Minimally Invasive Treatments for Breast Cancer
Interventional Radiology Treatments Offer New Options and Hope to Patients Who Are Not Good
Surgical Candidates
In the United States, a woman is diagnosed with breast cancer every three minutes and one woman will die from the disease every 13 minutes. For these women, as well as the thousands of men diagnosed each year, breast cancer treatments can be highly effective, but often require invasive treatment options such as surgery and chemotherapy.
Surgery offers the best chance for a cure. Until long-term data are available, interventional treatments are reserved for women who cannot have surgery.
Recent advancements in technology and imaging now offer patients more tools to fight breast cancer--minimally invasive treatments known as thermal ablation and laser therapy. Thermal ablation treatment builds on the two-decade trend toward less radical approaches and utilizes local treatments for breast cancer. Although the devices used in radiofrequency ablation, cryoablation and laser therapy are FDA approved, more research and long-term data are needed to determine the role these procedures will have in the fight against breast cancer.
About Breast Cancer
When breast tissue divides and grows at an abnormal rate, a mass of extra tissue can develop into a tumor.
To continue growing, a tumor generates its own blood supply to provide oxygen and nutrients. Although the
cancerous cells can grow in size in the breast, they can also travel throughout a person's blood stream
and become embedded in other organs, a process known as metastasis. Typically, 20 percent of breast
cancer develops in the lobules where milk is produced, while 80 percent originates in the mammary ducts
that carry milk from the lobules to the nipple.
As vascular experts, interventional radiologists are uniquely skilled in using the vascular system
to deliver targeted treatments via catheter throughout the body. In treating cancer patients,
interventional radiologists can attack the cancer tumor from inside the body without medicating or
affecting other parts of the body. For breast cancer, interventional radiologists use thermal ablation,
as well as some laser therapy, to kill the cancer cells. Although the devices used are FDA approved,
research to evaluate the long-term effects of these treatments is ongoing.
Prevalence
- In the United States, a woman has about a 13% lifetime risk of developing breast cancer.
- Women 50 years of age and older account for approximately 80 percent of all breast cancers.
- Between age 40 and 50 the incidence of breast cancer doubles, and by age 70 it doubles again.
- In the United States, African Americans have the highest death rate from breast cancer compared to
any other racial group.
- Breast cancer is the most common cancer among women.
- In American women, the breast is the leading cancer site and is second only to lung cancer in deaths.
Metastatic Cancer
Patients with invasive breast cancer are at risk for liver cancer. The liver serves as a
way-station for cancer cells that circulate through the bloodstream. These cells may grow and
form tumors in the liver. It is estimated that as many as 70 percent of all people with uncontrolled
cancer will eventually develop secondary liver tumors, or metastases (tumors formed by primary cancer
cells that have spread from other cancer sites). Interventional radiologists offer nonsurgical
treatments for liver cancer, including embolization to cut off the blood supply to the tumor,
radioembolization that delivers radiation directly inside the tumor, and chemoembolization, which
delivers the cancer drug directly into the tumor and then cuts off the blood supply.
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Breast Cancer Diagnosis
There are a number of tests that can help in the
diagnosis of cancer, including blood tests, physical
examination and a variety of imaging techniques including
X-rays (e.g., chest X-rays and mammograms); computed
tomography (CT); magnetic resonance (MR) and ultrasound.
Usually, however, the final diagnosis cannot be made
until a biopsy is performed. In a biopsy, a sample of
tissue from the tumor or other abnormality is obtained
and examined by a pathologist. By examining the biopsy sample, pathologists and other
experts also can determine what kind of cancer is present and whether it is likely to
be fast or slow growing. This information is important in deciding the best type of treatment.
Open surgery is sometimes
performed to obtain a tissue sample for biopsy. But in
most cases, tissue samples can be obtained without open
surgery with interventional radiology techniques.
Needle biopsy
Needle biopsy, also called image-guided biopsy, is usually performed using a moving X-ray
technique (fluoroscopy) computed tomography (CT), ultrasound or magnetic resonance (MR) to
guide the procedure. In many cases, needle biopsies are performed with the aid of equipment
that creates a computer-generated image and allows radiologists to see an area inside the body
from various angles. This "stereotactic" equipment helps them pinpoint the exact location
of the abnormal tissue.
Needle biopsy is typically an outpatient procedure with very infrequent complications;
less than 1 percent of patients develop bleeding or infection. In about 90 percent of
patients, needle biopsy provides enough tissue for the pathologist to determine the
cause of the abnormality.
Advantages of needle biopsy include:
- With image guidance, the abnormality can be biopsied while important
nearby structures such as blood vessels and vital organs can be seen and avoided.
- The patient is spared the pain, scarring and complications associated with open surgery.
- Recovery times are usually shorter and patients can more quickly resume normal activities.
An X-ray of a needle inserted into the lung to obtain a sample for biopsy.
Large core needle biopsy.
In this technique, a special needle is used that enables
the radiologist to obtain a larger biopsy sample. This
technique is often used to obtain tissue samples from
lumps or other abnormalities in the breast that
are detected by physical examination or on mammograms or
other imaging scans. Because approximately 80 percent of
all breast abnormalities turn out not to be
cancer, this technique is often preferred by women and
their physicians because it:
- is less painful and requires less recovery time than open surgical biopsy, and
- avoids the scarring and disfigurement that may result from open surgery.
A similar technique called fine needle aspiration can be used to withdraw cells from a suspected
cancer. It also can diagnose fluids that have collected in the
body. Sometimes, these fluid collections also may be drained
through a catheter, such as when pockets of infection are
diagnosed.
Many interventional radiology procedures
for the diagnosis and treatment of cancer can be performed on an
outpatient basis or during a short hospital stay. In many cases,
the procedures:
- offer new cancer treatment options
- are less painful and debilitating for patients
- result in quicker recoveries
- have fewer side effects and complications.
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Thermal Ablation Treatments
Radiofrequency Ablation
For cancerous tumors, radiofrequency ablation (RFA) offers a nonsurgical, localized treatment that
kills the tumor cells with heat, while sparing the healthy breast tissue. Because of the localized
nature of this treatment, RFA does not have any systemic side effects. Radiofrequency ablation can
be performed without affecting the patient's overall health and most people can resume their usual
activities in a few days.
In this procedure, interventional radiologists use imaging to guide a small needle through the
skin into the tumor. From the tip of the needle, radiofrequency energy is transmitted into the
target tissue, where it produces heat and kills the tumor. Most patients experienced mild to moderate
discomfort during the 15 minute RFA time. Following the RFA, the dead tumor tissue shrinks and
slowly forms an internal scar. Because there is no surgical incision, RFA barely affects the
appearance of the breast.
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Efficacy
Depending on the size of the tumor, RFA can shrink or kill the tumor, extending the patient's
survival time and greatly improving their quality of life while living with cancer. RFA can extend
patients' lives or in a small number of cases cure patients.
Because it is a local treatment that does not harm healthy tissue, the treatment can be repeated
as often as needed to keep patients comfortable. RFA is a very safe procedure, with few complications.
It is effective for small to medium-sized tumors, and emerging new technologies should allow the
treatment of larger cancers in the future. One study showed 100 percent tumor cell death using RFA,
with no complications after the procedure. 10 RFA is often reimbursed by insurance carriers.
Currently, the protocol is to "ablate and resect," in other words, to kill the tumor with heat and
then remove the dead cells to ensure all the cancer cells were destroyed. As research progresses,
the treatment pattern will become "ablate and follow"-simply treat the patient with RFA and track
their progress over the following years.
For some women, surgery is not an option, due to other health concerns. For these patients,
RFA is an excellent treatment option. In one study of postmenopausal women 60 years of age and older,
95 percent of women would be willing to have RFA again and 95 percent would be willing to have RFA
without definitive surgery if it was known that RFA could kill their entire tumor.
Although the use of RFA in other organs, especially in the liver, has shown promising results
for killing cancer cells, the technique is not a mainstream treatment option for breast cancer patients.
Current research is underway to further explore this treatment and the long-term effects on the disease
and patients.
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A LIVER TUMOR TREATED WITH
RFA
Dead tissue appears
larger and darker than the living tumor.
Over time, the tumor shrinks as the body
absorbs and excretes dead cells
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Benefits
- Has low complication rates
- May be performed under conscious sedation or general anesthesia
- Is well tolerated. Most patients can resume their normal routines the next day and may feel
tired only for a few days.
- Can be repeated if necessary
- May be combined with other treatment options
- Can relieve pain and suffering for many cancer patients
- Causes minimal postprocedure pain
Interventional radiologists use special X-ray equipment to guide therapy directly to the site of tumors
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Cryoablation
Cryoablation is similar to RFA in that the energy is delivered directly into the tumor by a
probe that is inserted through the skin. But rather than killing the tumor with heat, cryoablation
uses an extremely cold gas to freeze it. This technique has been used for many years by surgeons
in the operating room, but in the last few years, the needles have become small enough to be used
by interventional radiologists through a small nick in the skin, without the need for an operation.
The "ice ball" that is created around the needle grows in size and destroys the frozen tumor cells.
Laser Therapy
Laser therapy causes cell death through the delivery of laser energy by a fiberoptic probe
that is inserted into the tumor using imaging for guidance. During the procedure, local anesthesia
is applied around the tumor, followed by the insertion of four metal markers. Next, using imaging
for guidance, an interventional radiologists inserts a laser needle into the center of the tumor
through a small nick in the skin, followed by the insertion of a multisensor thermal needle through
another site. The laser needle is then replaced with an optic fiber through which the energy is
transmitted into the tumor. It is an outpatient procedure.
The current research is promising, with one study finding that complete tumor necrosis (death)
was achieved in 66 percent of the tumors treated10 and another study showing 93 and 100 percent
tumor death in two groups, with no adverse effects.
New Cancer Treatments on the Horizon
Interventional radiology is playing a role
in developing new techniques that may improve cancer treatment in
the future, including the use of magnetic particles to draw
cancer-killing agents into tumors; and the delivery of genetic
material, called gene therapy, to fight or prevent cancers. These
techniques are still investigational, but they offer new hope in
the war against cancer.
"Magnetic"Chemotherapy
Interventional radiologists are currently
investigating a new technique in which magnets are used to pull
chemotherapy drugs into tumors. Microscopic magnetic particles
are attached to the cancer-killing drugs and infused through a
catheter into the blood vessel that feeds the tumor. A rare earth
magnet is positioned over the patient’s body directly above
the site of the tumor. The magnet pulls the drug-carrying
particles out of the blood vessel so that they lodge in the
tumor. Although the technique is still experimental, early
research is promising. Physicians are hopeful that it will
bolster the effects of chemotherapy while avoiding some of the
drugs’ side effects, such as hair loss and nausea.
Gene Therapy
In recent years, scientists have gained a
new understanding about genes—the basic biological
units of heredity—and the role they play in disease.
This knowledge has set the stage for medical science to
alter patients’ genetic material to fight or prevent
cancer. Although the science of gene therapy is still in
the early, experimental stages, researchers are hoping
that in the future the therapy can be used to:
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Researchers in gene
therapy search for new ways to treat cancer and other
genetic diseases |
- alter the cells of a patient’s
natural immune system with cancer-fighting genes and
returning them to the body, where they could more
forcefully attack the cancer;
- remove cancer cells from the body and
alter them genetically so that the patient’s own
immune system will mount a strong defense against them.
In this technique, the altered cancer cells would act as
a cancer vaccine;
- replace a faulty gene responsible for
the growth of cancer with a "good" gene;
- inject a tumor with genes that will
make it more susceptible to chemotherapy or other
cancer-fighting agents; and
- make bone marrow and other organs
resistant to chemotherapy, so that the drugs will destroy
tumors without damaging healthy tissue.
One of the challenges of gene therapy is
finding safe and effective ways to deliver genes or genetically
altered cells to the site of the tumor. Interventional
radiologists, with their special expertise in using X-rays and
other imaging techniques to guide catheters and other tools
through the body are expected to play an important role in this
new technology.
Treatments for Cancer Complications
There are also a number of interventional
radiology techniques that are used to treat the complications of
cancer, including pain, bleeding, obstruction of vital organs,
blood clots and infection. Although these treatments do not cure
cancer, they can make patients more comfortable, extend life by
treating serious complications and improve the quality of life
for cancer patients.
Treating Pain
Control of pain is one of the most
important aspects of cancer care. Pain not only affects
patients’ quality of life and ability to function, it may
also lower their tolerance for needed cancer treatments.
In many cancer patients, pain results from
the spread of the tumor into surrounding nerves and other
tissues. For example, patients with cancer of the pancreas or
stomach, sometimes experience pain from the spread of the tumor
into a network of nerves and blood vessels in the abdomen called
the celiac plexus. To treat the pain, interventional radiologists
insert catheters or needles into the affected area and administer
alcohol or other agents that destroy the nerves causing the pain.
A particularly painful complication of
cancer is when the disease spreads (metastasizes) to bones. In a
technique called transcatheter embolization,
interventional radiologists inject tiny particles, the size of
grains of sand, through a catheter and into the artery that
supplies blood to the tumor. The particles cause clotting that
decreases the tumor’s blood supply, reducing pain and
decreasing the likelihood of bone fracture.
Controlling Bleeding
If a cancer spreads to the blood vessels it
may cause hemorrhage or bleeding. An interventional radiology
technique called transcatheter embolization can be used to
clot the affected blood vessels and stop the bleeding.
Treating Organ Obstruction and Infection
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Cancers
can obstruct the normal flow of urine or bile, causing
these fluids to build up in the body. If left untreated,
these conditions are not only painful but may also result
in organ failure or infection. Under X-ray guidance,
catheters can be inserted to drain the collection of
fluids. Often, a small device called a stent is
inserted into the organ to bypass the obstruction and
allow fluids to drain internally.
Treating Blood Clots
One common side effect of cancer or
cancer treatments is the development of blood clots, or
emboli, that can be life-threatening if they travel to
the brain, lungs or heart. There are two interventional
radiology procedures that can reduce the risks posed by
blood clots:
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Small mesh cylinders
called stents are used to open obstructed organs and
allow fluids such as urine and bile to drain.
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- Intra-arterial thrombolysis. In
this technique, the interventional radiologist guides a
catheter through the blood vessels and to the site of a
blood clot. Clot-busting drugs are infused through the
catheter to break up the clot.
- Filter placement. This
technique is most often used when a blood clot is
detected in the blood vessels of the leg (a condition
called deep vein thrombosis). The interventional
radiologist guides a small filter into the blood vessel
that receives blood from the lower body (the vena cava)
and carries it to the heart. If the blood clot dislodges
from the vein in the leg, the filter will trap it before
it can reach the heart.
Interventional Radiologists are Minimally Invasive Experts
Interventional radiologists work with other specialists on a multidisciplinary cancer team to determine the best treatment for each individual patient. Interventional radiology is a recognized medical specialty by the American Board of Medical Specialties. Interventional radiologists are board-certified physicians with extensive training in disease diagnosis, management and treatment. Their board certification includes both Vascular and Interventional Radiology and Diagnostic Radiology which are administered by the American Board of Radiology. This training marries state-of-the-art imaging and diagnostic expertise, coupled with clinical experience across all specialties and in-depth knowledge of the least invasive treatments. Interventional oncology is a growing area within interventional radiology.
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