And it's also in women where we're not treating the regional lymph nodes.
There are some very important nerves that run to the arm and so
the shorter course hasn't been tested in that region of the body.
So whether or not that's appropriate to do or not, we're not quite yet sure.
So that's the first criterion.
Then I think the other criterion come down a little bit into whether you're a lumper
or a splitter in some ways, if you will.
And so some people will look at the hypofractionation trials and
say okay, it is equivalent.
We have six weeks versus three to four weeks.
And the trials show it's equivalent, so therefore it's equivalent, end of story.
It's the same amount of radiation, and done.
We have other people who will say, well, you know, we have to look at who was
represented on that trial, and say that most of the women were Positive.
So maybe I'm not comfortable using it in women who have triple negative
breast cancer.
Or not as many of the women had chemotherapy on this trials, so
I'm not really comfortable using it in the setting after chemotherapy.
Or maybe the say, well it's predominantly in women over the age of 50.
So if I have a 35-year-old, then I'm not going to be quite so comfortable.
So it really depends on how you view the data.
And so I think even in our own practice we have some differences as to
how people think that's appropriate, but I think for most people, if
there's a woman with an estrogen-positive breast cancer who's 50 years old.
And requires treatment to the breasts only for an invasive breast cancer,
then most people would feel comfortable in our practice,
administering the shorter course radiation.
>> Yeah.
>> It comes down to a little bit different when we have young women,
people with pre-existing implants, triple negative breast cancers,
where people might have a little bit more caution in those scenarios.
And I think that's appropriate.
>> Yeah, it's another great example of why people should really
participate in clinical trials so that you do get kind of a diverse array
of patients because as is pointed out right here so many of the decisions
that we make are really defined based on the people who participate.
So another question, you mentioned this a little bit about treating regional lymph
nodes, and there's been some data coming out that's really talked about
radiation to regional lymph nodes.
Tell us about your thoughts on that and
whom do you recommend extra radiation to lymph nodes?
>> Absolutely, so, when we're looking to give
treatment to the regional lymph nodes, we're really trying to define
the women who are at highest risk of failure to those regions of the body.
The exciting trial it came out, it showed that there was
a disease-free survival benefit in adding radiation to the regional lymph nodes.
So, we certainly are considering it a lot more,
specifically in women who have positive lymph nodes, certainly.
That particular trial also had a small proportion of women who were sort of
the high risk node negative breast cancers,
where the lymph nodes were negative but they had some more aggressive features,
like lymphovascular invasion, or higher grade, or larger tumor size.
So, typically, we're looking at it the most
when we have women who have a no positive breast cancer.
So we're looking at treating not only the lymph nodes underneath the collar bone,
but we're also starting to look more at the lymph nodes that live beneath
the breast bone.
And that's an area that's sort of pendulum back and
forth over the years, in terms of how often it was treated.
And one of the nice things that we have now is that the toxicity of doing that
treatment has gotten a lot less because we are doing all
of our planning with CAT scans, and
we have techniques like breath hold that can move the heart out of the way.
That's where women will take a deep breath and
hold it to push the heart out of the way,
then we're able to consider doing these treatments in a wider array of women.
But I think it is a small disease-free survival benefit, so oftentimes it's
a decision that we make, sort of looking at the individual anatomy of the woman and
judging how much heart or lung would be exposed by adding those lymph nodes and
considering the benefit of that as well.
>> So another thing that we talked a little bit in lecture about
was prone positioning.
When do you do that?
When do you put people lying on their stomach when you treat them for radiation?
>> Yeah, so, the prone positioning technique has been shown to be very
helpful, particularly when you have women with very large breasts.
>> Mm-hm. >> One of the things that
we think a lot about in radiation, of course, is individual anatomy and
the shape because we have to cover the whole breast.
And so, sometimes what we can see is in women with large breast.
The breast will sort of fall to the side and
to the armpit when we lie them on the back.
And so, it will sort of hug the chest wall and when you're trying to cover the entire
breast, and the breast is hugging the chest wall, you're going to expose more of
the tissues deep to the breast, like the heart or the lung to radiation.
So, in women where were treating just the breast with early stage breast cancer.
So with no lymph nodes involved.
We'll sometimes look at doing treatment on their belly so that,
that way the breast falls forward, and we can minimize the amount of
