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Killing Breast Cancer Faster

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PLEASANTON, Calif. (Ivanhoe Newswire) – Two hundred thousand women will be told they have breast cancer this year. Once diagnosed, the first step is usually a lumpectomy to remove it, but weeks of radiation may be needed to kill cancer cells left behind. A precision treatment once reserved for other cancers is now changing that for breast cancer patients.

They start early in the Baratiak household. From the youngest to the oldest, music is in their blood. It was music that helped Nina Baratiak, a breast cancer survivor, make it through some tough days.

"I had a tumor in my left breast. My brain just shut down, like what? Really?" she told Ivanhoe.

After a lumpectomy—Nina chose to try a new type of radiation to kill any remaining cancer cells.

"Brachytherapy is a much more precise treatment. It delivers radiation right to the area at risk, right after surgery," Rakesh Patel, MD, past chairman of the American Brachytherapy Society and Director of breast cancer services at Western radiation oncology, told Ivanhoe.

Traditionally, cancer patients undergo external beam radiation therapy to treat the whole breast. It's 15 minutes, five days a week for six weeks. It's potentially damaging to nearby skin and tissues.

Brachytherapy is more targeted-- delivering radiation from the inside out ten minutes a day for just five days.

"It really hones in to that area and preserves some of that healthy tissue," Dr. Patel said.

At the doctor's office, a radiation seed is fed through this device into the area where the tumor was removed, allowing doctors to precisely program how much radiation is given and when. While it takes a lot less time, studies show that the recurrence risk for many women treated with brachytherapy is the same as those who go through whole breast radiation.

Nina is almost a year out from surgery and is cancer free, enjoying the newest member of the family.

"They chose her name Zoë and that means life, and we just felt that was a real sign to us," Nina said.

Brachytherapy is not for all women diagnosed with breast cancer. It works best on women with early stage breast cancer.

RESEARCH SUMMARY

BACKGROUND: About one in every eight women in the United States will experience breast cancer in their lifetime. Each year approximately 200,000 women will be diagnosed with breast cancer and around 40,000 women will die from it. Second to lung cancer, breast cancer is a major cancer that will cause deaths (Source: National Breast Cancer Association).

TYPES: There are two types of Breast Cancer:

  1. Ductal Carcinoma: Starts in the tubes (ducts) that move milk from the breast to the nipple. Most breast cancers are this type.
  2. Lobular Carcinoma: Starts in the parts of the breast called lobules that produce milk.

TREATMENT: The three main treatments for breast cancer are chemotherapy, radiation therapy, and surgery. The chemotherapy is used to kill cancer cells, the radiation therapy is used to destroy cancerous tissue, and the surgery is used to remove cancerous tissue. There are two types of surgery, a lumpectomy removes the breast lump, and a mastectomy removes all of part of the breast and possible nearby structures.(Source: http://www.ncbi.nlm.nih.gov)

In the past, radiation has been administered to a patient's "entire" breast (whole breast radiation) via external beam radiation therapy (EBRT). EBRT treatment is delivered to the tumor site via a radioactive beam from outside the patient's body on a daily basis over an approximate 7 week time period. Recent studies have shown that in most cases, limiting radiation to just "part" of the breast (partial breast radiation) is equally as effective and causes less injury to surrounding healthy breast tissue. (Source:http://www.cetmc.com)

NEW TECHNOLOGY: Brachytherapy is a procedure that involves placing radioactive material inside your body. Brachytherapy is one type of radiation therapy that's used to treat cancer. Brachytherapy is sometimes called internal radiation. Brachytherapy allows doctors to deliver higher doses of radiation to more-specific areas of the body, compared with the conventional form of radiation therapy (external beam radiation) that projects radiation from a machine outside of your body. Brachytherapy may cause fewer side effects than does external beam radiation, and the overall treatment time is usually shorter with brachytherapy. (Source: mayoclinic.com)

Brachytherapy is the quickest, most direct and conformal way to deliver the radiation to the target. High dose rate (HDR) brachytherapy for breast cancer is usually administered as a complete course given twice a day for a total of 5 days on an outpatient basis. There are two methods of brachytherapy depending upon the size and location of the tumor in relationship to the size and shape of the breast. One is known as "Tube and Button" and the other is referred to as "Balloon Catheter" or "Mammosite".(Source: http://www.cetmc.com)

INTERVIEW

Rakesh Patel, MD, Past Chairman of the American Brachytherapy Society and Director of Breast Cancer Services at Western Radiation Oncology in Pleasanton, CA, talks about targeting breast cancer with pinpoint precision.

Before brachytherapy how would you treat breast cancer?

Dr. Patel: The conventional way to treat breast cancer is with targeted therapies. When breast cancer is detected early, often times these cancer are amenable to a more limited surgery called a lumpectomy. After lumpectomy a patient undergoes external beam radiotherapy to address any residual cancer cells left behind, which treats the whole breast and that treatment is designed to give a little radiation every day Monday through Friday for about a ten to fifteen minute treatment and takes about six weeks to deliver.

What's the danger of treating the whole breast?

Dr. Patel: There is no inherent danger of treating the whole breast aside from the fact that it may not be necessary. Imaging has advanced significantly and we've learned that often times cancers are very limited to a small area of the breast and therefore our treatments can be focused as well.

Can this extra radiation cause more problems when you're radiating healthy tissue?

Dr. Patel: Yes. With whole breast radiation you're delivering radiation from the outside in, and so although the remaining cancer risk area may be just around the surgery, you have more collateral radiation exposure. This could lead to potentially more damage to the nearby healthy tissues including the skin, heart, lungs, ribs and normal breast that you may not have if you target the treatment area.

How does brachytherapy reduce that risk?

Dr. Patel: Brachytherapy is a much more precise treatment. It delivers more radiation right to the area at risk after surgery and it delivers radiation from the inside out. It really hones in to that area, and preserves a lot of the healthy tissue so you don't have some of the unnecessary radiation exposure that you do with conventional therapy.

And how does treatment work with brachytherapy?

Dr. Patel: Brachytherapy literally means arm's length therapy. That's what the word ‘brachy' means from the Greek derivative. It's short distance therapy compared to conventional therapy that treats the entire breast. Brachytherapy is again, a targeted type of treatment to the surgical bed that really hones in to the area that's at risk of having any residual disease after a lumpectomy. The more limited volume allows us to amplify the amount of radiation that's delivered every day, and allows us to deliver an equivalent dose of treatment over five days or one week.

How long for each treatment?

Dr. Patel: Each treatment lasts about five to ten minutes and over the course of a week and is therefore a more convenient option for patients compare to 6 weeks.

Is there a lot of side effects to this?

Dr. Patel: The advantage of having a targeted treatment is the side effect profile is significantly better than if you treat a wider area. You have less skin damage, you have less radiation to healthy tissues. The side effect profile with the studies that we have seen thus far is much more favorable.

You said that brachytherapy has been around for a long time and this is just new for breast?

Dr. Patel: Brachytherapy as a modality has been around for decades. It's application to breast cancer as an alternative to whole breast radiotherapy has actually been around for over fifteen years. We've been studying it in the US alone since the mid-nineties. What's really advanced is the devices that are available, so the innovation has made this much simpler for physicians and for patients while giving us much more control of the radiation dose that is delivered.

What difference do you see in your patients?

Dr. Patel: What I'm seeing primarily in breast cancer is patients are being detected much earlier of the evolution of breast cancer. With advances in imaging, with more awareness patients are being detected at a time when the cancer is really limited in the breast, and that makes it more amenable to targeted procedures. With that I see more eligibility for things like partial breast irradiation.

How long have you been doing this?

Dr. Patel: I have a special interest in brachytherapy so I've been doing it since the late nineties. I have had the privilege of researching this in the academic sector, and more recently in the community practice, and have treated well over fifteen hundred patients.

Why do you think it is slower to catch on?

Dr. Patel: Brachytherapy remains a subspecialty. It's used for multiple different body sites. Its utility in breast cancer really requires specialized clinical expertise coupled with modern technology, and because of that it's not available in every center.

Some people would rather have the whole breast radiated just in case there are other cells out there. Is there any risk that you're missing cells with such targeted therapy?

Dr. Patel: Conventionally we've always treated the whole breast after a lumpectomy and part of that was the notion that perhaps the entire breast is at risk of having cancer cells. We have learned from multiple studies both clinically and pathologically, that the whole breast is not at risk in all patients. When you compare studies in patients who have whole breast versus partial breast, the recurrence risk for cancer coming back in other portions of the breast that are not treated with brachytherapy is the same. All of the benefit of radiotherapy delivered after a lumpectomy is really around where that initial cancer presented.

What's the likelihood of recurrence if you have brachytherapy versus not having brachytherapy?

Dr. Patel: We have a lot of data worldwide on the utility of breast brachytherapy as an alternative to whole breast radiation therapy. There are some questions that still are out there and the questions really are how far you can push the envelope in terms of patient selection? In patients that have small lesions that are limited to the breast, we know that the outcomes are really equivalent. We have better toxicity profiles and some improvement in quality of life. More recently there was a study from MD Anderson that looked at Medicare billing claims and tried to compare patients that had whole breast radiotherapy with brachytherapy and used the subsequent mastectomy rates as a surrogate for local failures. What they found is that in patients who had brachytherapy that subsequent mastectomy rates were about four percent, and with the whole breast radiation they were just over 2 percent.

The report was based upon a review of Medicare claims data and, as such, is subject to limits in interpretation due to its retrospective nature and the inherent selection bias that exists in any study of this design. From prior analyses, we know that Medicare claims data are severely limited when it comes to extracting critically important details such as the general medical condition of the patient, the extent of the tumor, and many other important prognostic factors.

Despite brachytherapy or not, they would have had another cancer?

Dr. Patel: No. The way that study was conducted isn't necessarily the currency of what we use as scientific evidence. We have a significant body of evidence looking at brachytherapy and we have a significant amount of evidence looking at whole breast radiotherapy. The outcomes are really equivalent if you have similar patient's selection criteria. This study adds very little to what we know about breast radiation currently.

When you met Nina where was she in her breast cancer?

Dr. Patel: I met Nina in consultation. Nina was faced with an early stage breast cancer and had to make a decision on whether she wanted to have conventional whole breast radiotherapy after a lumpectomy or whether she wanted to have something more targeted.

Was there any question in your mind that she should just go brachytherapy?

Dr. Patel: When I see patients that are good candidates with favorable risk breast cancer I actually offer them both options. To me the focus is really patient cure, and then trying to adapt the treatment to what makes the most sense for them. The advantage of brachytherapy for Nina in particular was that you have equivalent local control rates because she's so favorable in her disease process, but it really offered her a more accelerated treatment and a more convenient option, allowed her to get back to her normal life quicker and with favorable toxicity profiles.

FOR MORE INFORMATION, PLEASE CONTACT:

Rakesh Patel, MD
Western Radiation Oncology
Patel@wradonc.com
(925) 734-8130 ext 140

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