Breast Brachytherapy with Scott Tannehill, M.D., Radiation Oncologist, Columbia St. Mary's

Posted: Oct. 1, 2004

A new treatment for breast cancer — breast brachytherapy — will soon be available at Columbia St. Mary’s. Scott Tannehill, M.D., a radiation oncologist with expertise in breast cancer and breast brachytherapy, joins the Columbia St. Mary’s medical staff on October 1, 2004.

Breast cancer treatments

Scott Tannehill, M.D., Radiation Oncologist, Columbia St. Mary’s Hospital "Breast brachytherapy is a new treatment for breast cancer. It is now regarded as a safe and effective alternative to standard external beam treatment for many patients with breast cancer; overall patient survival with either approach is going to be similar. The primary reason a woman would select breast brachytherapy over standard external beam radiation is time: external beam radiation requires over six weeks of daily treatment, but breast brachytherapy can be completed in one week."

This year, more than 200,000 new cases of breast cancer will be diagnosed in the United States. Surgical removal of the cancer lump (lumpectomy) is usually the first step. After this surgery, women with early breast cancer are offered mastectomy (surgical removal of the entire breast) or radiation therapy to the breast. Most women choose radiation because the survival rate for such treatment is the same as with mastectomy, and it allows the patient to preserve her breast.

External beam radiation begins four to six weeks after surgery. Patients receive one treatment a day for six to seven weeks. It is very successful in preventing recurrence of cancer in the breast, but many women find the long duration of treatment to be burdensome.

Breast brachytherapy is an alternative to external beam radiation that allows women to complete their radiation treatment in one week.

What is breast brachytherapy?
Brachytherapy (pronounced bray’ key therapy) involves placing a radiation source within or close to the cancer. Using brachytherapy, doctors can reduce the radiation exposure to nearby normal tissues that do not need – and can be harmed by – the radiation. Brachytherapy is used to treat many cancers, including prostate cancer and gynecologic cancers.

An older brachytherapy technique, low dose-rate (LDR) brachytherapy, involves placing a weak source in the patient for many days. Patients are confined to a specially shielded hospital room for several days, and often must remain in bed the entire time. Because of safety issues, visitors are limited. HDR brachytherapy is a newer technique, which requires special equipment and training.

HDR brachytherapy utilizes a strong radiation source, which is precisely positioned in the patient for a few minutes each time. These treatments are repeated over several days or weeks depending on the type of cancer. Patients are not admitted to the hospital for HDR brachytherapy and are usually in the radiation clinic for less than an hour for each treatment. For these and other reasons, many patients and physicians prefer HDR brachytherapy.

Dr. Tannehill has been a faculty physician at UW Hospital in Madison since 1999 and joins Columbia St. Mary’s Hospital this October. Dr. Tannehill is nationally recognized for his expertise in HDR brachytherapy and has performed over 5,000 HDR brachytherapy procedures for a variety of cancers including breast cancer.

“HDR brachytherapy for breast cancer is new,” said Dr. Tannehill. “We have used HDR brachytherapy for other cancers for many years, but recent evidence now shows HDR brachytherapy is a safe and effective alternative to external beam radiation for many patients with breast cancer. HDR brachytherapy deposits the radiation selectively around the area of the cancer, and treats much less skin and healthy breast tissue.”

It is this feature – less radiation to healthy tissues that don’t need radiation – that permits treatment with brachytherapy to be shortened down to one week compared to the six to seven weeks with external beam radiation, he explained.

Two techniques
There are two techniques of HDR breast brachytherapy: the balloon catheter technique and the multiple-catheter technique. Both are outpatient procedures performed under local anesthetic.

Balloon catheter HDR brachytherapy involves inserting a special catheter (a narrow, plastic tube) into the breast under local anesthetic. An inflatable balloon at the end of the catheter is positioned within the cavity left behind after surgery. The balloon remains in the breast while treatments are delivered twice-daily for five days. After the last treatment, the balloon is deflated and the catheter is removed.

With the multiple-catheter technique, small flexible catheters — without a balloon — are inserted into the breast. The catheters remain in the breast for about one week and are removed after the last treatment. The treatment duration and other details are otherwise the same as for the balloon technique.

“The choice of technique — balloon catheter or multiple-catheter — will vary with each patient,” Dr. Tannehill explained. “The balloon catheter technique is the simplest, and is the most common technique used in the community. But the balloon technique is limited by the location and shape of the fluid collection left in the breast after lumpectomy; only about 50% of patients are candidates for the balloon technique.”

“We also offer the multiple-catheter technique, which can be used in a wider variety of situations and in patients who may not be candidates for the balloon technique. By having both techniques available we are more successful in offering brachytherapy to our patients who are interested in this treatment,” he said.

Patient selection and potential advantages of HDR Breast Brachytherapy
HDR breast brachytherapy is appropriate for patients with small to medium-sized cancers who would otherwise receive external beam radiation after surgery. Also, patients should have limited cancer involvement in their lymph nodes.

HDR breast brachytherapy is not appropriate for all patients. External beam radiation is recommended for those patients with larger tumors and with more extensive involvement of their lymph nodes.

Dr. Tannehill added that there may be other advantages — in addition to shorter duration of treatment — with HDR brachytherapy. “One proposed advantage is that long-term side effects of breast radiation will be reduced with HDR brachytherapy because HDR brachytherapy focuses the radiation more to the area of the cancer and treats less of the patient’s healthy tissues,” he said.

“We don’t yet have long-term results to know for certain whether this is the case. My own suspicion is that the long-term side effects of HDR brachytherapy will not be lower than with external beam, specifically because the risk of serious side effects with standard radiation is extraordinarily low,” he said. “It will be difficult to improve on external beam in this regard. But on paper, a smaller volume of healthy tissue is treated with HDR brachytherapy and this appeals to some doctors and patients.”

Additionally, some women receive several months of chemotherapy after their surgery, and external radiation usually comes after the chemotherapy. In contrast, HDR breast brachytherapy can be performed soon after surgery but before chemotherapy begins, and without delaying chemotherapy. Also, the skin redness and soreness that can occur with external beam radiation is often worse if the patient received chemotherapy before radiation. This reaction is usually mild and heals in all cases, but HDR breast brachytherapy avoids this problem by not treating the skin with radiation.

Dr. Tannehill is quick to point out that the only scientifically proven advantage of HDR breast brachytherapy is the shortened treatment time compared to external beam radiation. “The other possible advantages — from treating less skin or lung or heart — are encouraging but we need more time to know for sure whether there is true benefit to our patients from this.”

And this ties in with one weakness of HDR breast brachytherapy: its shorter track record compared to external beam radiation. “We have about eight years of experience with HDR breast brachytherapy,” Dr. Tannehill said, “but we have over thirty years of experience with external beam radiation. Some side effects may appear many years after treatment, and we need to continue to follow those treated with breast brachytherapy for this reason.”

Dr. Tannehill concludes, “The take-home message is that the main advantage of HDR breast brachytherapy is a shorter duration of treatment compared to external beam radiation.” And for women with outside jobs and busy schedules at home, for elderly patients and for those who live far from a radiation treatment center, that benefit of breast brachytherapy may be a welcome alternative.

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