Frank A. Vicini, MD, FACR
Women diagnosed with early-stage breast disease have a variety of decisions to make regarding their treatment options. For example, some women may be eligible for breast-conserving surgery, which typically includes a lumpectomy followed by radiation. Radiation treatment after a lumpectomy has traditionally involved irradiation of the entire breast with an external beam over 6 weeks.
Recent data, however, suggest it may be time to break tradition.
conducted by the University of Pennsylvania Perelman School of Medicine analyzed the frequency of hypofractionated whole breast irradiation (WBI) versus conventional WBI after breast-conserving surgery in the United States from 2008 through 2013. Researchers defined hypofractionated
treatments as those spanning 11-24 fractions over approximately 3 weeks, and conventional
as 25-40 treatments over approximately 6 weeks.1
It is important to address a common misconception about radiation treatments analyzed in this 5-year study. The radiation volume for patients undergoing hypofractionated and conventional WBI are the same. However, the dosage per treatment is higher for hypofractionated, allowing a patient to receive the same total amount of radiation in a shorter time period. Both treatment types have the same effect on a cancer cell.
What researchers found is that although the percentage of patients treated with hypofractionation increased from 10.3% to 34.5% over 5 years, a majority of eligible women still did not receive this shorter, more intense course of radiation therapy.1
This means that a majority of women in the study who were eligible to receive the same amount of radiation in just 3 weeks unnecessarily received a longer course of treatment. Besides the inconvenience of a lengthier regimen, many women must travel some distance to receive radiation. The additional 3 weeks of radiation can put additional stress on patients with work and family responsibilities.
I believe that these results show that we, as healthcare practitioners, may be too slow to adopt newer techniques. Six weeks of WBI treatment has been the standard of care for years. Conventional radiation was the preferred method, in part because the benefits of delivering higher doses of radiation in a shorter period of time were unknown.Efficacy the Same With Shorter Treatment
The primary concerns around radiation were, and continue to be, about the toxicity, cosmetic outcomes, and survival rates. However, we now have data that show shorter courses of treatments provide the same efficacy as conventional treatment and allow for better cosmetic results. Shorter courses of radiation, including accelerated partial breast irradiation (APBI), are just as effective at treating breast cancer (in appropriately selected patients), yet have not become standard with physicians in the United States.2
One of the reasons for this may be the uneven education among medical professionals.
I believe members of the oncology care team need to constantly educate ourselves, so we can better educate our patients. Underutilized treatments may be the best choice for a woman, depending on her unique situation. One of these shorter courses of treatment is breast brachytherapy, a 5-day radiation therapy. While breast brachytherapy is less mainstream, I have treated women for 28 years with this method and have seen exceptional results.3
Breast brachytherapy is a form of APBI that delivers a dose of radiation from within the breast. The benefits of this approach to radiation are proven—reduced radiation exposure to healthy tissue, better cosmetic results, and fewer side effects for patients. Additionally, brachytherapy allows for additional treatment options in the event of a recurrence. With breast brachytherapy, radiation only reaches the targeted area most at risk. The rationale behind breast brachytherapy is to intensify treatment to the area most at risk for recurrence, treating just the affected part of the breast in order to control the cancer, reduce side effects, and improve overall quality of life.
It is important to note that for both the 3-week regimen and APBI, selection criteria must be followed. Not all women are candidates for either approach, and proper patient selection is critical.
The most important factor in selecting a treatment is a doctor’s recommendation, so it cannot be stressed enough that patients are relying heavily on our expertise.4
Patients interact with you, the oncology nurses, first. Staying up to date with the latest treatment techniques to familiarize ourselves with many different options is necessary to appropriately advise patients.Educating Patients About Options