Early in my practice, it became clear to me that breast cancer treatment was not just a health issue, but a family and work disruption issue for busy women. This was frankly pointed out by a patient who presented me with the book she had written after her treatment called “Breast Cancer? Let Me Check My Schedule.”
Cancer remains a disruption, but not nearly as much as three decades ago.
Thirty years ago, treatment was the same for most breast cancers and included mastectomy, chemotherapy and often radiation. Treatment could go on for six to nine months. Side effects were severe and kept patients from normal activities for the entire time. Since then, improved imaging with digital mammography, ultrasound and MRI have led to identification of an increased number of small, early-stage cancers, and that allows for more targeted therapies and shorter disruptions.
Today, the majority of women diagnosed with breast cancer undergo lumpectomy, which involves removing only the tumor and a margin of surrounding healthy tissue. Historically, lumpectomy has been followed by classic whole-breast radiation to reduce local recurrence of the cancer. The treatment takes in the entire breast and chest wall and sometimes the underarm area, often resulting in general fatigue, skin irritation and reduced range of motion. On occasion, the heart and lungs can be damaged. The treatment is time-consuming, requiring daily trips to the hospital for up to six weeks. Studies now show the outcome from a three-week course of radiation for patients with early-stage cancer is equal to a classic six-week course.
More targeted radiation treatments have been developed over the past 10 years to further reduce the side effects of radiation after it was recognized that most recurrences, after lumpectomy, occurred in the original area of tumor. Treatment of the lumpectomy cavity seemed a feasible alternative to treating the entire breast.
Techniques first developed for targeted radiation involved surgical implantation of radioactive wires around the lumpectomy site with hospitalization for five days. This has since evolved into placement of outpatient balloon catheters (brachytherapy) into the lumpectomy site to deliver radiation directly and more accurately. These balloons are placed into the lumpectomy cavity in the surgeon’s office under local anesthesia for suitable patients. This type of radiation treatment is limited to patients over age 50 with slow-growing, low-risk tumors and negative lymph nodes. The patient is treated twice a day for five days. The balloon is removed after the completion of all the treatments. Because radiation is limited to the lumpectomy cavity, patients have fewer problems with tiredness, redness and skin irritation, muscle fibrosis, decreased range of motion and heart or lung damage. The downside to this type of radiation is a slightly higher risk of infection in the lumpectomy site.
Developed in Europe
The most recent development is that of Intraoperative Radiation Therapy (IORT) to treat small, low-risk tumors. Originally developed in Europe to treat rural patients who were unable to travel and stay for long periods in an area where radiation was available, this treatment is now used in the United States. The radiation oncologist is present at the lumpectomy surgery to deliver IORT directly to the lumpectomy cavity after the surgeon removes the cancer. Recently a patient who is the primary caregiver for her elderly husband was able to have surgery and IORT in a single session, allowing her to return to full activity quickly with little disruption.
Reduced future risk
Study results are early, but in select patients IORT may be a good treatment option. Benefits include quicker radiation available at the time of lumpectomy, less radiation exposure to tissue around the tumor, and reduced risk of the cancer returning compared to similar patients with whole breast radiation. The downside is the possibility that the wound will be slow to heal and the need for whole breast radiation if the cancer is found in the lymph nodes after pathology reports are available.
Receiving a breast cancer diagnosis is never easy. But new, more targeted options for treatment can reduce physical side effects and the time needed for treatment.