At the time of her first diagnosis, the patient was 62 years old. She was diagnosed with an Infiltrating Ductal Carcinoma of the upper outer quadrant of the right breast. After a consultation with both her surgeon, Dr. Victor and radiation oncologist, Dr. Nuesch she chose a five day course of treatment with SAVI Brachy. She received a total dose of 34.0 Gy with a 6-1 applicator twice a day for 5 days.
Four years later, the patient presented with a second primary infiltrating ductal carcinoma also in the right breast but located in a different quadrant. She opted for a second lumpectomy and treatment with SAVI Brachy. She received the same radiation dose delivered with a 6-1 mini applicator.
At the current time, the patient is cancer free and pleased with both the outcome and cosmetic appearance of her breast. Dr. Nuesch and Dr. Victor give their perspective on the case to provide guidance for physicians and patients in their treatment decisions.
1. Why did the patient decide on SAVI Brachy?
BV: Working in collaboration with the radiation oncologist we discuss all the appropriate treatment options with the patient as it relates to their particular cancer. Despite her past history of ipsilateral APBI, considering the adequate distance from the first primary site, the patient was a candidate for another APBI intervention, absent field overlap. The prospect of a much more targeted radiation over a shorter period of time that did not adversely affect cancer control and did not compromise cosmetic outcome was very attractive to her.
2. If the patient had WBI for her first cancer treatment, what would her options have been for the second cancer in the same breast?
CN: Since WBI radiates the entire breast, a mastectomy would have been the only reasonable option. If she had WBI and opted for a mastectomy, it is important to note that breast reconstruction on an irradiated breast can have its own set of challenges. Two years ago, results from the Mastectomy Reconstruction Outcomes Consortium study revealed significant risks of capsular contractions, infections and hematomas in women radiated and reconstructed with implants. Women reconstructed with autologous flaps fared much better, but are obviously subjected to a much longer, technically more challenging and costly procedure that harbors their own specific risks.
3. Have you ever had a retreatment case like this before?
CN: While this is not common, I have had two patients who have had SAVI Brachy on the same breast after developing a second primary breast cancer. Both patients have had excellent outcomes.
4. Can you tell us why you were comfortable using SAVI Brachy for the second cancer?
CN: After imaging the second cancer (which was a stage 1 primary lesion) and determining that the location of the first cancer was in a different quadrant and a sufficient distance so there would be no overlapping radiation fields we felt comfortable that ABPI with SAVI Brachy was a viable option.
VB: We usually recommend a mastectomy if the cancer recurs or a second primary develops in the same breast – however, this patient did not want a mastectomy. She was happy with the outcome of her first SAVI facilitated treatment and was very comfortable considering this option once again.
5. What do you consider the biggest benefit of SAVI Brachy?
CN: With a sufficient body of data demonstrating ABPI equivalent to WBI in local recurrence and overall survival, ABPI is an extremely appealing course of treatment. We have the ability to not only preserve the breast but we can avoid the side effects of external beam radiation, most notable radiation reaction, which sometimes can be significant.
VB: SAVI Brachy offers patients a shorter duration of treatment, minimizes the dose of radiation to the rest of the breast without sacrificing cancer control and still provides an excellent cosmetic result.
6. Do you routinely counsel patients that if they have SAVI, they preserve their option of having SAVI APBI again if there was a recurrence or new cancer in the same breast?
VB: In counseling a patient we always review the risk of recurrence. As well, the odds of developing a new cancer in the ipsilateral or contralateral breasts is a question that is commonly asked but uncommonly occurs. Our immediate focus is on treating the cancer at hand but also must consider these long term issues. Thus, the management of recurrences would be much more appropriate in the counseling and shared decision making processes. However, based on this case, I certainly feel more comfortable, educated and experienced in counseling women on preserving treatment options in this event. Having APBI first did provide this patient more options, specifically preserving the option of breast conservation.
7. What should treating physicians keep in mind in counseling patients on their radiation options?
VB: Radiation options are always best addressed by the radiation oncologist. However, as a surgeon treating breast cancer, we should be intimately familiar with all modes of radiation available and applicable to managing this disease. It’s always part of my routine discussion with patients pre-surgery to discuss the biologic and genetic details of the cancer, look at the patients’ anatomic characteristics and discuss her preferences for treatment. These all play an important part in how I will optimally surgically address the cancer.
CN: I always present all the radiation options to the patient to help her choose the best treatment, not only for her particular cancer, but for her lifestyle. It is important to understand the benefits, risks, and options of APBI versus WBI.