Overview                                                                   

Breast Cancer is diagnosed in approximately 200,000 women per year in the United States.  Breast and lung cancers are the predominant causes of cancer mortality in women each year.

As shown below, the breast is made up of glandular tissues, fat, blood vessels, nerves and lymphatics.  The majority of breast cancers (adenocarcinomas) arise from the mammary ducts and lobules. Rarely, tumors arise in the fatty tissues or underlying muscles.

While tumors may arise in either breast, breast cancer is slightly more common on the left than right.  Of note, breast cancer may arise in both breasts simultaneously in approximately 1-2% of patients.  Cancers are most common in the upper outer quadrant of the breast, followed by the central area and the upper inner quadrant. 

Although breast cancer begins in the breast, it may spread to other sites outside the breast itself.  A common route of spread of breast cancer is to the regional (axillary) lymph nodes, located in the underarm area.  Risk of lymph nodal involvement is correlated with tumor size.  However, even small tumors may be associated with positive (involved) lymph nodes.  When tumors are more advanced, breast cancer may spread to other body organs including the lungs, liver and bones.

In the past, most women with breast cancer presented with palpable lumps.  Today, however, due to increased screening practices, many patients now present without a palpable lesion but simply with an abnormality seen on mammography. 

Interested in learning more about Breast Cancer? Click here for the American Cancer Society website (Breast Cancer section).

Role of Radiation Therapy                                     

Radiation Therapy has long occupied an important role in the treatment of women with breast cancer.  In fact, the very first patient undergoing radiotherapy was a woman with breast cancer (History of Radiation Therapy).

Today, radiotherapy is used in nearly all patients, particularly those undergoing breast conservation therapy (BCT).  Multiple clinical trials (view paper 1 and paper 2) have demonstrated the equivalence of BCT compared to more radical surgery (mastectomy) in terms of both local tumor recurrence and survival.  Consequently, BCT has become the treatment of choice in most breast cancer patients treated in the United States today.

Radiotherapy is also commonly used in patients following mastectomy if they are found to have certain “high risk” factors, e.g. tumor involvement in regional lymph nodes.  In these patients, radiation has been found to not only reduce the chance of a local recurrence, but it also has been shown in several large clinical trials to improve patient survival.

Radiation Therapy Techniques                              

Radiation Therapy in women treated with breast conserving surgery is typically delivered to the whole (entire) breast. Treatment often consists of two angled (tangential) beams designed to minimize dose to the underlying normal lung tissues.  A similar approach may be used in women treated to the chest wall following mastectomy.

Treatment Plan of an early stage right-sided breast cancer patient treated with two tangential radiation beams

In women found to have lymph node involvement, radiation is also often delivered to the regional lymph nodes (axillary and supraclvacular regions).  In these women, additional radiation beams are matched to the tangential (breast) fields.

Regional lymph node irradiation in a breast cancer patient with involved lymph nodes.  Treatment is delivered with a single field encompassing both the supraclavicular and axillary lymph nodes.  The shoulder joint is shielded to minimize toxicity.

Whole breast irradiation is typically delivered in 2 phases.  Initially, a dose of 50.4 Gy is administered over 5½ weeks. Treatment is then completed with an additional 10 Gy “boost” delivered over 5 days to the lumpectomy cavity alone.

Unlike the initial whole breast treatment which is delivered with photons, the boost may be delivered with a different type of radiation known as electrons, which deposit dose more superficially.

Partial Breast Irradiation (PBI)                                                                              

While whole breast irradiation is currently the standard approach in women undergoing BCT, increasing attention is being focused on an alternative approach known as Partial Breast Irradiation (PBI). As the name implies, PBI involves treatment of only a portion of the breast (the lumpectomy cavity plus a limited amount of surrounding tissues).

PBI series (view paper 1, paper 2 and paper 3) from a number of institutions have demonstrated that local recurrences rates are low and are comparable to those reported following whole breast irradiation.  Moreover, good-to-excellent cosmetic results have been achieved in the majority of patients.

Although promising, patients need to be carefully selected for PBI to minimize the risk of tumor recurrence.  The best candidates appear to be women with small (≤ 2 cm) tumors, negative resection margins, and without involvement of the regional lymph nodes.  Moreover, patients should be preferably over the age of menopause (post-menopausal).

Ask your Radiation Oncologist whether PBI is appropriate for you.  

Various PBI approaches have been used over the years.  Initially, PBI was performed with a technique known as interstitial brachytherapy, whereby hollow catheters are inserted into the breast and loaded with radioactive Iridium (192Ir). 

More recently, 3D Conformal Radiation Therapy (3DCRT) approaches have been used consisting of multiple shaped radiation beams focused on the lumpectomy site and surrounding tissues.

3DCRT Plan in a patient undergoing partial breast irradiation (PBI). Treatment consisted of 5 shaped photon fields.

Mammosite                                                                                        

An alternative PBI approach commonly used today is Mammosite (Cytyc Corporation , Mountain View, CA).  Mammosite is a form of intracavitary brachytherapy in which a high-dose-rate (HDR) source inserted into a specially-designed balloon catheter placed within the lumpectomy cavity.  

A total dose of 34 Gy is delivered twice daily over 5 days. If used solely as a boost following whole breast irradiation, a lower dose is delivered, typically over 1-2 days.

Schematic of Mammosite Treatment

To determine whether PBI is equivalent to whole breast irradiation, UCSD and other institutions are participating in a large clinical trial (NSABP B-39).  In this study, patients eligible for breast conserving therapy are randomized following lumpectomy to either whole breast irradiation or PBI.

Results of this important trial will help determine the care of breast cancer patients in the future. Ask your physician whether you are eligible for this important clinical trial.

Strut Assisted Volume Implant (SAVI)                                                        

SAVI (www.biolucent.com) is a novel intracavitary brachytherapy approach designed to deliver PBI in women with early stage breast cancer treated with breast conserving surgery.

Unlike Mammosite, SAVI consists of a multi-channel catheter system.  Each individual channel can be loaded with a brachytherapy source for varying lengths of time to better conform the dose to the shape of the lumpectomy cavity.  Moreover, lower doses can be delivered to the overlying skin and chest wall.

SAVI device

Treatment is delivered using the same number of treatments and total dose as the Mammosite device.  Once completed, the catheter is collapsed and withdrawn from the patient.

Ask your Radiation oncologist whether SAVI is appropriate for you.

AlignRT Coming Summer 2008

Align RT (www.visionrt.com) is a sophisticated, video-based image-guided radiation therapy (IGRT) approach which provides the ability to perform real-time tracking of the 3-dimensional (3D) surface of a patient for both setup and real-time monitoring.

The system consists of 2 ceiling mounted 3D cameras focused on the patient on the treatment table.  The cameras and a patterned light are used to reconstruct the 3D surface of the patient.

During treatment planning, a reference image is obtained with the patient in the optimal (ideal) position.  When the patient is ready to be treated, a new image is obtained each day and matched to the reference image. 

Computer software compares the two images and quantitatively calculates any differences.  The Radiation Therapists then use this information to accurately re-position the patient into the optimal position for treatment.

Align RT System

The system provides continuous monitoring of the patient during treatment to ensure accurate positioning throughout the fraction. Moreover, it is a video-based system, thus patients are not exposed to additional radiation.  Patients feel nothing and may at most notice a flash or a light shining from the cameras.

UCSD Breast Cancer Team                                                            

The UCSD Breast Cancer Team is comprised of dedicated professional with considerable experience in the treatment of breast cancer. 

Catheryn Yashar M.D. is the Chief of the Breast Cancer Service in the UCSD Department of Radiation Oncology.

Catheryn Yashar, M.D. Chief, Breast Cancer Service Department of Radiation Oncology

Initially trained in the fields of Obstetrics & Gynecology and Gynecologic Oncology, Dr. Yashar has many years of experience caring for women with cancer.  She has considerable expertise in a wide variety of radiotherapy techniques used in breast cancer patients, including breast brachytherapy.   

Working closely with Dr. Yashar in the treatment of breast cancer patients seen in the Department of Radiation Oncology is Radiation Nurse, Fiona Nasseradin, R.N.

Fiona Nasseraddin, R.N. Radiation Nurse Department of Radiation Oncology

Mary Ann Rose MD, Medical Director of the Encinitas Treatment Facility, is also a member of the Breast Cancer Service in the Department of Radiation Oncology.  Dr. Rose has nearly 20 years experience treating women with breast cancer.

Breast cancer treatment is a team approach. Dr. Yashar and Dr. Rose thus work together with a number of professionals from other UCSD Departments including Anne Wallace, M.D., Director of the Breast Cancer Unit  at the Rebecca and John Moore’s Comprehensive Cancer Center.

Anne Wallace, M.D. Breast Cancer Surgeon Director, UCSD Breast Cancer Care Unit

Other members of the UCSD Breast Cancer Unit include Medical Oncologists Barbara Parker, M.D., Teresa Helton, M.D. and Richard Schwab, M.D., and Breast Surgeon Sarah Blair, M.D.

Barbara Parker, M.D. Medical Oncologist

Sarah Blair, M.D. Breast Surgeon

Breast Cancer Publications by UCSD Radiation Oncology Faculty                   

Listed below are Breast Cancer Articles published by members of the UCSD Department of Radiation Oncology.  For a full list of published articles by UCSD Radiation Oncology faculty see Research section

Minor GI, Yashar CM, et al.  The relationship of radiation pneumonitis and treated lung volume in breast conservation therapy.  The Breast J 2006;12: 48

Gierga DP, Turcotte JC, Riboldi M, Sharp GC, Jiang SB, et al. Comparison of target registration errors for multiple modalities in image-guided partial breast irradiation. Int J Radiat Oncol Biol Phys 2006;66:S103

Ma CM, Ding M, Li JS, Lee MC, Pawlicki T et al. A comparative dosimetric study on tangential photon beams IMRT and MERT for breast cancer treatment. Phys Med Biol 2003;48:909.

Chen L, Mundt AJ, et al. Significance of family history in breast cancer treated with breast conservation therapy.  Breast J 1996;2:238

Mundt AJ, et al. Patterns of failure and outcome of complete responders following high-dose chemotherapy and autologous bone marrow transplantation for metastatic breast cancer. Int  J  Radiat  Oncol  Biol  Phys 1994;30:151

Ravi K, Sandhu APS, et al.   Results of treatment of advanced carcinoma breast - 10 year review. J  Clin Radiother Oncol 1993;8:19

Gupta BD, Singh DP, Sandhu APS, et al. Role of Iridium-192 Isotope in management of inoperable chest wall recurrence of carcinoma breast: A feasibility study. J Clin Radiother Oncol 1993; 8:55

Recht A, Schnitt SJ, Connolly JL, Gelman RS, Rose MA, et al. Prognosis following local regional recurrence after conservative surgery and radiotherapy for early stage breast carcinoma. Int J Radiat Oncol Biol Phys 1989;16:3-9

Rose MA, Olivotto L, et al. Conservative surgery and radiation therapy for early breast cancer: long term cosmetic results. Arch Surg 1989;124:153-157

Boyages J, Recht A. Connolly J, Schnitt S, Rose MA, et al. Factors associated with local recurrence as a first site of failure following conservative treatment of early breast cancer. Recent Results Cancer Res 1989;115:92-102

Leopold KA, Recht A, Schnitt SJ, Connolly JL, Rose MA, et al. Results of conservative surgery and radiation therapy for multiple synchronous cancers of one breast. Int J Radiat Oncol Biol Phys 1989;16:11-16

Epstein AH, Connolly JL, Gelman R, Schnitt SJ, Silver B, Boyages J, Rose MA, et al. Predictors of distant relapse following conservative surgery and radiotherapy for early breast cancer are similar to those following mastectomy. Int J Radiat Oncol Biol Phys 1989;17:747-753

Olivotto IA, Rose MA, et al. Late cosmetic outcome after conservative surgery and radiotherapy: analysis of causes of cosmetic failure. Int J Radiat Oncol Biol Phys 1989;17:711-717

Rose MA, Henderson IC, Gelman R, et al. Pre-menopausal breast cancer patients treated with conservative surgery, radiotherapy and adjuvant chemotherapy have a low risk of local failure. Int J Radiat Oncol Biol Phys 1989;17:717-724

Recht A, Connolly JL, Schnitt SL, Silver B, Rose MA et al. The effect of young age on tumor recurrence in the treated breast after conservative surgery and radiotherapy. Int J Radiat Oncol Biol Phys 1988;14:3-10

Recht A, Schnitt SJ, Connolly JL, Gelman RS, Rose MA, et al. Time-course of local recurrence following conservative surgery and radiotherapy for early stage breast cancer. Int J Radiat Oncol Biol Phys 1988;15:255-262

Harris JR, Silver B, Rose MA, et al. Conservative surgery and radiation therapy as treatment for patients with early breast cancer: treatment policy at the Harvard Joint Center for Radiation Therapy. Austral Radiol 1987;31:119-128

Rose MA, Feldman E. Choroidal metastases from breast cancer. In Harris JR, Hellman S (editors). Breast Diseases. JN Lippincott, Philadelphia, 506-507, 1987

Henderson IC, Hayes D, Rose MA, et al. Integration of radiotherapy and chemotherapy in the treatment of early breast cancer. In Breast Conserving Therapy of Mammary Carcinomas: Problems, Limitations and Prospects. Heidelberg International Workshop, Heidelberg, 1987

Gore SM, Come SE, Griem K, Rose MA, et al. Influence of the sequencing of chemotherapy and radiation therapy in node-positive breast cancer patients treated by conservative surgery and radiation therapy. In Adjuvant Therapy of Cancer, V. Salmon SE (editor). Orlando: Grune and Stratton, pp 365-373, 1987