Alternatives to Whole Breast Radiation

by Dr. Douglas Duven

The standard recommendations for treatment of breast cancer are mastectomy or partial mastectomy with Whole Breast Radiation (WBR). Patients with early stages of breast cancer may be offered a partial mastectomy (lumpectomy) followed by radiation treatment to the breast. This should assure the patient that they are reducing their chances of a recurrence in the same breast, an outcome that is similar to complete removal of the breast.

Those choosing partial mastectomy will have WBR as outpatient therapy for 30- 35 days over a 5-7 week time period. For some, this WBR may interfere with jobs and pose a transportation problem for those who travel to radiation treatments. Until recently there has been no alternative to WBR. Currently, however, there are radiation alternatives on the horizon and at a limited number of facilities that are usually involved in a study, that take less time than WBR. These alternative treatments take 20 minutes, twice daily for five days. Early study results suggest these shorter radiation alternatives have similar results as WBR.

The two alternatives to WBR are brachytherapy and intraoperative radiation. Because 80% of recurrences of breast cancers in a lumpectomy occur within 1/2 inch of the biopsy site, the radiation alternatives focus on the lumpectomy site and some surrounding tissue. The first alternative, brachytherapy, has been utilized for years in cancers of the prostate, lung and sarcomas and currently promises to be useful with breast cancer.

Two types are available:
1) Multiple catheter based brachytherapy – This treatment requires multiple small catheters (tubes) to be placed into the breast and left in place for 5 days. Twice a day for 5 days a radioactive seed is placed into each catheter for 20 minutes. Once treatment is finished the catheters are removed.
2) Balloon catheter brachytherapy – This treatment requires placement of a soft balloon attached to a catheter into the lumpectomy cavity. A tiny radioactive seed is placed twice daily into the balloon for 5 days. Once treatment is finished the balloon is then removed.

The second alternative to WBR is intraoperative radiation. This alternative can be done at the same time as the lumpectomy. The radiation therapist brings into the operating room a radiation source that is given after the lumpectomy has been performed but the incision is not closed. The cavity in which the cancer has been removed is given a one-time, 20-minute dose of radiation, which is about equal to six weeks of WBR.

Currently, these alternatives are available primarily in studies and are not yet readily available in all communities. Additionally, not all patients are candidates for the WBR alternatives. Favorable patients are post-menopausal women with stage To, T1, T2, small tumors and negative lymph nodes. Patients that are premenopausal, have large tumors or have small breasts may not be candidates for alternative therapy.

On a positive note, current studies continue to explore the outcome of each alternative and all seem to have similar results to six weeks of WBR. Outcomes so far show similar rates of recurrence, good cosmetic results and high patient satisfaction. Other benefits include no longer having to travel for several weeks to the WBR appointments and less loss of income due to spending less time away from work. 


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