A recent innovation offers a compelling new treatment for some women with the most common form of breast cancer.
Interoperative Radiation Therapy (IORT) is a recently approved treatment for invasive ductal carcinoma (IDC), which, according to nonprofit breastcancer.org, accounts for about 80 percent of all breast cancers. By applying radiation directly to the tumor area during surgery, IORT can eliminate up to three to six weeks of radiation therapy, though follow-up care and checkups are still involved.
In this segment, Jennifer Manders, MD., discusses IORT for breast cancer patients and when to refer to a specialist.
Intraoperative Radiation Therapy (IORT)—1-Day Breast Cancer Treatment
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Learn more about Jennifer B. Manders, MD
Jennifer B. Manders, MD
Jennifer B. Manders, MD earned her BS in Biological Sciences from the University of Illinois and her medical degree from The Chicago Medical School. She completed her general surgery residency at Rush University Medical Center and her breast surgery fellowship at Northwestern University Feinberg School of Medicine, where she also served as an instructor in the department of surgery.Learn more about Jennifer B. Manders, MD
Transcription:
Intraoperative Radiation Therapy (IORT)—1-Day Breast Cancer Treatment
Melanie Cole (Host): A recent innovation offers compelling new treatment for some women with the most common form of breast cancer – intraoperative radiation therapy or IORT. Here to tell us about it is my guest today, Dr. Jennifer Manders. She’s a surgical oncologist with The Christ Hospital Health Network. Welcome to the show, Dr. Manders. So, explain a little about typical radiation treatments and pretty much what's been done frequently and in the past.
Dr. Jennifer Manders, MD (Guest): So, when a woman undergoes a lumpectomy for breast cancer, the additional treatment to the rest of the breast has been whole breast radiation therapy, and that’s usually offered with external beam radiation. There have been different ways of offering that in the past. Traditionally, women were given six weeks of therapy, and recent studies have suggested that fewer fractions of treatment – given over a shorter period of time – offers the same benefit as six weeks. So, therefore, there have been shorter courses offered – three to four weeks – and have been shown to be equivalent to the six weeks of whole breast radiation therapy. Within the last several decades, there have also been approaches to looking at just partial breast radiation therapy – meaning irradiating just the area of the breast where the tumor was, and the reasoning behind that is because usually when breast cancers recur, they tend to recur in the same area of the previous cancer. And so the question often arises – if there is additional benefit of treating the whole breast if the area where the breast cancer used to be is such a small portion of the entire breast? So, for a select number of women who fall within certain criteria, they have been offered shorter courses of partial breast radiation therapy just of the area involved with the previous cancer. Those have been offered with the use of catheters placed into the breast after the surgery, and radiation offered through the use of a seed placed into these catheters, and there have been different types of catheters placed in the breast. One has been a balloon, but prior to that, there were all of these small catheters placed in – so called brachytherapy – and so that was able to reduce the treatment down to a week, demonstrating the same decrease in the risk for recurrence in the area where the cancer used to be as compares to whole breast radiation therapy. So, intraoperative radiation therapy is even one step shorter in that it can be offered at the time of surgery while the patient is asleep under anesthesia and can treat the area of the breast where the tumor is removed from at the time of the operation, and basically the patient’s with her radiation at the same time as being done with her surgery.
Melanie: Dr. Manders, at what point are you able to decide that IORT is the treatment that can come into play, and if it's done during surgery, then do you know ahead of time you're going to be able to do this treatment?
Dr. Manders: Yeah, so if a woman comes in with breast cancer and meets certain criteria – that is – she is in our institution, over the age of 60, has a small tumor – smaller than 3 centimeters – that is very well circumscribed, meaning it doesn’t look like it's extended – it looks like it's very easily identifiable and somewhat separate from the rest of the breast tissue, and does not have lymph node involvement, those are some of the criteria that can help us say, hey, this might be a good candidate for intraoperative radiation therapy. We also use breast MRI to make sure we're not missing anything that’s not visible easily on the mammogram. Once those two steps are met, then the surgeon refers the patient to a radiation oncologist to discuss this as a possibility, and the radiation oncologists all are of the same mindset that this is a great option for some women, but there may be issues that are identified after pathology results come back – maybe the cancer is bigger than we saw it; maybe the lymph nodes are positive – and so the fallback is always the standard of care, which is whole breast radiation therapy, and so, once the patient has had the opportunity to meet with the radiation oncologist, then our two staffs put together dates and times that are available for all of us so that we can all can be there together at the same time. So, my staff works with the radiation oncologist staff. We go to the operating room – to make sure that we're all going to the operating room on the same date and time. We’re all available. We head to the OR. We do the lumpectomy. We check the sentinel node biopsy as well. We have the pathologist come and look at all of the specimens and as long as the tumor looks to be excised well with normal appearing margins and the lymph nodes are negative, then we're a go. And then the radiation oncologist comes into the room; we place the catheter into the patient’s breast and then hand over the case to the radiation oncologist who then is able to use a special device to give radiation to the patient while she’s on the table.
Melanie: Is it as effective as traditional radiation treatment?
Dr. Manders: So, the studies that we have shown a decrease in the recurrence as compared to traditional studies from many, many years ago when lumpectomies were first being done, and I think that’s because, number one, our ability to predict elsewhere disease in the same breast has gotten better with better imaging. Number two, our systemic therapy has gotten better so these patients are all being put on anti-estrogen therapy as well, and number three, we're very careful about patient selection of who should be involved in this and not. So – but the overall risk for recurrence in the breast has been shown to be very low – less than 10%.
Melanie: Well, certainly there are advantages as far as convenience and shorter treatment time and healthier for the surrounding tissue for the patient. Are there certain advantages for the oncologist and for your team?
Dr. Manders: Well, it's a single dose. So, that is fewer number of treatments, obviously. The radiation oncologist has a much shorter interaction with the patient. From a convenience perspective, it's really no different whether I do this for the patient at this time during surgery or if she undergoes radiation post-operatively. It’s additional time in the operating room; it's additional time under anesthesia, but these patients are pretty well identified up front and are usually healthier and therefore can take the extra hour or hour and a half or so under anesthesia without any significant morbidity associated with it.
Melanie: And are there any side effects that might be different than traditional radiation?
Dr. Manders: So, there are fewer side effects, actually, than traditional radiation. Traditional radiation may cause redness and swelling to the whole breast. There’s often discussion of lymphedema of the arm. Well, after whole breast radiation therapy, many women suffer from lymphedema of the breast, and this can be painful. This can cause a lot of swelling, discomfort, and distortion of the appearance of the breast and cause pain for a long period of time. The skin burning that we see with whole breast radiation therapy is also much less with intraoperative radiation therapy. So, in general, there are very few side effects. It may add to some of the post-operative fatigue and recovery, but hard to differentiate that from what’s caused by the anesthesia and the surgery itself. The other thing is that if there is a reaction – erythema of the skin or swelling – it's somewhat delayed, and we tend to see that maybe two to three weeks out, and then the fatigue that we would normally see with radiation therapy that tends to happen towards the end of treatment, we see that maybe about two to three weeks out as well.
Melanie: And what about contraindications for institution of this treatment?
Dr. Manders: So, this should not be given to women who have large tumors or have what's called multicentric disease, which is more than one tumor in more than one area of the same breast, and if a woman’s had previous radiation therapy because of a previous breast cancer and now has experienced a recurrence, this is not necessarily a way to offer her to have a repeat lumpectomy. This is still an additional radiation therapy to the tissue which could be at the toxic dose for radiation. Women who have lymph node positive disease, this is somewhat controversial, and while it's not necessarily considered – the criteria – it doesn’t necessarily meet the criteria for a good candidate. This is somewhat considered cautionary and differs from institution to institution.
Melanie: So, tell us a little bit about the current research. What does that indicate? Give us a little blueprint for future research in this area.
Dr. Manders: So, interestingly, the use of radiation therapy has been looked at across the board as beneficial after a resection of any breast cancer, and that’s been applied to both invasive and non-invasive cancers, and while not every institution applies partial breast radiation therapy to ductal carcinoma in situ, which is non-invasive cancer, this may be an area especially in well-circumscribed, small areas of DCIS where this can be applied more frequently and considered less cautionary. The other area of interest is the use of genomics which is the expression of certain genes within the cancer cells that predict behavior and how that impacts likelihood of recurrence and therefore how does that impact the recommendation for radiation or not, and there are some studies as well, looking at the use of genomics to predict benefit from radiation therapy. We don’t have those studies yet. What we have is data that suggests there are certain tumors that benefit more from chemotherapy, but we don’t have any genomic studies yet and data yet to say whether or not tumors would respond to radiation therapy. So, I think there’s a lot of excitement and a lot of research happening around radiation in general and the application of IORT.
Melanie: So, in summary, doctor, please tell other physicians what you'd like them to know about IORT and when to refer to a specialist.
Dr. Manders: So, the use of IORT, although somewhat limited because of criteria, can be offered at specialized institutions to patients who may not be otherwise able to travel daily to get their radiation therapy and can give women the same reduction in recurrence as whole breast radiation therapy otherwise would, and so, if the patient could benefit from this therapy then it would be of great value to send them to a specialized institution.
Melanie: Thank you so much for being with us today, Dr. Manders. It’s really great information. You're listening to Expert Insights Physician Views and News with The Christ Hospital Health Network. For more information on Dr. Manders and all of The Christ Hospital physicians, please visit tchpconnect.org. That's tchpconnect.org. This is Melanie Cole. Thanks so much for listening.
Intraoperative Radiation Therapy (IORT)—1-Day Breast Cancer Treatment
Melanie Cole (Host): A recent innovation offers compelling new treatment for some women with the most common form of breast cancer – intraoperative radiation therapy or IORT. Here to tell us about it is my guest today, Dr. Jennifer Manders. She’s a surgical oncologist with The Christ Hospital Health Network. Welcome to the show, Dr. Manders. So, explain a little about typical radiation treatments and pretty much what's been done frequently and in the past.
Dr. Jennifer Manders, MD (Guest): So, when a woman undergoes a lumpectomy for breast cancer, the additional treatment to the rest of the breast has been whole breast radiation therapy, and that’s usually offered with external beam radiation. There have been different ways of offering that in the past. Traditionally, women were given six weeks of therapy, and recent studies have suggested that fewer fractions of treatment – given over a shorter period of time – offers the same benefit as six weeks. So, therefore, there have been shorter courses offered – three to four weeks – and have been shown to be equivalent to the six weeks of whole breast radiation therapy. Within the last several decades, there have also been approaches to looking at just partial breast radiation therapy – meaning irradiating just the area of the breast where the tumor was, and the reasoning behind that is because usually when breast cancers recur, they tend to recur in the same area of the previous cancer. And so the question often arises – if there is additional benefit of treating the whole breast if the area where the breast cancer used to be is such a small portion of the entire breast? So, for a select number of women who fall within certain criteria, they have been offered shorter courses of partial breast radiation therapy just of the area involved with the previous cancer. Those have been offered with the use of catheters placed into the breast after the surgery, and radiation offered through the use of a seed placed into these catheters, and there have been different types of catheters placed in the breast. One has been a balloon, but prior to that, there were all of these small catheters placed in – so called brachytherapy – and so that was able to reduce the treatment down to a week, demonstrating the same decrease in the risk for recurrence in the area where the cancer used to be as compares to whole breast radiation therapy. So, intraoperative radiation therapy is even one step shorter in that it can be offered at the time of surgery while the patient is asleep under anesthesia and can treat the area of the breast where the tumor is removed from at the time of the operation, and basically the patient’s with her radiation at the same time as being done with her surgery.
Melanie: Dr. Manders, at what point are you able to decide that IORT is the treatment that can come into play, and if it's done during surgery, then do you know ahead of time you're going to be able to do this treatment?
Dr. Manders: Yeah, so if a woman comes in with breast cancer and meets certain criteria – that is – she is in our institution, over the age of 60, has a small tumor – smaller than 3 centimeters – that is very well circumscribed, meaning it doesn’t look like it's extended – it looks like it's very easily identifiable and somewhat separate from the rest of the breast tissue, and does not have lymph node involvement, those are some of the criteria that can help us say, hey, this might be a good candidate for intraoperative radiation therapy. We also use breast MRI to make sure we're not missing anything that’s not visible easily on the mammogram. Once those two steps are met, then the surgeon refers the patient to a radiation oncologist to discuss this as a possibility, and the radiation oncologists all are of the same mindset that this is a great option for some women, but there may be issues that are identified after pathology results come back – maybe the cancer is bigger than we saw it; maybe the lymph nodes are positive – and so the fallback is always the standard of care, which is whole breast radiation therapy, and so, once the patient has had the opportunity to meet with the radiation oncologist, then our two staffs put together dates and times that are available for all of us so that we can all can be there together at the same time. So, my staff works with the radiation oncologist staff. We go to the operating room – to make sure that we're all going to the operating room on the same date and time. We’re all available. We head to the OR. We do the lumpectomy. We check the sentinel node biopsy as well. We have the pathologist come and look at all of the specimens and as long as the tumor looks to be excised well with normal appearing margins and the lymph nodes are negative, then we're a go. And then the radiation oncologist comes into the room; we place the catheter into the patient’s breast and then hand over the case to the radiation oncologist who then is able to use a special device to give radiation to the patient while she’s on the table.
Melanie: Is it as effective as traditional radiation treatment?
Dr. Manders: So, the studies that we have shown a decrease in the recurrence as compared to traditional studies from many, many years ago when lumpectomies were first being done, and I think that’s because, number one, our ability to predict elsewhere disease in the same breast has gotten better with better imaging. Number two, our systemic therapy has gotten better so these patients are all being put on anti-estrogen therapy as well, and number three, we're very careful about patient selection of who should be involved in this and not. So – but the overall risk for recurrence in the breast has been shown to be very low – less than 10%.
Melanie: Well, certainly there are advantages as far as convenience and shorter treatment time and healthier for the surrounding tissue for the patient. Are there certain advantages for the oncologist and for your team?
Dr. Manders: Well, it's a single dose. So, that is fewer number of treatments, obviously. The radiation oncologist has a much shorter interaction with the patient. From a convenience perspective, it's really no different whether I do this for the patient at this time during surgery or if she undergoes radiation post-operatively. It’s additional time in the operating room; it's additional time under anesthesia, but these patients are pretty well identified up front and are usually healthier and therefore can take the extra hour or hour and a half or so under anesthesia without any significant morbidity associated with it.
Melanie: And are there any side effects that might be different than traditional radiation?
Dr. Manders: So, there are fewer side effects, actually, than traditional radiation. Traditional radiation may cause redness and swelling to the whole breast. There’s often discussion of lymphedema of the arm. Well, after whole breast radiation therapy, many women suffer from lymphedema of the breast, and this can be painful. This can cause a lot of swelling, discomfort, and distortion of the appearance of the breast and cause pain for a long period of time. The skin burning that we see with whole breast radiation therapy is also much less with intraoperative radiation therapy. So, in general, there are very few side effects. It may add to some of the post-operative fatigue and recovery, but hard to differentiate that from what’s caused by the anesthesia and the surgery itself. The other thing is that if there is a reaction – erythema of the skin or swelling – it's somewhat delayed, and we tend to see that maybe two to three weeks out, and then the fatigue that we would normally see with radiation therapy that tends to happen towards the end of treatment, we see that maybe about two to three weeks out as well.
Melanie: And what about contraindications for institution of this treatment?
Dr. Manders: So, this should not be given to women who have large tumors or have what's called multicentric disease, which is more than one tumor in more than one area of the same breast, and if a woman’s had previous radiation therapy because of a previous breast cancer and now has experienced a recurrence, this is not necessarily a way to offer her to have a repeat lumpectomy. This is still an additional radiation therapy to the tissue which could be at the toxic dose for radiation. Women who have lymph node positive disease, this is somewhat controversial, and while it's not necessarily considered – the criteria – it doesn’t necessarily meet the criteria for a good candidate. This is somewhat considered cautionary and differs from institution to institution.
Melanie: So, tell us a little bit about the current research. What does that indicate? Give us a little blueprint for future research in this area.
Dr. Manders: So, interestingly, the use of radiation therapy has been looked at across the board as beneficial after a resection of any breast cancer, and that’s been applied to both invasive and non-invasive cancers, and while not every institution applies partial breast radiation therapy to ductal carcinoma in situ, which is non-invasive cancer, this may be an area especially in well-circumscribed, small areas of DCIS where this can be applied more frequently and considered less cautionary. The other area of interest is the use of genomics which is the expression of certain genes within the cancer cells that predict behavior and how that impacts likelihood of recurrence and therefore how does that impact the recommendation for radiation or not, and there are some studies as well, looking at the use of genomics to predict benefit from radiation therapy. We don’t have those studies yet. What we have is data that suggests there are certain tumors that benefit more from chemotherapy, but we don’t have any genomic studies yet and data yet to say whether or not tumors would respond to radiation therapy. So, I think there’s a lot of excitement and a lot of research happening around radiation in general and the application of IORT.
Melanie: So, in summary, doctor, please tell other physicians what you'd like them to know about IORT and when to refer to a specialist.
Dr. Manders: So, the use of IORT, although somewhat limited because of criteria, can be offered at specialized institutions to patients who may not be otherwise able to travel daily to get their radiation therapy and can give women the same reduction in recurrence as whole breast radiation therapy otherwise would, and so, if the patient could benefit from this therapy then it would be of great value to send them to a specialized institution.
Melanie: Thank you so much for being with us today, Dr. Manders. It’s really great information. You're listening to Expert Insights Physician Views and News with The Christ Hospital Health Network. For more information on Dr. Manders and all of The Christ Hospital physicians, please visit tchpconnect.org. That's tchpconnect.org. This is Melanie Cole. Thanks so much for listening.