History of Breast Brachytherapy
Brachytherapy was the second treatment for breast cancer in history. Prior to 1898, cautery (putting a hot iron on tumors!) and operating without anesthesia or sterile techniques were the only options. Because of these crude techniques and because most women were diagnosed late, the outcomes with surgery alone were very disappointing.
Marie Curie discovered radioactivity, the origin for all forms of
It was not long thereafter that radium found its way into the treatment of patients with various types of cancers.
Illustration: Dr. Keynes' technique of inserting radium needles into areas of breast cancer.
In the 1920s, many surgeons were performing increasingly radical operations for women with breast cancer, trying to improve the outcomes. A British surgeon by the name of Geoffrey Keynes, practicing in London, observed that these radical operations weren't really curing more women. He proposed a different approach: brachytherapy! He inserted special needles made of radioactive radium into the breast and even into armpit lymph nodes to sterilize the cancer. He published his results in the prestigious British Medical Journal in 1938, complete with patient photos, and surprised the medical community with excellent outcomes despite the fact that radical surgery was not performed.
He concluded this procedure was just as successful as radical surgery. Unfortunately, World War II broke out soon thereafter and his radium needles had to be buried throughout the countryside, so one lucky strike by a German bomb could not contaminate the city. After the war, Geoffrey Keynes gave up medical practice and brachytherapy as the sole method of irradiating breast cancer was abandoned. Dr. Kuske's and his colleagues rejuvenated this idea over 50 years later in New Orleans.
In 1991, a successful Venezuelan businesswoman named Rosario traveled to New Orleans after being diagnosed with early stage breast cancer. Rosario followed a long tradition of South Americans, including the famous Evita Perron of Argentina, who came to New Orleans for treatment of their serious illnesses. Dr. Kuske, was, at the time, Chairman of Radiation Oncology at the Ochsner Clinic in New Orleans.
After work-up in the clinic, Dr. Kuske offered Rosario the then standard options of either mastectomy or lumpectomy followed by six weeks of daily radiation. Rosario was a very busy businesswoman and the matriarch of her extended family. In her home country, she lived over 200 miles from the nearest radiation center. She declared to the physicians: "Doctors - I will not lose my breast to this cancer and I cannot stay in New Orleans for 6 weeks of radiation therapy!" Rosario challenged us to not only treat her cancer, but consider her social, professional, and personal situation in tailoring the treatment. She sent us to the drawing board to come up with a treatment that was customized to her person, not just her tumor.
Her surgeon, a colleague of Dr. Kuske's, suggested that they consider treating Rosario with brachytherapy after removal of the visible cancer mass (lumpectomy). This technique of removing the large mass and treating the surrounding area with brachytherapy was an accepted technique for sarcomas, an uncommon type of tumor arising in muscles and fat tissue of the arms and legs.
Illustration: After completion of the implant, small buttons are used to secure catheters so they won't fall out. This it what it looks like
when you go home.
when you go home.
Memorial Sloan Kettering Cancer Center, a world-famous cancer hospital in New York, had demonstrated this. Like other hospitals, we were emulating this technique in New Orleans and had comparably good results in treating these sarcomas. The appealing feature of this technique was its speed: catheters (thin hollow tubes) were placed in and around the surgery site immediately after the mass was removed and loaded with radiation a few days later. The entire radiation treatment was completed in less than a week.
And so, they took this concept of brachytherapy-after-surgery, held it up against the challenge Rosario had presented us, and it looked good! They offered this to Rosario and she accepted. She underwent removal of her cancerous lump, and immediately after this, with the wound still open, Dr. Kuske inserted catheters in and around the original location of the cancerous lump. Radiation was delivered through these catheters over the next few days using low-dose-rate Iridium-192 seeds, and the catheters were then removed and Rosario returned home.
Breast Brachytherapy since New Orleans
After Rosario's successful treatment, Dr. Kuske continued applying this technique in New Orleans for women who agreed to participate in their Institutional Review Board-approved clinical trial. In 1995, he wrote and designed a national research trial (the Radiation Therapy Oncology Group trial 95-17) in which other physicians in the country learned his technique and enrolled their patients, providing further evidence about brachytherapy. Ninety-nine women were treated with this new brachytherapy technique after their lumpectomy. These results were also favorable; importantly, this trial included centers from all over North America, proving that brachytherapy could, indeed, 'play in Peoria!'
It was women insisting on a 5-day alternative and bold physicians who also took up this challenge that moved this treatment into the mainstream of breast cancer care. Early implants were done 'by eye' in the operating room. After physicians positioned the catheters to their satisfaction, the surgeon would close the wound. They waited a few days for some basic healing to occur before the catheters were used for the radiation treatments. Many patients were treated after Rosario and the New Orleans results were outstanding. After 7 years of follow-up after treatment with brachytherapy, Dr. Kuske had 163 patients and only a 4% local breast recurrence rate. This was comparable to (or better than) the outcomes seen with the best radical mastectomy or whole breast radiation trials published to date.