Leslie Botnick, MD: Breast Cancer and the Importance of Radiation Oncology
Dr. Leslie Botnick discusses the role of the radiation oncologist in current breast cancer treatment and how it has evolved.
Dr. Botnick is the Chief Medical Officer and Founder of Vantage Oncology.
The Group Room at the 34th Annual CTRC-AACR San Antonio Breast Cancer Symposium was made possible by support from:
VIDEO TRANSCRIPT
Selma Schimmel, Founder & CEO, Vital Options International:
Hello and welcome to the Group Room where we’re at the 34th Annual CTRC-AACR San Antonio Breast Cancer Symposium. So now I’m joined by Doctor Leslie Botnick. Doctor Botnick is a board-certified radiation oncologist practicing at the Center for Radiation Therapy in Beverly Hills, California. You’re also the Co-founder and Medical Chief Officer of Advantage Oncology. And Doctor Botnick, I’ve had the pleasure of working with you for so many years. You are really one of the – I can say – pioneers in radiation oncology because you go back at a time where you trained in Boston and at Memorial Sloan Kettering, working with one of the true pioneers of radiation oncology, Doctor Sam Hellman.
Leslie Botnick, MD, Chief Medical Officer and Founder, Vantage Oncology:
My experience goes back to 1973; actually Sam left Memorial without me. I came out to California, he went to Memorial. But it was an exciting time because at the time we started most women got mastectomies. It was the first report came out in 1968 in this country, and it came out that – it started in 1968 but it came out, I think in the early ‘70s – and in Boston was the first city that really adopted the use of excision of the cancer staging of the axillary staging and radiation without mastectomy.
Selma Schimmel:
So you are really amongst the original generation of doctors that, it was a paradigm shift for breast cancer, and you were amongst those groups of doctors that made a difference in the lives of so many women like myself who had lymphectomy radiation rather than mastectomy. In a nutshell, maybe you can tell us, what’s really changed in the way we treat breast cancer with radiation?
Leslie Botnick, MD:
There’s a huge difference. First, obviously in diagnosis, which we’ve covered but in radiation we now have the ability to shape to be much better than we used to. We have much better ways to ensure accuracy of the positioning of a women during her treatment, so a lot of our treatments are all now CT-based treatments so we get three dimensional views. If we need to see the lymphatics we give intravenous contrast during the CT, we can shape the beam so you don’t treat the heart any more, you treat very little lung, you don’t get any of those kinds of things that people worry about. You don’t treat the esophagus, there’s no difficulty in swallowing, and since the dose are so uniform we can now treat things in 16 fractures for the whole brass so the actual length of the treatment a lot of times is compressed and only large-breasted women, or women we have to treat all the lymphatics we now go to the more conventional six to seven weeks. So a lot of things have changed, and especially the delivery of the radiation.
Selma Schimmel:
I’m curious, how much damage does the skin have to take today in radiation therapy? Must you radiate up close to the surface?
Leslie Botnick, MD:
No. In the circumstance where we’re not treating somebody with mastectomy, we actually try to spare the skin, and the skin is spared better today. You see less skin reaction long term the breasts are looking great. If the surgical scarring after radiation you can’t see most of the time because radiation inhibits scar formation, and what it does better than probably anything else is treat the lymphatics because it can get beneath the pectoral muscle, it could treat the internal mammary lymph nodes where needed, and treat those lymphatics without going through a lot of soft tissue.
Selma Schimmel:
Explain why when a woman has had lymphectomy she still needs to have radiation.
Leslie Botnick, MD:
The breast has multiple ducts in it. Everybody we have a paired organ here. Not only is there multiple ducts in the breast where the cancer is, there are ducts in the other breast and whatever that causes that cancer affects one breast more than the other but it affects all the ducts and especially the ducts in that breast we’re going to treat even more than the other side. So we know that when we used to do a lot of mastectomies, which sometimes I get concerned with doing today, when people serial-sectioned the breast they found about a 30% and sometimes a little higher risk of multifocality – some other thing, whether it’s DCIS, whether a small evasive cancer somewhere else in the breast. So the radiation is able to kill small collections of DCIS, tumor cells, and so we see cure rates exactly the same as mastectomy, and in some circumstances I believe it’s actually will be better.
Selma Schimmel:
I just want to drive home so that women understand, when you don’t have a mastectomy you’re going to have a lumpectomy that the treatment of lumpectomy, surgically removing the tumor isn’t complete until you have finished it off with radiation.
Leslie Botnick, MD:
Correct, especially invasive breast cancer and the only time we use lumpectomy alone is very low grade DCIS or very small breast cancers in somewhat older women who aren’t concerned about long term results.
Selma Schimmel:
You mentioned something a few minutes ago that we’re going to come back to because I know it means a real concern, and that is what you consider the overuse of mastectomy. And I want to talk about that because there are women who I know you have seen that you have felt could have gotten away with treatment using radiation rather than a more aggressive surgery to remove a breast or both breasts.
Leslie Botnick, MD:
With the techniques today, especially, probably 90% of women don’t need to have a mastectomy. And if you don’t have a mastectomy there sure is no reason to have a bilateral mastectomy. When you remove both breasts once you’ve had invasive breast cancer, it improves not one iota of survival; there are no differences, no scientific published data to shows taking both breasts off at the time of development of breast cancer improves curability. Women get frightened, depends who you talk to. If somebody tells you ‘well there is a risk, you can get something on the other side’ or say ‘oh, the way that help me stay alive for the rest of my life is I’ll take them both the breast tissue off’. Well, first you never take all the breast tissue off because mastectomy, even the old, modified radical mastectomy doesn’t take all breast tissue. Skin sparring takes less, nipple sparring takes less, so in essence any time we’ve compared these studies with invasive breast cancer, bilateral mastectomy does not improve curability. So why do it if you don’t need to do it?
Selma Schimmel:
So now many women will say ‘I feel safer. I would prefer to have the breast gone because psychologically if my breasts are gone I don’t feel as vulnerable’.
Leslie Botnick, MD:
I think a lot of it is presentation and the way people talk and explain to people. Most of the time I don’t see a woman when she presents – so she’s already seen one or two surgeons, a plastic surgeon who a lot of times knows nothing about radiation or has a very negative feeling about radiation, they may see a medical oncologist before – but those decisions is based on a cursory review and sometimes the presentation…and a lot of people want a lot more security. But we do things we travel on buses even though there’s a risk to be on a bus or a plane. And here we have no credible scientific basis of risk. It’s a fear. Sometimes you can’t change fear but if you don’t seek all the opinions and it’s not presented in a fear manner, you’re probably going to make an inappropriate decision.
Selma Schimmel:
I think one of the areas of big change too was when I was diagnosed your medical oncologist or your surgeon referred you to a radiation oncologist at the hospital and you go down to the basement and you get your radiation therapy. Today, patients have the option of going into the community, and seeking out and interviewing radiation oncologists.
Leslie Botnick, MD:
There’s a lot of free standing facilities, that are close by their homes, and since the treatments are daily treatment that can occur over four to seven weeks you really want to have something that’s accessible. You can get as good a treatment in a lot of these centers you can get in academic centers and sometimes even better. So you do have that ability; you have the ability to interview, find out what kind of equipment, what kind of doctor, what kind of experience, and what kind of physics is done at this center. Do they have a physicist all the time, things like that.
Selma Schimmel:
And can you please explain why the physicist is so important?
Leslie Botnick, MD:
Well, to check the equipment, making sure that we’re planning and there’s a review process, you don’t want one person looking at anything. You always have to have checks and balances, so you want a physicist, a dosimetrist to review those plans. Those plans are very complex – there’s multiple fields sometimes we do, you want to get the best results. You want to know they’re board certified, just as I’m board certified, there should be a board certified physicist, there should be a board certified dosimetrist and even oncology nurse. I think there’s a lot of people if you have good bedside manner in one doctor that’s terrific and that’s not always the best. You always have to see what the equipment is and what is the staff.
Selma Schimmel:
What about radiation therapy used in the operating room?
Leslie Botnick, MD:
This is the partial brass, sort of the electrons in the OR, they can actually do this, and it’s like a boost. As long as there’s conjunction with whole breast radiation, I think it’s just fine. But a lot of times in the OR you don’t know the margin so you don’t know the dose you should be getting, you can get a frozen section, so sometimes technology is used for technology sake. And I think we, again, if you want to study this, you want to look at it, intro-operative electron beam that’s just fine, it’s okay to do that. But do it under a study, see if it’s any better and next time it’s a boost or if it’s needed and just prepare those results.
Selma Schimmel:
And you were saying that the six to eight week course of what has been standard radiation therapy today may not be necessary to treat that long?
Leslie Botnick, MD:
In anybody who does not need lymph node radiation I suspect that 70% of women can be treated in approximately four weeks.
Selma Schimmel:
If one has had any positive nodes will they require lymph node?
Leslie Botnick, MD:
Sometimes to the extent – if your cells have lymph nodes, is it outer quadrant legion meaning it’s very close to that lymph node, radiation itself just treating the breast will treat that level one, lymph node region. So the answer is you don’t always need to have more extensive radiation in the four weeks of radiation that we’re talking about.
Selma Schimmel:
Doctor Botnick, you mentioned IMRT before and we should expand on that a little bit, and also some of the different types of – are they modalities – of delivery?
Leslie Botnick, MD:
The machines have changed in that there are now most new machines has the capacity to move the head of the machine’s blocking system while treating a field. So in reality you can actually rotate the machine and what the machine is looking at from different angles – some angles it sees the breast and no lungs so they’re going to treat more, another angle going to see mostly lung and a little breast, so those leaves will close, and they do it very fast.
Selma Schimmel:
You’re talking about the leaves on the machine where the beam comes…
Leslie Botnick, MD:
…leaves on the machine, it don’t touch you. So whether it’s a form of radiation called Rapid Arc, it’s called V-Mat, it’s all kinds. The machine is rotating and these beams are changing. Now when you treat the lymph nodes because the field is so little bit wider, meaning the lymph nodes are below the sternum, you have to treat the lymph nodes underneath the muscle, you may have to use that form of treatment where you modulate the radiation beam and you vary the intensity of the beam as it’s moving. So, hence, IMRT. Even with the fixed field breast where it’s treating the breast alone, you may want to modulate. But we don’t call that IMRT, it’s kind of simpler but it is a form of forward planning IMRT so the techniques have totally changed, the side effects are markedly different by using better contouring, CT scan base planning, and IMRT when necessary, but not always necessary in every breast cancer.
Selma Schimmel:
Doctor Botnick, what is image-guided radiation therapy?
Leslie Botnick, MD:
Today all machines come equipped with the ability to take regular x-rays or do modified CT scans on the machine, so you actually can do the setup what you plan at the time of the CT simulation and make sure it matches, make sure the exact field of arrangements is correct. So you can do that every day right prior to the treatment, you can even stop but if it’s a complex treatment you can do it during the treatment and if in certain circumstances you actually could put a type of seed into the breast, which is not being done a lot and actually follow that during the course of the treatment.
So image-guidance is exactly what it says. It’s almost like a GPS for radiotherapy where you can ensure much better that the breast isn’t moving, and now we can even measure the dose during the radiation. So if the cavity, which changes during the radiation, changes a lot with the dose in the region of the excision, is changing you can modify the physics planning of your treatment.
Selma Schimmel:
So in closing if you had to project what the hope is for the future of radiation oncology, what would it be?
Leslie Botnick, MD:
We continue to refine the way we deliver the radiation and I stop feeling that I’m in Groundhog Day where we’re back in the ‘60s and ‘70s where all these women are now getting mastectomies and bilateral mastectomies, and not even asking the question. I think those laws were changed to give women the right to ask the question, and now that we have the science in the back the fact that you don’t need to have this procedure done, why get it done?
Selma Schimmel:
Thank you Doctor Botnick. Doctor Leslie Botnick, Co-founder and Chief Medical Officer of Advantage Oncology.
Leslie Botnick, MD:
Thank you, Selma.
END OF VIDEO