Deanna Attai, M.D., F.A.C.S. of the Center for Breast Care, Inc. (Burbank, Calif.) discusses her perspective on successfully integrating breast brachytherapy into a surgical practice. She began offering APBI to patients in 2002 and was among the first in Southern California to use the SAVIT applicator.
From a surgeon’s perspective, what are the key elements of a successful APBI program?
Patient selection is probably the most important element. Surgeons need to identify patients who meet the appropriate criteria before they go into surgery. There are many aspects of treatment surgeons must plan prior to the lumpectomy, including coordination with the radiation oncologist, selecting the appropriate catheter and planning the cavity based on the chosen APBI device.
It’s incredibly important to collaborate with the radiation oncologist prior to beginning treatment. APBI should be a team approach in order to ensure better patient care, which means minimizing the interval of time between device insertion and commencing radiation treatment. In addition, it ensures that the surgeon has the full support of the radiation oncologist going forward- an essential element of a successful APBI program, particularly if surgeons rely on the radiation oncologist for HDR access.
A comfort with office-based procedures is necessary, as well. Ideally, surgeons will place the device post-operatively after final pathology is confirmed, meaning they must either employ ultrasound imaging, or have access to it. If a surgeon’s primary contact with patients typically occurs in the operation room, it will require time to adjust to office-based procedures before they can fully integrate APBI into their practice.
What is the most important information that surgeons should share with radiation oncologists?
It’s important to share the necessary clinical data, including pathology reports and imaging studies (if needed). Otherwise, the most important information to communicate is the timing of procedures. I contact the radiation oncologist’s office as soon as we schedule surgery and catheter placement so they can plan the patient’s consults, scans and radiation treatments within an appropriate amount of time. In fact, I require patients to see the radiation oncologist as soon as they choose APBI. Even if it’s just a day or two before surgery, it reinforces the team approach and ensures a coordinated effort throughout treatment.
What is some advice you would offer to surgeons looking to integrate APBI into their practices?
Most surgeons can easily incorporate APBI into their practice, particularly those who currently perform ultrasound-guided core biopsies. The patient flow between APBI and ultrasound-guided procedures is very similar, so those surgeons already have many of the important steps in place to successfully integrate APBI. Surgeons who don’t currently perform ultrasound procedures can ease the transition with careful planning and coordination prior to beginning the treatment process. If they select patients properly and collaborate with the radiation oncologist, the process will be very smooth. While there are some technical considerations in terms of selecting the appropriate device, it’s an easy procedure for surgeons to integrate into their practices.
In your opinion, how widely accepted is APBI among breast surgeons?
While many surgeons have embraced APBI, there are some who feel we don’t have the data to support the use of APBI in a clinical setting. This will change as we perform more cases and accrue more data, and as the data we already have matures.
I tell all my patients considering APBI that we don’t have 20-year data to support the procedure yet and that their options are limited to external beam radiation if they want a more proven treatment. I also tell them the results we have thus far are comparable to whole breast and that APBI potentially poses a lower risk in terms of damage to other areas of the breast. I’ve never had a patient change her mind because of the lack of data.
However, surgeons should be aware that APBI is becoming a patient-driven procedure. Women are much savvier these days, whether it’s from talking to other women or researching treatment options online. Many women have a choice as to where they go for treatment, so patients could start seeking out centers that already offer APBI. Thus, APBI could help build a surgeon’s practice by distinguishing them from other physicians, especially in an area where very few others offer it as a treatment option.
What is the best way for surgeons to educate themselves about APBI?
There are plenty of creative ways to educate themselves, from formal courses to seeking out the companies that manufacture the various catheters. The American Society of Breast Surgeons’ advanced ultrasound course discusses the placement of APBI devices, so members of ASBS or similar organizations have access to these programs at annual meetings. Surgeons can also approach the device companies and request a referral to a surgeon who already performs APBI. Watching a procedure or working through treatment planning with a radiation oncologist is an excellent way to learn more about the process. Radiation oncologists are another potential source of information, as they might have experience with APBI but didn’t think there was interest from the surgeon.
What are the main criteria you use to determine if patients are eligible for APBI?
I follow the guidelines issued by the ASBS, as well as the American Brachytherapy Society, which are pretty similar.
Patients eligible for APBI have:
- Invasive ductal carcinoma, or certain forms of DCIS
- Relatively small tumors (less than 3 cm)
- Clear margins and negative lymph nodes
- No multi-focal disease
In terms of age, ASBS allows patients over 45, while ABS allows women 50 and over. For younger patients interested in APBI, the NSABP B-39 trial is still accruing patients considered to be “high-risk.”
How does a surgeon’s attitude affect a patient’s treatment decision?
Often, patients choose the treatment option recommended by the surgeon, so attitude has a significant impact. If the surgeon doesn’t mention APBI, patients might not even be aware of its existence. I always mention APBI, even if the patient isn’t an appropriate candidate, just so they know about the range of available options.
Ideally, surgeons should be aware of APBI in the event that a patient requests information. It’s also important to educate surgeons about the most appropriate ways to discuss radiation therapy with patients. Some surgeons aren’t comfortable discussing APBI, thinking they need to go into the technical aspects of treatment. But during the initial discussion, patients don’t need that level of detail, and the discussion can actually be a simple, quick conversation. Once the patient has the basic information, they are better able to discuss their options in detail with the radiation oncologist. Remember – a successful APBI program involves a team approach.
Who tends to drive adoption of APBI — breast surgeons or radiation oncologists?
It varies based on every individual physician’s preference. In my opinion, who drives adoption is less important than the fact that someone – whether it’s the surgeon or radiation oncologist – is encouraging adoption and that both parties coordinate the patient’s care to the best of their abilities.
In my experience, it’s been easier for surgeons to drive adoption, because we’re the patient’s first point of contact, making it easier to identify potential candidates. The fact that we create the lumpectomy cavities also makes it easier to offer suggestions for the most appropriate device. In my practice, I give the radiation oncologist an assessment based on the size and location of the tumor, as well as the size and shape of the cavity, which helps guide device selection. Then again, there are many radiation oncologists who take the lead and even place catheters themselves. It’s simply a matter of individual preference and practice style- the most important part is that someone is taking the lead to offer APBI to women.
Does the ability to tailor radiation with the SAVI applicator eliminate the technical considerations you have to take into account when planning the lumpectomy cavity?
The main advantage of SAVI is that it can be used in more patients. The multiple catheters allow physicians to specifically tailor radiation and the overall profile of the device is significantly smaller than other APBI catheters, which provides greater flexibility in terms of the number of women we can treat. I still have to tailor the cavity with certain restrictions in mind, such as tissue conformance. But overall, SAVI provides a great deal of flexibility compared to other devices.
Is there any other advice you would give to surgeons considering APBI?
Like any new procedure, there is a learning curve and there are technical factors to take into consideration. But as the data from earlier studies matures and further supports the equivalency of APBI to whole breast, more physicians are incorporating it into their practices. As APBI becomes more widely used, it reduces the burden on individual physicians. It’s less intimidating for them to adopt APBI because they know they’re not the only ones using it. They can turn to colleagues for support, advice or feedback, which makes the overall implementation much easier.
About Dr. Attai
Dr. Attai is a board-certified surgeon specializing in the treatment of women with both benign and malignant breast conditions. She is an active member of the American Society of Breast Surgeons, and a Fellow of the American College of Surgeons. She has extensive experience with accelerated partial breast irradiation. Her private practice, the Center for Breast Care, Inc., is accredited by the American Institute of Ultrasound in Medicine. For more information, visit cfbci.com.