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Brachytherapy as Effective as Whole-Breast Radiation Therapy

Carlson, Robert H.

doi: 10.1097/


A media teleconference hosted by the American Society of Breast Surgeons (ASBrS) in advance of the Annual Meeting featured a wide range of abstract presentations, chosen both for scientific importance and public interest. Topics included the successful use of brachytherapy and radiofrequency ablation to treat breast cancers, the failure of screening with thermography vs. mammography, data showing worse breast cancer outcomes for men than women, and the safety of lumpectomy in high-risk patients with the disease.

Short reports follow below, with commentary on each by the Chair of the Society's Communications Committee, Deanna J. Attai, MD, a breast surgeon in private practice at the Center for Breast Care in Burbank, California, and a member of the ASBrS Board of Directors, who predicted that some of the studies could have a significant impact on current clinical practice in breast cancer.



Brachytherapy was as effective as whole-breast radiation after breast-sparing surgery in a study using the Mammosite Brachytherapy partial breast radiation registry involving 1,440 patients treated over two years with the technique. At five years of follow-up, the study showed a 3.7 percent risk of local recurrence—1.1 percent at the tumor site and 2.6 percent elsewhere in the ipsilateral breast, reported the co-principal investigator, Peter D. Beitsch, MD, a breast surgeon at the Dallas Surgical Group.

He said that in six trials in the literature of whole breast radiation, recurrence at the tumor site ranged from about two to seven percent, and elsewhere in the ipsilateral breast from about two to four percent. Historically, 69 percent of recurrences after whole breast irradiation occurred in the tumor bed and 31 percent, elsewhere, vs. basically the opposite ratio in the Mammosite registry data of 28 percent in the tumor bed and 72 percent elsewhere in the ipsilateral beast.

“Accelerated partial breast irradiation with Mammosite balloon brachytherapy may control the tumor bed more effectively than whole breast irradiation,” he concluded.

Attai said that historically, local recurrence is higher than “elsewhere failures” — “In the study, not only was partial breast radiation as good as whole breast radiation in local control, but at the tumor site it seemed to be better than whole breast radiation. That's something new, it's a pretty big deal.”

She noted that other recent studies have been demonstrating safety problems, higher recurrence rates, and higher subsequent mastectomy rates with partial radiation, but that this study shows that with five years of follow-up, the risk of recurrence at the lumpectomy site is lower than if the patient underwent whole breast radiation.

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Thermography: No Useful Role in Breast Cancer Screening

Infrared thermography to detect breast cancer was often unable to distinguish between benign and malignant lesions in patients with suspicious imaging abnormalities, in a study from researchers at Winthrop Rockefeller Cancer Institute at the University of Arkansas for Medical Sciences.

The study of the NoTouch BreastScan (NTBS) showed that the scan's higher sensitivity mode (NTBS2) also gave an unacceptable number of false positives.

“Mammography remains the gold standard for predicting the presence of malignancy in patients with suspicious radiologic breast abnormalities,” said the study's lead author, Andrea Barrio, MD, a breast surgeon at Bryn Mawr Hospital in Pennsylvania. “Infrared thermography cannot be used as a successful adjunct to mammography nor can it replace any of the screening modalities in standard practice today.”

The hypothesis was that infrared thermography detects increased blood flow to the breast due to angiogenesis and so the technique could be useful with screening. The researchers—first author was Cara Marie Guilfoyle, MD, a breast fellow at Bryn Mawr Hospital—evaluated both the abnormal breast and the normal contralateral breasts of 178 patients undergoing biopsy for suspicious findings on mammography, ultrasound, or MRI.

Depending on the scanning mode (high specificity vs. high sensitivity), thermography missed 50 percent of all the tumors when compared with the pathology results on the abnormal breasts.

On normal breasts, the device had a false-positive rate of 47 percent.

Attai said, “It would have been nice if this study were able to show that thermography was reliable in terms of detecting breast cancer, since it's been around for so long, isn't invasive, and doesn't involve radiation, but it didn't show that.”

She said many patients in the U.S. are looking for alternatives to mammo-graphy, because it is not available in their area or they do not want the radiation. Thermography does have one advantage over mammography, in that it will show changes that might lead the clinician to feel the need to follow a certain area more closely over time, even if thermography did not indicate cancer or the need for biopsy.

Part of the problem with the study results, she said, may have been that the thermographies were showing abnormalities that were not malignant but that might develop into tumors over time.

The research group is now following the high-risk patients over a longer period.

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Radiofrequency Ablation Found Good Alternative to Postop External RT

Only recently have surgeons begun exploring radiofrequency ablation (RFA) as an alternative to external radiation therapy to extend the margins of the tumor bed. Now a study shows that RFA of the lumpectomy site during breast cancer surgery can be an effective alternative to postoperative external RT, reducing repeat surgeries to achieve clear tumor margins.

And it is at least as effective in preventing local tumor recurrence as external radiation therapy following surgery, said first author Misti H. Wilson, MD, a breast fellow and instructor in the Department of Surgery at the University of Arkansas. The study was a subset of 73 patients on the ABLATE (Radiofrequency Ablation after Breast Lumpectomy Added to Extend Intraoperative Margins) trial treated for invasive cancer with lumpectomy and intraoperative RFA, but not with chemotherapy or radiotherapy.

Wilson said that with a median followup of 55 months, 16 of 19 patients (84%) who had close or focally positive margins and were treated with RFA were spared re-excision. Only three of the 73 (4%) required a second surgery.

The study's senior author was ASBrS's President, V. Suzanne Klimberg, MD, Chair in Surgical Oncology and Professor of Surgery and Pathology and Director of the Breast Cancer Program at the Winthrop P. Rockefeller Institute, both at the University of Arkansas for Medical Sciences.

Attai said she considered it still too early to make any long-term conclusion about the safety of RFA and the risk of recurrence, but that at least in the short term, patients not only had a lower recurrence rate, but there was also a “lower rate of needing to take patients back for a positive margin. Positive margins are a big problems in this country—about 10 to 40 percent of the time women undergoing lumpectomy have to have additional tissue taken.

“Whether or not RFA can be a replacement for postoperative radiation or partial breast radiation—or even bump intraoperative radiation off the map—we don't know.”

For now, she said, she would not consider radiofrequency ablation to be a possible replacement for radiation, only that it is a new and promising technology: “We don't know where it will fit in but it's worth further study and evaluation. We will never have a one size fits all [treatment to prevent recurrence], and it's good to have alternatives.”

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Men Less Likely to Survive Breast Cancer

An analysis of the National Cancer Data Base found that overall survival for men with early-stage breast cancer lags considerably behind women with early-stage breast cancer.

The analysis identified 13,457 cases of male breast cancer and compared those with 1,440,000 females with breast cancer in the database.

Men presented with larger tumors of higher grade that are more likely to invade lymph nodes and metastasize, the study showed.

Male breast cancer cases totaled 0.9 percent of all breast cancers reported, said first author Jon M. Grief, DO, a breast surgeon at the Alta Bates Summit Medical Center in Oakland, California. In this study of male breast cancer, which the authors said was the largest ever, the five-year overall survival rate for males was 74 percent (median survival of 101 months), compared with 83 percent and 129 months for females.

Men were also:

  • diagnosed with larger tumors—20.0 mm vs. 15.0 mm for females
  • more likely to have lymph node metastases—41.9 vs. 33.2 percent
  • more likely to be both estrogen receptor positive—88.3 vs. 78.2 percent—and progesterone receptor positive—76.8 vs. 67 percent
  • more likely to have distant metastases—four vs. three percent
  • more likely to be African American—11.7 vs. 9.9 percent
  • less likely to be Hispanic—3.6 vs. 4.5 percent
  • less likely to have grade 1 tumors—16 vs. 20.7 percent
  • less likely to have lobular carcinoma—10 vs. 18 percent
  • less likely to have partial mastectomy—33 vs. 62 percent
  • less likely to receive radiation—35.9 vs. 50.4 percent
  • more likely to be older, with diagnosis at age 63 vs. 59 for females.

Grief said the researchers hoped that heightened awareness among men and their physicians for this disease may lead to earlier detection and improved outcomes.

Attai said the report brought up some interesting points, such as that most people underestimate the incidence of male breast cancer, which is one of every 100 new breast diagnoses—“Even though we all know breast cancer happens in men, everybody just says it's rare, but one in 100 is not insignificant,” she said.

She speculated that survival for men was lower because men were diagnosed at a later stage. “No one is advocating men doing annual mammograms, but men need to do breast self-exams, as women do,” she said. “Nobody knows the appropriate frequency, but this study at least brings attention to that.”

“Another point was that even though the majority of men with breast cancer are ER-positive, many are not treated with tamoxifen. It's possible they weren't offered hormonal therapy, and also possible that if they were, they turned it down because of the expected side effects.”

She said that where appropriate, primary care physicians conducting a routine exam may do a chest wall palpation just as they listen to the heart and lung.

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Lumpectomy Possible in High-Risk, Locally Advanced Breast Cancer

The biology of a high-risk breast tumor dictates whether aggressive treatments are necessary after surgery, and not the choice of mastectomy versus lumpectomy, say researchers in the prospective I-SPY 1 trial.

The implication is that women with high-risk locally advanced cancers can be treated safely with lumpectomy, since the recurrence is more likely to develop away from the tumor bed.

First author Elizabeth L. Cureton, MD, a breast surgeon and oncology fellow at the University of California, San Francisco, said that typically, woman with biologically aggressive tumors receive neoadjuvant therapy. “But then they go on to mastectomy and whole breast radiation, even if the tumor shrinks to the point where they would qualify for lumpectomy.”

The four-year study of 206 women, classified with high-risk disease because of tumor size, node-status, and genetic markers included 90 patients treated with lumpectomy and 116 with mastectomy. At almost four years of follow-up, the study showed that among women in the lumpectomy group, of whom 78 of the 90 women (87%) received radiation, the local recurrence rate was seven percent, and the distant recurrence rate was 18 percent.

In the mastectomy group, in which 92 of the 206 women (79%) received radiation, the local recurrence rate was seven percent, and the distant recurrence rate was 25 percent. Among all 206 patients, 170 (83%) of whom received radiation, the local recurrence rate was seven percent, and the distant recurrence rate was 22 percent. And the five-year survival rate was 79 percent for patients undergoing lumpectomy and 72 percent for those having mastectomy.

“If radiation is indicated, breast conservation should be attempted as it has less complications and is safe in this high-risk population,” Cureton concluded.

Attai said these researchers showed that in women with biologically aggressive cancers, if the tumor responds to the chemotherapy, “you don't have to go full-out, all-aggressive surgery because they are not as much at risk for local recurrence, though they are at risk for systemic recurrence or metastatic disease because of the biology of the cancer.

“This says that no matter what you do to the breast, these women are more at risk for metastatic disease, and mastectomy is not going to improve survival and will decrease their quality of life—so do what you have to do, but nothing more.” Similarly, she said, post-mastectomy radiation would not be necessary if the biggest risk is metastatic disease.

© 2012 Lippincott Williams & Wilkins, Inc.
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