Improving Communication About RT for Breast Cancer

This transcript has been edited for clarity.
Kathy D. Miller, MD: Hi. I’m Kathy Miller, Professor of Medicine at the IU School of Medicine and Joining me today is Dr Richard Zellars, the Chair of the Department of Radiation Oncology at the Indiana University School of Medicine. Thank you for joining me, Dr Zellars.
Richard C. Zellars, MD: It’s my pleasure, Dr Miller.
Miller: What we want to talk about today is radiation therapy for breast cancer — the benefits and the risks and how you communicate that to patients.
Zellars: I’m sure you remember, there was a time when the only option locoregionally for breast cancer was a mastectomy. But in the field, we got a little smarter and we realized, wow, we don’t need to remove the entire breast. We can remove part of the breast but treat the remaining breast tissue with 6 weeks of radiation. A couple of years later, we got even smarter and realized maybe we don’t need 6 weeks of radiation. Then we got smarter. Maybe we don’t need to treat the whole breast. And now we’re able to treat in 15 treatments or as few as five. So, we’ve made a lot of progress.
Easing Fears of Radiation
Miller: I think the public perception doesn’t match the actual scientific progress because that is a huge change even during our careers. But radiation sounds scary. It sounds like something you would want to avoid.
Zellars: I think people are thinking of their grandmother’s radiation. We don’t see anywhere near the skin toxicity. Everyone’s heard horror stories about these horrible burns these women had from radiation. They’re very, very rare now, especially in women who are getting breast-conserving therapy alone. The patients who may have a little toxicity are those who have had locally advanced disease, and we must treat a much bigger area.
Miller: So, less trouble with the acute skin toxicity? I think a lot of patients are worried about long-term consequences. One [question] that I get asked a lot about is, what will this do to my heart health, to my heart function? Will I be at greater risk of having a heart attack?
Zellars: We’re not really seeing it now. If you look at studies, when you compare left-sided radiation vs right-sided radiation, before the 1980s, there was a clear sign that there was an increase in cardiac events. After the 1980s, we’re not really seeing that. And much of the reason for that is that we’re able to better aim our radiation post-1980s than we were before.
Miller: The other thing that patients ask me about is, couldn’t the radiation cause cancer?
Zellars: Yes, radiation can cause cancer, but the risk of causing cancer is incredibly low. I often quote less than 0.1%, whereas the benefit of radiation is much greater.
Miller: The other toxicity that patients worry about is their bones and particularly ribs that might be right under the area you need to treat. Can you avoid the ribs? Or are there still concerns about osteoporosis?
Zellars: Not so much osteoporosis with the ribs. Actually, now that we’re moving to partial breast radiation, we’re treating far less bone than we did before. If you look at the numbers of the actual women who have a rib fracture due to radiation, we think it is probably 1%-2%.
Miller: So that’s much better.
Zellars: Much, much better.
Comparing Risk vs Benefit
Miller: How do you communicate this to patients? Do you ask them about their fears of radiation, to kind of put all the cards on the table?
Zellars: Everyone has different fears and interests. And of course, they always have a friend who has a bad story, or they hear someone who had a bad story. I try to assure them that those [incidences] happen very rarely. But we take great precautions to follow them during the course of radiation afterwards. So, should they develop any of those acute toxicities or late toxicities, we’re there to help.
Miller: Do patients ask you how radiation works? Because it seems sort of mysterious. You can’t see it. You can’t feel it when it’s happening.
Zellars: Actually, I love when patients ask how radiation works because that means they’ve done a little homework, and they’ve thought about it a great deal. What I tell them is that radiation disrupts the DNA in the good cells and the cancer cells. The difference is that the good cells are able to repair the DNA damage or disruption that radiation caused. The good cells will stop what they’re doing and repair the DNA. Once that’s fixed, they go on and live happily. Cancer cells are in such a hurry to grow that they don’t stop to fix the DNA. And when they start to divide or try to grow with that broken DNA, they die.
Miller: That’s a great way of explaining it. I’m totally going to steal that example. Are patients worried about the cosmetic effect of radiation?
Zellars: Yes. Luckily, now that we’re moving to shorter courses and only partial breast surgeries, the cosmetic effects are quite small. The biggest concern are the women who have had reconstruction after mastectomy. Those tend to be affected by the radiation much more so than a natural breast. In those cases, they tend to develop a little fibrosis around the implant or the expander. That can often be treated with an additional surgery to shave out that fibrosis or scar tissue, and then things are repaired at that time.
Supporting Individual Patient Needs
Miller: So, Rich, our patients come to us with a lot going on with their lives that impact their receptiveness to information and to getting radiation. How do you help them work through that so they can get the care they need?
Zellars: Every patient is different. And when I evaluate every patient, I also evaluate their support network. Some women come with strong family support. Some women come alone. Some of those people need more handholding. I want to make sure that they’re able to understand everything and get through treatment well.
Miller: There are also sometimes language barriers that can make this challenging. Have you had experiences using interpreters?
Zellars: We always use interpreters when there’s a non-English speaker.
Miller: I think that’s crucially important. And there’s a temptation for us, and sometimes for our patients, to say, “Oh, my son is here. He’ll translate for me.”
Zellars: It seems natural, and that’s sort of how that family unit has operated in the past. But for what we do, it’s really not a good idea because the interpreter can introduce their own biases in the discussion. And you not speaking the language will not catch that.
Miller: It also puts their family members in a position of now being part of their care team in a very different way. I don’t think you can be [a patient’s] son and her interpreter and do both of them well.
Zellars: I agree.
Miller: So, how do you get the message of this incredible transformation of radiation out to the public? Because I’m sure there are some patients that don’t come who could benefit from this therapy.
Zellars: I’m hoping with time, as more women are able to go through radiation and find that it is not nearly as horrible as they expected, that they’ll spread the word. I often tell my patients, you know, “You’re going to start treatment and I know it’s really scary, but I promise you, by the third day, you’re going to be bored to tears.”
Miller: Usually, in our world, boring is good.
Zellars: Yes.
Miller: Rich, thank you so much for joining us.
Zellars: Thank you for having me.
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