The use of radiation therapy in patients with breast cancer and collagen vascular disease (CVD) is quite controversial. Current data indicate that in the presence of CVD, whole breast irradiation poses an increased risk of acute and chronic toxicities, including fibrosis, poor wound healing and inferior cosmesis. As a result, many physicians view radiation therapy to be contraindicated in patients with CVD, leaving mastectomy as the only surgical option.
However, a paper published in Brachytherapy presents a possible alternative for patients who have a strong desire for breast conserving treatment. Researchers examined the use of accelerated partial breast irradiation (APBI) via high-dose-rate (HDR) brachytherapy – including toxicity and cosmesis – in patients with CVD. Co-author and radiation oncologist S. Eric Olyejar, MD, discusses his experience treating CVD patients with APBI, including patient selection, dosimetric parameters and long-term follow up.
When it comes to breast cancer treatment, what are your concerns for patients with CVD as it relates to their condition?
The main concerns we have for patients with CVD are acute and chronic toxicities. There are several published case studies where patients suffered from profound acute morbidity resulting from external beam radiotherapy at various sites. The exact mechanisms as to why they are more susceptible to acute or chronic toxicities are not entirely clear, but based on the literature CVD patients seem to be more at risk than the average patient.
We also take into account the type of collagen vascular disease the patient has, as some conditions seem to pose a greater risk than others. Scleroderma is probably the one we are most concerned about. These patients can have very sensitive and fragile skin, and there is data suggesting they are most at risk for acute and chronic morbidity following radiation. Lupus is also a particular concern, considering there is skin involvement.
What is the current standard of care for breast cancer treatment for CVD patients? Do you think breast conservation therapy (BCT) with APBI should be more widely considered as the potential standard of care?
To avoid the acute and chronic morbidities associated with external beam radiation, the current standard of care for breast cancer patients with CVD is mastectomy. However, I think APBI gives eligible patients an option to preserve their breast by minimizing the overall volume of radiation delivered, and thus lowering the risk for potential morbidities.
Based on our paper I believe a prospective Phase II study is warranted to further explore the use of BCT with partial breast radiation for these patients. Conceptually, it makes sense that APBI would be better tolerated than whole breast radiation in patients who are at an increased risk of acute and late toxicities – it delivers a lower volume of radiation to only the tumor bed and spares much of the normal breast tissue. For the same reason, I personally believe brachytherapy is the preferred modality for these patients, compared to 3D conformal radiation therapy.
What patient selection criteria do you typically follow for offering APBI? If you have a patient with CVD, does that change your criteria at all?
I utilize the guidelines developed by the American Society of Breast Surgeons (ASBS) and the American Brachytherapy Society (ABS). While I also consider the American Society of Radiation Oncology (ASTRO) consensus statement, I recognize its limitations.
For patients with CVD, I require them to meet the ASBS and ABS guidelines, as well as demonstrate a strong desire for breast preservation. If the patient mostly meets the guidelines but has a single cautionary feature, I would be willing to offer them APBI with strong informed consent.
What has been your experience when treating CVD patients with APBI? What are the dosimetric parameters you observed?
My experience has been excellent. I’ve treated approximately 10 breast cancer patients who have some form of CVD with lumpectomy and APBI, some of them with more than five years of follow up since radiation therapy. Two of these patients had scleroderma, and they did fantastic. I’ve also treated patients with lupus and rheumatoid arthritis. From my personal experience, they’ve all been successfully treated and none have demonstrated any excess acute or late toxicities.
For these patients, I limited the skin dose to less than 100% of the prescription dose. I also aimed to keep the V200s as low as possible – all were less than 10 cc.
What coordination is required with the patient’s primary care physician and/or specialists?
With all my CVD patients, I’ve been in touch with their rheumatologist. Often patients with rheumatologic diseases are on chemotherapy, which creates the potential concern for radiosensitivity of the tissue. My primary discussion with the rheumatologist is whether or not it is feasible for the patient to suspend their cytotoxic therapy for the duration of the radiation treatment. If that is not possible, I won’t offer radiation therapy as an option, as I don’t want to add another layer of potential complications.
Is there a concern about the lack of guidance on offering APBI to a specialized patient population like this?
Aside from the article we published, there’s not a great deal of data demonstrating how much toxicity CVD patients are at risk for compared to the general population when it comes to APBI. Our study would point out that there’s no increased risk of toxicity and that it may not be necessary to exclude these patients from clinical trials of APBI. However, I think more studies should be done to explore the idea of lowering the overall volume of radiation delivered, thereby minimizing toxicity and enabling these patients to preserve their breasts.
Dr. Olyejar is Board Certified in Radiation Oncology and has practiced at the Ironwood Cancer Research Centers in Chandler, Ariz. since 2006. He specializes in the treatment of cancer of the breast, prostate, and head and neck. Dr. Olyejar is experienced and has special training and interest in brachytherapy for all sites including breast, prostate, head and neck, gynecologic, esophagus, skin and lung.