Brachytherapy for Breast Cancer Follow Up

Back in 2007, when I was diagnosed and treated for my breast cancer, I heard about this new technique for the radiation portion of treatment, brachytherapy. I was jealous. It was not offered at my hospital. The big thing I liked was that it took so much less time for treatment.

Breast cancer treatment takes a LONG time. I was diagnosed at the end of May, after two surgeries that went into July, I finished chemo in December, and needed one more surgery (don't ask). I was then facing 7 weeks of radiation. I just wanted to be done. Since brachytherapy wasn't available I had the standard radiation treatment. I couldn't even have the shorter radiation protocol where you go twice a day for a week (blanking on the name).

Now, I was reading another article discussing breast biopsies in follow up breast cancer treatment. Buried in the article is this statement:

"They looked at 41,510 breast cancer patients in MarketScan (the national database of patients with private insurance, age 64 years and younger), and 80,369 breast cancer patients in SEER-Medicare (patients age 65 years and older). All had Stage I - III disease and were diagnosed between 2000 and 2011. Diagnosis and procedural codes were used to identify biopsy rates during follow up.

Five- and 10-year overall incidence of breast biopsy was 14.7 percent and 23.4 percent, respectively, in the MarketScan cohort, and 11.8 percent and 14.9 percent, respectively, in the SEER-Medicare cohort. Adjuvant chemotherapy use, patient age, and endocrine therapy were independently associated with biopsy in both cohorts.

Of note, say the researchers, the five-year incidence of breast biopsy was higher in women treated with brachytherapy, compared to those treated with whole-breast radiation: 16.7 percent in the MarketScan cohort and 15.1 in the SEER-Medicare cohort..."

The study does note that women can become very anxious after breast cancer treatment but does not offer a reason why the biopsy rate is higher after brachytherapy. But says they are still actively recruiting patients. 

Shorter radiation is better

Sometimes editing takes out all the important information. This took  a lot of digging to find out what the hell it was talking about.

I first came across this article which says higher dose shorter radiation is better that the traditional radiation given to breast cancer patients. This makes sense because the damage from radiation is cumulative meaning that it gets worse and worse after each treatment. Other side effects such as fatigue are also lessened from the shorter course of treatment.

Well that is nice to know but how much shorter is it? I couldn't tell but did go find the referenced article, Differences in the Acute Toxic Effects of Breast Radiotherapy by Fractionation Schedule: Comparative Analysis of Physician-Assessed and Patient-Reported Outcomes in a Large Multicenter Cohort, on JAMA Oncology. You got that?

How's this instead?

"Randomized trials have established that hypofractionated regimens of radiotherapy to the whole breast can provide long-term disease control that is equivalent to the excellent outcomes of more protracted conventional fractionation schedules in selected patients undergoing lumpectomy for breast cancer. Hypofractionation might also result in lower rates of late toxic effects than conventional fractionation. Although the American Society for Radiation Oncology has issued consensus guidelines to identify patients in whom hypofractionation is appropriate and endorsed consideration of hypofractionation in its Choosing Wisely campaign, uptake of hypofractionated regimens has demonstrated considerable variability worldwide and has been relatively slow within the United States."

Okay, what if I tell you this:

"Traditionally, women undergoing lumpectomy for breast cancer were treated with 5-6 weeks of daily radiation after surgery. "Hypofractionated" regimens are shorter courses of radiation, in which a slightly larger dose of radiation is given per day, allowing radiation to be delivered in a shorter period of time, most commonly in 3-4 weeks."

Finally, I get to the truth and find that 2 weeks less, slightly higher dose radiation offers fewer side effects? Why couldn't they say that first?

Not a practical option

Earlier this week, or maybe it was last week, I saw several articles on this new intraoperative radiation for breast cancer. This is when a radioactive probe is inserted into the breast during surgery and allows the patient to skip traditional radiation. Of course, they may still need chemotherapy and other treatments.

The first articles I saw touted its benefits. I was a bit pessimistic about this. I have heard about it and think it is approved in the US (but I am no doctor so don't think I know all about this). It is only for certain early stage breast cancers so it is not for everyone.

The reason for this hype is that it was just approved in the UK's NHS. And then I just saw this article about a UK doctor's thoughts on this:

"The treatment, given approval for NHS use in draft guidance by the National Institute for Health and Clinical Excellence, would benefit up to 36,000 people nationwide.

The technique, called intra-operative radiation, is suitable only for patients who have caught their cancer early..."

"...The initial price of the treatment is expensive, with each probe costing £500,000.

The procedure is performed during surgery.

Once the tumour is removed, a probe is inserted into the breast and delivers radiation to the site of the cancer for about half an hour."

That is when I fell off my chair. Am I understanding this correctly? Each probe costs  £500,000. Clearly it must mean the entire big instrument. Not just an individual probe. But I can't tell for sure based on how the article is written.

If its £500,000 for a single treatment, that is crazy. And if the machine costs £500,000, that's just damn expensive. Not a practical option in my opinion.

I used to be jealous

Back in 2007 when I had radiation for my breast cancer. I had to undergo the traditional radiation treatment which meant 37 visits spread over 7 weeks - five days a week that lasted FOREVER. I knew people online who were getting the short version and getting radiation for five days - brachytherapy - with two visits a day. I was jealous because I was (and still am) sick of going to the (damn) hospital.

I had asked at the time and was told by my radiation oncologist that they did not offer the shorter option nor did most hospitals in Boston at that time. A few years later I attended a conference where I learned they were starting to offer the shorter option as well as expanding their other services.

Now new research on women over sixty who had brachytherapy after a lumpectomy are more likely to have a mastectomy five years later. They were more likely to have treatment complications that resulted in the mastectomies.

ASTRO is considering new guidelines for who would most benefit from brachytherapy and cautionary and unsuitable criteria. The number one criteria seems to be that it is best for women over sixty.

Since I do not fit their criteria I am glad I did not get brachytherapy as it could have increased risk for mastectomy. I am not jealous any more.

In the category of 'now they tell us'

Today's New England Journal of Medicine announces that women who are treated with radiation for breast cancer run a higher risk of ischemic heart disease. They claim that's okay because they got rid of the cancer so we shouldn't mind a little heart disease.

But I digress. The heart damage shows up five years after treatment and the risk continues for  more than twenty years.

Clearly in the category of what doesn't kill us makes us stronger.

New doesn't always mean better

Back in 2007 when I was diagnosed with breast cancer, all the patient boards were talking about this new kind of radiation called 'Mammosite' or brachytherapy. The advantage to it was you went twice a day for one week as opposed to once a day for 8 weeks. I asked my radiation oncologist and she said it was not yet available where I was treated. I was a tiny bit disappointed but figured I could suck it up and cope with daily visits for near 8 weeks. (The biggest pain about radiation treatment is having to go EVERY day for weeks.)

A few years later, I went to a cancer treatment conference at the same hospital and they said they were just beginning to offer this mammosite radiation to selected patients and explained the procedure how beads were inserted during surgery, etc. I felt a faint tinge of regret that I hadn't had the newer treatment type. It was newer so it must be better? Right?

Wrong. Now after it has been used for five years and on more than 50,000 women a clearer picture is emerging..

1. The outcome for patients is not necessarily better for women who have mammosite radiation than regular full breast radiation.
2. There is a much higher rate of side effects with mammosite radiation - 35% vs. 18% for regular radiation.
3. Mammosite radiation costs twice as much as traditional radiation.

Hmmm.... So newer isn't necessarily better. This doesn't mean that mammosite shouldn't be an option and maybe teh shorter treatment period will benefit some women. I think I'm happy with the course of treatment I had.

Often times there are treatment advances and cancer patients look back with regret 'why couldn't that treatment hve been available when I was being treated?' Not this time. No regrets for me.

News flash - cancer treatment can cause long term side effects

Who knew? The poisons of chemotherapy, radiation, and surgery could have long term effects on a cancer person's body and health.

A growing population of cancer survivors faces an increased risk of radiation-related second malignancy and cardiovascular disease (CVD) for which little evidence-based clinical guidance has emerged, researchers found.

Gee whiz. I never would have thought what can cure me might kill me too. Any medical treatment you receive where either the nurses have to wear special gowns to handle the drugs before they are injected in your body or the technician has to leave the room you are stuck in during the zapping. No dangers there.

I had RAI treatment in 1981 where I was given radioactive iodine to dissolve the rest of my thyroid tissue. Now the standard is that you go into isolation for a few days so you don't contaminate others. Not me, I was out in the real world as radiation isotopes decayed inside me emitting my own little radiation waves.

I know people who have had chemo and then were diagnosed with leukemia or lymphoma. I know one person who was treated with radiation to the chest for Hodgkins and decades later died of breast cancer which she was told was a known long term side effect of her previous diagnosis.

Well we can worry about it all we want, along with the R-word, as we go from doctor to doctor hoping nothing new shows up.

Its nice to know I am not alone

Back in the dark ages of the late 1970's through the early 1980's, there were approximately 10,000 cases of thyroid cancer annually in the US. More cases are in women than men and it did occur in teenagers as well as older adults. It included me in 1981. Its an isolating disease. I felt alone.

Then in 1984 I had a benign breast tumor. Then in May 2007 I had breast cancer. Then in December 2007, I had another benign breast tumor. Now it turns out, there are lots of people out there like me.

Finally there has been a study about people like me - 'Childhood Cancer Survivors At High Risk for Multiple Tumors as They Age'.

The Childhood Cancer Survivor study "was launched in 1994 to identify the challenges facing childhood cancer survivors and to develop new methods to ease or prevent late effects." Raising hand, 'yoo hoo - me too, me too!!!'. The study found that "1,382, or 9.6 percent, of survivors developed new tumors unrelated to their original cancers. About 30 percent of those survivors, 386 individuals, developed third tumors. Four or more tumors were found in 153 survivors in this study."

First they defined childhood cancers as age 20 and under. I was 19. They followed over 14,000 people who had had a childhood cancer, 70 percent had received radiation which has shown to increase the risk of later cancers. I did not have radiation but I did receive radioactive iodine. The study states "Female survivors whose childhood cancer treatment included radiation were among those at highest risk for later tumors, particularly breast tumors."

Additionally, "Risks were also associated with benign tumors. Investigators showed survivors whose second tumor was a non-melanoma skin cancer had a 1 in 5 chance of being diagnosed with another, more aggressive cancer within 15 years. The group included 485 survivors with either basal or squamous cell skin cancers. "These survivors are candidates for additional genetic evaluation to look for an underlying genetic propensity for tumor development or an inability to protect healthy cells against the harmful effects of radiation," Armstrong said."

Even though this focuses on skin cancers I find it interesting they want to have further studies on the high propensity for tumor growth.

I am not a medical person at all - just a patient (and because of my medical (mis)adventures, I can ace all the medical related Jeopardy categories). But I do find some comfort in the fact that there are more of us around. We need to have annual conferences with big parties to talk about life with cancer. Research oncologists could listen to us and learn more.

I am getting ahead of myself here but my point (and I need to have a point) is that more research is needed for this growing population on the results of the long term effects of cancer treatments, radiation in particular. What doesn't kill us, makes us stronger... but it may be our undoing in the end.

Radiation and thyroid cancer

With the disaster in Japan, people are desperately trying to find potassium iodine tablets to prevent thyroid cancer. Thyroid cancer patients are often told it is the 'good cancer'. I'm not kidding - we just want to slap those people.

But if you are going to get a cancer, thyroid cancer has a relatively good prognosis. Most thyroid cancers, except anaplastic which is always staged at IV due to its aggressiveness, are relatively slow growing. However once diagnosed it requires a lifetime of vigilance to ensure no recurrence as they have been known to occur as long as 45 years later.

I have been watching the news where in Japan there are dosing people with potassium iodine to prevent thyroid cancer. And the news in the US where there is a run on potassium iodine as well. Should I be concerned if thyroid cancer is the biggest risk? I know extreme exposure to radiation results in radiation sickness followed by organs dying off and then death of the patient. But if I already have had thyroid cancer and don't have a thyroid, is it a big deal? Since I don't have a thyroid would radiation go quicker to other organs? I don't know but I do know I don't need potassium iodine tablets. I'll go stock up on toilet paper instead.

3D vs. 2D

The FDA, has joined its cohorts in a few other parts of the world - Asia, Europe, South America (a small portion)- and approved 3D mammograms. Well, sometimes the FDA has a bit of a reputation as being slow. But in reading the fine print, in return for double the radiation that you receive in a 2D mammogram, you can increase the chance of finding a malignant tumor by 7%. I had to read both brief articles to find out all this.

Double vs. 7%, 3D vs. 2D. This is sort of like the dilemma between a CT scan and an Xray. A CT is basically a 3D xray where they scan you in slices and can put it all together essentially in a flip book and see your insides. But that gives a lot more radiation.

Here's a quote: An abdominal CT gives 20 times the radiation of a mammogram which gives 20 times the radiation of a mammogram. Doing that math an abdominal CT gives 400 times the radiation of a mammogram. There have been cases of cancer caused by the radiation from CT scans.

But I digress. The point is that the FDA was a little slow. But perhaps rightly slow here. Is double the radiation worth it for a 7% increase? Well, at this point, I would ask for one. Maybe not for the average woman. They say they are helpful for women with dense breasts but maybe I think what about high risk women.

If you are high risk and they think they might possibly see something, they send you back for a second set of exams. Twice the radiation. Maybe 3D is better. I'll ask about them at my next mammogram...