More women need breasts removed after brachytherapy
David Cohen, M.D.·Published 2 May 2012·9 min read
Key points
Women who got seed radiation as part of their breast cancer treatment were more likely to have an infection or breast pain than those who were treated with whole-breast irradiation, in a new study.
This year, more than 200,000 new cases of breast cancer will be diagnosed in the United States.
Patients treated with brachytherapy were also more likely to get an infection over the next year, or to have breast pain or fracture a rib during study follow-up, the researchers reported in the Journal of the American Medical Association.
High dose rate (HDR) is a technically advanced form of brachytherapy.
Women who got seed radiation as part of their breast cancer treatment were more likely to have an infection or breast pain than those who were treated with whole-breast irradiation, in a new study.
And more patients treated with the quicker and more local radiation technique, also called brachytherapy, went on to need a mastectomy as well - but there was no difference in their chance of dying in the few years after treatment.
"The decision of whether a patient was treated with brachytherapy or whole-breast irradiation was the single most important factor in whether a patient had a mastectomy," said study author Dr. Benjamin Smith, who called that result "surprising."
"It had generally been thought that if it was used carefully in the appropriate patients, the risks of mastectomy or recurrence would be basically the same in patients treated with brachytherapy or whole-breast irradiation," Smith, from the MD Anderson Cancer Center in Houston, Texas, told Reuters Health.
Brachytherapy involves putting a small device - a balloon or a catheter - into the breast, where it delivers a dose of radiation to kill any extra cancer around the cavity where a tumor was removed.
The technique is frequently used to treat prostate and cervical cancer, but it's only in the last decade that devices have been available to use in the breast, Smith said.
What is Brachytherapy?
This year, more than 200,000 new cases of breast cancer will be diagnosed in the United States. Surgical removal of the cancer lump (lumpectomy) is usually the first step. After this surgery, women with early breast cancer are offered mastectomy (surgical removal of the entire breast) or radiation therapy to the breast. Most women choose radiation because the survival rate for such treatment is the same as with mastectomy, and it allows the patient to preserve her breast.
Radiation treatments are given to kill off any possible remaining cancer cells in the breast. Radiation is done to help prevent a recurrence, or return, of breast cancer and can be given with external or internal radiation. External beam radiation, also called whole-breast irradiation (WBI), treats the whole breast from the outside, by aiming highly penetrating x-rays at your tumor cavity.
External beam radiation begins four to six weeks after surgery. Patients receive one treatment a day for six to seven weeks. It is very successful in preventing recurrence of cancer in the breast, but many women find the long duration of treatment to be burdensome.
The advantages over whole-breast irradiation - the other option for women who want to keep their breasts - is that less tissue gets hit with radiation. And brachytherapy only takes five days to complete, compared to six or seven weeks for whole-breast irradiation.
"It's really nice for women who work outside the home or women who live in rural areas because they can get it done much more quickly," said Dr. Todd Tuttle, a cancer surgeon from the University of Minnesota in Minneapolis.
Written and revised by
David Cohen, M.D.
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"It's become very popular in the United States, without a lot of good data so far," said Tuttle, who wasn't part of the research team.
Breast Brachytherapy( High Dose Rate Brachytherapy for Breast Cancer )
Increasingly, women are deciding to have treatment of breast cancer with a safe and effective form of radiation therapy known as "breast brachytherapy". This method of therapy, which delivers radiation directly into a tumor site from the inside out, is a way to save most of the normal breast tissue, preserve the cosmetic appearance of the breast, and avoid the physical and emotional trauma of extensive breast removal surgery.
In the past, radiation has been administered to a patient’s "entire" breast (whole breast radiation) via external beam radiation therapy (EBRT). EBRT treatment is delivered to the tumor site via a radioactive beam from outside the patient’s body on a daily basis over an approximate 7 week time period. Recent studies have however shown that in most cases, limiting radiation to just “part” of the breast (partial breast radiation) is equally as effective and causes less injury to surrounding healthy breast tissue.
While both external beam and brachytherapy can be utilized to deliver partial breast radiation, brachytherapy is the quickest, most direct, and conformal way to deliver the radiation to the target.
For the new study, Smith and his colleagues analyzed Medicare insurance claims for close to 93,000 older women with cancer who got breast-conserving surgery followed by radiation in 2003 through 2007. About 7,000 of them were treated with brachytherapy, and the rest with whole-breast irradiation.
Over the next five years, four percent of women who'd had brachytherapy got their breasts removed because of a cancer recurrence or for another reason. That compared to about two percent of those who got whole-breast irradiation and needed a mastectomy.
The Advantages of High dose rate Brachytherapy
- Overall treatment time is 1 week versus 6 to 7 weeks for external beam radiation therapy. - Conserve your breast and yield excellent cosmetic results. - Breast brachytherapy delivers a precisely targeted dose to the tissues most at risk for recurrence, increasing the likelihood of tumor control. - Reduces radiation dose to the lungs and opposite breast. - Avoids potential long term side effects by reducing radiation doses to healthy tissue. - Breast brachytherapy causes no delays in other treatments such as chemotherapy. - Placement of the applicator (Tube and Button or Mammosite balloon) is simple and safe. - Treatment is given on an outpatient basis, so no hospital stay is required.
Patients treated with brachytherapy were also more likely to get an infection over the next year, or to have breast pain or fracture a rib during study follow-up, the researchers reported in the Journal of the American Medical Association.
They calculated that 56 women would have to get brachytherapy instead of whole-breast irradiation for one to need a mastectomy. And between nine and 16 patients would need to get the local treatment for one extra woman to have a complication, such as an infection.
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"Many surgeons are starting to think twice about this kind of therapy for a lot of women," Tuttle told Reuters Health.
"Although it's very attractive at first because you are potentially treating a lot less of the breast and you're doing it in a much shorter period of time, the benefits may not be there. In fact you may see more patients having long-term complications," he said.
Still, Smith said outcomes were generally "very good" across all patients. Five years after their initial surgery, 87 to 88 percent of women were still alive, regardless of what type of radiation they'd received.
Dr. Jona Hattangadi, a radiation oncologist from Brigham and Women's Hospital in Boston, agreed the risks seemed to be low with both types of radiation.
What is Brachytherapy? The prefix "brachy" is the Greek word for "short" distance. Brachytherapy is a form of internal radiation treatment where radioactive sources are placed on or into cancer tissues. There are two kinds of brachytherapy. The radiation sources may be inserted either permanently or temporarily. The two most common forms of treatment are low dose rate (LDR) permanent seeds for prostate cancer and high dose rate (HDR) temporary brachytherapy, that can be used for prostate, gynecologic, breast, head and neck, lung, esophageal, bile duct, anorectal, sarcoma, and other cancers.
What is high dose rate (HDR) Brachytherapy?
High dose rate (HDR) is a technically advanced form of brachytherapy. A high intensity radiation source is delivered with millimeter precision under computer guidance directly into the tumor killing it from the inside out while avoiding injury to surrounding normal healthy tissue. For a more in depth explanation please visit the understanding HDR Brachytherapy page.
How does radiation kill cancer?
Cancer is made of abnormal cells that tend to grow without control. Cancer DNA is more sensitive to radiation than are normal cells, so radiation kills cancer directly or when the cells attempt to multiply while normal tissue in the region is able to repair and recover.
She pointed out the limitations of a so-called retrospective study - including that researchers can't prove the brachytherapy, itself, was to blame for extra complications and mastectomies.
It could be, for example, that the types of women who opt for brachytherapy are more likely to need a mastectomy anyway - such as if they go for longer periods of time without coming in to see their doctor.
The "gold standard" option would be a study that randomly assigned women to get one method of radiation or the other, researchers said. That type of analysis is being conducted now, but results won't be available for another few years.
"Physicians need to be selective in who they choose to offer (brachytherapy) to," Hattangadi told Reuters Health. "It may not be uniformly something that should be given to all patients."
"Some of the trade-offs in convenience, efficacy and complications between whole-breast irradiation and brachytherapy may be more complex than we initially appreciated," Smith said.
That doesn't mean women shouldn't get brachytherapy, especially those who are okay with a slightly increased chance they'll need their breasts removed.
But because the treatment "can be a little bit risky," patients should make sure they're having it done by experienced doctors who will monitor them carefully, Smith added.
And women should be educated about all of their radiation options before going forward with any treatment, according to Hattangadi, who wasn't involved in the new study.
"It's important for any woman really to discuss with her physician the risks and benefits of either approach," she said.
Association Between Treatment With Brachytherapy vs Whole-Breast Irradiation and Subsequent Mastectomy, Complications, and Survival Among Older Women With Invasive Breast Cancer
Main Outcome Measures Cumulative incidence and adjusted risk of subsequent mastectomy (an indicator of failure to preserve the breast) and death were compared using the log-rank test and proportional hazards models. Odds of postoperative infectious and noninfectious complications within 1 year were compared using the χ2 test and logistic models. Cumulative incidences of long-term complications were compared using the log-rank test.
Results Five-year incidence of subsequent mastectomy was higher in women treated with brachytherapy (3.95%; 95% CI, 3.19%-4.88%) vs WBI (2.18%; 95% CI, 2.04%-2.33%; P < .001) and persisted after multivariate adjustment (hazard ratio [HR], 2.19; 95% CI, 1.84-2.61, P < .001). Brachytherapy was associated with more frequent infectious (16.20%; 95% CI, 15.34%-17.08% vs 10.33%; 95% CI, 10.13%-10.53%; P < .001; adjusted odds ratio [OR], 1.76; 1.64-1.88) and noninfectious (16.25%; 95% CI, 15.39%-17.14% vs 9.00%; 95% CI, 8.81%-9.19%; P < .001; adjusted OR, 2.03; 95% CI, 1.89-2.17) postoperative complications; and higher 5-year incidence of breast pain (14.55%, 95% CI, 13.39%-15.80% vs 11.92%; 95% CI, 11.63%-12.21%), fat necrosis (8.26%; 95% CI, 7.27-9.38 vs 4.05%; 95% CI, 3.87%-4.24%), and rib fracture (4.53%; 95% CI, 3.63%-5.64% vs 3.62%; 95% CI, 3.44%-3.82%; P ≤ .01 for all). Five-year overall survival was 87.66% (95% CI, 85.94%-89.18%) in patients treated with brachytherapy vs 87.04% (95% CI, 86.69%-87.39%) in patients treated with WBI (adjusted HR, 0.94; 95% CI, 0.84-1.05; P = .26).
Conclusion In a cohort of older women with breast cancer, treatment with brachytherapy compared with WBI was associated worse with long-term breast preservation and increased complications but no difference in survival.
Grace L. Smith, MD, PhD, MPH; Ying Xu, MD, MS; Thomas A. Buchholz, MD; Sharon H. Giordano, MD, MPH; Jing Jiang, MS; Ya-Chen Tina Shih, PhD; Benjamin D. Smith, MD
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