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Breast Cancer
We at Valley Radiotherapy Associates Medical Group (VRA) endorse this approach and facilitate this multi-specialty integration. Our physicians are nationally recognized experts in breast cancer, and consultation with one of them precipitates the cascade of physician involvement. Treatment strategies are individualized and formulated to maximize cure rates, preserve the breast when possible, and improve a woman's overall quality of life. Radiation therapy plays a major role in the management of breast cancer of all stages. Quality radiation of a patient with breast cancer requires the availability of the latest technology as well as a physician who understands the latest biologic innovations. Approximately 75% of women who are diagnosed with breast cancer have what is referred to as early stage disease. This includes both Ductal Carcinoma In Situ (DCIS) and early invasive disease. Early invasive disease specifically refers to the clinical circumstances where a tumor measures 5 centimeters or less and there is no evidence of matted lymph nodes or disease outside the confines of the breast and surrounding lymphatics. The treatment for early stage breast cancer has evolved over the past several decades. In the 1960's surgical treatment almost invariably consisted of a radical mastectomy. Previously, physicians thought that more extensive surgery resulted in better cure rates. It is now recognized that more surgery does not necessarily translate into improved cure rates, and the radical mastectomy has been abandoned. This realization led to the design and implementation of numerous clinical trials in the U.S. and Europe comparing mastectomy to breast conservation therapy (BCT). BCT refers to limited surgery (e.g., lumpectomy, partial mastectomy, segmental resection), whereby only the tumor and a rim of normal surrounding breast tissue is removed, followed by radiation therapy to the whole breast. These trials have unequivocally shown that for most women with early stage breast cancer, BCT and mastectomy lead to similar survival rates. In fact, in 1990 the National Cancer Institute (NCI) convened experts from around the world to review the literature and to put forth an opinion regarding optimal management of early stage breast cancer. Their conclusions are summarized in the consensus statement that followed: "Breast conservation treatment is an appropriate method of primary therapy for the majority of women with stage I and II breast cancer, and is preferable because it provides survival equivalent to total mastectomy and axillary dissection while preserving the breast". VRA physicians are skilled experts in evaluating women for BCT and several have published extensively on this subject. The radiation oncologist's assessment of the margins of the excised tumor is critical for understanding whether a second excision is necessary. Pathologic review by the physician will also be important in determining the final doses necessary to be delivered to the breast as well as the tumor bed. VRA physicians review each patient's pathology, and when surgery was performed at an outside facility, will review the slides with another pathologist expert in the field of breast cancer. VRA physicians have treated over 1,000 patients with early stage breast cancer and we have followed our patients for up to 14 years. A local recurrence rate well below the national average has been demonstrated. Our patients' overall satisfaction, especially with regard to their breast appearance and sensitivity exceeds 90%. The recognition that breast cancer also responds to chemotherapy has propelled us even farther with regard to options that we are able to offer our patients. For example, chemotherapy has been, and continues to be delivered most often following surgery. However, when given before surgery it has been shown to result in tumor shrinkage. In fact, women presenting with tumors that previously were deemed too large to allow BCT are now often able to undergo BCT once chemotherapy has sufficiently reduced the size of the tumor. We strongly believe that each woman's case should be extensively reviewed in collaboration with the other medical specialties so that whenever possible (i.e., when her chances of recurrence are not thought to be increased) she can opt to preserve her breast. Unfortunately, mastectomy may still be considered the treatment of choice for a few women. Oncologists often recommend that women receive radiation to the chest wall and surrounding lymphatics following a mastectomy. Indications for post-mastectomy radiation have included tumor size 5 centimeters or greater, a positive margin of resection, and multiple positive lymph nodes. Sometimes other factors may lead us to recommend post-mastectomy radiation. Two studies recently published in the New England Journal of Medicine suggest that post-mastectomy radiation results in improved survival rates for women with positive lymph nodes (including 1). Again, these decisions require a highly focused, multi-disciplinary approach by physicians who are experts in assessing these factors. For women with metastatic disease (i.e., disease which has spread to other parts of the body) radiation therapy is often helpful in relieving symptoms that result from spread of the tumor. Pain is a frequent consequence of tumor spread and radiation therapy is considered the treatment of choice when pain is isolated to a focal area or region. When either the breast or chest wall is irradiated, moderate doses of radiation are used. Forty five hundred -5,040 centigray delivered over 5-5.5 weeks is customary. When the breast is irradiated, an additional boost dose (1,000-2,000 centigray) is delivered to the tumor bed. This type of radiation is very well tolerated. Side effects include some degree of tiredness, skin redness, and mild discomfort of the chest wall. Serious potential long-term effects occur approximately 1-2% of the time and should be discussed with your physician. VRA physicians use only advanced radiation techniques so that a minimum of normal tissue is irradiated. The oncologic community has made great strides in improving treatment and survival rates for breast cancer. However, a number of questions remain unanswered. Questions abound in the areas of epidemiology (including breast cancer genetics), treatment and psychosocial impact. Valley Radiotherapy Associates invite you and your family to discuss these and other issues with us. References:1. Harris J, Lippman M, Morrow M, Hellman S, eds., Diseases of the Breast, Lippincott- Raven publishers, Philadelphia, 1996 2. National Institutes of Health Consensus Conference: Treatment of early-stage breast cancer. JAMA 265:391, 1991 3. Jacobson J, Danforth D, Cowan K, et al. Ten-year results of a comparison of conservation with mastectomy in the treatment of stage I and II breast cancer. NEJM 332(14):907, 1995 4. Overgaard M, Hansen P, Overgaard J, et al. Postoperative radiotherapy in high-risk premenopausal women with breast cancer who receive adjuvant chemotherapy. NEJM 337:949, 1997 5. Ragaz J, Jackson S, Le N, et al. Adjuvant radiotherapy and chemotherapy in node-positive premenopausal women with breast cancer. NEJM 337:956, 1997 6. Hellman S. Stopping metastases at their source. NEJM 337:996, 1997 Further Information and Resources:
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The management of breast cancer from an oncologic perspective is complex and requires an integrated approach. The decision process requires coordination of multi-specialty physicians, including the surgeon, pathologist, radiologist, radiation oncologist, and medical oncologist.