1. Keisch, Martin MD

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Recent data led the American Society for Radiation Oncology (ASTRO) to release a consensus statement on patient selection criteria for accelerated partial-breast irradiation (APBI). The statement, prepared by a task force of eight physicians from major healthcare institutions in the U.S. and Europe, was based on newly published evidence and expert opinion.

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These new recommendations expand the eligibility pool, now deeming patients age 50 and over suitable, and including patients as young as 40 who meet other clinical criteria, along with patients with low-risk DCIS.


As a physician who has seen firsthand the benefits of APBI for my patients, and as a self-proclaimed "champion" of the therapy, I am an enormous proponent of the technique from both the cancer care and patient perspectives.


Breast conservation therapy was initially explored as an option that would allow for less radiation coupled with a shorter course. Since those early trials, studies have shown that APBI results in the same long-term benefits of the full breast therapy. While less time undergoing treatment is appealing, the key differentiator is that less radiation for the same end result will always be the best option.


By lowering the age of qualified patients and including DCIS, we've now increased the number of suitable candidates by about 30 percent, a significant improvement over what we've seen in the past. I'm hopeful that these new guidelines mark the beginning of the end of the arguments against APBI and lead to more widespread acceptance of this therapy as a viable alternative to whole breast radiation.


Whole vs. Partial-Breast Irradiation

Since I first entered the field of radiology oncology many years ago, I've witnessed significant advancements in breast cancer detection and therapy techniques. Over the past few decades, multiple randomized clinical trials and meta-analyses have shown the safety and effectiveness of whole breast irradiation and it has been successfully used to lower the risk of ipsilateral breast tumor recurrence after breast conserving surgery and increase the likelihood of long-term survival.


While I've personally dedicated a large portion of my career to studying and implementing an alternative technique, I'm pleased that in recent years there has been more broad-based interest and exploration of this other approach-APBI-as it offers a decreased treatment time and radiation dose to unaffected breast tissue and organs, allowing patients to get back to life sooner and with minimal side effects.


Historically, there have been varying schools of thought regarding the efficacy of the two therapy options, mostly triggered by the lack of viable data with which to categorize patients best suited for whole versus partial-breast irradiation.


The most frequently cited potential disadvantage of APBI is the possibility that occult foci of cancer are present in other areas of the breast and could be missed. Despite the varying opinions, according to ASTRO, more than 75,000 women in the U.S. have received APBI treatment since its introduction in the late 1990s. In fact, to date, more than 32,000 women in the U.S. have been treated with a breast brachytherapy catheter, which works inside the breast, targeting the area where cancer is most likely to recur, sparing healthy tissue and organs from the effects of radiation (Am J Surg 2000;180:299-304).


Fortunately, as interest in the therapy has grown, multiple clinical trials have begun to compare both the safety and effectiveness of each approach.


Impact on Patients

For patients, the option to have this new, localized treatment that provides an effective dose of radiation to the affected tissue, while reducing treatment time from 4 weeks to 7 weeks down to just 1 week, has a huge impact on quality of life.


Coming to my practice twice a day for a 10-minute treatment without the side effect of fatigue seems like a better option for some patients who have that schedule flexibility; for others, coming in once a day for 6 weeks seems like less of a burden on daily life and is more appealing. If given the choice, the majority of patients will opt for the therapy with the shortest treatment cycle and least amount of radiation and side effects.


What is often neglected in candid discussion on guideline recommendations and updates is the acknowledgment that these guidelines are in fact just that. It is our job as physicians to educate our patients and align on a treatment plan that is the best course of action for that particular individual-and our patients put their trust in us as caregivers to guide them and encourage them down a path that is best suited for those particular needs and situations.


The hope is that for a patient diagnosed with early-stage breast cancer, determining whether or not to choose APBI will be a conversation and decision between the patient, her family, and her physician. The reality is that this isn't always the case.


Being the APBI "champion" that I am, patients are often sent to my practice specifically because their referring physicians find them to be an optimal candidate for the treatment. The referring doctor has usually primed them with background on what the treatment is and what their options are moving forward.


Upon meeting a patient, my thoughts are always, in this order: does this patient meet the recommended guidelines and, second, what insurance do they have? At this point, I am acutely aware of which insurance companies view these guidelines as a tool to guide their reimbursement decisions, and which view them as stark lines in the sand when it comes to patient eligibility. These "guidelines," meant to be taken under careful consideration by experts, are oftentimes viewed as rules by insurance companies, and it is important that my patients make their treatment decisions with their eyes wide open.


I have seen hundreds of patients come into my practice who I feel are perfect candidates for APBI treatment, but whose insurance will not cover that care based on the current treatment guidelines. Last year, if a 58-year-old woman came into my practice with DCIS and chose not to have radiation, her insurance company would have nothing to say. Alternatively, if that same woman decided that undergoing APBI treatment was the right course for her, her insurance would be unwilling to accept it as a viable treatment option and wouldn't reimburse for it.


Of course, the circumstances vary, though I'm not exaggerating when I write that hundreds of patients fall into this situation, either because of age criteria or their tumor types. In some cases, I've had patients who have weighed the options and have chosen to pay out of pocket, with a plan to appeal and later win. I've had patients who simply pay out of pocket and don't attempt to appeal the decision, and the harsh reality is that I've sadly had patients without the means to pay for the treatment, the treatment I think is best for them, who have chosen alternative methods because of these unavoidable financial obstacles.


Looking to the Future

I am a firm believer that breast cancer treatment is not a one-size-fits-all approach, and simply can't be no matter what the guidelines might say. The bottom line is that the ability to marry a positive patient experience with successful clinical outcomes is the goal of every oncologist.


Therapies like APBI give patients real options when it comes to their health by lessening the side effects while still offering an equal outcome and giving them their lives back sooner. It is my hope that all women are offered this option, regardless of insurance provider. These updated guidelines are certainly a step in the right direction and I'm optimistic for what the future of APBI holds for my patients.


MARTIN KEISCH, MD, is a radiation oncologist at Cancer Healthcare Associates in Miami.

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