Chest Wall Margin 0.1mm after Mastectomy - radiation decision

dancetrancer

Just want to refer all of you who are contemplating radiation like me to a thread started by our amazing fantastic Beesie on a new Oncotype DCIS test that is soon to be available.  This test is done for post surgical DCIS pt's and can help identify who is likely to recur, and if you recur, how likely it is that it will be DCIS only or invasive.  Thus, it can help you make the decision about radiation.  

 I am asking my docs if my path slides could possibly be testing, awaiting an answer right now.  Anxiously awaiting! 

dancetrancer

Continuing my rads research, I've decided to focus on respiratory-gated rads, because that is the newest type of radiation being applied which they say results in lower heart and lung complications.  Here is one study I am currently reviewing:

Analysis of cardiac and pulmonary complication probabilities after radiation therapy for patients with early-stage breast cancer. Abstract

OBJECTIVE:
The purpose of this study was to evaluate the radiobiological implications of clinical use of respiratory-gated techniques for postoperative radiation therapy of early-stage left-sided breast cancer after breast-conserving surgery.

MATERIAL AND METHODS:
Radiation therapy treatment plans of 80 patients with early-stage breast cancer (stage I-II), receiving whole breast irradiation after breast-conserving therapy, were analyzed. The control group consisting of 47 patients received standard radiation therapy, and the respiratory-gated group consisting of 33 patients received deep inspiration-gated radiation therapy. Normal tissue complication probabilities (NTCP) for cardiac mortality and for clinical radiation-induced pneumonitis were calculated for all patients included in present study, using relative seriality model. NTCP data were analyzed for 113 radiation therapy plans, which included free breathing plans for the respiratory-gated groups.

RESULTS:
Pneumonitis probability was 0.6% (range 0.0-2.8%) and 0.3% (0.0-1.2%) for control and respiratory-gated group, respectively. Cardiac mortality was 1.3% (0.0-5.0%) and 0.2% (0.0-2.8%) for control and respiratory-gated group, respectively. Using respiratory-gated radiation therapy, NTCP was reduced in comparison with the control group by 83% (P<0.00001) and by 55% (P=0.01270) for cardiac mortality and for clinical radiation-induced pneumonitis, respectively.

CONCLUSIONS:
Use of respiratory-gated radiation therapy, for postoperative treatment of early-stage breast cancer, significantly reduces excessive cardiac mortality probability and pulmonary complication probability, as compared to standard radiation therapy techniques. This is especially important from heart complication probability point of view, as cardiac mortality remains one of the important issues of postoperative breast irradiation in patients with early stage breast cancer.

Note that this is not a long-term study, but one that modeled "normal tissue complication probabilities".   It explains how this is done in the article, but it was geek speak to me.  LOL

Natters

dancetrancer, where did that statistic about heart damage come from, if you can remember?

ZTeam

Great info, thanks dancetrancer.

I spoke with my radiation oncologist. My case will be presented next week at the weekly breast cancer conference to discuss radiation. They will also discuss the Oncotype DX, but my RO wasn't optimistic that we would use it here (in Canada) in time for me. I may be able to do it, but likely would have to pay for it myself.

Best,

Lisa 

dancetrancer

Natter - not sure which statistic you are referring to - can you copy the relevant part of my post you are referring to?

Natters

Dance - never mind! In your second post, you quoted it . Thanks!

dancetrancer

Zteam, I don't know if this will help you, but just an FYI about the Oncotype test - might be worth calling to check into this more, if they don't offer it in Canada in time.  from: http://www.oncotypedx.com/en-US/Breast/PatientCaregiver/InsuranceInfo.aspx

Genomic Health provides a comprehensive financial assistance program for patients with financial hardship and a program for uninsured and underinsured patients based on financial eligibility.

GAP has been designed to assist patients and authorized healthcare providers with any billing or reimbursement issues related to the Oncotype DX test. Genomic Health welcomes questions and encourages you to contact GAP if you have questions. Call Genomic Health Customer Service at 866-ONCOTYPE
(866-662-6897).

 I'm still waiting to hear back from my docs to see if they'll run this on me.  My 3rd opinion on rads is with Emory...and one of their docs happened to be an author on this study...hoping they'll say it can apply to post MX pts!  

ZTeam

Hi Dancetrancer,

Thanks for the link, I'll see if I qualify.

Let us know what your 3rd RO has to say about the test's applicability to post MX patients - that will be very interesting!

Hope you're well,

Lisa 

dancetrancer

Well, I haven't heard back from my 3rd RO yet about whether they'll do the test or not, but I had also asked my 2nd RO (the one who is recommending rads).  I figured it wouldn't hurt to do the shotgun approach, LOL.  Well, I got an email back today saying she won't do it b/c it doesn't apply to MX, but she also said I'm high risk anyways so it wouldn't change her recommendation.  Funny thing is, she hasn't been willing to give me a % as to how high of risk...I'm annoyed.  Give me some d*mn numbers, at least your best guess...grrrr.  I feel like I'm being blown off.  Maybe I'm just frustrated and being too sensitive.  Still holding out hope that the 3rd RO will be open to ordering it.  Here's the response I got from my 2nd RO, for those who might be interested:

Oncotype dx has been tested in DCIS in pts who have received breast conservation. Larry Solin and I quote, states "The DCIS Score will help physicians understand the underlying biology of DCIS for an individual patient and accurately gauge the risk for that person, enabling the patient and physician to decide on the appropriate course of treatment based on a more complete understanding of the risk involved". I think we know her biology is aggressive given the situation, and if she gets the oncotype dx and it returns intermediate risk (as I doubt it will be low), it would not change the recommendation. 

SheChirple

I understand your confusion and difficulty in making this decision.  I am right there with you.  I have .2 cm (DCIS) and .8 cm (IDC) margins.  I meet with the radiooncologist Friday and am trying to be fully prepared.  I thought I was good at .2cm, but who really knows.

Good luck with your decision.

Natters

Dance, none of my DRs wanted to talk numbers with me, either. I basically insisted my MO give me something finally. Nd he's the one who sold me on rads using that number. Actually, he wouldn't even tell me 20% but I calculated it for myself based on what he said (10% after rads, and rads cuts the risk in half after surgery, for those of us with lumps).



None of them told me about the VNPI, but I read about it on here and calculated it or myself once I got my path report. That also made me feel more resigned to rads. Maybe this new test can do the same for you. It sounds like you're not exactly at low risk of recurrence, despite the MX. It stinks, and I'm sorry you still might have 6 more weeks of tx ahead. it sounds like the micro fat grafting can help the skin recover from rads, though? I'm very interested in that if I have a recurrence.

dancetrancer

Natters, your MO didn't what a math geek you are did he?  LOL, jk - cracks me up that he didn't realize you'd figure that one out lickety-split!   Glad to know someone else had difficulty getting numbers.  I'm gonna try to pin someone down to some kind of number next week.  They can't just tell me my risk is "high", when everyone's opinion of what high risk is varies in their mind.  10% might be high risk to them, but not to me, etc.  

No one told me about the VNPI either.  I figured it out from here, too.  My score was a 9 or a 10 (depending on which pathology report you go by, margins < 1mm on one,  <2 mm on the other).  So I'm on the borderline for that study, depending on which pathologist I trust.  Oh, BTW, the study I'm referring to is one where they applied the VNPI to postMX:  http://www.springerlink.com/content/d70rn4j73m950552/fulltext.pdf  

Thank you for the empathy - it all pretty much s*cks when it comes to bc, eh?  LOL

Oh, and yes, microfat grafting helps with rads, for sure.  I'm so glad I had that done instead of implants, b/c now I don't have to worry about capsular contracture with rads.    Microfat grafting after rads takes many more surgeries, though, b/c it takes longer to get the skin/tissue to expand with Brava.  That is why my PS is squeezing one more session in Dec 23rd...and then if I have rads it will be in January.  

undercoverebel

Well add another question mark to the list. That's all I have left after seeing my second RO today. I will quote this genius:"You never really had cancer. And the reason we don't do studies too much on your type of case is because no one really wants to. It's not a big number of cases to study and it's so low risk for recurrence. However we would feel badly if you had a recurrence so we tell you about radiation. But after having a bi-lateral mastectomy and going thru all of that we would feel bad having you go thru radiation when the studies just don't show any real benefit. I think it's a reasonable decision you're making not to have them but understand if you want to overtreat your case. The studies just don't show enough to warrant it and the cases we have studied show no major difference. Of course we could have new stats next year showing something different. We at this Kaiser think you're more at risk because of your age and very small margin to the chest wall. But even with that it's a small risk. Now San Francisco Kaiser doesn't think you're at a higher risk with their studies. We can't say radiation won't cause heart issues,lung cancer and other problems.We can't say for sure that it does or doesn't. The risk is small at this point.But when you add up the diiferent problems people have after having it done we start to see where there could be a link. But we don't have too much information on that either."  Where to begin-he knows nothing about DCIS or the word carcinoma if he thinks I never had cancer. I guess the early stagers are left in the cold because we're not serious enough. I'll be sure to tell him my opinion if I ever recur.  

dancetrancer

OMG undercoverbel.  How infuriating, confusing, frustrating...ugggghhhhhhh!!!!!   

cycle-path

rebel: one of my friends used to remind me that in every graduating class of doctors there was one person who was at the top of the class and one who was at the bottom. 

undercoverebel

CYCLEPATH- Well he was assistant chief so I'd hate to see the others beneath him-oh,wait I did last time. *****DANCE-It sucks but if they keep telling you your risk is small you tend to believe it. Even w/everything I have it's small. But the obsessor in me can't let it go yet. There are not enough stats to make me truly believe it. I'll still check other doctors and internet sites for info as i'm not scheduled for surgery anytime soon.

mom3band1g

undercover.....what an asshat.  My blood was boiling just reading about your encounter with that "dr".  Run from him.  Seriously, what a &^%$(.

Natters

Why did you need a MX if you never had cancer??!!! I agree with mom: what an asshat!!!



Can you get a third opinion?



I'm finishingup rads this week with an RO I do not like, but I stuck with him because he was the only breast RO at the hospital I wanted....sucks to see him every week.

Springtime

ZT, I had rads, no question I needed them, but you have just DCIS. Good luck w/your decision. 

Just wanted to add that having Rads can have some side effects. I have Lymphedema partly from Rads (my RO says) and that area is very tight - I am still working on range of motion 3+ years later. (I had arm pit and clavacle also treated).  

If you do it, maybe just focus on chest wall and opt out of arm pit and clavacle. If I was you, and my RO said I didn't need it, I would skip it. Your cancer is not invasive and you had clear margin from the chest wall.

ZTeam

Hi Springtime,

Thanks so much for your response and advice. I've been concerned about the side effects of radiation and would kick myself if I did have one of the more serious complications when I don't really need to do rads. My grandmother had lymphedema after a mastectomy and rads, so I'm especially worried about that.

Wishing you well,

Lisa 

undercoverebel

MOM3-I was so tempted to pull the b**ch card but I didn't want to argue w/him. You cannot convince people they are wrong,especially the "specialists." I will def seek opinions elsewhere before recon surgery.*****NATTERS-I suppose he could think it wasn't "really cancer" because I elected to have the bmx,I don't know. I wasn't forced to as it wasn't thought of as a huge life-saver. To me it was. It reminded me of the "From zero to mastectomy" author. When her doctor said she didn't really have cancer she responded "Someone sign me up for the fake mastectomy!"   

dancetrancer

Ok ladies, I'm continuing my rads long term side-effects research...I looked at several articles that of course demonstrate definitely increased risk of heart damage for those having rads in the 70's and 80's (on the L side especially).  Here is an article from 2005 that looked at how that risk has been steadily decreasing over the years (but again, no long term studies on the newer techniques like respiratory-gated rads yet - b/c they haven't been around long enough to study that way - only have modeling studies).  I have highlighted some important points. 

---------------------

Risk of cardiac death after adjuvant radiotherapy for breast cancer.

Abstract
BACKGROUND:
Women with breast cancer who are treated with adjuvant radiation have a decreased risk of local recurrence but an increased risk of mortality from ischemic heart disease. Patients with left-sided breast tumors receive a higher dose of radiation to the heart than patients with right-sided tumors. Because radiation techniques have improved over time, we investigated whether the risk of death from ischemic heart disease after adjuvant breast radiotherapy decreased over time.

METHODS:
We used the 12-registry 1973-2000 dataset from the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) program. Women (n = 27,283) treated with adjuvant radiation for breast cancer diagnosed in 1973-1989 were included in the study. Ischemic heart disease mortality was calculated at 15 years and compared for women diagnosed during 1973-1979, 1980-1984, and 1985-1989. Cox proportional hazards models were used to calculate the hazard of death from ischemic heart disease for women diagnosed 1973-1988 and censored at 12 years. All statistical tests were two-sided.

RESULTS:
There were no differences in age, race/ethnicity, disease stage, or follow-up time between the 13 998 women with left-sided and 13 285 with right-sided cancer. For women diagnosed in 1973-1979, there was a statistically significant difference in 15-year mortality from ischemic heart disease between patients with left-sided (13.1%, 95% confidence interval [CI] = 11.6 to 14.6) and those with right-sided (10.2%, 95% CI = 8.9 to 11.5) breast cancer (P = .02); no such difference was found for women diagnosed in 1980-1984 (9.4%, [95% CI = 8.1 to 10.6] versus 8.7% [95% CI = 7.4 to 10.0], respectively, P = .64) or 1985-1989 (5.8% [95% CI = 4.8 to 6.8] versus 5.2% [95% CI = 4.4 to 5.9], respectively, P = .98). In the Cox model, the hazard ratio [HR] for ischemic heart disease mortality for women with left-sided versus women with right-sided disease was 1.50 (95% CI = 1.19 to 1.87) in 1979. With each succeeding year after 1979, the hazard of death from ischemic heart disease for women with left-sided versus those with right-sided disease declined by 6% (HR = 0.94, 95% CI = 0.91 to 0.98).

CONCLUSIONS:
Risk of death from ischemic heart disease associated with radiation for breast cancer has substantially decreased over time.

 ----------------------------------------------------

dancetrancer

Springtime - thank you for your input.  I will discuss opting out of the armpit and clavicle with my RO, should I decide to proceed with rads.  Ugggh...petrified of LE.  

Natters

Dance, I read some studies like that before I started rads and they were very comforting. My RO never mentioned respiratory-gating, but results like those (no differences between L and R side BC patients dating back to the 80s) made me think they weren't necessary for me. Apparently, he is able to avoid my heart completely and only urging a "clinically insignificant amount" of my left lung. But it might depend on your anatomy and pathology. They have much better imaging and rads techniques now (CT, IMRT) and dosimetry has probably also come a long way since the 80s. I'm not gonna lie and say I don't ever worry about it, because I do so much to keep my heart healthy and strong, but the data suggests we'll probably be OK.

dancetrancer

Here's some more interesting information.  On another thread, we were discussing how radiation has not been shown to affect overall mortality, but this had to do with what endpoint they were looking at (confusing, yes).  In this commentary I found below, they purport the reason an overall difference in mortality was not seen was because of the increased deaths due to cardiac events (scary, indeed, but read on).  The author of this commentary says that now we are seeing a reduction in long term mortality with the addition of radiation, due to improvements in rads resulting in a reduction in cardiac deaths.

------------------------------------------------------------ 

Radiotherapy for Breast Cancer

The role of radiotherapy in the treatment of breast cancer has a long and controversial history. One of the first clinical trials ever performed, beginning in 1949, studied this question (1,2), and it remains the subject of new trials that are still being initiated today. Early trials clearly demonstrated that radiotherapy reduced local relapse, with a relative risk reduction that is now known to be about 70%. However, the reduction in relapse rates did not translate to a reduction in mortality. Many theories were suggested to explain this disparity, including a detrimental effect of radiotherapy on immune function (3). These mortality concerns were crystallized in the first individual patient data overview of cancer trials (4), which showed that radiotherapy had little effect on mortality in the first 10 years of follow-up but was potentially detrimental in the longer term. A report of Rutqvist et al. (5) and further evaluation of cause-specific mortality from the first overview (6) clearly demonstrated that there was a late excess of cardiac deaths that was masking a potential reduction in deaths from breast cancer. Further confirmation of these findings was provided by a larger subsequent overview that included many more recent trials (7).

The point of these overviews was not to dismiss radiotherapy as a treatment for breast cancer but to make clear that changes in its administration were needed if its benefit in terms of reduced late breast cancer deaths was not to be nullified by increased cardiac mortality. Radiotherapists have heeded this call, and important modifications to the fields used and individual patient planning have greatly reduced the cardiac dose. It is a matter of some satisfaction that these early overviews have changed practice and that we are now beginning to see the benefits of these improved protocols. Excess cardiac deaths do not appear to be occurring in the more recent trials, and breast cancer deaths are indeed reduced (8,9).

-------------------------------------

I bolded that last statement because I went and looked at both studies.  I'm reviewing the first one right now.  It looked at Stg II and III bc, so of course it doesn't directly apply to our situation, but we can still learn from it.  It's an older article from 1997 - they looked at patients treated from 1982 to 1989.  These patients all had the MX and the same chemo, the difference was whether they had rads or not.   They found that overall survival at 10 years was greater for those who had rads.  

So in reading the study, I looked at the conclusion section and saw the following interesting comment:  

Recurrences on the chest wall and in the axilla (without concomitant distant metastases) were treated with curative intent. Most patients who did not receive radiotherapy were treated with resection of the recurrent tumor followed by radiotherapy, whereas patients who had received radiotherapy were treated with surgery alone. The significant difference in overall survival between the group treated with radiotherapy plus CMF and the group given CMF alone indicates that second-line treatment cannot compensate for inadequate primary therapy. 

------------------------------------------------- 

 Ok, so I bolded that last statement.  I know we cannot begin to compare these patients to those with DCIS, but I can't help but think that it is important to know that recurrence after rads, treated by surgery, had a better outcome than recurrence without rads treated later by rads and surgery.  I guess this catches my attention b/c in the back of my mind I had been thinking that if I have a recurrence then I'll be able to tx it with rads...but at least in this group of patients (again, remember, they are far from DCIS only), that wouldn't have been the best plan.  Just some food for thought and something to ponder on a Sunday morning...should we look at this study and learn anything from it, or throw it out b/c they aren't DCIS patients?  I think we cautiously try to gain something from it, without going overboard and jumping to conclusions, either.  Hope I haven't confused anyone, other than myself, LOL!  

dancetrancer

Thanks Natters!  I have read that your anatomy does make a difference - if you heart is very anterior you have more risk.  

dancetrancer

OK, here's a recent one I did NOT like to read, which shows increased risk still for those with radiation to the L side - done on patients treated from 1990 to 1994 and follow up completed 10 years later in 2004.  This is done on older patients, and they say you should consider that when doing rads...so I guess that means an older heart doesn't withstand the rads as well.  Anyone have thoughts on that? 

Long-term Safety of Radiotherapy and Breast Cancer Laterality in Older Survivors 

Abstract

Background: Although adjuvant radiotherapy (RT) following surgery for breast cancer improves overall survival, controversy exists about its long-term adverse impact on cardiovascular health in older survivors.

Aim: To determine whether incident cardiovascular disease (CVD) is associated with RT and whether tumor laterality modifies this association.

Methods: Women aged 65+ years diagnosed with stage I and II breast cancer between 1990 and 1994 were identified from three health plans. Women were followed through CVD outcomes, health plan disenrollment, death, or study end (December 31, 2004). The main independent variable was RT use. Adjusted HRs and 95% CIs were estimated using Cox proportional hazards models with time-dependent tamoxifen and RT use status. We adjusted for age, race, stage, estrogen receptor/progesterone receptor, hypertension, and diabetes.

Results: In the full cohort (N = 806), RT was not associated with greater risk of CVD (maximum follow-up was 14 years). However, within the RT-exposed group (N = 340), women treated for left-side breast cancer had a significant increased risk of CVD outcomes (HR = 1.53, 95% CI: 1.06-2.21) compared with women with right-sided tumors.

Conclusion: Laterality is critical to understanding the effect of RT on CVD. Studies of more contemporary cohorts of women treated with RT should incorporate this variable to determine whether the risk persists with refinements in the dosing and delivery of RT.

Impact: As some irradiation to the heart is unavoidable even with refined modern RT techniques, continued effort is required to minimize such exposures, especially in older women with left-sided tumors. Cancer Epidemiol Biomarkers Prev; 20(10); 2120-6. ©2011 AACR.

 -----------------------------------

I hope you all are still finding this useful, even though it's confusing. 

dancetrancer

Here are guidelines put out by the European Sociey for Medical Oncology (2010).  The description for radiation starts page 4.  

Cardiotoxicity of chemotherapeutic agents and
radiotherapy-related heart disease: ESMO Clinical
Practice Guidelines 

Selected snippets:

Risk factors for radiation-associated heart damage include:
dose >30-35 Gy, dose per fraction >2 Gy, large volume of
irradiated heart, younger age at exposure, longer time since
exposure, use of cytotoxic chemotherapy, endocrine therapy or
trastuzumab, presence of other risk factors such as diabetes,
hypertension, dyslipidaemias, obesity, smoking, etc. 

......

cardiac structures affected by radiation
Injury of the various structures and tissues in the heart can
cause a spectrum of radiation-induced CV diseases.
Arteritis of the endothelium of coronary arteries can cause
premature coronary artery disease and atherosclerosis mainly
in left anterior descending and right coronary artery. Time of
appearance is 10-15 years after RT.
Acute pericarditis and symptomatic (haemodynamic
compromise with constriction or tamponade) or
asymptomatic chronic pericardial effusion, appears usually 6-
12 months following RT.
Myocarditis and congestive heart failure due to non-specific
diffuse interstitial fibrosis.
Valvular stenosis and regurgitation mainly of mitral and
aortic valves.
Fibrosis of the conduction system and disturbed heart rate
and complete or incomplete heart block.
Some indirect implications on the heart may result from
irradiation of adjacent structures. Lung and mediastinal
fibrosis may result in respiratory insufficiency, pneumonic
hypertension and may complicate any potential heart surgery.
Hypothyroidism may affect the lipid profile and CV function.
Mediastinal venous and lymph vessel obstruction may cause
pericardial effusion or chylothorax. 

 ................

The article goes on to talk about ways to reduce the cardiac radiation effects; it was technical stuff - feel free to read on yourself, or I can post it if anyone is super interested.

Not happy reading all these latest studies I've posted.  OK, time for a break from this!  

undercoverebel

DT-My head is spinning w/that info. Well at least after all of this you can say you've read everything you could and you'll make the best decision possible.

mom3band1g

Dancetrancer - just an fyi...you wouldn't be getting rads to your clavicle or armpit.  That is for women with nodal involvement.