What Is Partial Breast Irradiation?

Radiation therapy, also called radiotherapy, is a common breast cancer treatment used to kill cancer cells and shrink tumours.

However, for some women with breast cancer, studies have shown there is no increased benefit of whole breast irradiation. Instead, they could be eligible to have partial breast irradiation.

Professor Julia White, a tenured Professor of Radiation Oncology and Koltz Sisters Chair for Cancer

Research at The Ohio State University, said partial breast irradiation helps safely reduce treatment for some breast cancer patients.

“Partial breast irradiation is a de-escalation strategy.”

“Historically when breast conservation treatment started, the whole breast was treated.”

“So, instead of surgically removing the entire breast, you remove the cancer from the breast (a lumpectomy), and then irradiate the entire breast and that’s what made the treatment equivalent to breast removal or mastectomy.”

“But we learned over time that women who undergo a lumpectomy alone or lumpectomy plus breast radiotherapy, that the most common place for them to have an in-breast recurrence is around where the original tumour was in the breast,” said Professor White.

“So that really raises the question: do you need to treat the whole breast or can we just treat where most of the recurrence happens and that’s what partial breast irradiation is.”

What Are The Different Types Of Partial Breast Irradiation?

Professor White said there are several different types of partial breast irradiation.

“Accelerated partial breast irradiation is where treatments, usually between five and ten treatments, are delivered in five to eight treatment days, either twice a day or once a day.”

“There’s inter-operative partial breast irradiation that’s done while the lumpectomy cavity is still open prior to closure.”

“And then there’s partial breast irradiation that’s done in a protracted (longer) fashion over three weeks, almost the same time scale as whole breast irradiation,” said Professor White.

“But our focus has really been on accelerated partial breast irradiation that reduces the course of treatment down to five to eight treatment days to reduce burden of care on patients.”

Who Is Best Suited For Partial Breast Irradiation?

Partial breast irradiation is not suitable for all breast cancer patients according to Professor White.

“Like all de-escalation, it’s really focused on luminal type breast cancers.”

“So those breast cancers that are hormone sensitive, lymph node negative, HER2 negative in women who are committed to taking their endocrine treatment for at least five years,” said Professor White.

According to Professor White, partial breast irradiation isn’t considered a ‘better’ treatment option for those patients. But a ‘non-inferior’ treatment option.

“Studies have shown that it’s non-inferior, meaning it will give comparable event rates,” said Professor White.

She said in her clinic at Ohio State University, around 20% of patients are undergoing accelerated partial breast irradiation.

“Particularity women who are still working, taking the time off daily for three to four weeks of radiation is burdensome.”

“They would rather come in and get it done in five days,” she said.

“It helps for women who live far away, they only need to find housing or lodging for about three days if we put the weekend in between and they can travel home on the weekend.”

Partial Breast Irradiation Clinical Trials Research?

Professor White advises that research is still ongoing into this de-escalated treatment.

“There have been several randomised clinical trials looking at the efficacy of accelerated partial breast irradiation, meaning the cancer recurrence rate is the same as with whole breast irradiation.”

“Those trials have all shown that a short course of radiation, in a population of women that are on average about 60 to 62 years old, post-menopausal and arepredominantly stage one hormone sensitive breast cancer, the likelihood of recurrence is very similar to whole breast irradiation. So, non-inferior.”

Professor White said a clinical trial ran at her institution studied partial breast irradiation for women in their mid-50s and younger who had grade three disease.

“We asked the question: can it replace whole breast irradiation and what we found is that partial breast irradiation was not equivalent to whole breast irradiation for that entire group of women undergoing breast conservation therapy.”

“So if you put those two studies together you come up with, I believe, a picture that tells you that partial breast irradiation is a good alternative to whole beast irradiation and will give you similar cancer recurrence rates in women who have hormone sensitive HER2 negative anatomic stage one breast cancer. So their lymph nodes are negative, and the tumour is less than 2cms and women are dedicated to taking their endocrine therapy for at least five years.”

“But that’s a large group of women. That’s probably 25-30% of women undergoing breast conservation.”

Why Support Services & Groups Matter For Breast Cancer Patients

Being able to access support services after a breast cancer diagnosis is an important part of the recovery process for some patients, as having access meet and relate with others in a similar situation can aid in alleviating some feelings of anxiety and isolation.

Breast Cancer Network Australia (BCNA) helps to connect those with breast cancer with support services in-person and online.

BCNA Chief Executive Officer Kirsten Pilatti said those who have been diagnosed seek the reassurance and warmth a support group or support person offers.

“I think support is something that everyone needs in very different ways and we know that for many people in Australia, they want to join support group.”

“Women say that they want to connect with someone else who’s made it through treatment, and who’s made it twenty years past their diagnosis.”

While BCNA helps to connect those recently diagnosed with in-person or online support groups and services, they also provide an online tool to help those recently diagnosed.

Ms Pillatti notes this is especially helpful for those who may not feel up to a group support setting.

“The My Journey online tool helps people to navigate a really complex system” said Ms Pilatti.

“What I hope is that we can continue to build the resources that we have to help people in the way that’s right for them.”

“The way we helped and supported people ten years ago is very different to how we support people now.”

“Everyone’s breast cancer treatment options are so different, so we need to provide a really tailored support program for people and it’s tricky” said Ms Pilatti.

“But we want to be there for every Australian and we want to make sure that we really are the voice for the people who find it hard to be connected and supported in their local communities.”

You can learn more about connecting with a support group in your area, or the online My Journey tool at bcna.org.au

What Is The CHEK2 Gene Mutation?

Around 5-10% of breast cancers are thought to be hereditary, caused by abnormal or mutated genes passed from parent to child.

Though the BRCA1 and BRCA2 gene mutations are the most well-known of these genetic abnormalities, there are numerous other genetic factors that can contribute to a higher-than-average risk of breast cancer.

One of these factors is the CHEK2 gene mutation.

The CHEK2 gene provides instructions for making a protein that stops tumour growth. An abnormal CHEK2 gene can, at least, double the lifetime risk of breast cancer. It can also increase colorectal and prostate cancer risk.

For women with CHEK2 mutations and a family history of breast cancer, the lifetime risk of breast cancer is estimated to range from 28% to 37%. However, the risk may be higher depending on the number of family members affected by breast cancer.

Cancer Geneticist Associate Professor Judy Kirk from the Familiar Cancer Service at Westmead Hospital said despite the lack of awareness of this genetic abnormality, it is more common that you would think.

“They’re not associated with the high risk, they’re not associated with ovarian cancer, and in a way, looking at the family history might give you just as much information as finding a mutation in CHEK2,” she said.

Professor Judy Kirk also said testing for the CHEK2 gene mutation is also not common.

“Some centres will test a lot of gene; some centres test only for the genes that are most relevant and going to make the most difference to the patient if we find something.”

“But remember for many families, in fact about 85% of our families, we can test an affected family member and find nothing and that doesn’t mean there’s no genetic problem.”

“All it means is that we haven’t found it.”

Centres are more likely to test for ‘high risk’ gene mutations, like BRCA1 and BRCA2, as they carry a higher risk of developing breast cancer.

As the CHEK2 gene mutation only carries a moderate risk, many who test positive decide to participate in less invasive preventative options.

“It’s probably about a three-fold increased risk in breast cancer and that’s something that would generally be approached by careful screening rather than a double mastectomy,” said Professor Kirk.

Risk management decisions are very personal and should be discussed with a medical professional. For those with a CHEK2 gene mutation, breast screening is typically recommended to begin earlier than the general population.

Risk management decisions are very personal and should be discussed with a medical professional. For those with a CHEK2 gene mutation, breast screening is typically recommended to begin earlier than the general population.

Supporting Yourself and Your Loved Ones

Having somebody close to you diagnosed with breast cancer can be traumatic and difficult.

It can be hard to know what to do or say to help support that person after they have received their diagnosis and as they go through treatment.

Clinical psychologist and Cancer Council SA Senior Research Fellow Dr Lisa Beatty said it’s  common to feel overwhelmed when someone close to you has received a diagnosis.

“We know from the research literature, the rates of distress for the loved ones of people with cancer are actually just as high, if not higher, than the patients themselves.”

“They can also be stuck in the position of not really feeling like they can voice that concern to the person with cancer, because they’re the ones that are going through it, but also to the family around them, because the focus, understandably, is on the patient at the time.”

Treating Breast Cancer As A Family Illness

Dr Beatty said when speaking with her patients, she emphasises that cancer is a ‘family illness’.

“It might be housed in one person’s body, but it affects everyone under the roof.”

“It is really important for the patient to actually be looking out for their loved one and keeping a bit of an eye on their mental health too and making sure there is the opportunity for the loved ones to have support around them, to speak to someone.”

Dr Beatty emphasised that this support does not have to be the patient, but it can help.

“Often the metaphor we use is two people leaning on each other is actually much stronger than each person trying to stand in isolation.”

“So, leaning on each other and de-briefing with each other as you go through is a really important thing to be doing during treatment.”

What Is The ‘Right Thing’ To Say To Someone Diagnosed With Breast Cancer?

The important thing to note is that you do not go silent on your loved one. It can be difficult to know what ‘the right thing to say’ is, but according to Dr Beatty, the only ‘wrong thing’ to say is to say nothing at all.

“That is probably the most hurtful thing that people will tell me.”

“It does often come out of that fear of ‘I don’t want to say the wrong thing’ that they end up finding that they lose support because people are so fearful of saying the wrong thing that they say nothing and back away.”

If finding the right thing to say is difficult, actions can often speak louder than words.

“Some people like to do up lists of practicalities that can be helped; in terms of going and doing grocery shopping or picking up kids from schools or coming in and doing some of the actual housework or people chipping in and paying for a cleaner,” said Dr Beatty.

Taking Care Of Yourself When Taking Care Of A Loved One

Dr Beatty said that while your energy may be focused on ensuring that your recently diagnosed loved one is coping, it’s very important to ensure you are also coping.

“I think the important thing is to make sure that you’ve got someone that you can talk to and you feel comfortable telling how you’re feeling.”

Dr Beatty said it is important to know that it is OK to not feel OK when someone close to you has been diagnosed.

“Whether it’s your GP, whether it’s a friend, go and speak to someone.”

“Quite often the services that are available to the patient are also available to the loved ones too.”

Understanding Your Breast Reconstruction Options

If you have had a mastectomy, either because you’ve been diagnosed with breast cancer or are at high risk of developing breast cancer, you may decide to have a breast reconstruction.

This is a very personal decision to make and it’s best to know all your options before choosing what is best for you.

If you have been diagnosed with breast cancer and need to undergo surgery as part of your treatment, you will be referred to a breast surgeon.

Dr Stuart McIntosh is a specialist breast surgeon at Belfast City Hospital, Ireland.

He said every person who has undergone or will undergo a mastectomy, should understand their reconstruction options.

“I think all women who are having a mastectomy are entitled to have a conversation about breast reconstruction and whether it’s something they want to peruse.”

Dr McIntosh emphasised there is no one-size-fits-all approach to breast reconstruction and patients should discuss the best option for their individual circumstance with their surgeon.

He said when talking to patients, he ensures they understand what the outcome of the surgery will be.

He said there are a variety of options available for those seeking a reconstruction.

“There are a variety of different types of implants and different ways of using those implants, such as putting them under the muscle of the chest wall or putting them on top of the muscle.”

“There is also the option to reconstruct the breast using the patient’s own tissue, whether taken from places like the back or the tummy, or sometimes even the buttock or the thigh.”

Do I Need To Have A Reconstruction After My Breast Cancer Surgery?

You can choose to not undergo a reconstruction if you do not want to.

While a lot of your treatment after a breast cancer diagnosis is determined by the expertise of your treatment team, you have more choice and control in regard to your reconstruction options.

This includes whether to have a reconstruction or not.

Dr McIntosh said that each patient will have differing priorities when it comes to their reconstruction options.

“I think for some people, treating the cancer and putting it behind them is very important. So, they may choose to have the simplest option so they can get the treatment behind them and get on with their life.”

“I think for some patients there is a need to have control over the procedure.”

“They’re being told they have to have a mastectomy; they have to have other treatments…being able to have a reconstruction is their way of maintaining some input or some control into the treatment process.”

“And for some women it’s an integral part of their self-image or their self-esteem.”

He emphasised that there is no correct answer and each patient will have different considerations that will influence their decision.

“Interestingly the uptake in immediate reconstruction, that’s a reconstruction at the same time as a mastectomy, has always hovered around the 25% mark and I think it’s important to make women aware that it is their choice.”

“They have the freedom to choose in this setting and not having a reconstruction is a legitimate choice, as is having a reconstruction,” he said.

“Some women feel that they must have it done and it’s important to make them recognise that this part of the treatment is their decision.”

What Else Do I Need To Consider If I Have Chosen To Get A Reconstruction?

Dr McIntosh said that your surgeon will consider your treatment regime and overall health and wellbeing when they are planning your reconstruction.

“There are factors around your cancer treatment we need to take into account when planning a reconstruction.”

“So, perhaps the patient is going to need radiotherapy after a mastectomy, we might want to consider that when making choices.

“We always also want to consider the general health and fitness of the patient, because having an immediate reconstruction is, without doubt, a bigger operation than having a mastectomy on its own.”

“So, it is important to take into account the general health, fitness, ability to withstand a longer operation and the increased risk of complications.”

Dr McIntosh said each surgical option will take a varying amount to undertake and recover from which may be an important consideration for a patient and their surgeon.

“A simple mastectomy without reconstruction may take 45 minutes to an hour.”

“An implant-based reconstruction may take a couple of hours, whereas reconstruction using patients own tissue may take four, five, six hours depending on where the tissue is coming from and how complex the procedure is.”

“And, obviously, the length of recovery is variable dependent on those features as well.”

What Questions Should I Ask Before I Make My Decision?

Dr McIntosh said that when you meet with your surgeon, ask as many questions as you need and don’t be afraid to express any concerns you may have.

He said to consider asking about how your options may affect your cancer treatment pathway or the timing of treatments.

He also said it was important to learn about the pros and cons of each option.

“Usually when I’m having this type of consultation with a patient, we’ll go through photographs so they can see examples of how the different reconstruction types look and perhaps some examples of ones that have worked well, and perhaps examples of ones that have not worked so well.”

And probably it’s always worth asking your surgeon how many times he or she has done that particular operation.”

While Dr McIntosh encourages patients doing their own research into their options, he strongly emphasises the importance of only reading reputable sources.

“While there is great information available online, you have to be careful as it’s not always applicable to everybody and some of it is better quality than others.”

Dr McIntosh also emphasised that when he guides patients through this process, he will often see patients as many times as they need. He stresses that there is no need to rush into making this decision.

“Maybe we can reach a decision after two consultations.”

“It may take three, it may take four, it may take some time with the breast care nurses, sometimes it’s useful to be able to talk to another patient whose gone through the process and if somebody wants to do that, then we try very hard to put them in touch with another patient.”