1. Early Breast Cancer:The role of Radiation Therapy Rationale How it’s Done What to Expect James T. Richardson, M.D. Radiation Oncologist

2. Objectives Magnitude and epidemiology of breast cancer including risk factors Role of radiotherapy in the context of Breast conservation for early breast cancer Ways of delivering radiotherapy to the breast Results and side effects Questions

3. Breast Cancer Most common cancer of American women Second most common cause of cancer death More than 200,000 diagnosed yearly Risk factors Female (only 1% of cases are in men) Older age Length of estrogen exposure Family history/Genetic risk Diet? Alcohol Pre-invasive changes DCIS & LCIS (marker  risk)

4. Early Stage Breast Cancer Noninvasive cancer---DCIS, LCIS Insitu = “in place” Invasive cancers up to 5 cm (2”) in size Infiltrating ductal cancer Infiltrating lobular cancer With or without involved lymph nodes---not adherent to one another or to surrounding tissues

5. Symptoms None at all---change in mammogram Lump or thickening Change in size, shape or consistency of breast Nipple discharge or tenderness

6. Mammogram

7. Local treatmentEarly Stage Cancer Mastectomy No lymph nodes involved— local treatment complete Lumpectomy “breast conservation” Local radiation to whole breast with or without addition of radiation to draining lymph nodes

8. Why give radiation? To decrease local recurrence risk Non-invasive cancer DCIS “pre-cancer” 32%16% (NSABP B-17, 12 year) 818pts 26%  15% (EORTC, 10 year) > 1000 pts Invasive cancer “breast cancer” 39.2%14.3% (20 year data) Same local control as mastectomy Same overall survival as mastectomy

9. Breast Cancer“Local Control”

10. Whole Breast Radiotherapy

11. Early Breast Cancer Local Treatment Surgery Mastectomy Lumpectomy “breast conservation” Requires radiation to remainder of breast +/- nodes Contraindications to breast conservation Diffuse cancer Incomplete removal of cancer Re-excision? Prior radiation Pregnancy Connective tissue disorders

12. Post-lumpectomy Radiation Whole breast radiation Standard of care 5 – 6 ½ weeks radiation M-F Accelerated whole breast radiation Larger daily doses per daily treatment Complete treatment in three to four weeks Equivalent local tumor control Well tolerated with similar side effects

13. Accelerated Partial breast radiation Limited radiation fields to tumor bed and margin Large doses twice daily. Complete in 1 week! Promising results for appropriate candidates Tumor found on mammogram Small tumors excised with negative margins 0-3 lymph nodes involved Surgical bed < 30% breast volume Not too close to skin surface Very low local recurrence rates: 0-4%

14. Partial breast radiation types Brachytherapy Needle implant Mammosite® Conformal external beam radiation 3-D treatment planning Multiple external beams converge on tumor bed with margin

15. Catheter Interstitial Brachytherapy

16. Mammosite® Balloon Brachytherapy

17. Partial Breast3-D external beam

19. Less disfiguring/morbid

21. Equivalent survival to mastectomy

22. Absolutely EQUIVALENT treatment to mastectomy`

23. Side Effects Radiation is focal therapy Fatigue? Skin reaction, usually mild “skin sparing” Redness, tanning Fibrosis, soft tissue thickening Lymphedema Rib fracture < 5% long term Coronary artery disease Pneumonitis

24. Conclusions Breast conservation is mainstay and preferred treatment for most women Breast conservation offers equivalent local tumor control and survival to mastectomy Partial breast accelerated treatment appears promising and exacts less time commitment but further study is needed Radiation therapy is well tolerated and results in good to excellent cosmesis