KIRAN DEVISETTY, MD: Radiation therapy - the big black box full of myths

When patients hear the word ‘radiation,’ they immediately think of the yellow symbol: it can cause cancer and it will do harm. However, when properly used in a controlled environment, it effectively will help treat and often cure cancer. 

Comprehensive Breast Care Surgeon Ashley Richardson, DO, discussed this topic with Radiation Oncologist Kiran Devisetty, MD, to help dispel the many myths about radiation therapy and explain why it is a critical component of cancer care, particularly in breast cancer patients. It often is called the biggest black box because it is a very small specialty and people have so many questions about it.

Here are a few myths about radiation therapy:

If the cancer is removed in surgery, patients don’t need radiation therapy. This is not true. Tiny, hidden cancer cells still can be growing inside other areas of the breast. In addition, cancerous cells also can return to the same area. 

The entire breast should be removed to make sure the cancer doesn’t return. This is not true.

Mastectomy alone compared to lumpectomy with radiation produces the same patient outcomes. 

If I undergo radiation therapy, I will become radioactive. This is not true. The radiation goes in and out of a person. 

Radiation will affect my heart. Radiation oncologists use a few techniques to minimize exposure to the heart: deep inspiration breath hold is one. 

Partial breast radiation is better than whole breast radiation. This is not necessarily true. There is a small chance more cancer cells are hiding in other areas of the breast.

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The views, thoughts and opinions shared in these podcasts are intended for general educational and informational purposes only and should not be substituted for medical advice, treatment or care from your physician or health care provider. Always consult your health care provider first. 

Transcript

Unknown Speaker  0:01  
Welcome to the breast of everything podcast your trusted resource for breast health information support and encouragement. Your host today is Dr. Ashley Richardson of comprehensive breast care. Welcome. Thank you for listening to the breast of everything Podcast. I am your host, Dr. Ashley Richardson and I am honored to introduce my colleague and friend Dr. Kiran diversity, a Board Certified radiation oncologist, we are going to answer all of your questions regarding radiation therapy related to breast cancer treatment. Thank you for joining me today Dr. Davis, Edie and when you please give us a brief intro and a background. Thank you, Ashley for having me. I'm very excited to be able to participate in your podcast. So as you mentioned, I am a board certified radiation oncologist, I did my medical school at University of Michigan and then my residency at University of Chicago. And then I came to the mid Michigan area in 2012 when I joined the Karmanos Cancer Institute at McLaren Flint, been here for eight years now I have a wonderful and busy practice that's primarily dealing with breast cancer patients. We of course, treat all patients but in a community setting, one of the most biggest malignancies we see is breast cancer, and so I have a strong passion for it. Well, I should also say go green sings how you mentioned you graduated from University of Michigan, and I'm a Spartan, but we won't focus on that our topic today mostly to discuss radiation oncology, and how that treatment plays into breast cancer. So why don't you give us a little bit of an overview of what radiation therapy is in general. Okay, so radiation therapy, also known as radiation oncology is one of the treatments that we use for cancer in general, as our listeners know, when patients are diagnosed with cancer, there's three main forms of treatment, there's surgery, there's chemotherapy, and then there's radiation therapy. And all three of these treatments work together to be able to treat our patients most effectively, I would have to say, out of the three radiation is probably the biggest black box, not only for patients, but even for physicians, it is very small subspecialty, for which there is very few providers relative to other types of providers. And so a lot of what we do is trying to educate people as to what it is and why we use it. When patients hear the word radiation, the mediately think about this yellow symbol, and that it causes cancer and it could do harm. But one of the things we try to teach our patients is that when it's used properly, in a way that is in a controlled environment, it can actually help us treat patients with cancer and ultimately cure their disease in the right situation. When I see a lady for a breast cancer console, I will talk to them about surgery, surgery, obviously, but we also touch on radiation a little bit. And I always give them a little bit of an overview from my perspective. And I always tell them that you have to give them the 1% rule that 1% of the time these bad things will happen. I think that's a lot of the feedback that I get from patients is the MIS that kind of surround radiation oncology in general. So can you touch on that on some of the things that you hear from patients as to why they're adamant against going forward with treatment? So the biggest conception I have to confront is when patients are diagnosed with breast cancer, obviously, they're going to have some form of surgery, whether it be a mastectomy or lumpectomy. And in their mind when the cancer has been removed, they naturally ask, well, then why do I need this radiation treatment. And so what I try to educate patients is first there's a story as to where we got to where we are today. And we recommend it as a means of either preserving the breast or as a means of preventing the cancer from coming back. So I usually like to go back to the old days, I really like the history of medicine. And as many patients know, back in the day, the main way we treated all patients with breast cancer is with a mastectomy, just removing the entire breast. But then a lot of people at some point started asking do we need to do such big surgeries often for very small cancers. And so then I go over this story about how we do clinical trials, I think people like that story to understand how the field evolved where we are today. And so one of those first important clinical trials was looking at patients who either had a mastectomy or a lumpectomy meaning removing a portion of the breast followed by radiation. And so what we did is we took a bunch of women where they enrolled in a trial, essentially a flip of the coin dictated if they would get a mastectomy or lumpectomy followed by radiation. And then we follow these patients for 30 years. And then at 30 years, there was no difference in the survival between both different groups. And so I tell my patients, we essentially learned two things from this one, you can have a mastectomy and be done with it presuming the lymph nodes are negative, or two. If the patients are interested in having a smaller surgery and saving their breast. There is no harm in doing a lumpectomy followed by radiation where they're not dying more often because of the radiation exposure, nor are they dying more often because of the breast cancer. And when I start off with that story immediately it helps them understand why we consider

Unknown Speaker  5:00  
The radiation, but then it comes into the question, Well, why do we still need the radiation after a lumpectomy if we still remove the cancer. And so then I go into the next set of clinical trials where they looked at women who are treated with lumpectomy alone, or lumpectomy followed by radiation. And when we compare these two groups of people, it turns out in the patients who did not get radiation, cancer was coming back much more often within the breast, and they're at greater risk of dying from it. And so then patients start understanding, okay, now I understand why we got to this point. So then the next thing I get into is, well, where does the breast cancer come back? Most often, it comes back in the exact spot where the cancer started, but occasionally can come back elsewhere in the breast. And so the usual standard for how we treat patients is we radiate the whole breast. And as I work through that story, they start getting a better understanding as number one, how did radiation get introduced, and why it became a standard of care option, especially for women who undergo a lumpectomy, I think you brought up several important points and the first being education. So educating the patient on why we do what we do, and how our recommend recommendations come about often relating to clinical trials, you mentioned that the overall survival is equivalent. So when you look at lumpectomy, which is breast conservation followed by radiation, in comparison to a mastectomy, the overall survival is the same. That is kind of mind blowing to a lot of patients, they don't quite realize that we could recommend that treatment plan that would be equivalent to removing the breast. And once they realize that they don't live longer in the recurrence rate is the same by the two treatment plans, I think they're able to really wrap their mind around. Okay, this treatment plan seems appropriate, I often help to tell people that I'm in the business of saving breasts, and that I would never recommend a treatment plan that would be inferior to them or decrease their overall survival.

Unknown Speaker  6:46  
When you talk about radiation, can you give us a little insight about the treatment course the length of the treatments and how patients do throughout the process? Absolutely. So you mentioned earlier about misconceptions of radiation. So when they start getting into the details of radiation, the first things they try to do is dispel some of those myths. And the very first comment I've always said is the radiation goes in you, it goes out of you, you're not radioactive afterwards. And some people laugh, but some people are almost relieved, because they're afraid when they get the radiation treatments, they'll essentially be glowing in the dark. They can't be around anybody. But radiation is literally something that enters and exit. And the patients are not radioactive afterwards. And they can be around whoever they want. And so that's a very important thing that I have to educate patients on. The other thing is they get worried about the whole body being affected. And so the next thing I get into as well, radiation only affects what we treat. So if we are treating the breast, that means we are not affecting the head, we're not protecting the abdomen or the pelvis. So a lot of patients say Will I lose my hair on my head, I said, if we're not radiating your head, you're not going to lose any hair there. And so that again brings up a lot of relief. Now radiation is kind of like a lot of other medicines in the sense that some patients will experience some side effects other patients will not affect the side experienced side effects. And so this goes back to the individuality of each patient and how they tolerate the treatments. So since radiation only effects what it treats then I start going over the potential effects that occurred during an after treatment. So for example, when we're radiating the breast or the lymph nodes around the breast, we talk about not only the breast we talked about the skin, the ribs, the lungs, the heart in sometimes some nerves that help control the arm. And when I say radiation is exposed to all those regions, those are the regions that can be affected. So during treatment, the main thing that we often see with patients when we're treating the breast is a skin irritation. A lot of patients will think of sunburns or burns, I like to use the word irritation as a more medically appropriate term. And what I often see with patients during treatment is the skin can turn red, dark, and often there can be some component of peeling. Sometimes it's a dry peeling, sometimes it can be a raw peeling. And if that raw peeling occurs, sometimes it can be painful. But what we do is we monitor our patients throughout treatment. As the skin reaction becomes a little bit more, we will give them specific creams that are based on the intensity, the reaction. And then if they need some pain medicines, we can give that as well. The other big thing we often see with patients is that they can feel tired. But the other thing I'd like to tell patients if they were working before or the radiation treatments, they often can keep working during the radiation treatments, so it's not an overwhelming fatigue. So many women if they're working full time, we try to work into their schedule so they can keep working full time throughout the course of treatment. And then there are certain times when we need to treat the lymph nodes around the breast and sometimes the throat can become a little bit sore in that situation. And if that happens, we can give the medications now the length of radiation is going to be a little variable. It can be anywhere from three weeks to around six weeks, if we're doing the traditional whole breast radiation

Unknown Speaker  10:00  
And then after the treatment, I often consult patients that they will heal up, within a few weeks to a few months, the skin tone will start to return back almost back to normal. in long term, what I tend to see is one breast is slightly darker than the other and the nipple slightly fuller than the other. And then the other things we talked about are the ribs, the lungs, and the heart. Very rarely do we see any sort of rib fracture, or lung exposure leading to any changes in breathing. So in general, I don't worry about that. But naturally, a lot of women worry about the heart when we have to do radiation on the left side. So that is something we are quite sensitive about. A lot of our radiation techniques are built around minimizing exposure to the heart, patients may have heard of something called Deep inspiration, breath hold, where we radiate the breath, when the patients take a deep breath, so the chest moves away from the heart. The other possibility is we have patients lie down on their stomach where the breast is falling through a board. And when the breast falls forward, it falls away from the heart. And so these are things we are extremely sensitive about. And yes, there if there is some radiation exposure to the heart there, that is a potential risk factor for heart disease. So what I often tell women is that they need to be heart healthy, if they can control what they can control, we can control what we can control, radiation often does not become a significant risk factor for heart disease. And then I go back to those old studies where we looked at mastectomy alone versus lumpectomy with radiation, as we talked about, at 30 years, they're living the same amount of time. So when radiation is done properly, they're not dying at any greater rate because of that radiation exposure. So it just goes back to me saying the 1% rule. So that's not incorrect, right? Not at all. I also think it's funny that you said you'd like to use irritation and not burn because I invariably tell patients, they will get a sunburn

Unknown Speaker  11:51  
on their breast. So I might want to reword that when I see them in consult, but you do mention things. You know, when I talk to patients, I always say, you know, you won't glow, you can hold babies, because that's their other big concern. A lot of these ladies have grandchildren, young children around, they're always concerned that, you know, they can't be around their young grandchildren, which is untrue. So I just it's, you know, we detail a lot of our conversations were largely related to the myths that they hear. With that being said, patients also come with a lot of pre determined bias from either family members or prior experiences. And oftentimes, I have to tell them, that prostate radiation is different from pancreas radiation, which is different from that of colon or breast. So do you find that often, where you have to kind of compare and contrast different radiation treatments to that of the breast all the time. But what I also tried to do is not minimize what they're going through. The reality is, when you radiate different parts of the body, there are going to be different side effects number one, and number two, every patient reacts differently to radiation. So that's one of the big take home points, I try to educate my patients, you mentioned different parts of the body. When we talk about like head and neck radiation when we're radiating the tonsil or the tongue. There, it is an incredibly morbid treatment, but often needed in order to get rid of the cancer. But those side effects are so different than what we do with with the breast, obviously, we're not exposing the tongue in that situation, where there can be a lot of side effects, but at the same time, it shouldn't minimize what they are going through. And so that's why when I do the education, I say there's a whole spectrum. A lot of women think if they're fair skinned, or if they had a history of sunburns, that they automatically are going to be more sensitive radiation. That is often not the case. The one thing I do see a little bit more often is breast size. I do notice, in general, for women who have larger breasts, they tend to have a little bit more of a skin reaction compared to those who have slightly smaller breasts. And that's one point I will emphasize during the treatment after I've done my physical exam, because we want to make sure we set up expectations, so they're not surprised during the course of treatment. I think that's a great point is appropriate expectations. So oftentimes just educating the patients and letting them know what to expect down the line helps patients deal with the adverse effects or possible complications or even just good expectations afterwards. When I see patients and follow up, I'll always say was the treatment what you expected worse than you expected or better than you expected, and almost invariably, patients will say that it was better than they expected. And I think that's because we appropriately informed them and give them expectations. You briefly you had mentioned whole breast radiation. Do you mind touching on the different types of radiations in regards to whole breast and partial breast radiation? Absolutely. So going back to one of those earlier studies I was talking about in the podcast when we did those studies of women that were treated lumpectomy alone versus lumpectomy with radiation I mentioned and those who got lumpectomy alone, the cancer came back much more often. So we went back and looked at those patients who did not get radiation and we asked Where is the breast cancer coming back most often and most often it was in the

Unknown Speaker  15:00  
area where the cancer started. And occasionally it came back elsewhere in the breast. So the usual standard of care is radiating the whole breast. But still people have asked, Well, if the cancer most often comes back just in the area where the cancer used to be, could we radiate just a portion of the breast and that's what we call partial breast irradiation. Now, partial breast irradiation can be done either through the traditional external radiation. But occasionally it can be done by an internal radiation through a device that is implanted shortly after the surgery. Now, conceptually, we have also compared these two treatments, whole breast radiation versus partial breast irradiation in a group of women that had similar types of cancer. And primarily, these women did not have evidence of cancer involvement in their lymph nodes. When we follow these patients for quite some time, it appeared that the treatments are almost equal, there may be at most a 2% difference in the rate of cancer coming back within the breast, when we compare these two groups at about 10 years of follow up. And so for the appropriately selected patient, we can consider this partial breast irradiation. Now, what I will also tell patients is that there's a lot of institutional variation, there's some centers that tend to prefer the whole breast radiation, there's some centers that tend to prefer the partial breast radiation. Historically, we've been most comfortable with the whole breast radiation. Now one of the big arguments about partial breast irradiation is it decreases the amount of normal breast tissue exposure, and it could decrease the exposure to both the heart and the lung in that area, which is obviously very attractive to many patients. But one of the counter arguments to that is, when we do the whole breast radiation, we are also taking a lot of care to minimize that heart exposure, minimize that lung exposure, and still get the benefit of radiating the whole breast. So there are some subtle nuances. And when I meet patients, I'll go over the risks and benefits. I'll talk about the very slight difference in cancer control between the two. And then I often have a discussion with the patients, what do they prefer? What do they think is most compatible with their desires? Do they really just want to focus on that area of the breast to minimize exposure to the rest of the breast? Or do they feel more comfortable reading the whole breast if there's a small chance of cancer cells possibly hiding out elsewhere in the breast? So those are a lot of good points. And I think the other attractive feature that I hear back from patients is the timeframe of treatment. So when you do partial breast irradiation, sometimes that treatment course is shorter as opposed to whole breast. So can you touch a little bit about the different timeframes that you undergo breast irradiation, and especially

Unknown Speaker  17:42  
with hyperfractionated treatment? Absolutely. So when it comes to whole breast radiation, the historical standard was somewhere between six and seven weeks of treatment. Over the last five to 10 years, we've done some studies looking at shorter treatments to the whole breast where one of the new standards or one of the more common standards is delivering the radiation over three to four weeks as opposed to the traditional six to seven weeks. And so for most of our women that have node negative breast cancer, and they're above a certain age, this three to four week treatment is the standard of care. When it comes to partial breast irradiation, it can be as short as one week, where when we use a device that is implanted into the breast, we deliver deliver the radiation twice per day over five days. So one week of treatment essentially. And for some women, that one week of treatment is incredibly attractive compared to the three to four or maybe even the six to seven weeks for those centers that are doing it. Now when we use this internal device, there are many different ones that are out there. But the one we use is a device that's implanted after the radiation. And there's a device that's literally inside their breast and with the device with a part of it sticking out sticking outside of the breast. And when the patients come in, we attach it to a machine that has a radioactive pellet in there, that radioactive pellet goes into the breast and then it goes out and then the patient leaves the department didn't come back in the afternoon. The obvious pluses of this device is that it's a one week treatment, and we're only radiating that portion of the breast. But one of the things we also counsel patients is when the device is there, there's something that's literally sticking out of them for a week, meaning that there can be some discomfort associated with it. And there is a small risk of infection. So we do keep them on antibiotics. And if and then the big thing that I also counsel is when that device is there, they really can't take a shower for a week. And for some women, that's a justifiable concern. So when we go over the different risks and benefits of either the internal device for one week versus the external radiation, given over three to four weeks most often that they weigh the differences and then decide that. Now one of the other emerging things that are happening right now with the partial breast irradiation is going beyond the device.

Unknown Speaker  20:00  
instead using the traditional external radiation, but just doing a narrow focus to where the breast cancer used to be. The early studies that looked at this found that there was a harm to the ultimate cosmetic outcome when we were using the external radiation and trying to target just a portion of the breast. But there have some been some recent studies that have looked at delivering this external radiation with a smaller volume trying to minimize the breast heart and lung exposure, and the cosmetic outcomes appear to be a little bit better. Now for centers that are doing this sometimes for the well selected patient, we can use as external radiation for total five treatments when it's given every other day, so about a week and a half treatment. And so for select patients, that is something that we can consider, I think you made a lot of awesome points. But what I took away from that was, I think I could go a week without showering. Honestly, it would be kind of nice.

Unknown Speaker  20:59  
No, but you did touch on a lot. And you know, when it looks at radiation, especially related to breast cancer treatment, you know, this is kind of an ever changing field when we look at surgery and medical oncology in regards to medical treatment, as well, as far as radiation. And with that note, we also have emerging proton therapy with breast. So I would just like you to take a couple minutes to talk about the difference between proton and photon therapy. So proton therapy is a form of radiation. It's been around for quite some time, but there are not many centers that have it. And the reason being is it's incredibly expensive to build and takes a lot of space. At the Karmanos Cancer Institute at McLaren Flint, we recently opened up proton center back in 2018. And we're one of two proton centers in Michigan and one of 35 proton centers throughout the country. So it is a technology for which there's limited access. But there is a lot of exciting excitement with protons because of some of the physical advantages it has, when it's compared to the traditional radiation. And it comes down to the ability to spare the organs that are next to the area that we are treating. So what I often tell my patients is we have the traditional photon radiation, which we've been doing for 100 years. And then we have the proton treatment, which really became available to patients over the last 30 years, pound for pound, each radiation is able to kill cancer equally. So there is no difference in the cure rate between the photon and the proton treatments in these situations. So then naturally, people ask, Well, if there's no difference in the cure, then why is there a difference in the treatment itself. With a with the traditional radiation, it's a through and through radiation, where the beam goes in goes out to the patient, and then it leaves the effects behind that it needs to with proton treatment, the radiation beam enters and then it stopped not the patient is not radioactive afterwards. But all the energy from the radiation is just delivered to a defined point. Meaning that beyond that point, the normal tissues are not being exposed to radiation. So naturally, when we're talking about a patient with a left breast cancer, the main thing we are concerned about is the heart. So naturally, if you have a radiation that just comes into stops, at a certain point, it improves our ability at sparing the heart and even the lung. And so for women who we expect in anticipate on living a long time, if we can decrease that reduce exposure to the heart, and maybe even the lungs, it can translate into decrease late side effects that can happen years if not decades later. Now this is an active area of investigation. While we see the physical advantages of the proton treatments over the traditional photon treatment, we also need the proof that it's translating into improved outcomes for our patients, because ultimately, the insurance companies that dictate a lot of these treatments need that proof. So just like I've talked about clinical trials to this point, we are participating in clinical trials moving forward, where we are essentially flipping a coin for patients and participating in these clinical trials looking at proton treatment versus full countryman, again, looking at ensuring that the rate of cure is the same, but more importantly, that we're doing a better job of sparing the normal organs. Yeah, I think we are extremely lucky to have Proton Therapy here in Flint and to be a part of clinical trials that really can change how breast cancer treatment develops over the next several years. So thank you for touching on that. And also, thank you so much for joining our podcast. You are truly one of the best in your field. And I consider myself extremely privileged to not only have trained with you but also to work beside you. And I'm incredibly sad for your departure down south. But thank you for taking the time on our podcast. Dr. Richardson, The pleasure is all mine working with you, you you have clearly exceeded the teacher in every way. And I can't say how great a surgeon you are, what an advocate you are for your patients. Every patient I've treated with you has just not only sang your praises, so thank you for having me here and thanks for being

Unknown Speaker  25:00  
Your great colleague. Well thank you so much. And thank you for listening to the rest of everything podcast, please report to our website at compress care.com for additional information. You've been listening to the best of everything podcast with your host and board certified breast surgeon, Dr. Ashley Richardson of comprehensive breast care. If you have a subject you would like the surgeons to discuss, please email your suggestions online at comp breast care. com. That's co MP br eastcare.com. The doctors want to hear from you. The views thoughts and opinions shared in this podcast are intended for general education and informational purposes only and should not be substituted for medical advice, treatment or care from your physician or healthcare provider. Always consult your health care provider first.