In 2005, John Schallenkamp, M.D. became the first radiation oncologist at Billings Clinic in Montana. Since then, the board-certified physician, along with Billings’ newest radiation oncologist, Christopher Goulet, M.D., has brought new treatment planning and innovative cancer treatment to the region – in 2008, the facility became the first in the state to utilize the SAVI applicator. Dr. Schallenkamp discusses his experience with SAVI and why he waited for the device to implement a breast brachytherapy program at his facility.
Prior to SAVI, what treatment options did Billings Clinic offer for women with early-stage breast cancer?
We were already offering accelerated partial breast irradiation in the form of 3D conformal external beam therapy as part of the NSABP-B39 trial. The only other option for breast conservation therapy was a lumpectomy followed by six weeks of whole breast radiation.
We serve both an urban and a rural population, with some patients traveling as far as 400 miles to receive treatment, which often limits a woman’s ability to choose BCT. The cost of traveling back and forth, or staying in Billings for six weeks, simply isn’t feasible for many people. Often, if they can’t receive radiation therapy in a convenient and cost-effective framework, many women may opt for a mastectomy.
It’s a real quandary for these women who want to preserve the breast and somehow have to find a way to fit six weeks of treatment into their busy lives. Obviously, we wanted to be able to offer a more convenient option that would allow more patients to choose BCT – but before the SAVI applicator, there wasn’t a device that we felt could accomplish those goals.
Why did you refrain from offering balloon brachytherapy?
We weren’t impressed with balloon brachytherapy and its inability to truly customize the radiation dose, because it often results in the device being removed prior to completing treatment. There is a lot of effort that goes into starting a breast brachytherapy program, and we were hesitant to invest the time and energy for something which would not maximize our ability to deliver successful treatment to our patients.
If you have a cavity that is the perfect shape, size and location, the balloon is simple – but you can’t count on every one being perfect. Flexibility is key for patient selection and even for the referring physicians. Despite requests from both patients and physicians to offer balloon brachytherapy, we were waiting for the right device.
What characteristics of the SAVI applicator convinced you to implement a breast brachytherapy program at Billings Clinic?
When we decided against balloon brachytherapy, we knew we wanted a device with multiple channels to deliver radiation. So when Dr. Goulet first learned about SAVI at the American Brachytherapy Society meeting in 2007, we reviewed the device and I immediately knew it was something I wanted to bring to Billings. With the ability to customize the dose, SAVI makes it more likely that we will have a successful treatment without having to remove the device.
We just needed the right device to be willing to offer breast brachytherapy. SAVI fulfilled our needs perfectly by allowing us to offer our patients the convenience of brachytherapy with a more reliable device that would have a significantly lower pull rate.
How does the availability of SAVI impact your patients’ treatment choices?
They have more options now. The ability to control and sculpt the dose provides greater flexibility in the types of patients that qualify for brachytherapy. More women can benefit from SAVI, particularly those who want BCT but can’t afford the time and expense of whole breast radiation – they don’t have to immediately turn to mastectomy. We see a lot of early-stage breast cancer patients, so I think as many as 40-50% of my patients who wouldn’t be candidates for balloon brachytherapy would be eligible for treatment with SAVI.
How do surgeons in your area feel about breast brachytherapy?
I think the surgeons were aware of the benefits, but since it wasn’t offered at Billings Clinic, no one was really advocating it. Surgeons are the first point of contact for patients to discuss treatment options – so if a woman chooses a mastectomy, we may not get a chance to discuss other options with her. But I think there’s a greater awareness and acceptance of brachytherapy, because we’re definitely noticing a change in referral patterns. Surgeons are sending patients to us much earlier, so we’re able to discuss the various options prior to their surgery.
How has your experience with the SAVI applicator been?
I like that we’re able to reduce the amount of radiation delivered to the nearby normal tissue. It’s significantly less than whole breast radiation and even APBI with 3D conformal therapy. We’re able to spare the lungs, chest wall, heart and normal breast tissue, which we expect early data to show results in fewer side effects. For our patients, the biggest advantage has been time. If we can successfully treat a patient with brachytherapy, we’ve just saved her a great deal of time and helped to preserve her breast.
For me, it’s all about maximizing the ability to treat someone correctly. In addition to increasing the number of patients who can receive brachytherapy, SAVI increases the possibility that everyone who is actually a candidate can receive successful treatment without pulling the device.
About Dr. Schallenkamp & Billings Clinic
Dr. Schallenkamp specializes in radiation oncology and is board-certified. He joined Billings Clinic in 2005 from the Mayo Clinic. The Billings Clinic Cancer Center serves a 4-state region and was one of only 10 organizations across the country chosen as a pilot site for the National Cancer Institute’s Community Cancer Centers Program.