APBI, would neoadjuvant endocrine therapy administered for extemporizing reasons (e.g., COVID diagnosis and recovery, rather than downstaging) preclude consideration of APBI?

Would you consider lymphovascular invasion at the margin to be a positive margin in breast cancer surgery?

Would you recommend re-excision or proceed to adjuvant therapy if the tissue margin is negative? Pathologist states that tumor foci at margin was only...

What dose constraints do you use for hypofractionated radiotherapy for breast cancer undergoing regional nodal irradiation?

How do you define LVSI in breast cancer?

What is "clinically significant" lymphvascular invasion? What are the standards for focal vs multifocal vs embolic vs extensive? How does this serve a...

Would you offer partial breast radiation to a women who otherwise meets suitability criteria but is not going to receive endocrine therapy?

Is there a role for radiation in a patient with supraclavicular and cervical node recurrence of breast cancer after prior whole breast RT (no ENI)?

If there are small but numerous nodes involving levels II-IV and V on the ipsilateral side would you treat the lymph nodes if they had not previously ...

Do you recommend sentinel node biopsy or ALND in cT4 or cT3 cN0 breast cancer patients?

ASCO 2016 guidelines specified that SLNB was not recommended for T3/T4 N0 patients but uptodate allows it.

Do you recommend a dose constraint for breast implants when treating a patient for NSCLC with radiotherapy?

In the case of conventional fractionation or SBRT, would you constrain the implants? (No history of breast cancer.)

What dose and volume(s) would you consider for a young woman with an axillary nodal recurrence from breast cancer s/p TBI as well as chest wall (only) radiation?

TBI was 20 years ago, chest wall RT was 8 years ago. The solitary nodal recurrence in axilla was resected, but with ENE+, PNI+, with no further ...

What is the longest treatment break you would accept when treating a patient for breast cancer?

For example, in a young high risk patient who completes less than half of her prescribed treatment and wants to resume after a period of months, how w...

What is the best way to compensate for hypofractionated radiation interruptions due to COVID?

For example, ultra-hypofractionated whole breast RT?

Is the skin dose adequate when treating a patient prone for breast cancer?

For breast patients being treated in prone position. The plans generally spare the skin more so than in the supine position. If a patient has a ...

Would you treat regional nodes in a patient with complete pathologic response on axillary dissection after neoadjuvant chemo for isolated axillary recurrence?

Initial presentation was stage 1 treated with lumpectomy and whole breast radiation.

Is there a role for adjuvant radiation in phyllodes tumors of the breast?

Is xeroderma pigmentosum a contraindication for adjuvant radiation therapy to the breast in the breast conservation setting?

Based on the SENTINA trial, is it reasonable to allow for axillary assessment via SLNB alone (without axillary dissection) after neoadjuvant chemotherapy for an upfront clinically node-positive patient?

Would there be concern that the false negative rate be too high with a SLNB alone? Is this mitigated by having the clinically involved node clip...

8 Answers available

How would you adjust your supraclavicular field, if at all, for a patient with a remote history of receiving radioactive iodine ablation for thyroid disease?

What techniques do you typically use for a photon breast boost?

Mini-tangents only? 3-4 fields including lightly weighed perpendicular to chest with some exit dose to lung?

Given the favorable data for the FAST and FAST Forward trials, can we consider those ultra-hypofractionated whole breast radiation schemes to be standard of care for early stage breast cancer?

How do you manage breast lymphedema after radiation?

Are there exercises, massage techniques, or support garments that are effective at preventing or reversing lymphedema of the breast?

In patients who had a lumpectomy alone without nodal evaluation for early stage breast cancer, how do you determine whether additional surgical LN evaluation is necessary?

If no surgical LN evaluation is performed, how do you determine what volumes to include in your radiation fields?

What is your approach for a PMRT patient that cannot tolerate prone or supine sim with necessary arm positioning?

Does invasive pleomorphic lobular breast carcinoma broaden your indications for adjuvant RT?

For example, in a woman who is post-mastectomy with early stage pleomorphic ILC with ITCs in a sentinel node, would the histology push you to recommen...

How would you manage a patient with locally advanced triple negative breast cancer s/p MRM, who refuses adjuvant chemo?

(e.g. bulky supraclavicular, internal mammary, as well as retrosternal lymph nodes)

Are there scenarios that new visits/consults with patients can be done virtually amidst the COVID-19 outbreak?

Are there any special considerations when giving breast radiation to a patient with Sjogren's syndrome?

Do you adjust dose/fractionation?

How would you manage a premenopausal female with stage I triple positive breast cancer who is asymptomatic and tests positive for COVID mid way through radiation therapy?

How do you approach a patient with cN0 breast cancer who has high risk features but did not have a sentinel node biopsy?

For example, would you consider high tangents in a patient who did not undergo SNB due to age and comorbidities, but has high risk features such as gr...

Are there any special radiotherapy considerations for women who have double lumpectomy?

ACOSOG Z11102 mandated radiation with a boost. Hypofractionation was prohibited. This isn't how we practice nowadays and some women might otherwise me...

How do you handle post-op, pre-radiation breast seromas and hematomas?

For a patient with oligometastatic breast cancer that has completed adequate local therapy, would you consider ablating synchronous oligometastatic disease?

If the oligometastatic lesions are not longer PET avid after neoadjuvant chemotherapy, would you consider further treatment with local therapy or obse...

Is there any role for differential cardiac substructure dose tolerances when treating with radiation for breast cancer?

Do you contour cardiac vessels and/or heart substructures? If so, which one(s) and what dose tolerances do you assign them?

Would you give/omit regional nodal irradiation in low nodal burden ER- Her2+ disease s/p BCS with SLNB?

e.g. Gingras et al., JNCI 2017, a secondary analysis of the ALTTO trial?

Do you offer RNI to a T1N0 breast cancer patient who underwent inadequate axillary dissection?

If a SLN biopsy could not be performed and only a few lymph nodes were removed by ALND that were negative, would you treat the nodes? What facto...

For a breast cancer patient who previously underwent lumpectomy/SLN biopsy and PBI with brachytherapy, what volume would you treat for an isolated axillary recurrence s/p ALND and chemo?

Since only part of the breast was treated before, would you include treatment of the whole breast now, despite no detectable disease?

Would you offer a male patient adjuvant radiation for treatment of his breast cancer if his axillary dissection specimen shows a single node with isolated tumor cell(s) (ITC)?

The treatment of ITC and micrometastases in lymph nodes in women with breast cancer is controversial. Given the rarity of male breast cancer, complex ...

How long can you delay the start of radiation in a patient who has received adjuvant chemotherapy after lumpectomy/mastectomy?

Do you always use the same CTV and PTV expansions when defining fields for lumpectomy bed boost?

Given the MA20 results, do you consider CW plus SCV or even regional nodal radiation postmastectomy for pT3N0 with high risk features?

High risk meaning LVI, triple negative, Grade 3, etc?

Should N1a breast cancer patients with positive intramammary node metastases but negative axillary sentinel node biopsy receive adjuvant post mastectomy radiation?

For intact breasts, should adjuvant radiation to the lymphatic drainage be added to breast radiation?

In a very young woman who is s/p mastectomy for a small, high grade, Her2 positive breast cancer, with a micromet in a sentinel node, would you favor completion axillary dissection or PMRT or close surveillance?

How do you counsel young and educated patients with non-metastatic breast cancer who choose non-proven "natural" treatments over standard therapy?

What do you do/say when a discussion of evidence-based information doesn't convince a patient that this is her best chance of cure? Some patients even...

Would you omit a lumpectomy boost in a younger patient (<50 y) with a primary tumor that is otherwise favorable?

Is age solely indication for boost irrespective of other factors?

Do you offer partial breast irradiation to women with tumors infiltrating the dermis (not epidermis) who otherwise fall in the "suitable" ASTRO category?

Do you recommend CDK4/6 inhibitor, radiotherapy, or both following surgery for a pathologic fracture from HR+ breast cancer?

Has anyone omitted post path fracture radiation of pelvis/long bone in favor of starting endocrine treatment first? Or would one omit RT and start a C...

What are the implications of a VP shunt located in the radiation field in a patient receiving treatment for breast cancer?

Should the VP shunt be moved prior to RT? Are there any complications of radiating a VP shunt?

Does histology (e.g., lobular vs ductal) impact your decision to offer omission of RT to women with breast cancer who are otherwise candidates?

Does margin width play a role in your decision making? Would no tumor on ink be acceptable? What if there was LCIS in the specimen as well with ...

When do you consider using protons for breast cancer?

How would you approach a patient who is s/p mastectomy with only DCIS in the breast and a large positive sentinel node?

Would implant reconstruction prior to radiation therapy change your recommendations? Would you ever treat just the nodes and omit the chest wall/recon...

When would you consider omitting breast radiation in a <65 yo woman who is s/p BCS?

If a patient meets all omission criteria per CALGB and PRIME except age would you consider omitting RT? Is there any evidence for such an approach?

How would you manage a positive deep margin in the setting of mastectomy and expander placement?

Would you boost the area of positive margin? Would you include the expander?

What is the management of residual bulky (~ 2cm) internal mammary lymph node metastasis from breast cancer after neoadjuvant chemotherapy?

Would you have CT surgery resect the mass, followed by adjuvant radiation?

Would you consider APBI in a primary breast adenoid cystic carcinoma?

Assuming the patient is otherwise a candidate for APBI.

What chest wall boost volume do you use for patients with inflammatory breast cancer?

Do you use a standard margin around the mastectomy scar (ie 2cm sup/inf), or do you extend the field to include the entire chest wall?

Would you recommend adjuvant radiotherapy with concurrent Ado-trastuzumab emtansine (T-DM1) in your breast cancer patients?

Is there a subset of patients with metastatic breast cancer in whom you would consider locoregional therapy?

How do the recent results from E2108 impact your practice? Would you consider locoregional therapy in patients who are good responders, have oligets, ...

Do you have a goal isodose line coverage for skin in the setting of post mastectomy RT with expanders in place?

How about in the setting of treatment after recurrent resected disease if it didn’t involve the skin: would you push for coverage even though pl...

Would you irradiate the breast of a patient with an unknown primary malignancy manifesting as bulky axillary adenopathy and non-specific poorly differentiated carcinoma histology?

Or would you only irradiate the axilla?

Are there any specific planning techniques that are used to avoid underdosing the match line in a single isocenter breast plan treating the chest wall and supraclavicular region?

Would you recommend adjuvant breast radiation following lumpectomy for a well-differentiated adenoid cystic carcinoma that appears to be a breast primary?

When treating an intact whole breast using breath-hold technique with a planned electron boost, do you generate a separate plan for the boost with a free-breathing scan, or plan the electron boost on the breath-hold scan, but treat free-breathing?

How would you approach a new solitary sternal metastasis for a triple positive breast cancer 1 year after hypofractionated breast radiation?

Would you modify your dose if there was overlap from the prior treatment?

Would you avoid radiation in a patient with breast cancer with active skin lupus?

In a patient with early stage breast cancer that would otherwise require radiation, would you recommend treatment if the patient has active skin lupus...

Would you recommend partial breast irradiation using LDR seeds after lumpectomy for a suitable candidate with early stage breast cancer?

What are the differences that a patient may expect with HDR vs LDR brachytherapy?

Would you recommend covering the dissected axilla in your radiation field in patients with cN2/N3 disease who had complete response to neoadjuvant chemo and an ALND?

What if ALND reveals no residual disease?

In a patient with early stage breast cancer previously treated with lumpectomy and RT, how would you manage a node positive recurrence s/p lumpectomy and SNB?

Would you consider reirradiating the breast and regional nodes? Further axillary surgery? Partial breast radiation? Or other?

Would you consider APBI in a patient who received neoadjuvant chemotherapy?

Would the degree of response (pCR vs no pCR) influence your decision making?

Which early stage breast cancer patients who are candidates for 3-week hypofractionated whole breast EBRT are not good candidates for 1-week whole breast EBRT?

i.e. FAST-Forward: 26 Gy in five daily fractions?

Would you recommend PMRT for a patient with a right breast mastectomy with closest margin less than 0.1cm?

Would you offer partial breast irradiation to women who have HER2+ disease?

If so, do you give RT before or after adjuvant chemotherapy?

In a locoregionally advanced breast cancer with multiple positive surgical margins, how safe is it to wait for a re-excision vs treating upfront with comprehensive RT if surgery cannot be done the short term due to the COVID outbreak?

Radiation in the setting of positive margins is sub-optimal and from my understanding high boost doses do not replace further surgery. Is it better to...

Do you use bolus for the lumpectomy cavity boost when the seroma is within 5mm of the skin?

Given COVID-19, is there a good hypofractionated regimen for postmastectomy radiation for locally advanced breast cancer?

In light of the COVID-19 pandemic, would you consider SBRT for appropriately selected early stage breast cancer patients?

Many hormone positive patients are beginning hormone therapy until they can go to surgery. With a prolonged pause in routine procedures seeming very l...

How should our selection for neoadjuvant chemotherapy for breast cancer change in light of COVID-19?

Are you altering your use of Active Breathing Coordination for breath hold technique patients in light of the COVID-19 pandemic?

Would you consider hypofractionated weekly whole breast irradiation for early stage breast cancer?

Do you consider this regimen based on the 10 year results of the UK FAST trial?

How do you deliver appropriate bilateral post-mastectomy radiation therapy for a young woman with a bilateral clinically node-positive lobular breast cancer with a pacemaker in place?

How do you measure the skin dose when you are concerned about dosing to the skin?

Is it possible to get a good measurement with TLDs? TLDs can overestimate the surface dose by 10 - 40%. Do you use a skin diode measurement on the fir...

Should we delay adjuvant breast radiotherapy for early stage breast cancers as the COVID-19 situation evolves?

Would your practice vary based on hormone receptor or Her2 status?

Is APBI appropriate for patients with rare tumor histology (mucinous, medullary, or tubular) if they meet all other suitability criteria?

What measures should we take regarding routine follow-up visits for well patients in surveillance during the coronavirus pandemic?

When a physical exam is important and telehealth is not a good option, should we be proactive and reschedule or should we continue to see them as sche...

How do you decide when to offer radiation therapy for pleomorphic lobular carcinoma in situ after lumpectomy?

Would you omit a lumpectomy boost in a patient with a single positive sentinel lymph node, with a primary tumor that is otherwise favorable?

i.e. T1, low grade, ER positive, margins negative, older age?

How would you manage a patient needing PMRT with a history of severe burn to the chest?

If a skin flap was required due to necrosis after the mastectomy, would you still provide PMRT assuming the patient is high risk?

How would you plan adjuvant radiation for a N+ breast cancer in a patient who had received prior lung SBRT near the treatment field?

Would you consider VMAT or protons?

Would you consider repeat lumpectomy and external beam partial breast reirradiation for in-breast recurrent cancers?

Given the recent results of the NRG/RTOG 1014 trial, would you consider it reasonable to offer breast conservation for women who meet the trial entry ...

For a patient with HER2+ breast cancer with progressive but asymptomatic disease in the brain, would you hold off on WBRT to do a trial of tucatinib, or proceed with WBRT then tucatinib?

Assuming the patient is not a candidate for SRS

Would an unfavorable molecular subtype cause you to proceed with ALNDx after a positive SLNBx?

In a patient with a positive SLNBx, would triple negative or Her2+ status affect your decision on whether or not to proceed with a full ALNDx?

For a patient with remote history of mantle field radiation for early stage Hodgkin's lymphoma, now with oligometastatic breast cancer, would you offer SBRT to chest wall metastasis?

Is surgery preferable? What dose/fractionation would you recommend?

Are there situations where you would use hypofractionated radiotherapy for Stage III breast cancer?

Would it be acceptable to treat a patient with locally advanced breast cancer (ex pT2N2a) s/p lumpectomy with a short course 4 week treatment ins...

In a patient with ypN+ breast cancer with an adequately dissected axilla, do you omit radiation to the dissected axilla when treating the regional nodes?

Would your decision change based on the patient's clinical nodal stage?

Would you consider an axillary dissection in a young patient with high grade breast cancer and one sentinel LN with isolated tumor cells?

Would you include the regional nodes when treating with PMRT in a patient with a high grade, large primary tumor, but low burden axillary disease with a complete axillary dissection (e.g. 1/20 nodes involved)?

Is it possible to have diffuse, bilateral pulmonary fibrosis as a late side effect of unilateral radiation therapy for breast cancer?

What is the role for RNI in a postmenopausal female with clinically N+, hormone receptor positive breast cancer s/p lumpectomy and ALND with low volume nodal disease (e.g., 1/12 nodes positive)?

Z11 and AMAROS tell us that in cN0 patients, an adequate ALND is considered definitive treatment, but what about patients who have low volume biopsy p...

For breast cancer patients s/p IORT with pathologic features indicating that follow-up whole breast radiation is needed, is the current standard of care to use conventional fractionation or are there data to support hypofractionation?

What radiation approach would you use for a young patient with locally advanced Her2+ breast cancer, with complete metabolic response after neoadjuvant chemotherapy who refuses surgery?

Would you offer definitive radiation? If so, what dose and technique?

Do you treat regional nodes for node negative (by SLN) patients with early stage breast cancer in a medial location?

What size cut off or other factors (i.e. LVI) do you consider? Do you only treat IMN and medial SCV vs include entire axilla if only SLN?

How would you treat a contralateral mastectomy scar recurrence of inflammatory breast cancer?

Assuming there is no other locoregional or distant disease. Would you treat the entire contralateral chest wall? Nodes?

Would you treat with consolidative SBRT for oligometastatic liver mets from HER2+ breast cancer if these lesions demonstrated radiographic CR/near-CR following neoadjuvant TCHP chemotherapy (and patient is receiving ongoing adjuvant HP therapy)?

Due to respiratory motion and resolution of the lesions on re-staging imaging, targeting the lesions on CT sim is extremely difficult. Also, is consol...

Under what circumstances would you offer adjuvant RT following breast-conserving surgery for borderline phyllodes tumors?

Do age or margins factor into your decision making? What dose and fractionation would you use?

When do you recommend a breast MRI for breast cancer surveillance?

Would you recommend it for a mammographically occult primary or if the patient had dense breasts? What if a high risk patient decides not to hav...

How would you approach an isolated supraclavicular nodal recurrence of breast cancer in a patient who was treated with breast conserving surgery and whole breast radiation without RNI?

If a patient who had mastectomy and implant reconstruction for T1N0 breast cancer developed a new lesion years later in the axillary tail, should the implant be removed and the chest wall treated or would you consider APBI to spare the implant?

For patients with breast cancer who are otherwise excellent candidates for omitting radiation based on their age and pathology; does a strong family history of breast or ovarian cancer influence your recommendation?

Let's assume genetic testing will not be done.

Are there situations where it's appropriate to offer postmastectomy radiation therapy to patients with biopsy-proven M1 disease?

What are the indications for local control of the breast in patients with metastatic breast cancer?

What dose objectives and constraints do you use for hypofractionateed whole breast irradiation?

When treating prone breast how do you recommend contouring the breast?

Do you still follow the atlas guidelines and contour the breast to the latissimus muscle laterally the the pectoralis muscle posteriorly or since the ...

When treating locally advanced breast cancer preoperatively that is progressing on neoadjuvant chemotherapy, to what doses do you treat the gross disease, breast, and regional nodes?

Is there any data to support SLNB instead of ALND in patients with clinically N2-3 breast cancer after neoadjuvant chemotherapy?

Alliance Z-1071 cohort had 5% with cN2 and <1% fixed or matted and the current Alliance trial 011202 only allows cN1. ALND has never been shown to ...

What RT fields should be used to treat a triple negative breast cancer with biopsy positive lymph nodes and a pCR to neoadjuvant chemotherapy?

If there is a pCR in the breast and nodes do you treat the breast/chest wall SCV and full axilla? IMNs? Would the type of surgery (lumpect...

Is Rad51D heterozygous mutation a contraindication to postmastectomy radiation?

How do you manage Paget's disease of the nipple?

Do you think about it in the same way as DCIS in terms of radiation decision making (i.e. grade, margins, age of patient)? Is Paget's disease le...

Should indications for postmastectomy radiation be different after a Goldilocks mastectomy?

For instance, would you be more inclined to treat a patient with T3N0 disease and no other risk factors? What if there were a small neighboring ...

When administering breast brachytherapy (10 fxs BID), is it critical that treatment start on a Monday (not straddle one weekend)?

How do you counsel patients who will undergo external beam radiation regarding complications with breast implants from previous breast augmentation?

What risk do you quote for contracture or failure? Does the type of implant or age of implants matter?

In women with locally advanced HER2+ breast cancer who have had a complete response to neoadjuvant chemotherapy, what factors impact your decision to offer PMRT?

Does your recommendation change for women with HER2- disease?

How do you define your treatment volumes when treating a patient with post-mastectomy radiation therapy?

For instance, in a woman with small volume disease in the breast, is your posterior border still the lung interface? Do you cover all drain site...

Would you consider post-mastectomy radiation in patient with a triple negative tumor pT2N0?

What high risk pathology factors would you consider in making your decision one way or another?Would it matter if this patient was elderly vs young? W...

What dose constraints, if any, do you use for the thyroid gland when treating with regional nodal irradiation for breast cancer?

What clinicopathologic features do you consider when deciding whether or not to use a PMRT scar boost?

Do you consider regional nodal irradiation for women with ER+ breast cancer with a single micrometastasis after lumpectomy and sentinel lymph node sampling?

Would T stage, Oncotype or any other factor affect your decision?

Following mastectomy with a SNB and single positive axillary lymph node, would you refer a patient back for an axillary dissection if she has borderline indications for PMRT?

For example, for T2N1a ER+ disease? Or would you offer PMRT and axillary nodal irradiation (as a replacement for ALND)?

Do you consider SABR for oligometastatic disease in patients with TP53 germline mutation?

In a patient with their second cancer, with oligometastatic disease, do the risks of RT related second malignancies outweigh the benefits?

How do you decide between high tangents or regional nodal radiation in patients with small, ER+ breast cancers who have a single positive sentinel node?

How would your recommendations for post-mastectomy radiation change for a patient with scleroderma?

Do you offer concomitant chemotherapy and radiation to patients with locally advanced ulcerated breast masses that have good performance status and are potentially curable?

How, if at all, do you use biozorb to help guide your external beam partial breast irradiation volumes?

How do you deliver whole breast radiation to a woman with pectus excavatum?

What techniques are most effective to minimize contralateral breast, heart, and lung dose? Do you recommend conventional fractionation?

In the case of a high upper outer quadrant early stage breast cancer without adverse histological factors, would you omit boosting the breast lumpectomy cavity if the treatment area would involve a significant portion of axilla due to risk of lymphedema?

Assume the patient had axillary lymph node dissection and taxane chemotherapy. How would you counsel the patient about risk of lymphedema?

Would you recommend nodal irradiation in a patient with breast cancer with a single positive sentinel node and a low Oncotype who does not receive chemotherapy?

When do you recommend prone breast radiation?

Are there any quantitative measures that you use to help select patients such as breast size or heart dose? Or do you use a case-by-case qualita...

Should special precautions be taken when treating oligometastatic disease in the sacrum or pelvis with SBRT in a patient with a long life expectancy?

For example in a patient with a good performance status and a biologically favorable cancer (ER+ breast cancer, EGFR+ NSCLC, or prostate cancer), are ...

Would you recommend reirradiation in a patient who has extensive subcutaneous chest wall nodules and axillary recurrence after previous PMRT?

How would you treat a patient who has a large DCIS status post mastectomy and implant with extensive positive margins?

Does the permanent implant change your dose?

What is the threshold for negative surgical margins in multifocal microinvasive carcinoma of the breast?

Do you follow invasive or DCIS guidelines? Would you consider re-excision in a patient with multifocal microinvasive carcinoma of the breast arising i...

How would you approach an elderly patient with early stage breast cancer with micropapillary histology?

Would you recommend observation? Whole breast irradiation? APBI?

What is your preferred approach to PMRT with inflammatory breast cancer with adverse risk features?

What is your preferred approach to PMRT with inflammatory breast cancer with adverse risk features (i.e. age <45, close/positive margins or poor re...

How do you approach positioning and irradiation of breast cancer in accessory breast tissue in the axilla? If the accessory breast tissue extends into the arm, how would you position/immobilize the arm?

What if this lesion was at the top of the hair bearing skin of the axilla?

Do you use the NM lymphoscintigram during sentinel node identification to decide whether to treat the internal mammary nodes?

Do you offer APBI to patients with PALB2 mutation who is a suitable candidate?

What dosimetric concerns do you have regarding PMRT in patients with magnetic valve tissue expanders?

These devices give off a significant amount of artifact on CT and some devices say they are a relative contraindication with adjuvant RT.

How do you image when using DIBH with breast treatment?

Do you use portal or orthogonal imaging or both?

For patients undergoing breast conservation therapy, how do you ensure dose to the skin during treatment planning?

What is an adequate dose to the skin?

Do you prescribe silvadene cream for patients with a sulfa allergy?

Do you ever use VMAT for breast cancer?

If so, what clinical indications? Are there any advantages of VMAT? Thoughts on concerns regarding lung and heart dose constraints?

Would you offer nodal RT for pT2N0 triple negative breast cancer s/p BCS?

Or would you offer high tangents with hypofractionation?

How soon after completing radiation should anti-estrogen medication start?

Some oncologists wait 1 day, 1 week or 1 month? Is there a preferred waiting period?

Would you recommend PMRT in a patient with a microinvasive component but a large DCIS component who had a mastectomy with negative margins?

What size of DCIS would make you concerned? Would you estimate the risk of recurrence with and without radiation?

Would you consider treating the regional nodes in addition to the breast in a patient with skin involvement (pT4b) after a lumpectomy with negative margins/nodes who refuses chemotherapy?

Would a limited axillary dissection influence your decision? Any other risk factors that would sway your decision?

Do you routinely treat the anterior oblique breast suprclav field with 6MV photons or do you use a higher dose, such as 10+ MV?

What's the minimum isodose coverage line you accept for coverage of higher level axillary lymph nodes?

Would you consider PMRT in a patient with N0(i+) luminal A disease?

Does the T stage influence your decision (for example, T1mic)? Would multiple positive nodes showing isolated tumor cells sway your decision? Would a ...

When would you recommend delaying PMRT until after breast reconstruction is completed?

Do you always recommend treating breast cancer patients with getting reconstruction with their tissue expanders in place? Or is there a scenerio you w...

When using EBRT to deliver APBI, what dose do you prescribe and to what volume?

NSABP B-39/RTOG 0413 prescribed a dose of 38.5 Gy using two fractions of 3.85 each daily, but prescribed to the ICRU 50 reference point dose (usually ...

What volume would you treat after solitary axillary nodal recurrence after previous lumpectomy in a breast cancer patient without prior radiotherapy?

Is it necessary to irradiate the breast?

Would you recommend observation for an early stage, low grade, ER+, pure tubular carcinoma of the breast after lumpectomy with negative margins for women younger than 65?

Would you offer PMRT for cT2N0 triple negative breast cancer s/p NAC and mastectomy with residual disease and no positive lymph nodes?

Patient will receive adjuvant xeloda.

What adverse pathological features would be an indication for WBI (whole breast irradiation) after a patient receives IORT for early breast cancer?

An ASTRO APBI update readers are warned “the combination of IORT and WBI should be used only with caution and limited to women with higher risk ...

Are weekly port films or daily cone beams considered standard of care for 3D breast treatment?

NCCN states that daily imaging is discouraged but in practice many radiation oncologists are doing daily cone beam for non-IMRT breast

Are there any known issues related to radiation in the setting of vitiligo?

There have been case series published on this topic (most recently, PMID:26853347) with reported depigmentation within the RT treatment field.

Would you recommend APBI in a suitable candidate if they have pre-existing breast implants?

Assume you have good margins and the cavity abuts the implant. Are there any specialized techniques that you would recommend?

How do you define your partial breast volumes when doing partial breast irradiation?

Do you use NRG/RTOG, IMPORT LOW, single institution data, or retrospective data?

Would you recommend radiation planning with air tissue expanders in patients who will receive PMRT?

An example of an air expander is located at: https://www.airxpanders.com/index.php How do you ensure accurate dosimetry with the use of air ...

Are connective tissue disorders a contraindication to breast radiation?

Specifically, any data or experience regarding Ehlers Danlos syndrome?

Is multifocal disease an indication for RT in an elderly patient with early stage and otherwise favorable breast cancer?

How does breast cancer histology affect your decision whether to omit radiation?

E.g. for lobular, etc.

When considering post mastectomy radiation, do your recommendations change for a biopsy proven positive intramammary node in the axillary tail (prior to neoadjuvant chemotherapy) vs. positive axillary node?

How would your radiation targets change? There are not recommendations for intramammary nodes in guidelines.

What recommendations do you give to patients who ask about diet during breast cancer treatment?

Is it acceptable to omit post-lumpectomy radiation in an elderly patient with recurrent, ipsilateral breast cancer but low risk features?

If the patient meets the CALGB criteria for the current cancer, are there situations where you would omit RT in a patient who has never had RT? What i...

How would you treat an axillary presentation of a breast cancer in the absence of a breast primary?

Would you recommend mastectomy? What would you irradiate? What are your fields?

When would you omit RT for pleomorphic LCIS?

Updated NCCN guidelines say there is no data to support radiation for pleomorphic LCIS. Previous discussion recommended radiation for LCIS https:...

Can a lumpectomy boost be omitted in a cN0 triple negative breast cancer that has a complete response after neoadjuvant chemotherapy?

If planning standard fractionation, what factors would you consider in omitting a boost (ie age, LVSI, etc)?

What criteria do you use to treat the supraclavicular region in women with T1-2 disease breast cancer and 1-3 positive lymph nodes?

Are there local control and/or toxicity differences between multi-catheter interstitial versus balloon catheter techniques for APBI?

Which do you favor, if so?

How do results from NSABP B-39 influence your practice for APBI compared to WBI in early stage breast cancer?

https://www.abstracts2view.com/sabcs18/view.php?nu=SABCS18L_568 Any concerns regarding toxicity with APBI?

Would you offer regional nodal irradiation for cN1 breast cancer patients who undergo neoadjuvant chemotherapy and experience a complete nodal response?

Assume she refused enrollment on B51.

Would you consider breast radiation in patients with atypical ductal hyperplasia bordering on low grade DCIS?

Would you recommend a simultaneous integrated boost with hypofractionated whole breast radiation?

How do you counsel your breast-cancer survivors about weight-loss/dietary modifications?

Do your recommendations differ if patients are pre or postmenopausal given the data?

Would you recommend local therapy for a residual breast tumor after chemotherapy following CR of distant disease in a patient with metastatic disease?

What factors influence your recommendation?

Are there any contraindications to treating early stage breast cancer with radiation in patients on rituximab?

If a patient is on rituximab for multiple sclerosis, do you recommend a particular fractionation to minimize chance of MS flare during treatment? If a...

Does the presence of interstitial lung disease affect your recommendation for BCT vs mastectomy for early stage breast cancer?

Would you recommend a patient get mastectomy to avoid radiation? If treating a breast cancer patient with ILD, what lung dose constraint do you use?

When do you consider neoadjuvant radiation for inflammatory breast cancer?

How do you counsel a patient with breast cancer and a rad50 mutation when deciding between lumpectomy and radiation vs mastectomy?

rad50 is a key DNA repair protein.

How do you sequence follow up mammograms in patients undergoing breast cancer treatment?

If a patient is due for their yearly mammogram on the breast that has been diagnosed with cancer but is still undergoing active treatment (chemo or ra...

Do you recommend matchline shifts when treating abutting photon and electron fields when treating the chestwall?

Would you consider hormonal therapy and no RT in an elderly pt who developed a contralateral early stage, ER+ breast cancer while on Tamoxifen for previous breast cancer?

Hormonal therapy would not be tamoxifen.

Do you differ your PMRT treatment if a patient had a nipple sparing mastectomy?

Would you do anything different than usual regarding bolus, energies, skin dose desired for post-mastectomy chest wall radiation if a nipple-sparing m...

Do you omit the breast boost in patients with lumpectomy bed near the nipple areolar complex?

Is there concern for increased risk of chronic nipple pain with NAC in the boost field?

When giving a breast boost, what are indications for a photon breast boost?

At what energy of electrons would it be better to use photons? How many fields and what field angles should be used for photon boosts?&nbs...

Would you recommend decreasing dose to the whole breast and nodes if constraints cannot be met?

Assume patient cannot do DIBH. Would techniques would you use to meet dose constraints? What minimum dose would you recommend?

Would you treat bilateral synchronous breast cancers in prone position?

What techniques have you used to evaluate for field overlap given the different setups? We have used a thick wire placed at midline during the verific...

Would you recommend hypofractionated treatment for early stage, bilateral breast cancers?

Assume each primary meets ASTRO 2018 guidelines

Why is it more preferable to perform SLNB after neoadjuvant systemic chemotherapy versus before therapy?

Per NCCN guidelines, SLNB after neoadjuvant chemotherapy is preferred.

Are there situations in which you would definitely recommend radiation in an elderly patient with ER+, early stage breast cancer?

Would multifocality, multicentricity, LVSI, N1mi, etc affect your decision making?

Would you initiate radiation before chemotherapy for the treatment of early stage breast cancer?

Results for oncotype Dx are not always available readily.

How would you manage an elderly patient with metastatic breast cancer with locally advanced bilateral primaries?

Assume the patient has bone only metastses and will be on hormonal therapy

Would you recommend radiation for an unresectable chest wall recurrence after two prior courses of radiation?

Do you consider dermal invasion an indication for PMRT in the absence of other risk factors?

If a patient has early stage disease with peau d'orange but does not meet criteria for inflammatory breast cancer, is PMRT indicated?

How does LVI affect PMRT decision in a node positive patient?

Should LVI be considered present in a patient with positive nodes? MSKCC showed that LVI is a risk for LRR with 1-3 positive nodes...

Would you offer radiation to the contralateral breast if after neo-adjuvant chemo and prophylactic contralateral mastectomy yielded ITC only in a single lymph node and no breast primary?

Would you treat both chest walls at the same time? What fields would you use for the contralateral side: chest wall and lymph nodes? or just lym...

Would you recommend modification of radiation dose or fields in a breast cancer patient in which radiation is recommended who has had prior total body irradation?

Would you recommend adjuvant radiation to the breast for low grade adenosquamous carcinoma after lumpectomy?

Are there any treatment related considerations in a patient with HIV who is on antiretroviral therapy and receiving adjuvant radiation for breast cancer treatment?

What if CD4 count was low?

What strategies to you use for large breasted women receiving whole breast radiation?

Particularly for patients too large for prone breast treatment, do you use a breast immobilization device or bra? Do you change your fractionat...

Would you consider radiation to the axillary lymph nodes ONLY (omitting chest wall) for patients with 1-3 axillary LNs who would otherwise not receive post-mastectomy radiation (T1-2, clear margins etc) when these patients have or will undergo breast reconstruction?

Several surgeons have asked this to reduce the time to reconstruction, complications like contracture, and the possibility of re-operation/failure of ...

How would you manage an axillary lymph node only recurrence after prior mastectomy, chemotherapy and hormone therapy?

Assume your patient did not receive radiation upfront and they had an axillary dissection due to recurrence. Would you recommend radiation? What would...

Would you offer PMRT to an ER/PR positive HER2 amplified early stage (node negative) breast cancer patient found to have less than pCR to neoadjuvant TCHP?

Would you recommend observation in an elderly patient with an ER positive, early stage breast cancer who has a high risk Oncotype Dx score?

Would your decision change if the patient is getting chemotherapy and hormonal therapy?

Would you recommend PMRT in a patient with dermal invasion as the sole adverse feature after a skin sparing mastectomy for an early stage breast cancer?

In the absence of epidermal invasion and absence of dermal lymphatic invasion (DLI)

What is your strategy for image surveillance for occult breast cancer after treatment?

How do you manage focal DCIS in mammoplasty specimen?

Any consideration on standard vs hypofractionation?

Would you ever recommend PMRT to the chest wall alone without nodal radiation for invasive or in situ breast disease?

For an early stage, estrogen receptor positive breast cancer in an elderly patient, would you recommend: hormonal therapy alone, radiation alone or both?

There has been shifting concerns with medication side effects (such as osteoporosis, blood clots), duration, and potential non-compliance.

How would you treat a patient who had a previous mastectomy for an early stage breast cancer (without XRT) and then develops an isolated axillary recurrence and undergoes ALND?

What volumes and dose would you treat? Would you treat the regional nodes alone (including IMN)? Would you treat the chest wall?

How do you counsel an early stage breast cancer patient with lupus regarding decisions on radiation?

How do you manage fatigue in women receiving chemotherapy/hormonal/radiation therapy for breast cancer?

Would you recommend ALND or sentinel node re-mapping in a patient with recurrent breast cancer of the areola complex who had previous nipple-sparing mastectomy and SLNB and no previous radiation?

Assume workup is otherwise negative and she will get XRT.

How would you treat a large-cell neuroendocrine carcinoma of the breast with bulky axillary involvement with good response to neoadjuvant chemo followed by mastectomy/ALND?

Would you consider traditional breast doses or higher? Would you consider treating only the axilla if the mastectomy specimen showed widely-negative m...

How do you counsel patients on multivitamin use during therapy?

How do you approach an AVL (atypical vascular lesion) of the breast?

What dose do you try to keep the contralateral breast when treating a PMRT inflammatory breast cancer that is extending across midline?

What techniques would you use to help meet that constraint?

How do you manage sexual dysfunction in women receiving ovarian suppression for breast cancer?

What fractionation would you recommend in a patient with recurrent early stage breast cancer who has had prior lumpectomy and IORT and refuses mastectomy?

Can you treat the regional lymphatics when using a prone technique for treating the whole breast?

If so, what is your technique?

Will the recent publication of the MA.20 and EORTC 22922 studies in NEJM, showing no survival advantage from regional nodal irradiation in early-stage breast cancer patient following surgery, change your standard of care for these patients?

How much will you weigh the demonstrated disease-free survival, including distant disease-free survival, in your recommendations?

How would you advise a woman who had a full axillary lymph node dissection on the risk of lymphedema with mountain climbing?

I have a patient who will be climbing to the base camp of Mount Everest. Does a climb to 15,000 feet increase her risk? Should she wear a compression ...

What is the maximum V20 on ipsilateral lung that can be safely accepted for 3 or 4-field breast plans?

V20 of 30% can be hard to attain if IMs are being treated.

Is ALND required in all patient with clinically positive axillary nodes?

Would you recommend axillary dissection for a patient with a clinically positive SCV or IMN node, who has a clinical CR to neoadjuvant chemo, but a positive SLNB?

Does it make sense to resect only the axillary nodes, but not the other involved nodal regions? Regional nodal radiation will be given.

Would you consider APBI in an otherwise-suitable patient who has ITC in a sentinel lymph node?

Does the location of tissue expander and implant (pre-pectoral vs post-pectoral) have any impact on outcomes in patients treated with postmastectomy radiation?

Would you ever treat the internal mammary lymph nodes in a high risk patient who is axillary sentinel lymph node negative?

What factors would you use to determine? Age, triple negative, LVSI, etc?

Would you recommend APBI in an otherwise suitable candidate who is undergoing chemotherapy?

The patient will be planned using IMRT and fiducial placement.

Would you ever recommend a breast boost using BID fractionation due to patient scheduling?

What if this was an electron vs photon boost? What fractionation scheme would you use?

What is the role of neoadjuvant breast radiation in patients with triple negative breast cancer progressing on AC-T?

Pt clinically has inflammatory breast cancer making mastectomy a poor option.

When is it necessary to boost the chest wall scar post-mastectomy?

Would you consider catheter-based APBI in the setting of a recurrent Stage I breast cancer in a patient who has received whole breast radiotherapy and is refusing mastectomy?

If so, what dosing amd fractionation would you use?

Do you hold palbociclib (or another CDK4/6 inhibitor) in a patient with metastatic HR+ breast cancer while receiving palliative radiation?

How would you treat a high grade sarcoma of the breast?

Is breast conserving surgery followed by radiation therapy an option?

How long after definitive treatment is it reasonable to consider reconstruction for a woman with inflammatory breast cancer?

Inflammatory breast cancer is a contraindication for immediate reconstruction at the time of surgery, but is there a disease free interval after all t...

Would you recommend PMRT in a male patient with a T2N0 breast cancer?

Do you recommend resection for positive anterior or posterior margins in a patient s/p mastectomy if the surgeon says they took all the breast tissue anteriorly to the skin or posteriorly to the fascia?

Would you recommend PMRT for these patients if they did not undergo resection? Would you boost if they had other indications for PMRT?

Would you re-irradiate the axilla after a resection for an isolated axilla recurrence in a breast cancer patient who had prior radiation to the breast and axilla?

If so, what fields would you treat? What dose/fractionation would you recommend?

Do you treat early stage breast cancer patients with hypofractionation in the prone position?

How do you manage early stage breast cancer in patients who can not have a surgery?

Do you recommend hypofractionated/Canadian fractionation for in-situ ductal cancer?

What about lobular carcinoma?

How do you treat women who have breast-conserving surgery with positive sentinel node/s and no axillary dissection?

After the publication of ACOSOG Z11 we are seeing these patients in increasing numbers.

Would you recommend hypofractionation in breast cancer patients who had partial mastectomy with significant oncoplasty?

What is the rate of a cardiac events that you quote to a patient with preexisting heart disease going on trastuzumab for metastatic Her2+ breast cancer?

How does it vary for patients with a history of hypertension, diabetes, CHF, and coronary artery disease?

In which patients do you omit a boost following whole breast irradiation?

Do patients > 60 years old with no high risk features have any significant benefit? Has the recent update of the EORTC boost trial affected your pr...

Is your decision to treat with hypofractionated radiation impacted by histology, ie lobular vs ductal cancers?

What about tumor subtype, ie luminal A/B, Her2 positive, triple negative?

Do you use a tumor-bed boost following whole breast irradiation for patients with DCIS?

When would you omit or include a boost for DCIS after whole breat irradiation?

When utilizing the Canadian Regimen of 4256cgy/16 fxn- what boost dose and fractionation are you using?

Does the molecular subtype of breast cancer influence your decision to give hypofractionated radiotherapy?

Should hypofractionation be avoided in triple negative disease?

Do you offer hypofractionated accelerated whole breast radiation therapy for women receiving trastuzumab during RT, particularly those with left sided primaries?

In START B ~ 23 % of women received some form of cytotoxic chemotherapy, and the trial was conducted in the trastuzumab era, but there is no ment...

Do you avoid hypofractionated regimen for Grade 3 early stage breast cancer?

The Canadian trial showed conventional fractionation might be better in the Grade 3 subset, but this was not shown in the START A/B update. What can e...

What dose-fractionation regimen do you prefer when treating with hypofractionated whole breast radiation therapy without a boost for early stage breast cancer?

Is there an age cutoff you use to determine when you will offer standard vs hypofractionated breast radiation in early stage breast cancer?

Do you offer hypofractionation to younger women?

How would you treat a patient who had bilateral mastectomies for a bilateral squamous cell carcinoma of the breast with a positive lymph node?

How does your approach differ due to squamous cell carcinoma histology? What are your radiation fields?

How do you approach breast cancer treatment planning for patients with tissue expanders that have magnetic valves or metal ports?

What dose calculation algorithm to you utilize (eg AAA, Acuros, etc)? Do you prefer a particular algorithm for certain sites? Do you take in...

Do you give radiation concurrently with adjuvant pertuzumab in locally advanced Her2 pos breast cancer?

Is there any data on safety of radiaiton with pertuzumab?

How would you treat recurrent unresectable skin nodules on the chest wall after mastectomy and axillary lymph node dissection?

Assume no history of radiation, no evidence of distant disease and no nodal disease on dissection. Would you treat the chest wall or the&nbs...

What role, if any, should Ki-67 play in decision making about the role of adjuvant radiotherapy in patients who meet CALGB 9343 entry criteria?

Would a high result give you pause about omission of RT? If yes what level is sufficiently high?

What is the complication profile of subpectoral versus sublgandular implants after PMRT?

What data do you quote patients with implants after PMRT?

What dose would you treat a patient to for a positive deep skeletal muscle margin after mastectomy who is not a candidate for re-resection?

Do you take any precautions in planning PMRT for patients who had taxane-induced pneumonitis?

Assuming the patient has N2-3 disease, would you consider omitting IMN? What other techniques would you consider to limit lung exposure?

What dose regimen do you use when a women with inflammatory breast cancer is not responding to chemotherapy and needs radiation prior to surgery?

Would you recommend PMRT in a patient with early stage breast cancer who has multicentric disease and close margins?

How are you using the data on cardiac morbidity in regards to the LV-V5 in breast cancer patients?

Is there a dose constraint you are using for LV-V5?https://www.ncbi.nlm.nih.gov/pubmed/28095159?dopt=Abstract

For breast cancer with occult primary, do you favor radiation therapy or mastectomy for local management?

At what point would you decide to forego local control managment (RT or mastectomy) in favor of chemotherapy alone?

Do you intentionally modify your breast cancer treatment plans for those on chronic immunosuppression to avoid secondary cancers?

This is in regards to the risk of secondary cancers after radiation therapy or cytotoxic chemotherapy (such as anthracyclines) in an immunosuppre...

Would you recommend RNI for a triple negative cancer s/p lumpectomy and ALND with low LN positivity rate?

Assume patient had 15 nodes removed. What if 1 or 2 nodes were positive?

Should regional nodes be included in whole breast RT for a favorable pT3N0 breast cancer after lumpectomy and SLNB?

Would patient age factor into your decision, such as a patient <30 or 40? If you would not give RNI for a favorable pT3N0, are there other risk fac...

Would you recommend post lumpectomy RT in an elderly woman with a T1N0M0 stage breast cancer ER/PR/HER2 positive?

CALGB 9343 included ER positive patients but did not separate them out based on herceptin status. Does the study help inform their risk?

How would you treat the axilla if a breast cancer patient had cN1 disease in the axilla but after neoadjuvant chemo the SLNB revealed no positive nodes and the clip placed in the axilla was not found?

How would you counsel a patient who will undergo breast irradiation in which a large port wine stain is overlying the breast?

Should the patient be counseled to anticipate a worse skin reaction than normal?

How would you treat a patient with ER/PR positive breast cancer with a single site of bone metastasis?

Is your approach different for oligometastatic versus oligoprogressive disease? If there is concurrent locally advanced disease, would you treat simul...

How do you treat an early stage breast cancer with cN0 but could not undergo a SLNB?

Would you recommend any imaging of the axilla before lumpectomy? Would you recommend standard breast fields vs high tangents to cover the lo...

If a SNB is positive after neoadjuvant chemo and mastectomy, should an axillary dissection be performed or xrt given to all?

How would you treat a biopsy proven isolated internal mammary node recurrence one year after a mastectomy and chemotherapy?

Assume the patient had no radiation, what would your volumes be? Would you recommend radiation if the patient had whole breast/chest wall radiati...

For women receiving breast RT who develop a severe skin reaction during treatment, what is your threshold for giving a treatment break?

When do you institute a treatment break for skin reaction for patients who receive breast radiation?

Would you treat your left sided breast cancer patients with DIBH (deep inspiration breath hold) and IMRT when the target includes regional lymph nodes?

Do concerns about matching with 3D plans justify IMRT?

Would you recommend APBI in an otherwise "suitable" patient who has had a previous history of estrogen replacement therapy prior to early stage breast cancer diagnosis?

There is anecdotal concern regarding history of estrogen replacement therapy causing stimulation of breast tissue and therefore potentially increased ...

Would you offer PMRT after NAC in a boderline patient with a pCR based on suspicious pre-chemotherapy IM nodes?

In other words, if there are borderline indications for PMRT (ex initial T3N0 or T2N1 disease) with a pCR, would the suspicious IM nodes lead you to o...

Would you consider adjuvant RT in an elderly patient with a T1N0 ER+ breast cancer who initially proceeds with endocrine therapy alone and is unable to tolerate it?

What is the maximal amount of time you would allow between the surgery the start of adjuvant RT? What other factors would you consider when deciding w...

When do you recommend PMRT for individuals with spindle cell carcinoma of the breast?

Do you use the typical indications for PMRT (nodal status, size of primary, LVSI, age, etc)? Or, do you recommended PMRT more frequently (...

Is post-mastectomy radiation required in patients with cT2N1 breast cancer who undergo neoadjuvant chemotherapy and are then found to have negative lymph nodes at the time of mastectomy?

What is the sensitivity of SLNB after neoadjuvant chemotherapy for cN0 patients?

When would you recommend that SLNB be performed prior to neoadjuvant chemotherapy? When would you recommend additional staging (completion axillary di...

Would you offer a patient over 70 years old with early stage, favorable breast cancer adjuvant whole breast radiation if her sentinel node biopsy shows a single node with isolated tumor cell (ITC)?

What fields would you treat?

What volume would you treat for an isolated axillary recurrence after BCS and whole breast RT who have resection of the recurrent disease?

Would you treat the regional nodes alone (not previously irradiated) or would you also re-treat the breast/chest wall?

Would you treat a patient with an early stage favorable breast cancer who has synchronous advanced (or metastatic) NSCLC?

What factors would help you make your decision? (Age, genetics of lung or breast cancer, triple negative, LVSI, T2, etc?)

What is your strategy and evidence to use hyperthermia and/or chemotherapy with radiation for recurrent breast cancer?

What are your considerations in choosing partial breast irradiation versus external beam hypofractionated whole breast RT for early stage breast cancer?

Are there any situations where a patient is a suitable candidate for ABPI but you still encourage standard whole breast hypofractionation?

How would you advise your patient about starting adjuvant breast radiation who has a planned vacation?

Would you rather they delay the start of treatment so that it was >3 months from date of surgery or have a break of several weeks during XRT? Assum...

Would you treat the chest wall alone in a patient that had a previous prophylactic mastectomy and later developed an early stage breast cancer pT1-2N0 after a "lumpectomy"?

How does radiation to the breast in a lactating woman affect milk production?

And does the fact that the breast is lactating affect radiation toxicity in anyway?

Is pectoralis muscle invasion an indication for post-mastectomy radiation (PMRT) for an otherwise early stage, node negative breast cancer with clear margins?

Would you give PMRT to a young woman with a T1-2 breast cancer with a micromet on SLNB?

What factors would help aid your decision?

What is the maximum acceptable hot spot for hypofractionation breast?

For hypofrac breast patient (such as 40 Gy in 15 fractions), what is the maximum hot spot that you will accept anywhere in the breast? 107-8%? 1...

Is superficial underdosing of hypofractionated breast RT acceptable in patients with a large breast separation?

When trying to eliminate dose heterogeneity during field in field planning for hypofractionated breast radiation with a large separation, the resultin...

For patients demonstrating ypN1 disease on SLNB following neoadjuvant chemotherapy, is it reasonable to proceed with regional RT in lieu of AxLND outside of the ALLIANCE A011202 trial?

In which Her2+ breast cancer patients would you recommend extended adjuvant therapy with neratinib?

The FDA recently approved neratinib based on data from the ExteNET trial; however, benefit appears modest and the risk of toxicity is not low.

Would you offer breast conservation or PMRT (if clinically warranted) to someone with breast cancer in the context of Li Fraumeni syndrome?

When treating with high tangents, do you use conventional fractionation or hypofractionation?

Would you offer whole breast RT in an elderly patient with early stage breast cancer with EIC?

If the patient meets CALGB criteria but has EIC would you lean towards giving RT? What other factors would lead you to give whole breast RT an elderly...

Is breast conservation therapy appropriate for mutation carriers?

Is the risk of IBRT any greater than in non mutation carriers?

Are there any cases for which you would limit the dose to the scapula or ribs when treating the breast/chest wall and regional nodes?

What is your practice regarding axillary isolated recurrence after surgery when a patient received previous whole breast radiation?

Does neoadjuvant chemotherapy with complete response in the axilla alter your management preferences?

Would you consider omitting breast radiation in a male with early stage breast cancer who has undergone BCT?

If a male has early stage breast cancer and would otherwise meet criteria for the CALGB or PRIME II trials, would omission of radiation be an option? ...

What dose-fractionation schedule do you utilize to treat a locally advanced, symptomatic breast mass in a patient with metastatic breast cancer?

What do you recommend to a patient who has biopsy positive DCIS or invasive carcinoma and at time of lumpectomy the pathology is benign (assuming biopsy pathology and post surgical tumor needle localization verified)?

Do you try to cover the entire mastectomy scar with PMRT even if it crosses over midline to contralateral side?

Any recommendations on technique?

When treating the regional nodes, what factors cause you to treat the lower axilla?

e.g. how does the tumor burden on axillary dissection, sentinel biopsy only, extracapuslar extension, and the size of hte metastasis play into your de...

Does the upstaging of breast cancer based on grade and hormone receptor status in AJCC 8 change your treatment recommendations?

Is it still acceptable to deliver hypofractionation for what was previously a Stage I TN breast cancer, now Stage IIIA? Should RNI be considered? Or e...

What is your approach to left sided PMRT in patients with on-going cardiac issues (ie. cardiomyopathy, heart failure, coronary heart disease)?

How do you best counsel their radiation risks?

Would obtaining a breast MRI for patients going to be treated with APBI be beneficial?

Would you treat the supraclavicular field and IMNs for a patient with cT3N0 breast cancer who has a complete response following neoadjuvant chemotherapy?

The subquestion can be "Ex if you are offering PMRT for reasons like young age and Her2+?

Do you recommend PMRT and if so, do you treat the regional nodes, in patients who are cT4N0 (non-inflammatory) treated with neoadjuvant chemotherapy who have a pCR at the time of mastectomy?

What do you do for patients who require radiation for breast cancer (either post-lumpectomy or post-mastectomy) but who have a pacemaker on the ipsilateral side?

Do you attempt to have the pacemaker moved? If the patient is non-dependent, would you ever treat with the pacemaker in field?

Would especially young age (eg 20's) influence your recommendation for breast conservation vs mastectomy in an early stage breast cancer?

How do you counsel women with a history of breast cancer who have dense breasts, with regards to mammography screening?

Is there a role for routine use of additional or alternative imaging modalities for these patients, such as tomosynthesis, MRI, or ultrasound? I...

How do you manage anticoagulation for patients with DVT/PE who have brain metastases?

Some medical oncologists tend to hold anticoagulation in patients who develop brain metastases for fear of causing intracranial hemorrhage. Is t...

Would you offer radiation to an elderly patient with DCIS who would otherwise not meet criteria for RTOG 9804?

E.g. someone with high grade and/or >2.5cm disease? If we use age as a cutoff in invasive disease to omit adjuvant radiation based on the...

Do you ever withhold adjuvant RT after BCS in older women with stage I triple positive/Luminal-Her2 subtype breast cancers?

Her2 status was not evaluated as part of the PRIME 2 or CALGB trials and luminal Her2 patients likely represent a small minority of those enrolle...

How do you manage patients who need radiation for synchronous locally advanced head and neck cancer and locally advanced breast cancer?

Would you recommend a mastectomy for her breast cancer in attempts to avoid RT? If the patient undergoes a lumpectomy or needs PMRT, would you a...

How would you manage a patient with a rapidly growing, clinically localized breast cancer who is medically inoperable?

If a patient has a mediport within the radiation field, will you insist the patient have it removed prior to radiation?

If not, are there certain dose constraints one considers?

Do you ever use molecular assays such as Oncotype to modify your recommendations for withholding RT after lumpectomy in invasive breast cancer?

Is it safe to offer breast/chest wall radiotherapy while a patient is receiving Perjeta?

Does the presence of multifocal disease impact your decision on whether or not to recommend post-mastectomy radiation?

Is it a factor you consider, especially in borderline cases?

Are your criteria for PMRT in men different than your criteria for PMRT in women?

For instance, are you more likely to offer PMRT to a man who is node negative but with several high risk features such as high grade, LVI, high oncoty...

Are there situations for which you consider concurrent chemoradiation for breast cancer patients?

This is rarely done, but recently came up in a tumor board discussion. Which chemotherapy would you consider using, and when?

What strategies do you use for dose escalation when irradiating patients with inflammatory breast cancer?

Do you ever use BID fractionation? What patient factors do you use to individualize the treatment?

Do you routinely perform an axillary ultrasound in women with newly diagnosed breast cancer without palpable axillary nodes?

If no, in what patients should axillary ultrasounds be performed?

What is the best management of early stage breast cancer in patients with a minimal life expectancy (<10yrs)?

Would your management change if the patient had extensive DCIS?

What margin do you give around the internal mammary vessels when treating IMN nodes for breast cancer?

How many intercostal spaces do you include? Do you vary these parameters based on the disease characteristics?

Should pre-pectoral implants be avoided for reconstruction in breast cancer patients out of concern that it may mask local recurrences?

When treating patients with hypofractionated radiation to the breast in 16 fractions do you typically treat 4 or 5 days a week?

When treating patients with whole breast RT with a sequential boost, what technique to you use for the boost when treating patients prone for whole breast irradiation?

In patients with 3 or more positive sentinel lymph nodes who get a SLNB only, do you advocate for an ALND even if you are planning to treat their regional nodes regardless?

These patients were not eligible for Z0011 and represents less than 5% of the patient population in AMAROS. Thus, can you apply these two trials to ju...

How would you approach a patient with metastatic breast cancer with extensive skin involvement?

Would you send the patient to a surgeon for consideration of a mastectomy? Would you then consider post mastectomy radiation when the risk of re...

Is it safe to hypofractionate for whole breast RT in patients with a BRCA 1/2 or CHEK2 mutation to chose to have breast conservation for early stage breast cancer or DCIS?

What is the best treatment management for a metaplastic carcinoma of the breast (such as adenosquamous)?

What are indications for adjuvant radiation for a early stage well differentiated adenosquamous carcinoma of the breast? What is the best radiation th...

What dose would you use to treat an unresectable axillary breast cancer recurrence in a patient who has not previously received radiation therapy?

Do you offer post-mastectomy radiation for invasive lobular carcinomas?

What factors in particular guide your recommendation of PMRT for invasive lobular carcinoma?

How do you manage moist desquamation when treating breast cancer?

Is it necessary to cover the drain sites during post-mastectomy radiation?

Would your management change if including the drain sites requiree treating more lung or adding separate electron fields?

After chemotherapy for early and locally advanced breast cancer, how long do you advise women to wait before attempting to conceive?

Does your recommendation change depending on the agents they received?

When would you offer PMRT to a patient after prior TNI for lymphoma?

What factors do you consider when offering PMRT? Would you change your dose/fx and/or field size?

After cryoablation for early breast cancer are there any particular considerations to take when planning adjuvant RT?

In a patient with ER+/HER2- breast cancer, do you ever use Oncotype testing to assist in decision-making regarding adjuvant chemotherapy when the tumor size is less than 0.5 cm, or when there are positive lymph nodes?

In women with cN0 breast cancer who receive neoadjuvant chemotherapy due to other high-risk features, how does the finding of treatment effect in a post-chemo sentinel lymph node affect your radiation recommendations?

Women with cN1 disease at diagnosis who are ypN0 after neoadjuvant chemo can be randomized on NSABP B-51, but not those with cN0 disease and treatment...

Would you ever boost the lumpectomy cavity and the scar after whole breast RT?

What about in cases of a tunneled lumpectomy cavity using a circumareolar incision?

Is hypofractionation ever appropriate in women with early stage breast cancer and latent lupus who have never experienced skin symptoms in their lifetime?

Do you always stick with a conventional fracionation, or in some cases, are you comfortable hypofractionating? Do you ever use a wait and see approach...

Does finding a positive surgical margin containing pleomorphic LCIS in a patient with early-stage invasive ductal carcinoma of the breast affect your management in regards to breast conservation therapy?

Would you recommend re-excision of a positive margin containing only pleomorphic LCIS prior to radiation for BCS? Does the presence of ...

What options would you present to an otherwise healthy patient with early-stage breast cancer who absolutely refuses surgery?

Are there any data to support whole breast RT, SBRT, or cryoablation?

Are there any circumstances in which you would treat only the lymph nodes and omit the chest wall for PMRT?

Can close surveillance be used to manage an intracystic papillary carcinoma that is associated with a small amount of low grade DCIS?

What factors do you consider when adding post-lumpectomy radiation therapy for treatment of an intracystic papillary carcinoma?

For early stage breast cancer patients, should lumpectomy + RT be recommended over mastectomy?

Randomized trials in the 1980s demonstrated equivalent survival and disease control outcomes for lumpectomy + RT vs mastectomy, but several recent pop...

How should bolus be utilized with different types of surgical reconstruction?

Do you have a formalized approach, or is it a case by case decision? Do you use bolus differently for a TRAM, tissue expanders, implants, etc?

When deciding whether to include an IMN field in a PMRT case, what do you consider a "safe dose" to the heart that you are willing to accept?

Do you prioritize certain dosimetric parameters over others (e.g., considering the Darby report, mean dose to the heart vs. mean LAD dose?)

How should a contralateral breast cancer be treated when found during a prophylactic mastectomy?

In a patient who recently completed NAC, TM/LND and PMRT for a hormone positive locally advanced breast cancer and is then found to have a contralater...

For a patient with inflammatory breast cancer after standard initial systemic therapy with only a partial response, do you recommend more systemic therapy, pre-operative radiation, or proceed to modified radical mastectomy?

Assuming the patient is a candidate for either of these treatments?

Should patients receive PMRT if they just have a positive internal mammary lymph node on imaging and a negative axillary dissection?

If so, what fields should be used?

Is it feasible to use MV fluoroscopy to monitor the treatment port for left-sided breast cancer with DIBH?

Are there any tips on how to best use this technique?

How do you minimize skin toxicity in patients who have a significant amount of breast tissue contacting the couch during prone breast radiotherapy?

If there is a signifcant amount of breast tissue contacting the couch in the prone position, are there strategies that can be used to mitigate po...

Do you recommend delayed versus immediate breast reconstruction in patients who will require post-mastectomy radiation therapy?

Is there data, or even anecdotal reports, of cosmesis or capsular contracture of a previously augmented breast after lumpectomy and hypofractionated whole breast radiation?

In what situations do you order an Oncotype DX DCIS score for a patient with DCIS?

Is there a way to predict clinically or from CT which patients with left sided breast tumors would benefit more from the prone v. supine position?

Comparison of prone versus supine positioning showed that 85% of patients with left sided breast cancer benefit more from the prone versus supine posi...

Is there evidence to support partial breast irradiation with daily fractionation?

Since we know that both the "Canadian" fractionation and partial breast irradiation work as treatment for early stage breast cancer in the same patien...

What is the age cut-off to omit radiation therapy after breast conserving surgery for early stage breast cancer?

The Hughes study looked at women > 70 years of age. In light of the PRIME II results, can women aged 65 - 70 avoid RT or is longer follow up needed...

What is the appropriate nodal coverage a invasive ductal carcinoma status post lumpectomy with 50% or more of the SLN biopsied (for example, 2 of 4 SLN) showing micrometastases?

Would you change your management based on receptor status (ER/PR+/HER2 neg vs triple neg) or menopausal status (pre vs post menopausal)? Would you tre...

Is there a role for partial breast RT in DCIS?

Would this be considered acceptable in an older woman with high grade disease?

In light of the DBCG-IMN study, are you treating internal mammary nodes in women with positive axillary LN who have path CR after neoadjuvant chemotherapy?

Are there certain clinical scenarios that make you favor a lower whole breast total dose but higher lumpectomy cavity boost?

Is PMRT routinely recommended for all patients with positive lymph nodes after neoadjuvant chemotherapy?

Can it be avoided in patients with a microscopically positive lymph node?

Should a lumpectomy cavity boost be given to cN0 patients who receive neo-adjuvant chemotherapy and have a path CR, if planning to complete hypofractionated whole breast radiation?

When using conventionally fractionated breast RT, does one need to treat the whole breast to 50Gy or is 45Gy, followed by a boost satisfactory?

Dose in many studies were often prescribed to a point rather than a volume and with 3D planning, we may be upping the breast dose. The D2eq dose...

Would you consider whole breast irradiation in a woman who develops a second primary breast cancer or recurrence after lumpectomy and partial breast balloon brachytherapy and declines mastectomy?

Does triple negative breast cancer influence your decision to boost an older patient post lumpectomy?

In patients receiving PMRT do you perform a boost if they have had reconstruction (tissue expanders,…)?

If so, how do you target this boost?

Do you consider 1.8Gy and 2Gy fraction sizes completely equivalent when performing whole breast radiation therapy?

Do you administer prophylactic antibiotics during a partial breast balloon brachytherapy treatment course?

In which patients receiving regional nodal irradiation do you include the internal mammary nodes?

Does the recent Danish Breast Cancer Group IMN study (JCO 11/23/15), showing a survival benefit to IM irradiation in patients with early stage no...

Is systemic sclerosis an absolute contraindication for breast conserving therapy?

If not, do you have any experience with acceptable late toxicity and cosmesis with whole breast radiation in these patients?

Do you routinely include IMNs for left sided inflammatory breast cancer?

Can the IMNs ever be spared, or would you consider it mandatory for all inflammatory breast cancers?

Is it safe to treat patients who have thermal burn scars in the field?

E.g. breast? I have found no literature on skin tolerance acutely or chronically.

What factors would make you strongly consider re-irradiation of the chest wall in a patient who has previously undergone whole breast irradiation?

For breast cancer patients requiring staging, should one order a CT C/A/P & bone scan or PET scan?

Our Radiation Safety officer reports a higher radiation dose to the patient from the two scans vs the PET.

Do you consider APBI a reasonable alternative to mastectomy for women with early stage breast cancer and collagen vascular diseases?

Do you put more weight on specific CVDs such as scleroderma as contraindications for any RT?

In determining the need for regional nodal irradiation following breast cancer surgery, do you consider positive intramammary lymph nodes the same as positive axillary lymph nodes?

Is your decision influenced by factors such as the location of the intramammary nodes and/or the mapping of sentinel nodes to the axilla?

Do you advise patients to avoid deodorant during breast radiotherapy?

There seem to be good prospective studies (Australian study and Canadian study) which debunk the thought that deodorants/antiperspirants increase skin...

Is post-mastectomy RT recommended for patients who have a local failure after partial breast irradiation?

If the patient has no pathologic risk factors that would ordinarily necessitate PMRT, do you omit it? Does triple negative subtype affect your decisio...

Are there situations in which hypofractionated breast RT is acceptable after neoadjuvant chemotherapy and lumpectomy?

Would you give breast radiotherapy to a patient with a history of bilateral retinoblastoma?

Would the risk of radiation-induced second malignancy outweigh the benefit of locoregional control for a young patient with high grade DCIS?

How do you manage patients with early stage breast cancer with autoimmune disorders such as rheumatoid arthritis and collagen vascular disorders?

Do you have any concern for increased toxicity when you treat a patient with radiation therapy who has an autoimmune disorder? (hypofractiationation v...

Would accelerated hypofractionated whole breast irradiation therapy be contraindicated in a patient opting for breast conservation in the setting of breast implants?

Can the addition of posterior axillary boost (PAB) for breast cancer increase the risk of brachial plexopathy?

With conventional RT, the dose to the brachial plexus should be no more than 50-55Gy max. One exception to this is the addition of PAB in conventional...

What is the most accurate method to determine initial tumor size prior to neoadjuvant chemotherapy and mastectomy?

Do you look at pretreatment breast MRI or post surgical assessment of the tumor bed/treatment effect? How would you resolve discrepancies betwee...

Does the presence of multiple positive intramammary lymph nodes in the setting of negative sentinel lymph nodes cause you to treat regional lymphatics?

Would triple negative disease effect your decision?

Would you offer PMRT for an axillary-only recurrence after a remote mastectomy and ALND in a patient with early stage breast cancer?

In a patient with a T1 breast cancer who underwent mastectomy and ALND and recurred in the axilla a year later, would you offer RT to the chest wall a...

Do you make any distinction or have any special consideration when considering a patient for hypofractionation for left versus right breast cancer?

i.e. are there any situations where you may recommend against using hypofractionation for a patient with left sided breast cancer such as dose constra...

Do you recommend breast MRI for patients with invasive lobular breast cancer considering breast conservation therapy?

Is post mastectomy radiation therapy indicated based only on pre chemo MRI and PET CT positive axillary lymphadenopathy, if surgery following neoadjuvant chemo showed CR ?

What if the pre-chemo FNA of the suspicious node is negative?

Regarding regional nodal irradiation for triple positive breast cancers, how much do you weigh in the availability of effective adjuvant systemic therapies (i.e, hormonal and anti-Her2 therapy) in theory being able to control subclinical nodal disease without the need for RT consolidation?

Borderline cases such as patients that received NAC with a complete response or N1 disease with 1-3 positive nodes make me think frequently about this...

When do you offer PMRT for clinical T3N0 breast cancer with a pCR after neoadjuvant chemotherapy?

Would extensive residual DCIS (>5cm), hormone receptor negativity, Her2+ status, or age < 40 effect your decision?

What is the optimal/safest regimen for re-irradiation of a partial chest wall following surgical resection of an isolated chest wall recurrence?

Is there any literature supporting that a gentle fractionation/bid regimen (i.e., 1.5Gy bid x 30 = 45Gy) is safer than a standard fractionation ...

Do you ever consider treating the axilla in patients with multiple nodes with ITCs?

Does the axilla have to be addressed surgically or with RT, given that the AMAROS trial eligibility criteria were amended to address sentinel lymph no...

Would you recommend definitive local treatment of locally recurrent breast cancer with a positive contralateral axillary lymph node and no signs of distant metastasis?

Or, as this is presumed metastatic disease, would you recommend systemic treatment and defer RT?

What is the evidence that we should do anything different in breast cancer patients with 1 to 3 nodes involved versus those with four or more nodes involved?

Do you use breath hold techniques to minimize heart dose in whole breast radiation?

If so, how do you decide which patients to treat with breath hold vs. free breathing? Do you routinely perform 4D CTs?

How do you counsel young women who want to become pregnant after breast radiotherapy?

A 40 year old patient receiving post-op RT for breast cancer asked me if there is any risk for her becoming pregnant after completing RT. Eric H...

What is the treatment volume for primary breast lymphoma?

In a patient with Stage IE DLBCL, is your treatment volume postchemo ISRT or whole breast? Would you consolidate if a lumpectomy was performed prior t...

How long should patients wait before undergoing reconstruction following PMRT?

Is it a function of the type of reconstruction contemplated?

How often do you order follow up mammograms after breast radiotherapy?

The 2013 ASCO guidelines and current NCCN guidelines recommend yearly mammograms but our radiologists are still recommending mammograms every 6 m...

Do you consider treatment of the supraclavicular region mandatory for breast cancer patients with a chest wall recurrence?

If the patient has negative axillary nodes and no other signs of high risk disease other then a local chest wall failure, do I still need to treat the...

Is there solid evidence for the proper sequencing of tamoxifen/SERM and breast radiation?

They used to be given concomitantly now they are done sequentially. I can only find conflicting data to justify this trend.

Do you order a post-lumpectomy mammogram before starting RT?

If so, do you do this routinely or only in certain circumstances? Is there data to support routine mammogram before breast radiotherapy?

Should we be more concerned about cardiac toxicity following breast radiotherapy?

In a case-control study by Darby et al in the New England Journal of Medicine, patients treated for breast cancer with radiation were found to have an...

In the absence of other risk factors, do you treat the regional lymph nodes in triple negative breast cancer?

Or for that matter, offer PMRT on the basis of a patient having triple negative disease?

Should nodal fields be added to post-mastectomy radiation treatment after neo-adjuvant chemotherapy if there is a CR in the nodes?

In light of the cosmesis and toxicity outcomes of the RAPID trial, should external beam partial breast irradiation be avoided?

Should I use Oncotype to determine whether to offer adjuvant radiation to women with DCIS?

I'm not sure how to interpret the results of the study published in JNCI earlier this year.

Does current data support use of intraoperative breast radiotherapy?

My institution is considering a major investment/purchase of this technology to complement our existing array of breast radiotherapy options.

Is irradiation of the supraclavicular and internal mammary lymph nodes now considered the standard of care in women with node positive breast cancer?

In other words, have the results of the MA.20 and EORTC trials changed your practice?

Which patients with DCIS can be observed following lumpectomy?

Has the recent 12-year ECOG update for surgical excision of DCIS without radiation therapy changed your practice management?