I'm Dr. Sonali Rudra, I serve as the service director for the Breast
Radiation Oncology Program at MedStar Georgetown University Hospital.
I treat primarily women with breast and gynecologic malignancies. Currently, I
treat primarily breast cancer patients. Some of the patients I see before
they've had surgery, others I see after they've had surgery. So I see the whole
range of breast cancer patients. There are many tools that we have to try to
decrease the side effects of treatment. I think proton therapy is a technologic
advance that will help us decrease the side effects of treatment. The difference
between proton radiation and standard radiation is that it can decrease the
dose beyond where we're treating. So for breast cancer patients, for example, where
we're trying to treat the breast and chest wall there is some dose that goes
to the lung and heart which is right underneath the breast and chest wall.
With proton therapy, we can decrease the dose to the lungs and heart much more
then we can with photon therapy or traditional radiation therapy. Our breast
cancer patients have the option of coming for a multidisciplinary clinic.
This means that they can see all their necessary physicians on one day. We
typically discuss the patients earlier in the week, and we know exactly what
physicians they'll need to see. And we try to set up those appointments for the
patients ahead of time, so it's nice for someone who just has a new diagnosis of
breast cancer to be able to know exactly what their treatment will entail and
what the steps are. Many of my patients are young women who are my age or you
know my mother's age, my sister's age, so the way I view them is as a family
member, and I try to treat them as I would want my family members to be
treated. So I try to give them as much attention and
care and dedication as I would if it were a relative of mine that was being
treated under my care.
The role of radiation therapy in breast cancer is to decrease the risk of a
recurrence, which means to decrease the chance of the breast cancer coming back.
And for some women, radiation can actually improve survival in breast
cancer. After a lumpectomy, all patients are candidates for radiation therapy.
There are some cohorts of women, some groups of women, who don't need radiation
therapy. However, the majority of women will be a candidate for some form of
radiation therapy after they've undergone a lumpectomy. After a
mastectomy, some women do not need radiation therapy; however, women who have
larger tumors or tumors that involve the skin, chest wall, or lymph nodes, are
usually recommended to receive radiation therapy.
When we treat breast cancer patients with traditional radiation therapy, we
treat the breast and the chest wall, but there is low dose that goes to the
underlying structures like the lungs and heart. With proton therapy, we can control
the dose better so that there's less dose to the lungs and heart. So I think
for young women who have left-sided tumors, there could be a significant
benefit with proton therapy compared to a traditional radiation therapy.
So for left-sided tumors, sometimes we need to treat the lymph nodes which
include lymph nodes in the lower part of the neck, lymph nodes in the armpit or
axillary region, and lymph nodes right along the sternum. The lymph nodes right
along the sternum are sometimes hard to treat with radiation therapy because
they're right above the heart, especially in left-sided tumors. In women who have
lymph node involvement by the sternum, those are called the internal mammary
lymph nodes. So women who have internal mammary lymph node involvement we, want
to treat those lymph nodes to a high dose. But we're often limited because the
heart and lungs are right underneath. So those women are the ones that could
potentially benefit the most from proton therapy compared to traditional
radiation therapy. In addition, young women, they have a longer life span so
they may live long enough to actually have an appreciable difference in their
toxicity as a result of even the slow dose of long and hard radiation. There
are other unique situations where we may recommend proton therapy for breast
cancer patients. Those include women who have had previous radiation, women with
genetic abnormalities that may make them more susceptible to the side effects of
radiation therapy, or women with anatomic abnormalities in which giving
traditional radiation might give them an unacceptable dose to the heart and lungs.
There are side effects associated with radiation therapy,
both traditional radiation therapy and proton therapy. I divide the
side effects into short term side effects, those that they feel during
treatment and those that they feel long term. So the short term side effects of
radiation are fatigue, skin changes, and maybe some tenderness in the breast or
chest wall. The degree to which people feel them differs from person to person.
But everyone gets some degree of skin changes, some amount of fatigue, and maybe
some tenderness. I meet with patients once a week while they're on treatment
to make sure that they're doing okay and address the side effects as needed. Long
term, the biggest side effects are darkening of the skin in the area that
we're treating and kind of thickening of the skin and soft tissues in the area
that we treat. The difference between proton therapy and photon therapy is
that potentially it could decrease the risk of toxicity to the heart and lungs
and potentially even decrease the risk of secondary malignancies.
During the actual treatment, patients don't feel anything. It's invisible
x-rays that are penetrating their body. So they are lying flat on the table
usually with the arms up about their heads, the machine rotates around them
and points the radiation to the area that we're trying to target. And they
don't feel, see, or smell anything during the actual treatment. And that is true
with traditional radiation or with proton radiation.
There are several institutions that have been treating breast cancer patients with
proton radiation for a few years. They have published the results, and they
showed that proton therapy is safe and effective and produces very similar
results to what we see with traditional radiation therapy. The real benefit of
proton therapy, especially in our breast cancer patients will be seen I think
10-15 years down the road when we can see whether or not patients with proton
radiation therapy have improved cardiac toxicity or lung toxicity compared to
traditional radiation therapy. And we have to wait a few more years before we
get those results.
Proton therapy cannot replace chemotherapy or surgery. Proton therapy
is an alternative to traditional radiation therapy or photon radiation
therapy, but it can't be seen as an alternative to chemotherapy or surgery.
Surgery really is the definitive treatment for breast cancer.
There may be certain in instances where surgery is not an option, and in those
cases, potentially radiation especially with proton radiation might be a good
alternative because we can deliver higher doses of radiation safely
compared to traditional photon radiation therapy.
If it's an appropriate time to start radiation therapy, the first step is to do a CT
scan in our department to plan the radiation treatment. And about one and a
half to two weeks after that is when you actually start your treatment. Once you
start, treatment is every single day Monday through Friday over the course of
three to six weeks. While you're on treatment you meet with the nurse and
radiation oncologist once a week to assess you for side effects and see how
you're doing. And after you're done with your radiation therapy, we usually see
you and follow up every six months for at least the first one or two years.
Radiation therapy is usually the last step of breast cancer treatment. Surgery
is often the first step, but if you have a larger tumor or lymph nodes involved,
sometimes chemotherapy will come first and then you'll have your surgery and
then you'll have radiation therapy. If you're getting radiation after surgery,
usually we start about four to six weeks after your surgery, but some patients
will start up to 12 weeks after their surgery. After chemotherapy, radiation
generally starts about four to six weeks later.
Being a Comprehensive Cancer Center means that
you have all of your specialists here. For a breast cancer patient, they
definitely have to see the breast surgeon and medical oncologist often
times the radiation oncologist, but there are a lot of other services that they
need. You know if it's a young woman with a significant family history, they'll
need to see a genetic counselor. A lot of women who are undergoing mastectomy will
need to see a plastic surgeon. There's social services available. We have
a dietitian that's available. So it's not just the two or three main physicians
that a patient will need to see but if they're part if they come to a
Comprehensive Cancer Center they have access to the physicians and all the
other supporting services and supporting physicians as well.
I think MedStar Georgetown University Hospital is a great option for a
breast cancer patient to be treated because you have all of your specialists
under one roof. And all the treating physicians really specialize in
breast cancer. You know, we meet on a regular basis to discuss patient's cases,
and it's helpful when all the physicians have treated you because there are
nuances to each patient and their tumor characteristics and if everyone on at
the table knows your case then it helps develop the best possible treatment plan
for the individual patient.