Two women, every fifteen minutes, will die of breast cancer. However, due to new drugs and new treatments, many, many more women will beat this disease.
There is a new breakthrough that has women leaving the hospital in one day, surgery, radiation and all!
Joanne Duffy is a part of a survivors group; this group helped Duffy face her breast cancer. However, Joanne's treatment was different than the other women. She is one of the first to have a lumpectomy and all of her radiation in one surgery.
"If a woman has a lumpectomy for breast cancer, the site where the cancer will most likely come back is the site where it was before," Doctor Stephen Grobmyer, MD, Surgical Oncologist at The Cleveland Clinic Breast Center, told Ivanhoe.
That's why immediately following the tumor removal, surgeons at The Cleveland Clinic are using Intra-Operative Radiation Therapy to specifically target the area where the tumor was removed.
"The radiation only travels about a centimeter, so it really has no chance of damaging normal tissue," Doctor Grobmyer explained.
Traditionally, patients would start monthly chemotherapy infusions for a year after surgery, and then follow that by daily radiation treatments for three to five weeks. The
Intra-Operative treatment cuts out all the radiation treatments for many patients. Whether chemo is needed depends on the size and type of tumor.
"It's allowing us to tailor the treatment specifically to the patient and their type of breast cancer," Doctor Grobmyer said.
Intra-Operative Therapy wiped out Joanne's cancer, and now she's focusing on helping other women.
"I feel like a woman who's 71, but I feel like I'm 31," Joanne Duffy, Breast Cancer Survivor, told Ivanhoe.
Because healthy tissue is not damaged, recovery time is quicker. In fact, some patients can go home the same day of surgery and they don't have to come back!
Since this is still being studied long term, doctors are using it for patients with early stage breast cancer that are age sixty or older.
BACKGROUND: Breast cancer refers to when cancer forms somewhere in breast tissue, most commonly beginning in the lining of the milk ducts. Breast cancer can also originate in the milk glands, called lobules, and is considered to be invasive when the cancer spreads to surrounding healthy tissue from where it first began. With more than 200,000 new cases diagnosed in 2013 alone, breast cancer is one of the most common cancers in women. Men can also have breast cancer, but it is highly unusual and only 2,240 men were diagnosed with the disease in 2013. (Source: http://www.cancer.gov/cancertopics/types/breast)
RISK FACTORS: Certain lifestyle choices and hereditary factors can raise women’s risk of developing breast cancer. In particular, women with the BRCA1 and BRCA2 genes have a significantly higher likelihood of breast and ovarian cancer. Women now have the choice of being tested for these genes so that they can take preventative measures. Starting your period before age 12 or menopause after age 55 can also raise women’s risk and the likelihood of breast cancer is naturally higher as women age. While these risk factors are out of people’s control, women can control other factors such as weight, alcohol consumption, and use of birth control. (Source: http://www.nlm.nih.gov/medlineplus/breastcancer.html)
NEW TECHNOLOGY: Intraoperative radiation therapy gives women a full dose of radiation therapy at the same time as their lumpectomy surgery. Before patients had to undergo a lumpectomy and then six weeks of radiation, they can now have it all done within a two and a half hour operation. Intraoperative radiation therapy is more convenient for patients and ensures that they receive all of the necessary treatment in order to prevent recurrence. Completing all of the treatment in one procedure prevents women from neglecting to follow through with the radiation treatments because of time, money, distance and access to a treatment facility. Intraoperative radiation therapy also has fewer side effects than traditional radiation therapy including redness, rashes, irritation, fatigue, swelling, tissue stiffness, and scarring. (Source: http://www.nmh.org/nm/intraoperative-radiation-therapy-for-breast-cancer)
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Dr. Stephen Grobmyer, Director of Surgical Oncology and Director of the Breast Center at the Cleveland Clinic, talks about breast cancer treatments and the options women now have.
Traditionally, how would you treat breast cancer?
Dr. Grobmyer: The first thing we would do is evaluate the patient with a physical exam and then do imaging studies which would include a mammogram and ultrasound. Normally if there is a suspicious mass either on the exam or on the imaging studies, we'd do a biopsy and then we would make a diagnosis. We used to think of breast cancer as just one disease now we think of it as a variety of different diseases based on what type of breast cancer it is.
Usually the course of action is either a lumpectomy or a mastectomy?
Dr. Grobmyer: For patients with early stage breast cancer, that is having a small tumor confined to the breast, disease, surgery is usually the first step in treatment, Surgery becomes the first treatment and the options for the patient are to have either a lumpectomy, which is only removing the area where the tumor is in the breast, or to remove the entire breast, which is called a mastectomy with or without reconstruction.
The surgery sounds hard but that is usually the easiest part of the whole process for a patient because after that is when it really gets tough.
Dr. Grobmyer: Right. These days many patients need surgery, radiation, and chemotherapy, but not all do and that really depends on the type of breast cancer and the stage of breast cancer, which is usually determined at the time of surgery. However, patients respond to each phase of the treatment process differently so we try to help each patient individually through each of those phases.
Let's talk about radiation. Chemo can take a lot out of a patient?
Dr. Grobmyer: Yes it can. Traditionally, after a patient has a lumpectomy, if it is decided that they needed chemotherapy then it would be surgery, chemotherapy, and then radiation therapy. In patients who do not need chemotherapy it would be surgery then radiation therapy.
In general, what does chemo and radiation do to a patient?
Dr. Grobmyer: It's associated with a lot of fatigue. Certainly patients getting chemotherapy will often lose their hair. There may be periods of nausea and vomiting, great fatigue, and energy loss. There'll often be periods of time where the patient will need a reduced work load or won't be able to work at all for short periods of time around their treatment. Radiation therapy can be associated with changes in the skin and also makes people fairly tired as the body responds to the radiation treatment.
I think for a lot of women, they fear breast cancer and getting that diagnosis is hard, but your mind just automatically goes to losing your hair and being sick for months on end. I think that's where most patients' minds go when you say breast cancer.
Dr. Grobmyer: These days there are still many patients who do need all those treatments, but more and more we're learning that all patients don't need all treatments and we can get very good outcomes without the toxicity of a lot of these treatments that really aren't benefitting people. We can identify many people ahead of time that we realize aren't benefitting from the treatments and have an excellent prognosis without the treatment. So, we are able to avoid the treatments in those patients.
For the patients that can't avoid the treatments, it can be a long process. Talk about what happens after the lumpectomy. What's traditionally the course of action if you have to do all three?
Dr. Grobmyer: Well, you have surgery and then once all the surgical events are completed there's usually a delay of a month to six weeks. Then chemotherapy would start, which would last in the neighborhood of four months or in some cases the medical therapy may continue for up to a year.
Dr. Grobmyer: Usually every three weeks or so, but this can vary depending on the regimen.
For how long?
Dr. Grobmyer: For four months, but this can very depending on the type of treatment given.
For how many hours?
Dr. Grobmyer: Each infusion may last up to several hours, and then there's sort of a recovery time after that. However, there are a lot of different approaches to how chemotherapy is given and the dosing. So, the treatment schedule, the dosing, and the time really vary by the particular regimen that a patient has been placed on by the doctor.
Then how does radiation work?
Dr. Grobmyer: Radiation traditionally is given once chemotherapy is over for patients who have had a lumpectomy mostly. For those patients, radiation would occur every day during the week for anywhere between three weeks and five weeks. Some patients after mastectomy are also recommended to have radiation.
How long would those treatments take?
Dr. Grobmyer: Those treatments generally don't take very long but every day the patient has to travel to the radiation facility, wait to be treated, they have a short treatment, and then they can go on. It can modify their daily life with having to go to the radiation facility every day.
Both chemo and radiation before this affected your whole body instead of just the area in the breast that needed treatment, right?
Dr. Grobmyer: Right. In terms of chemotherapy, one of the goals of treatment is to treat the whole body because radiation and surgery would only treat the area immediately around the breast. Chemotherapy is designed to treat the whole body so that in case any cells have broken loose from the breast, they would be treated. Radiation therapy was given to the whole breast and in doing so other parts of the body often received some dose of radiation, which obviously is less than desirable if not needed.
What's the risk of radiation in other tissue?
Dr. Grobmyer: If you radiate normal tissue there can be chronic damage to that tissue. For instance, if you radiate the whole breast, which is sometimes necessary, then you have normal breast tissue getting radiation and there's chronic radiation change, which is thickening of the skin, heaviness in the breast, and there can sometimes be chronic swelling in the breast related to that. Radiating other tissues like the lung and the heart which sometimes occurs when people get whole breast radiation can also result in some chronic changes to those organs and a decrease in function.
What could be the risk in that?
Dr. Grobmyer: There was recently a study in the New England Journal that associated the administration of whole breast radiation for breast cancer with an increased incidence of heart disease. That's just one example of what we're learning may be some of the side effects of traditional treatments. That's not to say that in certain patients with certain stages of disease that whole breast radiation therapy isn't beneficial, it's just something we need to be aware of as we counsel patients about what their treatment options are.
Now, there's some positive news about radiation that's very, very targeted.
Dr. Grobmyer: Right. One of the advances that have been made in the last fifteen years is based on the observation that if a woman has a lumpectomy for breast cancer, the site where the cancer will most likely come back is the site where the cancer was before. So, it led many people in the last ten or fifteen years to raise the question of do we really need to be radiating the entire breast; that has evolved into a concept called partial breast irradiation. In a partial irradiation you only radiate the area in the breast with the greatest risk, which is the site where we removed the tumor from. The advantages of partial breast irradiation, which can be done in any number of different ways, are that you minimize the damage to normal tissue and maximize the treatment to the area of greatest risk.
Up until now, for a partial breast radiation the person had to come in every day for a month?
Dr. Grobmyer: No, all forms of partial breast usually take less time than whole breast irradiation. There are different ways this could be done and often there are shorter courses of external partial breast irradiation. There are other techniques where the patients will have catheters coming out of the body and those catheters will stay in while the radiation is delivered inside the catheters. Those treatment times may last up to a week or ten days where the patients have a catheter coming out of the breast. There are other catheter based techniques that are used that also require several days of treatment with multiple visits to the doctor. The approach we and a growing number of centers are now pursuing is the idea that we can give radiation therapy during surgery. For selected patients with early stage breast cancer, we think these patients get very good outcomes and get all of their treatment done during that surgery while they're asleep in the operating room.
How does that work?
Dr. Grobmyer: We use a special machine which delivers a single dose of radiation that we can bring sterilely into the operating area. After we've removed the tumor from the breast and we're sure all of it has been removed, working with our colleagues in radiation oncology we bring this machine in and give just a single dose of radiation. The radiation only travels about a centimeter so it really has no chance of damaging normal tissues while effectively treating the tumor bed, which is really our goal. It delivers a very precise and therapeutic dose of radiation right to the area of greatest risk.
Is it a stronger dose? How can you take a month's worth of radiation and put it into one?
Dr. Grobmyer: It has a lot to do with radiation biology. The total dose of radiation that a patient receives with this intra-op radiation is significantly less than would be with whole breast. It's just that we're giving a larger dose in one treatment than we would otherwise. The real answer to that question lies in what toxicity do we see with this single dose treatment, and the toxicity that we've observed is very minimal and patients actually tolerate it very well. We've not seen an increase in infections associated with it nor have we seen a problem with wound healing associated with it. It actually turned out to be a very safe treatment and that's evidenced by the thousands of people who have now been treated with this.
Are there any side effects?
Dr. Grobmyer: Really pretty minimal. I mean, there's always with any radiation a risk of toxicity to the skin or a little redness or burning of the skin. During surgery we take very careful measurements to try to reduce the chance that that will happen. There's also a very small chance, less than five percent, that the patient will develop a significant fluid collection in the operative area. That's called a seroma and it's usually very simply treated by just aspirating the fluid in the office, but again, that's less than five percent of the time. So, it's actually very well tolerated.
Does this mean women will not have to get chemo after this?
Dr. Grobmyer: This doesn't really affect our decisions about chemotherapy. The decisions that we help patients make regarding chemotherapy and radiation therapy are separate. The factors that lead to decisions for chemotherapy are more related to the size of the tumor, the status of the lymph nodes under the arm, and the type of breast cancer. The radiation decisions are made based on the size and type of tumor really.
Who would be a good candidate for this?
Dr. Grobmyer: We've been treating selected early stage patients over the age of 60 years at the Cleveland Clinic, but some centers are treating younger patients. The reason we've chosen to treat not the youngest patients in our center is that most of the experience today in the world has been developed in patients who are in the middle to older age groups. There's been a little less experience in younger patients and in general, breast cancers in younger patients can be more aggressive so we've chosen to treat them a little more traditionally until further research is done.
Is the one dose radiation aggressive?
Dr. Grobmyer: We develop new treatments for breast cancer or any cancer in general very cautiously and base new treatments on the results of trials. We don't like to try new things on people without sufficient evidence to prove their efficacy. The trails that have been done are really focused on patients with an average age of around 60 or a little older.
What do you call this?
Dr. Grobmyer: It's called intraoperative radiation therapy single dose.
Is there a comparison that you can give me between this and traditional radiation?
Dr. Grobmyer: The comparisons are on one hand the patient would have all their radiation treatment done at the time of surgery. So after surgery, if the patient doesn't need chemotherapy they are done with their treatment, but many of these women would be recommended to take a pill in the future to block estrogen and reduce the chance of cancer coming back. With whole breast radiation the patient completes their surgical procedure then they have to go back to the doctor's office for some planning with CAT scans. Once the CAT scan planning is done, that begins the process of this multi-day radiation. So there really are differences in terms of the length of treatment, the side effects of treatment, and the toxicity to the normal tissues which with the intra-op treatment we're trying to avoid.
Anything I'm missing?
Dr. Grobmyer: One of the things we talk about is a bigger concept which is focused on the idea of personalizing the treatment of breast cancer to the specific type of cancer that a patient has, the patient's specific situation, and the other health issues that patients have. I would say 15 years ago patients would come in with breast cancer and they were pretty much all treated the same way because we didn't know who was going to do well and who wasn't going to do well. I think this is an excellent example of our learning about the biology of breast cancer and how different treatments we have affect patients with different biology. It's allowing us to really tailor the treatment specifically to the patient and their type of breast cancer. The benefit to patients of course is they can often get more effective therapies this way and avoid treatments that really aren't helpful to them. The same thing is happening in the world of medical oncology with chemotherapy. Nowadays we have molecular tests where we actually test the tumor and with those tests we can determine which patients will actually benefit from chemotherapy and which won't. If a patient is not going to benefit much from chemotherapy, we can counsel them that maybe we should not take chemotherapy in this particular case. So, I think this is just the beginning of a very exciting time where we're able to tailor specific treatments to a patient's needs.
Are there certain breast cancers that you can say you would definitely use this on?
Dr. Grobmyer: We use it generally in patients with smaller breast cancers. In this country we see many patients with small breast cancers because they're picked up on mammographic screening. The other groups of patients we concentrate on are those who have hormonally sensitive breast cancers which constitutes the majority of breast cancers these days.
How long have you been treating breast cancer patients?
Dr. Grobmyer: Since 1995.
Of the breast cancer patients that you've treated, how often do you see that chemo and radiation had no impact?
Dr. Grobmyer: That's hard to say in an individual patient. We make these recommendations based on large studies. So, we analyze the type of tumor that a patient has with certain gene assays for instance, and we can say that based on the gene expression profile the patient may only have a ten percent chance of recurrence. If a patient were to take chemotherapy based on the studies we have, they might benefit by one or two percent and many patients in that setting may say the benefit of chemotherapy is not worth the side effects. We're able to specifically counsel patients about what their risks are and what the potential benefits are with certain treatments and that is where I think we're continuing to move in this field.
You sound like you're excited about where the treatment for breast cancer is going.
Dr. Grobmyer: It's continually improving and we're continually developing new drugs that I think we are offering patients more hope than ever for a chance for a cure.
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