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Older Women Report Better Cosmetic Results With Lumpectomy and Brachytherapy

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A woman who’s been diagnosed with early-stage breast has a number of treatment options, including:

  • lumpectomy followed by whole-breast radiation
  • lumpectomy followed by brachytherapy
  • lumpectomy alone (or followed by hormonal therapy, if the cancer is hormone-receptor-positive)
  • mastectomy with no radiation
  • mastectomy followed by radiation

Brachytherapy is a newer form of radiation therapy and an alternative to whole-breast external beam radiation therapy. Brachytherapy delivers a higher dose of radiation to a smaller area of the breast over a shorter period of time compared to traditional external beam radiation therapy. Brachytherapy is also called accelerated partial breast irradiation.

While several studies have looked at how younger women rate the cosmetic results of their treatment choices, no studies have asked older women about this topic.

A study suggests that women 67 and older diagnosed with early-stage breast cancer are more satisfied cosmetically with lumpectomy and brachytherapy compared to other treatment options.

The research, "Patient-reported cosmetic outcomes in older breast cancer survivors: A population-based survey study," was presented at the 2016 San Antonio Breast Cancer Symposium on Dec. 9, 2016.

"There's very little in the literature regarding older patient-reported outcomes -- either they were not included in previous studies or were not asked about their cosmetic satisfaction," said Cameron Swanick, M.D., of the University of Texas MD Anderson Cancer Center, who presented the research. "With our study, we wanted to survey women to better understand their long-term cosmetic satisfaction and compare satisfaction across local therapy strategies."

Traditional external beam radiation therapy aims cancer-destroying energy at the whole breast or to the area of the breast where the cancer was. The source of the radiation is outside the breast, which is why it's called "external beam." The drawbacks of traditional radiation therapy include daily trips to the hospital for treatments -- typically 5 days a week for 4 to 6 weeks. Traditional radiation therapy also has a large field and may expose healthy tissue, such as the heart and lungs, to radiation.

To overcome the drawbacks of traditional radiation therapy, doctors have developed different ways to deliver radiation. Brachytherapy places the radiation source inside the breast.

There are three types of brachytherapy:

  • Multi-catheter internal radiation, also called interstitial needle-catheter brachytherapy. This approach uses radioactive "seeds" to deliver radiation directly to the area where the cancer was. The seeds are placed in very small tubes (catheters) that are stitched into place under the skin. The seeds are left in the tubes for a few hours or a few days. You remain in the hospital during treatment. Once the treatment is completed, the seeds, tubes, and stitches are removed and you go home.
  • Balloon internal radiation, known by the brand name MammoSite. This approach places a special tube with a balloon on one end in the breast where the cancer was. The tube comes out of the skin through a small hole. The tube and balloon are placed either during lumpectomy or afterward in a surgeon's office. During each treatment, a machine places a radioactive seed into the center of the balloon for 5 to 10 minutes -- just long enough to deliver the required dose of radiation. After the seed is removed, you may leave the treatment center. A total of 10 treatments are usually given over 5 days. That means two treatments per day, about 6 hours apart. When the final treatment is done, the balloon and tube are removed through the small hole in the skin.
  • 3-D conformal external beam radiation (3DCRT). This experimental approach starts with a planning session (simulation). A special MRI or CAT scan of the breast is done and is used to map out small treatment fields for the area at risk. The type and distribution of radiation is designed to maximize the dose to the area that needs to be treated and avoid or minimize radiation to tissue near the area. The radiation is delivered with a linear accelerator, the same machine used in traditional external radiation, twice a day for 1 week.

In the study, the researchers sent a survey to 1,253 women age 67 and older who had been diagnosed with breast cancer in 2009 and treated with one of the five options mentioned at the beginning of this article. The survey asked about the women’s satisfaction with the cosmetic results of the treatment.

The researchers used two well-known tools to analyze the answers from the 498 women who completed the survey. About half the women were younger than 73 and half were older.

Overall feelings about cosmetic results were:

  • women who had lumpectomy followed by brachytherapy were the most satisfied
  • women who had lumpectomy alone were the second most satisfied
  • women who had lumpectomy followed by whole-breast radiation were the third most satisfied
  • women who had mastectomy alone were the fourth most satisfied
  • women who had mastectomy followed by whole-breast radiation were the least satisfied

Because lumpectomy followed by whole-breast radiation is considered the standard of care for early-stage breast cancer, the researchers used women who had that treatment as a reference group. They found that women who had lumpectomy followed by brachytherapy and lumpectomy alone were more cosmetically satisfied. Women who had mastectomy and whole-breast radiation were much less cosmetically satisfied. Women who had mastectomy alone and lumpectomy followed by whole-breast radiation had about the same cosmetic satisfaction.

The researchers said that the results suggest that the less radiation given, the better the long-term satisfaction of the patient.

"We need treatment that is gentler than whole-breast radiation, but provides broader coverage than brachytherapy," said Benjamin Smith, M.D., another study author. "There are plenty of hints in the literature that indicate there's a happy medium in between these two treatments, and that's probably the sweet spot for many breast cancer patients."

It’s important to know that an earlier study done by these same researchers found that older women who have brachytherapy after lumpectomy are more likely to have a mastectomy 5 years after surgery compared to women who had traditional external beam radiation therapy because they had a recurrence. So while cosmetic results may be better with brachytherapy, the risk of recurrence also may be higher.

If you're an older woman who’s been diagnosed with early-stage breast cancer, you and your doctor are likely discussing several treatment options based on the unique characteristics of the cancer, your health history, and your personal preferences.

While this study suggests that cosmetic satisfaction may be the highest for women who have lumpectomy followed by brachytherapy or lumpectomy alone, other research suggests that recurrence rates are higher after brachytherapy compared to traditional external beam radiation.

If you are having lumpectomy, and will be receiving radiation therapy after surgery, you and your doctor may consider brachytherapy as an alternative to traditional external beam radiation therapy. Perhaps the daily trips to the treatment center would be a burden because of distance. Talk to your doctors about their experience with brachytherapy compared to traditional radiation therapy. You also may want to ask about their familiarity with the technical aspects of delivering brachytherapy since placement of the tubes is a skill that can take some time to master.

The Radiation Therapy section has more information on both traditional external beam radiation therapy and brachytherapy.

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