Written in the stars.

The plethora of data on hypofractionated radiation in the setting of breast conservation has led to sweeping changes in practice guidelines in recent years. Too bad the same caliber of data doesn’t yet exist for those undergoing mastectomy. This commentary on the recent publication of the Wang trial synthesizes what we know so far, as well as what we continue the theorize. Reassuring is the equivalent number of local failures with either regimen, working to debunk the theory that high-risk disease may not been as amenable to hypofractionation. Also promising are the equally-low rates of toxicity. Though this theoretically may play out differently with regional nodal coverage, it didn’t seem to in such a subset of the START-A and B trials. Most promising, skin toxicity was actually less with hypofractionation, in line with what’s seen in breast conservation. TBL: All signs point to go with post-mastectomy hypofractionation, but it’s not wrong to diligently wait for more diverse phase 3 trials. | Jagsi, Lancet Oncol 2019