Now, there’s some positive news about radiation that’s very, very targeted.
Dr. Grobmyer: Right. One of the advances that have been made in the last fifteen years is based on the observation that if a woman has a lumpectomy for breast cancer, the site where the cancer will most likely come back is the site where the cancer was before. So, it led many people in the last ten or fifteen years to raise the question of do we really need to be radiating the entire breast; that has evolved into a concept called partial breast irradiation. In a partial irradiation you only radiate the area in the breast with the greatest risk, which is the site where we removed the tumor from. The advantages of partial breast irradiation, which can be done in any number of different ways, are that you minimize the damage to normal tissue and maximize the treatment to the area of greatest risk.
Up until now, for a partial breast radiation the person had to come in every day for a month?
Dr. Grobmyer: No, all forms of partial breast usually take less time than whole breast irradiation. There are different ways this could be done and often there are shorter courses of external partial breast irradiation. There are other techniques where the patients will have catheters coming out of the body and those catheters will stay in while the radiation is delivered inside the catheters. Those treatment times may last up to a week or ten days where the patients have a catheter coming out of the breast. There are other catheter based techniques that are used that also require several days of treatment with multiple visits to the doctor. The approach we and a growing number of centers are now pursuing is the idea that we can give radiation therapy during surgery. For selected patients with early stage breast cancer, we think these patients get very good outcomes and get all of their treatment done during that surgery while they’re asleep in the operating room.
How does that work?
Dr. Grobmyer: We use a special machine which delivers a single dose of radiation that we can bring sterilely into the operating area. After we’ve removed the tumor from the breast and we’re sure all of it has been removed, working with our colleagues in radiation oncology we bring this machine in and give just a single dose of radiation. The radiation only travels about a centimeter so it really has no chance of damaging normal tissues while effectively treating the tumor bed, which is really our goal. It delivers a very precise and therapeutic dose of radiation right to the area of greatest risk.
Is it a stronger dose? How can you take a month’s worth of radiation and put it into one?
Dr. Grobmyer: It has a lot to do with radiation biology. The total dose of radiation that a patient receives with this intra-op radiation is significantly less than would be with whole breast. It’s just that we’re giving a larger dose in one treatment than we would otherwise. The real answer to that question lies in what toxicity do we see with this single dose treatment, and the toxicity that we’ve observed is very minimal and patients actually tolerate it very well. We’ve not seen an increase in infections associated with it nor have we seen a problem with wound healing associated with it. It actually turned out to be a very safe treatment and that’s evidenced by the thousands of people who have now been treated with this.
Are there any side effects?
Dr. Grobmyer: Really pretty minimal. I mean, there’s always with any radiation a risk of toxicity to the skin or a little redness or burning of the skin. During surgery we take very careful measurements to try to reduce the chance that that will happen. There’s also a very small chance, less than five percent, that the patient will develop a significant fluid collection in the operative area. That’s called a seroma and it’s usually very simply treated by just aspirating the fluid in the office, but again, that’s less than five percent of the time. So, it’s actually very well tolerated.
Does this mean women will not have to get chemo after this?
Dr. Grobmyer: This doesn’t really affect our decisions about chemotherapy. The decisions that we help patients make regarding chemotherapy and radiation therapy are separate. The factors that lead to decisions for chemotherapy are more related to the size of the tumor, the status of the lymph nodes under the arm, and the type of breast cancer. The radiation decisions are made based on the size and type of tumor really.
Who would be a good candidate for this?
Dr. Grobmyer: We’ve been treating selected early stage patients over the age of 60 years at the Cleveland Clinic, but some centers are treating younger patients. The reason we’ve chosen to treat not the youngest patients in our center is that most of the experience today in the world has been developed in patients who are in the middle to older age groups. There’s been a little less experience in younger patients and in general, breast cancers in younger patients can be more aggressive so we’ve chosen to treat them a little more traditionally until further research is done.
Is the one dose radiation aggressive?
Dr. Grobmyer: We develop new treatments for breast cancer or any cancer in general very cautiously and base new treatments on the results of trials. We don’t like to try new things on people without sufficient evidence to prove their efficacy. The trails that have been done are really focused on patients with an average age of around 60 or a little older.
What do you call this?
Dr. Grobmyer: It’s called intraoperative radiation therapy single dose.
Is there a comparison that you can give me between this and traditional radiation?
Dr. Grobmyer: The comparisons are on one hand the patient would have all their radiation treatment done at the time of surgery. So after surgery, if the patient doesn’t need chemotherapy they are done with their treatment, but many of these women would be recommended to take a pill in the future to block estrogen and reduce the chance of cancer coming back. With whole breast radiation the patient completes their surgical procedure then they have to go back to the doctor’s office for some planning with CAT scans. Once the CAT scan planning is done, that begins the process of this multi-day radiation. So there really are differences in terms of the length of treatment, the side effects of treatment, and the toxicity to the normal tissues which with the intra-op treatment we’re trying to avoid.
Anything I’m missing?
Dr. Grobmyer: One of the things we talk about is a bigger concept which is focused on the idea of personalizing the treatment of breast cancer to the specific type of cancer that a patient has, the patient’s specific situation, and the other health issues that patients have. I would say 15 years ago patients would come in with breast cancer and they were pretty much all treated the same way because we didn’t know who was going to do well and who wasn’t going to do well. I think this is an excellent example of our learning about the biology of breast cancer and how different treatments we have affect patients with different biology. It’s allowing us to really tailor the treatment specifically to the patient and their type of breast cancer. The benefit to patients of course is they can often get more effective therapies this way and avoid treatments that really aren’t helpful to them. The same thing is happening in the world of medical oncology with chemotherapy. Nowadays we have molecular tests where we actually test the tumor and with those tests we can determine which patients will actually benefit from chemotherapy and which won’t. If a patient is not going to benefit much from chemotherapy, we can counsel them that maybe we should not take chemotherapy in this particular case. So, I think this is just the beginning of a very exciting time where we’re able to tailor specific treatments to a patient’s needs.
Are there certain breast cancers that you can say you would definitely use this on?
Dr. Grobmyer: We use it generally in patients with smaller breast cancers. In this country we see many patients with small breast cancers because they’re picked up on mammographic screening. The other groups of patients we concentrate on are those who have hormonally sensitive breast cancers which constitutes the majority of breast cancers these days.
How long have you been treating breast cancer patients?