About Breast Cancer

Whole Breast Radiation

Results Without Radiation Therapy

Why can’t I have just a lumpectomy for my breast cancer? Why is radiation therapy recommended?

Surgery and radiation work together to cure cancer in the breast. The lumpectomy procedure is surgical removal of the cancerous lump. The amount of breast tissue removed can be as small as a golf ball, or as large as an orange; every situation is different. Radiation therapy is usually given four to six weeks after lumpectomy, after all the surgical wounds have healed. Very few patients have a local recurrence after lumpectomy and radiation, and the very small percentage of patients who do have a local recurrence after lumpectomy and radiation may still have a mastectomy and be cured of their cancer. The result is that the cure rate for women choosing breast conservation is the same as for women undergoing mastectomy. And for this reason, most women with early breast cancer have the option of breast conservation in addition to the old standard of mastectomy.

Illustration: Invisibly small amounts of cancer can be left behind after lumpectomy. Radiation therapy can successfully eliminate these deposits.
It is important that all visible cancer be removed by the surgery, because large amounts of cancer cannot always be eliminated by radiation therapy. That’s why we sometimes describe breast conservation as surgery for the “big piece,” and radiation for the “little pieces.” Once in awhile, a patient needs a second lumpectomy to remove remaining visible cancer – a big piece – which is left behind after the first lumpectomy. Breast conservation is still very safe and effective if all the visible cancer can be removed in this second surgery. Rarely, large amounts of cancer remain despite a second lumpectomy procedure, and the patient usually has a mastectomy because breast conservation is less effective in this situation.
Some patients with early breast cancer still choose mastectomy even if they could have breast conservation. Rushing to mastectomy is often the first impulse a woman feels after discovering she has breast cancer, and that reaction is understandable. But, it is important that a patient hear all of her options before making a decision about treatment. In fact, it is the obligation of her cancer doctors to provide her with this information and, moreover, to make this information understandable before she makes her decision. Every patient is unique. Some will choose mastectomy for the smallest cancer even if breast conservation is possible, and this is perfectly fine, as long as the patient understands all of her options. Other patients will go to any length to conserve their breast and avoid mastectomy.
Women who choose to have a mastectomy rather than breast preservation usually do not need radiation after the mastectomy. The exception is a woman whose cancer is unexpectedly larger at the time of surgery or if many lymph nodes have cancer in them. In these patients, radiation may be used to treat the chest and lymph node regions (the armpit and area behind the collarbone) because radiation therapy lowers the chance of the cancer coming back in this area and improves her chances of surviving the breast cancer. This type of radiation is called post-mastectomy (meaning after mastectomy) radiation.

Results With Radiation Therapy

What are the chances of the cancer recurring in my breast if I choose breast conservation with lumpectomy and radiation?

Recurrence of cancer in the breast is around 5% after lumpectomy and radiation. This is much less than the one-in-three recurrence rate seen after lumpectomy only. And this is about the same recurrence seen with mastectomy, which is also well under 10%.

FOOTNOTE: In fact, this number – the one in three patients who recur if they undergo only lumpectomy – might be smaller or larger, depending on the size the cancer, the age of the patient, and other features. In some very specific situations, the risk of recurrence might be higher, perhaps as high as 40%.

In other situations, the risk is quite small with lumpectomy alone; some recent information identified patients with less than a 10% risk of recurrence after lumpectomy alone – provided that the patients took an estrogen-blocking drug like tamoxifen afterwards. But as we discuss below, radiation will decrease the risk of recurrence for all patients and reduce the risk of local recurrence. Most doctors still recommend radiation be used after lumpectomy for patients with breast cancer.

External Beam Radiation

The standard method of giving radiation after lumpectomy is external beam radiation. A radiation beam is created in a machine called a linear accelerator – linac for short. These beams are carefully shaped and aimed at the breast while the patient lies on the table under the machine.
A typical course of external beam radiation for breast cancer consists of once daily treatment, five days a week, for six to seven weeks. Patients do not stay in the hospital. In fact, each visit to the radiation clinic usually lasts less than 30 minutes. Many patients chose to continue to work during treatment and most are able to go about their normal activities. Most patients feel nothing during daily treatment with external beam radiation. No part of the treatment machine – the linac – touches the patient. The radiation beam is invisible and is projected out of the machine and penetrates through the breast.
There are two categories of side effects for patients getting radiation therapy. Short-term side effects occur during treatment and may last for several weeks after treatment is over. Short-term side effects are temporary and disappear a few weeks after all the treatments are over. Long-term side effects generally occur several months after treatment or even years later. A small number of long term side effects can be permanent, but are almost always mild and do not affect a woman’s long term quality of life.

Despite current screening mammography, some patients are diagnosed with locally-advanced and inflammatory breast cancers. These patiets need external beam radiation to reduce recurrence rates after chemotherapy and surgery.

Our physicians have over 30 years of the technical expertise to deliver this treatment with comprehensive coverage of all sites at risk, but minimizing lung and heart exposure. External beam radiation for breast cancer is very successful. With this treatment, recurrence of cancer in the breast is very uncommon and side effects are usually very mild.

The results after external beam radiation can be seen in the following photos. These excellent results are what you can expect.
Illustration: Radiation “targeted” beam treating the breast.
Long term results after External Beam Radiation
Another view of the results after External Beam Radiation

What to Expect

The short-term side effects of external beam radiation usually start a few weeks into treatment.

Fatigue

Fatigue is common and is usually mild or moderate, and resolves a few weeks after completion of radiation. It is almost never severe. Almost all patients can continue to go about their normal job or daily tasks, including driving.

Skin Reaction

A radiation skin reaction that occurs towards the end of treatment is very common. It is probably best described as a sunburn, although it is a little different. The skin of the breast and lower armpit become red, itchy, and may hurt like a sunburn. It may also become swollen, and the swelling is often the most obvious around the nipple. During treatment, patients are given special ointments to keep the skin healthy and to prevent drying and cracking. Some patients’ skin will peel, but the skin reaction heals completely in all cases within a few weeks of completing radiation.

Pain Expectations

Mild pain is uncommon. Severe pain is rare. Most pain is from the skin reaction discussed above, and is usually mild. Over-the-counter pain medicines usually control this pain, but doctors will provide stronger medicines if needed. In addition to skin pain, some patients will report very brief shooting-type pains in the breast during the course of treatment. These may occur a few hours after each treatment, or may come at any time. Sometimes these shooting pains are felt into the arm or hand. These shooting pains are almost always very brief and go away after radiation is completed.

Late Effects

There are very real long-term side effects from external beam radiation. Fortunately, most are mild.
Serious side effects are rare. Some possible long-term side effects reported by patients and doctors are discussed below.

  • Slight thickening of the skin of the treated breast is common. There is also some mild increased firmness of the breast, which can be permanent. In some patients the breast may sit slightly higher on the chest than the other (untreated) breast. This is called retraction and is the result of slight scarring in the breast that occurs under the skin. Surgery and radiation both contribute to this retraction.
  • The surgery and radiation may often lead to the treated breast looking different than the other breast. This is called asymmetry and this is an uncommon side effect. Often the treated breast is slightly smaller than the untreated breast, and has a small visible scar from the lumpectomy surgery. Depending on the location of the cancer, the scar that remains after the patient has healed from the lumpectomy may or may not be easily visible, and may or may not contribute to breast retraction. Scars in the very lower part of the breast are more obvious. Scars that are curved around the nipple area (called circum-areolar meaning around the nipple area) are less obvious and may even be invisible after a few months of healing. The location of the scar depends on the location of the cancer and the technique used by the surgeon.
  • Tenderness in parts of the treated breast is common. This is usually very mild, and patients note it only during a breast exam or mammogram. Sometimes this tenderness is permanent, but it is usually mild. The tenderness is usually located around the lumpectomy area.
  • Arm-swelling (edema) is rare with modern lymph node surgery and radiation therapy. Lymph node surgery alone will cause arm swelling in less than 10% of patients. Most of this swelling is mild, and severe swelling – that is, serious enough to affect a woman’s quality of life – occurs in less than 4%. Most arm-swelling occurs in patients who have had a full axillary dissection (which removes more lymph nodes and causes more scarring) combined with external beam radiation. Arm swelling can be permanent. Sentinel node surgery has reduced arm swelling rates even more because this procedure removes less tissue from the armpit and causes less scarring. Arm swelling occurs in about 1% of patients who have sentinel node surgery and radiation.
  • Rib fractures from external radiation are rare, occurring in about 1% of patients. They occur several months after the radiation treatment and may cause a side ache for a few months. All such fractures heal themselves and no specific treatment is needed.
  • Nerve or muscle damage from external beam radiation is very rare. This is much less common than arm edema. In fact, most radiation doctors will never see a case of this even if they practice for many years. We only include this side effect on this list because many patients ask about this during their consultation. Most cases of serious nerve problems in breast cancer patients are actually due to cancer growth, not the treatment. And most cases of radiation-caused nerve and muscle damage occur in patients who receive unusually high doses of radiation to the axilla (armpit area), after a full axillary dissection. We think that all the scarring that occurs after such surgery and high dose radiation damages the nerves over many months or years. Such surgery and high radiation doses are essentially never used for patients with early stage breast cancer.

AccuBoost®

Radiation of the breast tissue can be performed by different techniques.

When an early state breast cancer tumor is surgically removed by lumpectomy, physicians usually recommend a course of radiotherapy to minimize the chances of cancer recurrence. Radiation therapy is used to effectively “sterilize” any residual cancerous or pre-cancerous microscopic tissue that may exist in the vicinity of the tumor. Radiation therapy is an indispensable part of the breast conservation therapy procedure.

Radiation of the breast tissue can be performed by different techniques. The established standard-of-care for breast radiotherapy is whole breast irradiation (WBI). This is a procedure that is performed daily for a period of 6-7 weeks after surgery. An important part of the WBI process is the delivery of a higher localized dose, known as the “boost dose,” to the lumpectomy cavity margin – the most likely site for cancer recurrence. AccuBoost is designed to target and deliver the all-important boost dose accurately and reliably.

For women having whole breast irradiation, the surgical cavity is boosted to a slightly higher dose. The boost usually takes 5-8 treatments given daily. A small field is mapped out around the surgical cavity.

Using Ultrasound

The boost field is then defined by Ultrasound images. Electrons are used to deliver the radiation so that they will no penetrate too deep into the underlying chest wall or lungs.

The AccuBoost system is designed to take the guess work out of “daily patient positioning” and “dose targeting” for the boost phase of the procedure. By using real-time image guided radiation therapy (IGRT), the AccuBoost system provides a simple, accurate method for accurate boost dose targeting. Furthermore, by sharing the same platform for imaging (by IGRT) and applicator positioning, the AccuBoost system targets the dose precisely to where it needs to go and minimizes side effects of radiation.

Clinical Trials

The boost field is easy to locate and treat without any exiting dose to lungs or ribs. As the company states, “you see what you treat and treat what you see.” This is a very exciting new technique providing yet another option for women!

As these breast cancer treatment results matured, and the previously mentioned national phase II clinical trial run by the Radiation Therapy Oncology Group (RTOG) and sponsored by the National Cancer Institute was successfully completed, momentum and support for brachytherapy spiraled upward.

The RTOG 95-17 results have been peer-reviewed and published in an international medical journal in 1998 by Drs. Arthur, Kuske, and others. Currently a national phase III clinical trial (NSABP B-39/RTOG 0413) is on-going, and directly compares 6 weeks of whole breast irradiation with 5 days of partial breast irradiation. Over 3000 patients have heroically signed-up for this trial, with a planned total of 4300 patients to be enrolled by 2011. Dr. Kuske has been privileged to play a major role in the design and leadership of this trial, and Dr. Kuske, Dr. Quiet and the women of Arizona have been the leading participants out of over 250 institutions! We have enrolled more women onto phase III breast cancer trials than the radiation departments of Harvard, Memorial Sloan Kettering, and MD Anderson combined!

The Pivotal Breast Board

Pivotal Treatment Solution for Prone Breast Care Offered at our North Phoenix Location

Pivotal Prone Breast Care is providing our patients with a new option for the treatment of breast cancer. Typically, breast cancer patients are treated on their back, in the supine position. With Pivotal Prone Breast Care, we can now treat patients lying face down, in the prone position.

A customizable positioning device (we call it a breast board), allows the woman to lie comfortably in the prone position for radiation treatment. The affected breast falls away from the chest wall, allowing for more targeted delivery to affected area.

Studies have shown that treatment in the prone position for breast cancer limits the radiation dose to the heart and lungs during treatment delivery, and may possibly improve the short and long-term effects of radiation on the treated skin. Furthermore, respiratory motion may be reduced in the prone position, helping to improve treatment accuracy.

Studies have shown that treatment in the prone position for breast cancer limits the radiation dose to the heart and lungs during treatment delivery, and may possibly improve the short and long-term effects of radiation on the treated skin. Furthermore, respiratory motion may be reduced in the prone position, helping to improve treatment accuracy.

Pivotal Prone Breast Care is designed for treatments of either the left or right breast, including whole breast, partial breast, and accelerated partial breast treatments. Adjustable CT risers can accommodate varying breast size for CT simulation. The technology also allows radiation delivery to the nodal beds if clinically necessary.

Take a moment to watch this video with Dr. Coral Quiet as she describes how Pivotal Prone Breast Care works.

Following are the benefits of using the Pivotal Treatment Solution

Patient Positioning:

360-degree access allows for maximum visibility during patient setup, which allows for full utilization of lasers and field lights.
Multiple indexing options are available, and knee-positioning guides provide confirmation of patient alignment.
All patient positioning features lead to enhanced set-up reproducibility; helping to confirm the patient is in the same position for each treatment.

Imaging Benefits:

Less scatter allows for high-quality, low-dose images.
Images are typically clearer because chest wall motion is reduced in the prone position.
The couch insert is designed specifically to minimize CT image artifacts.

Convenience Features:

The ergonomically designed insert snaps quickly in and out of position for ease of use by our therapists.

Patient Comfort:

Patients can more easily get on and off the couch-top because the couch insert has a low profile.
A memory foam pad contributes to patient comfort while maintaining accuracy.
The inverted wing design adds to patient comfort.
A dual handgrip relieves stress on the patient’s wrists.
Patients with limited arm mobility can use the ipsilateral handgrip.
The patient’s head can be positioned face down or to the side, using one of two headrest options.
Patients can breathe freely, due to the prone headrest design. Lateral light slots promote an open feeling.

We have over 30 years of experience with external beam radiation. External beam radiation for breast cancer is very successful. As discussed above, with this treatment recurrence of cancer in the breast is very uncommon and side effects are usually very mild.

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