Breast Cancer: Treatment Options and Radiation
Guest: Dr. Joseph “Buddy” Jenrette – Radiation Oncology
Host: Dr. Linda Austin – Psychiatry
Dr. Linda Austin: I am Dr. Linda Austin. I am interviewing Dr. “Buddy” Jenrette who is professor of Radiation Oncology and chair of the department. Dr. Jenrette, let’s talk, today, about radiation treatment, radiotherapy, for breast cancer. Who ends up getting that as a treatment?
Dr. Buddy Jenrette: Most women who have breast cancer get radiation if they conserve their breast. Many years ago only mastectomies were allowed. As of about 25 years ago, we have developed techniques in which women can save their breasts. We learned that if they had just a part of the breast removed, and nothing else happened, there was an unacceptably high recurrence rate. But, if we gave radiation treatment afterwards, the results were the same as mastectomy which had been the gold standard for years in terms of survival. So, women have the advantage of a high rate of survival and retaining their breasts.
Dr. Linda Austin: Now, of course, when women have breast cancer, one of the things that happens is they get staged. Can you walk us through what those stages mean?
Dr. Buddy Jenrette: Surely. Staging is a way that we can address and compare results with different doctors. It helps us in planning out treatment. So, every cancer is staged according to the size of the tumor. In breast cancer, whether it is 2 cm or smaller is the first T (T1) stage, the tumor-size stage. If it is between 2 and 5 cm, it is a T2. If it is greater than 5 cm, it is a T3. If it is involving things like the skin or the underlying muscles, it is a T4. That is the tumor part of the staging. The other parts of the staging are the nodal status, whether there is a presence or absence of nodes. Then, it gets subcategorized into whether they are clumped together, whether the nodes have more or less exploded with cancer, and so forth. So, there is either no nodes which is N0, or N1 or N2. Then, finally, whether there is metastatic disease at presentation. Either there is metastatic disease, which would be M1, that could be disease involving the bones or lungs or brain, or M0 which means there is no disease that has spread. Then, it gets to, really, complicated staging where there is a traditional Stage 1, 2, 3 and 4, and it is based on these different groupings of how the T and the N and the M are grouped together.
Dr. Linda Austin: So, that really is more complex, I suppose, than most people might think. Now, when you do get to Stage 1, Stage 2, Stage 3 and Stage 4, at what stage does a women merit having her cancer treated with radiation therapy?
Dr. Buddy Jenrette: We are involved, really, in all four stages but our role may vary from stage to stage. One of the nice things about breast cancer is that treatment is done by a team of physicians. So, there is no one physician that has total purview over the care, we meet as a team. We meet weekly, here, at MUSC on what is called a tumor board. We will discuss the cases prospectively. We will go over their pathology and their staging. We will review their mammograms and discuss them. Then, we will also meet later in a clinic where we actually examine the patients together.
So, a woman has the benefit of seeing a surgeon, radiation oncologist and medical oncologists all in one day. I call it a triple play. It saves time for the patients and it is a real homerun for the patients to be able to go through all of those things at once rather than have to go to one building one day or maybe across town another day. If it is Stage 1, or any Stage, where they may be preservation of the breast then we try to see the patients on the same day that the surgeon does initially. The reason being, if the woman chooses breast preservation and mastectomy, she needs to realize that radiation will be part of that or there is a high risk of a recurrence in the breast.
So, I like to sit down and talk to the patient and her family on the first day of the encounter and go over this so that they know that we will be part of the treatment later on. We explain to them what is involved with radiation treatments, how it is given, what some of the side effects would be, what the outcomes and expectations would be. We also try to de-mythologize some of their fears. Cancer patients come to physician encounters and they are very scared and it is hard for them to focus on too many issues at once. So, we try to take out some of the mythological aspects of cancer care and put a reality base to it, explain to them what we do and why we are doing it so they will understand. It would be a shame for a woman to come in and have surgery and have the lump removed and then see us and say, I would have never done this, I would have rather had a mastectomy than go through radiation. We try to make it understandable so they can make that choice up front.
Dr. Linda Austin: Dr. Jenrette, you and I have shared some cases in the past and I have heard from my patients how exceptionally empathetic and helpful you are in those conversations. That is really such a big piece, I think, of the whole treatment program. Let’s take the simplest case scenario in which a woman has breast cancer that is treated with radiation therapy. I am sure it can take many forms and become fairly elaborate. But, what is the simplest case scenario of what a course might be?
Dr. Buddy Jenrette: The simplest is when breast cancer is just diagnosed mammographically. We could not have done that when I was in medical school. We only had palpable lesions that we could feel. Sometimes we could even see them erupting through the skin. But, today we can actually see when there are almost just a few cells that are forming the cancer. The surgeons can go in and they can remove that, then we can give treatments following that. Frequently, depending on their age and other medical conditions that they might have, that may be all the treatment that they need. They may not need chemotherapy or any kind of other involvement with hormonal treatments or anything beyond that. That would be the simplest.
We have choices with how we do the radiation in that circumstance. We have what is called whole-breast irradiation. That is what I would call traditional x-ray treatment to the breast. It is taking the idea that we used to remove the whole breast surgically because we thought that was the only way that they could be cured. When we went to lesser surgery, less sort of mutilating surgery, to just the lumpectomy, we took the idea that if the whole breast had to be removed before, we probably should have to irradiate the whole breast. So, for many years, that was all we did. That was their only real option. But, there are always a few rogue physicians who challenge dogmas. Some physicians started asking, well, do we really need to treat the whole breast, could we do partial breast radiation?
Now we have techniques where can place a tiny catheter with a balloon on the end of it into the cavity where the cancer was removed and insert a little radioactive pellet for five days, twice a day, for about 10 minutes which partial breast radiation. That exchanges six weeks of conventional x-ray therapy, treating the whole breast, for just five days, treating with this localized partial breast radiation. Those are really the simplest. In as sense, it makes things more complicated for women because they have choices. It is almost like going to a nice restaurant and having a menu of things that they can decide from. In the earliest stages, it could be mastectomy. It could be lumpectomy with whole breast radiation. It could be lumpectomy with partial breast radiation. We try to explain all the different ideas, their pros and cons, so that they can make a choice.
Dr. Linda Austin: I have heard many cancer patients say that is one the most difficult aspects of having cancer, that there are choices and the best choice is not always clear. I am wondering what recommendations you would have, let’s say, for a family member or a distant relative living elsewhere who is trying to make their way through the huge array of websites and information and different recommendations. If you were to try to simplify that process of making a decision for a patient, what would you recommend?
Dr. Buddy Jenrette: I think the most important thing for patients to remember is that they are in control. They are the ones making the decisions, they are really our bosses; we are not their boss. I think that is a different concept than the way medicine used to be and for some patients it is uncomfortable to be given choices. They would rather just be told. I think that is a process that we try to do a lot to turn that around so that they realize that they do have these choices and they can make the decisions. When they make them in an informed setting, I think people feel better about it because they have not lost their usefulness within their home and their family, they are still making decisions and doing so in an informed way.
We are not going to let patients make decisions based on faulty information. If they read things on the internet that are just not true, we will tell them that. We will try to lead them down the path of what the best choices would be and balance it against what the benefits would be and the particular risks of the treatment might be. So, in the end, hopefully, the patient and his/her family can make a decision about what they think would be best for them. What would be good for me may not be good for someone else. People have certain religious beliefs about surgery or maybe phobias against x-ray treatments or chemotherapy. It may be based on things that their family have gone through earlier in cancer management. Those are all valid problems that have to be addressed. But, in the end, I think patients, once they realize that they do have the opportunity to make their own decisions, I think they really come to accept the process and feel better about things. I think that is the whole part of restoring good health. The patients not only get well from the cancer, they also feel good about making their own decisions and managing their care.
Dr. Linda Austin: There is so much more we can say about this topic. Let’s pause now and continue in a second podcast. Thanks Dr. Jenrette.
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