Decreasing Toxicities of Radiation Therapy for Breast Cancer Patients

Transcript

00:00 --> 00:02Funding for Yale Cancer Answers is
00:02 --> 00:04provided by Smilow Cancer Hospital.
00:06 --> 00:08Welcome to Yale Cancer Answers with
00:08 --> 00:10your host doctor Anees Chagpar.
00:10 --> 00:12Yale Cancer Answers features the
00:12 --> 00:15latest information on cancer care by
00:15 --> 00:16welcoming oncologists and specialists
00:16 --> 00:18who are on the forefront of the
00:18 --> 00:20battle to fight cancer. This week,
00:20 --> 00:22it's a conversation about radiation
00:22 --> 00:24therapy for breast cancer patients
00:24 --> 00:26with Doctor Meena Moran.
00:26 --> 00:28Doctor Moran is a professor of
00:28 --> 00:29therapeutic radiology at the
00:29 --> 00:30Yale School of Medicine,
00:30 --> 00:32where Doctor Chagpar is a
00:32 --> 00:34professor of surgical oncology.
00:36 --> 00:37Maybe you can start off
00:37 --> 00:39by telling us a little bit about
00:39 --> 00:41yourself and what it is you do?
00:41 --> 00:43I wear many hats.
00:43 --> 00:45But first and foremost I identify
00:45 --> 00:48myself as a radiation oncologist who
00:48 --> 00:50takes care of breast cancer patients.
00:50 --> 00:54And then I hold a lot of different
00:54 --> 00:57administrative and roles on committees
00:57 --> 01:01and and organizations that basically
01:01 --> 01:06are organizing standards and policies.
01:06 --> 01:09For breast care across the country,
01:09 --> 01:12so let's start with what I think
01:12 --> 01:14is oftentimes a confusing issue
01:14 --> 01:17for many people, and that is what's
01:17 --> 01:20the difference between radiology
01:20 --> 01:23like a radiologist and therapeutic
01:23 --> 01:26radiology or radiation oncologist.
01:26 --> 01:27I find that sometimes people
01:27 --> 01:29get those two terms confused.
01:29 --> 01:31Can you help to help us to
01:31 --> 01:33understand the differences?
01:33 --> 01:35Sure, that's an excellent question,
01:35 --> 01:37actually, and it is true that.
01:37 --> 01:40Even my patients will say radiology
01:40 --> 01:42oncologists or variations of that.
01:42 --> 01:47So a radiologist is someone who
01:47 --> 01:50does diagnostic imaging and that
01:50 --> 01:52can include mammograms, Mris,
01:52 --> 01:56CAT scans, PET CT's bone scans,
01:56 --> 01:57that kind of thing.
01:57 --> 02:00A radiation oncologist is actually
02:00 --> 02:04someone who delivers high energy
02:04 --> 02:06X rays which are radiation,
02:06 --> 02:08but they're at a much.
02:08 --> 02:12Higher level of radiation than
02:12 --> 02:14with the the diagnostic levels of
02:14 --> 02:17X rays and and what we do is we
02:17 --> 02:19use that for therapeutic purposes
02:19 --> 02:21and treat primarily cancer but
02:21 --> 02:24also some benign diseases as well.
02:24 --> 02:27So the other question that I want to
02:27 --> 02:29kind of get off the table right at
02:29 --> 02:33the outset is many patients also are
02:33 --> 02:36confused about the differences between
02:36 --> 02:38radiation and chemotherapy often.
02:38 --> 02:40Thinking that these are the same,
02:40 --> 02:43can you clarify the differences between
02:43 --> 02:46the two and maybe a little bit about how
02:46 --> 02:49they're different in terms of first of all,
02:49 --> 02:52what the objective of the modality is,
02:52 --> 02:55and 2nd the side effects that each of them
02:55 --> 03:00carry? Sure, so chemotherapy.
03:00 --> 03:03Or systemic therapy, generally speaking,
03:03 --> 03:06is when when something is administered
03:06 --> 03:10either by mouth or through the vein and
03:10 --> 03:12actually goes throughout your whole body,
03:12 --> 03:14your whole system.
03:14 --> 03:16And that's why it's called systemic
03:16 --> 03:18chemotherapy or systemic therapy.
03:18 --> 03:20It also includes the broader
03:20 --> 03:22umbrella of these targeted agents
03:23 --> 03:25and and endocrine therapy as well.
03:25 --> 03:28All of them have the ability of of
03:28 --> 03:31circulating throughout your bloodstream.
03:31 --> 03:36And affecting any cells that might be
03:36 --> 03:39anywhere where blood transverses in the body,
03:39 --> 03:41which is pretty much you
03:41 --> 03:42know throughout the body.
03:42 --> 03:45Radiation, on the other hand is a very
03:45 --> 03:49focused high energy X ray beam and the
03:49 --> 03:52purpose of the radiation is really just to,
03:52 --> 03:56uh, primarily eradicate or to kill
03:56 --> 04:01off any microscopic or macroscopic.
04:01 --> 04:03Disease in the area where the
04:03 --> 04:04beam is targeted.
04:04 --> 04:06So, for example,
04:06 --> 04:08for breast radiation after,
04:08 --> 04:09for example,
04:09 --> 04:11when someone has a lumpectomy or
04:11 --> 04:13breast conserving surgery and their
04:13 --> 04:15primary tumor in the breast is removed,
04:15 --> 04:18we will target the whole breast
04:18 --> 04:23area so that the radiation can
04:23 --> 04:25eradicate any microscopic cells that
04:25 --> 04:28might be left behind after surgery.
04:28 --> 04:31And that has been shown to diminish the.
04:31 --> 04:33The chances of the cancer coming
04:33 --> 04:35back within the breast.
04:36 --> 04:39So so that leads us to this whole for a
04:39 --> 04:41of of the discussion that we'll have in
04:41 --> 04:44terms of radiation oncology as it plays
04:44 --> 04:46a role in breast cancer.
04:46 --> 04:49So one of the areas in which
04:49 --> 04:51radiation plays prominently in the
04:51 --> 04:53treatment of breast cancer patients
04:53 --> 04:55is after lumpectomy or breast
04:55 --> 04:57conserving surgery as you mentioned.
04:57 --> 04:59And I find that another question that
04:59 --> 05:02often comes up for patients, is this.
05:02 --> 05:04Why do I need radiation?
05:04 --> 05:06If the surgeon already removed
05:06 --> 05:09the cancer and got a nice clean
05:09 --> 05:12rim of tissue all the way around,
05:12 --> 05:13isn't the cancer gone?
05:13 --> 05:15Why would I need radiation
05:15 --> 05:17to presumably normal tissue?
05:17 --> 05:19Yeah, that's that's a very,
05:19 --> 05:21very good question that patients do
05:21 --> 05:25ask a lot, and so it's not intuitive.
05:25 --> 05:28But despite the fact that the primary
05:28 --> 05:32tumor has been removed with a 3
05:32 --> 05:35dimensional circumference of normal
05:35 --> 05:38unaffected breast tissue as well.
05:38 --> 05:42What we know from looking at mastectomy
05:42 --> 05:45specimens from patients years ago that
05:45 --> 05:47have passed away of breast cancer.
05:47 --> 05:50Is that the primary tumor?
05:50 --> 05:53Has little tiny microscopic tentacles of
05:53 --> 05:57disease that can extend as far as 3/4
05:57 --> 06:00centimeters away from the primary tumor.
06:00 --> 06:03So despite the fact that the surgeon
06:03 --> 06:05is removing the primary tumor
06:05 --> 06:07with a margin there,
06:07 --> 06:11there is a high chance of having
06:11 --> 06:14microscopic disease in about 30 to
06:14 --> 06:1740% of all breast cancer patients,
06:17 --> 06:19and that's what the radiation.
06:19 --> 06:20Is actually targeting.
06:20 --> 06:23Which then brings up the question.
06:23 --> 06:27Well, if there are these tentacles of
06:27 --> 06:29disease or the possibility of microscopic
06:29 --> 06:32disease in the rest of the breast,
06:32 --> 06:33wouldn't I just be better
06:33 --> 06:35off to have a mastectomy?
06:35 --> 06:38I mean, how can it be that breast conserving,
06:39 --> 06:41surgery and mastectomy are
06:41 --> 06:45equivalent in terms of survival?
06:45 --> 06:48When there still is potential
06:48 --> 06:50for disease, right?
06:50 --> 06:52So, uhm, so they've done.
06:54 --> 06:57You know several large randomized
06:57 --> 07:01studies where they've taken women
07:01 --> 07:03with breast cancer with early stage
07:03 --> 07:05breast cancer and randomize them
07:05 --> 07:08to either a lumpectomy or breast,
07:08 --> 07:11conserving surgery or lumpectomy,
07:11 --> 07:15plus radiation versus mastectomy. And.
07:15 --> 07:18What you consistently see throughout
07:18 --> 07:21all of these studies is that the
07:21 --> 07:24survival outcomes are the same,
07:24 --> 07:26but that when you do the lumpectomy alone,
07:26 --> 07:30that the risk of the cancer coming
07:30 --> 07:34back is significantly greater, so.
07:34 --> 07:37Whether you choose to do a mastectomy
07:37 --> 07:39or breast conservation really is
07:39 --> 07:42just it is a personal choice and
07:42 --> 07:44it's up to the individual patient,
07:44 --> 07:46but a lot of women think it's
07:46 --> 07:48better to do a mastectomy,
07:48 --> 07:50and that's just not the case.
07:50 --> 07:52Outcomes ultimately are are the
07:52 --> 07:55same in terms of of survival,
07:55 --> 07:57and the issue for an individual
07:57 --> 07:59patient would be do.
07:59 --> 08:01I want to conserve my breast.
08:01 --> 08:03Do I want to keep my breast
08:03 --> 08:05doing a mastectomy is a much.
08:05 --> 08:07Larger surgery there's the issue of
08:07 --> 08:10asymmetry and and then thinking about,
08:10 --> 08:12you know,
08:12 --> 08:14reconstruction and contralateral
08:14 --> 08:15prophylactic mastectomy.
08:16 --> 08:17So there's a lot of additional
08:17 --> 08:19issues that need to be thought
08:19 --> 08:21about in the mastectomy realm,
08:21 --> 08:23and I think that that's something
08:23 --> 08:25that patients struggle with,
08:25 --> 08:28especially when they're in given a
08:28 --> 08:30new diagnosis of a breast cancer.
08:30 --> 08:32So I think it's just important
08:32 --> 08:33that patients know that the
08:33 --> 08:35ultimate survival rates.
08:35 --> 08:38Are the same whether you have the
08:38 --> 08:40entire breast removed or whether
08:40 --> 08:43you have the tumor removed and then
08:43 --> 08:45received the radiation to the breast.
08:45 --> 08:48The difference being that if you just
08:48 --> 08:50remove the tumor and don't do radiation,
08:50 --> 08:52then your risk of it coming
08:52 --> 08:53back in the breast is higher,
08:54 --> 08:57which then leads us to OK.
08:57 --> 09:00So tell me about the radiation.
09:00 --> 09:02How how is it delivered?
09:02 --> 09:03How much is it?
09:03 --> 09:05How often do I have to
09:05 --> 09:06come for the treatments?
09:06 --> 09:08How long are the treatments?
09:08 --> 09:09And what are the side effects?
09:09 --> 09:12So oftentimes people will ask,
09:12 --> 09:13you know, will my hair fall out?
09:13 --> 09:15Will I get sick?
09:15 --> 09:17What about all of those questions?
09:17 --> 09:17Sure,
09:17 --> 09:19sure. So uhm again,
09:19 --> 09:21radiation is a high energy X ray beam.
09:21 --> 09:23Not only do we use it in the
09:23 --> 09:24breast conservation setting,
09:24 --> 09:26but we also use it after
09:26 --> 09:28mastectomy in higher risk patients.
09:28 --> 09:32For example those that have involved lymph
09:32 --> 09:35nodes to eradicate microscopic disease.
09:35 --> 09:38It you know along the chest
09:38 --> 09:40wall and in the nodal regions.
09:40 --> 09:43So what it does is it affects
09:43 --> 09:46the rapidly dividing cells or the
09:46 --> 09:49DNA of rapidly dividing cells,
09:49 --> 09:50and that's what cancer cells are.
09:50 --> 09:52They're they're rapidly dividing,
09:52 --> 09:55and so it has the ability to affect the
09:55 --> 09:58cancer cells more than it does normal tissue,
09:58 --> 10:00and that and that's how it works.
10:00 --> 10:02I like to tell patients that it's
10:02 --> 10:04kind of like taking a jackhammer,
10:04 --> 10:07opening up a perfect looking car,
10:07 --> 10:10and just basically, you know.
10:10 --> 10:12Kind of trashing it and the engine
10:12 --> 10:14and you know you wouldn't notice and
10:14 --> 10:17then if you close close the the the
10:17 --> 10:19engine up you wouldn't necessarily
10:19 --> 10:21know that there's an issue with the
10:21 --> 10:24car until you try to turn it on.
10:24 --> 10:25And that's basically what happens
10:25 --> 10:26with the radiation.
10:26 --> 10:29It affects the DNA of the cancer cells
10:29 --> 10:32more than it does the normal cells,
10:32 --> 10:35and so if the cells try to reproduce
10:35 --> 10:38at any point down the road you realize
10:38 --> 10:40the engine is damaged and they're not.
10:40 --> 10:42Able to do that,
10:42 --> 10:43and that's how the radiation decreases
10:43 --> 10:46the chance of the cancer coming back.
10:47 --> 10:49So just to clarify, are you saying that
10:49 --> 10:51if a patient gets radiation therapy,
10:51 --> 10:54they can never get a recurrence?
10:54 --> 10:56Well, there's always. There are always
10:56 --> 10:58ways in which you know.
11:01 --> 11:03It's never 100% in terms
11:03 --> 11:05of how efficacious it is,
11:05 --> 11:08but it but it it does diminish the
11:08 --> 11:10recurrence rate significantly.
11:10 --> 11:12And and particularly these days
11:12 --> 11:16with the use of additional agents
11:16 --> 11:18such as endocrine therapy and
11:18 --> 11:20some patients that are getting
11:20 --> 11:21hormone getting chemotherapy,
11:21 --> 11:24we see that the that the recurrence
11:24 --> 11:26rates are in the single digits,
11:26 --> 11:28so it's it's pretty low.
11:29 --> 11:32So tell us about what there's.
11:32 --> 11:34There's always a price to pay in
11:34 --> 11:35terms of getting any benefit,
11:35 --> 11:37and I think all of us know that
11:37 --> 11:39just in terms of not just medicine,
11:39 --> 11:41but but life in general.
11:41 --> 11:44So tell us about the side effects
11:44 --> 11:46of radiation. How often do you
11:46 --> 11:47need to get these treatments?
11:47 --> 11:50How many treatments are there?
11:50 --> 11:53Is it painful? Do I lose my hair?
11:53 --> 11:55Do I get sick?
11:55 --> 11:56What can I expect?
11:57 --> 11:59Sure, so as far as.
11:59 --> 12:02The way radiation is delivered,
12:02 --> 12:04it's delivered on a daily basis.
12:04 --> 12:05It's fractionated,
12:05 --> 12:08so it's delivered on a daily basis
12:08 --> 12:11over a period of time and the the
12:11 --> 12:13biology behind that is that it
12:13 --> 12:15allows the normal tissue cells
12:15 --> 12:17to recover and the cancer cells
12:17 --> 12:19don't have the ability to recover,
12:19 --> 12:24so it's given over a period of days or weeks.
12:24 --> 12:26Now, typically in the breast
12:26 --> 12:27conservation setting it's given
12:27 --> 12:29over 5 weeks to the whole breast,
12:29 --> 12:31and then sometimes we deliver.
12:31 --> 12:33A what we call a boost a smaller
12:33 --> 12:38area to where the lump was removed.
12:38 --> 12:38Nowadays,
12:38 --> 12:42with the newer studies that are
12:42 --> 12:46being done in in an effort to try to
12:46 --> 12:49reduce treatment burden on patients,
12:49 --> 12:52we are actually shortening that and they're.
12:52 --> 12:54They're ongoing investigations to
12:54 --> 12:57shorten that course of radiation
12:57 --> 13:00from 5 to 6 1/2 weeks down to,
13:00 --> 13:01you know,
13:01 --> 13:03anywhere from 2 to 3-4 weeks
13:03 --> 13:06and and also down to one week
13:06 --> 13:07depending on the patient.
13:07 --> 13:09So you have to qualify for it.
13:09 --> 13:11But but there is some promising data that
13:11 --> 13:14we can even do it in as short as one week.
13:14 --> 13:16So as far as side effects,
13:16 --> 13:18generally the side effects are
13:18 --> 13:20related to where we're targeting.
13:20 --> 13:23So for the breast or the chest wall,
13:23 --> 13:25it's primarily just that
13:25 --> 13:27localized area and they will have.
13:27 --> 13:30Patients will have most commonly
13:30 --> 13:31fatigue and skin reaction,
13:31 --> 13:33and the skin reaction is kind
13:33 --> 13:36of like a sunburn as turn as as
13:36 --> 13:37far as long term side effects.
13:37 --> 13:41Again, it's related to where the beam.
13:41 --> 13:42Actually intersects with the
13:42 --> 13:44body in the normal tissue,
13:44 --> 13:45and so,
13:45 --> 13:48besides having chronic changes in
13:48 --> 13:51the skin or scar tissue there are,
13:51 --> 13:54there is a small chance that they can
13:54 --> 13:57have problems with their wound there.
13:57 --> 13:59There's a small chance of having
13:59 --> 14:01a lung issues.
14:01 --> 14:04Most commonly it's something
14:04 --> 14:05called pneumonitis,
14:05 --> 14:08where the lung can get a little
14:08 --> 14:10inflamed just in the area where
14:10 --> 14:13that portion of Lung sees radiation,
14:13 --> 14:15not life threatening,
14:15 --> 14:17usually treated with a short
14:17 --> 14:18course of steroids,
14:18 --> 14:22often asymptomatic and then the heart.
14:22 --> 14:24Obviously for left sided patients
14:24 --> 14:26in particular is sometimes
14:26 --> 14:28in the path of the beam,
14:28 --> 14:31and so we have to be very careful
14:31 --> 14:33to make sure that we minimize the
14:33 --> 14:35radiation dose to the heart and
14:35 --> 14:37we have techniques to do that,
14:37 --> 14:40and so the long term heart issues.
14:40 --> 14:42Have significantly diminished
14:42 --> 14:43over the last several decades.
14:44 --> 14:46Alright, well we're gonna pick up
14:46 --> 14:48this conversation right after we take
14:48 --> 14:50a short break for a medical minute.
14:50 --> 14:52Please stay tuned to learn more about
14:52 --> 14:53radiation therapy for breast cancer
14:53 --> 14:55with my guest doctor Meena Moran.
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16:15 --> 16:17Welcome back to Yale Cancer Answers.
16:17 --> 16:18This is doctor Anees Chagpar
16:18 --> 16:20and I'm joined tonight
16:20 --> 16:22by my guest doctor Meena Moran.
16:22 --> 16:23We're talking about radiation
16:23 --> 16:25therapy for breast cancer patients
16:25 --> 16:28and right before the break Meena,
16:28 --> 16:30you had mentioned some of the side
16:30 --> 16:32effects that people can get with
16:32 --> 16:36radiation in terms of skin toxicities.
16:36 --> 16:37A little bit of dryness,
16:37 --> 16:40a little bit of redness, it might
16:40 --> 16:43interfere with the wound a little bit.
16:43 --> 16:46You had mentioned things.
16:46 --> 16:49Like pneumonitis, and avoiding the heart,
16:49 --> 16:52some of those sound not so bad.
16:52 --> 16:55Some of those sound a little scary.
16:55 --> 16:59Tell us about how you as
16:59 --> 17:01radiation oncologists try to
17:01 --> 17:02minimize those side effects,
17:02 --> 17:04particularly in terms of
17:04 --> 17:06avoiding the the lung in
17:06 --> 17:07the heart and so on.
17:07 --> 17:10Sure, so we've actually come
17:10 --> 17:14a really long way in terms of.
17:14 --> 17:16Minimizing the amount of heart and
17:16 --> 17:18lung in the field years ago when
17:18 --> 17:20when patients were treated it was
17:20 --> 17:22just a tangential beam that kind of
17:22 --> 17:23skimmed the chest wall encompassed
17:23 --> 17:25the whole breast or the chest wall
17:25 --> 17:27and and whatever was underneath
17:27 --> 17:29was inevitably in the beam.
17:29 --> 17:33Now we have the ability to.
17:33 --> 17:35Actually plan and modulate the
17:35 --> 17:38beam so that it is tailored for
17:38 --> 17:40each individual patient's body.
17:40 --> 17:43So what we do is we get a CAT scan
17:43 --> 17:45at the time of treatment planning
17:45 --> 17:47and we call that a treatment
17:47 --> 17:48planning CAT scan and the whole
17:48 --> 17:50process is called a simulation.
17:50 --> 17:52We have the patient come in,
17:52 --> 17:54we kind of outline the areas that
17:54 --> 17:56we we want to cover and the patient
17:56 --> 17:58will put their arms up on the table,
17:58 --> 18:00which will be exactly how they'll
18:00 --> 18:01be in the treatment position,
18:01 --> 18:03will put them through the scanner.
18:03 --> 18:06And then we use that scan,
18:06 --> 18:08which is not a diagnostic scan,
18:08 --> 18:11but is is purely just for treatment planning.
18:11 --> 18:11Well,
18:11 --> 18:15actually outline the the breast tissue
18:15 --> 18:19or the chest wall and the lymph nodes.
18:19 --> 18:23Every incremental 3 millimeter slice
18:23 --> 18:28in order to then change the the.
18:28 --> 18:30Way the beam actually intersects with
18:30 --> 18:33normal tissue so that we're blocking
18:33 --> 18:35as much normal tissue as possible,
18:35 --> 18:37so that's one thing that has
18:37 --> 18:38been a major advancement for us.
18:38 --> 18:40Is 3 dimensional treatment planning
18:40 --> 18:43and the use of beam modulation.
18:43 --> 18:45The second thing is that we use deep
18:45 --> 18:47inspiration breath hold technique,
18:47 --> 18:49which is a very,
18:49 --> 18:52very precise way of for us to have
18:52 --> 18:54the patient take a deep breath
18:54 --> 18:57when you take a deep breath.
18:57 --> 18:59What happens is that your chest.
18:59 --> 19:01Ball moves away from your heart and
19:01 --> 19:03that creates a space between the
19:03 --> 19:06heart and the chest wall and allows us
19:06 --> 19:08to get those tangential beams to go
19:08 --> 19:11through and minimize the dose to the heart.
19:11 --> 19:15The machine only turns on when the
19:15 --> 19:17patient is in that breath hold position,
19:17 --> 19:21and there are multiple multiple
19:21 --> 19:24lasers on the patient's skin 3
19:24 --> 19:26dimensionally that monitor exactly
19:26 --> 19:29when that patient is in the precise.
19:29 --> 19:31Breath hold position which has to
19:31 --> 19:34be within a 3 millimeters of of the
19:34 --> 19:37position they were in at the time
19:37 --> 19:40of the CT scan so it takes longer
19:40 --> 19:42to deliver that treatment because
19:42 --> 19:43the patient can only hold their
19:43 --> 19:45breath for 20 seconds at a time
19:45 --> 19:47and then they take a break and then
19:47 --> 19:48they hold their breath again,
19:48 --> 19:51but it ensures that the that the
19:51 --> 19:53radiation is delivered in such a
19:53 --> 19:56way that that the heart is away
19:56 --> 19:58from the chest wall and then we
19:58 --> 19:59have other techniques also.
19:59 --> 20:01That we've been using,
20:01 --> 20:04such as cardiac blocks and prone positioning.
20:04 --> 20:08Those are other kind of technical
20:08 --> 20:10tricks that we've used to also
20:10 --> 20:13minimize the amount of heart dose
20:13 --> 20:16and the good news from all of
20:16 --> 20:19that is that based on our data,
20:19 --> 20:21the the progress that we've made from
20:21 --> 20:23a technical standpoint in minimizing
20:23 --> 20:26the amount of heart and lung in
20:26 --> 20:28the field has really benefited in
20:28 --> 20:30decreasing the cardiac toxicity.
20:30 --> 20:32In the long toxicity that breast cancer
20:32 --> 20:34patients experience in the long term,
20:34 --> 20:37so that is data that is, you know,
20:37 --> 20:39a well known and has been established
20:40 --> 20:41so mean a.
20:41 --> 20:43I mean that really sounds incredible.
20:43 --> 20:46And for people who are listening,
20:46 --> 20:49it may sound really technologically
20:49 --> 20:51quite advanced in terms of how
20:51 --> 20:54you can plan this and have lasers
20:54 --> 20:56that identify precise landmarks
20:56 --> 20:58on a patient within 3 millimeters
20:58 --> 21:00and delivered the dose precisely.
21:00 --> 21:03One question that people who may be
21:03 --> 21:05listening may be asking themselves
21:05 --> 21:07is is that widely available?
21:07 --> 21:09I, I can't say that it's.
21:10 --> 21:14Available at small remote centers that are,
21:14 --> 21:16you know, private, necessarily.
21:16 --> 21:19I think most academic centers have it,
21:19 --> 21:22and especially now that so many
21:22 --> 21:23institutions are requiring smaller
21:23 --> 21:25hospitals and smaller practices.
21:25 --> 21:27It's being standardized so
21:27 --> 21:29that it it is recommended,
21:29 --> 21:33for example by the NCCN as a
21:33 --> 21:36method to strongly consider for
21:36 --> 21:37decreasing the cardiac dose.
21:37 --> 21:39So I think it it is becoming
21:39 --> 21:40more and more prevalent.
21:40 --> 21:43OK, so patients should ask their radiation
21:43 --> 21:45oncologist wherever they're being treated.
21:45 --> 21:48Whether these techniques are available
21:48 --> 21:49to them is that right? Sure,
21:50 --> 21:52so the other question that I have
21:52 --> 21:56for you is before the break you were
21:56 --> 21:59mentioning that the dosage of radiation,
21:59 --> 22:02how it's delivered, how long that
22:02 --> 22:05treatment is has really morphed overtime,
22:05 --> 22:08and what used to be 5 and a half six weeks
22:08 --> 22:12can now be as little as. Even one week,
22:12 --> 22:14so a couple of questions on that.
22:14 --> 22:17First of all, can you tell us a little bit
22:17 --> 22:19more about the different the different
22:19 --> 22:22treatment plans in terms of the one week
22:22 --> 22:24versus three weeks versus six weeks?
22:24 --> 22:25Are these equivalent,
22:25 --> 22:28and are there specific patients who
22:28 --> 22:30benefit more from one or the other?
22:30 --> 22:32I mean, because patients might
22:32 --> 22:34be listening to this thinking.
22:34 --> 22:36Why on Earth wouldn't anybody
22:36 --> 22:37just do one week?
22:37 --> 22:42If it was as good as six weeks so?
22:42 --> 22:44So as I mentioned earlier,
22:44 --> 22:46the standard you know for the breast
22:46 --> 22:49conservation trials and for the post
22:49 --> 22:51mastectomy trials was five weeks to
22:51 --> 22:53the whole breast or to the chest wall,
22:53 --> 22:55followed by a boost plus or minus
22:55 --> 22:58a boost to the localized area and
22:58 --> 23:04subsequent to that there have now been.
23:04 --> 23:06More than four randomized trials
23:06 --> 23:09that have looked at using what we
23:09 --> 23:11call hypofractionated radiation,
23:11 --> 23:15which means giving a larger daily dose.
23:15 --> 23:18So it then shortens the amount of
23:18 --> 23:20time the total dose is actually lower,
23:20 --> 23:22but because you're delivering
23:22 --> 23:23a higher daily dose,
23:23 --> 23:26you're able to shorten the
23:26 --> 23:28overall treatment duration,
23:28 --> 23:31and that those studies all looked
23:31 --> 23:33at three weeks and have found.
23:33 --> 23:35Now we have long term data,
23:35 --> 23:38showing that three weeks is just as
23:38 --> 23:42efficacious as the five weeks in terms
23:42 --> 23:45not just of breast cancer control and.
23:45 --> 23:47The ability to eradicate
23:47 --> 23:49those microscopic cells,
23:49 --> 23:50but also more,
23:50 --> 23:53just as importantly in terms of the toxicity,
23:53 --> 23:55because the major concern is always
23:55 --> 23:57been the toxicity of the treatment.
23:57 --> 23:59We don't want to do harm to the
23:59 --> 23:59normal tissue.
23:59 --> 24:01And if we're giving a higher daily dose,
24:01 --> 24:04are we?
24:04 --> 24:06Going to damage the normal tissue
24:06 --> 24:08to the point where we're not there.
24:08 --> 24:10It's not going to be able to recover,
24:10 --> 24:12and so these studies have shown
24:12 --> 24:15us that we can deliver the dose
24:15 --> 24:17in three weeks very safely.
24:17 --> 24:20Now the in terms of the the
24:20 --> 24:21slightly faster regimens,
24:21 --> 24:23and they're ironically called the
24:23 --> 24:26faster the Fast forward regimens.
24:26 --> 24:27There are two of them,
24:27 --> 24:30one of them is 5 fractions that is
24:30 --> 24:32delivered once a week for five weeks,
24:32 --> 24:34and then the other one is 5 fractions.
24:34 --> 24:37Delivered every day for one
24:37 --> 24:40week and those also look very,
24:40 --> 24:41very promising.
24:41 --> 24:45We are using them at Yale and
24:45 --> 24:47other institutions and places
24:47 --> 24:50are also using them as well,
24:50 --> 24:51particularly with COVID and
24:51 --> 24:53wanting to minimize the number of
24:53 --> 24:55times that patient has to come in
24:55 --> 24:57and out of a medical facility.
24:57 --> 25:00But the the one week regimen
25:00 --> 25:02only has five year data,
25:02 --> 25:04and so that's one of the limitations.
25:04 --> 25:05The other thing.
25:05 --> 25:08As you asked about was was,
25:08 --> 25:10why wouldn't every patient quality,
25:10 --> 25:11you know want to do this?
25:11 --> 25:12If they qualified?
25:12 --> 25:12Well, look.
25:12 --> 25:14The issue is that they have to qualify,
25:14 --> 25:17and so because the daily
25:17 --> 25:19dose is so much higher,
25:19 --> 25:21we have to do it safely.
25:21 --> 25:24And there are pretty stringent dose
25:24 --> 25:26constraints that we have to follow for
25:26 --> 25:29the normal tissue in terms of the lung,
25:29 --> 25:29the heart,
25:29 --> 25:31the chest wall,
25:31 --> 25:33all those things end up,
25:33 --> 25:34particularly in the setting of
25:34 --> 25:36postmastectomy or when there's
25:36 --> 25:38nodes involved those patients.
25:38 --> 25:40Don't qualify because those studies didn't
25:40 --> 25:43really include a lot of those patients,
25:43 --> 25:45so right now it's primarily for whole breast,
25:45 --> 25:48but if you qualify, there's really
25:48 --> 25:52no reason to not consider it as,
25:52 --> 25:54as you know, an alternative.
25:54 --> 25:55But again,
25:55 --> 25:56the data,
25:56 --> 25:59the amount of data that we have is is,
25:59 --> 26:00you know,
26:00 --> 26:04less robust than we do for the traditional
26:04 --> 26:05three weeks or the five
26:05 --> 26:07week regimens that we have.
26:07 --> 26:10So let me just. To make sure that
26:10 --> 26:11I understand this correctly,
26:11 --> 26:14we have long term data that the three
26:14 --> 26:16weeks is equivalent to six weeks.
26:16 --> 26:19So is it safe to say that essentially
26:19 --> 26:21everybody should be treated now
26:21 --> 26:23with the three week regimen as
26:23 --> 26:26opposed to the six weeks? So
26:26 --> 26:28that that's that's excellent question,
26:28 --> 26:32because yes, in terms of breast
26:32 --> 26:36conservation in terms of the mastectomy,
26:36 --> 26:39they can be treated with the three week.
26:39 --> 26:41Course, the issue being that if
26:41 --> 26:45they're going to have reconstruction,
26:45 --> 26:46there's very little data,
26:46 --> 26:48and there's ongoing studies now
26:48 --> 26:51looking at how these higher daily
26:51 --> 26:52fractions and hypofractionated
26:52 --> 26:54radiation effects reconstruction,
26:54 --> 26:56so that's a big question mark,
26:56 --> 26:58and that's why it hasn't become the standard
26:58 --> 27:01of care in the postmastectomy setting.
27:01 --> 27:02The other area where we
27:02 --> 27:03don't have a lot of data,
27:03 --> 27:05but I think you know enough that
27:05 --> 27:08if the situation calls for it,
27:08 --> 27:10we would do the three weeks.
27:10 --> 27:13Is is when we're including regional nodes,
27:13 --> 27:14so that's just a discussion with
27:14 --> 27:16between the patient and the doctor.
27:16 --> 27:17It's not the standard,
27:17 --> 27:20it can be done it it is
27:20 --> 27:21likely to be very safe,
27:21 --> 27:23but there there's a lot of
27:23 --> 27:25variation in the practice for that,
27:25 --> 27:26if that makes sense.
27:26 --> 27:28OK, so essentially,
27:28 --> 27:30if you're a patient and you had
27:31 --> 27:33lumpectomy and you are no negative.
27:33 --> 27:35You should be doing three weeks
27:35 --> 27:37of radiation instead of six weeks.
27:37 --> 27:37Is that fair?
27:38 --> 27:40Yes, absolutely. And then
27:40 --> 27:41followed by a boost absolutely
27:42 --> 27:45and so and the one week we don't
27:45 --> 27:47have sufficient long term data.
27:47 --> 27:50So are people being treated with the one
27:50 --> 27:53week regimen as part of standard of care,
27:53 --> 27:55or are there still clinical trials
27:55 --> 27:56ongoing that patient should be
27:56 --> 27:58asking their doctor about if they
27:58 --> 28:00want to participate in that one
28:00 --> 28:04week regimen so very quickly.
28:04 --> 28:06The NCCN has said it can be considered
28:06 --> 28:09as a modality for treatment.
28:09 --> 28:12Right now it really we're using it
28:12 --> 28:14selectively in patients who really
28:14 --> 28:16need to have it done in one week more
28:16 --> 28:19often than we're using the once a week
28:19 --> 28:23for five weeks with just just as easy,
28:23 --> 28:25because that has 10 year data.
28:25 --> 28:27So I think that they're both going to
28:27 --> 28:29ultimately show to be very promising,
28:29 --> 28:31but it's just about waiting for
28:31 --> 28:32that data to mature a little bit.
28:33 --> 28:35Doctor Meena Moran is professor
28:35 --> 28:36of therapeutic radiology at
28:36 --> 28:38the Yale School of Medicine.
28:38 --> 28:40If you have questions,
28:40 --> 28:42the address is canceranswers@yale.edu
28:42 --> 28:45and past editions of the program
28:45 --> 28:48are available in audio and written
28:48 --> 28:49form at yalecancercenter.org.
28:49 --> 28:51We hope you'll join us next week to
28:51 --> 28:53learn more about the fight against
28:53 --> 28:55cancer here on Connecticut Public radio
28:55 --> 28:57funding for Yale Cancer Answers is
28:57 --> 29:00provided by Smilow Cancer Hospital.

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January 16, 2022

Yale Cancer Center

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