Radiation Treatment for Breast. Cancer. Melissa James Radiation Oncologist August 2015

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1 Radiation Treatment for Breast Cancer Melissa James Radiation Oncologist August 2015

2 OUTLINE External Beam Radiation treatment. (What is Radiation, doctor?) Role of radiation. (Why am I getting radiation, doctor?) Radiation Scheduling. (How often will I be going in?) Side effects of Radiation (Will it burn me, will I glow I the dark?) What is new in Radiation?

3 BACKGROUND Surgery remains the mainstay of treatment for early breast cancer. Mastectomy Lumpectomy (breast conserving surgery) Adjuvant treatments play an important role in preventing relapses and therefore preventing cancer death: Chemotherapy RADIOTHERAPY Hormone therapy

4 Radiation: The Process

5 RADIATION TREATMENT- THE PROCESS Planning CT Planning Breast treatment

6 Radiation: The Role

7 ROLE OF RADIATION IN BREAST CANCER Breast conservation Post mastectomy DCIS Palliation

8 ROLE OF RADIOTHERAPY IN EARLY BREAST CANCER Indicated in MOST WOMEN post lumpectomy (Breast Conservation) Post surgery local recurrence 20-30% Radiation decreases the risk of tumour recurrence in the remaining breast tissue This translates into a small survival advantage.

9 BREAST-CONSERVING SURGERY (BCS) Meta analysis There were 7300 women with BCS in trials of RT 5-year local recurrence risks (mainly in the conserved breast): 7% vs 26% (reduction 19%) 15-year breast cancer mortality risks: 30.5% vs 35.9% (reduction 5.4%, SE 1.7, 2p=0.002) 15-year overall mortality risks: 35.2% vs 40.5% (reduction 5.3%, SE 1.8, 2p=0.005) EBCTCG Lancet 2005; 366:

10 ROLE OF RADIOTHERAPY IN EARLY BREAST CANCER Indicated in SOME WOMEN post mastectomy Recurrence of breast cancer in chest wall may be catastrophic. Chest wall recurrence is frequently associated with metastatic disease Thus prevention of recurrence important

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12 MASTECTOMY AND AXILLARY CLEARANCE: N+VE Meta analysis There were 8500 women with mastectomy, axillary clearance, and N+ve disease in trials of RT 5-year local recurrence risks: 6% vs 23% (reduction 17%) 15-year breast cancer mortality risks: 54.7% vs 60.1% (reduction 5.4%, SE 1.3, 2p=0.0002) 15-year overall mortality risks: 59.8% vs 64.2% (reduction 4.4%, SE 1.2, 2p=0.0009) EBCTCG Lancet 2005; 366:

13 ROLE OF RADIOTHERAPY IN EARLY BREAST CANCER Indications for post mastectomy radiation treatment 4 or more nodes involved T3 (5 cms or larger) Close or involved margins Other factors 1-3 nodes positive considered High risk features: lymph vascular space invasion, grade three

14 ROLE OF RADIOTHERAPY IN DCIS DCIS treated with a WLE Reduces recurrences by 2/3 50% of the recurrences will be further in situ disease 50% recurrences will be invasive recurrences No overall survival benefit Consider for High grade Large lesions Close margins

15 ROLE OF RADIOTHERAPY IN PALLIATION Painful bone metastases (80% will have pain reduction) Brain metastases Spinal cord compression Skin metastases Skin/ nodal recurrences Bronchial obstruction

16 SO radiotherapy is a very well established treatment in breast cancer

17 Radiation: The Scheduling

18 SCHEDULING RADIATION TREATMENT Daily Monday to Friday Each treatment Minutes Beam on time is for only a few minutes Most time is set up time Treatment duration Most commonly 16 fractions (3+ weeks) May also have 25 fractions (5 weeks)

19 HYPOFRACTIONATED RADIATION Why the move to shorter treatments for early breast cancer?

20 META ANALYSIS Radiation treatment Hypofractionated treatment (>2Gy per fraction) Conventional fractionation (1.8-2 Gy per fraction). James ML, Lehman M, Hider PN, et al. Fraction size in radiation treatment for breast conservation in early breast cancer. Cochrane Database Syst Rev 2010;(11):CD

21 HYPOFRACTIONATION The meta analysis found no difference in local recurrence rates with shorter fractionation. No difference in long-term cosmesis. Less short-term toxicity. A SHORTER, MORE CONVENIENT RADIATION SCHEDULE WITH EQUIVALENT CANCER OUTCOMES

22 Radiation: The Side Effects

23 RADIATION THE SIDE EFFECTS Acute (Happen during radiation treatment and immediately after) Skin reaction Erythema Dry desquamation Wet desquamation Breast/ Chest wall discomfort Lethargy (No Nausea, hair loss, radioactivity)

24 RADIATION THE SIDE EFFECTS Erythema Wet desquamation

25 RADIATION THE SIDE EFFECTS Late (Happen 6 months following the radiation treatment) Skin Pallor, atrophy, telangiectasia Soft tissue Fibrosis Pulmonary Fibrosis Asymptomatic Lymphoedema (Only if nodes are treated) 10-30% Brachial plexopathy (Only if nodes treated) <0.1% Cardiac toxicity Left sided patients <1% excess cardiac mortality with modern radiation at 15 years Second malignancy (Radiation induced)] 1-2:1000 at 10 years

26 Radiation: What is new in breast treatment?

27 WHAT S NEW IN RADIOTHERAPY? Excellent local control and survival rates for early breast cancer Focus of Research is in decreasing the potential toxicity

28 IMPROVING ACUTE SIDE EFFECTS A dressing has been shown to improve rates of wet desquamation in breast cancer patients receiving radiation treatment 1. The dressing is called mepitel This is being introduced for post mastectomy patients in Christchurch hospital 1. Radiother Oncol Jan;110(1): doi: /j.radonc Epub 2014 Jan 30.

29 IMPROVING LATE SIDE EFFECTS Cardiac Toxicity Meta analyses have shown a greater breast cancer specific improvement with radiation treatment but less benefit in overall survival This is at least in part related to cardiac toxicity. Cardiac toxicity may take years to develop and is of particular concern to younger women undergoing radiation treatment. These patients may also be receiving cardio- toxic chemotherapy

30 IMPROVING CARDIAC OUTCOMES IN PATIENTS We now are better than ever able to see the heart position and model the dose to the heart with planning software This allows us to shield the heart Move the radiation beams to shield the heart Set the patient up differently (prone technique)

31 IMPROVING LATE SIDE EFFECTS Deep inspiratory breath hold is a method of helping patients to maintain a good lung expansion, which keeps the amount of heart in the radiation field to a minimum.

32 Safe MODERN RADIATION TREATMENT FOR BREAST CANCER Effective

33 MORE INFORMATION