Radiation for Breast Cancer
- Generally, most women who have a lumpectomy for early stage breast cancer are recommended to get radiation after their lumpectomy. But breast cancer survivors who have undergone a lumpectomy, are going to take endocrine therapy for five years, are over age 70 and potentially over 65, have tumors less than 2cm, have negative lymph nodes and hormone receptor positive disease are potential candidates for omission of radiation.
- Women with low risk DCIS [ductal carcinoma in situ] are also potential candidates for radiation omission.
- Women who have tumors less than 5cm with no skin or muscle invasion, with negative lymph nodes and with negative surgical margins do not need radiation after a mastectomy.
- But there is a study being done to determine if it’s safe to extend the bottom age cutoff for radiation omission from age 70 to age 50.
- In addition, there are alternative treatments, like proton therapy, and ways to minimize damaging side effects of typical radiation like partial breast radiation, deep inspiration breath hold and prone positioning.
- Women with breast cancer should ask their doctors if radiation is right for them.
Questions for Breast Cancer Patients To Ask Their Doctors
- Do I need radiation?
- If I need radiation, what kind of dosage are we looking at and how many treatments would that require?
- What position would I be in for radiation? What techniques will be used to minimize any potential damage to nearby organs/bones?
- If I don’t have to do radiation, what are the alternative treatments and their potential down sides?
- What’s the chance radiation will contribute to my developing a secondary cancer later on?
- Is proton therapy a good option for me?
Before we get into radiation treatment protocols, let's understand what this treatment entails for breast cancer patients.
What Is Radiation?
Read MoreThe goal of radiation is to extend disease free survival for breast cancer survivors by reducing the risk of their cancer returning, or recurrence, but there are also potential side effects of the treatment to consider. The National Cancer Institute lists the following as possible side effects of radiation to the breast:
- Fatigue
- Hair loss
- Skin changes
- Swelling (edema)
- Tenderness
Skin Care: Dealing With the Side Effects of Radiation
But long term damage to the ribs and nearby organs like the heart and lungs is definitely something to think about as well as the potential for a secondary cancer.
"I think long term side effects to your heart, your lungs, your ribs, those are all very important things," Dr. Kim said of things to consider when it comes to radiation. "For young patients, secondary cancer risk because radiation can induce a secondary cancer. It’s not very high, but it’s there. And for a young patient who’s in their late 30s or early 40s, a secondary cancer can occur 20 to 30 years down the line and guess what that is absolutely in their lifetime."
What Do Current Recommendations Look Like Regarding Radiation For Breast Cancer Patients?
Now that we know what radiation is, Dr. Naamit Gerber, a radiation oncologist and co-director of the breast cancer and hematologic malignancies disease management groups at NYU Langone's Perlmutter Cancer Center, can explain the guidelines for getting radiation in the first place.
The Debates Around Radiation for Breast Cancer
"Generally, most women who have a lumpectomy for early stage breast cancer are recommended to get radiation after their lumpectomy," Dr. Gerber said.
If a breast cancer survivor who's undergone a lumpectomy fits into the following criteria, however, they can be an exception to that rule.
"Yeah, so older women over 70 and potentially over 65 as well based on one study who have tumors less than two centimeters, negative lymph nodes and hormone receptor positive disease and are going to take endocrine therapy for five years, those are potential candidates for omission of radiation," Dr. Gerber said. "And then women with low risk DCIS [ductal carcinoma in situ] are also potential candidates for omission."
What Is Stage Zero Breast Cancer?
Ductal carcinoma in situ (DCIS), also known as stage zero breast cancer, means that abnormal cells are lining the duct in a breast. A normal breast is made up of lots of ducts (these ducts carry milk to the nipple in a woman who is lactating).
Dr. Laura Esserman, director of the UCSF Carol Franc Buck Breast Care Center, is a renown expert who questions whether radiation is necessary for women with stage zero, or DCIS, breast cancer.
“With the exception of some very high-risk situations, why are we radiating people with DCIS?” Dr. Esserman explained in a 2016 article published by Medscape.
Less women undergo radiation after having a mastectomy, but Dr. Gerber says its the right choice for some patients.
"After a mastectomy not all women get radiation," Dr. Gerber explained. "The main indications for post-mastectomy radiation therapy are positive lymph nodes and/or positive surgical margins or a very large tumor size as well.
"Women who have tumors less than 5cm with no skin or muscle invasion, with negative lymph nodes and with negative surgical margins do not need radiation after a mastectomy."
Do Some People Outside Of Guidelines Get Radiation Regardless?
That being said, there is nuance to every guideline and some people who might not be a normal radiation candidate might want the treatment regardless.
"I think it’s always really helpful to have a conversation with a radiation oncologist to talk about the benefits relative to the risks and make an individualized decision," Dr. Gerber said.
One of the factors that helps Dr. Gerber determine whether or not a patient should undergo radiation even if they are eligible to omit is if the person can tolerate endocrine (hormone) therapy since there's currently no patient with invasive breast cancer that can omit both radiation and hormone therapy.
"If I think they might not be able to tolerate five years of endocrine therapy, then we would generally recommend the radiation," Dr. Gerber said.
Age and health status also play a big role in determining the treatment path for these patients. To illustrate an example of someone who wasn't within the normal guidelines for radiation but decided to pursue it anyway, Dr. Kim shared the story of one of her very fit, older patients.
"Now, one thing I found is that a lot of patients here in the Pacific Northwest, they’re extremely healthy," Dr. Kim explained. "So when I see a 70 year old, they’re not your usual 70 year old. They are very healthy."
Thinking back to a specific 80-year-old patient, Dr. Kim recalled that this woman was on her Peloton bike every day during radiation "racking in more miles than I drive in a week."
"I have no doubt she’s gonna be around for a long time," Dr. Kim said of this patient. "She wasn’t comfortable omitting radiation, especially because the deal then is if you’re gonna omit radiation… you really need to commit to the medicine for five years, this anti-estrogen medicine that has side effects as well."
So for this particular patient, "focused radiation" was the answer.
"It’s called accelerated partial breast radiation, where we literally delivered radiation to just the tumor cavity with some margin and did that treatment in five days, and she was done," Dr. Kim explained. "And it was wonderful because not only are you treating just the high risk areas, but… we laid off the rest of her breast tissue that was really low risk. We stayed off her heart, we stayed off her lungs and her ribs, just treated the area."
Dr. Kim explained that the reason she was able to do that was because, historically, women who had lumpectomies, omitted radiation and, unfortunately, has a cancer recurrence mostly saw that cancer return right where it originated.
"So, that’s why we took advantage of that and said, 'Okay, you know what then, if her tumor is in the left breast, two o’clock position, I’m not gonna worry about the four o’clock, the six o’clock the 10 o’clock locations because that’s not high risk," Dr. Kim explained. "And so we were able to safely deliver the radiation where it was needed, and really minimize exposure to all the other underlying organs, which was a big win-win for her."
And even when this patient went on to endocrine therapy and didn't like it, both Dr. Kim and the patient were comfortable with the fact that she had the focused radiation and the surgery.
"So I think a lot of times, omitting radiation completely isn’t always the answer that patients want. Sometimes they feel a little bit like well, you know what, I don't like this all or nothing. Is there something in between? And sometimes there is, you know, sometimes you can come up with things like accelerated partial breast radiation, or you can do you know, maybe shorter courses of radiation. And that, you know, I think is something that we’ve been able to offer to patients, because just as different as breast cancers are, patients are as well."
Are There Alternatives To Typical Radiation Or Ways To Prevent Negative Side Effects?
Just like in the case above, accelerated partial breast radiation is an option for some breast cancer survivors who've undergone a lumpectomy. But there are other alternatives to standard radiation and methods used to minimize damaging side effects such as the following:
- Proton therapy, also known as proton beam therapy. This is a radiation treatment that precisely delivers a beam of protons to disrupt and destroy tumor cells. "[Proton therapy] is another way of delivering radiation to help reduce exposure to underlying organs like the heart and lungs and things like that," Dr. Kim said. It's worth noting, however, that this form of radiation can be more expensive and isn't offered everywhere.
- Deep inspiration breath hold (DIBH). DIBH is when you take a deep breath and hold it causing your diaphragm to pull your heart away from your chest. This practice can help protect the heart during radiation therapy for breast cancer.
- Prone positioning. This is a specific position that breast cancer survivors can lay in to limit the normal tissue that’s in the radiation field.
- Calendula cream. Dr. Kim gives this to her patients because it has "homeopathic properties against sunburns" which can occur because of radiation.
Are Some Breast Cancer Survivors Being Over-Treated With Radiation?
Oncology practices are always evolving as science progresses. And when asked if a subset of breast cancer survivors who are potentially being over treated with radiation, Dr. Kim said yes.
"I absolutely think that we are over-treating," Dr. Kim said, adding that researchers are trying to figure out exactly who needs radiation and who doesn't. "I think, though, we’re doing a little better of a job trying to be careful and figuring out who that group is.
"I think you would be delusional to think we’re not over-treating in some way. I think, not only with radiation, but chemotherapy and maybe even surgeries. You know, I think there’s lots of room still to de-escalate our therapies… we’re working on it."
One of the ways NYU Langone is hoping to de-escalate breast cancer treatment is with its ongoing DEBRA trial.
"Right now, we already have published studies that show that it’s safe to omit radiation for women over 70. What DEBRA is trying to do is to see if we can extend the bottom age cutoff." Dr. Gerber explained. "[The trial] is looking at the potential for omission of radiation in women ages 50 to 70, who have small hormone receptor positive tumors and have a lower oncotype score, but that is investigational at this point."
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