Breast Radiation Treatment

There are different type of skin changes that can occur with breast radiation. These include:

1. Pigment change;
2. Change in elasticity
3. Hydration;
4. Depilation (hair loss);
5. Lymphatic flow;
6. Vascularity.

I'm not sure the time course for how long skin changes last has been carefully described, and some are likely interrelated.

Anecdotally, pigment changes usually don't last beyond a month or two but can be a permanent change, more likely persistent tanning than loss of pigment. Skin may be slightly dryer but less common that it's enough to be itchy/flaky. I suspect that make a year or two to improve but may last. A minority of women may also have fluctuating or permanent breast swelling/edema or atrophy. Fine spidery blood vessels, called telangiectasias, may show up months or years later but not that common.

Good question. Advantages of HDR breast brachytherapy for partial breast irradiation (PBI) include shorter treatment time, radiation exposure to less normal tissue, and that may translate into fewer side effects (not yet proven). Anecdotally, external beam PBI has had an issue with rib fractures so I've leaned toward HDR for PBI, though it can occue with either.

That's a good lead-in to disadvantages. The dose each treatment is higher and given twice a day, so there is the potential for higher injury to that more focused area of tissue. The other issue is concern that by not irradiating the entire breast, some cancer cells might not be treated and lead to a higher risk of cancer coming back within that breast.

The conservative gold standard remains whole breast radiation because of the overall low toxicity and highly effective results to prevent cancer recurrence. The strongest current argument for HDR PBI is convenience, and many doctors want to wait for data from a clinical trial underway now, NSABP B-39/RTOG 0413, before being comfortable to offer it as an alternative standard option.

The use of radiation therapy has been a standard treatment option for women undergoing lumpectomy since publication of NSABP B-06, a clinical trial conducted about 30 years ago. At that time external beam radiation (also called teletherapy) was used to treat the whole breast. While there have been some tweaks, whole breast radiation therapy remains the current evidence-based gold standard.

There has been interest if focusing radiation more on the surgivcal area only, the lumpectomy cavity. This is called partial breast irradiation and is currently under study, though promising results suggest it a reasonable option. High-dose rate brachytherapy (brachy meaning close) is a way to deliver higher doses to a more focused area.

Criteria for using HDR brachytherapy on clinical trials NSABP B-39 are listed here: http://bit.ly/r8rED1 . Currently, off study there are patients who are considered suitable based upon consensus guidelines from 2009:

Patient Factors: Women 60+ years; no BRCA mutations.
Tumor Factors: 2 cm or less invasive ductal cancer; ER+; negative margins (2mm or more); no lymphovascular invasion; no involved nodes.

Here's a link to a screenshot from the article. http://i.imgur.com/2YxQt.jpg
There are also some technical considerations.

However, not everyone agrees. William Beaumont has tended to be more willing to consider HDR brachytherapy and PBI for some patients deemed unsuitable in the 2009 consensus paper (link = http://1.usa.gov/qPYTv0). It's a controversial area that's still evolving, and varies beyond just the criteria above for each patient. So worth a long discussion if you're thinking about lumpectomy for the pros/cons of whole breast vs partial breast radiation.

There is a lot of literature regarding treatment timing. It depends mostly on the type of reconstruction being performed. For example, autologous tissue (DIEP, TRAM) reconstruction is typically done prior to any radiation. With implants with or without tissue expanders, radiation therapy can be done either before or after the reconstruction. It is very important to discuss these possibilities with the entire team of surgeon, reconstructive surgeon, medical oncologist, and radiation oncologist beforehand.

Some of the practices that we employ to minimizing damage to normal cells during breast radiation treatment includes precise target acquisition and minimization of movement along with patient monitoring. With regard to target acquisition, we use one of the best treatment machines, the Elekta Infinity which gives great images of the patient; one of the best CT-simulators, the new Toshiba large bore, which acquires very clear anatomical images; and we also use AccuBoost, the most precise way of locating the patient's lumpectomy cavity and treating that area (http://www.thefarbercenter.com/cancers/breast.php_).
To monitor patients we utilize c-rad sentinel, which gives a laser topography image of the patient real time during treatment.

Yes to both parts. While the criteria for post-mastectomy radiation is evolving, it is often offered for tumors greater than or equal to 5 cm, positive or close margins, skin involvement, and involved lymph nodes. Historically, 4 or more lymph nodes positive were the indication with regard to lymph node positivity, however, recent studies have shown a benefit to post-mastectomy radiation even in patients with 1 to 3 lymph nodes positive, especially in pre-menopausal women. Also, if patients received pre-mastectomy chemotherapy, depending on their initial disease, post-mastectomy radiation may be indicated.
We often deliver radiation with expanders in place, however, we require the expansion to be complete or not changed from the time the radiation is planned until after the treatment is completed.

Different physicians follow different guidelines for brachytherapy versus external beam radiation for breast cancer. We typically follow the American Brachytherapy Society guidelines for APBI:
Age ≥ 50-years-old; Histology (Infiltrating Ductal Carcinoma); Clinical stage (T1, and T2 ≤ 3.0 cm, N0, M0: no distant metastases.)
This is the website: http://www.americanbrachytherapy.org/guidelines/abs_breast_brachytherapy_taskgroup.pdf
It is also very important that your surgeon is on board as often times closure of the lumpectomy cavity will factor in.
As we are selective in which patients are good candidates, both types have been equally successful in my practice.

Breast radiation treatment hurts both the cancer cells and the healthy cells.

The two primary side effects of radiation treatment in breast cancer are:
- Fatigue
- Changes in your skin (dry skin, itchy skin, redness, peeling and blistering).

It is important to take care of your skin during treatment. Lotions and creams are available to apply to relieve the discomfort.

Side effects usually disappear about 2 months after the completion of radiation therapy.