Welcome again to the Breast Cancer Surgery Center of MD's informational series on breast cancer and breast health. We have attempted to provide you with the most up to date information to enable you to participate with your care provider in making sound decisions for prevention, diagnosis, and treatment. We have received favorable comments from so many of you, and we thank you for your readership. This issue's article deals with the role of radiation therapy in the treatment of breast cancer. In the past few years, the delivery of radiation has seen a revival in the technique of partial breast radiation and it has now become a popular option.

      When Dr. William Halsted, of the Johns Hopkins Hospital, first devised the operation of radical mastectomy, radiation was not available, and the tumors were generally greater than 5 cm in diameter. As medical care progressed through the 50's and 60's, modified radical mastectomy, which spared the muscles, became the "gold standard". The removal of the entire breast meant that radiation was not used except for recurrent or metastatic disease.

      The use of radiation to accompany and supplement surgery is called adjuvant radiation therapy. As the delivery of radiation became more precise and safe, it opened the door for breast conservation surgery (termed partial mastectomy, lumpectomy, or tylectomy). Mammography enabled breast cancers to be found at the less than 1 cm stage. For these patients, breast conservation surgery became the new standard of care. Whole breast radiation is required to enable the partial mastectomy patients to achieve the same low recurrence rate that a total mastectomy would have achieved.

      Whole breast radiation (external-beam radiation) is safe and effective. It affords the benefit of treating the entire breast and may play a role in preventing the development of a second cancer elsewhere in the breast. Several disadvantages are inherent in this technique. The first is that the treatments must be divided into approximately 30 daily doses requiring travel to and from the radiation center and five to six weeks before completion of treatment. Another is that the skin receives a greater dose of radiation than the tumor bed. Also, although great efforts are made to prevent radiating tissues near the breast (such as lungs, ribs, and heart) some radiation does affect these structures.

      Studies have shown that women who have a left breast cancer, rather than a right breast cancer, have a statistically higher risk of developing heart failure within the next 10 years after their radiation treatment. This is almost certainly due to slight damage to the heart caused by the external beam radiation therapy. Many women, especially those with larger breasts, develop significant changes in their skin due to radiation. This can range from a mild "sunburn" effect to nipple dryness and crusting, and a leathery feel to the skin.

      Mammosite catheter Women with small cancers, who did not need to have the axilla treated with radiation, may do well to treat only the breast tissue within 1 cm of the original tumor. This can be accomplished by placing the radiation source (a radium seed) inside the breast for a few minutes a day. This is termed partial breast radiation, since only a portion of the breast receives a significant dose. The skin receives less radiation than the tumor bed.

      A second advantage is that other, nearby organs are affected by the radiation to a significantly lesser degree. A third, but not inconsequential, benefit is that the radiation is completed with five days of treatment instead of the usual thirty. In Maryland, women generally have access to a number of centers from which to receive radiation treatment. Some patients, on the Eastern Shore and in the western part of the State, may need to travel 20 or 30 mi. to a center, but do not have the 100 mi. distances that some patients travel in the Midwest and Western states. This technique has become very popular in those areas where a hotel stay is required for the treatments. Five days is often feasible whereas 30 days may not be.

      Partial breast irradiation has been given for many years. The only technique available in the past, however, was to pass multiple (12-16) plastic or metal rods through the breast. Radium seeds were placed in the these tubes for varying lengths of time each day. The technological change which has revolutionized partial breast radiation is the development of a balloon catheter which is surgically placed into the lumpectomy cavity. The balloon is filled with a sterile fluid which conforms to the lumpectomy cavity and keeps the balloon in a constant position. In the center of the balloon is a dry sterile channel into which the radium seed is advanced.

      Twice a day, the catheter is connected to a computer-controlled machine, which delivers the radium seed into the center of the balloon for a precise period of time. Two treatments are able to be given each day, spaced six hours apart. In this way, 10 treatments are given in five days, and the radiation dose is completed. These treatments are painless and the presence of the catheter in the breast is well tolerated. Patients are given a special "sports bra" to hide the presence of the catheter which exits through a small incision in the breast. Antibiotics are given for as long as the balloon catheter remains in the breast. At the conclusion of the treatments, the balloon is deflated and the catheter is painlessly removed.

      The first company to provide such a catheter is Proxima Therapeutics, Inc. They have called their catheter MammoSiteŽ. Information about this catheter can be obtained at www.mammosite.com. We were among the first in the Country to provide this treatment alternative for our patients. The results of our treatments are kept in a "registry" for both the effectiveness and cosmetic results. Thus far, patients who have chosen this alternative have been very pleased with their decision and would recommend it highly to others.

      In our last installment of this series published in Women's I, we will discuss some of the features that distinguish the Breast Cancer Surgery Center of MD from other care providers who may not have the level of experience or interest that we have. This will include the role of our Breast Cancer Coordinator, our support group, the Genevieve Thomas Breast Cancer Library, our Treatment Plan NotebookŠ, and our Navigator Program, which pairs each newly diagnosed patient with a trained survivor who can guide this person through the first eight to ten weeks of important decision-making. We look forward to "seeing" you next month! Be on the lookout for our new website, BCSCofMD.net which should be up and running by March or April, 2006.