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.
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.
Clinical 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.
A preliminary 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
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 for you.
- 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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