Proton Therapy and the Treatment of Breast Cancer: Ask Dr. Sonali Rudra

Proton Therapy and the Treatment of Breast Cancer: Ask Dr. Sonali Rudra


I’m Dr. Sonali Rudra, I serve as the
service director for the Breast Radiation Oncology Program at MedStar
Georgetown University Hospital. I treat primarily women with breast and
gynecologic malignancies. Currently, I treat primarily breast cancer patients.
Some of the patients I see before they’ve had surgery, others I see after
they’ve had surgery. So I see the whole range of breast cancer patients. There
are many tools that we have to try to decrease the side effects of treatment.
I think proton therapy is a technologic advance that will help us decrease the
side effects of treatment. The difference between proton radiation and standard
radiation is that it can decrease the dose beyond where we’re treating. So for
breast cancer patients, for example, where we’re trying to treat the breast and
chest wall there is some dose that goes to the lung and heart which is right
underneath the breast and chest wall. With proton therapy, we can decrease the
dose to the lungs and heart much more then we can with photon therapy or
traditional radiation therapy. Our breast cancer patients have the option of
coming for a multidisciplinary clinic. This means that they can see all their
necessary physicians on one day. We typically discuss the patients earlier
in the week, and we know exactly what physicians they’ll need to see. And we try
to set up those appointments for the patients ahead of time, so it’s nice for
someone who just has a new diagnosis of breast cancer to be able to know exactly
what their treatment will entail and what the steps are. Many of my patients
are young women who are my age or you know my mother’s age, my sister’s age, so
the way I view them is as a family member, and I try to treat them as I
would want my family members to be treated. So I try to give them as much
attention and care and dedication as I would if it
were a relative of mine that was being treated under my care. The role of radiation therapy in breast
cancer is to decrease the risk of a recurrence, which means to decrease the
chance of the breast cancer coming back. And for some women, radiation can
actually improve survival in breast cancer. After a lumpectomy, all patients
are candidates for radiation therapy. There are some cohorts of women, some
groups of women, who don’t need radiation therapy. However, the majority of women
will be a candidate for some form of radiation therapy after they’ve
undergone a lumpectomy. After a mastectomy, some women do not need
radiation therapy; however, women who have larger tumors or tumors that involve the
skin, chest wall, or lymph nodes, are usually recommended to receive radiation
therapy. When we treat breast cancer patients
with traditional radiation therapy, we treat the breast and the chest wall, but
there is low dose that goes to the underlying structures like the lungs and
heart. With proton therapy, we can control the dose better so that there’s less
dose to the lungs and heart. So I think for young women who have left-sided
tumors, there could be a significant benefit with proton therapy compared to
a traditional radiation therapy. So for left-sided tumors, sometimes we
need to treat the lymph nodes which include lymph nodes in the lower part of
the neck, lymph nodes in the armpit or axillary region, and lymph nodes right
along the sternum. The lymph nodes right along the sternum are sometimes hard to
treat with radiation therapy because they’re right above the heart, especially
in left-sided tumors. In women who have lymph node involvement by the sternum,
those are called the internal mammary lymph nodes. So women who have internal mammary lymph node involvement we, want to treat those lymph nodes to a high
dose. But we’re often limited because the heart and lungs are right underneath. So
those women are the ones that could potentially benefit the most from proton
therapy compared to traditional radiation therapy. In addition, young
women, they have a longer life span so they may live long enough to actually
have an appreciable difference in their toxicity as a result of even the slow
dose of long and hard radiation. There are other unique situations where we may
recommend proton therapy for breast cancer patients. Those include women who have had previous radiation, women with genetic abnormalities that may make them more susceptible to the side effects of radiation therapy, or women with anatomic abnormalities in which giving traditional radiation might give them an
unacceptable dose to the heart and lungs. There are side effects associated with
radiation therapy, both traditional radiation
therapy and proton therapy. I divide the side effects into short term side
effects, those that they feel during treatment and those that they feel long
term. So the short term side effects of radiation are fatigue, skin changes, and
maybe some tenderness in the breast or chest wall. The degree to which people
feel them differs from person to person. But everyone gets some degree of skin
changes, some amount of fatigue, and maybe some tenderness. I meet with patients
once a week while they’re on treatment to make sure that they’re doing okay and
address the side effects as needed. Long term, the biggest side effects are
darkening of the skin in the area that we’re treating and kind of thickening of
the skin and soft tissues in the area that we treat. The difference between
proton therapy and photon therapy is that potentially it could decrease the
risk of toxicity to the heart and lungs and potentially even decrease the risk
of secondary malignancies. During the actual treatment, patients
don’t feel anything. It’s invisible x-rays that are penetrating their body.
So they are lying flat on the table usually with the arms up about their
heads, the machine rotates around them and points the radiation to the area
that we’re trying to target. And they don’t feel, see, or smell anything during
the actual treatment. And that is true with traditional radiation or with
proton radiation. There are several institutions that have been
treating breast cancer patients with proton radiation for a few years. They
have published the results, and they showed that proton therapy is safe and
effective and produces very similar results to what we see with traditional
radiation therapy. The real benefit of proton therapy, especially in our breast
cancer patients will be seen I think 10-15 years down the road when we can
see whether or not patients with proton radiation therapy have improved cardiac
toxicity or lung toxicity compared to traditional radiation therapy. And we
have to wait a few more years before we get those results. Proton therapy cannot replace
chemotherapy or surgery. Proton therapy is an alternative to traditional
radiation therapy or photon radiation therapy, but it can’t be seen as an
alternative to chemotherapy or surgery. Surgery really is the definitive
treatment for breast cancer. There may be certain in instances where
surgery is not an option, and in those cases, potentially radiation especially
with proton radiation might be a good alternative because we can deliver
higher doses of radiation safely compared to traditional photon radiation
therapy. If it’s an appropriate time to
start radiation therapy, the first step is to do a CT scan in our department to plan the
radiation treatment. And about one and a half to two weeks after that is when you
actually start your treatment. Once you start, treatment is every single day
Monday through Friday over the course of three to six weeks. While you’re on
treatment you meet with the nurse and radiation oncologist once a week to
assess you for side effects and see how you’re doing. And after you’re done with
your radiation therapy, we usually see you and follow up every six months for
at least the first one or two years. Radiation therapy is usually the last
step of breast cancer treatment. Surgery is often the first step, but if you have
a larger tumor or lymph nodes involved, sometimes chemotherapy will come first
and then you’ll have your surgery and then you’ll have radiation therapy. If
you’re getting radiation after surgery, usually we start about four to six weeks
after your surgery, but some patients will start up to 12 weeks after their
surgery. After chemotherapy, radiation generally starts about four to six weeks
later. Being a Comprehensive Cancer Center
means that you have all of your specialists here.
For a breast cancer patient, they definitely have to see the breast
surgeon and medical oncologist often times the radiation oncologist, but there
are a lot of other services that they need. You know if it’s a young woman with a significant family history, they’ll need to see a genetic counselor. A lot of
women who are undergoing mastectomy will need to see a plastic surgeon. There’s
social services available. We have a dietitian that’s available. So it’s not
just the two or three main physicians that a patient will need to see but if
they’re part if they come to a Comprehensive Cancer Center they have
access to the physicians and all the other supporting services and supporting
physicians as well. I think MedStar Georgetown University
Hospital is a great option for a breast cancer patient to be treated
because you have all of your specialists under one roof. And all the
treating physicians really specialize in breast cancer. You know, we meet on a
regular basis to discuss patient’s cases, and it’s helpful when all the physicians
have treated you because there are nuances to each patient and their tumor
characteristics and if everyone on at the table knows your case then it helps
develop the best possible treatment plan for the individual patient.

Leave a Reply

Your email address will not be published. Required fields are marked *