The decision about whether or not you require radiation therapy is based in part on whether or not you previously received radiation, and if so, what dose of radiation was delivered and when. The reason for this is that there are certain doses of radiation that are considered safe to give to the breast, and the details of your previous treatment would dictate whether or not radiation would be a part of your treatment plan.
In general, radiation therapy is a part of the standard treatment for women with inflammatory breast cancer, and I would advise you to make an appointment to see a radiation oncologist to have her review your previous and current oncologic records to decide if radiation can be delivered safely. Because inflammatory breast cancer can be aggressive, it is important to expedite visits with all of the oncologists involved in your care.
At our institution, we have had very good rates of tumor control treating patients with inflammatory breast cancer with a more intensive radiation regimen involving twice daily treatments for approximately 4 weeks. Because of the general rarity of inflammatory breast cancer, I would advise any patient with this diagnosis to be seen at a cancer center that is familiar with this particular disease, as there are nuances in the treatment technique (ie; ensuring that the skin is sufficiently targeted with radiation dose) that are different from what we typically offer as radiation oncologists to women with other forms of breast cancer.
I evaluate all of my patients after surgery, once the final pathology report has returned, with a CT scan of the breast. The purpose of this is for me to assess the geometry of the lumpectomy cavity and to communicate this with the breast surgeon in order to pick the best brachytherapy catheter.
Later that same day, the patient will be seen by the breast surgeon and have the catheter placed in the office with local anesthetic. The surgeon uses a hand-held ultrasound to help guide the catheter into the appropriate position. Patients are typically prescribed antibiotics by the surgeon at this time, in order to decrease the risk of infection while the catheter is in place.
The following day, the patient returns to see me and I perform another CT scan of the breast with the device in place. I draw marks on the patient’s skin to help with verifying the correct alignment of the device before each treatment. I also measure the length of the catheter protruding from the patient’s breast. The medical physicist also takes measurements of the catheter. X-ray images are also taken of the device with the patient in the treatment position on this day and before each treatment, again to confirm the correct configuration of the device with respect to the patient’s anatomy. The patient then goes home while I work with a medical physicist to prepare a plan that is optimized to meet her unique anatomical needs.
The following day, the patient returns for treatment. Two treatments are given per day, each with a 6 hour time gap between the treatments, typically with one treatment given in the morning and the second one in the afternoon. Before each treatment, I verify the positioning of the device using both the original marks drawn on the skin, a measurement of the catheter, and x-ray images. Treatments typically last anywhere from 2-10 minutes. After a patient receives treatment, one of our nurses assists her with dressings of the catheter. On the last day of treatment, I remove the catheter, typically with local anesthetic. The incision site is closed with bandages and no stitches are needed.
Accelerated partial breast irradiation is most commonly delivered twice daily for five business days (Monday through Friday). There are other treatment regimens, particularly offered in other countries, that range from one treatment at the time of surgery (intraoperative radiation) to up to fifteen once daily treatments (Monday through Friday).
I evaluate all of my patients who are interested in receiving APBI with a CT (computed tomography) scan of the breast prior to deciding which brachytherapy catheter to use. I take measurements of the lumpectomy cavity, the area of the breast where the tumor used to be that was removed by the surgeon. This cavity typically fills with fluid and air following surgery and is usually easy to visualize on the CT scan. Based on the measurements of the cavity and the dimensions of the three different catheters (the SAVI, Contura and MammoSite), I decide which device would best target the area based on its unique geometry. The catheters have unique characteristics, such as a vacuum port to remove trapped air and catheters that are either within a balloon or directly abutting the breast tissue, all of which provide for certain advantages depending on the clinical situation.
I personally do not offer patients multicatheter interstitial brachytherapy at this time, because it is not a technique with which I and my physics staff have frequent enough usage to be able to provide a high quality program to patients. However, in medical centers where interstitial brachytherapy is offered frequently, with staff that have a high degree of expertise, this technique has the advantage of being able to adapt the most to each patient’s unique anatomy.
A breast cancer patient should at a minimum see a radiation oncologist following surgery, in order to find out if radiation therapy is needed.
If a patient with early stage breast cancer is debating between treatment with mastectomy versus lumpectomy plus radiation therapy, it is helpful to meet with a radiation oncologist before surgery. The radiation oncologist can then describe to the patient what is involved with daily radiation treatments and the anticipated side effects. It is important that when patients make a decision regarding the type of surgical treatment they want to receive that they understand that this oftentimes influences whether or not they will need radiation therapy.
For women with more advanced breast cancer that will require a mastectomy, it is helpful to meet with a radiation oncologist before surgery, in order to discuss the coordination of reconstruction (ie; plastic surgery) with radiation therapy. Certain forms of reconstruction withstand radiation better than others, and as a radiation oncologist. A balance must be made between expediting a good cosmetic outcome and obtaining maximum tumor control.
APBI refers to radiation treatment focused to part of the breast given over an accelerated time course compared to the standard 6 week treatment delivered to the whole breast irradiation. Brachytherapy is one modality by which APBI can be delivered. APBI can also be delivered using high energy megavoltage x-rays and electrons, which are the standard external beam form of delivering radiation therapy. APBI can also be delivered using protons, which are available at a few facilities in the United States. Alternatively, APBI can be given to patients at the time of surgery using intraoperative techniques of electrons of kilovoltage x-rays.
Brachytherapy is typically offered following lumpectomy to select women with early stage breast cancer. This treatment is focally delivered only to the area where the tumor was originally present.
Historically, brachytherapy had been given as an additional “boost” dose, in order to augment treatment to the whole breast with a higher dose of radiation to the tumor bed. While this approach is still feasible, it is less commonly given.
Brachytherapy is most commonly delivered using one of three different catheters, the Contura, SAVI, and MammoSite. Each of the catheters is produced by a different manufacturer and has unique physics characteristics that provide benefits that fit the needs of a unique subset of patients. Each of these three devices involves having one small incision made in the breast under local anesthetic. Through this incision, the device is then placed via ultrasound guidance into the area of the lumpectomy. All of this is done as an outpatient. Following this, radiation is delivered as an outpatient in the radiation oncologist’s office, twice daily, typically for five business days.
Another form of brachytherapy, multicatheter interstitial brachytherapy, involves placing multiple separate small catheters through the breast. This is done under local anesthetic and enables more individualized placement of each separate track through which the radioactive source can pass. This technique requires a high degree of expertise both by the radiation oncologist and the medical physicist that is a part of the team. Currently, very few centers in the United States offer this treatment.
Multiple factors are examined when determining if a patient requires radiation therapy after lumpectomy. For the vast majority of women with invasive breast cancer, radiation is recommended following lumpectomy. This is recommended because multiple randomized trials have demonstrated that radiation therapy decreases the risk of tumor recurrence in the breast and regional draining lymphatics. In the long-run, this local benefit translates into a longer survival, which is why radiation therapy is so very important.
However, in a small subset of patients, the benefits of radiation therapy are incrementally small, and it is reasonable to omit radiation. This applies particularly to women age seventy or older with relatively small tumors that express the estrogen receptor. The biology of these tumors is particularly favorable, and it is considered reasonable to not offer radiation if patients receive treatment with a medication that will target the estrogen receptor, which is typically given for five years.
For women with ductal carcinoma in situ, which is stage 0 breast cancer, there have been many efforts to better define who does and who does not need radiation therapy. For women with high grade DCIS, I generally recommend radiation therapy after lumpectomy. For women with low to intermediate grade DCIS, the decision about giving radiation therapy is dependent on the size of the tumor and the degree of surgical resection (also known as the margin status).
For all women, it is extremely important following treatment for breast cancer with lumpectomy (either with or without radiation therapy) to continue to have regular mammograms as a part of surveillance.
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