In the Clinic

On Cancer: Blanket Coverage: New Radiation Technique Improves Breast Cancer Treatment

By Jim Stallard, MA, Writer/Editor  |  Monday, January 20, 2014
Pictured: Alice Ho Radiation oncologist Alice Ho helped develop a treatment plan for breast cancer that covers a larger area without endangering the patient.

Radiation therapy for breast cancer can be a double-edged sword. The treatment is usually given to destroy any stray cancer cells that may have been left behind after a breast tumor is surgically removed. But if there is evidence the disease has spread locally — to the chest wall and nearby lymph nodes — the chest and multiple nodes must be targeted while minimizing the dose to the lungs and heart.

This is a challenging task, even with an advanced method like intensity-modulated radiation therapy, or IMRT, which targets tumors using multiple beams at different angles and intensities. Too much radiation to the lungs can cause an inflammatory condition known as pneumonitis, while in the heart it can cause thickening and stiffness of muscle tissue and connecting arteries, increasing the risk of heart disease.

The standard IMRT approach, which uses three to five beams, has provided somewhat patchwork coverage. While it helps preserve heart and lung function, the uneven radiation levels create “hot” and “cold” pockets that increase the risk of missing microscopic disease that could spread.

“If you’re targeting the chest wall and multiple nodes, it gets very complicated to design a way to treat the entire area safely,” says Memorial Sloan Kettering radiation oncologist Alice Y. Ho. “In addition, an increasing percentage of breast cancer patients are having reconstructive surgery and receiving implants, which present a technical challenge to work around.”

Expanding Coverage with Additional Beams

Dr. Ho, in collaboration with Radiation Oncology Department Chair Simon Powell, decided to investigate whether spreading the radiation dose over a larger number of beams would make it possible to cover the area more thoroughly without endangering the patient. Working with medical physicists Ase Ballangrud-Popovic and Guang Li, they developed a treatment plan using eight to 12 beams that targeted potential disease sites while sculpting the radiation around multiple obstacles in the anatomy.

The approach leaves less margin for error around the targets — being even a few millimeters off can miss cancer cells and greatly undermine results. “This technique has a very steep dosage fall-off, meaning that the radiation drops right off at the edge of the treatment area,” Dr. Ballangrud-Popovic says. “Because of this, we have to make certain the patient is positioned more accurately than with standard therapy.”

To accomplish this, the team employed a new 3D surface imaging system called Align RT®, which uses three cameras to track the position of the patient in relation to the radiation beam. The system continuously monitors any movement during treatment so adjustments can be made. The Align RT surface images are used in combination with conventional x-ray images that rely on bones as landmarks.

The combination of the new IMRT planning approach and the Align RT imaging system was recently tested in a pilot study involving 106 breast cancer patients who were given the treatment following surgery. Each patient received 25 radiation doses, with some getting chemotherapy as well. The results show conclusively that the method, while covering a larger area, does not increase detectable side effects to the heart or lungs.

Unexpected Benefits

The study also suggests the new method may provide some unexpected cosmetic benefits. Because the higher number of beams provides a more evenly spread dose, there are fewer pockets of high radiation that cause red or dark spots in the breast skin. Fibrosis — a scarring and stiffness in the breasts of women with implants — may also be minimized or avoided.

A new study is now planned to look specifically at the question of whether the new IMRT approach produces better results than conventional therapy in women with implants. “It will be significant if we improve the cosmetic appearance of women with implants,” Dr. Ho says. “It has become clear that this is a major concern for patients, so this benefit alone would be very important.”

This blog entry is part of a larger feature about advances in radiation oncology published in the October 2013 issue of Center News.

Comments

I am so happy with this finding. We always knew there is a risk with radiation period. Hopefully this will help those in the future.

Prevention of Radiation Fibrosis is important. The pain and limitation it causes has a real effect on us.

What about Tomo/Tomography which is even more exacting? That's the treatment I received. And what about the accuracy of the cyber knife? Can you compare?

Pat, thank you for your comment. We are consulting with one of our radiologists and working on getting a response to your questions.

Pat, we consulted with radiation oncologist Alice Ho and she responded:

The two approaches (multibeam IMRT and tomography) are very similar in that both use multiple beams to conform high dose of radiation around the target—they just use different machinery. The guidelines we use originated with tomography and improved upon them. The multibeam breast cancer treatment described in the story was done “on protocol” following very specific guidelines. Regarding CyberKnife, it is a pinpoint form of radiation, used for focus on a very small target, usually not applicable to breast cancer where you may be targeting not just a tumor but also lymph nodes etc.

What about PARTIAL BREAST RADIATION...DIRECT RAD TO SURGICAL SITE ONLY (2 x DAY x 5 DAYS)...was this trial discontinued?..is it an option in 2014?...txs,jmb.............

Jeneatte, thank you for your comment. We are consulting with one of our radiologists and working on getting a response to your questions.

Jeanette, we consulted with radiation oncologist Alice Ho and she responded:

We are still offering the treatment, but off protocol (not as part of a study) because the trial is closed. A patient would need to go through a consultation with the physician to determine whether this treatment is appropriate for them.

Do you offer SAVI treatment for DCIS?

Patricia, thank you for your comment. We consulted with Dr. Beryl McCormick who responded:

"SAVI is a form of brachytherapy that treats only part of the breast. The standard of care remains whole breast treatment (a recent randomized trial comparing both closed last year and we are awaiting results). So for now we are not offering the SAVI treatment."

This is GREAT news if it works! My wife, Catherine Denise Winston was a patient there for Inflammatory Breast Cancer. She underwent radiation there in 2010. But I feel that current technique did HER more harm than good. She passed away on 08/09/10. I have since become a medical marijuana activist, because it appears from more and more studies that it actually CURES cancer!

I am 62 years old and I just had a lumpectomy for Stage O Intraductal Carcinoma in Situ Stage O. This still remained stage O and the sentential Node Biopsy was negative. I was told that I would have to have radiation . I am also Estrogen Receptor Positive and they are talking about Tamoxifan. I found out today that my cancer was only 7 mm. I feel like I am being treated cookie cuter style and I live in a small Rural Community. I want to be absolutely sure that I don't have needless radiation to my heart and lungs. I wonder if I even need radiation?? Would you at Sloan Kettering be willing to do a consult for me and answer some of my concerns? I am uncomfortable having Radiation without a second opinion. I am otherwise healthy. I see that there are minimal radiation options available.

Theresa, If you would like to make an appointment with a Memorial Sloan-Kettering physician for a second opinion, please call our Physician Referral Service at 800-525-2225 or go to http://www.mskcc.org/cancer-care/appointment. Thanks for your comment.

I am 48 years old and currently receiving chemotherapy for Stage 2 breast cancer. I have to also do radiation. Is this new procedure for radiation being done at other hospitals? I worry about the effects on my lungs and heart as mentioned above. I live in Delaware.

Cindy, we are unaware of other hospitals that are using this particular multi-beam approach for breast cancer, although some places may be investigating its use. If you would like to make an appointment with a Memorial Sloan-Kettering physician, please call our Physician Referral Service at 800-525-2225 or go to http://www.mskcc.org/cancer-care/appointment. Thanks for your comment.

I had stage 3 breast cancer 7 years ago . at the time I had implants in both breasts. I only had a lumpectomy on the rt which had the cancer. after a few years it became quite hard and implant started to leak . I had it replace but contacted mersa and had to have it removed. a year later I had an expander put in and after a month got mersa again. my surgeon says because of radiation I had I will most likely keep rejecting the implant. what do I do now I have lost so much of my breast tissue I have to wear a prostesthis. I am 58 years old and want to look normal again. should I try 1 more time with implant ? thank you, sue

Dear Susan, we are sorry to hear all you've been through. Unfortunately, we cannot answer personal medical questions on the blog. If you would like to make an appointment for a consultation with one of our breast reconstruction specialists, please call our Physician Referral Service at 800-525-2225. Thanks for reaching out to us.

After doing a radiation, is there an effect for the people surrounded by the patient? I just want to know so i be careful what to do for a person undergoing radiation... Thanks

Jan, the type of radiation described in this article is external-beam radiation, which does not pose any risk to other people who may be near or around the patient following the treatment. Thanks for your comment

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