Combining Radiation and Surgery for the Successful Treatment of Breast Cancer

I saw a long time patient yesterday in the office. Gloria drops in once a year for a checkup. She brought me a funny birthday card and we teased each other about the effects of gravity and aging. During her exam she detailed for me how much fun she and her husband Francis are having running a small entrepreneurial business (home remodeling). She is a perfectly healthy 55- year old woman with a thriving business and an essentially normal bilateral mammogram. Her breast exam is also normal except for a faint scar in the upper outer breast and a second incision in the underarm region where I removed lymph nodes in 1989. Gloria is a ten year survivor of breast cancer and appears to be cured by her therapy including excision of the 1.5 cm breast cancer followed by a series of radiation treatments administered in our well-run but unsung Radiation Oncology center here at Presbyterian Hospital of Dallas. 

A small confession- I’ve taken most of the credit for Gloria’s successful treatment. The surgical part was the easiest aspect of her care. Breast conservation is a flawed strategy without follow-up radiation directed at the entire breast, and I would be less than gracious if I did not recognize the contribution of my colleagues in radiation oncology. Without radiation, the cancer grows back in the breast with terrifying frequency - 36% in the landmark NSABP B-06 trial. Fifteen years ago when this trial was published in the New England Journal, I was skeptical. My surgical training at Southwestern Medical School in the late 70’s warned me that long term cures for breast cancer were more assured with complete removal of the breast- the infamous mastectomy. But I did know how to study a randomized, prospective trial report and most importantly how to shoot holes in it. The NSABP in their carefully conducted trial and long follow-up convinced me and most of the surgeons in this country that we could offer the combination of tumor excision and radiation in lieu of mastectomy for the treatment of Stage I and II breast cancer. Since the publication of the NSABP results, I’ve used their principles of breast conservation in the successful treatment of over 1000 breast cancers at Presbyterian Hospital of Dallas and the associated Margot Perot Hospital for Women and Children. I see a lot of women who like Gloria are cancer-free years after treatment (and dare we say it-cured).

What I’ve learned from my twenty year experience treating breast cancer is to sit up and take notice when dedicated and committed experts from other disciplines like radiation oncology tell me there’s a better way to treat a terrible disease like breast cancer. Early in my career, I was exposed to the huge MD Anderson Cancer Center experience with breast conservation through my colleague Dr Don Schwarz. Don had been a part of the radiation therapy department at MDAH when he and Dr. Eleanor Montague and others worked out the most efficacious and least harmful means of using the power of the ionizing radiation to prevent the re-growth of breast cancer following surgical excision. The successful formula for today’s treatment of both invasive and in-situ breast cancer calls for surgical excision of the malignant disease combined with radiation therapy to the affected breast for several weeks following. 

And that combination works in 90+% of properly selected cases. Radiation is not without side-effects, but for the most part these are short term. The breast often swells particularly if it’s a C cup or larger; it often looks sunburned in limited areas toward the end of treatment and the skin may blister and peel in the areas most affected. A few patients complain of breast sensitivity afterwards and the skin is often tanned and leathery for a period of time that may last months ( or years in a small fraction). In the fair-skinned, the blood vessels of the skin may break down (spider veins). An infrequently mentioned plus is that breast conservation as a concept obviates the necessity of breast reconstruction. 
Long term problems with modern radiotherapy are mercifully rare. The worst complication, of course, is local re-occurrence in the breast, an outcome that is exceptionally uncommon when well-known principles governing patient selection are observed. 

The biggest inconvenience with primary radiotherapy of the breast is the investment in time to achieve the desired curative effect. At the Presbyterian Radiation Oncology Center (Dr. Schwarz’ outfit), the treatments take place over a period of 5-6 weeks. Computer-generated calculations of radiation exposure are made for each individual. Safety and accuracy are assured by taking into account the variability in shape and size of the breast for each individual patient. In the actual treatment, powerful (and expensive) linear accelerator generates a precisely directed beam that is focused specifically on the breast sparing other non-breast tissues. Ultimately the tumor scar, the most likely site of re-occurrence, receives an intense boost. The boost effect leaves the skin of the breast more deeply pigmented and the “boosted” sector of the breast a little more sensitive. On mammography the scar within the breast is a prominent feature for several years because of the combined effect of lumpectomy and radiation. I don’t worry about local re-occurrence unless I see some ominous change in the mammogram or by examination. Inadequate margins and multi-centric tumors are the most common causes of re-occurrence. Arm swelling or lymphedema occurs in 8-10% of cases treated by axillary node dissection and/ or radiotherapy. The advent of sentinel node biopsy for node-negative cancers reduces the risk for lymphedema significantly. 

My own personal experience over the past twenty years with breast cancer has demonstrated that a breast conserving strategy employing meticulous surgery, reliable pathology, and careful radiotherapy is a very effective combination in the treatment of primary breast cancer. My thanks to Dr. Schwarz and his colleagues for providing state-of-the-art technology that works. I’ll tell Gloria to send him a birthday card next year. 

Dr Bourland is a surgeon specializing in the treatment of breast cancer. He is director of Margot Perot Center Breast Consultants in Dallas  www.caregate.net .