Alternative Way to Treat Early-Stage Breast Cancer With Radiation By Editing NAI
08/26/2015 5:37 a.m.

Breast-cancer specialists are sharply divided over a new radiation technique that costs less and is more convenient than conventional therapy.

The technique, known as intraoperative radiation therapy, or IORT, involves administering a single dose of radiation at the same time a patient is having lumpectomy surgery to remove a tumor. A large, randomized controlled trial concluded that IORT has fewer side effects and appears to prevent the return of cancer nearly as well as traditional treatment, in which patients undergo radiation sessions five days a week for up to seven weeks.

Oncologists with opposing opinions have been debating that conclusion in letters and editorials in major medical journals, including the Lancet and BMJ. Some critics point out that the study found women who had IORT face twice the risk of a cancer recurrence compared with traditional radiation (3.3% versus 1.3% over five years).

Some also criticize the design of the IORT study and say patients haven’t been followed long enough to draw conclusions. “A lot of us are scratching our heads as to why [IORT] would be appropriate,” says David Wazer, chair of radiation oncology at Brown and Tufts medical schools and a vocal critic.

Yet proponents of IORT say the risk of recurrence with either radiation treatment over five years is tiny, and IORT’s advantages could outweigh the higher risk of recurrence for some patients.

“A lot of women who hear about this option make an informed decision to use it,” says Stephen Grobmyer, director of the breast center at the Cleveland Clinic, which is collecting data on nearly 1,000 patients who have had the treatment at 19 U.S. centers.

At many radiation centers, a big portion of revenue comes from delivering lengthy courses of treatment to breast-cancer patients. “Depending on your perspective, [moving to a single treatment during surgery] is either a significant threat or a quantum leap forward,” Anthony Zietman, editor in chief of the International Journal of Radiation Oncology, wrote in an editorial this month.

Radiation has revolutionized breast-cancer treatment since the 1980s, allowing older women with small, early-stage tumors to opt for lumpectomies rather than mastectomies. Survival rates are similar, because radiation helps destroy any stray cancer cells left behind. About 60% of the more than 200,000 women in the U.S. diagnosed annually with early-stage breast cancer undergo lumpectomy with radiation.

Radiation’s side effects include fatigue, skin redness and blistering. In rare cases, it can damage patients’ hearts, lungs and rib cages. Weeks of treatment are disruptive for women who work, care for children or live far from radiation centers. About one-third of women who begin radiation don’t finish their prescribed courses, studies show.

Experts have developed new methods to maximize the effectiveness of radiation treatments while minimizing the inconvenience and damage to healthy tissue. One approach delivers fewer but higher doses of radiation over three to four weeks. Several new technologies target only the tumor site instead of the whole breast. Some versions deliver radiation from inside the breast, using high-dose radioactive pellets held in place by balloon catheters for brief periods, a technique called brachytherapy.

To date, however, only conventional, whole-breast external-beam radiation has a long record of safety and effectiveness, which is why some radiation oncologists say they are reluctant to abandon it.

Use of IORT for breast-cancer patients, with just a single radiation dose during surgery, started in Europe in the late 1990s. In 2000, developers of one method called targeted intraoperative radiotherapy, or TARGIT, organized a clinical trial to compare it with traditional radiation. They enrolled 3,451 women from 33 centers in 11 countries, including the U.S.; about half the participants received IORT and the rest got conventional therapy.

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