BREAST CANCER TREATMENT OPTIONS
Women with early stage breast cancer often don't know what to do when offered multiple choices
of treatment. In the 1960s, it was well accepted that a woman had to undergo removal of the whole breast (mastectomy) to
save her from breast cancer. However, that is not true today.
Several landmark clinical trials
done in the 1980s showed that with radiation to the whole breast, it was possible to save a woman from the disfiguring consequences
of removal of the whole breast. Breast conservation therapy (BCT), involving removal of just the breast lump (lumpectomy)
followed by 6 weeks of radiation to the whole breast, was found to be at least as effective (and possibly more effective)
than removing the whole breast in fighting the cancer. Specifically, breast conservation was as good as mastectomy in eradicating
the cancer and saving a woman's life from breast cancer. Moreover, this approach saved a woman's natural breast to preserve
a sense of wholeness and well being for the woman and her family. In the modern era of breast cancer treatment, more recent
studies have shown that breast conservation actually delivers a higher survival than a mastectomy.
In the early 2000's, radiation oncologists were faced with a new approach which treated only
part of the breast with radiation, and do so over a period of 1 week. While accelerated partial breast irradiation (APBI)
saved time, there were concerns that this treatment might be more toxic, might not control disease elsewhere in the breast,
and might result in more mastectomies if treatment failed, or possibly even worse survival.
trials are being conducted to evaluate the effectiveness of this treatment, and until then, only women who are not candidates
for the clinical trial should be considered for APBI off-study. Selected women who are at the lowest risk of recurrence (recurrence
means the cancer coming back) may be offered APBI. This includes women who are older than age 60, with small cancers under
1 inch in size, located in just one spot of the breast, which were removed with wide margins of cancer-free tissue surrounding
it, and those that do not have certain features when looking at the cancer under the microscope. While women fitting these
criteria may do well, in general, about 1 in 3 women have cancer cells in the rest of the breast that is best treated with
radiation to the whole breast. Whole breast radiation is like an insurance policy that these other cells will be killed once
and for all, and studies may very well show superiority of this approach.
Women who are concerned
about cosmetic outcome should be aware that whole breast radiation has been shown to have better cosmetic outcomes than APBI.
This may come as a surprise at first, since less of the breast is treated with partial breast techniques such as APBI. However,
the latest evidence from clinical trials showed just that. The data were presented at a national meeting (ASTRO) in the end
of 2012. There, one of the best studies done on this subject to date compared the cosmetic outcomes achieved with APBI vs.
whole breast radiation. Independent groups of patients, nurses, and doctors were asked to judge the look, feel and shape of
the treated breast compared with the other normal breast. While all patients started out with the same cosmetic result at
baseline, there was agreement among the three groups that those receiving APBI had significantly poorer cosmetic outcome,
twice as often, as those receiving whole breast radiation (33% vs. 17%). This was likely related to the shorter 1-week time
frame used, resulting in harder, thicker and scarred breast tissue in the area of the surgical cavity. This also resulted
in more breast pain. Furthermore, during the study period, the differences in cosmetic outcome worsened with time, suggesting
that as patients are followed out over the next 5-10 years, differences will be magnified.
study looking at cancer control urges caution with APBI. Researchers at MD Anderson Cancer Center showed a higher rate of
cancer recurrence using APBI, requiring a mastectomy. We await the results of more definitive studies being conducted throughout
the world to get the final word on this. In the meanwhile, you should talk to your radiation oncologist to find out more about
if whole breast or APBI is right for you.
At Florida Center for Breast Conservation, we use the
latest techniques to treat the breast using radiation. We are one of the few centers in the country that offer "deep
inspiration breath hold" techniques and IMRT to spare the heart, skin, and breast tissue from high doses of radiation.
This results in the least cardiac toxicity and more preservation of the normal breast while using time-tested whole breast
treatment approaches that are known to be highly effective. We also offer accelerated radiation treatment for suitable patients.
Our cancer professionals have tremendous experience treating breast cancer and can help you make a decision that is right
- Fisher B at al. Twenty-Year Follow-up of a Randomized Trial
Comparing Total Mastectomy, Lumpectomy, and Lumpectomy plus Irradiation for the Treatment of Invasive Breast Cancer, N Engl
J Med 2002; 347:1233-1241.
- Smith BD et al. Accelerated Partial Breast Radiation Consensus statement from the American Society
for Radiation Oncology (ASTRO), Int J Radiat Oncol Biol Phys, 2009 Jul 15; 74(4):987-1001.
- Whelan TJ et al. Interim Toxicity Results from RAPID: A randomized trial of accelerated partial breast
irradiation (APBI) using 3D conformal external beam radiation therapy (3D-CRT). ASTRO 2012 plenary session, courtesy of ASTRO.
- Hwang ES et al. Survival after lumpectomy and mastectomy for early stage invasive breast cancer. Cancer, epub
ahead of print.
- Smith BD et al. Association between treatment with brachytherapy vs. whole breast irradiation and subsequent
mastectomy, complications, and survival among older women with invasive breast cancer. JAMA 2012 May 2; 307(17): 1827-37.
- National Cancer Institute. Studies raise concern about partial breast radiation therapy. NCI Cancer
Bulletin, January 10, 2012, Volume 9, Number 1.
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