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The radiation oncologists apologetically informed us that they would not be able to offer my wife Paula a sixth week of treatment — a “boost” therapy aimed at the place where her breast cancer had resided before she received her lumpectomy. This tumor bed was no longer localizable, because Paula had received immediate reconstruction that had obscured its location. I was aghast. Although Paula would receive 5 weeks of whole-breast irradiation, she would not receive the benefits of that final week of treatment, the boost therapy that, according to National Comprehensive Cancer Network (NCCN) guidelines, is “recommended” for women like Paula, whose breast cancer is diagnosed before they are 50 years of age and who have axillary involvement.1
After the radiation oncology appointment, I obtained the main clinical trial that had established the value of boost therapy2 and looked for the survival curves that corresponded to the size and location of Paula's tumor. I could see how much boost therapy would have reduced her chance of local recurrence. But I could also see the downside of this treatment, which increased the risk of breast fibrosis. It made me wonder: how did the NCCN come to so definitively recommend boost therapy for women like my wife?
A couple of years later, I stood in front of an audience of radiation oncologists, presenting a lecture on shared decision making. I asked them to imagine that they faced a choice between two types of radiation therapy for early-stage breast cancer. The first treatment would leave them with a 15% chance of local recurrence and a 10% chance of moderate or severe breast fibrosis. The second treatment would leave them with only an 8% chance of local recurrence but a...