A Team Approach to MammoSite 5-Day Targeted Radiation Therapy

Video Transcript: With partial breast irradiation, the surgeon really needs to partner with the radiation oncologist from the beginning, because patient selection is very important and they need to be agreeable that this is an option for the patient for radiation.

So, when I see a patient in my office with early stage breast cancer, and I think that she may be a candidate for partial breast irradiation, I consider having her see the radiation oncologist, sometimes even before her surgery is done.

Video Transcript: Patients are introduced to this technique predominately by the surgeons because that’s going to be the point of entry after the diagnosis is made. But there is a collaborative effort between the surgeons or there should be a collaborative effort between the surgeons and the radiation oncologist so then we can both present the rationale, the available data and the options for that patient.

Video Transcript: If we look at the patient throughput in my particular practice, this is how we do it. The surgeon places the catheter as an outpatient procedure and they present themselves either the next day or within 48 hours to our facility. At that time, with the patient in the treatment position, a CAT scan is performed in order to do CT assisted treatment planning. At the time of treatment planning, we look at all the areas of constraints that are necessary for an adequate delivery of the treatment. We look at balloon conformality. Is there seroma, is there not, is there air, is there not. We look at symmetry of the balloon. We look at skin spacing. One of the things that we actually do is put the skin in as a target volume. In other words, we can analyze the surface area dose because if you’re close, it may be at one point versus the entire surface of the balloon and that becomes critical when you’re making the decision on the adequacy of the delivery. We follow up the patients on the following Monday because the initial encounter is usually on a Thursday or Friday. Monday is the first day of initiation in a treatment. We follow up with another repeat scan and replan them. Not so much looking at conformality because--well we do look at conformality, but looking at what has been the volume. We actually calculate the volume of air that might be there. And usually by that time, it’s dissipated virtually to nothing. And we again still want to look at adequacy of placement of the catheter. When you begin the treatment, you have to have some system in your clinic that allows you to verify catheter position before each treatment. It certainly can be done with CT scan if you have readily access to that. One of the techniques that has worked in our particular department because of the difficulties of accessing the CT even though it’s the next door over, is we rely on the ultrasound. So we verify the position by ultrasound before each encounter. After the 10th treatment or the fifth day, the catheter is deflated and removed by the radiation oncologist. The nurse applies the dressing and post-treatment care again is reinstructed to the patient in order to decrease the risk of infection and other things of that nature

Video Transcript: I believe that the success of MammoSite program involves close collaboration between the surgeon and the radiation oncologist.

When I was developing my program at my hospital with the radiation oncologist, Dr. Muñoz and I sat down and we worked out what criteria that we would follow in terms of patient selection.

We used the criteria that were set out by the American Society of Breast Surgeons and the American Brachytherapy Society.

We established a protocol in terms of how patient referrals will come from me, how to get them in to see to him as soon as possible.

We established a protocol of placement of the catheter, catheter care, antibiotic therapy and so forth. Once we decided that this was our program, we actually even wrote it down in a kind of a document and I have been able to take that and partner with other radiation oncologists. It was really very simple to get going once we both had the same philosophy of the care of the patient.

Video Transcript: My initial surgeon actually participated in the FDA initial study for FDA approval for the MammoSite and then when I got my HDR unit at my local facility, we participated in the registry. So I think there was a great deal of commitment on both of our sides. We looked at the data. We looked at it was rational and it made sense. And even more importantly, it potentially gave women access to care where there may have been a barrier. We live in a metropolitan area, but the thing we must be aware of is people who do not live in a metropolitan area, distance from a treatment facility can be a barrier to care and ultimately have an impact on their overall survival.

Video Transcript: When the patient is part of a collaborative program between the surgeon and the radiation oncologist, I believe that they have a better experience. I have to tell you from personal experience that when patients have different opinions about their care, it is very upsetting to them, because they, they don’t know what is the right thing to do. They hear it from me and they hear it from their radiation oncologist, this just really solidifies for them the confidence that this is excellent therapy for them.

Video Transcript: The biggest strides that we’ve made in cancer care today is the realization that the care is a multidisciplinary approach. What it does mean is you have to develop a team that has full communication. When the first patient accesses the care, it’s often going to be through the mammographer who actually does the diagnoses because this technique is reserved for early stage disease. So they come with a diagnosis then the referral goes to the surgeon. At that point, there has to be communication with the surgeon and the radiation oncologist. Oftentimes, the patients are going to be seen before even the definitive lumpectomy and lymph node evaluation is done. In order to educate the patient and assess whether or not this patient may even be a candidate and then certainly follow up after the lumpectomy and follow--up pathology is available is critical. It really needs an orchestrated team that communicates well together to provide optimal care for the patient.

Video Transcript: When discussing this with other surgeons who may not be familiar with the technique, the first thing that you must do is present them the data because this does require a paradigm shift from what we have been traditionally taught and what we offer our patients.

Previously it was lumpectomy for breast conservation tied to whole breast radiation. But you can begin to present the data suggesting that local treatment is the critical thing. If local treatment in the region of the tumor is critical, why not confine your treatment to the local area.

The data for MammoSite is maturing. There are a number of patients and studies that have been beyond the five year interval and that’s critical because when you look at the previous breast studies that are out there, five year mark is when the majority of the recurrences have occurred. So if you’ve made it five years statistically, it’s unlikely that you’re going to see a significant increase in recurrence. So when you practice evidence-based medicine, the evidence is what can sway you to potentially offer a new technique to the patient and then you look at quality of life issues and access for the patient. And then you look at this maybe a new modality that you can offer in your market and allow your patients access to this care.

Video Transcript: When I talk to physicians about MammoSite radiation therapy as an option for their patients with breast cancer, and when I sense some skepticism about this technology, I like to go back in time and look back into the ‘60’s and the ‘70s where all women were treated with radical mastectomies.

There were some surgeons back then that had a vision and they felt that all women did not have to remove their breast for breast cancer. They could have a partial mastectomy and have radiation therapy, and they would be cured of their breast cancer just as much as the, just as often as the women who had radical surgery.

Those visionary doctors back then were ostracized and there were so many skeptics that women were going to die left, right and center because they didn’t have enough surgery or they had the wrong cancer surgery. And thank goodness for those visionary surgeons that we were able to adopt a less invasive and less mutilating operation for the proper--for the selected patients.

I am so proud of the surgeons back then that had this vision and proud of the doctors that adopted that option for their patients. We need to take a fresh look at radiation in the same way. We need to understand that just like we didn’t have to remove the whole breast to have a very high cure rate, we do not have to radiate the whole breast, in order to enjoy a very low risk of recurrence in the breast. And so, if I was a surgeon in the ‘70s which I wasn’t, I would have hoped that I would have been a doctor that adopted the newer technology and the less surgery for the patient. And just like general surgeons have gone to laparoscopic cholecystectomy instead of open cholecystectomy, they have learned new things, in 2007 we can learn a new radiation therapy for patients with breast cancer that’s going to be better for the patient.

Video Transcript: When a patient--in my opinion would--may need to have chemotherapy I collaborate closely with the medical oncologist as well as the radiation oncologist in the care of the patient, because the timing of chemotherapy needs to be adjusted for the MammoSite radiation therapy. The patient would first have the MammoSite, and then after her MammoSite treatment is finished, then she would go on to chemotherapy. And we need to wait two or three weeks before chemotherapy is started. There is what’s known as radiation recall, which is an inflammation in the breast, around the radiation site that is triggered by some of the chemotherapy drugs that are used for breast cancer. So, the medical oncologist needs to kind of partner in with the care of the patient in this procedure. So, again we get back to a collaborative approach for the care of the breast cancer patient.

Video Transcript: The MammoSite catheter can be placed either in the operating room at the time that the lumpectomy is done, or it can be done in the operating room as a second procedure, or it can be done in the, in the office.

I recommend that the MammoSite be placed not at the time of lumpectomy. And the reason I say that is because the surgeon does not have the final pathology. The margins need to be clear, and we don’t have that until after the--after we get the results back, usually within a day or two.

I personally am very excited about being able to do this procedure in my office. It is so much friendlier for the patients. They don’t have to go through an inpatient or even outpatient day surgery procedure with, with all of the registration and the operating room charges and so forth that go along with that. <

There is an in-office procedure kit that is available for the, for the surgeon to use, that contains everything that you need to do it. It’s a simple procedure to be done in the office in a, in a sterile way. I have a nurse that works with me, we’ve again established our protocol so that we can easily place this in the office in a very short period of time. In fact I did one this morning that went very, very well.

Video Transcript: Being able to place the MammoSite catheter in my office is an advantage for me as a physician, as it is an advantage for the patient as well. Going to the hospital whether it is the main operating room or an outpatient surgical facility does create some anxiety for patients. This has been well documented that within an operating room environment, it increases a patient’s anxiety. So to be able to place the catheter in my office brings it down from a surgical procedure to almost an office visit. Also for me I don’t have to negotiate with the operating room and being delayed by two or three hours, if the room is busy. I have control over my office and my time. I explain to the patient what I am going to do. She is familiar with my exam room, with my procedure room, because it is where I have usually done her needle biopsy, and the whole environment is very calm and comforting. It does not take very long. I can place the catheter, have it done and then go and see several other patients who might be waiting for me. So it’s very time efficient for me, and time efficient for the patient as well. Once the catheter is placed then she goes over to the radiation oncologist for her evaluation by him and the measurements that are done for her planned treatment. So it’s really kind of a seamless, very easy process for her which reduces any, what I think reduces her anxiety.

Video Transcript: Today we deal with a much more informed patient population. They come in much more aware about the disease and the treatment options that might be available. Many of them certainly in the more recent time have come in asking about the five day MammoSite treatment. What you have to do is sit down and discuss with them what the selection criteria are for this patient and then if their surgeon has not been an adopter of the technique, I will sit down and talk with the surgeon and say the patient asked about this, this is the published data that is available, I can provide it to you, this is what the rationale may or may not be and that may be a vehicle for the physician, the surgeon to be involved in this treatment technology.