Mary Wilde, M.D., a breast surgical oncologist at the Scripps Clinic in San Diego, California, explains how the EIORT is a precise way to radiate tumors in breast cancer, and how that reduces time spent in radiation for the patients.
Interview conducted by Ivanhoe Broadcast News in March 2017.
Dr. Wilde: It is just incredible. In the olden days, to treat breast cancer there was only surgery to be offered. They would do a modified radical mastectomy or even a radical mastectomy, which is removing the entire breast and some of the chest wall muscle and all of the lymph nodes under the arm. That worked very well, but it was a dramatic type of treatment, so then surgeons decided, gosh, maybe we can remove less of the breast. Surgeons started removing just the tumor itself; that didn’t work quite as well because those cancers tended to grow back. Rather than going back to the olden days, the addition of radiation therapy where the whole breast was radiated came about, and that worked very well. It kept the reoccurrence rate very low, it allowed the woman to keep the healthy part of her breast, and it wasn’t as disfiguring as a mastectomy. Now we have moved on from that. We original removed the whole breast, then we removed the cancer and radiated the whole breast, and now we can remove the cancer, and radiate just that vulnerable part of the breast and that is where the IORT (Intraoperative Radiation Therapy) comes in. It is just an incredible advance for these patients. At the time of surgery, we remove the cancer, so that is called a lumpectomy or partial mastectomy, and then we put a protective shield behind the tissue that is being radiated. Then Dr. Shimizu and his colleagues come into the OR and place the cone into where the cancer used to be. He then radiates right in that area, and only in that area. The radiation is very precise. It doesn’t scatter to other parts of the breast or body. It is stopped behind the tissue that needs to be radiated by that protective shield. It is really a very precise way to radiate the area that could still have some tumor cells there. It is obviously very convenient for the patient because the patient comes in, she has her lumpectomy, she has her radiation, she goes home that afternoon, and she has had all of her treatment for the local part of her breast cancer. Some of those patients still take pills for a few years afterwards, but the treatment for the breast cancer in the breast itself is done. Rather than coming back for several weeks after the surgery to have radiation, they are completely done that day and it is really a wonderful convenience for these patients. It is not only for convenience that we think this is an excellent treatment modality. It is also a more precise way to radiate the tissue that is at risk to have cancer grow back. It is a convenience for the patient and it is really in the end less expensive for the healthcare system overall. It is a wonderful sort of blend of advantages.
Is it just for lumpectomy or is it for the mastectomy as well?
Dr. Wilde: The patients who are treated with radiation in the operating room are not patients who are having mastectomies; it is just for patients who are having partial mastectomies, which are also called lumpectomies. There are patients who are not good candidates for this treatment. It is a select group of patients to whom we can offer this treatment. But those patients are very, very well served by this new technology. They generally have smaller tumors, the patients need to be fifty years old or older, and there are certain tumor types that are not suitable for this kind of treatment. But many, many tumor types are and this has been a real advantage for those patients.
What would not be DCIS, triple negative?
Dr. Wilde: Patients who have invasive lobular carcinoma we do not treat in this fashion.
What have the women been saying?
Dr. Wilde: The patients are thrilled. First of all, sometimes the patients think there is going to be some pain associated with radiation. It is completely painless, it is done while they are asleep while having their surgery. They wake up, they go home, and they are done with their treatment. The feeling of relief, you see it on their faces in the recovery room; it is just remarkable. When they come in with breast cancer and they go home, and they do not have breast cancer; it is just almost miraculous. It is really wonderful.
If these patients are not going to go on to chemotherapy, is it just surgery radiation and they are done.
Dr. Wilde: These patients will generally not be having chemotherapy. Some of them will take an endocrine agent, meaning tamoxifen or an aromatase inhibitor, to reduce the risk of other cancers in the breast. The surgery and radiation just treats the cancer that is currently present. But these patients generally would not be having chemotherapy.
Do you know roughly, how many patients who have come through this and how long have you been doing this here?
Dr. Wilde: We have been doing this since December 2014. We did our first case on December 9, 2014 and we have done about eighty cases since then. The program is just growing so quickly. Dr. Shimizu and I started the program, and Dr.Koka and Dr. Olson, two other Scripps physicians, have now joined us and are very active in the program also.
Is this something that has taken off across the country?
Dr. Wilde: Yes, it has, and there are places across the country that has been doing it for substantially longer than we have. Part of the requirement of getting this program going is getting a linear accelerator that gives the radiation in the operating room, and that is a very expensive piece of equipment, about one and a half million dollars. We had to raise the money to get that equipment and we were happy to do that and to offer this technology to people in San Diego County, but there are no other locations in San Diego County that are offering this technology at this time.
Do you see the program as expanding to women with maybe mastectomy or bigger tumors?
Dr. Wilde: I think patients with larger tumors may eventually be able to be treated this way, as we collect more data about the outcomes for this. I think it will expand in its utility. I do not think patients with mastectomies will be treated this way because generally if patients who have had a mastectomy require radiation, it is a larger field of radiation that they are receiving. But certainly, I think that additional histology or tumor types may be included in this treatment and patients in the younger age group maybe eventually be included as well.
Is there anything else I have not asked you that you think is important to get across.
Dr. Wilde: It is very important to acknowledge the philanthropic community we work with. Scripps is very fortunate to have generous donors to these kinds of programs, and it is a wonderful thing when the community and the patient, and the physician all come together and offer these kinds of advance treatments for the patients. Everyone wins, so it has been very exciting to be a part of this. Scripps has been just unrelentingly supportive of this effort and that is not always the case with other hospital systems. Hospitals and hospital systems have a lot of calls on their time and their attention, and I really admire the administration of Scripps for supporting this because it has been clearly an advantage for these patients. One big advantage of this technique is that patients can have oncoplastic surgical closures. What that means is when you take a piece of the breast tissue out there is an empty space in the breast and in the past that is something that we really could not repair at the time of the surgery. There are some other older techniques where you can also radiate just part of the breast but they left an opening or a cavity there after the treatment that didn’t heal very well. One of the great things about IORT is, once the radiation is done, the radiation is done. The patients are not going to go back and have additional radiation, so at the time of that lumpectomy we surgeons can go in and do an oncoplastic closure, which means close that tissue so there is not that big empty space there, and cosmetically it is really very much nicer for the patients. They heal beautifully.
Because they would have this gap otherwise?
Dr. Wilde: Yes.
If they have radiation afterwards?
Dr. Wilde: If they have radiation afterwards, it is harder to make sure that that area is closed and heals nicely.
What about the piece that you are talking about underneath the radiation so it doesn’t spread? Does that come out or does it stay in?
Dr. Wilde: The shield that we put in to protect the tissue that is underneath where we are radiating is removed after the radiation. That is a disk of copper that goes in and stops those electrons right where they need to be stopped.
If a patient has this radiation afterwards is there another surgery to pull that out after or you do not use that?
Dr. Wilde: This intense radiation and it is very, very precise. It just goes right to the area that it needs to radiate, it does not go to the surrounding area, it does not go to the underneath area, and it does not radiate the skin which is very important. When patients have radiation after surgery, and I do want to acknowledge that radiation after surgery is still done and it is a very good technique for patients who need it, but in patients who can have IORT, the radiation doesn’t pass through the skin because in the operating room the skin is open and that protects the skin from radiation. The skin doesn’t get any damage from the radiation at all. It is just a beautiful closure and the patients come in two days after the surgery and sometimes you can barely see that they have had surgery and radiation, it is really just extraordinary. Dr. Shimizu and I recently treated our wonderful patient Judy Collins and she had bilateral breast cancer and had this treatment on both sides and I believe she was on the tennis court ten days later. No matter how many times I asked her, please hold off a little bit, she is just a go-getter and she really wanted to get back out there and it has just worked beautifully for her.
She is older, so you said there is a fifty-year-old lower limit is there an upper limit?
Dr. Wilde: There is not an upper limit that I would worry about. Judy is older but you would never know it. She is a very, very active person and part of the advantage of this technique is patients who have home responsibilities, who are taking care of children, who are taking care of parents, who have jobs outside the home, who have activities that they want to get back to, this really shortens the time that they are out of commission. For standard radiation we do the surgery and they heal up in about three to four weeks and then the patients start radiation and that can go from three weeks to six and a half to seven and a half weeks, every day. IORT keeps them from having to have that radiation after surgery and it is really wonderful. We have really given them back that period of time. We all know how busy people get these days and many of these women have so many other responsibilities and things that they want to get back to in their lives; it is a real advantage for them.
END OF INTERVIEW
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