Dr. Kerri Perry, M.D., FACS
With multiple sets of criteria guiding patient selection, some cases may prove more challenging than others when determining if APBI is an appropriate course of treatment.
Kerri Perry, M.D., FACS discusses her views on patient selection — and points out the #1 thing physicians should utilize when making the decision to offer APBI.
What criteria do you follow to identify patients who are eligible for APBI?
I use the guidelines issued by the American Society of Breast Surgeons (ASBS) as my primary reference for patient selection. According to those guidelines, women are eligible for APBI if they have: invasive ductal carcinoma or DCIS; tumors less than or equal to 3 cm; negative nodes and margins; and are 45 years of age or greater. A majority of the women I treat with APBI meet these criteria.
However, no set of issued guidelines can substitute for a physician’s own clinical judgment. I make the final decision for the most appropriate course of treatment based on individual patient pathology. For instance, I will recommend APBI to a woman less than 45 years of age if she meets certain pathological criteria, i.e. small tumor size, that indicates APBI to be a suitable treatment option.
How does the availability of multi-catheter devices impact your patient selection for APBI?
It has enabled me to offer APBI to a much larger group of women. I think the greatest benefit of SAVI is that as long as a woman meets the histologic criteria for partial breast irradiation, she is a candidate for treatment with the SAVI applicator. Unlike other APBI devices, which require at least 5-7 mm of distance between the applicator and the skin, there are no skin distance issues with SAVI.
SAVI is the next closest option to interstitial breast brachytherapy in terms of the ability to sculpt the dose to patient anatomy. The multiple catheters offer so many different ways to introduce the radiation. It provides a greater flexibility that allows the radiation oncologist to direct radiation where it needs to be, while pulling dose away from the skin. Multi-catheter devices like SAVI provide both women and physicians with more options.
What proportion of your patients is typically ineligible for balloon brachytherapy?
Approximately 25% of my patients who are eligible for APBI are not candidates for treatment with balloon due to limited skin spacing. In the seven years since balloon brachytherapy was approved, I’ve had hundreds of patients who could have chosen partial breast radiation if SAVI had been available. Before SAVI, if a patient wasn’t a candidate for the balloon, she most likely couldn’t take advantage of APBI. If she required radiation, she would have to opt for the traditional seven weeks of whole breast radiation.
I have some patients who travel great distances for partial breast radiation. Several years ago, I had a woman who traveled more than seven hours from Amarillo in the hopes of getting balloon brachytherapy, but she unfortunately didn’t have the appropriate amount of skin spacing. Women in her situation used to be forced to choose between the lengthier whole breast radiation, or foregoing breast conservation therapy altogether and having a mastectomy. Fortunately, the availability of SAVI provides a lot more options.
After treating patients with SAVI for nearly a year and a half, what have you observed in your follow-up of these patients?
I focus exclusively on breast care, so I follow my patients very carefully. Following breast cancer treatment, I see my patients every six months for a follow-up mammogram and ultrasound. I’ve been very impressed with results I’ve seen with SAVI – my patients have done extremely well with it. None of the patients I’ve treated with SAVI have experienced infections or developed clinically significant seromas. In contrast, I have many patients who I treated with balloon brachytherapy several years ago that have developed persistent seromas.
As we continue to get more follow-up with SAVI, I think we’ll see that the advantages of the device’s open architecture and dose sculpting are less seroma formation, better cosmesis and overall less visible evidence that the patient has had radiation therapy of any kind.
What advice would you give to other surgeons who are considering the use of the SAVI applicator?
Don’t be afraid to try it. I would encourage physicians to try SAVI, because they’ll find it has a lot of advantages. It’s easy to use and allows you to offer APBI to so many more women. I know a general surgeon in South Dallas who had never even placed a breast brachytherapy device before. He treated a patient with SAVI and said the experience was amazing – the patient was happy and the whole treatment went well. Even with minimal brachytherapy experience, you can easily start with SAVI.
Dr. Perry is a breast surgeon with a private practice located in Denton, Texas.