{"entity":{"id":"idea-prev-omit-radiotherapy-low-risk-breast-default","kind":"idea","name":"Make skipping radiotherapy the default for very low-risk breast cancer","aka":[],"tldr":"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.","summary":"LUMINA, PRIME II and IDEA show low local recurrence without radiotherapy in luminal A breast tumours in older women, yet most still receive it, so this idea makes omission the default pathway, with PAM50 genomic confirmation where needed, and tracks it as a quality metric. The evidence exists; the barrier is inertia and fee-for-service incentives, so payers would measure omission rate and five-year local recurrence. The test is a stepped-wedge implementation across cancer centres with registry follow-up. Being tested at scale, it addresses the bottlenecks Overdiagnosis and false alarms, Toxicity and quality of life are undervalued and Incentives reward me-too drugs and marginal gains.","asOf":"2026-09-08","links":[{"label":"Bottleneck evidence (Overdiagnosis and false alarms): Welch & Black, Overdiagnosis in cancer (JNCI 2010)","url":"https://doi.org/10.1093/jnci/djq099"}],"tags":[],"related":[],"cancers":["breast-hr-positive"],"sections":["radiation"],"technologies":[],"targets":[],"drugs":[],"companies":[],"institutions":[],"pathways":[],"terms":["pam50"],"trials":[],"people":[],"bottlenecks":["b-overdiagnosis","b-toxicity-qol","b-incentive-misalignment"],"keyPapers":["paper-welch-j-natl-cancer-inst"],"journals":[],"dependsOn":[],"notes":[],"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.","test":"Stepped-wedge implementation across cancer centres with registry follow-up.","maturity":"being-tested-at-scale","actor":"payer","cost":"small","horizonYears":4},"route":"/ideas/idea-prev-omit-radiotherapy-low-risk-breast-default/","neighbours":{"cancer":[{"id":"breast-hr-positive","kind":"cancer","name":"HR-positive / HER2-negative breast cancer","route":"/cancers/breast-hr-positive/"}],"section":[{"id":"radiation","kind":"section","name":"Radiation Therapy","route":"/fronts/radiation/"}],"term":[{"id":"pam50","kind":"term","name":"PAM50 / intrinsic subtypes","route":"/terms/pam50/"}],"bottleneck":[{"id":"b-incentive-misalignment","kind":"bottleneck","name":"Incentives reward me-too drugs and marginal gains","route":"/bottlenecks/b-incentive-misalignment/"},{"id":"b-overdiagnosis","kind":"bottleneck","name":"Overdiagnosis and false alarms","route":"/bottlenecks/b-overdiagnosis/"},{"id":"b-toxicity-qol","kind":"bottleneck","name":"Toxicity and quality of life are undervalued","route":"/bottlenecks/b-toxicity-qol/"}],"paper":[{"id":"paper-welch-j-natl-cancer-inst","kind":"paper","name":"Overdiagnosis in cancer","route":"/key-papers/paper-welch-j-natl-cancer-inst/"}]}}