Patient-Centered Breast Radiotherapy Fractionation and Treatment Approach
Oluwadamilola Oladeru M.D., discusses patient-centered breast radiotherapy fractionation and treatment approach. She describes the changing trend of radiotherapy fractionation over the last 20 years and the long-term results of UK FAST and FAST FORWARD studies. Lastly she describes the patient selection for short course treatment and its benefits in terms of patient convenience.
Featuring:
Dr. Oladeru received her medical degree from the Renaissance School of Medicine at Stony Brook University. She completed her internship at NYU Winthrop Hospital, prior to completing her radiation oncology residency training at Massachusetts General Hospital/Brigham & Women’s Hospital - Harvard Radiation Oncology Program. She also earned an MBA from Johns Hopkins University, with a concentration in Healthcare Management and Leading Organizations.
Dr. Oladeru’s research has published more than 50 research papers, presentations, and book chapters. She is the recipient of numerous awards and recognitions, including the Gold Foundation for Humanism in Medicine Honor Society Award in 2015; the Research Recognition Award from Winthrop University Hospital in 2016; and the AAWR Eleanor Montague Distinguished Resident Award in Radiation Oncology in 2020.
Her research interests include technological advancements in radiation oncology, high quality radiation treatment delivery, health policy to address inequities in underserved populations, and global radiation oncology. Her clinical focus at UF Health is patient centered treatment of all types and stages of breast cancer.
Oluwadamilola (Lola) Oladeru, M.D.
Dr. Oladeru earned her bachelor’s degree in molecular, cellular and developmental biology at Yale University. She then obtained her master’s degree in African studies and medical anthropology from Yale Graduate School of Arts and Sciences with a concentration in global health from Yale Jackson Institute for Global Affairs.Dr. Oladeru received her medical degree from the Renaissance School of Medicine at Stony Brook University. She completed her internship at NYU Winthrop Hospital, prior to completing her radiation oncology residency training at Massachusetts General Hospital/Brigham & Women’s Hospital - Harvard Radiation Oncology Program. She also earned an MBA from Johns Hopkins University, with a concentration in Healthcare Management and Leading Organizations.
Dr. Oladeru’s research has published more than 50 research papers, presentations, and book chapters. She is the recipient of numerous awards and recognitions, including the Gold Foundation for Humanism in Medicine Honor Society Award in 2015; the Research Recognition Award from Winthrop University Hospital in 2016; and the AAWR Eleanor Montague Distinguished Resident Award in Radiation Oncology in 2020.
Her research interests include technological advancements in radiation oncology, high quality radiation treatment delivery, health policy to address inequities in underserved populations, and global radiation oncology. Her clinical focus at UF Health is patient centered treatment of all types and stages of breast cancer.
Transcription:
The University of Florida College of Medicine is accredited by the Accreditation Council for Continuing Medical Education, ACCME, to provide continuing medical education for physicians. The University of Florida College of Medicine designates this enduring material for a maximum of 0.25 AMA PRA category 1 credit. Physicians should claim only the credit commensurate with the extent of their participation in this activity.
Melanie Cole (Host): Welcome to UF Health MedEd Cast with UF Health Shands Hospital. I'm Melanie Cole. And joining me today is Dr. Lola Oladeru. She's an Assistant Professor in the Department of Radiation Oncology at the University of Florida College of Medicine, and she practices at UF Health Shands Hospital. She's here to highlight patient-centered breast radiotherapy fractionation and treatment approach.
Dr. Oladeru, it's a pleasure to have you with us today. I found this so interesting when I was doing my research for this particular topic. So can you tell us right off the bat, what is fraction radiotherapy? How does this practice seek to maximize the destruction of malignant cells while minimizing damage to healthy tissue? Tell us a little bit about fractionation.
Dr Oluwadamilola Oladeru: Thank you very much. So in radiation, we discuss fractions. That's the number of treatments that we account for and plan to deliver our total dose of radiation through. So typically, a radiation is delivered every day during the weekdays. And as you may know, we have sort of evolved in radiation oncology from bringing patients in for multiple weeks at length for radiation. And now, they're coming in for shorter lengths of time to get their radiation complete.
So essentially, what has happened in the past was people would come in typically for breast radiation over five to six weeks. And over the last decade or so, we have done studies to show that it is safe to increase the dose of radiation per fraction, meaning per treatment or per day, and finish the entire course of treatments in a much shorter.
So now, typically, whole breast radiation would be done in four weeks as opposed to five to six weeks, historically. What has now happened and what's going on, and even with COVID, it has accelerated us towards going from standard fractionation, meaning the gentle small dose per day over six weeks to what we call hypofractionation, where it's a little bit more of a dose per day that you finish in four weeks. And now, we're in the realm of ultra-hypofractionation, where we're getting done in just five total treatments, as opposed to 20 treatments. And that trial that sort of introduced us to all of this came from the United Kingdom.
Melanie Cole (Host): Wow. Isn't that interesting? And what a cool time to be in your field. So tell us a little bit about the difference between the many types of fractionation, conventional, hyper, hypo, accelerated palliative. You've touched on a few. Can you just tell us a little bit about how these are different, how you're using these?
Dr Oluwadamilola Oladeru: So the first thing to note is in total, when you look at all of these approaches, the three different types of fractionation schedules, your total biological dose to the breasts, to the tumor, to the target is all equivalent. We're just giving a higher dose per treatment, also known as per fraction. And the patient is completing treatment sooner and also with less side effects.
So what we are doing is for patients who have early stage, low risk, very good prognosis breast cancer, meaning they're T1 to T2 node-negative breast cancer patients, we are offering them the protocol called the FAST protocol. The FAST trial, FAST, was published and they've published their 10-year results in the Journal of Clinical Oncology in 2020, where they compared going through radiation over four weeks to completing it in five days. And they delivered those five days of radiation treatment as once per week. Let's say you come in on a Monday, you'd come every Monday for five consecutive weeks and you'd be done with radiation over five treatments. And what they found when they compared both groups, the ones that came in every day for four weeks to once a week for five total weeks, they found that the outcomes in terms of cancer control was equivalent. But more importantly, they found that the cosmesis, shrinkage, induration, edema, telangiectasias were much lower in the arm that finished quickly, meaning had shorter fractions of five fractions versus the 20 fractions.
And when we're in the peak of the pandemic, where we had an issue of bringing patients in every single day for radiation, it was very important throughout the country to consider the safety of patients being exposed to a very infectious disease during this time and shortening the length of treatment. And so there was a rapid adoption throughout the country of ultra-hypofractionated approach where patients could be done in five treatments as opposed to coming in 20 times.
At UF Health Shands, we have also adopted this because, unfortunately, one of the issues we faced with COVID was the shut down of the hostel where people used to stay for cancer treatment. And so when Hope Lodge, the cancer hostel, was closed down during COVID, it actually has never been reopened. And so our patients who would typically come from Georgia, from Tallahassee, these patients were making very long, expensive trips down here every day. And for us, in our breast cancer team, we are offering those that are coming from very far distances, the option to still get their care here at UF Health Shands, but still complete it in a reasonable time, coming in once a week without compromising their cancer control outcome.
Melanie Cole (Host): So you just mentioned, obviously, patient convenience and you mentioned the FAST study, but what have you seen as far as your outcomes when patients are doing this type of fractionation treatment? And certainly, once a week for five weeks is preferable to every day for four weeks. How have been your outcomes and what have your patients been . About it?
Dr Oluwadamilola Oladeru: Oh, they love it. So typically, with breast radiation, the first week, you don't notice anything. The second week, with the typical four-week approach, second week you start feeling tired. You start noticing changes in the color of the skin of the breast. It will look more red. We call that dermatitis. It increases in appearance of redness as you get closer to the fourth week and final radiation date of 20 total treatments.
When I compare that with the patients who are getting five treatments in total, these patients, they barely have any side effects. They have barely any redness, any soreness, any fatigue, because they're not coming in every day. They're finishing in five total treatments, though it's drawn out over five weeks, but it's only one day a week. So it makes it very easy and convenient for them. And it doesn't feel like a very burdensome chore for them. And in addition, that time in between fractions is giving the normal tissue time to recover and heal. So they received it very well. It's also helped us to keep some of our patients here to be treated UF Health Shands, as opposed to them looking for places to be treated out in the community.
Melanie Cole (Host): What would you like to tell other providers, as we wrap up, about patient-centered breast radiotherapy fractionation as a treatment approach, if they are counseling their patients and referring them to UF Health Shands Hospital? What would you like them to know about telling their patients about this option?
Dr Oluwadamilola Oladeru: So, do not be afraid that a patient did not get adequate radiation if you get a report saying they got five treatments. Because things have evolved in the world of breast radiotherapy, the biological effective dose of radiation delivered over five treatments is calculated to be equivalent to the typical historical way of coming in for four weeks, five weeks or six weeks. And so do not be alarmed when you see that a patient only got five treatments. Things have changed.
Secondly, when patients are asking about where they can get treated and be done sooner without any negative impact on cancer control, we want you to be comfortable knowing that UF Health Shands is a safe place to do that. Because we are giving a higher dose per treatment or per fraction, we are very careful in our delivery, our physics calculation, our radiation planning, our dosimetry, all of that is carefully designed and planned before we deliver such a high dose per treatment.
Melanie Cole (Host): Thank you so much, Dr. Oladeru, for joining us today. Really very interesting. Thank you again. And to refer your patient for patient centered breast radiotherapy, or to listen to more podcasts from our experts, please visit ufhealth.org/medmatters. That concludes today's episode of UF Health MedEd Cast with UF Health Shands Hospital. I'm Melanie Cole.
The University of Florida College of Medicine is accredited by the Accreditation Council for Continuing Medical Education, ACCME, to provide continuing medical education for physicians. The University of Florida College of Medicine designates this enduring material for a maximum of 0.25 AMA PRA category 1 credit. Physicians should claim only the credit commensurate with the extent of their participation in this activity.
Melanie Cole (Host): Welcome to UF Health MedEd Cast with UF Health Shands Hospital. I'm Melanie Cole. And joining me today is Dr. Lola Oladeru. She's an Assistant Professor in the Department of Radiation Oncology at the University of Florida College of Medicine, and she practices at UF Health Shands Hospital. She's here to highlight patient-centered breast radiotherapy fractionation and treatment approach.
Dr. Oladeru, it's a pleasure to have you with us today. I found this so interesting when I was doing my research for this particular topic. So can you tell us right off the bat, what is fraction radiotherapy? How does this practice seek to maximize the destruction of malignant cells while minimizing damage to healthy tissue? Tell us a little bit about fractionation.
Dr Oluwadamilola Oladeru: Thank you very much. So in radiation, we discuss fractions. That's the number of treatments that we account for and plan to deliver our total dose of radiation through. So typically, a radiation is delivered every day during the weekdays. And as you may know, we have sort of evolved in radiation oncology from bringing patients in for multiple weeks at length for radiation. And now, they're coming in for shorter lengths of time to get their radiation complete.
So essentially, what has happened in the past was people would come in typically for breast radiation over five to six weeks. And over the last decade or so, we have done studies to show that it is safe to increase the dose of radiation per fraction, meaning per treatment or per day, and finish the entire course of treatments in a much shorter.
So now, typically, whole breast radiation would be done in four weeks as opposed to five to six weeks, historically. What has now happened and what's going on, and even with COVID, it has accelerated us towards going from standard fractionation, meaning the gentle small dose per day over six weeks to what we call hypofractionation, where it's a little bit more of a dose per day that you finish in four weeks. And now, we're in the realm of ultra-hypofractionation, where we're getting done in just five total treatments, as opposed to 20 treatments. And that trial that sort of introduced us to all of this came from the United Kingdom.
Melanie Cole (Host): Wow. Isn't that interesting? And what a cool time to be in your field. So tell us a little bit about the difference between the many types of fractionation, conventional, hyper, hypo, accelerated palliative. You've touched on a few. Can you just tell us a little bit about how these are different, how you're using these?
Dr Oluwadamilola Oladeru: So the first thing to note is in total, when you look at all of these approaches, the three different types of fractionation schedules, your total biological dose to the breasts, to the tumor, to the target is all equivalent. We're just giving a higher dose per treatment, also known as per fraction. And the patient is completing treatment sooner and also with less side effects.
So what we are doing is for patients who have early stage, low risk, very good prognosis breast cancer, meaning they're T1 to T2 node-negative breast cancer patients, we are offering them the protocol called the FAST protocol. The FAST trial, FAST, was published and they've published their 10-year results in the Journal of Clinical Oncology in 2020, where they compared going through radiation over four weeks to completing it in five days. And they delivered those five days of radiation treatment as once per week. Let's say you come in on a Monday, you'd come every Monday for five consecutive weeks and you'd be done with radiation over five treatments. And what they found when they compared both groups, the ones that came in every day for four weeks to once a week for five total weeks, they found that the outcomes in terms of cancer control was equivalent. But more importantly, they found that the cosmesis, shrinkage, induration, edema, telangiectasias were much lower in the arm that finished quickly, meaning had shorter fractions of five fractions versus the 20 fractions.
And when we're in the peak of the pandemic, where we had an issue of bringing patients in every single day for radiation, it was very important throughout the country to consider the safety of patients being exposed to a very infectious disease during this time and shortening the length of treatment. And so there was a rapid adoption throughout the country of ultra-hypofractionated approach where patients could be done in five treatments as opposed to coming in 20 times.
At UF Health Shands, we have also adopted this because, unfortunately, one of the issues we faced with COVID was the shut down of the hostel where people used to stay for cancer treatment. And so when Hope Lodge, the cancer hostel, was closed down during COVID, it actually has never been reopened. And so our patients who would typically come from Georgia, from Tallahassee, these patients were making very long, expensive trips down here every day. And for us, in our breast cancer team, we are offering those that are coming from very far distances, the option to still get their care here at UF Health Shands, but still complete it in a reasonable time, coming in once a week without compromising their cancer control outcome.
Melanie Cole (Host): So you just mentioned, obviously, patient convenience and you mentioned the FAST study, but what have you seen as far as your outcomes when patients are doing this type of fractionation treatment? And certainly, once a week for five weeks is preferable to every day for four weeks. How have been your outcomes and what have your patients been . About it?
Dr Oluwadamilola Oladeru: Oh, they love it. So typically, with breast radiation, the first week, you don't notice anything. The second week, with the typical four-week approach, second week you start feeling tired. You start noticing changes in the color of the skin of the breast. It will look more red. We call that dermatitis. It increases in appearance of redness as you get closer to the fourth week and final radiation date of 20 total treatments.
When I compare that with the patients who are getting five treatments in total, these patients, they barely have any side effects. They have barely any redness, any soreness, any fatigue, because they're not coming in every day. They're finishing in five total treatments, though it's drawn out over five weeks, but it's only one day a week. So it makes it very easy and convenient for them. And it doesn't feel like a very burdensome chore for them. And in addition, that time in between fractions is giving the normal tissue time to recover and heal. So they received it very well. It's also helped us to keep some of our patients here to be treated UF Health Shands, as opposed to them looking for places to be treated out in the community.
Melanie Cole (Host): What would you like to tell other providers, as we wrap up, about patient-centered breast radiotherapy fractionation as a treatment approach, if they are counseling their patients and referring them to UF Health Shands Hospital? What would you like them to know about telling their patients about this option?
Dr Oluwadamilola Oladeru: So, do not be afraid that a patient did not get adequate radiation if you get a report saying they got five treatments. Because things have evolved in the world of breast radiotherapy, the biological effective dose of radiation delivered over five treatments is calculated to be equivalent to the typical historical way of coming in for four weeks, five weeks or six weeks. And so do not be alarmed when you see that a patient only got five treatments. Things have changed.
Secondly, when patients are asking about where they can get treated and be done sooner without any negative impact on cancer control, we want you to be comfortable knowing that UF Health Shands is a safe place to do that. Because we are giving a higher dose per treatment or per fraction, we are very careful in our delivery, our physics calculation, our radiation planning, our dosimetry, all of that is carefully designed and planned before we deliver such a high dose per treatment.
Melanie Cole (Host): Thank you so much, Dr. Oladeru, for joining us today. Really very interesting. Thank you again. And to refer your patient for patient centered breast radiotherapy, or to listen to more podcasts from our experts, please visit ufhealth.org/medmatters. That concludes today's episode of UF Health MedEd Cast with UF Health Shands Hospital. I'm Melanie Cole.