Improving Breast Cancer Treatment Through Accelerated Partial Breast Irradiation
Guest
: Douglas Arthur, MD
From the Show: VCU Health System
Breast cancer surgery is often followed by radiation treatment. Dr. Douglas Arthur, Chair of Radiation Oncology at VCU Massey Cancer Center, discusses accelerated partial breast irradiation.
Transcription:
Alyne Ellis (Host): Once you’ve had breast cancer surgery, radiation is often the next step in your recovery. Here to tell us about a very effective and less invasive radiation procedure is Dr. Douglas Arthur, Chair of Radiation Oncology at VCU Massey Cancer Center. Welcome to Healthy with VCU Health. I’m Alyne Ellis. Dr. Arthur, thanks for joining me. What is APBI, Accelerated Partial Breast Irradiation?
Douglas Arthur, MD (Guest): Let me give you a little bit of background and then we’ll go right into it. For early stage breast cancer – those women with relatively small tumors and negative nodes – they have the option to either have a mastectomy with or without reconstruction or preserve the breast by removing the tumor with a rim of normal tissue and then following with radiation therapy to take care of any microscopic disease that might be left behind, thus giving the same results from a mastectomy or with breast conservation therapy.
Traditionally, that radiation has meant treating the whole breast, and it was started with a regimen of treatments given each day, Monday through Friday, break on the weekends, for about six to seven weeks to deliver a short burst of radiation. It’s typically well tolerated; some local problems such as skin reaction, maybe some breast swelling, maybe some fatigue, but overall, well tolerated. Over time, we’ve been looking at how we can make the experience better for the patient and allow the patient to have some choices.
In the early 1990s, we realized that if the cancer is going to come back after a lumpectomy, it’s most likely going to come back right in that area. Very rarely does it come up elsewhere in the breast. And so the thought was, do we really need to treat the whole breast? And if we don’t have to treat the whole breast; therefore, partial breast, could we do it quicker and accelerate the treatment? So, a lot of things have happened since the 1990s. First, we initiated treatments with accelerated partial breast irradiation where we would treat just the area around the lumpectomy bed twice a day for five days, which is a great advance over having to come into the clinic every day Monday through Friday, break on the weekends, for six to seven weeks.
But at about the same time, investigation was going into whether we could make whole breast radiotherapy better. Latter data came out showing that you could increase the dose per day, treat the same whole breast field and get it done in three to four weeks, which greatly improved that experience. But, simultaneously, back and forth, we also had some advances in accelerated partial breast radiotherapy in two ways. One, as of December 2019, we achieved 10-year data presentation from a large 4200 patient national trial, which showed that the outcome between whole breast radiotherapy and partial breast radiotherapy was equivalent, not only in terms of disease control but also in regards to cosmetic outcome. Also during that time, we found that, using all what we know about radiation, we could take that regimen of twice a day for five days and further accelerate it and get that treatment down to only three treatments, therefore getting things done in two days.
Host: Explain to me how very precise this particular procedure is.
Dr. Arthur: Accelerated partial breast radiotherapy utilizes highly conformal dose delivery approaches to achieve our goals. The original way we started doing this was with brachytherapy. Brachytherapy is the use of radioactive sources either temporarily or permanently within the tissues. Many patients know about it because we’ve been doing it for a long time in prostate cancer, where we put radioactive sources into the prostate and they stay, deliver the dose over time and essentially “burn out” over time and deliver a dose that’s very effective.
In the case of breast, we started with a temporary placement of device or some catheters to deliver short bursts of radiation using a radioactive source into a highly defined area twice a day over five days. We also have an external beam approach, which delivers the dose to a highly conformal treatment field that has been delivered twice a day for five days for a total of ten treatments, just like the brachytherapy. There also is some data talking about delivering radiation once a day for five treatments, but delivering it every other day, so it stretches out after two-and-a-half weeks. And actually, there is a third technique where they are using some permanent radioactive sources placed within the breast to deliver this dose.
So, there are a lot of different methods and approaches to deliver this partial breast treatment. All of them focus on highly conformal fields to the area at rest and accelerating the treatment to get it done safely and effectively so that the patient can move on either for additional treatment or just move on with their life and put this behind them.
Host: Who are the patients who are eligible for this particular treatment approach?
Dr. Arthur: This treatment approach focuses on early stage disease. So, candidates for this approach are women who have small tumors – less than three centimeters; have a lumpectomy that achieves a negative margin, which is what the goal of the lumpectomy is; does not have any positive nodes; and has a cavity that’s left behind from the surgeon that’s easily identifiable, so we have a target and is approachable by one of the techniques.
Patients who wouldn’t be eligible or appropriate for this are more advanced cancer cases.
An additional way that we are looking at the utilization of this approach and which we have recently published from a national trial is in women who have had traditional whole breast radiotherapy, have subsequently developed a new cancer within that breast but still want to keep the breast. Traditionally, they have a mastectomy because of the previous radiation. But in this trial, we’ve shown that the surgeon can repeat a lumpectomy and we can use this partial breast radiation therapy to continue to preserve the breast and control the cancer effectively.
So, those are a couple of areas where this may be appropriate.
Host: So, APBI can be repeated more than one time?
Dr. Arthur: Yes, but it depends on the situation. If you’ve had partial breast radiotherapy initially, and you develop another cancer in that breast, you may be able to do radiation again. But oftentimes in that situation, we’ll do a lumpectomy for the new cancer and then treat the whole breast with radiation. In other words, because you had partial breast irradiation doesn’t mean that you have to lose the breast if things don’t work out in your favor.
And the reverse of that would be if you have had whole breast radiotherapy and then the cancer recurred or a new cancer popped up, you may still be able to keep the breast by going through partial breast radiation.
Host: So, as far as benefits go, in addition to the breast not swelling as much with APBI, what other physical benefits are there to using this procedure?
Dr. Arthur: Side effects of radiation therapy depend on a combination of factors: where we are delivering the radiation, how high the dose is that we are giving and the volume of tissue that we are treating. So, in this particular case, in comparison to whole breast radiotherapy, we are still treating breast tissue, and we are still giving an effective dose, but the main difference is it is a much smaller volume of tissue being treated. And so, we have the ability to decrease the skin dose and decrease the volume of breast tissue that is getting treated that would lead to swelling and scar tissue, and potentially have less toxicity from the treatment.
I will tell you from the national trial; however, that the toxicity was relatively well accepted in whole breast radiotherapy. It’s hard to make a lot of improvement, but there may be individuals who we will identify that would be better off with partial breast radiotherapy, such as a woman with a large breast where a whole breast radiotherapy may have a bigger impact in a negative way than if we only treated a small volume of tissue. And so, we are trying to figure out in whom the toxicity would be less if we did partial breast on a reliable basis.
Host: And you’ve been involved in these trials. What’s going on at the moment that you are testing?
Dr. Arthur: Right now our biggest thing is trying to move it to an even shorter treatment approach. As I mentioned to you, it has been twice a day for five days, which often includes the weekend, and therefore you are looking at about eight days of having catheters or a device in place or coming in and out for the external beam approach. Now that we are starting to move to even shorter treatments, which have only recently been found with equivalent toxicity, we are still working through the logistics and focusing on getting it even shorter. Trying to get it down to reliable two days so patients can come in, maybe have one night with a device or catheters in place and then have them removed the next day and move on.
Host: Dr. Douglas Arthur is the Chair of Radiation Oncology at VCU Massey Cancer Center. To learn more about breast cancer care at VCU Massey Cancer Center, visit www.masseycancercenter.org or call 877-4MASSEY. To listen to other podcasts from VCU Health visit www.vcuhealth.org/podcasts. This is Healthy with VCU Health. I’m Alyne Ellis. Thanks for listening.
Alyne Ellis (Host): Once you’ve had breast cancer surgery, radiation is often the next step in your recovery. Here to tell us about a very effective and less invasive radiation procedure is Dr. Douglas Arthur, Chair of Radiation Oncology at VCU Massey Cancer Center. Welcome to Healthy with VCU Health. I’m Alyne Ellis. Dr. Arthur, thanks for joining me. What is APBI, Accelerated Partial Breast Irradiation?
Douglas Arthur, MD (Guest): Let me give you a little bit of background and then we’ll go right into it. For early stage breast cancer – those women with relatively small tumors and negative nodes – they have the option to either have a mastectomy with or without reconstruction or preserve the breast by removing the tumor with a rim of normal tissue and then following with radiation therapy to take care of any microscopic disease that might be left behind, thus giving the same results from a mastectomy or with breast conservation therapy.
Traditionally, that radiation has meant treating the whole breast, and it was started with a regimen of treatments given each day, Monday through Friday, break on the weekends, for about six to seven weeks to deliver a short burst of radiation. It’s typically well tolerated; some local problems such as skin reaction, maybe some breast swelling, maybe some fatigue, but overall, well tolerated. Over time, we’ve been looking at how we can make the experience better for the patient and allow the patient to have some choices.
In the early 1990s, we realized that if the cancer is going to come back after a lumpectomy, it’s most likely going to come back right in that area. Very rarely does it come up elsewhere in the breast. And so the thought was, do we really need to treat the whole breast? And if we don’t have to treat the whole breast; therefore, partial breast, could we do it quicker and accelerate the treatment? So, a lot of things have happened since the 1990s. First, we initiated treatments with accelerated partial breast irradiation where we would treat just the area around the lumpectomy bed twice a day for five days, which is a great advance over having to come into the clinic every day Monday through Friday, break on the weekends, for six to seven weeks.
But at about the same time, investigation was going into whether we could make whole breast radiotherapy better. Latter data came out showing that you could increase the dose per day, treat the same whole breast field and get it done in three to four weeks, which greatly improved that experience. But, simultaneously, back and forth, we also had some advances in accelerated partial breast radiotherapy in two ways. One, as of December 2019, we achieved 10-year data presentation from a large 4200 patient national trial, which showed that the outcome between whole breast radiotherapy and partial breast radiotherapy was equivalent, not only in terms of disease control but also in regards to cosmetic outcome. Also during that time, we found that, using all what we know about radiation, we could take that regimen of twice a day for five days and further accelerate it and get that treatment down to only three treatments, therefore getting things done in two days.
Host: Explain to me how very precise this particular procedure is.
Dr. Arthur: Accelerated partial breast radiotherapy utilizes highly conformal dose delivery approaches to achieve our goals. The original way we started doing this was with brachytherapy. Brachytherapy is the use of radioactive sources either temporarily or permanently within the tissues. Many patients know about it because we’ve been doing it for a long time in prostate cancer, where we put radioactive sources into the prostate and they stay, deliver the dose over time and essentially “burn out” over time and deliver a dose that’s very effective.
In the case of breast, we started with a temporary placement of device or some catheters to deliver short bursts of radiation using a radioactive source into a highly defined area twice a day over five days. We also have an external beam approach, which delivers the dose to a highly conformal treatment field that has been delivered twice a day for five days for a total of ten treatments, just like the brachytherapy. There also is some data talking about delivering radiation once a day for five treatments, but delivering it every other day, so it stretches out after two-and-a-half weeks. And actually, there is a third technique where they are using some permanent radioactive sources placed within the breast to deliver this dose.
So, there are a lot of different methods and approaches to deliver this partial breast treatment. All of them focus on highly conformal fields to the area at rest and accelerating the treatment to get it done safely and effectively so that the patient can move on either for additional treatment or just move on with their life and put this behind them.
Host: Who are the patients who are eligible for this particular treatment approach?
Dr. Arthur: This treatment approach focuses on early stage disease. So, candidates for this approach are women who have small tumors – less than three centimeters; have a lumpectomy that achieves a negative margin, which is what the goal of the lumpectomy is; does not have any positive nodes; and has a cavity that’s left behind from the surgeon that’s easily identifiable, so we have a target and is approachable by one of the techniques.
Patients who wouldn’t be eligible or appropriate for this are more advanced cancer cases.
An additional way that we are looking at the utilization of this approach and which we have recently published from a national trial is in women who have had traditional whole breast radiotherapy, have subsequently developed a new cancer within that breast but still want to keep the breast. Traditionally, they have a mastectomy because of the previous radiation. But in this trial, we’ve shown that the surgeon can repeat a lumpectomy and we can use this partial breast radiation therapy to continue to preserve the breast and control the cancer effectively.
So, those are a couple of areas where this may be appropriate.
Host: So, APBI can be repeated more than one time?
Dr. Arthur: Yes, but it depends on the situation. If you’ve had partial breast radiotherapy initially, and you develop another cancer in that breast, you may be able to do radiation again. But oftentimes in that situation, we’ll do a lumpectomy for the new cancer and then treat the whole breast with radiation. In other words, because you had partial breast irradiation doesn’t mean that you have to lose the breast if things don’t work out in your favor.
And the reverse of that would be if you have had whole breast radiotherapy and then the cancer recurred or a new cancer popped up, you may still be able to keep the breast by going through partial breast radiation.
Host: So, as far as benefits go, in addition to the breast not swelling as much with APBI, what other physical benefits are there to using this procedure?
Dr. Arthur: Side effects of radiation therapy depend on a combination of factors: where we are delivering the radiation, how high the dose is that we are giving and the volume of tissue that we are treating. So, in this particular case, in comparison to whole breast radiotherapy, we are still treating breast tissue, and we are still giving an effective dose, but the main difference is it is a much smaller volume of tissue being treated. And so, we have the ability to decrease the skin dose and decrease the volume of breast tissue that is getting treated that would lead to swelling and scar tissue, and potentially have less toxicity from the treatment.
I will tell you from the national trial; however, that the toxicity was relatively well accepted in whole breast radiotherapy. It’s hard to make a lot of improvement, but there may be individuals who we will identify that would be better off with partial breast radiotherapy, such as a woman with a large breast where a whole breast radiotherapy may have a bigger impact in a negative way than if we only treated a small volume of tissue. And so, we are trying to figure out in whom the toxicity would be less if we did partial breast on a reliable basis.
Host: And you’ve been involved in these trials. What’s going on at the moment that you are testing?
Dr. Arthur: Right now our biggest thing is trying to move it to an even shorter treatment approach. As I mentioned to you, it has been twice a day for five days, which often includes the weekend, and therefore you are looking at about eight days of having catheters or a device in place or coming in and out for the external beam approach. Now that we are starting to move to even shorter treatments, which have only recently been found with equivalent toxicity, we are still working through the logistics and focusing on getting it even shorter. Trying to get it down to reliable two days so patients can come in, maybe have one night with a device or catheters in place and then have them removed the next day and move on.
Host: Dr. Douglas Arthur is the Chair of Radiation Oncology at VCU Massey Cancer Center. To learn more about breast cancer care at VCU Massey Cancer Center, visit www.masseycancercenter.org or call 877-4MASSEY. To listen to other podcasts from VCU Health visit www.vcuhealth.org/podcasts. This is Healthy with VCU Health. I’m Alyne Ellis. Thanks for listening.