Radiation necessary in an early stage cancer

PIP, anybody who had a biopsy showing DCIS and then a surgical path showing otherwise did not JUST have pure DCIS when they were diagnosed  - they had a mixture of both DCIS and invasive disease, and it's that invasive disease that could become metastatic.  If a case of pure DCIS has been surgically removed in it's entirety AND there's no invasive disease present, then not only is the chance of that DCIS causing metastatic disease minisule, it's actually more like absolute ZERO.

Lot's of people get diagnosed with both invasive and non-invasive disease at the some time and because of the invasive component, it's possible they might eventually develop positive nodes or mets at some time...but if they do, it's NOT because of the DCIS - it's because of the invasive disease. Many, many more get diagnosed with PURE DCIS...and these people are not going to have positive nodes or of develop metastatic disease if what they have at the time they are diagnosed and treated is just pure DCIS and nothing else. 

You asked "Why does it seem so unthinkable to you that some, maybe many, of the followup tx  never reveals what is truly in the breast." 

I don't know where on earth you get the idea that I think it's unthinkable that there could be something other than DCIS in the breast which never gets detected. Of course there's always that possibility. That's why women sometimes have MRI's looking for it as part of the diagnostic process and that's what I was talking about when I wrote of occult disease - "occult disease" is the presence of something undetectable, yet known to be there.   

And by the way, I'm not the one suspicious of the monetary motives of rad oncs either - that's MDB and I am not MDB.  I'm willing to forego the recommended rad treatment NOT because I'm suspicious that they're only doing it for money, but because:

1) I had a small, low grade invasive breast cancer with all otherwise prognostically favorable variables which was removed with very wide margins and thus very likely to have been surgically cured. Considering this fact, I'm perfectly comfortable assuming the small amount of potential risk of recurrence by not doing radiation. Some people aren't - but I AM. 

2) my cancer was left sided and I have valvular heart disease and didn't want to risk the rads worsening that problem or causing coronary artery disease in the future  -  bad risk vs benefit ratio, 

3) Because I've been a smoker since the age of 16 and didn't want to assume the very significant additional risk of radiation induced lung cancer that goes along with recieving rads to the chest area when someone has a past or present history of smoking - again, bad risk vs benefit ratio.

So you see, my decision to refuse radiation has absolutely nothing whatsoever to do with concerns about money making schemes. It's strictly about making an educated decision, weighing the risks vs potential benefit and choosing what's best for me and my particular situation. 

Pardon the sarcasm. Living with stage IV can make one that way. Since your post affirms my statement, I'm not understanding why your panties are in such a wad.

I'm SO SORRY if it makes me just a little bit HOSTILE when I see people taking what I believe are UNNECESSARY RISKS and making statements that can have the affect of frightening someone away from what *might* be appropriate in their case at one of the most vulnerable time of life he or she will ever experience. 

I sincerely and deeply wish that no one else would ever have to be dx'ed with stage IV. I think that, perhaps, there is motivation in the medical establishment to "push" treatments on early-stage cancers that *seem* to be overkill because they tend to see the results of what can happen when a stray cell or two gets a foothold.  From my perspective, I wish that everyone would pursue the most aggressive treatment available to him or her because I know firsthand what it's like to hear the words, "You're terminal." It IS a personal decision that one should make as fully informed as possible.  

I'm SO SORRY if it makes me just a little bit HOSTILE when I see people taking what I believe are UNNECESSARY RISKS and making statements that can have the affect of frightening someone away from what *might* be appropriate in their case at one of the most vulnerable time of life he or she will ever experience. 

 Thank you Badboob.  I too have been highly insulted by this charlatan who calls herself MDB (not Marie Kelly) and who blasts the medical profession and Radiation as "Bullshit'. 

I wish you well and hope you are successful in treating your condition as a chronic disease instead of a terminal disease. 

Okay, I just checked the metastasis board, and we now have 3 women with no nodes positive, and tiny tumors who are metastasized.  They had the whole works.  One has had a reccurence first, all the others did NOT HAVE a reccurence first, went from diagnosis to mets. I did not ask the stage of their cancers, I felt I was intruding as it was with my question. We have 14 responses, all had no recurrence before mets but the one.

We still don't seem to have a really good study telling us if radiation has any affect on metastasis.  It is generally described as a "local treatment", to pick up any cells around the original site.  At least that was what I was told.

I don't really know what to say, this whole disease is a crapshoot, that I know for sure.

DCIS can surely be trouble.  If nothing else, you never feel the same about your bodies.  The very word "cancer", in any context throws us all into a real world of hurt.

So on we go, sisters dear, trying our hardest to come to terms with a difficult time in our lives and help each other too.  

And Gayle, truly, I don't think anyone will say anything about your decision about rads, the big objection was broad statements telling people that the only reason so many are given rads is for money, or it was a knee jerk, unthought out prescription for everyone.  I think we have an obligation to sorta stay with our own decisions, for sure, but not make broad "reasons" why one or the other treatment is recommended.  That might scare off the very people we need to help.  No one objects to you saying, "I have chosen not to have rads".  Perfectly legitimate.  Your own personal choice.  But if you say, "No one should have radiation, unless they have a high grade tumor or node involvement" is getting into dangerous territory, mainly for the newcomers, since it doesn't seem anyone knows for sure if radiation is useless in small cancers with no nodes, except for recurrence, which would annoying as the dickens, but not fatal.   

Gentle hugs, Shirlann 

Oh yeah, worriedhubby, this whole thing is really, really a very scary journey.  And my favorite of all is, "It is your decision".  WHAT!  I was a history major.  They have the medical degree.  But of course, the "one size fits all" is annoying too.  I often wonder, my mom was 114lbs, my second son is6' 5" and when (at different times) they both got sick, they got the same prescription with the very same dosage.  Seemed wrong.

So the same old thing, as usual, applies, do your homework as best you can.  Seek out the onc/doc/surgeon who has the best reputation if you can (we are limited to a list of docs/surgeons, etc.) when possible.  Read, read, read.

I take tons of supplements, but once you have cancer, it is a little late to expect good health habits will be of a lot of help.  Because, they should have started in childhood, and for most of us, it didn't.  But it is never too late to begin to change that, if it accomplishes nothing more, you at least feel you are doing all you can.

I think one reason we have to decide on our own treatment, with some help and advice from the oncs, is that this disease is so darn quirky, no one, and I mean no one, has all the answers.

Then we get into genetics.  I think almost all of us have been there.  My mom's side had absolutley no cancer we could ever find.  Her, her brother and sister, all their cousins, parents, grandparents, etc. no cancer of any kind.  My dad WOW, he died of lung, his father of stomach, his mom of colon cancer, one sister of ovarian, one sister of liver and one sister of bladder.  Of all these siblings they had 5 natural children.  2 have died of cancer, I have had it, and one cousin died at 45 of a heart attack.  Leaving only one cousin that has not been touched.  BUT, no breast cancer.  Sheesh, makes you want to tear out your hair.

Do the oncs often just go with the flow?  Of course, we are all only human, and if you are smart, you learn all that you can and then do the best you can.  After that, it is in the lap of the Gods.

Dr. Love had a great story in her book.  A woman was brought to her from Asia by her two sons.  She had a locally advanced, huge tumor.  Dr. Love thought to herself, "this lady is toast".  Well, the lady did not speak one word of english, all the conversations were translated, very briefly to her by her sons.  !0 years later, the lady came back (was brought back) for a check up and was just fine.  Dr. Love said, "I believe in my heart of hearts that part of it was she did not have a clue what was wrong with her and had no stress at all".  Who knows.

So on we go, we all do the best we can and hope we get to be old ladies in a rest home, cradling a doll, calling a sweet nurse "mama".

Hugs and kisses to all, Shirlann 

I have been avoiding this thread because I didn't feel it was my place to post with my diagnosis but some of the comments made on both sides of the debate have been extremely disturbing to me.  It is not neccessary to be rude, disrespectful or derisive to express your opinion.  As for my opinion:

Those who have other medical conditions that may be negatively affected must always take all aspects of their health into consideration when deciding on a course of treatment.  Looking at the big picture may easily over ride the best treatment for BC.

I feel that those who are diagnosed as being totally "in situ" are reasonable in considering the alternative of skipping radiation. 

Personally I would never consider skipping radiation for any "invasive" BC regardless of size or grade but It is a personal decision and one that I am looking at from the perspective of someone who was metastatic at diagnosis. 

I would also not be one to have too much faith in a mammo being able to catch a reoccurance early, again due to my personal experience.  With me, a mammo clearly showed a lump that was not palpable in the upper outer quadrant however the lumpectomy failed to get clear margins.  When I finally did get a mastectomy after doing chemo, not only was there the tiny little tail left from the lumpectomy but there was also LCIS, ALH and they found flecks of IDC scattered throughout the breast, the largest of which measured 4 mm.  None of this showed up on the mammo or US done before chemo and who knows how big it was then.  Maybe it would have shown up on a MRI but MRIs are not generally offered as they tend to show so much detail that there are high numbers of suspicious findings prompting biopsies for benign conditions.

And now, for what it's worth, you know how I feel about it.

Bethesda, MD-

Radiation exposure, a well-established risk for cancer, likely also ups the risk of heart disease, radiation researchers write in a Comment in the August 30, 2008 issue of the Lancet [1].

While the cancer risks associated with radiation are well documented, less is known about the effects on the heart, Dr Parveen Bhatti (National Cancer Institute, Bethesda, MD) and colleagues write.

Study coauthor Dr Kiyohiko Mabuchi (National Cancer Institute) explained to heartwire that the link between high-dose cancer radiotherapy and increased heart disease has long been known. "This has resulted in a substantial reduction, though not total elimination, in cardiac doses from radiotherapy for breast cancer, Hodgkin's lymphoma, etc," he said.  "What is new is that recent studies, such as those of Japanese atomic-bomb survivors and patients with benign diseases irradiated at lower doses, have reported an increased CVD risk associated with radiation doses hitherto considered too low to cause cardiovascular effects."

The "most convincing evidence so far," the authors write, is a dose-response study of patients who underwent radiation for peptic-ulcer disease with cardiac radiation doses of 1.6 to 3.9 Gy, which suggested that radiation exposure even lower than the standard "therapeutic" doses can increase cardiovascular risk.

The main barrier to establishing a causal link between radiation and cardiovascular disease-and whether low doses (less than 5 Gy) may damage the heart and circulatory system-is the lack of an "established biological model," Bhatti et al write. But they point out that an inflammatory response to radiation is a "plausible" pathway by which atherosclerosis could develop, although further studies would be needed to address this possibility.

The problem, they note, is that the much smaller relative risk of cardiovascular disease from radiation, as compared with the relative risk of cancer, means that cancer risk will always be the focus, particularly since any bump in CVD is occurring on a high background rate of CVD.

"The low-dose radiation effects on CVD risk are likely to remain challenging and controversial-even more so than the linear no-threshold arguments for cancer risk that are debated to this day-but should not be dismissed," Bhatti et al conclude.

Mabuchi emphasized to heartwire that physicians across disciplines should be aware of the potential radiation risks to the heart. "The effect of low radiation dose on CVD should be a concern for radiation oncologists who are involved in treatment of breast cancer, Hodgkin's lymphoma, and other cancers and for radiologists and cardiologists who are increasingly using interventional radiology and other new techniques-eg, intensity-modulated radiation therapy; these may deliver considerable doses to the heart. The effects of very low doses, as seen in nuclear workers, are still uncertain, as we emphasize in the Comment, but are of potential concern because of the large number of people occupationally exposed to such doses, including medical radiation workers."

I reallly haven't said much on this thread.....Too hot for me! 

owever, I just posted my thoughts on another thread... much like this one....and decided to do the same here.

For what it's worth, deciding to do rads after my lumpectomy was not a hard decision fo rme to make....That's because I wanted to do the best I could to irridacate the Monster from my body.  I knew Tamox was not an option for me, so this was my best shot at preventing a recurrence in the future.

During my treatmetns..which ended this past Monday....I took great satisfaction   in knowing any left over caner cells were being...hopefully....fried to a crisp..... The total experieince was a positive one....My techs and nurses were very supportive, and my doctor was great.  I saw him once a week, and will see him again on September 12th.....The day after I turn 65!  (Sept. 11th)...

My fear...when reading certain posts...is that someone new will read them and decide not to do radiation when it would be clearly beneicial for her to do so....The negative posts may be just the thing that will tip the scales when a woman is trying to make an informed decison...and she is already afraid of radiation...I was concerned, too, but knew I wanted to do the best I could to get rid of my cancer.

To say...in a cavalier way...that if your cancer comes back you will simply have it cut out.. again..is, I think irresponsible.....The idea is to prevent recurrencces, because no one knows just what form a recurrence will take.....DCIS can easily come back as IDC....That may happen to me, but I know that I have done my best to prevent it....Knowing that I cannot take Tamox made it even more important to me that I had radiation....Although I am sure I would have done it regardless of whether or not I could have taken Tamoxefin...

Sandy

As you quoted me, "Radiation as Bullshit."  I don't think I ever said that, but it's a fair summation, of what I believe. Radiation is bullshit, for early stage breast cancer. Which is what I had.

Yea you did.  These are quotes from you in your post before your latest:

 And the current "story of the day," in this presidential election is Universal Health Care." Meaning, universal "paying for everyone's illnesses." And bullshit treatments, like Breast Radiation. For Stage 1 cancers, with no node involvement. Or even Stage 0 cancers, which aren't even cancer.

 Sure beats bullshit radiation, treatments

You also said:

Ha, I know I should just ... leave this board.  I don't belong here, anymore.

Even I wouldn't necessarily agree with this because even the truly ignorant and foolish, and you are nothing if not that,  should have the right to speak. 

This is a confusing Thread, but this pretty well lays it out:

Radiation Therapy for Breast Cancer

This is a confusing Thread, but this pretty well lays it out:

Radiation Therapy for Breast Cancer

Overview

The objective of radiation therapy to the breast is to kill cancer cells that could otherwise persist after therapy and cause breast cancer to relapse locally in the breast, surrounding chest wall, or axilla. Radiation therapy uses high energy x_rays to kill cancer cells that remain in the breast or surrounding lymph nodes after surgery. Radiation therapy is almost always utilized as part of the overall breast_conserving strategy because radiation decreases the risk of local cancer recurrence and improves survival. Radiation therapy is delivered to the breast and surrounding lymph nodes from a machine outside the body and is called external beam radiation therapy. Treatments are typically given daily over a 5_6 week period and additional concentrated radiation treatment, called a boost, may be given directly to a smaller area of the breast where the cancer was found.

Side effects from radiation therapy may include a swelling or heaviness in the breast, sunburn_like changes in the skin, and fatigue. Changes to the breast and skin usually go away in 6_12 months; however, in some women the breast may become smaller or firmer following radiation therapy. The size of the breast and the woman's desire for breast reconstructive surgery are important considerations that should be addressed prior to receiving radiation treatment.

Ductal Carcinoma In Situ (DCIS)

Patients with DCIS treated with mastectomy do not need treatment with radiation therapy. Radiation therapy after a lumpectomy decreases the risk of cancer recurrence. In one clinical study, 818 women with DCIS and negative surgical margins were treated with breast radiation or no further therapy after a lumpectomy. Eight years following treatment, the recurrence of invasive cancer was 3.9% for patients treated with radiation therapy and 13.4% for patients not treated with radiation therapy.

Stage I Breast Cancer

Patients with node negative stage I breast cancers treated with breast_conserving surgery utilizing a lumpectomy are currently recommended to receive additional treatment with radiation therapy. This recommendation is based on 4 clinical studies that directly compared lumpectomy to lumpectomy plus radiation treatment. These studies found that patients treated with the combination of lumpectomy plus radiation had a superior clinical outcome. Other clinical studies have demonstrated that patients treated with lumpectomy without radiation are more likely to experience cancer recurrence than women treated with the combination of breast_conserving surgery and radiation.

Standard radiation therapy following a lumpectomy consists of a limited dose of radiation (50 Gy) to the entire affected breast. While this treatment leads to long_term outcomes similar to those from mastectomy, women under age 50 experience higher rates of local recurrences following this treatment regimen compared to their elder counterparts. Researchers have theorized that an additional boost of radiation aimed only at the area from which the cancer was removed would reduce the rates of local recurrences, especially in younger patients.

The European Organization for Research and Treatment of Cancer conducted a clinical trial evaluating 5,318 women diagnosed with stage I or II breast cancer who had undergone a lumpectomy followed by the standard dose of radiation. Approximately half of the patients were given an additional small dose of radiation (16 Gy) to the area where the cancer had been located, while the other half received no additional treatment. Data indicated that the additional dose of radiation to the site of the removed cancer reduced the overall rate of a local recurrence by nearly 50%. Women 40 years old and younger exhibited the largest benefit, with local recurrences occurring in only 10.2% of patients receiving additional radiation, compared to 19.5% of those receiving standard treatment. Overall survival rates and the development of distant metastases were similar whether women received an additional boost of radiation or standard therapy. Side effects including cosmetic results and fibrosis (formation of scar tissue) were not affected by the additional radiation.

Patients with stage I node negative breast cancers treated with mastectomy do not typically require additional local treatment with radiation therapy. Some patients treated with mastectomy may however have an increased risk of local cancer recurrence. In these cases, the role of radiation therapy to prevent local cancer recurrence should be discussed with the treating oncologist. Node negative cancers at increased risk of local recurrence include cancers that involve the margin of resection.

Stage II_III Breast Cancer

Patients with node negative stage II breast cancers treated with breast_conserving surgery utilizing a lumpectomy are currently recommended to receive additional treatment with radiation therapy because radiation decreases the risk of local cancer recurrence and improves survival.

The role of radiation therapy following mastectomy in women with stage II or III breast cancer is somewhat controversial. An analysis of several clinical studies begun before 1985 found that radiation decreased the risk of local cancer recurrence by 67% and decreased the risk of dying from breast cancer by 6%, but did not improve survival. Survival was not improved because patients treated with radiation died for other reasons. These deaths resulted mainly from heart problems in older patients and could have been a late side effect from the radiation treatment. Because of these analyses, radiation therapy was not typically recommended for women with stage II or III breast cancer treated with mastectomy.

Standard radiation therapy following a lumpectomy consists of a limited dose of radiation (50 Gy) to the entire affected breast. While this treatment leads to long_term outcomes similar to those from mastectomy, women under age 50 experience higher rates of local recurrences following this treatment regimen compared to their elder counterparts. Researchers have theorized that an additional boost of radiation aimed only at the area from which the cancer was removed would reduce the rates of local recurrences, especially in younger patients.

The European Organization for Research and Treatment of Cancer conducted a clinical trial evaluating 5,318 women diagnosed with stage I or II breast cancer who had undergone a lumpectomy followed by the standard dose of radiation. Approximately half of the patients were given an additional small dose of radiation (16 Gy) to the area where the cancer had been located, while the other half received no additional treatment. Data indicated that the additional dose of radiation to the site of the removed cancer reduced the overall rate of a local recurrence by nearly 50%. Women 40 years old and younger exhibited the largest benefit, with local recurrences occurring in only 10.2% of patients receiving additional radiation, compared to 19.5% of those receiving standard treatment. Overall survival rates and the development of distant metastases were similar whether women received an additional boost of radiation or standard therapy. Side effects including cosmetic results and fibrosis (formation of scar tissue) were not affected by the additional radiation.

In late 1997, the results of two clinical studies evaluating treatment with mastectomy followed by chemotherapy with or without radiation in premenopausal women with stage II_III breast cancer were reported in the New England Journal of Medicine. In both studies, women treated with radiation following mastectomy and chemotherapy lived longer and were less likely to develop a recurrence of cancer. Radiation therapy decreased the risk of dying from cancer by approximately 33%. The probability of surviving 10 years from treatment was increased from 54% to 64% and 45% to 54% in the two studies, respectively. No significant long_term side effects of radiation therapy were reported. Current evidence increasingly supports the use of radiation following surgery and chemotherapy in women with stage II or III breast cancer. Certain groups of women known to be at high risk of local breast cancer recurrence should strongly consider radiation therapy. These include:

Cancer greater than 5 centimeters in greatest dimension

4 or more involved axillary lymph nodes

Cancer involving the margin of resection

What is the Optimal Sequence of Radiation in Stage I_III Breast Cancer?

The timing or sequence of radiation therapy may be important. A large clinical study has addressed the question of whether radiation therapy should be given before or after chemotherapy following breast_conserving surgery. Following breast_conserving surgery, half the patients were treated with chemotherapy followed by radiation and half were treated with radiation followed by chemotherapy. The patients treated with chemotherapy followed by radiation were more likely to be alive 5 years from treatment than patients treated with radiation followed by chemotherapy. Patients treated with chemotherapy survived longer because they were less likely to experience systemic (metastatic) recurrence of their cancer. Patients treated with radiation first, however, were less likely to experience a local recurrence of their cancer.

It is much easier to treat local recurrence of cancer than systemic recurrence of cancer and this may explain why patients treated with chemotherapy followed by radiation had improved survival compared to patients treated with radiation followed by chemotherapy. An additional explanation is that delivering radiation therapy before chemotherapy treatment of systemic disease may adversely affect the doctor's ability to deliver the chemotherapy treatment. Although the sequence of treatments is undergoing continued evaluation, the current data suggest that standard treatment of breast cancer outside the context of a clinical study should include definitive surgery first, followed by systemic chemotherapy and lastly, radiation. Hormone therapy can begin during or following radiation therapy. One notable exception to this sequence is patients with locally advanced breast cancer. In these patients, administration of chemotherapy prior to surgery (neoadjuvant) may allow for greater breast conversation.

Stage IV or Recurrent Breast Cancer

Radiation therapy also plays an important role in women with stage IV or recurrent breast cancer. Chemotherapy and hormonal treatment are the mainstay for women who have stage IV breast cancer at the time of diagnosis. Local control of breast cancer eradication has less impact on a patient's outcome because the major cause of treatment failure is systemic cancer recurrence. Therefore, radiation therapy to the involved breast has not typically been recommended for women receiving systemic chemo_hormonal therapy for metastatic breast cancer.

More recent aggressive chemotherapy treatment of stage IV breast cancer has been reported to produce long_term survival without cancer recurrence in 15_20% of women. Since these women are not experiencing a systemic cancer recurrence, prevention of cancer recurrence in the breast or lymph nodes is of greater importance. The results of a clinical study in which women with stage IV breast cancer achieving a complete remission to chemotherapy followed by high_dose chemotherapy and autologous stem cell transplant and local radiation to the breast was recently reported and raises the question of whether radiation may be beneficial in women with stage IV breast cancer in complete remission.

In this study, the patients in complete remission treated with radiation therapy had a lower relapse rate and were more likely to be alive without evidence of cancer recurrence than women not treated with radiation therapy. The chance of relapse was 36% in patients not treated with radiation, compared to 19% in patients treated with radiation. Thirty_one percent of patients treated with radiation were alive without evidence of cancer recurrence at 4 years following treatment, compared to 21% of patients who were not treated with radiation. Patients treated with radiation were also more likely to live longer, with 30% alive 4 years following treatment, compared to only 16% of patients not treated with radiation.

While this clinical study was not designed to evaluate the role of radiation therapy in patients achieving a complete remission to chemotherapy, consolidative treatment with radiation therapy after chemotherapy_induced clinical remissions in women with stage IV breast cancer appears to reduce the risk of cancer recurrence and may improve a patient's chance of overall survival. Future clinical studies will need to be designed to evaluate the role of radiation in patients with stage IV breast cancer in a more formal manner.

Radiation for Palliation

Radiation therapy also plays an important role in providing symptomatic relief from advanced breast cancer. Patients developing metastatic cancer to the bone, skin, selected lymph nodes, and other sites can achieve a complete remission when treated with radiation to the site of cancer recurrence. Radiation can relieve symptoms from cancer and prevent fractures of bones when used early.

Copyright Breast Cancer Information Center on CancerConsultants.com

http://www.ufscc.ufl.edu/Patient/content.aspx?section=ufscc&id=667

worriedhubby wrote:..But with IMRT where the heart is not in the field of radiation, I don't understand how the heart will be damaged." 

Worried Hubby, even with IMRT, the heart still gets radiation in a left sided breast cancer as does the lung and contralateral breast in both right and left. It's just not as great as with conventional radiotherapy, but it hasn't been eliminated completely.  I'd love to be able to explain to you how it happens, but I don't know enough about the physics of radiation to even try. , All I know is from what I read in the research - and in them, there's no doubt that IMRT has not totally eliminated the problem of radiating areas other than the tumor itself.  ***and note the trade off mentioned here in this first one - more normal tissue receiving low dose radiation with IMRT, therefore a theoretical increased risk of secondary cancer as compared to conventional radiation.

Int J Radiat Oncol Biol Phys. 2007 Nov 1;69(3):918-24. Links

Is multibeam IMRT better than standard treatment for patients with left-sided breast cancer?

Radiation Therapy Program of the British Columbia Cancer Agency, Vancouver Island Centre, Victoria, British Columbia, Canada. wbeckham@bccancer.bc.ca

PURPOSE: When treatment intent is to include breast and internal mammary lymph nodes (IMNs) in the clinical target volume (CTV), a significant volume of the heart may receive radiation, which may result in late morbidity. The value of conformal intensity-modulated radiation therapy (IMRT) to avoid heart dose was studied. METHODS AND MATERIALS: Breast, IMNs, and normal tissues were contoured for 30 consecutive patients previously treated with RT after lumpectomy for left-sided breast cancer. Eleven-beam, conformal, inverse-planned IMRT plans were developed and compared with best standard plans. Conformity Index (CI), Homogeneity Index (HI), and doses to normal tissues were compared. RESULTS:Intensity- modulated RT significantly improved (two-sided paired t test) HI (0.95 vs 0.74), CI (0.91 vs 0.48), volume of the heart receiving more than 30 Gy (V30-heart) (1.7% vs 12.5%), and volume of lung receiving more than 20-Gy (V20-left lung) (17.1% vs 26.6%) all p < 0.001. The mean Healthy Tissue Volume (HTV = CT set - PTV) dose was similar between IMRT and best standard plans (6.0 and 6.9 Gy, respectively),  But IMRT increased the volume of normal tissues receiving low-dose RT: V5-right lung (13.7% vs. 2.0%), V5-right breast (29.2% vs. 7.9%), and V5-HTV (31.7% vs. 23.6%), all p < 0.001. IMRT plans were generated in less than 60 min and treatment delivered in approximately 20 min, suggesting that this technique is clinically applicable. CONCLUSIONS: IMRT significantly improved conformity and homogeneity for plans when the breast + IMNs were in the CTV. Heart and lung volume receiving high doses were decreased, but more healthy tissue received low doses. A simple algorithm based on amount of heart included in the standard plan showed limited ability to predict the benefit from IMRT.

PMID: 17889273 [PubMed - indexed for MEDLINE]

Am J Clin Oncol. 2006 Feb;29(1):80-4. Links

Does breast size affect the scatter dose to the ipsilateral lung, heart, or contralateral breast in primary breast irradiation using intensity-modulated radiation therapy (IMRT)?

Department of Radiation Oncology, University of Pittsburgh School of Medicine, Pittsburgh, PA 15232, USA.

PURPOSE: To evaluate the relationship between the primary breast volume and dose received by the ipsilateral lung, heart (for left-breast cancers), and contralateral breast during primary breast irradiation using intensity-modulated radiation therapy (IMRT). METHODS AND MATERIALS: Sixty-five patients with breast carcinoma were treated using 6-MV photons with IMRT technique using the Eclipse Planning System following breast conserving surgery. All patients had a treatment planning CT scan. The primary breast, ipsilateral lung, and heart were contoured on the axial CT slices. The primary breast volume was calculated using the Eclipse Planning System. The mean ipsilateral lung and heart doses were obtained from the dose-volume histogram. The contralateral breast dose was measured using paired thermoluminescent dosimeters (TLDs) placed on the patient's contralateral breast, 4 cm from the center of the medial border of the primary breast irradiation field. RESULTS: The mean dose delivered with photons to the primary breast for all patients was 49.97 Gy. The mean volume of the primary irradiated breast was 1167.9 cc. As a percentage, the mean ipsilateral lung, heart, and contralateral breast doses were 11.2%, 6.1% and 7.2%, respectively.  The primary breast volume positively correlated with the contralateral breast dose (P < 0.0005). There was no significant correlation between the breast volume and the ipsilateral lung or heart dose (P = 0.463 and 0.943, respectively). CONCLUSION: This study suggests that the primary breast size significantly affects the scatter dose to the contralateral breast but not the ipsilateral lung or heart dose when using IMRT for breast irradiation.

PMID: 16462508 [PubMed - indexed for MEDLINE]

louishenry wrote: Keep in mind that not everyone with DCIS has a 30% chance of recurrence...Radiation after lumpectomy for all  DCIS  cases is not standard care anymore.

And that's a very good point, Louise. And the same can be said for invasive disease in regards to not everyone having the same level of risk.  It took a very, very long time for the master minds of standards of care to finally concede that some cases of DCIS probably don't need radiation. And it will take even longer for the same type of concession regarding invasive disease. But it WILL happen, eventually.

If my cancer had been much larger or high grade, I probably would have made different treatment decisions. Still, I doubt I would have considered having radiation even then - maybe would have just had a mastectomy, and probably bilateral. And that may well be what I decide to do if I get another breast cancer someday...or maybe just another lumpectomy without radiation. It would all depend on the situation at the time. 

Ive got to say that your contention that my DCIS Stage 0,Grade 1 wasn't breast cancer got to me.The  C in DCIS stands for carcinoma, which is, indeed, cancer....My treatment...lumpectomy and radiation was for early stage, low grade breast cancer....I find you attitude to be a bit arrgant.

I am not generally one to answer on thy fly like this (I'm on my way to Mass), but your asertion that radiation is bullshit and that my cancer wasn't....was upsetting.....Tell the millions of women whose lives have been saved by radiation therapy that their efforts are "bullshit"..They may have a different opinion.

I wanted the very last cancer cell to be GONE....I did what I had to to reduce my chances of a reurrene...And I would do it again.

Sandy

I wanted to mention that I did not turn down radiation. I had all intentions of doing it. My docs in Chicago, including pathologist Michael Lagios who, along with Mel Silverstein developed the VNPI index, did not recommend it for me. One thing I will say. The "carcinoma" in DCIS is very misleading. It is NOT life threatening and CAN NOT metastisize. Some studies that I have read say that there are many women who decide to have elective mastectomies out of fear, I respect that. Dr. Ann Partridge writes on this subject. She feels that too many docs call with the dx and say "I'm sorry , You have breast cancer," but then go on to say that " the great news is that it is not going to kill you" Huh?My doctor said to me" I wish that I had better news, but I don't have bad news." He explained what it was and what I needed to do. The key, he said, was to try  and prevent " the real deal".  He said DCIS is in it's own category and is not included in the 1 in 8. That is why many of our top minds in this country, Susan Love, do not call it a cancer as we know it. However, having said that, DCIS can be very serious if not properly treated. Even though about half of the docs call it "cancer" and about half do not, what they all will agree on is that those cells have to come out in order to prevent a future event. I'm not here to defend anyone's opinion, I personally think this thread is getting ridiculous (not sure why I'm here anymore), but MDB's  opinion on Dcis not being cancer is not an isolated one. But, why can't we all just agree to disagree?

  Hi Marie kelly, I think I was editing as you were writing! We said the same thing. That study you published, I believe that was written by Dr. Partrige. She puts all into perpective. Certainly DCIS can't be ignored and we must be more diligent going forward, but we need to take a deep breath and realize what we are actually dealing with. Another great book by Pat Kelly, a geneticist," Assessing your true risk of breast cancer" is a must. Easy to read. Recommended to me by Michael Lagios. Nada