John Hayes, Jr., MS, MD
Though long-term data are beginning to show that breast brachytherapy is as safe and effective as whole breast irradiation for a certain patient population, there remains a great deal of debate as to which patients fall into that category. Patient selection criteria from various medical societies, including the American Brachytherapy Society (ABS), American Society of Breast Surgeons (ASBrS) and American Society for Radiation Oncology (ASTRO), are varied on many characteristics, including age, tumor size and histology.
Perhaps most controversial are the ASTRO guidelines and the treatment of patients in the “cautionary” or “unsuitable” categories. Though numerous studies have been published showing no difference in outcomes with WBI or APBI for many of these patients, the guidelines have not been updated since the initial release in 2009 to reflect this emerging data.
Radiation oncologist John Hayes, Jr., MS, MD, of Gamma West Cancer Services, Salt Lake City, Utah, discusses his views on patient selection for breast brachytherapy, including recently published data on DCIS patients and why he calls the ASTRO guidelines “quite dated.”
What is your patient selection criteria for breast brachytherapy?
I prefer the most recent guidelines published by the American Brachytherapy Society as a starting point. However, I feel it is important for patients to appreciate controversy in breast care and to understand that there are other guidelines and others may have different opinions.
The EHR mentality that tries to group patients into a well defined electronic box doesn’t seem to apply very well in my clinic. The human organism is complex and no electronic box is nuanced well enough to quite get the big picture. Each deserves the time and effort to appreciate the uniqueness of her individual circumstance.
There are several studies showing no difference in outcomes for patients in the ASTRO “cautionary” or “unsuitable” categories – so why do you think many physicians continue to offer brachytherapy only to those in the “suitable” category?
I think that tradition, convenience and medical economics are playing roles in how patients are managed. The ASTRO guidelines are now becoming quite dated, and yet clinicians still use those as a “gold standard” for the reasons noted above. I think this is unfortunate for patients who would be good candidates for APBI as the studies you have eluded to suggest. Also, I think the more recent data is not reaching practitioners, giving them no reason to change practice patterns.
How do you respond to patients who request APBI, but are outside the suitable category, such as DCIS and/or age <60?
I explore the management options available to them and review the published guidelines and articles addressing their strengths and weaknesses. If patients are informed and understand why the criteria for the guidelines are put in place then they can make educated decisions for themselves.
How does your recent study on the use of interstitial brachytherapy in DCIS patients support the use of APBI in this patient population?
There are more and more published data supporting APBI in patients with DCIS and my own experience has shown great outcomes as well. The study, titled Interstitial Multicatheter Brachytherapy for Select DCIS: A Multi-Institutional Study, is a collaborative effort from five institutions with extensive experience in treating breast cancers with interstitial brachytherapy.
It was recently presented by Dr. Robert Kuske at the American Society of Breast Surgeons meeting in Las Vegas. From 1997-2013, 147 patients with stage 0 breast cancer were treated with breast-conserving surgery and adjuvant APBI using interstitial multi-catheter brachytherapy. We concluded that APBI was an acceptable option for select women with DCIS with recurrence and survival rates that are similar to published outcomes of 6- to7-week whole-breast irradiation outcomes or mastectomy
In the data collection, I talked to study subjects treated many years ago and they were very happy with their choice of treatment. The outcomes are from a large cohort of women and show that interstitial brachytherapy is a safe and effective form of adjuvant treatment for women with DCIS with a favorable side effect profile.
It’s been five years since ASTRO release its consensus statement on APBI. In light of the data that has emerged since then, do you think it’s time for the organization to revisit and update its guidelines?
I give a definite yes on that one. The ASTRO guidelines were written the way they were because of a lack of published data at that time. When the guidelines were published, they acknowledged that updates would be needed as more and more data were published.
What are your thoughts on those who say patients >70 might not require radiation?
This is a very interesting topic and patterns of care vary substantially across regions of the US. Educating patients on their risks of local recurrence with and without radiotherapy is important and what the consequence of a recurrence means. Radiation oncologists can deliver adjuvant treatment very well with several different treatment strategies. APBI is one treatment that is worthy of mention here as it is completed in one week, pain is minimal, there is no skin burn, cosmetic results are very favorable, control of the local disease very effective, and costs are less than alternative radiation treatments.
For some women, any decrease in local recurrence will be wanted while others are comfortable forgoing radiation.
How do you balance the needs/considerations of individual patients with patient selection guidelines?
Guidelines are not imperatives. It is important to take into account the complexities of each patient and to deny a one size fits all mentality. Educating patients on their options and explaining why they may or may not fall in or out of some of the published guidelines goes a long way.
I think it important to respect physiologic age. I recently heard of an 86 year old woman who was the primary caregiver to her mother until the day she died at age 106 years. Making rigid decisions based on age excludes a vast amount of clinical perception. Observation may be appropriate. I think often it is not. Mastectomy usually remains a feared event to women of all age.
As radiation oncologists I think we too often do not have the opportunity to be involved in the long term follow-up of our patients. I recently met a 48-year-old patient who had a second breast primary tumor in the contralateral breast 20 years after treatment that included chemotherapy and WBRT. She was not a candidate for APBI. Breast volume reduction from WBRT after 20 years was extensive. Regarding previously treated patients, out of sight and out of mind does not always mean everything is well. In APBI, I think less will become more if long-term clinical data shows equivalence in local control.
Dr. Hayes is a board certified radiation oncologist at Gamma West Cancer Services in Salt Lake City, Utah. He has been performing brachytherapy procedures since 1988 and has performed over 5,000 implants.