An Overview of Radiation Therapy: Where we've been and Where we're going"
(Or what you have always wanted to know about radiation but were afraid to ask!)
Linda K. Wobeck, M.D.
Piedmont Hospital
Department of Radiation Oncology
1968 Peachtree Rd, N.W,
Atlanta, GA 30309
(404) 605-3319
Department of Radiation Oncology at Howell Mill
3200 Downwood Circle, suite 150
Atlanta, GA 30327
(404) 605-6090

Dr. Wobeck's Disclaimer- This presentation is specific for the hospital/radiation center where I work. This is only intended to be a guide. Each radiation center has their own routines, equipment and policies.

What is Radiation?
Why use Radiation?
When is Radiation used in Breast Cancer Treatment?
. . . Breast Conservation (after lumpectomy)
. . . . . Who are candidates?
. . . . . Why is this often favored?
. . . ....After Mastectomy
What is the process?
. . . Consultation with the Radiation Oncologist
. . . . . Review your history, pathology, perform physical examination
. . . . . Determine if radiation is/may be needed
. . . . . Discuss- "Overall risks/benefits/side effects, rationale and logistics"
. . . . . . . . . .When does Radiation Begin?
. . . . . . . . . . . . . After Surgery
. . . . . . . . . . . . . After Chemotherapy
. . . . . . . . . .How long does it last daily, total treatment?
. . . . . . . . . .Simulation - Planning Steps
. . . . . . . . . .Actual Treatment
. . . . . . . . . .What are the side effects (breast, chest wall or to reconstructed breast)?
. . . . . . . . . . . . . During treatment
. . . . . . . . . . . . . After treatment
. . . . . . . . . .What does the breast, chest wall, reconstructed area look like years after?
. . . . . . . . . . Is surgery possible (reconstruction post mastectomy) after radiation?
What is new in breast cancer radiation?
. . .**IMRT (intensity modulated radiation therapy)
. . . .Investigational - Brachytherapy

Quick Answers

What is Radiation? -"High energy X-rays" that are targeted to destroy cancer cells, often made in a large machine called a linear accelerator or in natural compounds (i.e. - "radiation seeds").

Why use Radiation? Targeted therapy, often referred to as local, that is aimed at the area you want to treat. Used in breast cancer to eliminate potential microscopic cancer cells in the remaining breast, chest wall or lymphatic areas.

When is Radiation used in Breast Cancer Treatment?
Breast Conservation
-Used after lumpectomy to prevent a recurrence in the breast tissue. In general radiation felt to reduce the risk of a local recurrence to ~ < 10%. Candidates include women whose tumors are < 4-5 cm, can be removed with a rim of normal breast tissue (negative surgical margins) and have an acceptable cosmetic appearance afterwards to the woman. Often favored, as the breast remains with less surgery with overall survival equal to mastectomy..
After Mastectomy
- Used in certain circumstances-ex- large tumor, multiple tumors, close surgical margins, positive LN (usually >3-4) to prevent the cancer from returning in the chest wall or nearby lymphatic areas.

What is the process?
Consultation with the Radiation Oncologist-
Can be anytime after a diagnosis is made. Helpful t o some patients before definitive surgery in making a decision for lumpectomy versus mastectomy. Can be after final surgery, before or after chemotherapy (if indicated).
. . . .
Review your history, pathology, do a physical examination
. . . . Determine if radiation is needed
. . . . Discussion- "Overall risks/benefits/side effects, rationale and logistics"-
. . . . Rationale- to decrease risk of recurrence in the breast, chest wall or lymph node . . . .areas.
. . . . Logistics:
. . . . When does Radiation Begin?
After surgical healing, -usually 3~6 weeks or ~3-6 weeks after chemotherapy is finished.

How long does it last daily, total treatment? Daily, the actual radiation only takes a few minutes. The patient is on the table in the radiation room for ~ 10- 15 minutes and in the center ~ 20-40 minutes. Treatments are Monday through Fridays. Total treatment time is usually ~ 6 -7.5 weeks. It all takes place in either Radiation Facility you choose (or in general any radiation facility).

What is treated during this time? During the first 5-5.5weeks all of the breast tissue, chest wall and nodal areas (if indicated) are treated. In the last 1-2 weeks a "boost" is given when the radiation is either directed to the area where the initial tumor was in the breast (tumor bed) or around the mastectomy scar, TRAM area.

Simulation - Planning Steps - 1-2 planning steps,
Step one:
Done at Piedmont Hospital in our department on our CAT Scan, takes ~ 30-40". A mold is made that your body lies in, arm is above your head, marks placed around your breast on the skin, wires placed on top of them on the skin. Cat Scan in this position. When scanning finished, one or two tattoos marks (very small ink dot under the skin- no horses or roses placed) when finished. These are permanent but are very small. They help guide the laser lights used in daily treatment for positioning and accuracy of the radiation. This is a very important step, after which the doctor contours in the breast tissues, heart, lungs from which the treatment plan is determined.
Step two
Return a few days later- often to our Howell Mill Facility- where the treatment fields are double checked, takes ~ 40".

Actual Treatment- Starts the next day or the following Monday- can be at either Piedmont or Howell Mill Facility- staff will do their best to find a time most convenient for you, much shorter time needed than planning steps! Once a week "port films"are taken which are X-ray films to verify correct positioning during treatment.

"Boost Planning"- Done towards the end of the first 5 - 5.5 weeks of daily radiation. For patients with intact breast, we use the CAT scan simulation again to target the area where the tumor was. Often a "tumor cavity" or surgical clips can be seen, as well as information form surgery, mammogram are used to identify the area.

What are the side effects (breast, chest wall or to reconstructed breast) irradiation?
During treatment-
Mild to moderate " reddening or tanning" of breast or chest wall (more skin effects than with the breast), mild breast fullness, chest wall tenderness, fatigue variable- many patients just feel more sluggish towards the end of their treatment (weeks 5-7) normal activities not limited, many patients able to work, rarely are blood counts decreased, no nausea, vomiting or hair loss!

After treatment- Most symptoms go away in first few months- year, but faint tanning may remain, mild firmness over years (expected to be less with IMRT-see below) Very rarely, late complication to lung, heart (listed in consents) Lymphedema very rare when breast alone is treated, slightly higher if lymph node areas (depends on extent) in treatment field.

What does the breast, chest wall, reconstructed area look like years afterwards? Often will look similar to what it did after surgery, with some mild firmness at the scar area due to surgical scarring and radiation "boost".

Is surgery possible (reconstruction) after radiation? Yes, recommend waiting 6-12 weeks to allow healing of skin after post mastectomy radiation.

What is new in breast cancer radiation???

**IMRT (intensity modulated radiation therapy)- Very exciting treatment technique where the radiation dose is made more even though out the breast ("less hot spots"- areas where breast and skin get more irritated because or higher dose in these areas) -This results in less radiation redness, darkening, peeling and better cosmetic appearance long-term (softer breast).

Investigational - Brachytherapy- Technique in which radiation seeds are put in a catheter and put in the surgical bed where the tumor was removed. Only a limited area of the breast is treated. Long term data not available, not approved yet by FDA, may be appropriate in the future for certain select patients.

Other questions???….

End of Dr. Wobeck's Presentation


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