Dr. Mark Gittleman

Educating referring physicians is a key component of a successful breast brachytherapy program. Cianna Medical has created a number of tools and programs that can help you reach out to referring physicians to grow your practice while improving patient care.
Get the BEST in Brachytherapy Data

The BEST Forum is a new educational resource for physicians to obtain the latest findings and research in breast brachytherapy. At the BEST Forum website, physicians can view presentations from brachytherapy experts, as well as download white papers, presentation slides and supporting clinical data, and register for future presentations. Visit thebestforum.com to learn more.
Become a SAVI Center of Excellence

As a Center of Excellence, you have access to an award-winning marketing and communications guide with customizable tools that will enable you to differentiate your services and help you reach out to referring physicians and women in the community. In addition, you can take advantage of an online CME program to educate primary care physicians about advances in breast cancer treatment options. Email info@ciannamedical.com to learn more about becoming a Center of Excellence.

Partners in Care: Surgeons & Radiation Oncologists in Multi-Disciplinary Breast Cancer Care

Mark Gittleman, MD

The delivery of breast brachytherapy requires the cooperation of multiple specialties, but perhaps none more so than surgery and radiation oncology. Every step of the process – from discussion of treatment options to device selection to treatment planning and scheduling – must be carefully coordinated among the two teams.

Breast surgeon Mark Gittleman, MD, discusses the “dance” that takes place between surgeons and radiation oncologists, who should lead, and the importance of a team approach for a successful breast brachytherapy program.

Why is a team approach so important for a successful brachytherapy program?

Like any treatment that involves multiple specialties, the patient is going to benefit if there’s good coordination among the team that’s delivering the treatment. A successful breast brachytherapy program requires members of the team that are dedicated to the treatment itself and truly believe in the procedure, and coordinate their activities to make it seamless for the patient. The patient must interact with both the surgeon and the radiation oncologist for the planning, treatment and follow up, so a successful program must have agreement upfront about logistical protocols, including a means of addressing any issues that can arise during the course of treatment.

What are some of the major logistical concerns when coordinating a patient’s APBI treatment?

Timing is critical. Once it’s determined that a patient is a candidate for APBI, the major logistical concern is the timing of the placement of the brachytherapy device and coordinating that with the radiation oncology consultation, the CT scan treatment planning and the actual treatment delivery. All of that must be coordinated ahead of time so there aren’t any surprises – for example, a patient showing up at the radiation oncologist’s office with a brachytherapy device in place, not aware that the physicist is on vacation that week.

What are some ways surgeons and radiation oncologists can work together to ensure coordinated patient care?

For a new brachytherapy program to be successful, it’s essential to have the involvement of surgeons and radiation oncologists that are in favor of doing the procedure. If either one, or both, aren’t enthusiastic about brachytherapy, they’re not going to offer it to their patients, or they might offer it in a way that discourages patients from choosing it.

Once you have your team of brachytherapy champions, the surgeons and radiation oncologists need to sit down together and discuss the logistical protocol and selection criteria they will be using in their community. They need to decide on the exact protocol for their program – such as whether the patient sees the radiation oncologist before or after lumpectomy surgery – and the specific selection criteria they’ll be using so there’s no confusion as to which patients are eligible for APBI. All of this has to be done ahead of time, and everyone has to be on the same page – otherwise there’s a potential for conflict.

What is the best way for surgeons, radiation oncologists and physicists to communicate if issues arise during the treatment planning process?

There has to be open communication, and everyone has to make themselves available to discuss anything that comes up during the time of treatment planning. Any technical issues that develop need to be addressed immediately, so there has to be an understanding in working together and setting up the protocol. It’s about identifying the potential issues that can arise, and determining who is going to take care of the problem. I once received a call from the radiation oncologist during the treatment planning because there was an inverted strut on the SAVI device. The physicist thought they couldn’t treat the patient because they would have to remove the device. However, I suggested they simply not load that particular strut and just use the remaining channels when planning the treatment, which enabled them to successfully treat the patient. There has to be that communication back and forth – otherwise you might have a patient that has a device pulled where the issue could have been resolved if the disciplines simply talked to each other.

Who should ultimately make the decision regarding which brachytherapy applicator to use for a patient’s treatment?

Like everything else, it’s a partnership with the radiation oncologist. Again, device selection is part of the protocol that should be agreed upon ahead of time. Some radiation oncologists prefer the treatment planning with the SAVI device and request that it be used whenever possible, so surgeons should take that into consideration. As a team, you agree what your preferences are, but then you assess each situation for a variety of factors (i.e. the size of the cavity, anatomical constraints, skin issues) to decide which device is going to be most appropriate for the patient – which is primarily the surgeon’s responsibility. If the surgeon is placing the device, they have to be sure it’s placed correctly to ensure a successful treatment.

What are the other key elements of a successful brachytherapy program?

In addition to having a team that is willing to work together and cooperate completely, the other key element is marketing the program effectively to both patients and medical colleagues. Direct marketing to your community lets patients know you offer this procedure, and if your competitors aren’t offering brachytherapy, that can really help differentiate your program. However, marketing to referring physicians in the form of educational events is also important. Reach out to family physicians and gynecologists so they understand the concept of partial breast radiation, as they are the ones sending patients for mammograms and breast biopsies. Then when their patients go back to them and ask their opinion about breast brachytherapy, they’ll have some knowledge about and will hopefully speak favorably about it.

Dr. Gittleman has been practicing general surgery for over 30 years. In 1995, he dedicated his practice exclusively to the surgery and disease of the breast. In addition to being a Board Certified Surgeon he is also certified in breast ultrasound and stereotactic interventional breast procedures by the American Society of Breast Surgeons. Dr. Gittleman is also a principal clinical investigator in a number of clinical trials regarding the diagnosis and treatment of breast cancer.