[ RadSafe ] Breast Cancer Brachytherapy

[Sandy Perle]

In addition to Shawn's citations, here are additional links. Just goes to
show that just because a scientist doesn't know about a widely used
technique, doesn't mean that its application is "ridiculous"!


http://www.mammosite.com/radiation-therapy/radiation-options.cfm

NOTE: A technique used since 1917:
Delivering radiation from inside the body - also called "brachytherapy" - is
used to treat many cancers. For example, use of brachytherapy as a treatment
of prostate cancer goes back as far as 1917, and has been the standard of
care for prostate cancer for several decades.

http://www.americanbrachytherapy.org/resources/healthapps.cfm

Breast Cancer
Breast conservation treatment has long since been established as an
effective treatment alternative to mastectomy for early stage breast cancer.
Standard breast conservation treatment consists of breast conserving surgery
for tumor removal (lumpectomy) followed by external radiation to the whole
breast. Although this treatment approach offers many advantages over
mastectomy and provides in-breast cancer control rates that approach 95-100%
with good to excellent cosmetic results in nearly all patients, six weeks of
daily treatment has proved prohibitive for some patients. As a result, some
women refuse external radiation (putting themselves at higher risk for
recurrence) or choose mastectomy and have the breast unnecessarily removed.
Those finding six weeks of daily treatment inconvenient or impossible
include working women, elderly patients, and those who live a significant
distance from a treatment center. Breast brachytherapy as the sole method of
radiation following lumpectomy is a new treatment approach that offers
equivalent local control, breast conservation and improved convenience of
treatment delivery. Although most women with breast cancer are appropriate
candidates for standard breast conservation treatment and can be treated
with lumpectomy and external radiation, only a subgroup of these women will
be appropriate candidates for breast brachytherapy. However, even with
strict selection criteria it is estimated that 71,000 women each year would
be appropriate candidates for breast brachytherapy.
The ABS has issued guidelines for the use of brachytherapy for the treatment
of breast cancer. For specific study information and guidelines, please see
Oncology, Vol. 15, No. 2 (February 2001). In this publication, we reviewed
the use of breast brachytherapy as boost treatment, for the treatment of
in-breast recurrences and as the sole modality following lumpectomy.
Although the majority has remained unchanged, the consensus on the role of
brachytherapy as the sole method of radiotherapy has been altered to reflect
recent findings in the published literature. At the time of publication,
"brachytherapy as a sole modality is to be considered investigational and
should be performed in the context of a controlled clinical trial." Based on
recent clinical publications the ABS now considers accelerated partial
breast irradiation an appropriate alternative to standard whole breast
radiotherapy in appropriately selected patients. Details have been prepared
and a manuscript has been submitted for publication. 


http://www.americanbrachytherapy.org/news/index.cfm#story2

For Immediate Release

NEW RADIATION TREATMENT FOR BREAST CANCER IMPROVES BREAST CONSERVATION AND
QUALITY OF LIFE

February 2002, Oak Brook, IL -- Brachytherapy for selected early stage
breast cancer is an innovative treatment approach that may increase breast
conservation, and also reduce the need for mastectomy. Treatment time for
breast brachytherapy takes five days instead of six weeks for traditional
radiation, according to physicians from the American Brachytherapy Society
(ABS). 

"Breast brachytherapy as the sole method of radiation following lumpectomy
is a new treatment approach that offers breast conservation with improved
convenience of treatment delivery," said Douglas Arthur, M.D., associate
professor at the MCVH of Virginia Commonwealth University Health Systems.

Although most women with breast cancer are candidates for standard breast
conservation treatment and can be treated with lumpectomy and external
radiation, only a subgroup of these women will be candidates for breast
brachytherapy, according to Dr. Arthur. However, even with strict selection
criteria it is estimated that 71,000 women each year would be candidates for
breast brachytherapy.

Breast conservation treatment has long since been established as an
effective treatment alternative to mastectomy for early stage breast cancer.
Standard breast conservation treatment consists of breast conserving surgery
for tumor removal (lumpectomy) followed by external radiation to the whole
breast. Although this treatment approach offers many advantages over
mastectomy and provides in-breast cancer control rates that approach 95 % -
100% with good to excellent cosmetic results in nearly all patients, the
standard six weeks of daily treatment has proved prohibitive for some
patients. As a result, some women refuse external radiation - putting
themselves at higher risk for recurrence - or choose mastectomy and have the
breast unnecessarily removed. Those finding six weeks of daily treatment
inconvenient or impossible include working women, elderly patients and those
who live a significant distance from a treatment center.

About Brachytherapy
Brachytherapy is a radiation treatment approach that has been used for
treatment of cancer for over 100 years. Specifically, brachytherapy for
breast cancer is the use of radioactive sources that are placed temporarily
or permanently into the target cancerous tissues or cavities being treated.
The technique allows the radiation oncologist to focus the radiation into a
defined target and avoid delivering radiation to surrounding various many
different locations of the body.

Initially brachytherapy for breast cancer was used in addition to five weeks
of external radiation to boost a portion of the breast to higher doses.
However, over the past 10 years, the application of brachytherapy in breast
cancer has changed. In early stage breast cancer, research has shown that
the area that requires radiation treatment to prevent the cancer from
returning is the breast tissue that surrounds the area where the initial
cancer was removed. Because this typically includes only one-third to
one-half of the breast, brachytherapy is now being used to treat the
targeted portion of the breast and as a result allows accelerated delivery
of the radiation dose so that treatment is completed in four to five days. 

About Breast Brachytherapy Procedures
Several locations around the country currently offer breast brachytherapy as
the sole method of radiation delivery following lumpectomy, including Dr.
Robert Kuske (University of Wisconsin in Madison, Wisconsin), Dr. Frank
Vicini (William Beaumont Hospital in Detroit, Michigan) and Dr. Douglas
Arthur (MCVH of Virginia Commonwealth University Health Systems in Richmond,
Virginia). Although there may be some variation in the technique, all follow
the same basic principles. As breast brachytherapy only treats the breast
tissue surrounding the lumpectomy cavity, patient selection criteria must be
used to assure that the area at risk for tumor recurrence will be covered by
the brachytherapy treatment. These criteria include the tumor size, tumor
type, lymph node status as well as other pathologic characteristics that
minimize the risk that cancer cells are in other parts of the breast.

The first step in the brachytherapy procedure is the placement of needles
and/or catheters into the area of the breast to be treated. This is usually
done under local anesthesia as an outpatient and can be done at the time of
lumpectomy or as a separate procedure. The needles/catheters are about the
size of a spaghetti noodle and are placed in the area of the lumpectomy
cavity. Depending on the technique used it may require 15-20 catheters to
assure the target is covered with an even dose of radiation. Once the
catheters are placed, the actual treatment can begin following the
completion of a day or so of computer planning to determine where and how
much radiation will be delivered. The catheters remain in place until the
treatment delivery is complete. The only pain felt during the treatment,
according to Dr. Arthur, is the limited discomfort that results from the
catheters being present in the breast; the delivery of the radiation is
painless. 

The radiation dose can be delivered as an inpatient or an outpatient. As an
inpatient, radioactive sources are placed into each catheter and remain
there for four to five days. The patient is confined to an isolated room
with limited visitation. "Some view this as a welcome break from the world,"
contends Dr. Arthur, "whereas others are unable to deal with the
confinement."

New technology known as a high dose rate (HDR) remote afterloader now
provides an outpatient brachytherapy treatment option. In short, the patient
comes to the department for a series of treatments, typically twice a day
for four to five days. For each treatment session, the HDR remote
afterloader is connected to each of the catheters and a computer driven
radioactive source pushed into the catheters for a prescribed amount of
time.

After the treatment session is finished, the catheters are disconnected and
the patient is free to go until the next treatment session. Following the
last treatment session, the catheters are easily removed in the clinic and
the treatment area is cleaned and dressed. Some patients are able to carry
on their routine daily living activities and work with the catheters in
place; however, many take a break during treatment knowing they will be able
to return as soon as the catheters are removed. 

"Although this may sound and look like a painful experience," said Dr.
Arthur, "most women have limited discomfort with only a few women requiring
pain medication." 

While not every patient will be eligible for treatment with breast
brachytherapy, it is a viable option for many women who present with early
stage breast cancer. This accelerated treatment approach is presently only
offered in select locations. However, the ABS anticipates that this will
change over the next few years and become a more widely offered treatment
option based on the treatment results, the enthusiasm seen from treated
patients, and the interest shown by physicians treating breast cancer.


http://www.medicalmoment.org/_content/treatment/oct04/262973.asp


Breast Brachytherapy with Scott Tannehill, M.D., Radiation Oncologist,
Columbia St. Mary's

A new treatment for breast cancer - breast brachytherapy - will soon be
available at Columbia St. Mary's. Scott Tannehill, M.D., a radiation
oncologist with expertise in breast cancer and breast brachytherapy, joins
the Columbia St. Mary's medical staff on October 1, 2004. 

Breast cancer treatments 
 


 Scott Tannehill, M.D., Radiation Oncologist, Columbia St. Mary's Hospital


"Breast brachytherapy is a new treatment for breast cancer. It is now
regarded as a safe and effective alternative to standard external beam
treatment for many patients with breast cancer; overall patient survival
with either approach is going to be similar. The primary reason a woman
would select breast brachytherapy over standard external beam radiation is
time: external beam radiation requires over six weeks of daily treatment,
but breast brachytherapy can be completed in one week." 
 
This year, more than 200,000 new cases of breast cancer will be diagnosed in
the United States. Surgical removal of the cancer lump (lumpectomy) is
usually the first step. After this surgery, women with early breast cancer
are offered mastectomy (surgical removal of the entire breast) or radiation
therapy to the breast. Most women choose radiation because the survival rate
for such treatment is the same as with mastectomy, and it allows the patient
to preserve her breast. 

External beam radiation begins four to six weeks after surgery. Patients
receive one treatment a day for six to seven weeks. It is very successful in
preventing recurrence of cancer in the breast, but many women find the long
duration of treatment to be burdensome. 

Breast brachytherapy is an alternative to external beam radiation that
allows women to complete their radiation treatment in one week. 

What is breast brachytherapy? 
Brachytherapy (pronounced bray' key therapy) involves placing a radiation
source within or close to the cancer. Using brachytherapy, doctors can
reduce the radiation exposure to nearby normal tissues that do not need -
and can be harmed by - the radiation. Brachytherapy is used to treat many
cancers, including prostate cancer and gynecologic cancers. 

An older brachytherapy technique, low dose-rate (LDR) brachytherapy,
involves placing a weak source in the patient for many days. Patients are
confined to a specially shielded hospital room for several days, and often
must remain in bed the entire time. Because of safety issues, visitors are
limited. HDR brachytherapy is a newer technique, which requires special
equipment and training. 

HDR brachytherapy utilizes a strong radiation source, which is precisely
positioned in the patient for a few minutes each time. These treatments are
repeated over several days or weeks depending on the type of cancer.
Patients are not admitted to the hospital for HDR brachytherapy and are
usually in the radiation clinic for less than an hour for each treatment.
For these and other reasons, many patients and physicians prefer HDR
brachytherapy. 

Dr. Tannehill has been a faculty physician at UW Hospital in Madison since
1999 and joins Columbia St. Mary's Hospital this October. Dr. Tannehill is
nationally recognized for his expertise in HDR brachytherapy and has
performed over 5,000 HDR brachytherapy procedures for a variety of cancers
including breast cancer. 

"HDR brachytherapy for breast cancer is new," said Dr. Tannehill. "We have
used HDR brachytherapy for other cancers for many years, but recent evidence
now shows HDR brachytherapy is a safe and effective alternative to external
beam radiation for many patients with breast cancer. HDR brachytherapy
deposits the radiation selectively around the area of the cancer, and treats
much less skin and healthy breast tissue." 

It is this feature - less radiation to healthy tissues that don't need
radiation - that permits treatment with brachytherapy to be shortened down
to one week compared to the six to seven weeks with external beam radiation,
he explained. 

Two techniques 
There are two techniques of HDR breast brachytherapy: the balloon catheter
technique and the multiple-catheter technique. Both are outpatient
procedures performed under local anesthetic. 

Balloon catheter HDR brachytherapy involves inserting a special catheter (a
narrow, plastic tube) into the breast under local anesthetic. An inflatable
balloon at the end of the catheter is positioned within the cavity left
behind after surgery. The balloon remains in the breast while treatments are
delivered twice-daily for five days. After the last treatment, the balloon
is deflated and the catheter is removed. 

With the multiple-catheter technique, small flexible catheters - without a
balloon - are inserted into the breast. The catheters remain in the breast
for about one week and are removed after the last treatment. The treatment
duration and other details are otherwise the same as for the balloon
technique. 

"The choice of technique - balloon catheter or multiple-catheter - will vary
with each patient," Dr. Tannehill explained. "The balloon catheter technique
is the simplest, and is the most common technique used in the community. But
the balloon technique is limited by the location and shape of the fluid
collection left in the breast after lumpectomy; only about 50% of patients
are candidates for the balloon technique." 

"We also offer the multiple-catheter technique, which can be used in a wider
variety of situations and in patients who may not be candidates for the
balloon technique. By having both techniques available we are more
successful in offering brachytherapy to our patients who are interested in
this treatment," he said. 

Patient selection and potential advantages of HDR Breast Brachytherapy 
HDR breast brachytherapy is appropriate for patients with small to
medium-sized cancers who would otherwise receive external beam radiation
after surgery. Also, patients should have limited cancer involvement in
their lymph nodes. 

HDR breast brachytherapy is not appropriate for all patients. External beam
radiation is recommended for those patients with larger tumors and with more
extensive involvement of their lymph nodes. 

Dr. Tannehill added that there may be other advantages - in addition to
shorter duration of treatment - with HDR brachytherapy. "One proposed
advantage is that long-term side effects of breast radiation will be reduced
with HDR brachytherapy because HDR brachytherapy focuses the radiation more
to the area of the cancer and treats less of the patient's healthy tissues,"
he said. 

"We don't yet have long-term results to know for certain whether this is the
case. My own suspicion is that the long-term side effects of HDR
brachytherapy will not be lower than with external beam, specifically
because the risk of serious side effects with standard radiation is
extraordinarily low," he said. "It will be difficult to improve on external
beam in this regard. But on paper, a smaller volume of healthy tissue is
treated with HDR brachytherapy and this appeals to some doctors and
patients." 

Additionally, some women receive several months of chemotherapy after their
surgery, and external radiation usually comes after the chemotherapy. In
contrast, HDR breast brachytherapy can be performed soon after surgery but
before chemotherapy begins, and without delaying chemotherapy. Also, the
skin redness and soreness that can occur with external beam radiation is
often worse if the patient received chemotherapy before radiation. This
reaction is usually mild and heals in all cases, but HDR breast
brachytherapy avoids this problem by not treating the skin with radiation. 

Dr. Tannehill is quick to point out that the only scientifically proven
advantage of HDR breast brachytherapy is the shortened treatment time
compared to external beam radiation. "The other possible advantages - from
treating less skin or lung or heart - are encouraging but we need more time
to know for sure whether there is true benefit to our patients from this." 

And this ties in with one weakness of HDR breast brachytherapy: its shorter
track record compared to external beam radiation. "We have about eight years
of experience with HDR breast brachytherapy," Dr. Tannehill said, "but we
have over thirty years of experience with external beam radiation. Some side
effects may appear many years after treatment, and we need to continue to
follow those treated with breast brachytherapy for this reason." 

Dr. Tannehill concludes, "The take-home message is that the main advantage
of HDR breast brachytherapy is a shorter duration of treatment compared to
external beam radiation." And for women with outside jobs and busy schedules
at home, for elderly patients and for those who live far from a radiation
treatment center, that benefit of breast brachytherapy may be a welcome
alternative. 


----------------------------------------------------------------
Sander C. Perle 
President
Global Dosimetry Solutions, Inc. 
2652 McGaw Avenue
Irvine, CA 92614
 
Tel: (949) 296-2306 / (888) 437-1714 Extension 2306 
Fax:(949) 296-1144
 
E-Mail: sperle at dosimetry.com
E-Mail: sandyfl at cox.net 
 
Global Dosimetry Website: http://www.dosimetry.com/