FoRTitude.

Ah, lymphoma, where we are always left with a value judgment of data interpretation. This cross sectional look at Medicare beneficiaries receiving radiation alone for any diagnosis of lymphoma aimed to provide some guesswork on trends of care for either definitive radiation for indolent (probably follicular) lymphoma or palliative radiation for any lymphoma—the only common indications for radiation without chemo. Importantly, it excluded the sickest patients who failed to live >90 days from treatment in an attempt to exclude more aggressive lymphomas but surely also excluding the worst performance statuses. It also includes an unknown number of non-chemo candidates receiving definitive radiation for more aggressive lymphomas, where the recommended dose is 45-50 Gy in ≤2 Gy per fraction. Most (70%) received over 10 fractions, which the authors see as too many. Granted, that is too many for straight-up palliation. But it also rekindles the discussion on the appropriate “definitive” dose for follicular lymphoma: 2 or 12 fractions? Where some (read: NCCN guidelines) view FoRT as demonstrating 1 in 5 patients will be spared (safe) retreatment at 5 years with 24 Gy in 12 fractions, others (read: the authors) emphasize the need to find “balance between local control, patient treatment-related burden, and health care spending.” | Tringale, JAMA Health Forum 2022