Pmrt For Early Stage Breast Cancer
Most patients that have a mastectomy for early stage breast cancer will not need radiation. There are a few important situations that may require Post Mastectomy Radiation Therapy for Early Stage breast cancer.
Positive Margins: This is when invasive cancer is found under the microscope on the edges of the surgically removed breast tissue from a mastectomy. This means there may be some cancer cells left behind in the surgical area that carry a high chance of growing back. PMRT reduces the chance of local recurrence in patients with positive margins.
Lymph nodes contain cancer: If three or more lymph nodes are involved with cancer, then post mastectomy radiation is usually recommended. This reduces the chance of the cancer recurring in the breast and remaining lymph nodes in the region. Studies have shown that radiation in these situations improve long term survival.
There are a few situations where PMRT is recommended for those with only one or two nodes that are found to have cancer after a mastectomy. This usually involves premenopausal women who carry a higher risk of their cancer recurring. A consultation with a radiation oncologist is essential for you to understand if radiation will be needed in these situations.
What Does New Evidence Suggest
The new evidence suggests that younger women with tumor features similar to those described above might also be able to forego radiation without raising their odds of recurrence. Instead, they would take endocrine therapy for five years.
The study involved 500 women ages 55 and older with early-stage breast cancers similar to established criteria for skipping radiation during treatment. It also allowed women to enroll if the margin of normal breast tissue removed was very thin . The analysis used an extra test on tumor cells removed during lumpectomy to confirm that they were slow-growing.
Over an average follow-up of five years, the study revealed that the rate of breast cancer recurrence in the same breast was 2.3% in women who skipped radiation after lumpectomy and took endocrine blockers instead the same rate expected with radiation use, which was impressive, Dr. Tung says. “Most recurrences will happen within five years. If reproducible, the results could suggest a new set of criteria for avoiding radiation.”
Split Opinions In Practice Perception
U-M researchers mailed a survey to 879 surgeons and 713 radiation oncologists who regularly treat breast cancer. The survey questions evaluated physician attitudes, knowledge, communication and recommendations regarding the omission of radiation therapy in older women with early stage breast cancer.
In this large national sample, published in the Annals of Surgical Oncology, researchers found that 40 percent of surgeons and 20 percent of radiation oncologists were uncomfortable with omitting radiation after lumpectomy.
A sizable minority in both specialties erroneously associated radiotherapy in this scenario with improvement in survival for early stage patients. They also overestimated the risk of local recurrence if radiation is omitted.
Additionally, clinicians who overestimated the benefits of radiotherapy were more likely to consider radiotherapy omission to be an unreasonable option.
To better assess attitudes, the survey proposed specific patient scenarios. In one scenario, physicians were asked if they would recommend radiation to an unhealthy 81-year-old woman who was a borderline surgical candidate.
One-third said they would a margin that surprised the research team.
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What Are The Types Of Radiation Therapy For Breast Cancer
There are different ways to receive radiation therapy. Your healthcare provider will choose the best method based on the cancer location, type and other factors.
Types of radiation therapy for breast cancer include:
- External beam whole-breast irradiation: During external beam whole-breast radiation therapy, a machine called a linear accelerator sends beams of high-energy radiation to the involved breast. Most people get whole-breast radiation five days a week for one to six weeks. The time frame depends on factors including lymph node involvement. In some cases, intensity-modulated radiation therapy may be used.
- External beam partial-breast: This treatment directs radiation to the tumor site only, not the entire breast over 1 to 3 weeks with 3-dimensional conformal radiation or IMRT.
- Brachytherapy: Some people get internal radiation therapy or brachytherapy. Your provider places an applicator or catheter. A radioactive seed is moved into the tumor site. The seeds give off radiation for several minutes before your provider removes them. You receive two treatments every day for five days.
- Intraoperative:Intraoperative radiation therapy takes place in the operating room before your provider closes the surgical site. Your provider delivers a high dose of radiation to the tumor area of the exposed breast tissue.
Risk Of Heart Disease From Breast Cancer Radiation
Although radiation exposure from breast cancer treatment is associated with a small risk of subsequent heart disease, the risk is lower than it was 20 years ago, according to the results of a study published in JAMA Internal Medicine.9
Radiation is used after surgery to kill any remaining cancer cells and this decreases the risk of local recurrence and improves survival. Like any treatment however, radiation carries risksâincluding an increased risk of heart disease when radiation is used on the left breast, which is closer to the heart.
Because long-term breast cancer survival rates have improved dramatically in recent decades, researchers continue to look for ways to minimize long-term treatment-related complications. Researchers conducted an analysis to evaluate the risk of developing heart disease as a result of radiation treatment to the left breastâand found that the risk varies depending on the underlying risk of heart disease.
They report that the average risk of developing heart disease as a result of radiation exposure for breast cancer treatment is less than one percent. The risk increases for woman who already have a high underlying risk of developing heart diseaseâin these cases, the risk may be as high as 1 in 30. In contrast, women who already have a very low underlying risk of heart disease may face odds as low as 1 in 3000, which is a tiny risk.
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How Can I Make A Decision Between Mastectomy And Breast Conservation Therapy
Breast conservation therapy is often used for patients with early-stage invasive breast cancers . It is also used for patients with DCIS . Some of the reasons to not have breast conservation therapy include: personal preference increased risk of complications from radiation therapy in individuals with certain rare medical conditions such as certain autoimmune disorders surgery that would require removing a large amount of diseased breast tissue that would lead to a poor cosmetic result and tumors that are more likely than average to have a relapse in the breast with breast conservation therapy. Women who are carriers for the breast cancer gene may sometimes elect for a double mastectomy.
Most patients may choose a treatment based on other factors, such as convenience or personal preference . Most women prefer to keep their breast if this is possible to do safely, but there is no right answer that is best for everyone. This decision is one that is ideally made in partnership between a patient and her physician. In some cases a pre-surgical consultation with a radiation oncologist may be helpful in answering questions about breast-conserving therapy.
Nearly all physicians will recommend patients be treated with mastectomy instead of breast conservation therapy when the risk of recurrence in the breast is more than 20 percent. This is the case if the tumor is large or multifocal . This situation occurs for only a small number of women, however.
Mastectomy: Advantages And Disadvantages
For some women, removing the entire breast provides greater peace of mind . Radiation therapy may still be needed, depending on the results of the pathology.
Mastectomy has some possible disadvantages:
- Mastectomy takes longer and is more extensive than lumpectomy, with more post-surgery side effects and a longer recuperation time.
- Mastectomy means a permanent loss of your breast. and usually loss of sensation in the skin on the chest wall, even if you have a breast reconstruction.
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Some Younger Women With Early
Gene testing helped doctors identify a group of women who skipped radiation therapy because their cancer showed very low risk of coming back following surgery, according to findings presented Tuesday at a meeting of the American Society of Clinical Oncology , held in Chicago.
Forgoing radiation therapy worked out well for them, it turned out.
The patients had a little more than 2% risk of their breast cancer returning, said study leader Dr. Timothy Joseph Whelan, chair of breast cancer research at McMaster University in Hamilton, Ontario, Canada.
Between 10% to 15% of breast cancer patients in the United States and Canada fit this genetic risk profile, he said, meaning that 30,000 to 40,000 North American women a year might be able to skip radiation therapy without worrying about their cancer returning.
“The results are pretty dramatic,” Whelan said. “The risk is very low. It’s comparable to the risk of developing a new cancer in the other breast. So we feel it could be practice-changing.”
Previous studies in women over 70 years of age found that their risk of recurrence was 4% to 5%, according to an ASCO news release. These findings suggest the risk is even lower in younger women with luminal-A breast cancer.
The overall survival rate for participants was 97%, the researchers reported.
What Are The Different Kinds Of Radiation Therapy
Most radiation therapy is administered by a radiation oncologist at a radiation center and usually begins three to four weeks after surgery. The radiation is used to destroy undetectable cancer cells and reduce the risk of cancer recurring in the affected breast.
There are two main kinds of radiation therapy that may be considered, and some people have both.
- External Beam Breast Cancer Radiation
- Internal Breast Cancer Radiation
Keep in mind that the course of treatment you decide is something you should discuss with your radiation oncologist in order to ensure that it is as effective as possible.
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Promising Results But Daunting Obstacles Remain
The studys results are considered preliminary, and further well-vetted research is needed to confirm its results. An additional barrier makes it difficult to translate these trial results to clinical practice: the reliability of the test used in the study to demonstrate that the cancers were slow-growing called Ki67 varies, and many hospitals dont routinely use it to assess breast tumors.
“It will help to assess the results of other studies omitting radiation to feel confident we have identified additional patients with invasive breast cancer for whom radiation can safely be omitted,” Dr. Tung says. “Some of these studies use molecular testing to assess features of the breast cancer, and we await those trial results as well.”
Radiation Therapy And Breast Reconstruction With Implants
If your treatment plan includes mastectomy, radiation therapy and breast reconstruction, discuss possible risks with your plastic surgeon and radiation oncologist.
Learn more about breast reconstruction.
New radiation therapy methods are under study in clinical trials.
Learn more about clinical trials.
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What Should A Person With Stage 0 Or Stage 1 Breast Cancer Expect Regarding Treatment
Even though Stage 0 breast cancer is considered non-invasive, it does require treatment, typically surgery or radiation, or a combination of the two. Chemotherapy is usually not part of the treatment regimen for earlier stages of cancer.
Stage 1 is highly treatable, however, it does require treatment, typically surgery and often radiation, or a combination of the two. Additionally, you may consider hormone therapy, depending on the type of cancer cells found and your additional risk factors. Like stage 0, Chemotherapy is often not necessary for earlier stages of cancer.
Material on this page courtesy of National Cancer Institute
Medically Reviewed on April 15, 2020
Questions To Ask Your Cancer Team
For women diagnosed with early-stage breast cancer who want to know if radiation is necessary after lumpectomy surgery, Dr. Tung suggests asking your oncology team these questions:
- Does my tumor type meet the criteria to avoid radiation therapy? If not, why? “I think many radiation oncologists arent usually asked this question,” Dr. Tung says.
- What are the chances my tumor will recur if I do or dont have radiation? If youre given the choice, its important to understand the difference in your odds of recurrence or cure, Dr. Tung says.
- Would I need to take medication instead of having radiation? If so, for how long, and what are the possible side effects?
- What are the possible side effects if I undergo radiation? “Radiation can cause redness, like a burn on the breast,” she explains, “and the treated breast can shrink a bit over time. Ask about both short- and long-term side effects.”
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Complementary And Alternative Treatments
Some people with breast cancer might be interested in exploring complementary or alternative treatments like vitamins, herbs, acupuncture, and massage.
These treatments are used alongside traditional breast cancer therapies to treat cancer or relieve cancer symptoms and uncomfortable side effects of treatments like chemotherapy. You can explore these treatments at any stage of breast cancer.
Examples of alternative therapy include:
- using massage to relax
- using peppermint tea to reduce nausea
- using cannabis to relieve pain
While some alternative medicine treatments might help you feel more comfortable, its important to keep in mind that many are unproven and could be harmful to your health. To be safe, talk with your doctor about alternative treatments youre interested in pursuing.
Breast cancer that spreads to other parts of the body can cause pain, such as bone pain, muscle pain, headaches, and discomfort around the liver. Talk with your doctor about pain management.
Options for mild to moderate pain include acetaminophen and nonsteroidal anti-inflammatory drugs , such as ibuprofen.
For severe pain in a later stage, your doctor may recommend an opioid such as morphine, oxycodone, hydromorphone, or fentanyl. These opioids have the potential for addiction, so they are only recommended in certain cases.
While breast cancer stage has a lot to do with treatment options, other factors can impact your treatment options as well.
What Should I Expect Before Radiation Therapy For Breast Cancer
Most people who have breast cancer treatment receive external beam radiation therapy. The goal is to destroy any remaining cancerous cells while protecting healthy tissue.
Before your first treatment, you will have a planning session . This simulation helps your provider map out the treatment area while sparing normal tissues . This session may take one hour or longer.
During the simulation, your provider:
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Patients Refusal Of Surgery Strongly Impairs Breast Cancer Survival
This was a Swiss study by Verkooijen et al, published in 2005 in the Annals of Surgery that looked at 5339 patients under the age of 80 with non-metastatic breast cancer. It didnt examine CAM, just the decision to refuse breast cancer surgery. It compared patients who refused breast cancer with those that those that accepted surgery. Only 1.3% of women refused surgery. Of that group, 37 had no treatment, 25 had hormone-therapy only, and 8 had other types of treatments. So only a small percentage refused all treatment. In this study, the five-year survival of women that refused surgery was 72% versus 87% of women who had surgery. Adjusting for prognostic factors, the authors estimated that women that refused surgery had a 2.1-fold increased risk of death from breast cancer compared to conventional treatment. The survival curves make this clear:
The bottom line in this paper was that a decision to forgo surgery for breast cancer is associated with dramatically worse outcomes and survival.
Stage 0 Breast Cancer
What is Stage 0 breast cancer?
Stage 0 breast cancer is when the cells that line the milk ducts have become cancerous. This type of cancer is called ductal carcinoma in situ , or non-invasive or pre-invasive breast cancer.
At this stage, the cancer has not spread to surrounding tissues. And while its considered non-invasive, its important to remember that it can still become invasive and spread beyond the milk ducts if it isnt treated.
What are the treatment options for Stage 0 breast cancer?
- Surgery Breast surgery is often the first step at Stage 0. Depending on the size of the tumor, how fast the cancer appears to be growing and your personal preferences, there are two types of surgical options:
- Lumpectomy A lumpectomy is a targeted surgery that removes the lump or tumor in question, and a small amount of normal tissue around it. This is commonly referred to as breast conservation surgery . In the United States, most women with Stage 0 breast cancer undergo a lumpectomy followed by radiation therapy.
- Mastectomy If the cancer has spread throughout the ducts and affects a large part of the breast, doctors may recommend a mastectomy. With this surgery, the entire breast is removed and possibly some lymph nodes as well.
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