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Accelerated (3 week) and individualized radiation therapy (RT) in early stage breast cancer treatment
Surgery to remove just the cancer (lumpectomy) rather than the whole breast (mastectomy) is a widely accepted treatment alternative for early stage breast cancer. Radiation therapy after lumpectomy reduces recurrence in the remaining breast and improves long-term survival. In the US, the usual RT treatment (dose fraction) schedule is 1.8Gy to 2Gy per fraction to a total of 46 to 50Gy for the entire breast, followed by an additional (boost) dose of 10 to14Gy to the lumpectomy site. This typically takes 6 to 7 weeks.
There is growing evidence that a shorter, accelerated RT schedule is as effective in treating early stage breast cancer. Furthermore, technical advances in radiation therapy make it possible to shape the RT dose delivered to the target (the cancer) while sparing nearby normal tissue and organs, and also to use the amount of cancer seen under the microscope to adjust the dose further We show the radiation therapy plan for the right breast of a woman who is supine (on her back) (FIGURE I) and the left breast for a woman who is prone (on her stomach) (FIGURE II).
At CCCNY, we have carefully selected patients with early stage breast cancer to receive the shorter 3 week schedule instead of the typical 6-7 weeks. We have observed minimal short term side effects and excellent local (breast) control of cancer. The rate of 5-year survival without a local cancer relapse is 99% (FIGURE III). Two thirds of the patients had mild RT-related skin side effects on the treated breast, including increased sensitivity, redness and darkening of the skin (a suntan effect) on the treated breast. None of the patients had severe skin reactions to radiation therapy.
FIGURE I Supine
FIGURE II Prone
FIGURE III Five-year Local Relapse Free Survival
Patients whose cancer returns or who develop another cancer in the breast after lumpectomy and radiation therapy are routinely treated with mastectomy. However, some patients are unwilling to consent to mastectomy. At CCCNY, we offered such patients a second chance for breast conservation on a research program.
From 2000 to 2010, we treated 19 breast cancer patients who had a small local recurrence or a new cancer in the same breast and had refused mastectomy. All patients underwent another lumpectomy and partial breast re-irradiation. We used radioactive seeds, or brachytherapy, for partial-breast irradiation that delivered a carefully contoured dose to the target while sparing nearby structures, such as lung, heart, and chest wall, as well as the rest of the breast away from the lumpectomy area.
At a median follow up of 73 months, 3 patients developed a local relapse and underwent salvage mastectomy and remain free of disease. This approach gives patients a high probability of being alive and well with the breast intact, estimated at 79% up to 12 years later (FIGURE I).
Others who, like us, have selected patients very carefully have also shown that women with prior breast radiation can have a second chance at breast conservation and avoiding mastectomy (Table 1).
Figure I: Survival (in years) without a mastectomy after partial-breast radiation in patients with an earlier lumpectomy followed by radiation to the whole breast.
Table 1. Other institutions’ success with second lumpectomy and re-irradiation with partial breast brachytherapy
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