Breast Cancer&nbsp;&nbsp;&nbsp;

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?

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

Z 0011 population, cN0 with 1-2 SLN involvement with low likelihood for additional non SLN metastases?

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

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...

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

How are you using DCISionRT (PreludeDx) in the management of DCIS?

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

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...

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?

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?

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?

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.

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 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...

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?

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 ...

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

For example, ultra-hypofractionated whole breast RT?

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?

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?

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...

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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?

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 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?

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?

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 beast 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. Gringas 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...

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

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?

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...

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?

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?

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 ...

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...

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

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?

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?

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?

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?

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?

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...

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?

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 b...

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?

Would you recommend PMRT for a patient with a right breast mastectomy with closest margin less than 0.1cm?

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 offer partial breast irradiation to women who have HER2+ disease?

If so, do you give RT before or after adjuvant chemotherapy?

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?

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?

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?

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...

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.

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...

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 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?

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

Would you consider an axillary dissection in a young patient with high grade breast cancer and one sentinel LN with isolated tumor cells?

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

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)?

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?

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?

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?

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

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)?

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

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?

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...

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?

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

Assume no nodal involvement.

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?

Would you recommend hypofractionated PMRT with a positive deep margin?

How would you dose?

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?

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?

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?

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 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?

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...

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 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 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?

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

7 Answers available

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 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?

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 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?

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 ...

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

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.

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?

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.

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 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 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.

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

Assume patient is otherwise a suitable candidate.

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?

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.

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?

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

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 case of T1N0 breast cancer advising patient to n...

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?

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

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?

Should axillary imaging be routinely performed in all patients with a new diagnosis of 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.

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, ulcerated breast.

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.

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...

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

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 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...

When is it necessary to boost the chest wall scar post-mastectomy?

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

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

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?

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

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.

7 Answers available

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 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 hypofractionate breast cancer patients with >25 cm separation?

Do you boost when employing this regimen?

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?

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 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...

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...

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...

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 ...

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

NSABP B51 and B52 specifically prohibit this.

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. As...

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?

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?

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?

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?

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

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 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...

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?

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?

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...

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

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?

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

What would you consider when thinking about your boost?

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?

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?

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?

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

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 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?

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

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?

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 ...

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...

When do you use IMRT in breast radiotherapy?

Do you also use DIBH in these cases?

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?

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)?

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?

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...

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?

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

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

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 ...

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.

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.

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 have a margin requirement beyond negative for DCIS when considering observation following lumpectomy?

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...

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...

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?

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...

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. JCO 200...

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...

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

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.

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?

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.

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

Do you deflate to a specific volume?

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

No tumor at ink? 1-2mm?

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?