Breast Cancer   

Questions discussed in this category



Would the recommendation differ based on HR+ vs. TNBC vs HER2+ classification? Would you recommend against immediate breast reconstruction?

Many hormone positive patients are beginning hormone therapy until they can go to surgery. With a prolonged pause in routine procedures seeming very l...

Do you consider this regimen based on the 10 year results of the UK FAST trial?

Personally, my practice is to guide patients directly to surgery or to do neoadjuvant chemotherapy rather than to do neoadjuvant endocrine therapy, bu...

For example, if you had a triple positive breast cancer found on breast biopsy and repeat ER/PR/HER2 testing at the time of surgical resection showed ...

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...

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...

If a skin flap was required due to necrosis after the mastectomy, would you still provide PMRT assuming the patient is high risk?

ie, not a classic NTRK3-ETV6 fusion.The patient has progressed through CDk4/6 inhibitors and intolerant of alpelisib, and does not want chemotherapy.&...

She has no other site of disease progression and has been on an aromatase inhibitor (progressed in the CNS while on a study with adjuvant abemaciclib)...

The APT trial reported excellent DFS, OS and RFI for tumors <=3cm but few were smaller T2s (2-3 cm) and few were >70 years old.

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 ...

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?

This patient is interested in conceiving and therefore would like to wait to start the tamoxifen.

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...

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

For example, if a patient had testosterone pellets injected, perhaps making endocrine therapy less efficacious, would that sway you to use chemo?

Being that this is a favorable histology would you use Oncotype Dx to help decide on neoadjuvant chemotherapy? Would you recommend neoadjuvant endocri...

In the absence of side effects, would you be inclined to continue beyond 10 years as chemoprevention? Would you factor an intermediate/high oncotype R...

How would you manage symptoms? How would you adjust the adjuvant regimen (dose reduce, omit paclitaxel etc)? What strategies would you consider for pr...

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

Data presented at the 2017 SABCS (abstract GS1-01) of the EBCTCG meta-analysis stating a benefit of dose-dense chemotherapy applies to ER positive and...

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...

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? 

Assuming there is no other locoregional or distant disease.  Would you treat the entire contralateral chest wall? Nodes?

Do you offer EPO and TPO support? Do you modify your systemic therapy up front or after subsequent cycles?

Do age or margins factor into your decision making?  What dose and fractionation would you use? 

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...

Data from the SOFT/TEXT trials showed clinical benefit in ovarian suppression + aromatase inhibition for high risk, premenopausal ...

Endocrine therapy is usually not indicated for DCIS s/p bilateral mastectomy, but would the fact that residual tissue (nipple-sparing) alter your deci...

Would you offer adjuvant chemotherapy to a post-menopausal woman with a BRCA2 mutation and a T2N0 ER positive breast cancer with an oncotype of 12?

Are there exercises, massage techniques, or support garments that are effective at preventing or reversing lymphedema of the breast?

It is included in favorable histologies on NCCN, but no mention of how to treat based off HER2 status.

She had disease progression on palbociclib and letrozole. She also has a PIK3CA mutation however did not tolerate alpelisib due to Grade 3 hyperglycem...

What are the indications for local control of the breast in patients with metastatic breast cancer?

Do you still follow the atlas guidelines and contour the breast to the latissimus muscle laterally the the pectoralis muscle posteriorly or since the ...

Knowing that benefit of contralateral mastectomy is lower in older women who has already manifested BRCA related cancer and 10-20 % mastectomy related...

Margins were negative and there was no evidence of LCIS or lobular component in the lumpectomy specimen. Role for possible mastectomy?    ...

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 ...

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...

Does the results of the tnAcity trial influence your decision in choosing a 1st line option?

Status post nasolacrimal stent with improvement.  Would you re-challenge or permanently discontinue docetaxel?

More generally, do absorption issues effect the efficacy of tamoxifen and/or aromatase inhibitors?

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...

Prior localized HR+,HER2- breast cancer treated with adjuvant AC-T (5years ago) Recent ipsilateral axillary recurrence (HR-,HER2+) s/p neoadjuvant TC...

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 ...

Would you consider an aggressive approach with RT and/or surgery to the bone lesion and treat the primary as locally advanced breast cancer?

Received neoadjuvant ddAC/T followed by adjuvant capecitabine for residual disease and found to have metastatic pulmonary nodules within months of sur...

< 4 lymph nodes involved, initial diagnosis was 11 years ago when she was treated with mastectomy and adjuvant tamoxifen for 5 years.  

How would you approach a post-menopausal woman who now wishes to start adjuvant endocrine therapy more than 3 years since surgery?  

Would you prefer first-line AI/CDK 4/6 inhibitor, or first-line AI followed by 2nd-line fulvestrant/CDK 4/6 inhibitor (either abemaciclib, once availa...

Is this new SSO choosing widely guideline being widely adopted and are there any concerns regarding this for clinical practice?

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...

How does this mutation compare to BRCA mutations in terms of risk and screening implications for family members?

If yes, would you still recommend dual HER2 directed therapy? After the TRYPHAENA trial, neoadjuvant therapy with dual HER2 directed therapy has beco...

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...

Given that DBA is associated with increased incidence of MDS, AML and other solid tumors, would this modify your treatment recommendations?

For early stage disease in a single breast, would you consider neoadjuvant chemotherapy or upfront surgical staging followed by adjuvant therapy? What...

Do you tailor treatment to a goal response?  Do you refer to data illustrating improved prognosis if the patient develops a CR or PR?

Provided the sternal lesion was low volume and treated with curative intent and patient has been on tamoxifen for < 5 years, would you switch to AI...

PIK3CA and ESR1 mutations on NGS without other targets and who has progressed on CDK 4/6 & AI and several single agent chemotherapies.  Aside...

Would you substitute the paclitaxel for an alternative agent or just abort chemotherapy? How might your plan change in ER+ or ER- patients?

Following SRS to the brain lesions, is it safe to closely follow the patient for recurrence?  

What advantages/disadvantages are there over OncotypeDx DCIS assay or traditional clinical pathologic factors? What other concerns do you have?

Tamoxifen prophylaxis has not been studied in women <35 years old, but it would be reasonable to assume they would benefit.

I have seen some advocate for this in the community, although a Cochrane metanalysis did not find an advantage to giving the taxane earlier.

In a patient with who had undergone neoadjuvant TCH-P, lumpectomy, and RT and is currently on AI, pertuzumab, and trastuzumab, how do you think about ...

In a patient with their second cancer, with oligometastatic disease, do the risks of RT related second malignancies outweigh the benefits?

Neratinib was studied following adjuvant trastuzumab. Do you extrapolate that data to give neratinib to patients who have received adjuvant T-DM1 inst...

The ABC trials (Blum, JCO, 2017) used six cycles of TC. Is it because of the superiority seen with TC x four cycles versus standard AC x four cycles (...

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...

Often patients are referred to medical oncology for adjuvant therapy for early stage breast cancer after BCS and just before starting radiation.

What techniques are most effective to minimize contralateral breast, heart, and lung dose? Do you recommend conventional fractionation?

The GeparSixto, CALGB 40603, and more recently Prospero support doing it; however, it is not currently endorsed by NCCN and the latter Prospero s...

She developed biopsy proven skin nodules while on paclitaxel. PDL-1 positive and BRCA negative. Would you consider atezolizumab with a different agent...

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...

She is otherwise asymptomatic and no LFT abnormalities. Would you switch to chemotherapy or offer different endocrine therapy?

Would you offer this patient chemotherapy? What are your thoughts about OFS plus AI and avoiding chemotherapy?

For example in a patient with a good performance status and a biologically favorable cancer (ER+ breast cancer, EGFR+ NSCLC, or prostate cancer), are ...

Do you follow invasive or DCIS guidelines? Would you consider re-excision in a patient with multifocal microinvasive carcinoma of the breast arising i...

Why do the NCCN guidelines suggest using neoadjuvant therapy only for patients with T2 or greater tumors?

 If so, would you treat as node + BC with  anthracycline and taxane regimen or   non-anthracycline regimen (i.e  docetaxel and cyc...

Patient defers chemotherapy. She is currently on anastrozole/Herceptin and perjeta with a response but it is suboptimal. I would like to add a CDK 4/6...

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...

Data was presented at ASCO in 2017 that abemaciclib has brain activity in HR positive breast cancer.

Most guidelines recommended adjuvant chemotherapy if tumor size was >3cm at the time of TAILOR Rx and patients with tumors >5cm were not include...

The use of neoadjuvant CDK 4/6 inhibitors is not standard of care, but there are clinical trials looking at this question and patients who are chemoth...

These devices give off a significant amount of artifact on CT and some devices say they are a relative contraindication with adjuvant RT.

AI+ CK4/6 inhibitor? Fulvestrant + CK4/6 inhibitor? AI + fulvestrant? AI + fulvestrant + CK4/6 inhibitor?

Do you use portal or orthogonal imaging or both?

Would you proceed with modified radical mastectomy followed by systemic therapy, or would you consider neoadjuvant therapy? Would biomarker status mat...

Does the presence of N1 disease push you towards offering chemotherapy or would you continue endocrine therapy based on the PR?

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

The woman was on on a GnRH agonist + AI due to her premenopausal status at diagnosis and now wants to know if she continues to need the GnRH agonist.&...

I know that many advocate using vaginal estrogen in this situation.  Most of the studies of vaginal estrogen in this situation have been small an...

If so, what clinical indications? Are there any advantages of VMAT? Thoughts on concerns regarding lung and heart dose constraints?

Some oncologists wait 1 day, 1 week or 1 month? Is there a preferred waiting period?

What size of DCIS would make you concerned? Would you estimate the risk of recurrence with and without radiation?

What's the minimum isodose coverage line you accept for coverage of higher level axillary lymph nodes?

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 ...

Does the T stage influence your decision (for example, T1mic)? Would multiple positive nodes showing isolated tumor cells sway your decision? 

Do you always recommend treating breast cancer patients with getting reconstruction with their tissue expanders in place? Or is there a scenerio you w...

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

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...

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 ...

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

NCCN gives category 2b recommendation for either ER+ or ER-, HER2+ tumors, from the Tolaney NEJM 2015 paper with trastuzumab/paclitaxel.  However...

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 ...

NCCN states that daily imaging is discouraged but in practice many radiation oncologists are doing daily cone beam for non-IMRT breast 

There have been case series published on this topic (most recently, PMID:26853347) with reported depigmentation within the RT treatment field.

Assume you have good margins and the cavity abuts the implant. Are there any specialized techniques that you would recommend?

In obese patients, would it make sense to switch from a GnRH agonist to an antagonist based on the data from the recent JCO study of dagrelix vs. trip...

Do you use NRG/RTOG, IMPORT LOW, single institution data, or retrospective data?

NCCN recommendations seem to mention these patients as not candidates for preoperative systemic therapy if the invasive carcinoma extension cannot be ...

What would be the optimal sequence of surgery, radiation, and chemotherapy for this patient? This patient has an excellent performance status and...

For example, a patient has had multiple dose reductions for neutropenia and required an admission for infection while on palbociclib. Would you switch...

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 ...

Clinical T1c patients were included in the KATHERINE trial that often are treated with adjuvant paclitaxel and trastuzumab

Is there a point at which there may be no benefit? More than 3 months from breast surgery? 6 months? 1 year?

Would you maintain dose density of chemotherapy and use peg-filgrastim prior to delivery of the baby? Would you defer taxane and anti-HER2 therapy unt...

If so, what would be the regimen that you would consider and what factors would sway you for or against chemotherapy for such patients?

The ABC trials show a DFS advantage of anthracycline-based regimens. Would age alone procure you from using it in a patient?

Specifically, any data or experience regarding Ehlers Danlos syndrome?

This patient is a young lady with stage IV ER/PR positive, Her2 negative with oligometastatic  breast cancer undergoing a planned bilateral oophe...

Can repeating Oncotype on a locoregional recurrence show a change in the biologic behavior of the cancer over time and guide treatment decisions?

The recurrence was 2 years after treatment with ddAC + T.  If you elect for systemic therapy after local therapy, what chemotherapy would you use...

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...

Would you recommend mastectomy? What would you irradiate?  What are your fields?

Updated NCCN guidelines say there is no data to support radiation for pleomorphic LCIS. Previous discussion recommended radiation for LCIS https:...

If planning standard fractionation, what factors would you consider in omitting a boost (ie age, LVSI, etc)? 

Is there a subset of patients for which you consider one regimen over the other (i.e. AC-THP v.TCHP)? If using an anthracycline regimen, do you u...

https://www.abstracts2view.com/sabcs18/view.php?nu=SABCS18L_568 Any concerns regarding toxicity with APBI?  

One such patient progressed through trastuzumab/pertuzumab/letrozole and TDM1 alone.  How would you combine ER+ approaches (eg CDK 4/6 inhibitor ...

Do your recommendations differ if patients are pre or postmenopausal given the data?

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...

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?

For instance, in stage III, would you use chemotherapy in neoadjuvant or adjuvant setting?  What regimen would you use?

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 ...

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...

And how long? According to the ABCSG-16 Trial there was no difference in extending AI beyond 2 years after an initial 5 years.  

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

Does the answer vary based on whether it is neo/adjuvant or metastatic setting?

Would you do anything different than usual regarding bolus, energies, skin dose desired for post-mastectomy chest wall radiation if a nipple-sparing m...

Is there concern for increased risk of chronic nipple pain with NAC in the boost field? 

One example is the original breast cancer ER high 90%, PR mod to high 40%, Her2 negative.  A liver metastasis diagnosed 2 years later showed ER l...

For example first-line ribociclib/letrozole, and second-line palbociclib/fulvestrant?  Without data, would there be any expected benefit?

The patient was previously treated with TAC x 6 (cumulative Adriamycin dose of 300 mg/m2) for a triple negative breast cancer. She is now with node-po...

 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...

OS benefit was limited to patients with endocrine sensitivity, defined as either a documented clinical benefit (CR, PR, or SD for ≥24 weeks) f...

Assume patient cannot do DIBH. Would techniques would you use to meet dose constraints? What minimum dose would you recommend?

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...

Assume patient is otherwise a suitable candidate.

If a patient has early stage disease with peau d'orange but does not meet criteria for inflammatory breast cancer, is PMRT indicated?

Does an age over 70 years, size, histology and hormone receptor status affect this decision? 

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 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...

The patient only had disease involving the right breast and axillary, cervical, and supraclavicular lymph nodes. She had complete response to with ddA...

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

There is a gray area in clinical decision making where the practice seems to be different for borderline size tumors such as a 7 mm lesion with no oth...

If yes, what dosage and do you use it continuously or intermittently? Regarding provera, many patients with ER/PR (+) breast cancer worry about taking...

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

Particularly for patients too large for prone breast treatment, do you use a breast immobilization device or bra?   Do you change your fractionat...

Assume your patient did not receive radiation upfront and they had an axillary dissection due to recurrence. Would you recommend radiation? What would...

Not to decrease recurrence risk, but for chemoprevention of new ER-positive DCIS or invasive disease based on the Gail Model. If so, is there data to ...

Other than when there are obvious contraindications to anthracycline, such as cardiac dysfunction, when do you use a non-anthracycline containing regi...

Any consideration on standard vs hypofractionation?

There has been shifting concerns with medication side effects (such as osteoporosis, blood clots), duration, and potential non-compliance.  

What volumes and dose would you treat? Would you treat the regional nodes alone (including IMN)? Would you treat the chest wall?

The patient is a pre-menopausal woman with low-grade, stage I IDC who initially could only tolerate 10 mg of tamoxifen for her first year of trea...

Young woman with Her2 positive disease involving her right breast, regional lymph nodes, and liver had a CR on PET after therapy with THP and now plan...

The NEJM 2015 paper by Tolaney et al only included 1.5% of patients with micrometastases.

If a patient has ER/PR+ and Her2 positive disease in the primary tumor while axillary lymph node core biopsy is ER/PR+ Her-2 negative, do you man...

Would you consider traditional breast doses or higher? Would you consider treating only the axilla if the mastectomy specimen showed widely-negative m...

In a patient treated over 10 years ago with mastectomy and chemo now with recurrence in the ipislateral axilla, would you offer additional with chemot...

If a patient previously received taxane-based chemotherapy for ER/PR+ Her2 negative disease three years ago, is additional chemotherapy recommended at...

Specifically, this patient had a new left lacrimal gland metastatic lesion that developed four years from her initial diagnosis and is currently under...

Would you do this for ER+ patients? According to the PERSEPHONE trial presented on ASCO 2018, in HER2+, non-metastatic breast cancer, 6 months Hercep...

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 ...

Would you give neoadjuvant chemotherapy in a patient with T1 N1 M0 ER/HER-2 positive cancer if they are candidates for upfront lumpectomy?

Does it make sense to resect only the axillary nodes, but not the other involved nodal regions?  Regional nodal radiation will be given.  

If there is no response to neoadjuvant AC -->T, would you offer additional adjuvant chemotherapy?

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

High enough risk to justify anthracycline+taxane chemotherapy followed by ovarian suppression + aromatase inhibition.

Many times we encounter patients who do not have a tissue sample readily available or in whom obtaining such a sample would be hard. On a more molecul...

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...

The PERSEPHONE trial to be presented at ASCO suggests 6 months of Herceptin is non-inferior to 12 months in early Her2 postive disease.

What if this was an electron vs photon boost? What fractionation scheme would you use?

With studies showing non inferiority to zoledronic acid q 3 months in support of bone metastatic disease, would you consider extrapolating this data a...

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...

Has the publication of the recent EBCTCG metaanalysis changed your practice?

Is breast conserving surgery followed by radiation therapy an option? 

What is the optimal regimen for a pre-menopausal female with progression of ER+,PR+ and Her2 neu negative breast cancer while on tamoxifen for six mon...

The patient initially had a great response to THP for four months, but now with quite a bit of lung, pleural, and nodal involvement.

Do you offer additional adjuvant chemotherapy, proceed to adjuvant endocrine therapy, or search for a suitable clinical trial?

Intramammary lymph node involvement has been shown to have a poorer prognosis (Hogan, Surg Onc, 2010). Would Oncotype be useful in these patients...

Inflammatory breast cancer is a contraindication for immediate reconstruction at the time of surgery, but is there a disease free interval after all t...

Knowing that the analysis now is more detailed than it was 10 years ago. What about non-Ashkenazi Jewish breast cancer patients with suspic...

While we await the results of TailorX, what has been the experience in your practice? If the decision for adjuvant chemotherapy is made, do you f...

Patient does not qualify for breast cancer screening by annual MRI per criteria (IBIS lifetime risk<20%, no known genetic predisposition,...

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...

After the publication of ACOSOG Z11 we are seeing these patients in increasing numbers.

Originally received anthracycline and taxane based regimen.  Would you use carbo/paclitaxel or capecitabine or a different approach?

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...

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?

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...

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

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

When would you omit or include a boost for DCIS after whole breat irradiation?

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...

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 calculation algorithm to you utilize (eg AAA, Acuros, etc)? Do you prefer a particular algorithm for certain sites? Do you take in...

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

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.  As...

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...

Is there a difference among all the commercial genetic testing labs? Is there anything beyond CLIA- and CAP-certification that we should look for...

After mastectomy for the locally recurrent disease, would you consider "pseudo-adjuvant" chemotherapy for local recurrence per the CALOR trial? If so,...

Can you apply the ACOSOG Z0011 study to women who have HER2 positive disease?  

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

Assuming the patient has N2-3 disease, would you consider omitting IMN? What other techniques would you consider to limit lung exposure?

Recent NEJM study showed an increased breast cancer relative risk in longer durations of hormonal contraceptive use that could last up to 5 years. Pre...

An article (BRCA mutation and outcome in BC. Ellen Copson, et al. Lancet Oncol. 2018) showed G3, BRCA+ breast cancer had poorer prognos...

http://www.nejm.org/doi/full/10.1056/NEJMoa1612645?rss=searchAndBrowse&#article_abstract If so, how do you sequence it with adjuvant radiotherapy...

Pt has progressed on AI and Faslodex. Goal is radiation to axilla as a palliative intent and Capecitabine to control systemic disease. 

Are you using post-neoadjuvant Xeloda based on preliminary data from the CREATE-X trial? Does BRCA mutation influence your decision?

Is there a dose constraint you are using for LV-V5? https://www.ncbi.nlm.nih.gov/pubmed/28095159?dopt=Abstract

At what point would you decide to forego local control managment (RT or mastectomy) in favor of chemotherapy alone?

If so, when? Are there certain ERBB2 mutations that would predict response to trastuzumab and/or neratinib? 

Following the dosage guidelines based on absolute neutrophil count may cause the patient to end up receiving lower doses.

Would you consider using CKD inhibitors upfront in triple positive breast cancer previously treated with chemotherapy, endocrine therapy, and Hercepti...

This is in regards to the risk of secondary cancers after radiation therapy or cytotoxic chemotherapy (such as anthracyclines) in an immunosuppre...

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...

CALGB 9343 included ER positive patients but did not separate them out based on herceptin status. Does the study help inform their risk?

Would you try to treat the single met with radiation and then treat it as locally advanced breast cancer?

Would you recommend any imaging of the axilla before lumpectomy? Would you recommend standard breast fields vs high tangents to cover the lo...

Would you treat with 1st line AI/CDK inhibitor if patient is only low or moderately ER positive? ( example between 1-30%)

Assuming the patient was initially treated with surgical resection and adjuvant chemotherapy followed by radiation and appropriate endocrine therapy.

What do you do with low grade (grade 1/3) tumors? In other words, does high grade pathology over rules?

Assume the patient had no radiation, what would your volumes be? Would you recommend radiation if the patient had whole breast/chest wall radiati...

In light of two phase III randomized trials showing duloxetine (S1202) and acupuncture (S1200) both improve AIMSS, which would you try first? Wou...

Would the exact Oncotype score guide your decision (ie closer 25-30 v. >30-35)? NCCN recommends Oncotype only for tumor size < 5mm but this case...

When do you institute a treatment break for skin reaction for patients who receive breast radiation?

If Oncotype is high risk, what regimen of adjuvant chemotherapy would you recommend?

Would you use a regimen with lower incidence of neurotoxicity such as CMF or a taxane-based regimen with a low threshold to dose-reduce?

There is anecdotal concern regarding history of estrogen replacement therapy causing stimulation of breast tissue and therefore potentially increased ...

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 using ckd inhibitors in triple positive breast cancer previously treated with chemotherapy, endocrine therapy, and Herceptin? NCCN ...

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...

Do you use the typical indications for PMRT (nodal status, size of primary, LVSI, age, etc)?  Or,  do you recommended PMRT more frequently (...

How do you approach treating ER/PR positive/HER-2 positive metastatic breast cancer? Do you combine hormonal therapy / chemotherapy and HER-2 directed...

When would you recommend that SLNB be performed prior to neoadjuvant chemotherapy? When would you recommend additional staging (completion axillary di...

We often treat elderly women with lumpectomy and adjuvant hormonal therapy without radiation. I am concerned about how to proceed after the 5 year poi...

Many women are distressed when asked to discontinue hormone replacement therapy or use intravaginal estrogen suppositories.

Some patients request chemotherapy scheduling adjustments to avoid feeling ill on major holidays. Delaying chemotherapy by a few days isn't of particu...

Example case: Patient given neoadjuvant docetaxel + cyclophophamide achieves a partial response after 3 cycles of Taxotere + cyclophosphamide but is u...

Would you treat the regional nodes alone (not previously irradiated) or would you also re-treat the breast/chest wall?

Are results of BCIRG-006 trial applicable for patients with triple positive breast cancer or only for those with HER2+? 

What factors would help you make your decision? (Age, genetics of lung or breast cancer, triple negative, LVSI, T2, etc?)

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...

And does the fact that the breast is lactating affect radiation toxicity in anyway?

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...

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

When trying to eliminate dose heterogeneity during field in field planning for hypofractionated breast radiation with a large separation, the resultin...

Tamoxifen prophylaxis is FDA-approved, but would you extrapolate from adjuvant/metatastic data for hormone receptor positive breast cancer in post-men...

In the absence of data demonstrating a clinical benefit for one strategy versus the other, what do you do in practice?  

Should one consider use of PARP inhibitor in a patient with metastatic triple negative breast cancer and finding of a somatic PALB2 mutation on genomi...

Given the data noting predictive benefit of utilizing genomic testing in predicting later relapse of hormone receptor positive breast cancer.

Being that there is limited data on CNS penetration with either regimen, what would you prefer in a patient who already received whole brain RT?

The FDA recently approved neratinib based on data from the ExteNET trial; however, benefit appears modest and the risk of toxicity is not low.

Do you have a cutoff in terms of tumor size, number of LN, Oncotype score, etc that makes you choose lower vs higher intensity chemo?

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...

There is limited data that suggests steroidal AI exemestane could be of some benefit after nonsteroidal AI failure (Lonning PE et al. J Clin Oncol 200...

Is the risk of IBRT any greater than in non mutation carriers?

Does neoadjuvant chemotherapy with complete response in the axilla alter your management preferences?

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? ...

I.e. either for treatment of high-risk disease or intolerance/contraindication to tamoxifen. Will you continue it for the full 5 year course?

Aside from local therapies (intrathecal, radiation), are there therapies that are known to have better CNS penetration?

Assume good compliance with oral therapy, equivalent access to either agent, no contraindictions to either therapy, and absence of any visceral crisis...

Do you reserve this approach for only women with triple negative breast cancer or all-comers?

For example, does a higher recurrence score influence your choice of TC versus AC-T?  Or your choice to add ovarian suppression to a premenopausa...

What would you choose if there is no response to neoadjuvant AC-T? Taxol, THP, TCHP?

Do you prefer neoadjuvant chemotherapy or proceeding directly to surgery, followed by adjuvant therapy?  Which chemotherapy regimen do you recomm...

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...

Assuming cytotoxic chemotherapy is given, would you still then proceed with adjuvant endocrine therapy?  Would you switch agents or classes of en...

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...

(For instance, TCX4 instead of AC->T for smaller tumors?)Does this affect your decision about treating with neoadjuvant versus adjuvant chemotherap...

Do you prefer this approach based on the FALCON trial showing improved PFS with frontline fulvestrant?

Do you extrapolate the results of OPTIMIZE-2 and CALGB 70604 showing that an every 12 week dosing of zolendronic acid is noninferior to ever...

Do you attempt to have the pacemaker moved? If the patient is non-dependent, would you ever treat with the pacemaker in field?

Is there a select patient population that you use it for? Is it also being used in cancers other than breast cancer?

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 ...

There are many options to choose from, including large gene panels with up to 80 genes at the same cost as BRCA 1/2 testing, while others offer j...

Is there a role for routine use of additional or alternative imaging modalities for these patients, such as tomosynthesis, MRI, or ultrasound?  I...

Some medical oncologists tend to hold anticoagulation in patients who develop brain metastases for fear of causing intracranial hemorrhage.  Is t...

Are there differences between palbociclib and ribociclib?  What would make you choose one over the other?

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...

Is there any role for aromatase inhibitors?  What duration of therapy do you recommend?

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...

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...

For example, if a post-menopausal patient is treated in the first line setting with docetaxel, herceptin, and perjeta, would you add an aromatase...

At what point do you send these test, and in what instances do the results influence your treatment recommendations?

If so, how do you counsel patients who are node positive with low or intermediate risk scores? How do you interpret the existing data? NCCN and ASCO g...

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)?

In a patient who underwent lumpectomy for presumed DCIS and was found to have a focus of invasive triple negative disease, would you offer chemotherap...

Is a monthly schedule x 1 year, followed by q3 months, now the the standard of care, as per the recently published OPTIMIZE-2 trial? 

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...

What tumor or patient characteristics lead you to consider the use of neoadjuvant hormonal therapy without chemotherapy?

This is rarely done, but recently came up in a tumor board discussion.  Which chemotherapy would you consider using, and when?

Do you ever use BID fractionation?  What patient factors do you use to individualize the treatment?

How many intercostal spaces do you include? Do you vary these parameters based on the disease characteristics?

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...

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...

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

Do you consider placing an Ommaya for IT chemo with methotrexate or cytarabine? Knowing that leptomeningeal carcinomatosis carries such...

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...

The CALOR study showed a benefit of adjuvant chemotherapy for local recurrence but the regimens given were "physicians choice".

How do you counsel them on risk in the curative setting?  Do you approach treatment in the metastatic setting any different than patients with &g...

What are indications for adjuvant radiation for a early stage well differentiated adenosquamous carcinoma of the breast? What is the best radiation th...

Does switching AIs help?  If so, is there a role for switching from a steroidal AI to a non-steroidal AI or vice versa?  Are there other adj...

Based on results from PALOMA1 and recently reported MONALEESA2, do you use a CDK4/6 inhibitor as initial therapy?  In what circumstances would yo...

What factors in particular guide your recommendation of PMRT for invasive lobular carcinoma?

Would your management change if including the drain sites requiree treating more lung or adding separate electron fields?

What factors do you consider when offering PMRT? Would you change your dose/fx and/or field size?

The results of the 70 gene panel Mammaprint in combination with Adjuvant! Online were published in NEJM recently. How will you incorporate this data i...

Do you ever consider de-escalating or stopping therapy in this situation? What is your approach to this conversation?

The MA17R trial only included "postmenopausal women" so how do you make a decision for men and pre-menopausal women.

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...

What about in cases of a tunneled lumpectomy cavity using a circumareolar incision?

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...

Do you use cytotoxic chemotherapy as first line or hormonally-targeted therapy such as letrozole + palbociclib?

Based on the CALOR trial (http://www.ncbi.nlm.nih.gov/pubmed/24439313), adjuvant chemotherapy should be considered, but what regimen is preferred?&nbs...

What factors do you consider when adding post-lumpectomy radiation therapy for treatment of an intracystic papillary carcinoma?

Randomized trials in the 1980s demonstrated equivalent survival and disease control outcomes for lumpectomy + RT vs mastectomy, but several recent pop...

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?

Do you prioritize certain dosimetric parameters over others (e.g., considering the Darby report, mean dose to the heart vs. mean LAD dose?)  

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...

The recently published MA.17R trial showed a DFS benefit for extending AI therapy to 10 years in post-menopausal women.

A recent publication of the TEXT and SOFT trials http://www.ncbi.nlm.nih.gov/pubmed/27044936 showed an improvement in breast cancer-fre...

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...

Should patients be managed similar to BRCA patients and consider bilateral mastectomies as an alternative to BCT?

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

Comparison of prone versus supine positioning showed that 85% of patients with left sided breast cancer benefit more from the prone versus supine posi...

Since we know that both the "Canadian" fractionation and partial breast irradiation work as treatment for early stage breast cancer in the same patien...

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...

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...

Would this be considered acceptable in an older woman with high grade disease?

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...

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...

If not, do you have any experience with acceptable late toxicity and cosmesis with whole breast radiation in these patients?

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...

Can the IMNs ever be spared, or would you consider it mandatory for all inflammatory breast cancers?

E.g. breast? I have found no literature on skin tolerance acutely or chronically.

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

Are there any clinical or pathologic factors that lean you towards or away from giving trastuzumab?

Our Radiation Safety officer reports a higher radiation dose to the patient from the two scans vs the PET.

Is your decision influenced by factors such as the location of the intramammary nodes and/or the mapping of sentinel nodes to the axilla?

I sometimes receive pathology reports that state the margin is negative but do not quantify DCIS proximity to margin. I typically like a margin of 2-3...

There seem to be good prospective studies (Australian study and Canadian study) which debunk the thought that deodorants/antiperspirants increase skin...

If the patient has no pathologic risk factors that would ordinarily necessitate PMRT, do you omit it? Does triple negative subtype affect your decisio...

Would the risk of radiation-induced second malignancy outweigh the benefit of locoregional control for a young patient with high grade DCIS? 

Do you have any concern for increased toxicity when you treat a patient with radiation therapy who has an autoimmune disorder? (hypofractiationation v...

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

Do you look at pretreatment breast MRI or post surgical assessment of the tumor bed/treatment effect?  How would you resolve discrepancies betwee...

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...

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...

I have heard of long term pentoxifylline and Vitamin E daily combination that can prevent and even reverse radiation fibrosis (Delanian et al. JCO 200...

Would extensive residual DCIS (>5cm), hormone receptor negativity, Her2+ status, or age < 40 effect your decision?

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  ...

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...

If so, how do you decide which patients to treat with breath hold vs. free breathing? Do you routinely perform 4D CTs? 

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...

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...

The 2013 ASCO guidelines and current NCCN guidelines recommend yearly mammograms but our radiologists are still recommending mammograms every 6 m...

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...

They used to be given concomitantly now they are done sequentially.  I can only find conflicting data to justify this trend.

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?

If so, do you do this routinely or only in certain circumstances? Is there data to support routine mammogram before 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...

Or for that matter, offer PMRT on the basis of a patient having triple negative disease?

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...

I'm not sure how to interpret the results of the study published in JNCI earlier this year.

My institution is considering a major investment/purchase of this technology to complement our existing array of breast radiotherapy options.

Has the recent 12-year ECOG update for surgical excision of DCIS without radiation therapy changed your practice management?


Papers discussed in this category


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Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 2015-11-20

The New England journal of medicine, 2013-03-14

International journal of radiation oncology, biology, physics, 2010-07-15

Annals of surgical oncology, 2013-10

Lancet (London, England), 2014-02-15

Brachytherapy, 2014

Lancet Oncol., 2013-12-01

Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 2013-07-01

International journal of radiation oncology, biology, physics, 2006-12-01

Journal of the National Cancer Institute, 2013-05-15

Lancet Oncol., 2013-04-01

The Lancet. Oncology, 2008-04

Lancet (London, England), 2008-03-29

Lancet Oncol., 2013-10-01

Radiology, 2012-08

JAMA, 2011-02-09

Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 2014-11-10

Lancet Oncol., 2014-11-01

Lancet (London, England), 2014-06-21

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N. Engl. J. Med., 1997-10-02

Lancet, 1999-05-15

Radiother Oncol, 2007-03-01

Int J Radiat Oncol Biol Phys, 2009 Jul 15

International journal of radiation oncology, biology, physics, 1990-10

Plastic and reconstructive surgery, 2011-06

Plastic and reconstructive surgery, 2012-09

Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 2014-07-10

Annals of oncology : official journal of the European Society for Medical Oncology, 2011-11

N Engl J Med, 2015 Jan 8

Radiother Oncol, 2001-03-01

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Radiother Oncol, 2014-01-01

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International journal of radiation oncology, biology, physics, 2013-03-15

International journal of radiation oncology, biology, physics, 2011-05-01

International journal of radiation oncology, biology, physics, 2011-11-01

Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 2014-02-20

Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 2009-01-01

J Clin Oncol, 2003 Feb 1

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The New England journal of medicine, 2015-02-19

Ann. Oncol., 2014-05-01

Radiother Oncol, 2012-12-01

The New England journal of medicine, 2002-08-22

J. Clin. Oncol., 2004-01-01

Lancet Oncol., 2012-04-01

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International journal of radiation oncology, biology, physics, 2012-06-01

Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 2014-05-10

Lancet Oncol., 2015-01-01

Radiother Oncol, 2009-01-01

The breast journal, 2011

International journal of radiation oncology, biology, physics, 2011-09-01

International journal of radiation oncology, biology, physics, 2004-12-01

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N. Engl. J. Med.,

Radiother Oncol, 2017 Nov 15

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Practical radiation oncology, 2018

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Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 2006-08-20

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Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 2013-03-01

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Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 2009-10-20

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J. Clin. Oncol., 2016-12-20

Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 2001-03-01

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J Clin Oncol, 2006 Mar 1

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Brachytherapy, 2011

The Lancet. Oncology, 2014-02

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Lancet (London, England), 2014-07-12

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International journal of radiation oncology, biology, physics, 2012-11-15

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International journal of radiation oncology, biology, physics, 2012-11-01

Eur. J. Cancer, 2015-03-01

International journal of radiation oncology, biology, physics, 2016-03-01

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N. Engl. J. Med., 2004-09-02

European journal of cancer (Oxford, England : 1990), 2013-07

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Radiation oncology (London, England), 2012-09-24

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Cancer discovery, 2016-07

Clinical breast cancer, 2010-12-01

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The breast journal, 1999-01

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International journal of radiation oncology, biology, physics, 2006-02-01

Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 2003-03-15

Journal of the National Cancer Institute, 2001-12-05

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Lancet, 2007-05-19

Nat. Med.,

Lancet (London, England), 2016-12-17

Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 2018-02-01

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Clinical breast cancer, 2006-12

Lancet (London, England), 2014-03-22

The New England journal of medicine, 2011-06-23

Journal of the National Cancer Institute, 2005-09-07

Breast cancer research and treatment, 2010-12

International journal of radiation oncology, biology, physics, 2012-08-01

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Breast, 2015-06-01

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Int. J. Radiat. Oncol. Biol. Phys., 1990-11-01

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ESMO Open, 2016-01-01

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Oncologist, 2007-09-01

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Medicine and science in sports and exercise, 2010-07

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Zhonghua Zhong Liu Za Zhi, 2016-07-01

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Int. J. Radiat. Oncol. Biol. Phys., 2017-11-15

Breast cancer research and treatment, 2009-03

Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 2011-07-20

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