Breast Cancer and Tattoo-Less Radiation at MSK

Boris Mueller, MD, Director, Radiation Oncology at MSK Bergen is seen standing in a hallway.

Boris Mueller, MD, is Director of Radiation Oncology at MSK Bergen in northern New Jersey. He helps lead the MSK effort to provide tattoo-less radiation therapy, which is being offered to people diagnosed with early stage breast cancer.

  • Memorial Sloan Kettering Cancer Center offers tattoo-less radiation therapy for early-stage breast cancer.
  • MSK’s tattoo-less radiation uses Surface Guided Radiation Therapy that is just as accurate as radiotherapy with tattoos and can be done more quickly.

The experts at Memorial Sloan Kettering Cancer Center (MSK) are using a new approach to relieve anxiety sometimes associated with radiation therapy for early-stage breast cancer. And in the process, they are helping change many years of standard practice.

Radiation oncologist Boris Mueller, MD, MPH, Director of Radiation Oncology at MSK Bergen, helps lead the MSK project. He explains: “For decades, a standard component of radiation therapy has been to give people small tattoos. These tattoos are used to help align precisely calibrated lasers in the treatment room and make sure the patient is positioned correctly.”

For some people, however, the tattoos are a source of stress. “Again and again, the people we care for told us they would prefer to avoid these tattoos,” says Dr. Mueller. “One common theme is that they don’t want a lifelong reminder of cancer.”

To help, MSK experts have begun using Surface Guided Radiation Therapy (SGRT) to deliver tattoo-less radiation treatment for patients with early-stage breast cancer.

Doctors say this new method has proven just as accurate as radiotherapy using tattoos and also shaves a few precious minutes off the time needed to give treatment, meaning people spend less time in each radiation session.

According to Dr. Mueller, “MSK is one of just a handful of hospitals around the country using this approach.”

Why Tattoos Are Used for Radiation Therapy for Breast Cancer

MSK radiation oncologists and technicians always try to minimize the number of tattoos used for radiation treatments. However, tattoos have long proven vital to delivering radiation exactly where it’s needed.

For breast cancer treatment, “the usual procedure is to tell people they will receive several pinpoint tattoos — from four up to as many as a dozen — that are about the size of a freckle,” Dr. Mueller explains. “These will fade, but they will always be there. And they are clearly tattoos, not a natural skin feature.”

He continues, “The tattoo color is the same for every skin tone, and they’re typically placed on the sternum between the breasts, underneath the breasts, along the ribs, or near the armpit.”

Why Many People Dislike Tattoos for Breast Cancer Radiation Therapy

While these tattoos have been a medical necessity, they are unpopular. Dr. Mueller says: “There is a growing body of research that people feel real psychological distress from tattoos that lasts way beyond the treatment. They feel it’s a permanent reminder of a cancer diagnosis.”

Dr. Mueller and his colleagues have heard from some people that they feel compelled to change the way they dress to cover up the tattoos. Others feel uncomfortable at the beach or gym where the tattoos are more likely to be seen. Some women may also feel conflicted about receiving tattoos based on cultural or religious beliefs.

How MSK Performs Tattoo-Less Radiation Therapy

Dr. Mueller says the key to MSK’s tattoo-less radiotherapy is the Surface Guided Radiation Therapy (SGRT) technology.

He explains that “this technology uses light emitted from specialized camera units in the radiation treatment room, which are above the patient.”

Each month, we have several people who come to MSK for radiation treatment in part because they have heard about the tattoo-less option we offer.
Boris A. Mueller radiation oncologist

He continues: “The system can track a patient’s position before and during radiation, and it’s the person’s own skin surface anatomy that is used to align the patient in the correct treatment position. That means the technology can track a person in real time and eliminate the need to mark the body that is required with a traditional system, which uses laser imaging.”

The SGRT technology that MSK uses is called AlignRT. Dr. Mueller and colleagues presented research about MSK’s experience with SGRT at one of the world’s largest radiation oncology conferences in 2022. “We found that this new method is just as accurate as using tattoos,” says Dr. Mueller. “And it’s actually a bit faster, meaning a radiation session on average is about two minutes shorter.”

That may not seem like much time, admits Dr. Mueller. But he points out that when people undergo radiation therapy, they always appreciate spending the least amount of time possible in a treatment room.

Jasmin’s Experience With Tattoo-Less Radiation

MSK patient Jasmin Guisao seen outdoors

Jasmin Guisao received tattoo-less radiation therapy at MSK.

Jasmin Guisao came to MSK after a concerning mammogram and being diagnosed with DCIS (ductal carcinoma in situ), which are abnormal cells in milk ducts that have the potential to become invasive cancer.

Jasmin, a labor and delivery nurse now in graduate school studying women’s health, researched MSK doctors and was treated by breast surgeon Andrea Barrio, MD. “From the moment I stepped through the doors at MSK, everything was absolutely wonderful,” she recalls. “It was a very personal experience. They heard my concerns and were with me throughout the journey.”

She also admits with a laugh, “Healthcare providers like me can often be the worst patients, because we know too much.”

When it came time for radiation therapy after surgery, Jasmin says: “I hadn’t given much thought to the tattoos. I made a joke to one of my doctors that I was looking forward to getting my first tattoo.”

But Jasmin’s outlook changed as she read about other people’s experiences on breast cancer advocacy websites. “I realized I didn’t want a marker on my body to remind me of what I went through. I knew the tattoos would have a negative connotation for me.”

Jasmin says she was thrilled to learn that MSK offers a tattoo-free option when she began treatment with radiation oncologist Dr. Quincey LaPlant, MD, PhD.

“The summer of 2022, when I was getting treatment, was very taxing and depressing,” she recalls. “I couldn’t do many of the things I enjoy like running, swimming, and biking. I had also moved to suburban Rockland County about a year earlier, and my 25-year-old son remained in Brooklyn. So my support system was not quite the same.”

Looking back a few months later, “I was glad that, on top of everything else, I didn’t also have tattoos to remind me of what I was going through,” Jasmin says.

“About a week before radiation therapy, they had me lie on a table to take many different measurements of me,” Jasmin recalls. “Those were input into a computer program, so then they knew exactly where to target the radiation.”

Next Steps for Tattoo-Less Radiation Therapy

MSK Bergen, which serves northern New Jersey and southern New York, has been the hub of MSK’s use of tattoo-less radiation therapy. “Going forward,” says Dr. Mueller, “we expect to treat all people who undergo partial breast irradiation” — like Jasmin — “with the tattoo-free approach.”

Already, word is spreading among people diagnosed with early-stage breast cancer. “Each month, we have several people who come to MSK for radiation treatment in part because they have heard about the tattoo-less option we offer,” says Dr. Mueller.

In 2023, Dr. Mueller expects a few hundred people will be treated at MSK with SGRT. There are plans to use the approach in more advanced cases of breast cancer, when people often require more intensive treatments, including chest wall and regional nodal radiation.

MSK experts believe SGRT may also prove useful in radiation treatment for other forms of cancer, affecting the brain, lungs, skin, extremities, prostate, and spine. Dr. Mueller says: “Tattoos will eventually be a thing of the past for radiation therapy. MSK took an important first step by doing this for our early-stage breast cancer patients.”

Jasmin definitely feels it was the right step for her. “I would recommend the tattoo-less option where it’s possible. It was one of the many ways that MSK really delivered on taking care of me.”