ideasIdea
Make skipping radiotherapy the default for very low-risk breast cancer
Trials show older women with the lowest-risk breast cancers gain almost nothing from radiotherapy after lumpectomy. Yet most still get it. Track and reward omission.
LUMINA, PRIME II, and IDEA show low local recurrence without radiotherapy in luminal A tumours in women over 55-65. Propose a quality metric and default-omission pathway (with genomic confirmation where needed), with omission rate and five-year local recurrence as measures.
Hypothesis
A default-omission pathway raises radiotherapy omission from about 20% to at least 60% of eligible patients with five-year local recurrence of 3% or less.
Rationale
The evidence exists; the barrier is inertia and fee-for-service incentives.
What would test it
Stepped-wedge implementation across cancer centres with registry follow-up.
Maturity
being tested at scale
Who has to act
payer
Cost to try
Small (under $1M)
Years to first evidence
4
Bottlenecks it attacks
- Overdiagnosis and false alarms · Finding more cancer is not the same as saving lives. Screening also finds cancers that would never have hurt anyone, and treats them.
- Toxicity and quality of life are undervalued · Trials measure how long people live, not how they live. Side-effects are under-reported and under-treated.
- Incentives reward me-too drugs and marginal gains · The system pays the same for a drug that adds two months as for a cure, so companies race to copy rather than to cure.