Radiation Oncology Update - Dr Andrew See
Mark Ryan • February 14, 2016
Breast Radiotherapy
Radiotherapy is typically delivered via a course of painless daily visits on a Monday to Friday basis spanning between three and 6 ½ weeks.
Splitting the treatment up into small sessions delivered daily over many weeks is called ‘fractionation’. Fractionation ensures that the radiotherapy treatment will be safe as the normal body tissues cope very well with radiation when delivered in this manner.
Traditional Fractionation – 6 weeks
Traditionally, radiotherapy has been administered over 6 to 6 ½ weeks comprising between 30 and 33 daily treatments. This is delivered in two phases. The first phase, which spans 5 weeks, is termed ‘whole breast radiotherapy’. During this phase, the whole breast is treated through a technique called opposed tangents. The second phase of treatment, also called the ‘boost’, is delivered in the final 1 to 1.5 weeks. During this component of therapy, just the immediate breast tissue surrounding the original primary tumour is irradiated. Not all women require a ‘boost’ dose however in those who do, it is considered to further improve local tumour control.
Shortening the Radiotherapy Course - 3 weeks
Over the last two decades, a number of clinical trials have explored the merits as to whether it is possible to shorten the duration of whole breast radiotherapy from the traditional 6 ½ weeks to anywhere between three and 3.5 weeks. These studies were conducted in countries where radiotherapy machines were scarce and as a result the waiting times for treatment unacceptably long. Three trials, accruing over 5000 women have now been published and peer reviewed. They appear to show that a select group of women can be safely treated with a shortened 3.5 week course of therapy yet still enjoy equivalent long term cure rates and acceptable cosmetic outcome.
In some groups of women, it is still preferential to extend the treatment over 6 ½ weeks. This is particularly so for women who are large breasted, as the very same trials did show that shortening the treatment in large breasted women can lead to an increase in the risk of long term breast fibrosis and shrinkage, which may lead to dissatisfaction with the overall cosmetic outcome. Furthermore, women who are intending to undergo breast reconstruction of any type and women who also require treatment of the supraclavicular fossa (glands above the collarbone as well as the breast) will generally be managed on a standard six week course.
New Radiotherapy Techniques - Improving Safety & Minimising Risk
In the modern era, radiotherapy is considered safe and equitable although there still are some potential long-term side effects that can manifest years after the treatment has been administered. In the case of women who require left-sided breast radiotherapy one of the long-term side effects involves the potential for radiotherapy to damage the heart. This occurs because the radiotherapy beams do come close to the front of the left ventricle (main chamber of the heart that pumps blood around the body) and also the left anterior descending coronary artery (main artery that feeds the left chamber of heart). Although the overall risk is considered to be low, a small increase in ischemic heart disease is observed when treating left sided breast cancer that is not apparent when managing right sided disease. This risk is magnified even further in women requiring left sided breast radiotherapy who also have other cardiac risk factors such as diabetes, active smokers, hypertension or a familial history or predisposition for heart disease.
Deep Inspiratory Breath Hold for Left Sided Breast Cancer
A recent refinement in the management of left-sided breast cancer is a technique called ‘deep respiratory breath hold’ or DIBH.
A single treatment of radiotherapy usually lasts 6-10 minutes. During this time women are asked to take shallow comfortable breaths in and out of an open mouth.
With deep respiratory breath hold, additional coaching occurs prior to radiotherapy planning and women are asked to take a deep purposeful breath inward and then to hold the inspired position for as long as they feel comfortable (20-30seconds). The radiotherapy is only administered while the breath is held in this phase. This manoeuvre pushes the heart back and away from the radiation beam further reducing the dose to the heart. Women are usually required to wear video feedback goggles or watch a computer monitored during their therapy which allows instant feedback as to whether their breathing is maintained in the desired phase. Furthermore, breathing drills similar to which are taught in a Yoga class are practiced in the weeks leading up to the commencement of radiation therapy. Not all radiotherapy departments offer this technique although in the years ahead it is likely to be more widely available.
Dr Andrew See consults out of the unit on Monday mornings.
CONTACT US
Melbourne Breast Unit
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East Melbourne VIC 3002
Phone: (07) 3272 2202
Fax: (07) 3272 2202
Breast Care News
This is a very high percentage of people who may be experiencing anxiety and fear of recurrence of breast cancer. Following a diagnosis of cancer it is important to have resources available which help to maintain a good quality of life. The following article from BCNA outlines and provides links to resources designed to provide strategies to deal with these fears. This includes discussions from health professionals and information on ongoing care. If you feel that fear or anxiety is having a negative impact on your life, it is important to talk to your treating doctor or GP. For the full article please click here .
Breast prosthesis can help to restore self image and femininity. This is why BRA are conducting much needed research into the design and comfort level of breast prosthesis. A breast prosthesis can sometimes feel uncomfortable for some women, depending on many factors. Research involving women who have used or are currently using a prosthesis will ensure it continues to improve the quality of life of women after breast cancer surgery. To read the full article and access contact information to be apart of this research please click here .
Cancer Council Victoria is reminding people how important community participation on Daffodil Day is to raise funds for cancer research, prevention programs and support services. "We want to beat cancer through more research, through educating the public on ways to prevent cancer and by helping people who have cancer get the best treatment and care." For more information on getting involved this Daffodil Day, click here .
Several of our patients have been subjected to workplace discrimination after their breast cancer diagnosis. Either in the form of unfair dismissal whilst on treatment, or simply a lack of understanding while trying to arrange a return to work post-treatment. We see widespread misunderstanding in the workplace that the end of chemotherapy or radiotherapy signals the end to any need for work flexibility or compassion. Many patients still struggle emotionally after the treatment for a breast cancer diagnosis and the workplace will not always instinctively be so supportive. This personal story is truly illustrative of the problem. If you find yourself in need of the legal or workplace resources mentioned in this personal account, you’ll find some suggested avenues at the end of the article. Suzanne Neil Breast Surgeon
Mammography and ultrasound has an established role in breast cancer screening and detection. Most cancer(s) can be detected, sized and staged with conventional mammograms and thorough ultrasound evaluation. However the advent of MRI and its role in management of breast disease is ever increasing. In Australia facilities performing and reporting breast cases are not widespread, unlike general radiology. Specialist Radiologists who perform and report the studies are limited. It is therefore important to send a patient to a centre where Breast MRI is routinely performed. MRI serves in the role of screening, diagnosis and management of breast cancer primarily as an adjunct to conventional methods of mammogram and ultrasound.
The Epworth Medical Foundation has recently installed the Paxman Hair Loss Prevention System, a new machine to prevent hair loss during chemotherapy. Epworth are now offering the revolutionary system to patients thanks to generous contributions from donors through the Epworth Medical Foundation. Hair loss is a major concern for breast cancer patients facing treatment, the thought of losing their hair is a very frightening one. The ability to control this is not only a big step for the industry but for patient comfort too. Scalp cooling has been available for over 40 years, older versions using crushed ice or frozen gel caps. The previous caps sometimes resulted in temperatures of -25 degrees, causing unbearable patient discomfort. Only through the recent advances technology with Paxman system has it been effective and comfortable for patients. It is widely available in the UK and Europe, today there are currently machines installed in over 1800 centres worldwide. A UK observational study reported an 89% success rate after using the Paxman system, with only 11% having severe hair loss requiring a wig or head covering. The Paxman Hair Loss Prevention System uses a ‘scalp cooling’ method or ‘cold cap treatment’ system. The Paxman system is a small refrigerated unit which is plugged in next to the patient during chemotherapy treatment. The machine pumps a liquid coolant through a light silicone cap that is attached to the cooling machine, therefore extracting heat from the scalp. The cap is worn before, during and after chemotherapy has been administered, depending on the patients type of treatment this could take up to 2-3 hours. The scalps reduced temperature causes vasoconstriction of blood vessels in the area, therefore reducing blood flow to the scalp and hair follicles while the drugs are circulating in the body, minimising the damage to the follicles. A mild discomfort is often felt by patients on first contact but the system otherwise has no side effects and does not interfere with treatment in any way.
The highly-specialised and dedicated multidisciplinary team at MBU provide a diagnostic, treatment and support service for women (and men) with breast concerns. Working in conjunction with Breast Imaging Victoria, a private radiology service, breast surgeons Dr Suzanne Neil and Dr Su-Wen Loh provide a comprehensive (inpatient and outpatient) breast care service. Complementing the team is medical oncologist Dr Yen Tran , radiation oncologist Dr Andrew See , together with experienced breast care nurses, radiologists, pathologists and psychologists. The Clinic is uniquely designed to ensure that all necessary diagnostic procedures can be performed onsite, in one convenient, comfortable and private location. Most patients will have results of their assessments and a treatment plan before they leave the Clinic. The team at MBU provide a comfortable and professional environment for patients and are committed to ensuring a positive and stress-free experience. They are able to provide a wide array of information including DVDs; connections to support services; answer questions; and refer to other medical professionals, as appropriate. Our goal is to provide a world-class breast care service and to guide our patients appropriately. Our priority is patient wellbeing.
