Welcome back to an introduction to breast cancer, I'm Dr. Anise Chagpar. I am so excited to have with me today Dr. Sue Evans. Dr. Evans is radiation oncologist here at Yale who treats breast cancer patients. We've talked a lot in our lectures about radiation oncology but let's talk to the experts. Thank you so much for joining me. >> Thank you for having me Anise. >> So Sue, we've talked a little bit about radiation and how radiation is delivered. So sometimes you will decide to give whole breast radiation, treat the whole breast. Sometimes you'll do accelerated partial breast irradiation and there are a bunch of ways of doing that. And then there's even some places that do interoperative radiation. How do you decide which modality is best? And how should patients decide which one they should be looking for? >> Absolutely. So that's a great question, and there's a lot of it goes in to that decision making. So, you know, one of the first criteria that we use is age. When we look at the studies that have examined partial breast radiation, most of the studies has been in women who were post menopausal. So age is one of the first things that we look at when we are deciding in between a partial breast approach or a whole breast radiation approach. The other thing we want to look at are actual specific features of the breast cancer itself. So again when we talk where partial breast has been examined, most of the studies that have been done have been fairly small studies, not big, sort of randomized trials where one is pitched up against another, although those have been done we're just still waiting for the results, unfortunately. And so, most of these tumors that have been examined for a partial breast approach have been more favorable. So they've been responsive for estrogen and progesterone. They're smaller size breast cancer, so usually and you know what we call a T1 breast cancer or something smaller than two centimeters. >> Uh-huh. >> So not a large breast cancer. And really a lymph node negative breast cancer where the lymph nodes have been sampled and they're found to be negative. So those are, you know, really the tumors where we might consider a partial breast approach. Now, whenever I meet with a woman who's interested in partial breast radiation, one of the things we talk about is, well, is the status of the data. And, we really don't have a head-to-head comparison that's saying, tried and true. Partial breast is equivalent to whole breast radiation. So if you have a woman who's not a pioneer and wants to go with really the tried and true approach, then whole breast radiation is really where she's going to be leaning most of the time. As you say, there are various different ways of delivering partial breast radiation. So it can be delivered from external radiation that's just targeted with maybe four or five different angles to one portion of the breast. It can be done with an implant, where there's actually a balloon sitting inside the breast that the radiation is then inserted into. And there are several different vendors which sell those balloons. Or also, you've mentioned about interoperative radiation. Interoperative radiation is really quite different than the other modalities. Because when we talked about what we use to decide, you notice that I mentioned several pathologic criterion, right? So, how large the cancer is, are the lymph nodes involved and, of course, we want the margins to be negative as well and intra-operative radiation is really undertaken before we know any of those things. >> Right. >> So, there is a subset of women who require whole breast radiation after intra-operative radiation. So that's something that we talk about as well. But I think for me, the biggest factor is sort of where the woman is in terms of the state of the data. If you have somebody who's priority is really going with the tried and true and sort of knowing, head to head that it's absolutely going to be equivalent, then they're going to steered more toward a partial breast approach. However, if you have somebody who is, perhaps, a little bit older, willing to take the fact that she's well-represented by those small trials, and it should be fine, but we don't know 100% that it's absolutely equivalent, then certainly, that's a reasonable approach, as well. >> So whole breast is really the standard, it's kind of the go to. But, even in whole breast radiation, there are a couple of different modalities, or different types. So, some women will get radiation five days a week for six weeks, some women can get that in three to four weeks. Hypofractionation, and we started to talk a little bit about this in our lecture. Can you expand on that? How do you decide whether these two are really equivalent and who should get one or the other or if they really are the same? >> Right. Absolutely.. And so I think that's one of the more controversial things in radiation oncology right now. So, you know, in 2013, ASTRO did the Internal Medicine Choosing Wisely campaign. And so that's a campaign, for those of you who aren't familiar with it, it really seeks to talk about what are the things that have changed in medicine, what should practitioners look at adopting? And basically, what they came out with was their number one, first choosing wisely thing that they ever did was don't embark on a course of whole breast radiation in a woman with a lymph node negative breast cancer over the age of 50 without considering a hypo-fractionated course. So that was really a pretty powerful statement for the National Radiation Oncology Organization to make, and over time we've been able to show in some of the research, that us at Yale and others across the country have done, that the adoption of hypofractionated radiation has really been quite slow nationally. It's only about 14% of practices nationally that are doing this shorter course radiation. So, it takes a while to sort of change that and I think, as you know a lot of people do as they're trained and if it's not broke don't fix it and are sort of slow to adopt these things. But we've had some really compelling evidence form MD Anderson this past summer that Ben Smith who is a Yale medical residency trainee graduate as well. Who published, he did a very nice study looking at quality of life. >> Uh-huh. >> And so he looked at endpoints like skin irritation and fatigue and itchiness of the skin during breast radiation and so he took women with the standard course and the shorter course and found that quality of life was better with a shorter course. >> So we're excited about using the shorter course raditation and we offer it to women whenever possible. Now, when is it possible? So when we look at when hypofractionation is a possibility. It's in women who are treated with a lumpectomy, so they still have their native breast. And it's also in women where we're not treating the regional lymph nodes. There are some very important nerves that run to the arm and so the shorter course hasn't been tested in that region of the body. So whether or not that's appropriate to do or not, we're not quite yet sure. So that's the first criterion. Then I think the other criterion come down a little bit into whether you're a lumper or a splitter in some ways, if you will. And so some people will look at the hypofractionation trials and say okay, it is equivalent. We have six weeks versus three to four weeks. And the trials show it's equivalent, so therefore it's equivalent, end of story. It's the same amount of radiation, and done. We have other people who will say, well, you know, we have to look at who was represented on that trial, and say that most of the women were Positive. So maybe I'm not comfortable using it in women who have triple negative breast cancer. Or not as many of the women had chemotherapy on this trials, so I'm not really comfortable using it in the setting after chemotherapy. Or maybe the say, well it's predominantly in women over the age of 50. So if I have a 35-year-old, then I'm not going to be quite so comfortable. So it really depends on how you view the data. And so I think even in our own practice we have some differences as to how people think that's appropriate, but I think for most people, if there's a woman with an estrogen-positive breast cancer who's 50 years old. And requires treatment to the breasts only for an invasive breast cancer, then most people would feel comfortable in our practice, administering the shorter course radiation. >> Yeah. >> It comes down to a little bit different when we have young women, people with pre-existing implants, triple negative breast cancers, where people might have a little bit more caution in those scenarios. And I think that's appropriate. >> Yeah, it's another great example of why people should really participate in clinical trials so that you do get kind of a diverse array of patients because as is pointed out right here so many of the decisions that we make are really defined based on the people who participate. So another question, you mentioned this a little bit about treating regional lymph nodes, and there's been some data coming out that's really talked about radiation to regional lymph nodes. Tell us about your thoughts on that and whom do you recommend extra radiation to lymph nodes? >> Absolutely, so, when we're looking to give treatment to the regional lymph nodes, we're really trying to define the women who are at highest risk of failure to those regions of the body. The exciting trial it came out, it showed that there was a disease-free survival benefit in adding radiation to the regional lymph nodes. So, we certainly are considering it a lot more, specifically in women who have positive lymph nodes, certainly. That particular trial also had a small proportion of women who were sort of the high risk node negative breast cancers, where the lymph nodes were negative but they had some more aggressive features, like lymphovascular invasion, or higher grade, or larger tumor size. So, typically, we're looking at it the most when we have women who have a no positive breast cancer. So we're looking at treating not only the lymph nodes underneath the collar bone, but we're also starting to look more at the lymph nodes that live beneath the breast bone. And that's an area that's sort of pendulum back and forth over the years, in terms of how often it was treated. And one of the nice things that we have now is that the toxicity of doing that treatment has gotten a lot less because we are doing all of our planning with CAT scans, and we have techniques like breath hold that can move the heart out of the way. That's where women will take a deep breath and hold it to push the heart out of the way, then we're able to consider doing these treatments in a wider array of women. But I think it is a small disease-free survival benefit, so oftentimes it's a decision that we make, sort of looking at the individual anatomy of the woman and judging how much heart or lung would be exposed by adding those lymph nodes and considering the benefit of that as well. >> So another thing that we talked a little bit in lecture about was prone positioning. When do you do that? When do you put people lying on their stomach when you treat them for radiation? >> Yeah, so, the prone positioning technique has been shown to be very helpful, particularly when you have women with very large breasts. >> Mm-hm. >> One of the things that we think a lot about in radiation, of course, is individual anatomy and the shape because we have to cover the whole breast. And so, sometimes what we can see is in women with large breast. The breast will sort of fall to the side and to the armpit when we lie them on the back. And so, it will sort of hug the chest wall and when you're trying to cover the entire breast, and the breast is hugging the chest wall, you're going to expose more of the tissues deep to the breast, like the heart or the lung to radiation. So, in women where were treating just the breast with early stage breast cancer. So with no lymph nodes involved. We'll sometimes look at doing treatment on their belly so that, that way the breast falls forward, and we can minimize the amount of underlying tissue, as well as promoting a nice even dose of radiation to the breast. One of the things that's come out for cosmetic outcome in breast radiation is having a very even dose of radiation throughout the breast is quite helpful. As we all know, the breast is not a square. It's a different shapes. So the thinner parts of the breast, close to the nipple will sort of reach their prescribed dose of radiation sooner than the deeper, thicker parts of the breast, right up against the chest wall. And when you have somebody lying on their belly with a very large breast, it sort of flattens out and becomes very thick. Whereas when they're on their belly it elongates, and sort of teardrops out or thins out. And so getting a nice even dose of radiation is easier just by the physics of the radiation when you have sort of, less tissue to cross, if you will. >> So the other area that we talked a little bit about radiation in lecture was, after mastectomy, so we now talked a lot about radiation after partial mastectomy or a lumpectomy, and everybody remembers that we do that to reduce the chances of local regional recurrence. But some patients need to have radiation after a mastectomy. Tell us a little about your thinking in terms of who needs radiation after a mastectomy, and why? >> Yeah, so that's a great question. So when we look at the trials for radiation after mastectomy, we've come to understand that its more applicable than we realized even a few years ago. It used to be that we would only consider radiation after mastectomy in women with four lymph nodes involved or more. Now, we're strongly considering it with any woman with lymph node positive disease. And the reason is that the randomized trials have really borne out that there's a survival benefit to that. It always sort of strikes patients as a little bit funny. That it took years for us to prove that if you prevented breast cancer from coming back, you saved more lives from breast cancer. But in fact, in the local area, that is indeed the case. Because we can't always salvage or sort of fix the situation when that happens. So, the radiation after a mastectomy is targeted to the chest wall, and often the lymph nodes above the collar bone as well as the lymph nodes underneath the breast bone. And the reason for that is that when we look at sort of the natural history of breast cancer, and how it recurs after mastectomy, about three-quarters of the time, in the setting of the local recurrence, it recurs somewhere in the chest wall as you know. And so it's often a surprise to patients that even though the breast is gone, the chest wall is still at risk. So, that's really what we look at when we're making that decision. So a lot of it has to do with the lymph node positivity. And then there's little shades in between them, so if you have somebody who's 75 years old, and has a very strongly positive estrogen receptor tumor. And they had one tiny little three millimeter lymph node, she's probably not going to get post-mastectomy radiation necessarily. And if you have somebody who got a 5 centimeter breast cancer that's triple negative, and is 32 years old, and has half a millimeter in their lymph node. Then, that might be someone who we're offering post mastectomy radiation to, so there's a lot of nuance in terms of that node positive subset, but certainly. >> One of the other things that we often dance around, and this is one of those areas that again has got some controversy, and a bit of coordination that's required is What do you do in terms of radiation after reconstruction in people who have had a mastectomy? >> Absolutely. So it's always a little bit of a challenge because we know that there are some complications for sure in radiation after a mastectomy when there's a reconstruction in place. We've had a very good experience at Yale, as you know, with doing the deep flap reconstructions. And those have tolerated radiation quite well. When we talk about the implant reconstructions, we're always worried about the loss of the implant or capsular contracture. And such things that can require further surgeries or that can impact the cosmetic outcome. And it's always surprising to me how different that is from woman to woman. I have some women who will have a capsular contracture. And it's just a slight difference. Maybe a fingers breadth difference of the height of the breast. But it will be quite bothersome. And I have other women where it's more pronounced and it's not bothersome as much. But, really, it's a lot of multidisciplinary coordination between each other. We're very lucky to have a very good group. Because oftentimes when we're doing radiation and women have expanders in place, sometimes the expanders will be quite close together. And in order to treat the right side the expander is expanded so much that I can't angle my radiation beam to avoid the lung appropriately unless that expander is partially deflated. And so it's a lot of coordination with the plastic surgery team to really do a nice job. And we spend a lot of time on the radiation planning too as well. Making sure that that radiation dose is even, sort of drawing from the knowledge that cosmetic outcome and the amount of fibrosis that we see in the native breast is very much related to the evenness of radiation dose. So certainly we look to make that a nice even dose and reconstructive breasts as well. And hopefully that'll translate to better outcomes. >> So the other question that we often touched on a little bit in every question that we've answered so far during this interview, Has been really about toxicity. How do you minimize the lung dose? How do you minimize the heart dose? What do you tell patients about toxicities that they can expect after radiation? What are the numbers for getting another cancer after radiation? Which is another fear that a lot of patients have. And what do you do as a radiation oncologist to minimize that toxicity? >> Absolutely. Thankfully, pretty much every radiation center in the country these days is doing CT planning. So that's the simplest thing that we can do, right? Is to actually know what we're treating. And take very detailed analysis of that. So, for every patient who's getting radiation treatment. We literally draw on their lung and draw on their heart and draw on the breast tissue at risk. And we know the doses at the end of treatment, what those will be before a single treatment is delivered. So that's our time to modify, right? So if those doses are higher than we think are reasonable, or desirable, right? >> Yeah. >> Because it's not just reasonable, we want to make sure that any plan that we're delivering is something that we'd be comfortable receiving. So that's really the time where we're evaluating that. The things that we expect, so, certainly we expect some skin redness during treatment. And that can be varying degrees and I tailor that to the woman I'm talking to. So when I have a woman who's a b cup and 120 pounds, I'm talking to her about skin toxicities and I'm kind of laying it on light because I expect that she's not going to have a lot of skin toxicities. If I have someone who has a very, very large breast, sometimes we'll treat women with three or four liters worth of breast, I'm going to counsel her that she may indeed have some peeling that's pretty profound and even some wet peeling or deeper peeling that's going to be uncomfortable for her. Fatigue is something that pretty much everybody sees during the course of radiation. It's very variable, woman to woman. Some people just get a little bit of fatigue, and other people get quite tired and are finding themselves going to bed at 8:00 at night instead of their normal 10 p.m. We talk about the risk of pneumonitis or inflammation of the lung from radiation. Typically when we're treating the breast only, that risk is only about .7% and it is very manageable and treatable. If you Google pneumonitis, you'll come across radiation pneumonitis in relationship to lung cancer and see all sorts of scary things. But breast cancer, it's a completely different beast, and it's not a beast at all. It's more of a nuisance, so certainly I want women to know what to expect with that. There is about a one to two% risk of a broken rib after radiation. So we're always counseling women about that possibility and also giving them sort of practical advice so if they find themselves with a horrible bronchitis or horrible pneumonia. And they're coughing all night long maybe take some Robitussin and knowing that you might be a little bit more fragile on those ribs and a broken rib can happen just from coughing and that's not fun. It heals but, it takes several weeks to heal. The other things that we think about are cardiac dose so, the dose of radiation to the heart. And so we've got some very nice data now that showed that that's a linear relationship with actual dose of radiation that the heart receives. So the higher the dose, the higher the likelihood, and conversely of course the lower the dose, the lower the likelihood. So sometimes we're managing that by just shaping the beam of radiation to block the heart out of the way. Sometimes we're having women take a deep breath and holding it during radiation treatment which is expanding the lungs pushing the heart away from the chest and also down in the chest. I use to think it was the away that was the biggest help. And I've come to appreciate how much the down helps us too. Because the breast is in the same position but if we move the heart down. The heart is all of a sudden out of the way, so that's actually quite helpful as well. And other times just lying them on their belly will help to avoid the heart. So, those are the things that we really think about. Luckily, the second cancer risk is very, very small. We do counsel women, if they are active smokers, that they really do need to stop that, because that can be additive to that risk. We talked to them as well about making sure to modify other behaviors related to care of the skin. I just give someone a hard time about a tanning bed this morning, wearing sunscreen, all of those sorts of things. And also, some education, right? So, one of the things that's very uncommon, but it's pretty tightly associated with breast radiation. It's the second cancer common angiosarcoma. And it presents really funny, as you know, in the yeast, and so it's. Sort of looks almost like a bruise almost. Very sort of almost reddish purply. And very sort of this weird vascular thing on the skin. And certainly I think it's strange to a lot of people that something like that would happen and it wouldn't be a mass but it would still be something quite serious that needs to be looked at so whenever I'm meeting women I'm counseling them this is very very uncommon but they were to see a bruise that didn't heal and didn't go away and you know started to grow don't delay get it looked at, make sure that there is nothing going on. Feel free to have me take a peek. I am happy to do that. It is quite rare but certainly but we dont want these sorts of things going unchecked and untreated. >> Perfect. So last question. What's the future for breast radiation oncology? What's new and exciting? >> I think there is a lot new and exciting. I think what we are learning. I suspect that, you know, over the upcoming years, we're going to start expanding the trials for the hypofractionated treatment. >> Uh-huh. >> In looking at women who need their regional nodes treating >> And seeing if that can be done safely and effectively, and so that's really exciting, because that's a huge savings for women in terms of their convenience and quality of life. As we all know, getting treatment for breast cancer can be a very long procedure, especially if they need chemotherapy. So I think that's really exciting. The other thing that I'm really excited about is there are a couple of trials coming out that are looking at some of the molecular markers. So I think that's going to be fascinating. I'm really hopeful that we can risk stratify better. So I think we're learning. There are some women who do well without radiation. So certainly we know women over the age of 70 with estrogen positive cancers who are going to take hormonal therapy a lot of times could do very, very well without radiation. And I expect that we're going to find that that population is going to expand through molecular profiling. We're going to be able to better determine who really needs it. So I'm excited that we're going to hopefully be using lesst radiation and shorter the courses of radiation because I think that's going to have a lot of promise. >> Terrific. Well, thank you so much for being my guest today. >> Thank you for having me.
