What is the standard of care when it comes to breast conserving therapy, in other words
lumpectomy.
Well in general, always part of that standard of care is having some kind of radiation therapy.
The radiation therapy can be of the whole breast, it can be just of the area where the
cancer was and remember that is called accelerated partial breast irradiation.
Now are there exceptions that women who have had a lumpectomy don't necessarily need radiation
therapy?
And the answer of the question is yes, there are exceptions.
There can be tiny areas of in situ breast cancer as an example, that is a reason if
you take out a large enough lumpectomy specimen with wide margins and a low grade cancer that
you may not need radiation therapy at all and so those decisions are made on an individual
basis working with the multidisciplinary team.
There has also been a fair amount of data that perhaps women who are older than age
70 don't need radiation therapy after lumpectomy but we have got to be careful about this recommendation
because again, even in women over 70, not all cancers are the same.
Often in this age group, these are smaller cancers, especially if they are found with
screening mammograms, they are usually estrogen receptor positive, so the patient will be
put on an antihormonal regimen and with women who are older than 70, particularly as women
get into their 80s or so, they may have other illnesses, we call those comorbid factors,
so that the percentage of women older than 70 that may not need radiation therapy may
be smaller than certainly those under the age of 70.
I am looking here at a study from the Department Of Radiation Oncology And Surgery at the University
of Pennsylvania and Philadelphia.
This is a 20-year analysis using what is called SEER data.
S-E-E-R, surveillance, epidemiology and results, this is the largest sort of population based
database that we have got that the federal government maintains, it is a wonderful source
of research and so, one of the things that this group did was to look at the 20-year
time period from 1988 to 2007 and the thing that I am going to particularly focus on in
this paper was the omission of radiation therapy and what they found was there was sort of
a steady state of approximately 20% of patients not undergoing radiation therapy.
Now in all fairness, the authors do point out that whether patients had radiation therapy
or not is one of the difficult parts of this particular national database that have filled
in properly or to put it in other way that people may have had radiation therapy but
it simply did not get recorded in the database and so this particular study also looked at
the incidents of mastectomy over this 20-year period and found that people having mastectomy
rate was going down but I want to focus on the issue of radiation therapy and what was
fascinating to me about those who did not in this database have a radiation therapy
was besides being elderly patients or older than age 70, there was also a lower percentage
of people who are African American who did not get radiation therapy.
The use of radiation therapy also varied geographically within the United States with a lower incidence
apparently of using radiation therapy in the South and the South East.
The highest use of radiation therapy was in the North East and then it varied around the
country.
So, what is the important part of this and in the discussion that goes with this paper,
they did point out that other series show that the use of radiation therapy can be as
high as 90%.
For those who are worried about radiation therapy and we know there are people worried
about it that perhaps the radiation therapy itself can cause cancer or I have done a previous
video about damaging the heart or just the overall fear of radiation therapy which can
vary tremendously by cultural groups and my own experience as an example, there is a great
deal of fear in the Hispanic community to have radiation therapy.
A lot of these are cultural myths that have passed down the way.
But if you are going to have breast conserving surgery, in general please remember that you
always need radiation therapy, the data is really clear, when you have the radiation
therapy, the chance of the cancer coming in back in your breast goes down, survival is
improved, the benefits are irrefutable as when it comes to radiation therapy.
Please also remember that there are choices now for radiation therapy, from the traditional
whole breast radiation therapy that will take six weeks including boosting the area where
the cancer was originally, now shorten down then to whole breast radiation therapy called
hypofraction at three weeks, coming down to accelerated partial breast irradiation, APBI
where devices can be put into the breast or the ultimate of accelerated partial breast
irradiation therapy is intraoperative radiation therapy.
And when it comes to intraoperative radiation therapy, we can do that at the time of the
lumpectomy to start the radiation therapy and that is called the boost or in selective
cases, intraoperative radiation therapy can be used as what is called a single fraction
meaning one shot and you are done.
That kind of treatment in the United States, the single fraction is being done under research
protocols which is appropriate.
The research and single fraction is more robust when it comes to data out of Europe.
It is clear to me that more and more women are going to one single fraction and that
is a really excellent alternative which you have got to be working with a multidisciplinary
team who know the limitations of the single fraction, so please find such a team, please
look at all the options and please have the necessary radiation therapy.
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