An Alternative Therapy for Some Breast Cancer Patients

Gary M. Freedman, MD, is an associate professor of radiation oncology at the Perelman School of Medicine and physician at Penn Radiation Oncology.

For more than 25 years, breast-conserving surgery and radiation therapy have been standard alternatives to mastectomy for women with early stage breast cancer. Radiation after a lumpectomy reduces the risk of a recurrence in the breast, and for some women it may also improve survival. The past decade has seen many advances in radiation that aim to preserve the high rates of success, but often must choose between optimizing the treatment delivery and reducing acute or long-term side effects, or reducing cost and convenience of care.

Hypofractionation uses fewer, larger dose radiation treatments (also called fractions) usually given over a shorter time period when compared to conventional radiation fraction sizes.

Hypofractionated radiation has been associated with a reduction in the length of a course of treatment by two to three weeks compared to conventional schedules that can last as long as six to seven weeks. This reduced length of treatment reduces cost to patients and insurance payers, reduces costs of travel or lost days of work to patients, and reduces the inconvenience of daily radiation treatments. This is particularly important in today’s national concern for cutting health care costs.

Hypofractionated whole-breast radiation has been a major subject of research outside of the United States for more than a decade. Randomized trials have been reported from Canada and the United Kingdom that show low breast recurrence rates using hypofractionation with long-term follow up of five to 10 years. In addition, these large studies did not show significant differences in cosmetic appearance of the breast or other negative side effects in women treated with a shorter course of radiation.

Despite the successful outcomes in these randomized trials from Canada and the United Kingdom, there has not been significant adoption of hypofractionation in the United States. The American Society of Radiation Oncology convened a task force of experts to make consensus recommendations. After a review of the available literature and randomized trials, consensus was reached that hypofractionation should be used only for selected patients. This recommendation was based on the many clinical questions that still remain about hypofractionation that are not able to be addressed by the data from the existing randomized trials.

At Penn Medicine, selected women meeting these optimal criteria are being offered the shortened radiation schedule. Current trials could make hypofractionation even more widely accepted for patients with early stage breast cancer. The Radiation Therapy Oncology Group opened a phase III randomized trial in May 2011 that proposes to establish a whole-breast three-week hypofractionation schedule that can be applied to a broader patient population. The study will compare typical whole breast radiation given over four and a half to six and a half weeks to a shorter schedule of only three weeks.

In summary, prospective randomized trials outside of the United States have established the principle that hypofractionation may be used with acceptable low side effects and equally low breast recurrence rates as conventional fractionation. However, for hypofractionation to become more widely applied in the United States, more data are needed about the optimal radiation techniques and limits on patient eligibility. This data may come from a newly opened phase III trial in the RTOG now opening at Penn Medicine and locations across the country. If successful, hypofractionation may be more widely accepted for use in the majority of patients with early stage breast cancer in the United States.

Learn more about breast cancer treatment at Penn’s Abramson Cancer Center.

Learn more about radiation therapy for breast cancer at Penn Medicine.

The Abramson Cancer Center (ACC) is pleased to present the Focus on Women's Cancers Conference featuring:

• 20th Life After Breast Cancer
• 10th Focus On Gynecologic Cancers
• Focus On Your Risk of Breast and Ovarian Cancer

Attend Penn Medicine’s Focus On Women’s Cancer Conference

Friday, October 28, 2011
7:30 am to 3:30 pm

Hilton Hotel, 4200 City Avenue, Philadelphia, PA 19131

Register and view the full agenda at The Abramson Cancer Center, or register by phone at 800-789-PENN(7366).

Please register for only one conference but feel free on the day of the conference to attend sessions at any of the 3 conferences.


Portions of the program will be livestreamed at PennMedicine.org/Abramson/WomensCancersLIVE on the day of the conference.

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Woman Beats Breast and Esophagael Cancer: Wants to Give Back

A 12-year breast cancer survivor, Gail Slappy was diagnosed with esophageal cancer in April 2009. Upon being diagnoses, Gail began receiving treatment at Penn Medicine's Abramson Cancer Center. When she retires from a teaching career this upcoming Spring, Gail plans on volunteering at the Abramson Cancer Center.

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My name is Gail Slappy. I’m a breast cancer survivor. In April of 2009 I was diagnosed with esophageal cancer.

I felt fullness in my chest that wouldn’t go away. After repeated attempts at diagnosing myself, I went to my primary care physician. She referred me to Gregory Ginsberg, MD, from Penn Gastroenterology.

Following an endoscopy, it was determined that I had a mass at the bottom of my esophagus leading into my stomach. Dr. Ginsberg informed me that I had esophageal cancer.
I thought to myself, “Oh no, not again!”

I’m a 12-year survivor of breast cancer. I was shocked that I was having another recurrence of cancer.

The multidisciplinary approach

Then, Dr. Ginsberg and I began to talk. I’m familiar with Dr. Ginsberg because he has been treating me over the years. He told me how he would handle my cancer treatment. Then, a team of doctors came in and discussed how I would be treated. The team consisted of Ursina Teitelbaum, MD, a hematology/oncologist; John Plastaras, MD, a radiation oncologist; and Ernest F. Rosato, MD, a surgeon. We all discussed how my case would be handled.

I felt quite relieved and confident that I was receiving the best treatment possible. There was a comprehensive team of doctors, and everyone was consulting with one another about my treatment.

Compassionate care

Throughout my experience at Penn Medicine's Abramson Cancer Center, I felt supported. Everyone was just so compassionate towards me and my care. I would receive phone calls at home asking how I was doing.

At my lowest point, I grew quite weak from the combination of radiation and chemotherapy. When I would go to receive therapy, everyone understood how I was feeling and treated me with the most compassion I could ever receive. One time, when I was receiving radiation, one of the radiation therapists talked to me so nicely. The nature of his voice and the way he spoke to me so calmly let me know I would be alright. It truly made all of the difference. He even said that I looked great even though I felt lousy and I probably looked lousy too! He was endearing and he helped me a great deal.

After I had my surgery, the nursing staff and the doctors in the hospital were so kind and gentle. They helped me through the whole process. Everyone was very concerned, very attentive, and genuinely interested in my care, my progress, and my recovery. People always asked what they could do to make me comfortable and how they could help me. That was the sentiment throughout my whole recovery at the hospital.

That’s why I like the comprehensive approach at the Abramson Cancer Center because everyone is in dialogue with one another. They are constantly updating each other on your condition, and making sure that you are okay.

Giving back
I’ve been recovering from my illness. I’m a teacher, and I plan to retire in June. Once I heal, I want to give back. I plan on volunteering at the Abramson Cancer Center. I want to help other individuals who may be diagnosed with cancer and help them get through it. I want them to know it’s not a death sentence or the end of the world. In spite of the seriousness of the illness, you can conquer it. You can be a champion.

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