'Cutting Edge' in Local Breast Cancer Therapy
'Cutting Edge' in Local Breast Cancer Therapy
Dr. Miller: I want to take it to the other component of local therapy. At the same time, we have been doing less extensive surgery. We have been doing more radiation, particularly more radiation to the lymph node basins or more radiation after mastectomy.
I used to think of those as equivalent local therapies, at least equivalent with respect to benefits. They are different methods with different toxicities certainly, but equivalent benefits. I seem to have been wrong on that front as well. Why the shift to less of one and more of the other?
Dr. Dixon: With respect to comparing a straightforward mastectomy with a wide-look incision and radiation therapy, there is now increasing evidence that if the patient has a small cancer, you may be better off saving the breast.
Data are coming through on a number of fronts that suggest that outcomes are at least as good, or maybe better in many respects, for lumpectomy and radiation therapy compared with mastectomy. We used to believe that local recurrence rates were higher with lumpectomy. That doesn't appear to be the case anymore.
So, if you are comparing basic lumpectomy and radiation therapy with a mastectomy, then the outcomes are pretty much similar. You are right. Many patients are having mastectomy and then radiation.
The good news is -- and the people in the United Kingdom appreciate this -- we have a study, SUPREMO, which is a bit like the study we are presenting today on all patients. We are trying to avoid radiation therapy in that intermediate-risk group to try and determine which patients actually need radiation therapy after mastectomy. At the present time, we are doing less surgery, but they want to do more radiation therapy. That doesn't make sense.
Dr. Miller: At the same time, there is a camp in the radiation community focusing on doing less radiation, or at least less radiation to a lesser part of the breast with partial-breast radiation. It is an area of huge interest and equally huge controversy. Is that technique ready for prime time?
Dr. Dixon: I am not sure that it is ready for prime time because, first of all, we can't decide which is the best partial-breast radiation therapy technique. There are lots of different partial-breast radiation therapy techniques. They all have their problems. They all treat different amounts of tissue. We don't yet have the concept of how much you need to treat.
Which of the options should we adopt? I don't think we know at the present time. It is an exciting option for the future. But as yet, we don't really know what the best partial-breast radiation therapy technique is. We don't know what the long-term outcomes are, because many studies of partial-breast radiation therapy have shown problems with cosmetic outcomes. Some have shown that other complication rates are increased over those with straightforward whole-breast radiation therapy.
In a study in the United Kingdom, they are looking to give whole-breast radiation therapy in 5 sessions.
Dr. Miller: So, even shorter?
Dr. Dixon: Shorter durations of whole-breast radiation therapy, so what are the advantages of partial-breast radiation therapy when we can irradiate the whole breast in 5 days?
Dr. Miller: We will stay tuned, because that story is certainly not done.
Dr. Dixon: That is what I would conclude. We need to find out more before we know exactly what to do.
Radiation: More Questions Than Answers
Dr. Miller: I want to take it to the other component of local therapy. At the same time, we have been doing less extensive surgery. We have been doing more radiation, particularly more radiation to the lymph node basins or more radiation after mastectomy.
I used to think of those as equivalent local therapies, at least equivalent with respect to benefits. They are different methods with different toxicities certainly, but equivalent benefits. I seem to have been wrong on that front as well. Why the shift to less of one and more of the other?
Dr. Dixon: With respect to comparing a straightforward mastectomy with a wide-look incision and radiation therapy, there is now increasing evidence that if the patient has a small cancer, you may be better off saving the breast.
Data are coming through on a number of fronts that suggest that outcomes are at least as good, or maybe better in many respects, for lumpectomy and radiation therapy compared with mastectomy. We used to believe that local recurrence rates were higher with lumpectomy. That doesn't appear to be the case anymore.
So, if you are comparing basic lumpectomy and radiation therapy with a mastectomy, then the outcomes are pretty much similar. You are right. Many patients are having mastectomy and then radiation.
The good news is -- and the people in the United Kingdom appreciate this -- we have a study, SUPREMO, which is a bit like the study we are presenting today on all patients. We are trying to avoid radiation therapy in that intermediate-risk group to try and determine which patients actually need radiation therapy after mastectomy. At the present time, we are doing less surgery, but they want to do more radiation therapy. That doesn't make sense.
Dr. Miller: At the same time, there is a camp in the radiation community focusing on doing less radiation, or at least less radiation to a lesser part of the breast with partial-breast radiation. It is an area of huge interest and equally huge controversy. Is that technique ready for prime time?
Dr. Dixon: I am not sure that it is ready for prime time because, first of all, we can't decide which is the best partial-breast radiation therapy technique. There are lots of different partial-breast radiation therapy techniques. They all have their problems. They all treat different amounts of tissue. We don't yet have the concept of how much you need to treat.
Which of the options should we adopt? I don't think we know at the present time. It is an exciting option for the future. But as yet, we don't really know what the best partial-breast radiation therapy technique is. We don't know what the long-term outcomes are, because many studies of partial-breast radiation therapy have shown problems with cosmetic outcomes. Some have shown that other complication rates are increased over those with straightforward whole-breast radiation therapy.
In a study in the United Kingdom, they are looking to give whole-breast radiation therapy in 5 sessions.
Dr. Miller: So, even shorter?
Dr. Dixon: Shorter durations of whole-breast radiation therapy, so what are the advantages of partial-breast radiation therapy when we can irradiate the whole breast in 5 days?
Dr. Miller: We will stay tuned, because that story is certainly not done.
Dr. Dixon: That is what I would conclude. We need to find out more before we know exactly what to do.