Radiation

I see. I did not realize it was an individual plan related to autonomy. Very helpful. Patients who need radiation after reconstruction are at a risk of complications with regard to their reconstruction. A woman may have her reconstruction done at the time of surgery (immediate reconstruction) or at some point in the future (delayed reconstruction). Each carries with it different possible complications. Patients need to discuss all options with their surgeons – patient’s cancer and their anatomy play an important role in the determination of which type of reconstruction is appropriate. Regardless, it is essential that proper radiation planning take place and good dialogue between the treating radiation oncologist and the plastic surgeon.

"Internal" radiation or brachytherapy involves use of a variety of radioactive isotopes which are placed inside or near the tumor/cancer. By doing so, radiation does not have to go through the normal tissue between an external source and the target of radiation. Depending on whether the radioactive isotope is placed permanently or used temporarily, brachytherapy is categorized into two categories of permanent and temporary.

The most common form of permanent brachytherapy is prostate seed implant. In this form of treatment either Palladium (Pd-103) or Iodine (I-125) seeds are implanted inside the prostate. These seeds would irradiate the prostate gland and the cancer inside it as long as they are radioactive but eventually become inert.

Depending on the strength and therefore speed of delivery of radiation, temporary brachytherapy is categorized into Low Dose Rate and High Dose Rate brachytherapy. The most common example of temporary brachytherapy is the use of either Low Dose Rate (LDR) or High Dose Rate (HDR) forms of brachytherapy for the treatment of gynecological cancers specifically cervical and endometrial cancer. Through special catheters either cesium-137 (LDR) or iridium-192 (HDR) would be inserted nearby the tumor. During the period of time when the catheters remain in area, the prescribed dose of radiation would be delivered to the target. This would take about 48 hours in LDR but only a few minutes in HDR treatment.

HDR brachytherapy is also used in the treatment of breast cancer. This form of radiation for breast cancer is called Accelerated Partial Breast Irradiation or APBI. After a lumpectomy a special applicator such as Mammosite or Contura balloon catheter or a Savi applicator is placed inside the lumpectomy cavity. Using HDR technology an iridium-192 radioactive source is inserted into any of these catheters to deliver radiation to the wall of the lumpectomy cavity.

Intraluminal brachytherapy is also used for the treatment of endobronchial tumors, esophageal cancer and cancers of biliary tract. Other forms of temporary brachytherapy include radioactive eye plaque in treatment of choroidal melanoma and Strontium-90 applicators for treatment of pterygium. "Internal" radiation or brachytherapy involves use of a variety of radioactive isotopes which are placed inside or near the tumor/cancer. By doing so, radiation does not have to go through the normal tissue between an external source and the target of radiation. Depending on whether the radioactive isotope is placed permanently or used temporarily, brachytherapy is categorized into two categories of permanent and temporary.

The most common form of permanent brachytherapy is prostate seed implant. In this form of treatment either Palladium (Pd-103) or Iodine (I-125) seeds are implanted inside the prostate. These seeds would irradiate the prostate gland and the cancer inside it as long as they are radioactive but eventually become inert.

Depending on the strength and therefore speed of delivery of radiation, temporary brachytherapy is categorized into Low Dose Rate and High Dose Rate brachytherapy. The most common example of temporary brachytherapy is the use of either Low Dose Rate (LDR) or High Dose Rate (HDR) forms of brachytherapy for the treatment of gynecological cancers specifically cervical and endometrial cancer. Through special catheters either cesium-137 (LDR) or iridium-192 (HDR) would be inserted nearby the tumor. During the period of time when the catheters remain in area, the prescribed dose of radiation would be delivered to the target. This would take about 48 hours in LDR but only a few minutes in HDR treatment.

HDR brachytherapy is also used in the treatment of breast cancer. This form of radiation for breast cancer is called Accelerated Partial Breast Irradiation or APBI. After a lumpectomy a special applicator such as Mammosite or Contura balloon catheter or a Savi applicator is placed inside the lumpectomy cavity. Using HDR technology an iridium-192 radioactive source is inserted into any of these catheters to deliver radiation to the wall of the lumpectomy cavity.

Intraluminal brachytherapy is also used for the treatment of endobronchial tumors, esophageal cancer and cancers of biliary tract. Other forms of temporary brachytherapy include radioactive eye plaque in treatment of choroidal melanoma and Strontium-90 applicators for treatment of pterygium.

A patient may not be eligible to receive radiation treatment either because radiation therapy is not indicated for treatment of that particular cancer or stage of the disease or because, even though indicated, it would not be safe to receive radiation.

Contraindications to radiation therapy are often categorized as relative or absolute contraindications. Generally speaking autoimmune/connective tissue diseases increase the risk of acute and chronic side effects of radiation therapy. These patients may be at risk of severe skin reaction, severe scarring and even soft tissue necrosis. Depending on the type and level of activity of this form of diseases, radiation can be relatively or absolutely contraindicated. For example Scleroderma and active lupus are considered absolute contraindications to radiation therapy but an inactive, or limited Lupus such as Discoid Lupus and Rheumatoid Arthritis are considered relative contraindications to radiation therapy.

In recent years and with the invention of sophisticated radiation technology such as CyberKnife and Steroeotactic Radiosurgery, a traditional contraindication to radiation therapy due to previous radiation to the same target area, has been challenged. Without this precise form of targeting the tumor, a relatively significant dose of radiation was given to adjacent normal tissues. Each critical organ in our bodies has a certain tolerance to radiation. That is the dose an organ can safely receive without permanent and irreversible damage. Traditionally we could not reirraidate the same target area because we would have exceeded the safe dose an adjacent organ could tolerate. With this new technology, we can deliver additional doses of radiation to the same target without exceeding the safe dose to the adjacent organs. Despite this technology, at some point, we may reach a point when no additional radiation can be safely delivered and that would make a patient ineligible for additional radiation.

Patients' ineligibility for receiving radiation is a very compelling reason for a multidisciplinary approach to the treatment of cancer. As an example would it not be a shame to subject a patient ineligible for radiation therapy to a lumpectomy when radiation is a critical part of breast conservation therapy? That would sadly would subject the patient to a second operation, a mastectomy, because lumpectomy without radiation would not adequately address the risk of a recurrence in that breast. To avoid similar scenarios, consult all the members of a treatment team before initiating any form of treatment and undergoing any form of procedure. Be proactive! A patient may not be eligible to receive radiation treatment either because radiation therapy is not indicated for treatment of that particular cancer or stage of the disease or because, even though indicated, it would not be safe to receive radiation.

Contraindications to radiation therapy are often categorized as relative or absolute contraindications. Generally speaking autoimmune/connective tissue diseases increase the risk of acute and chronic side effects of radiation therapy. These patients may be at risk of severe skin reaction, severe scarring and even soft tissue necrosis. Depending on the type and level of activity of this form of diseases, radiation can be relatively or absolutely contraindicated. For example Scleroderma and active lupus are considered absolute contraindications to radiation therapy but an inactive, or limited Lupus such as Discoid Lupus and Rheumatoid Arthritis are considered relative contraindications to radiation therapy.

In recent years and with the invention of sophisticated radiation technology such as CyberKnife and Steroeotactic Radiosurgery, a traditional contraindication to radiation therapy due to previous radiation to the same target area, has been challenged. Without this precise form of targeting the tumor, a relatively significant dose of radiation was given to adjacent normal tissues. Each critical organ in our bodies has a certain tolerance to radiation. That is the dose an organ can safely receive without permanent and irreversible damage. Traditionally we could not reirraidate the same target area because we would have exceeded the safe dose an adjacent organ could tolerate. With this new technology, we can deliver additional doses of radiation to the same target without exceeding the safe dose to the adjacent organs. Despite this technology, at some point, we may reach a point when no additional radiation can be safely delivered and that would make a patient ineligible for additional radiation.

Patients' ineligibility for receiving radiation is a very compelling reason for a multidisciplinary approach to the treatment of cancer. As an example would it not be a shame to subject a patient ineligible for radiation therapy to a lumpectomy when radiation is a critical part of breast conservation therapy? That would sadly would subject the patient to a second operation, a mastectomy, because lumpectomy without radiation would not adequately address the risk of a recurrence in that breast. To avoid similar scenarios, consult all the members of a treatment team before initiating any form of treatment and undergoing any form of procedure. Be proactive!

The three common treatment modalities in treatment of breast cancer can be given in different sequences. The most common sequence is to start with surgery, continue with chemotherapy if indicated and finish with radiation therapy. But in some cases chemotherapy is delivered before surgery and is followed by radiation therapy. There is one exception to this general rule of radiation therapy being the last modality in the sequence of treatments and that is when Accelerated Partial Breast Irradiation (APBI) using brachytherapy balloons such as Mammosite, Contura or Savi applicator is the form of radiation utilized. In APBI, radiation is delivered immediately after surgery and chemotherapy, if recommended, would follow radiation.

Therefore a "delay" in beginning of radiation treatment can be a planned or an unplanned one. For example we often recommend 4-6 weeks between surgery and beginning of radiation in order to make sure that all the surgical incisions are completely healed. One of the potential side effects of radiation is delay in healing of wounds and that is the reason behind that planned delay. We also recommend about 2-4 weeks of gap between last chemotherapy administered and beginning of radiation therapy. This form of planned delay in beginning of radiation is due to the fact that some chemotherapy agents are radiosensitizers and may potentially increase the risk of side effects from radiation therapy.

The unplanned or undesired delays in beginning of radiation therapy may be due to an unhealed surgical incision or persistent seroma or a hematoma in the lumpectomy cavity or in soft tissue pouches after a mastectomy. Radiation therapy is based on very accurate measurements and calculations of the volumes of tissue irradiated and the doses delivered. If the calculations and radiation plan is based on a certain size of breast and certain size of lumpectomy cavity and this volume is changed due to an enlarging seroma or hematoma, our calculations and therefore radiation doses would be off. Therefore we would await resolution of a seroma or a hemtoma either by giving it some time to absorb or by aspirating it before planning the radiation treatment.

With increase in the use of tumor genetic assay tests such as Oncotype DX, often there is a delay in determining whether a patient requires chemotherapy or not. In this scenario, the radiation oncologist would need to await the test result before starting patient's radiation because if the Oncotype DX result indicates benefit from chemotherapy, this treatment should be delivered before beginning of radiation therapy. The three common treatment modalities in treatment of breast cancer can be given in different sequences. The most common sequence is to start with surgery, continue with chemotherapy if indicated and finish with radiation therapy. But in some cases chemotherapy is delivered before surgery and is followed by radiation therapy. There is one exception to this general rule of radiation therapy being the last modality in the sequence of treatments and that is when Accelerated Partial Breast Irradiation (APBI) using brachytherapy balloons such as Mammosite, Contura or Savi applicator is the form of radiation utilized. In APBI, radiation is delivered immediately after surgery and chemotherapy, if recommended, would follow radiation.

Therefore a "delay" in beginning of radiation treatment can be a planned or an unplanned one. For example we often recommend 4-6 weeks between surgery and beginning of radiation in order to make sure that all the surgical incisions are completely healed. One of the potential side effects of radiation is delay in healing of wounds and that is the reason behind that planned delay. We also recommend about 2-4 weeks of gap between last chemotherapy administered and beginning of radiation therapy. This form of planned delay in beginning of radiation is due to the fact that some chemotherapy agents are radiosensitizers and may potentially increase the risk of side effects from radiation therapy.

The unplanned or undesired delays in beginning of radiation therapy may be due to an unhealed surgical incision or persistent seroma or a hematoma in the lumpectomy cavity or in soft tissue pouches after a mastectomy. Radiation therapy is based on very accurate measurements and calculations of the volumes of tissue irradiated and the doses delivered. If the calculations and radiation plan is based on a certain size of breast and certain size of lumpectomy cavity and this volume is changed due to an enlarging seroma or hematoma, our calculations and therefore radiation doses would be off. Therefore we would await resolution of a seroma or a hemtoma either by giving it some time to absorb or by aspirating it before planning the radiation treatment.

With increase in the use of tumor genetic assay tests such as Oncotype DX, often there is a delay in determining whether a patient requires chemotherapy or not. In this scenario, the radiation oncologist would need to await the test result before starting patient's radiation because if the Oncotype DX result indicates benefit from chemotherapy, this treatment should be delivered before beginning of radiation therapy.

The best way to deal with fatigue from radiation therapy is creating a balance between getting enough rest and staying active enough. To succumb to the fatigue and give up physical activity would create a vicious cycle resulting in less energy and more fatigue. Yet you don't want to push yourself too much. It is all right to go to bed earlier, get up a little bit later or even take a nap during the day if one feels that tired but it is important to schedule a routine daily activity such as walking and stick with it throughout the course of radiation therapy. The other very important factor is to stay hydrated. Dehydration would negatively impact one's level of energy and may even interfere with their sleep pattern. This is particularly important during the warmer seasons and during the routine daily activity. Extremes of temperature should be avoided. A minimum of 8 cups of fluid per day will prevent dehydration. (That is 64 ounces, 2 quarts, or 1 half-gallon). Beverages containing caffeine do NOT count neither do alcoholic ones. Maintaining good nutrition can help you feel better and have more overall energy. Sticking to a regular schedules such as going to bed at a certain time and eating at regular hours would also be very helpful in creating that fine balance between resting and staying active. The best way to deal with fatigue from radiation therapy is creating a balance between getting enough rest and staying active enough. To succumb to the fatigue and give up physical activity would create a vicious cycle resulting in less energy and more fatigue. Yet you don't want to push yourself too much. It is all right to go to bed earlier, get up a little bit later or even take a nap during the day if one feels that tired but it is important to schedule a routine daily activity such as walking and stick with it throughout the course of radiation therapy. The other very important factor is to stay hydrated. Dehydration would negatively impact one's level of energy and may even interfere with their sleep pattern. This is particularly important during the warmer seasons and during the routine daily activity. Extremes of temperature should be avoided. A minimum of 8 cups of fluid per day will prevent dehydration. (That is 64 ounces, 2 quarts, or 1 half-gallon). Beverages containing caffeine do NOT count neither do alcoholic ones. Maintaining good nutrition can help you feel better and have more overall energy. Sticking to a regular schedules such as going to bed at a certain time and eating at regular hours would also be very helpful in creating that fine balance between resting and staying active.

Radiation therapy is a very technical treatment and takes a great deal
of work by the radiation oncologist, the dosimetrist and the radiation
physicist to create a radiation plan which would deliver the required
dose of radiation to the cancer while minimizing radiation dose to the
surrounding normal and critical organs. To create such a fine balance,
sophisticated technology and treatment planning software are utilized.

Traditional radiation therapy used plain X-ray films to map the target
area and radiation fields. This was a two-dimensional technique and
the exact dose of radiation to critical organs was not determined
carefully. Three-dimensional conformal radiation therapy uses CT scans
to carefully define each and every critical organ at risk of receiving
radiation as well as the tumor itself.

Over the past decade or so a more sophisticated form of
three-dimensional conformal radiation therapy called IMRT (Intensity
Modulated Radiation Therapy) has evolved. This technique utilizes
reverse planning. That is instead of learning how much of radiation
the critical organs would receive should we deliver a certain dose of
radiation to a tumor, we can set limits on how much of radiation these
organs can tolerate in advance.

Nowadays we also have the capability of fusing MRI and PET images with
our CT scan images to enhance the quality of our contours and mapping
of the target areas. By doing so we can be more precise in focusing
radiation on the areas requiring radiation.

So in general before starting radiation treatments a planning session
or simulation is required. During this session immobilization devices
are used prior to obtaining CAT scan of the area which requires
radiation. Once the images are obtained, a radiation oncologist would
define i.e. contour the target area as well as adjacent critical
organs. Radiation oncologist would set limits on how much of radiation
these organs can safely receive and also prescribes the required dose
of radiation to the tumor.

Using sophisticated treatment planning software, the dosimetrist would
generate one or more plan for the radiation treatment. Radiation
oncologist would review the plans and chooses the plan which has
optimized the dose of radiation to the target and adjacent organs.
Once the optimal plan is chosen, the physicist would review the plan
for quality assurance and subsequently approved by radiation
oncologist.

Prior to delivering the very first fraction of radiation, patient
would undergo another simulation consisting of obtaining films on the
radiation table (AKA Port Films). Radiation oncologist would review
these films to make sure that everything is aligned with what has been
planned. Once the radiation oncologist approves these films, the
actual treatments can begin.

Patients are anxious to begin radiation immediately but as you can
appreciate, a considerable amount of time and work is spent in
preparation for radiation. Our moto as radiation oncolgoists: safety
first! Radiation therapy is a very technical treatment and takes a great deal
of work by the radiation oncologist, the dosimetrist and the radiation
physicist to create a radiation plan which would deliver the required
dose of radiation to the cancer while minimizing radiation dose to the
surrounding normal and critical organs. To create such a fine balance,
sophisticated technology and treatment planning software are utilized.

Traditional radiation therapy used plain X-ray films to map the target
area and radiation fields. This was a two-dimensional technique and
the exact dose of radiation to critical organs was not determined
carefully. Three-dimensional conformal radiation therapy uses CT scans
to carefully define each and every critical organ at risk of receiving
radiation as well as the tumor itself.

Over the past decade or so a more sophisticated form of
three-dimensional conformal radiation therapy called IMRT (Intensity
Modulated Radiation Therapy) has evolved. This technique utilizes
reverse planning. That is instead of learning how much of radiation
the critical organs would receive should we deliver a certain dose of
radiation to a tumor, we can set limits on how much of radiation these
organs can tolerate in advance.

Nowadays we also have the capability of fusing MRI and PET images with
our CT scan images to enhance the quality of our contours and mapping
of the target areas. By doing so we can be more precise in focusing
radiation on the areas requiring radiation.

So in general before starting radiation treatments a planning session
or simulation is required. During this session immobilization devices
are used prior to obtaining CAT scan of the area which requires
radiation. Once the images are obtained, a radiation oncologist would
define i.e. contour the target area as well as adjacent critical
organs. Radiation oncologist would set limits on how much of radiation
these organs can safely receive and also prescribes the required dose
of radiation to the tumor.

Using sophisticated treatment planning software, the dosimetrist would
generate one or more plan for the radiation treatment. Radiation
oncologist would review the plans and chooses the plan which has
optimized the dose of radiation to the target and adjacent organs.
Once the optimal plan is chosen, the physicist would review the plan
for quality assurance and subsequently approved by radiation
oncologist.

Prior to delivering the very first fraction of radiation, patient
would undergo another simulation consisting of obtaining films on the
radiation table (AKA Port Films). Radiation oncologist would review
these films to make sure that everything is aligned with what has been
planned. Once the radiation oncologist approves these films, the
actual treatments can begin.

Patients are anxious to begin radiation immediately but as you can
appreciate, a considerable amount of time and work is spent in
preparation for radiation. Our moto as radiation oncolgoists: safety
first!

Palliative treatment are usually given either to palliate pain, remove compression of tumor on a vital organ such as spinal cord, preventing fracture if the cancer has spread to a weigh-bearing bone, or in the case of brain metastasis to relieve the life-threatening pressure inside the brain. Palliative treatments are often given in short courses of 2-3 weeks not only because the radiation dose per individual treatments (aka fractions) is usually higher but also because the total dose of radiation is lower. Palliative radiation is often used stage IV. That is when the cancer has spread to other organs and even though it might be treatable, it is not curable.

Definitive treatment is given when, based on the stage of the cancer, statistically there is a chance for its cure (i.e. stage I-III). Depending on the type of cancer, definitive radiation can take up to 9 weeks not only because the radiation dose per individual treatments (aka fractions) is usually lower but also because the total dose of radiation is higher. Definitive treatments are given to the primary site of cancer (i.e. original site where the cancer started). Palliative treatment are usually given either to palliate pain, remove compression of tumor on a vital organ such as spinal cord, preventing fracture if the cancer has spread to a weigh-bearing bone, or in the case of brain metastasis to relieve the life-threatening pressure inside the brain. Palliative treatments are often given in short courses of 2-3 weeks not only because the radiation dose per individual treatments (aka fractions) is usually higher but also because the total dose of radiation is lower. Palliative radiation is often used stage IV. That is when the cancer has spread to other organs and even though it might be treatable, it is not curable.

Definitive treatment is given when, based on the stage of the cancer, statistically there is a chance for its cure (i.e. stage I-III). Depending on the type of cancer, definitive radiation can take up to 9 weeks not only because the radiation dose per individual treatments (aka fractions) is usually lower but also because the total dose of radiation is higher. Definitive treatments are given to the primary site of cancer (i.e. original site where the cancer started).

Even though the new radiation technology has given us the capability to spare patients from significant skin burns, depending on the type of cancer and its location, sometimes either the skin itself is the target of radiation or it is impossible to spare it completely. Skin burn from radiation in many ways is similar to a sunburn. There are a number of products that radiation oncologists may recommend to alleviate the discomfort from the skin burn. These include but are not limited to Aquaphor ointment, Miaderm Lotion, Aloe Vera gel, Calendu, RadX Radiation Therapy cream, Radia-Guard lotion and many other products. If the skin has blistered or the shiny and moist part of skin is exposed Silvadene cream and/or a variety of gel wound dressings may be recommended. In worst case scenarios, your radiation oncologist may decide to advise a break in the course of treatment but this has to be weighed carefully against the negative impact of breaks during radiation on the final outcome of treatment. Avoiding sun exposure and products containing alcohol is advisable. Cleaning the area with mild and fragrance-free soap and water to prevent infection is essential. If the affected area is in perineal area, sitz baths with water and Hydrogen Peroxide would be helpful. Women should avoid wearing wired bras if the treatment area includes the chest. Please do not use any product without consulting your radiation oncologist first. Even though the new radiation technology has given us the capability to spare patients from significant skin burns, depending on the type of cancer and its location, sometimes either the skin itself is the target of radiation or it is impossible to spare it completely. Skin burn from radiation in many ways is similar to a sunburn. There are a number of products that radiation oncologists may recommend to alleviate the discomfort from the skin burn. These include but are not limited to Aquaphor ointment, Miaderm Lotion, Aloe Vera gel, Calendu, RadX Radiation Therapy cream, Radia-Guard lotion and many other products. If the skin has blistered or the shiny and moist part of skin is exposed Silvadene cream and/or a variety of gel wound dressings may be recommended. In worst case scenarios, your radiation oncologist may decide to advise a break in the course of treatment but this has to be weighed carefully against the negative impact of breaks during radiation on the final outcome of treatment. Avoiding sun exposure and products containing alcohol is advisable. Cleaning the area with mild and fragrance-free soap and water to prevent infection is essential. If the affected area is in perineal area, sitz baths with water and Hydrogen Peroxide would be helpful. Women should avoid wearing wired bras if the treatment area includes the chest. Please do not use any product without consulting your radiation oncologist first.

What form of radiation a radiation oncologist would recommend depends on many factors but mainly the type of cancer, the stage of cancer and its location. What equips a radiation oncologist is not only four years of specialty training including radiation physics and biology but the evidence supporting these forms of treatments based on decades of research in the field. For each type of cancer there is a standard of care basically dictating what the appropriate radiation should consist of. For example for cervical cancer a combination of external radiation and brachytherapy is used. For prostate cancer one can use either external radiation or seed implant of a combination of both. What form of radiation a radiation oncologist would recommend depends on many factors but mainly the type of cancer, the stage of cancer and its location. What equips a radiation oncologist is not only four years of specialty training including radiation physics and biology but the evidence supporting these forms of treatments based on decades of research in the field. For each type of cancer there is a standard of care basically dictating what the appropriate radiation should consist of. For example for cervical cancer a combination of external radiation and brachytherapy is used. For prostate cancer one can use either external radiation or seed implant of a combination of both.

In general, no. However, there may be reasons to avoid certain foods depending upon where the radiation is being directed. Your radiation oncology physician or nurse would be the best source of information for your particular situation. Although anti-oxidants interfere with radiation, there is no evidence that the anti-oxidants found in whole foods (not dehydrated, concentrated versions of what was once a whole food) are harmful during treatment. In general, no. However, there may be reasons to avoid certain foods depending upon where the radiation is being directed. Your radiation oncology physician or nurse would be the best source of information for your particular situation. Although anti-oxidants interfere with radiation, there is no evidence that the anti-oxidants found in whole foods (not dehydrated, concentrated versions of what was once a whole food) are harmful during treatment.

Side effect of radiation therapy entirely depends on the area we are irradiating. For example the side effects of radiation the the brain because of a brain metastasis are entirely different from the side effects due to the radiation of a bone metastasis in a bone. Generally speaking though some fatigue and minor skin reaction would be involved with radiation no matter where it is given. Due to significant improvements in the radiation technology in the past couple of decades, we are increasingly capable of sparing most of normal tissue and critical organs from unnecessary radiation and focus radiation on the area we intend to irradiate. That is even in radiation therapy field we are moving into the direction of targeted therapy and are able to deliver higher doses of radiation to the cancer only without causing major side effects which is usually as a result of unnecessary radiation to the normal tissues. Side effect of radiation therapy entirely depends on the area we are irradiating. For example the side effects of radiation the the brain because of a brain metastasis are entirely different from the side effects due to the radiation of a bone metastasis in a bone. Generally speaking though some fatigue and minor skin reaction would be involved with radiation no matter where it is given. Due to significant improvements in the radiation technology in the past couple of decades, we are increasingly capable of sparing most of normal tissue and critical organs from unnecessary radiation and focus radiation on the area we intend to irradiate. That is even in radiation therapy field we are moving into the direction of targeted therapy and are able to deliver higher doses of radiation to the cancer only without causing major side effects which is usually as a result of unnecessary radiation to the normal tissues.

Brachytherapy is a more inclusive name for radiation that is delivered at a 'short distance' (the name 'brachy' means arm's length). Brachytherapy techniques include the Mammosite balloon technique. Mammosite is a balloon with a single catheter running down the middle. http://www.mammosite.com/ A small radiation seed (about the size of a grain of rice) is then run down the catheter and stops at various positions along the way to deliver the prescribed radiation dose. Other brachytherapy techniques include using multiple catheters that pierce the skin (interstial brachytherapy - used rarely now but was the original technique pioneered by Robert Kuske, MD) and single entry/multiple catheter devices (SAVI, Mammosite Multi-Lumen, and Contura). The radiation seed goes down each catheter (just as in the single catheter Mammosite) for a set time to deliver the prescribed dose.

I feel very comfortable offering properly selected patients - accelerated partial breast irradiation (5 days instead of 6-7 weeks) usually with one of the single entry/multicatheter devices. Brachytherapy is a more inclusive name for radiation that is delivered at a 'short distance' (the name 'brachy' means arm's length). Brachytherapy techniques include the Mammosite balloon technique. Mammosite is a balloon with a single catheter running down the middle. http://www.mammosite.com/ A small radiation seed (about the size of a grain of rice) is then run down the catheter and stops at various positions along the way to deliver the prescribed radiation dose. Other brachytherapy techniques include using multiple catheters that pierce the skin (interstial brachytherapy - used rarely now but was the original technique pioneered by Robert Kuske, MD) and single entry/multiple catheter devices (SAVI, Mammosite Multi-Lumen, and Contura). The radiation seed goes down each catheter (just as in the single catheter Mammosite) for a set time to deliver the prescribed dose.

I feel very comfortable offering properly selected patients - accelerated partial breast irradiation (5 days instead of 6-7 weeks) usually with one of the single entry/multicatheter devices.

There is always some leeway in these criteria including discussing all radiation options with the patient but generally
age >45
tumor size < 3 cm
Margins - neg
Lymph nodes - neg

Here is the link to the American Society of Breast Surgeons Offical Statment.
https://www.breastsurgeons.org/statements/PDF_Statements/APBI.pdf There is always some leeway in these criteria including discussing all radiation options with the patient but generally
age >45
tumor size < 3 cm
Margins - neg
Lymph nodes - neg

Here is the link to the American Society of Breast Surgeons Offical Statment.
https://www.breastsurgeons.org/statements/PDF_Statements/APBI.pdf

The study presented by Dr. Grace Smith at the San Antonio Breast Cancer Symposium entitled Partial Breast Brachytherapy is Associated with Inferior Effectiveness and Increased Toxicity Compared with Whole Breast Irradiation in Older Patients has garnered a tremendous amount of print and internet media attention. After reading the abstract (paper not in press yet), seeing the talk live in San Antonio, and discussing the study with many colleagues in the breast surgery and radiation oncology fields, it has become necessary to try to clarify the data on APBI, discuss the 'information' in the abstract and the hyperbole in the lay press that is distressing our patients.

First and unequivocally, Acellerated Partial Breast Irradiation is a safe and effective form of treating the breast after appropriately performed lumpectomy in patients over age 45-50 with early stage invasive (typically <3cm primaries and lymph node negative) and non-invasive breast cancer. Numerous retrospective studies and 2 prospective randomized (the gold standard) studies have shown no difference in survival, local-regional recurrence rates or complications between APBI and Whole Breast Irradiation (WBI). The American Society of Breast Surgeons Mammosite Registry has published more than 16 papes showing the safety and efficacy (comparable to WBI) of Mammosite APBI.

The abstract and presentation is drawn from the Medicare claims-SEER database which is a large database with cancer patient data linked to Medicare claims data. The database is managed by the NCI and sold to institutions to do research. The linked database has information about cancer type and treatments but no specific data on margin status, prognostic factors such as ER/PR and Her2Neu, or even local, regional or distant recurrence. The study stated that 'subsequent mastectomy' is a 'validated surrogate for local failure' although I am unaware of any literature that states this. The 'two-fold increased risk for subsequent mastectomy' is misleading (and inaccurate - it's 4.0% for APBI vs. 2.2% for Whole Breast Irradiation in their study). Both of these rates are quite small and questionable whether there is any clinical significance between the two. Not emphasized but equally (?more) important is the overall survival rates which were equivalent. The study also stated that infections were higher for APBI (not surprising since it involves the insertion of one or more catheters in the breast) but there is no statement regarding severity (were the APBI patients just placed on prophylactic antiobiotics and that is how an infection was defined?). Fat necrosis and breast pain were also significantly higher in the APBI group although there is absolutely no uniform definition of what fat necrosis is nor a statement about the severity or the fat necrosis or breast pain. Lastly, they state there was a 9.6% hospitalization rate for APBI patients vs 5.7% for WBI patients. This is quizzical since no diagnosis was given for hospitalization nor the time period over which they were hospitalized (was it APBI related[doubtful] or related to first chemotherapy cycle [perhaps] or other unrelated health issues [APBI often used in older, sicker patients who may not be candidates for 6-7 weeks of WBI]). In summary, this retrospective study of an inherently inacurate (no data on tumor characteristics and margin status - both known to be significant determiners of local recurrence) database with questionable outcomes (admission rate) and non-validated 'surrogate endpoints' (subsequent mastectomy=local recurrence) should be looked at with appropriate skepticism in the face of 20 years of retrospective studies and 2 prospective randomized trial to the contrary.
Thanks for the question! The San Antonio Breast Cancer Symposium is one of the largest and most prestigious breast cancer conferences, and often exciting and innovative research is presented. However at the recent meeting, a study was presented by a group from MD Anderson, questioning the safety and effectiveness of accelerated partial breast irradiation (APBI) for early-stage breast cancer - specifically they noted that patients undergoing this treatment have a higher rate of complications and eventual mastectomy. Unfortunately before the study was even presented, it received national media attention, leading to significant anxiety and confusion among women. This stresses the importance of reading the study, not just listening to the sound bite - here are some facts:
- The study used retrospective (after the fact) "claims data" to do their evaluation. That means they took Medicare billing information, not actual patient data, and drew some conclusions. It is NOT possible to accurately determine complication rates from claims data as they are not always reported. It is also not possible (and the authors admitted this) to determine why the women treated with APBI subsequently underwent mastectomy - it could have been for an entirely different cancer, even one in the other breast!
- The absolute increased risk of mastectomy was 1.8% which is quite low, and again we have no way to know why the women underwent mastectomy
- APBI has been the subject of multiple prospective (going-forward) and peer-reviewed studies, and has been shown to have an equivalent or in some cases better rate of breast cancer control compared to whole-breast irradiation; the complication rate is also equivalent.

3 respected professional medical societies published responses critical of the MD Anderson study, and I expect more criticism will come. The responses are from the American Society of Breast Surgeons: https://www.breastsurgeons.org/news/article.php?id=122, the American Brachytherapy Society: http://campaign.r20.constantcontact.com/render?llr=kdofiegab&v=001rj64Pj8NTf4ISgwN4cSdZYtZBR53GjAi73j4En_qeygPzWmSUe1qgGI7U-jt8HRV7NouL9sMViv1IOOeGT2QHMAaDWrfEuOApREAHj-8Z60%3D and the American Society for Radiation Oncology: https://astro.org/News-and-Media/News-Releases/2011/ASTRO--APBI-safe,-effective-for-some-breast-cancer-patients.aspx

It is again unfortunate that this poorly designed study with no real valid clinical data was allowed to be presented at such a prestigious meeting, and that it received immense national media attention before the scientific community was allowed to interpret the study and respond. I am hopeful that this will not happen in the future, as many women (and many physicians) were caused unnecessary anxiety regarding their breast cancer treatment options.

My doctor was very clear that I could not use anything except Aquaphor during treatments. Afterward I used Vit. E oil with a bit of lavender mix in. It seemed to help my skin heal. Brenda My doctor was very clear that I could not use anything except Aquaphor during treatments. Afterward I used Vit. E oil with a bit of lavender mix in. It seemed to help my skin heal. Brenda

Our patients have had a lot of success with Udderly Smooth cream - it comes in a big tub - good for elbows and feet, too! There are several skin care options. Some of the topical creams and lotions we recommend include Aquaphor, Biafine, Mederma, and Jean's Cream. We also recommend the use of Aloe Vera (plant or gel) or vitamin E cream. Much of this is individualistic and a matter of comfort.

1) 3D mammograms are also called tomosynthesis and they are superior to 2D (regular) mammograms. This type of imaging is a special kind of mammogram that produces a 3D image of the breast. The image is obtained by using several low dose x-rays taken at different angles. The breast is compressed similar to the way it is for a mammogram except the x-ray tube moves in a circular arc around the breast; the imaging is completed in less than 10 seconds.
The reasons tomosynthesis is superior to 2D mammograms are:
Less breast compression (less discomfort)
Shorter length of time for test to be completed (10 seconds vs. several minutes)
More pictures are obtained in multiple different angles of the breast (more accurate)
A 3D image makes it easier to find an abnormality than traditional mammogram.

2) There are some discrepancies in the difference in amount of radiation exposure between standard mammogram versus 3D mammogram.
According to the American College of Radiology there is about twice the amount of radiation in a 3D mammogram but “it improved the accuracy with which radiologists detected cancers, decreasing the number of women recalled for a diagnostic workup.”

A study published in Radiographics, peer-reviewed journal, lists the radiation dose of tomosynthesis at 145 mrad.

Just an fyi, the National Cancer Institute lists an average two-view mammogram as delivering 200-400mrad.

Everything I read and studied listed the doses for 3D mammogram as being under 300mrad (see resources below).

Thanks,
Heather

Resources:

http://www.cancer.gov/cancertopics/pdq/screening/breast/healthprofessional/page6" target=_blank>http://www.cancer.gov/cancertopics/pdq/screening/breast/healthprofessional/page6

http://www.acr.org/SecondaryMainMenuCategories/NewsPublications/FeaturedCategories/CurrentACRNews/FDA-approves-first-3-d-mammography-system.aspx" target=_blank>http://www.acr.org/SecondaryMainMenuCategories/NewsPublications/FeaturedCategories/CurrentACRNews/FDA-approves-first-3-d-mammography-system.aspx

http://radiographics.rsna.org/content/27/suppl_1/S231.full#sec-2" target=_blank>http://radiographics.rsna.org/content/27/suppl_1/S231.full#sec-2

http://www.acrin.org/PATIENTS/ABOUTIMAGINGEXAMSANDAGENTS/ABOUTMAMMOGRAPHYANDTOMOSYNTHESIS.aspx" target=_blank>http://www.acrin.org/PATIENTS/ABOUTIMAGINGEXAMSANDAGENTS/ABOUTMAMMOGRAPHYANDTOMOSYNTHESIS.aspx 1) 3D mammograms are also called tomosynthesis and they are superior to 2D (regular) mammograms. This type of imaging is a special kind of mammogram that produces a 3D image of the breast. The image is obtained by using several low dose x-rays taken at different angles. The breast is compressed similar to the way it is for a mammogram except the x-ray tube moves in a circular arc around the breast; the imaging is completed in less than 10 seconds.
The reasons tomosynthesis is superior to 2D mammograms are:
Less breast compression (less discomfort)
Shorter length of time for test to be completed (10 seconds vs. several minutes)
More pictures are obtained in multiple different angles of the breast (more accurate)
A 3D image makes it easier to find an abnormality than traditional mammogram.

2) There are some discrepancies in the difference in amount of radiation exposure between standard mammogram versus 3D mammogram.
According to the American College of Radiology there is about twice the amount of radiation in a 3D mammogram but “it improved the accuracy with which radiologists detected cancers, decreasing the number of women recalled for a diagnostic workup.”

A study published in Radiographics, peer-reviewed journal, lists the radiation dose of tomosynthesis at 145 mrad.

Just an fyi, the National Cancer Institute lists an average two-view mammogram as delivering 200-400mrad.

Everything I read and studied listed the doses for 3D mammogram as being under 300mrad (see resources below).

Thanks,
Heather

Resources:

http://www.cancer.gov/cancertopics/pdq/screening/breast/healthprofessional/page6" target=_blank>http://www.cancer.gov/cancertopics/pdq/screening/breast/healthprofessional/page6

http://www.acr.org/SecondaryMainMenuCategories/NewsPublications/FeaturedCategories/CurrentACRNews/FDA-approves-first-3-d-mammography-system.aspx" target=_blank>http://www.acr.org/SecondaryMainMenuCategories/NewsPublications/FeaturedCategories/CurrentACRNews/FDA-approves-first-3-d-mammography-system.aspx

http://radiographics.rsna.org/content/27/suppl_1/S231.full#sec-2" target=_blank>http://radiographics.rsna.org/content/27/suppl_1/S231.full#sec-2

http://www.acrin.org/PATIENTS/ABOUTIMAGINGEXAMSANDAGENTS/ABOUTMAMMOGRAPHYANDTOMOSYNTHESIS.aspx" target=_blank>http://www.acrin.org/PATIENTS/ABOUTIMAGINGEXAMSANDAGENTS/ABOUTMAMMOGRAPHYANDTOMOSYNTHESIS.aspx

Breast cancer patients can report pain in the irradiated breast for years after treatment. Quality of life studies have actually been to assess this issue. In one study, it showed roughly the same percentage of chronic pain (25%) after lumpectomy + RT and after mastectomy without RT. Other prospective trials followed women after lumpectomy WITHOUT radiation and women WITH radiation. One study showed no difference in breast pain between the two groups at 1 year. The other study showed women who received RT to have more pain in the first 2 years but after the 2-year mark, both groups were the same. After lumpectomy, with modern equipment and technology, skin changes referred to as portal hyperpigmentation, should go away within a few weeks of completing therapy. Telengiectasias – or dilations of the skin vasculature — can be a late effect following radiation for breast cancer. This is much more common after mastectomy than it is after lumpectomy. Skin thickening or fibrosis (referred to here as 'scar tissue') can also occur after radiation to the breast. Most of these late toxicities are influenced by total dose and dose per fraction of the radiation when it was given. So that was the LONG answer — the short answer is that side effects from breast cancer treatment are complex. At the very least, they are quite patient-specific and likely reflect a combination of the surgical procedure and the radiation. It is very important to have good follow-up with all of your breast cancer doctors. Breast cancer patients can report pain in the irradiated breast for years after treatment. Quality of life studies have actually been to assess this issue. In one study, it showed roughly the same percentage of chronic pain (25%) after lumpectomy + RT and after mastectomy without RT. Other prospective trials followed women after lumpectomy WITHOUT radiation and women WITH radiation. One study showed no difference in breast pain between the two groups at 1 year. The other study showed women who received RT to have more pain in the first 2 years but after the 2-year mark, both groups were the same. After lumpectomy, with modern equipment and technology, skin changes referred to as portal hyperpigmentation, should go away within a few weeks of completing therapy. Telengiectasias – or dilations of the skin vasculature — can be a late effect following radiation for breast cancer. This is much more common after mastectomy than it is after lumpectomy. Skin thickening or fibrosis (referred to here as 'scar tissue') can also occur after radiation to the breast. Most of these late toxicities are influenced by total dose and dose per fraction of the radiation when it was given. So that was the LONG answer — the short answer is that side effects from breast cancer treatment are complex. At the very least, they are quite patient-specific and likely reflect a combination of the surgical procedure and the radiation. It is very important to have good follow-up with all of your breast cancer doctors.

I am not sure I understand this question. I can answer the following: Under what circumstances is radiotherapy considered necessary for women who DON'T undergo breast-conserving lumpectomies, but rather mastectomies? (I apologize if this is not the intended question.) Radiation is considered standard of care after lumpectomies (also called partial mastectomies). Radiation is also advised after mastectomy in certain clinical situations. And this is based on tumor size, extent of resection (ie were there positive margins at the time of mastectomy?), nodal status (and if so, how many nodes were involved?), and other factors associated with the mastectomy specimen that is reported by the pathologist. In general, radiation is suggested if the risk of local recurrence is significant enough to justify the risks. I am not sure I understand this question. I can answer the following: Under what circumstances is radiotherapy considered necessary for women who DON'T undergo breast-conserving lumpectomies, but rather mastectomies? (I apologize if this is not the intended question.) Radiation is considered standard of care after lumpectomies (also called partial mastectomies). Radiation is also advised after mastectomy in certain clinical situations. And this is based on tumor size, extent of resection (ie were there positive margins at the time of mastectomy?), nodal status (and if so, how many nodes were involved?), and other factors associated with the mastectomy specimen that is reported by the pathologist. In general, radiation is suggested if the risk of local recurrence is significant enough to justify the risks.

'synchronous' means 'at the same time'. In this context, it would mean getting chemotherapy and radiation at the same time rather than getting it 'sequentially' or one after the other. 'synchronous' means 'at the same time'. In this context, it would mean getting chemotherapy and radiation at the same time rather than getting it 'sequentially' or one after the other.