The Role of Radiation Therapy in the Treatment of Breast Cancer
Guest
: Neha Bhooshan, MD
From the Show: UPMC Pinnacle
Dr. Neha Bhooshan, a radiation oncologist at UPMC Hillman Cancer Center in Harrisburg, discusses the process, as well as the side effects of radiation therapy in the treatment of breast cancer.
Transcription:
Bill Klaproth (Host): As we know from the American Cancer Society in 2019, there was an estimated 268,600 new cases of invasive breast cancer in women and 2,670 cases in men. Additionally, there were an estimated 48,100 cases of ductal carcinoma in situ cases. And approximately 41,760 women and 500 men passed away from breast cancer in 2019. Very sobering statistics. So, we are here today with Dr. Neha Bhooshan, a Radiation Oncologist at UPMC Hillman Cancer Center in Harrisburg to discuss the role of radiation therapy in the treatment of breast cancer.
This is Healthier You, a podcast from UPMC Pinnacle. I'm Bill Klaproth. Dr. Bhooshan, it is always great to talk with you. Thank you so much for your time. So, first off, what is the general approach to treating breast cancer once it has been diagnosed?
Neha Bhooshan, MD (Guest): Thank you so much for having me here. And I'm always happy to discuss cancer treatment with our patients. As I had discussed in my previous podcast, cancer treatment typically involves three pillars of treatment. Surgery, systemic therapy, which includes chemotherapy and hormone therapy and radiation therapy. So once all the necessary work imaging and biopsy has been done, and we know the staging of the patient's breast cancer, we can determine what treatments are necessary. For most breast cancer patients, they will proceed first with surgery. With either mastectomy, which is the removal of the entire breast or lumpectomy, which is the removal of just where the tumor is in the breast.
Typically, the lymph nodes are also assessed at that time. Depending on what is seen in the tissue taken from the surgery and any additional testing if needed, we then decide if the patient needs additional treatment like chemotherapy and or radiation therapy.
Host: Okay. So, let's talk a little bit more about radiation therapy. What types of breast cancer radiation therapies are there?
Dr. Bhooshan: There are several ways that we can deliver radiation depending on the machine, the target, the dose, et cetera. So, when the patient meets with a radiation oncologist, they will review the patient's entire oncologic history to determine what is the optimal treatment or treatments for that specific patient. The most common way we deliver radiation therapy is external beam radiation therapy with a machine called a Linear Accelerator. It is basically like getting an x-ray. If the patient underwent a mastectomy, then there are certain indications that must be met for the patient to be offered radiation. Such as positive lymph nodes or a positive margin from the surgery. The target would be the chest wall, with or without the regional lymph nodes. If the patient underwent a lumpectomy, then the standard of care is to offer breast radiation and there are several options to consider. The most common treatment is to give radiation therapy to the entire breast. Sometimes the regional lymph nodes are included depending on the pathology from the surgery.
External beam radiation therapy is given daily, Monday through Friday for a certain number of weeks, which will be determined by the radiation oncologist. For certain patients who meet a very strict set of criteria, accelerated partial breast radiation may be an option and would be discussed by the radiation oncologist. This involves giving radiation only to where the tumor bud is. This is typically a shorter treatment and can be delivered either using the Linear Accelerator machine or at our York facility using a specialized technique called Brachytherapy. Every patient is different. So, again, when the patient meets with the radiation oncologist, they will review the patient's entire oncologic history and review the best treatment option or options for that specific patient.
Host: So, for someone who does need breast radiation, what is the process by which a patient does get breast radiation therapy.
Dr. Bhooshan: First, they will meet with the radiation oncologist to discuss the rationale, the logistics, and obviously the side effects of the radiation treatments. Once the patient agrees to proceed with radiation, they will then be scheduled for a CT Simulation Scan. We do customized radiation. Everyone's tumor and body anatomy is different. So, we fit the radiation beams to the patient's specific tumor and anatomy.
The other issue is, is that if the patient is laying on the treatment table and then starts moving, the radiation machine or Linear Accelerator cannot track a patient's body in real time. We want to make sure that the patient is in the same position every time for radiation treatment, so, we can be confident the radiation is going where it is supposed to go. To address those two issues we have patients undergo what is called a CT Simulation Scan or a Planning Scan.
Every radiation oncology clinic in the UPMC Pinnacle network has its own CT scanner for this purpose. Patients will come in and be placed in the treatment position using a mold. The patient is then scanned. Our radiation therapist will then place very small permanent tattoos, the size of a freckle on the patients, since we have lasers in the treatment room and use those tattoos to ensure accurate set up every day.
The patient then goes home. On our end, we contour where the tumor is on that CT scan. The nearby normal organs or structures, or also contoured. The radiation beams are then placed to give the prescribed dose to the target, to the tumor, while minimizing radiation dose to those nearby organs in order to minimize potential side effects of the radiation treatment.
We have physicists on staff here who do a QA or safety check on the radiation plan to make sure everything is safe. Once the radiation plan is ready, the patient will then return to our clinic and start radiation. The planning process typically takes one to two weeks to then generate the customized radiation plan.
The patient then comes and we'll start the radiation. A typical breast radiation treatment is approximately 10 to 20 minutes. Patients will not feel anything during treatment. It is just like getting an x-ray or a CT scan. The patient will not feel, hear, or smell anything. Typically patients are not radioactive while getting radiation nor afterwards. And they are safe to be around their family and pets during the radiation treatment.
Host: Wow. That is really interesting. So, let me ask you this, about side effects. You were talking about minimizing the radiation dose to those nearby organs, in order to minimize the potential side effects of the radiation treatment. So, what are the side effects of breast radiation?
Dr. Bhooshan: That is a very important question, since patients are obviously concerned about potential side effects with cancer treatments. I always emphasize to my patients that radiation is a local treatment. Wherever the beams go, the radiation goes. So, breast radiation is typically targeted to the breast or chest wall with or without the regional lymph nodes, which are essentially the axilla or the armpit going up to the base of the neck on that same side.
There are side effects that happen during radiation treatments, since it may be several weeks and there were side effects that happen after the radiation is done. Common side effects that can happen during the radiation include mild fatigue. It is not like chemotherapy fatigue. I have many patients who are able to work during breast radiation, since it is mild fatigue.
All the other side effects are local to where the beam is directed, which again is the breast or chest wall area. So, common side effects include irritated skin in the treatment field. The skin can get pink. It can get red, it can tan or get very dark. It can peel, maybe even blister, like a sunburn or maybe open in very small areas.
We review skin lotions with our breast cancer patients to help minimize that reaction. And we keep a very close eye on our patients during the treatment, since they're coming in every day for treatment, as it is. After the radiation treatment is done the skin typically heals within a few weeks.
The radiation can also irritate the breast tissue or the chest wall tissue. So, patients may develop mild soreness or swelling in those areas. Typically, over the counter medications, such as Tylenol or ibuprofen are sufficient, and that irritation usually resolves once the treatment is done. The radiation oncologist will go into a detailed discussion of potential side effects during treatment.
Host: Okay. So, that's a great rundown of the side effects during treatment. And you said there are side effects during treatment and after treatment. So, I'm curious about the side effects and what can happen after breast radiation is done. Can you go more into depth on that?
Dr. Bhooshan: Of course. After the radiation is done, the skin typically heals very well, once the radiation is done, especially any open areas and a very small percentage of patients may have permanent skin changes after the radiation. The breast or chest wall may develop scar tissue, which may affect the cosmetic look of the breast. There's a very small risk of breast lymphedema, which is persistent swelling of the breast that may cause pain or discomfort.
We have an excellent physical therapy clinic with select physical therapy called revital,
Dr. Bhooshan: Which is dedicated to our breast cancer patients and can help with breast lymphedema. If that occurs. A small sliver of the underlying lung on the treated side may be exposed to the radiation. So, scar tissue can develop in that exposed lung.
The risk of any permit breathing changes from that scar tissue is very low. There was also a very low risk of that lung scar tissue getting inflamed causing a pneumonia like condition that we call radiation pneumonitis. If that occurs, we treat with high dose steroids and that typically resolves the issue.
There is also a very low risk of any injury to the underlying ribs or chest wall nerves. Now a small sliver of the heart may also be in the radiation field for left sided breast cancer patients. And what we worry the most about that is scar tissue may develop in any exposed coronary blood vessels, which are the vessels carrying blood to the heart so that it can do its job. So, I basically consider left sided breast radiation to be a risk factor for developing heart disease. There is also a very low risk of radiation causing a second cancer. Again, the radiation oncologist will go into a very detailed discussion of potential late side effects that may occur after breast radiation treatment.
Host: So, let's continue this discussion about the heart. And you said that a small sliver of the heart may be in the radiation field. Are there ways to be safe with radiation to the heart?
Dr. Bhooshan: Yes. Patients with left sided breast cancers are understandably very concerned about how radiation may affect the heart. So, obviously we take that very seriously. That is why we do a detailed planning process to develop that customized radiation plan and reduce the radiation dose to the heart as much as possible. We also have an additional technique available at all of our UPMC Pinnacle Radiation Oncology facilities called deep inspiration breath hold. So, interestingly enough, when you take a deep breath in and hold it, your heart actually changes position within your chest. It moves down and away from the front of your chest. Which is the target of the radiation. Now, obviously we can't ask patients to hold their breath for 10 to 20 minutes for radiation treatments. All we need is for them to hold their breath for at most 20 seconds at a time. That is the maximum amount of time we need to deliver one field. And typically a breast radiation treatment may use three to four fields to deliver one treatment.
So, patients will be asked to hold their breath and the field will be delivered. They can then breathe and then they'll hold their breath again. And the next field is delivered and so forth until the entire treatment is given. We use very specialized technology to accomplish this, which we review with the patient when they come in for that CT Simulation Scan. We have been using this deep inspiration breath hold technology for over five years now and have had great success with it. So, we are already safe with the radiation dose to the heart, and this technique really helps us further reduce the radiation dose to the heart.
Host: Really great information and comforting to know all the safety procedures that you take. Dr. Bhooshan, and as always, this has really been informative and fascinating. Thank you so much for your time. We really appreciate it.
Dr. Bhooshan: Thank you again so much for having me come on here. I'm always happy to discuss about what we can do for our cancer patients in the UPMC Pinnacle Network.
Host: And that's Dr. Neha Bhooshan. And for more information, please visit UPMCPinacle.com/cancer. And if you found this podcast helpful, please share it on your social channels and check out the full podcast library for topics of interest to you. This is Healthier You, a podcast from UPMC Pinnacle. I'm Bill Klaproth. Thanks for listening.
Bill Klaproth (Host): As we know from the American Cancer Society in 2019, there was an estimated 268,600 new cases of invasive breast cancer in women and 2,670 cases in men. Additionally, there were an estimated 48,100 cases of ductal carcinoma in situ cases. And approximately 41,760 women and 500 men passed away from breast cancer in 2019. Very sobering statistics. So, we are here today with Dr. Neha Bhooshan, a Radiation Oncologist at UPMC Hillman Cancer Center in Harrisburg to discuss the role of radiation therapy in the treatment of breast cancer.
This is Healthier You, a podcast from UPMC Pinnacle. I'm Bill Klaproth. Dr. Bhooshan, it is always great to talk with you. Thank you so much for your time. So, first off, what is the general approach to treating breast cancer once it has been diagnosed?
Neha Bhooshan, MD (Guest): Thank you so much for having me here. And I'm always happy to discuss cancer treatment with our patients. As I had discussed in my previous podcast, cancer treatment typically involves three pillars of treatment. Surgery, systemic therapy, which includes chemotherapy and hormone therapy and radiation therapy. So once all the necessary work imaging and biopsy has been done, and we know the staging of the patient's breast cancer, we can determine what treatments are necessary. For most breast cancer patients, they will proceed first with surgery. With either mastectomy, which is the removal of the entire breast or lumpectomy, which is the removal of just where the tumor is in the breast.
Typically, the lymph nodes are also assessed at that time. Depending on what is seen in the tissue taken from the surgery and any additional testing if needed, we then decide if the patient needs additional treatment like chemotherapy and or radiation therapy.
Host: Okay. So, let's talk a little bit more about radiation therapy. What types of breast cancer radiation therapies are there?
Dr. Bhooshan: There are several ways that we can deliver radiation depending on the machine, the target, the dose, et cetera. So, when the patient meets with a radiation oncologist, they will review the patient's entire oncologic history to determine what is the optimal treatment or treatments for that specific patient. The most common way we deliver radiation therapy is external beam radiation therapy with a machine called a Linear Accelerator. It is basically like getting an x-ray. If the patient underwent a mastectomy, then there are certain indications that must be met for the patient to be offered radiation. Such as positive lymph nodes or a positive margin from the surgery. The target would be the chest wall, with or without the regional lymph nodes. If the patient underwent a lumpectomy, then the standard of care is to offer breast radiation and there are several options to consider. The most common treatment is to give radiation therapy to the entire breast. Sometimes the regional lymph nodes are included depending on the pathology from the surgery.
External beam radiation therapy is given daily, Monday through Friday for a certain number of weeks, which will be determined by the radiation oncologist. For certain patients who meet a very strict set of criteria, accelerated partial breast radiation may be an option and would be discussed by the radiation oncologist. This involves giving radiation only to where the tumor bud is. This is typically a shorter treatment and can be delivered either using the Linear Accelerator machine or at our York facility using a specialized technique called Brachytherapy. Every patient is different. So, again, when the patient meets with the radiation oncologist, they will review the patient's entire oncologic history and review the best treatment option or options for that specific patient.
Host: So, for someone who does need breast radiation, what is the process by which a patient does get breast radiation therapy.
Dr. Bhooshan: First, they will meet with the radiation oncologist to discuss the rationale, the logistics, and obviously the side effects of the radiation treatments. Once the patient agrees to proceed with radiation, they will then be scheduled for a CT Simulation Scan. We do customized radiation. Everyone's tumor and body anatomy is different. So, we fit the radiation beams to the patient's specific tumor and anatomy.
The other issue is, is that if the patient is laying on the treatment table and then starts moving, the radiation machine or Linear Accelerator cannot track a patient's body in real time. We want to make sure that the patient is in the same position every time for radiation treatment, so, we can be confident the radiation is going where it is supposed to go. To address those two issues we have patients undergo what is called a CT Simulation Scan or a Planning Scan.
Every radiation oncology clinic in the UPMC Pinnacle network has its own CT scanner for this purpose. Patients will come in and be placed in the treatment position using a mold. The patient is then scanned. Our radiation therapist will then place very small permanent tattoos, the size of a freckle on the patients, since we have lasers in the treatment room and use those tattoos to ensure accurate set up every day.
The patient then goes home. On our end, we contour where the tumor is on that CT scan. The nearby normal organs or structures, or also contoured. The radiation beams are then placed to give the prescribed dose to the target, to the tumor, while minimizing radiation dose to those nearby organs in order to minimize potential side effects of the radiation treatment.
We have physicists on staff here who do a QA or safety check on the radiation plan to make sure everything is safe. Once the radiation plan is ready, the patient will then return to our clinic and start radiation. The planning process typically takes one to two weeks to then generate the customized radiation plan.
The patient then comes and we'll start the radiation. A typical breast radiation treatment is approximately 10 to 20 minutes. Patients will not feel anything during treatment. It is just like getting an x-ray or a CT scan. The patient will not feel, hear, or smell anything. Typically patients are not radioactive while getting radiation nor afterwards. And they are safe to be around their family and pets during the radiation treatment.
Host: Wow. That is really interesting. So, let me ask you this, about side effects. You were talking about minimizing the radiation dose to those nearby organs, in order to minimize the potential side effects of the radiation treatment. So, what are the side effects of breast radiation?
Dr. Bhooshan: That is a very important question, since patients are obviously concerned about potential side effects with cancer treatments. I always emphasize to my patients that radiation is a local treatment. Wherever the beams go, the radiation goes. So, breast radiation is typically targeted to the breast or chest wall with or without the regional lymph nodes, which are essentially the axilla or the armpit going up to the base of the neck on that same side.
There are side effects that happen during radiation treatments, since it may be several weeks and there were side effects that happen after the radiation is done. Common side effects that can happen during the radiation include mild fatigue. It is not like chemotherapy fatigue. I have many patients who are able to work during breast radiation, since it is mild fatigue.
All the other side effects are local to where the beam is directed, which again is the breast or chest wall area. So, common side effects include irritated skin in the treatment field. The skin can get pink. It can get red, it can tan or get very dark. It can peel, maybe even blister, like a sunburn or maybe open in very small areas.
We review skin lotions with our breast cancer patients to help minimize that reaction. And we keep a very close eye on our patients during the treatment, since they're coming in every day for treatment, as it is. After the radiation treatment is done the skin typically heals within a few weeks.
The radiation can also irritate the breast tissue or the chest wall tissue. So, patients may develop mild soreness or swelling in those areas. Typically, over the counter medications, such as Tylenol or ibuprofen are sufficient, and that irritation usually resolves once the treatment is done. The radiation oncologist will go into a detailed discussion of potential side effects during treatment.
Host: Okay. So, that's a great rundown of the side effects during treatment. And you said there are side effects during treatment and after treatment. So, I'm curious about the side effects and what can happen after breast radiation is done. Can you go more into depth on that?
Dr. Bhooshan: Of course. After the radiation is done, the skin typically heals very well, once the radiation is done, especially any open areas and a very small percentage of patients may have permanent skin changes after the radiation. The breast or chest wall may develop scar tissue, which may affect the cosmetic look of the breast. There's a very small risk of breast lymphedema, which is persistent swelling of the breast that may cause pain or discomfort.
We have an excellent physical therapy clinic with select physical therapy called revital,
Dr. Bhooshan: Which is dedicated to our breast cancer patients and can help with breast lymphedema. If that occurs. A small sliver of the underlying lung on the treated side may be exposed to the radiation. So, scar tissue can develop in that exposed lung.
The risk of any permit breathing changes from that scar tissue is very low. There was also a very low risk of that lung scar tissue getting inflamed causing a pneumonia like condition that we call radiation pneumonitis. If that occurs, we treat with high dose steroids and that typically resolves the issue.
There is also a very low risk of any injury to the underlying ribs or chest wall nerves. Now a small sliver of the heart may also be in the radiation field for left sided breast cancer patients. And what we worry the most about that is scar tissue may develop in any exposed coronary blood vessels, which are the vessels carrying blood to the heart so that it can do its job. So, I basically consider left sided breast radiation to be a risk factor for developing heart disease. There is also a very low risk of radiation causing a second cancer. Again, the radiation oncologist will go into a very detailed discussion of potential late side effects that may occur after breast radiation treatment.
Host: So, let's continue this discussion about the heart. And you said that a small sliver of the heart may be in the radiation field. Are there ways to be safe with radiation to the heart?
Dr. Bhooshan: Yes. Patients with left sided breast cancers are understandably very concerned about how radiation may affect the heart. So, obviously we take that very seriously. That is why we do a detailed planning process to develop that customized radiation plan and reduce the radiation dose to the heart as much as possible. We also have an additional technique available at all of our UPMC Pinnacle Radiation Oncology facilities called deep inspiration breath hold. So, interestingly enough, when you take a deep breath in and hold it, your heart actually changes position within your chest. It moves down and away from the front of your chest. Which is the target of the radiation. Now, obviously we can't ask patients to hold their breath for 10 to 20 minutes for radiation treatments. All we need is for them to hold their breath for at most 20 seconds at a time. That is the maximum amount of time we need to deliver one field. And typically a breast radiation treatment may use three to four fields to deliver one treatment.
So, patients will be asked to hold their breath and the field will be delivered. They can then breathe and then they'll hold their breath again. And the next field is delivered and so forth until the entire treatment is given. We use very specialized technology to accomplish this, which we review with the patient when they come in for that CT Simulation Scan. We have been using this deep inspiration breath hold technology for over five years now and have had great success with it. So, we are already safe with the radiation dose to the heart, and this technique really helps us further reduce the radiation dose to the heart.
Host: Really great information and comforting to know all the safety procedures that you take. Dr. Bhooshan, and as always, this has really been informative and fascinating. Thank you so much for your time. We really appreciate it.
Dr. Bhooshan: Thank you again so much for having me come on here. I'm always happy to discuss about what we can do for our cancer patients in the UPMC Pinnacle Network.
Host: And that's Dr. Neha Bhooshan. And for more information, please visit UPMCPinacle.com/cancer. And if you found this podcast helpful, please share it on your social channels and check out the full podcast library for topics of interest to you. This is Healthier You, a podcast from UPMC Pinnacle. I'm Bill Klaproth. Thanks for listening.
