Faculty Bibliography

Ductal carcinoma in situ of the breast has rapidly increased in incidence over the past several decades secondary to an increased use of screening mammography. Local treatment options for women diagnosed with ductal carcinoma in situ include mastectomy or breast-conserving therapy. Although several randomized trials have confirmed a >50% reduction in the risk of local recurrence with the administration of radiation therapy (RT) compared with breast-conserving surgery alone, controversy persists regarding whether or not RT is needed in selected "low-risk" patients. Over the past two decades, two prospective single-arm studies and one randomized trial have been performed and confirm that the omission of RT after surgery is associated with higher rates of local recurrence even after selecting patients with optimal clinical and pathologic features. Importantly, these trials have failed to consistently and reproducibly identify a low-risk cohort of patients (based on clinical and pathologic features) that does not benefit from RT. As a result, adjuvant RT is still advocated in the majority of patients, even in low-risk cases. Future research is moving beyond traditional clinical and pathologic risk factors and instead focusing on approaches such as multigene assays and biomarkers with the hopes of identifying truly low-risk patients who may not require RT. However, recent studies confirm that even low-risk patients identified from multigene assays have higher rates of local recurrence with local excision alone than would be expected with the addition of RT.

Ductal carcinoma in situ of the breast has rapidly increased in incidence over the past several decades secondary to an increased use of screening mammography. Local treatment options for women diagnosed with ductal carcinoma in situ include mastectomy or breast-conserving therapy. Although several randomized trials have confirmed a >50% reduction in the risk of local recurrence with the administration of radiation therapy (RT) compared with breast-conserving surgery alone, controversy persists regarding whether or not RT is needed in selected "low-risk" patients. Over the past two decades, two prospective single-arm studies and one randomized trial have been performed and confirm that the omission of RT after surgery is associated with higher rates of local recurrence even after selecting patients with optimal clinical and pathologic features. Importantly, these trials have failed to consistently and reproducibly identify a low-risk cohort of patients (based on clinical and pathologic features) that does not benefit from RT. As a result, adjuvant RT is still advocated in the majority of patients, even in low-risk cases. Future research is moving beyond traditional clinical and pathologic risk factors and instead focusing on approaches such as multigene assays and biomarkers with the hopes of identifying truly low-risk patients who may not require RT. However, recent studies confirm that even low-risk patients identified from multigene assays have higher rates of local recurrence with local excision alone than would be expected with the addition of RT.

Telehealth sessions including a physical therapist have been implemented for physical examinations, shared diabetes appointments, and obesity and weight management classes.

Breast cancer radiotherapy represents an essential component in the overall management of both early stage and locally advanced breast cancer. As the number of breast cancer survivors has increased, chronic sequelae of breast cancer radiotherapy become more important. While recently published data suggest a potential for an increase in cardiac events with radiotherapy, these studies do not consider the impact of newer radiotherapy techniques commonly utilized. Therefore, the purpose of this review is to evaluate cardiac dose sparing techniques in breast cancer radiotherapy. Current options for cardiac protection/avoidance include (1) maneuvers that displace the heart from the field such as coordinating the breathing cycle or through prone patient positioning, (2) technological advances such as intensity modulated radiation therapy (IMRT) or proton beam therapy (PBT), and (3) techniques that treat a smaller volume around the lumpectomy cavity such as accelerated partial breast irradiation (APBI), or intraoperative radiotherapy (IORT). While these techniques have shown promise dosimetrically, limited data on late cardiac events exist due to the difficulties of long-term follow up. Future studies are required to validate the efficacy of cardiac dose sparing techniques and may use surrogates for cardiac events such as biomarkers or perfusion imaging.

Breast cancer radiotherapy represents an essential component in the overall management of both early stage and locally advanced breast cancer. As the number of breast cancer survivors has increased, chronic sequelae of breast cancer radiotherapy become more important. While recently published data suggest a potential for an increase in cardiac events with radiotherapy, these studies do not consider the impact of newer radiotherapy techniques commonly utilized. Therefore, the purpose of this review is to evaluate cardiac dose sparing techniques in breast cancer radiotherapy. Current options for cardiac protection/avoidance include (1) maneuvers that displace the heart from the field such as coordinating the breathing cycle or through prone patient positioning, (2) technological advances such as intensity modulated radiation therapy (IMRT) or proton beam therapy (PBT), and (3) techniques that treat a smaller volume around the lumpectomy cavity such as accelerated partial breast irradiation (APBI), or intraoperative radiotherapy (IORT). While these techniques have shown promise dosimetrically, limited data on late cardiac events exist due to the difficulties of long-term follow up. Future studies are required to validate the efficacy of cardiac dose sparing techniques and may use surrogates for cardiac events such as biomarkers or perfusion imaging.

PURPOSE/OBJECTIVE:To compare reimbursement and cost efficacy between accelerated partial breast irradiation (APBI) techniques. MATERIALS/METHODS/METHODS:Four hundred fifty-three patients were treated with APBI using either 3-dimensional conformal radiotherapy (3D-CRT, n=207) or balloon-based brachytherapy (BB) [single-lumen (SL, n=161) and multilumen (ML, n=85)] between March 2000 and October 2011. To evaluate cost-effectiveness, reimbursement by treatment technique was calculated based on 2011 Medicare schedules. Facility costs were generated by technique based on ICD-9 codes. Incremental cost effectiveness ratios (ICER), which compares cost with clinical outcomes, were calculated according to the difference in reimbursement to the criteria being evaluated. RESULTS:With a median follow-up of 3.6 years, the 5-year rate of local recurrence was 1.9% for all patients (3D-CRT, 0%; BB, 4.1%; P=0.23). When pooled, BB patients had a significant improvement in excellent/good cosmesis (91.6% vs. 80.0%; P=0.03). Rates of combined grade 2 or higher dermatitis, hyper/hypopigmentation, pain, or fibrosis per technique were 62%, 28%, and 34% for 3D-CRT, SL, and ML patients, respectively (P=0.26). The ICER per percent improved cosmesis for SL/ML was $519/$850 based on reimbursement and $301/$643 based on cost compared with 3D-CRT. CONCLUSIONS:On the basis of ICER, brachytherapy for APBI is a cost-effective option with regard to cosmesis and toxicity. This economic analysis suggests the increased cost of applicator-based brachytherapy may be justified in appropriately selected patients.

PURPOSE/OBJECTIVE:To compare reimbursement and cost efficacy between accelerated partial breast irradiation (APBI) techniques. MATERIALS/METHODS/METHODS:Four hundred fifty-three patients were treated with APBI using either 3-dimensional conformal radiotherapy (3D-CRT, n=207) or balloon-based brachytherapy (BB) [single-lumen (SL, n=161) and multilumen (ML, n=85)] between March 2000 and October 2011. To evaluate cost-effectiveness, reimbursement by treatment technique was calculated based on 2011 Medicare schedules. Facility costs were generated by technique based on ICD-9 codes. Incremental cost effectiveness ratios (ICER), which compares cost with clinical outcomes, were calculated according to the difference in reimbursement to the criteria being evaluated. RESULTS:With a median follow-up of 3.6 years, the 5-year rate of local recurrence was 1.9% for all patients (3D-CRT, 0%; BB, 4.1%; P=0.23). When pooled, BB patients had a significant improvement in excellent/good cosmesis (91.6% vs. 80.0%; P=0.03). Rates of combined grade 2 or higher dermatitis, hyper/hypopigmentation, pain, or fibrosis per technique were 62%, 28%, and 34% for 3D-CRT, SL, and ML patients, respectively (P=0.26). The ICER per percent improved cosmesis for SL/ML was $519/$850 based on reimbursement and $301/$643 based on cost compared with 3D-CRT. CONCLUSIONS:On the basis of ICER, brachytherapy for APBI is a cost-effective option with regard to cosmesis and toxicity. This economic analysis suggests the increased cost of applicator-based brachytherapy may be justified in appropriately selected patients.

PURPOSE/OBJECTIVE:Limited outcomes exist in patients who develop an ipsilateral breast tumor recurrence (IBTR) after accelerated partial breast irradiation (APBI). The purpose of this study was to evaluate these outcomes and patterns of failure in our cohort of patients undergoing APBI. METHODS AND MATERIALS/METHODS:A total of 534 patients with early-stage breast cancer were treated with APBI between 1993 and 2010. Clinical, pathologic, and treatment-related variables were analyzed. Clinical outcomes, including further IBTR, regional recurrence, disease-free survival, cause-specific survival, and overall survival were analyzed. RESULTS:Eighteen (3.3%) patients developed an IBTR, for a 5-year actuarial rate of 2.0%; 14 (77.8%) of the recurrences were thought to represent new primary cancers. After IBTR, 13 (72.2%) patients were managed with salvage mastectomy and 4 (22.2%) patients with a second attempt at breast-conserving therapy. Five-year rates of disease-free survival, cause-specific survival, and overall survival after salvage mastectomy for IBTR were 81%, 100%, and 100%, respectively. In the 4 patients treated with a second attempt at breast-conserving therapy, no IBTR, axillary failure, regional recurrence, or distant metastases were noted at 5 years. CONCLUSIONS:IBTRs that developed after APBI resulted in excellent clinical outcomes comparable with those observed after whole-breast irradiation.