Elisa Port, MD, FACS, Chief of Breast Surgery at The Mount Sinai Medical Center, NY talks about improvements to internal radiation for women with breast cancer.
Interview conducted by Ivanhoe Broadcast News in July 2019.
I want to start by asking you, the internal radiation for women with breast cancer, how new is this for them to have this option?
PORT: The procedure is actually not terribly new. What I feel is that it’s been perfected over the years. Remember the big impetus for offering this kind of radiation is that given the inconvenience of five days a week for six weeks which was the standard regimen – still is for many people – and was the only option for many years made it really logistically impossible for a lot of people, given their geographic locations, to have a lumpectomy if the radiation was sort of a package deal. And so that led a lot of people who are innovators to think, is there a way that we could deliver radiation that allowed for people who lived in more rural areas, two hours, three hours from a radiation center who couldn’t travel back and forth every day in any realistic way? It’s been done for a while, it’s just that over the years the devices to deliver the radiation have been perfected and refined. And I think we’re now giving it at a much higher level. The aesthetics are much better. And what we’re able to offer today is markedly improved.
Talk to me a little bit about how this would work?
PORT: Sure. The first thing to remember is that not all patients are eligible for this kind of radiation. The typical way that this happens is that most patients with newly-diagnosed breast cancer, their first stop along the way once they’re diagnosed is the surgeon. And it’s really the surgeon whose job it is to identify treatment. We’re sort of the gatekeepers to the rest of the potential downstream treatments. And our job is really to identify candidates who may be appropriate for this type of treatment based on criteria for inclusion, exclusion, who the best candidates are. Once we’ve identified those candidates as you can imagine we’re giving the intraoperative radiation therapy in a very targeted way so we don’t want to include people who have a higher likelihood of having microscopic areas of cancer in other parts of their breast. We may not want to give it to some of our very younger patients who are at higher risk of recurring over their lifetime. There are certain subtypes of cancer that are more aggressive that may not be appropriate for this kind of targeted radiation. So it’s really our job to pick which of the patients are sort of the best suited and have the best chance of a great outcome.
Can you walk me through the surgery?
PORT: Sure. I think the really wonderful part is really the lumpectomy part of the surgery happens pretty much the same way that we would do it in someone who is not getting intraoperative radiation treatment. We’re always very conscious whether someone’s getting intraoperative radiation therapy or not regarding the aesthetics, the incision placement, et cetera, the thickness of the skin overlying the area. So it’s really the same attention to detail in someone who is getting the intraoperative radiation therapy that we’ve always paid. But once the tumor and its surrounding area, the margin, is out and in patients where we check lymph nodes, that’s done. There’s really sort of a cavity there almost like a little sphere, empty space. And what we do is in collaboration with our radiation oncologist there’s this little metal spherical ball on a stalk. There are different sizers and you select the appropriate size that really fits really nicely into that remaining cavity. So for someone who’s a larger breast and a larger cavity you want to use the larger globe so that there’s really like a hand in glove effect with the radiation deliverer and that it really fits kind of snugly to the surrounding tissue. So there’s nice approximation.
What is the benefit of having it? Why is it necessary to have that fit?
PORT: You don’t want there to be a space between where the radiation transmitter is and empty space and then the target where you want it to get to. You want it really to be right up one against the other so that you can give the maximal effective dose to the tissue at risk.
How long does the treatment take?
PORT: The treatment is actually customized – the length of the treatment is variable and based on a variety of different factors including the size of the cavity and the applicator. But it’s usually on the shorter side, 15 to 20 minutes, and on the longer side up to 30 to 40 minutes.
What’s the benefit for the patient?
PORT: The one thing to remember is that breast cancer recurrence is very, very low. So most women after lumpectomy the risk of recurrence is less than 5% and most women find that number to be acceptable. When it does recur it tends to recur primarily in the tissue immediately around where the cancer was and that makes sense. And so we’re giving a much higher dose to the area around where the cancer is and focusing on that area. And the main benefit is really logistic, the idea that again we live in New York City and everyone lives relatively close to a radiation center. But there are other challenges related to getting radiation whether it’s navigating work, the work process, and taking time out of your day either early or late in the day. We’ve had patients for example who are taking care of other individuals in their family and they’re the sole caregivers. So the idea that they don’t have to take out of time every day to drive to a radiation place, have the radiation and drive back which could be an hour or more, it has been a huge benefit. For sure, there are people who we find that based on the pathology after the surgery that the radiation that they had was not sufficient. And the benefit of the kind of IORT that we give is that you can always back it up with full breast radiation to follow as one normally would. The beauty of what we’re doing is we’re not burning any bridges and if we find out after surgery based on the results from surgery that the person’s tumor was more aggressive or they need more aggressive treatment, we can revert to that.
And you would not to do the intraoperative then again? You do standard radiation?
PORT: Correct. We would augment with standard external beam.
But having this does not preclude you.
PORT: Correct.
It doesn’t bar you from having additional treatments.
PORT: Correct. Remember most people who have standard radiation have external beam and then a boost to the area of the tumor. And so effectively what we’re doing is just sort of reversing that area and treating the IORT as the boost to the tumor bed. And that has worked very, very well in terms of understanding that process.
How long have you done that here at Mt. Sinai?
PORT: We have been doing the IORT here in this methodology with this protocol for about two years now.
What kind of success have you had, Dr. Port, even if it’s anecdotal?
PORT: I think that you can measure success in a variety of different ways. I think patient satisfaction has been immense. I think of course the ultimate measure of success is making sure that the treatment is as effective as standard in terms of reducing the risk of breast cancer coming back. And two years is too short of a time to know that it is 100% as effective. However IORT as I said with other devices has been done for quite a long time with devices that I feel are much less effective and also give much less desirable results. And those results have been very, very encouraging in long term effects of controlling cancer recurrence.
Is there anything then that I didn’t ask you that you would want to make sure people know?
PORT: What I think it’s important to know is for women diagnosed with breast cancer across this country there is no one size fits all anymore. The reason why the cure rate for breast cancer is so high in 2019 and women with breast cancer have every reason to be optimistic is because there are so many options. And we customize and tailor the treatment of breast cancer based on the individual, everything from age, to patient preference, to underlying medical conditions, to definitely the size shape extent of their tumor. And my biggest piece of advice for women who are newly diagnosed with breast cancer is to make sure they go to a specialized center and a high volume breast cancer center where they offer the whole spectrum of options based on a patient’s individual case. Not every woman is going to be eligible for IORT but a breast specialist, someone who does this kind of thing, will know for whom the procedure is safe and appropriate and so forth.
END OF INTERVIEW
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