Robert Kuske, MD
In Part 1 of our Oncoplastic Surgery series, Gail Lebovic, MD, gave a surgeon’s perspective on this increasingly popular surgical approach. In Part 2, radiation oncologist and brachytherapy pioneer Robert Kuske, MD, discusses his views on oncoplastic surgery – including why partial breast radiation and oncoplastic surgery are not mutually exclusive treatment options.
Is brachytherapy an option for patients who undergo oncoplastic breast surgery?
Absolutely. Some people believe partial breast radiation competes directly against oncoplastic surgery and that the two are mutually exclusive. But with good teamwork and communication between surgeons and radiation oncologists, this doesn’t have to be the case. Interstitial brachytherapy will almost always be an option, provided the radiation oncologist has a target to treat. Single-entry brachytherapy devices require even greater collaboration across disciplines, as the goal of many oncoplastic surgeries is to eliminate the cavity. However, radiation oncologists can work with surgeons to ensure they leave a cavity that exposes the tissue at the greatest risk for recurrence to the device.
Increasing the availability of 5-day radiation following oncoplastic surgery depends not only on good communication, but also on a radiation oncologist that has experience with a variety of APBI techniques, including interstitial brachytherapy, single-entry brachytherapy devices and even 3D conformal. As radiation oncologists, we need to have all the tools at our disposal so that we’re able to offer the most appropriate treatment for a particular patient.
When it comes to oncoplastic surgery, at what point in a patient’s surgical treatment planning should the radiation oncologist become involved?
I recommend getting involved as soon as the diagnosis is made. The surgeons I work with contact me when they receive the results of the core needle biopsy. This gives me the opportunity to review the patient’s pathology and use that to determine her eligibility for various radiation therapy options – which will ultimately influence how the surgery is performed. Even if I can’t see the patient in person for preoperative assessment, I will consult with the surgeons involved to discuss management before the surgery is ever performed. Again, this kind of collaboration is essential, particularly if the patient is interested in a 5-day radiation option.
Can you provide examples of how can radiation oncologists and surgeons can work together to ensure 5-day radiation is an option following oncoplastic breast surgery?
There has to be an inter-disciplinary cross-fertilization. It can’t just be happenstance. It almost has to be choreographed like a great dance. If the physicians evaluate the patient as a team, map out a strategy and decide where the surgeon can leave a cavity, the patient will be a candidate for brachytherapy, even with a single-entry device.
If I were using a single-entry device, I would want the breast surgeon to remove the tumor with clear margins and place six surgical clips around the lumpectomy site (superior, inferior, medial, lateral, superficial and deep). The surgeon can then manipulate the tissue to make a cosmetically appealing breast while making sure the clips end up in the appropriate places so I can be confident I’m treating the target tissue.
The worst case scenario is when a surgeon tells the patient they can have 5-day radiation therapy, but doesn’t consult with the radiation oncologist prior to the surgery. I’ve had cases where a patient shows up in my office after surgery with no evidence of where the surgeon operated. If there are clips, I can offer them partial breast irradiation with interstitial brachytherapy. But if there is no cavity and there are no clips, targeted therapy is no longer an option. Then I have no choice but to look that patient in the eye and tell them the only option available is 6 weeks of whole breast radiation. In those cases, I’ll go back to the surgeon to explain how we can work together in the future to create a definable target so we can offer their patients 5-day radiation.
What is the biggest challenge oncoplastic surgery presents for radiation oncologists?
The most significant challenge is that some surgeons equate oncoplastic surgery with complete elimination of the cavity. Surgeons with a mind for APBI will leave a cavity, but currently they are the minority. In many ways, this mind set makes sense – it goes back to the first surgical principles they learn in residency, which is to close cavities to avoid complications like seroma or infection. But without a cavity, there is no possibility for single-entry devices and the options for offering an accelerated form of therapy are very limited. If the cavity is closed but clips are present, interstitial brachytherapy remains an option. Some keys are investigating single-dose intraoperative radiotherapy to the cavity walls before the cavity is closed, but they do not have the advantage of having a pathology report ensuring eligibility.
Within the next 5-10 years, what role do you see oncoplastic surgery playing in the overall care and management of breast cancer patients? How will this affect radiation oncologists?
One thing is for certain – oncoplastic surgery is here to stay. It’s a very attractive option not only for patients, but for surgeons as well. As a result, I foresee an explosion in the amount of oncoplastic surgery being performed. In the near future, I predict as many as 60 percent of all breast cancer surgeries will be performed using oncoplastic techniques.
This will affect not only radiation oncologists, but all disciplines involved in treating breast cancer patients. As the number of women undergoing oncoplastic surgery grows, this increasingly large patient population will be looking for a 5-day radiation alternative. As healthcare providers, we have a responsibility to prepare for that. I think physicians from every discipline – including radiologists, pathologists, medical oncologists, breast surgeons and radiation oncologists – need to get together and strategize so we can make brachytherapy an option for more of these patients.
Dr. Robert Kuske is a radiation oncologist at Arizona Breast Cancer Specialists in Scottsdale, Arizona. He previously led the breast cancer program at the University of Wisconsin and was chairman of Radiation Oncology at the famed Ochsner Clinic in New Orleans. While in New Orleans, Dr. Kuske and colleagues pioneered accelerated partial breast irradiation, and he is now a co-principal investigator of the North American 4300 patient phase III trial through the NSABP and RTOG, approved and funded by the National Cancer Institute. In April 2011, Dr. Kuske received the American Brachytherapy Society Presidential Award for contributions to the science of his field of radiation oncology.
Stay tuned next month for the final installment of our three-part series, in which a surgeon discusses specific techniques for incorporating an APBI device with oncoplastic surgery.