Breast cancer: getting painted

I really had no idea that part of starting up radiotherapy was getting decorated:

(This is principally the middle-side of my chest; the long red line is part of the incision.)

It is very important that whatever delivers the radiation does so to a pre-determined site.  Somehow that site has to get marked.  I did know that in the olden days one could get a nice array of tatoos on one’s chest.  And even today some hospitals use tatoos that are  like tiny dots.  But mine, in an unusual recognition of patients’ sensibilities, realized that one doesn’t really want permanent reminders of radiation scrawled across one’s body.  So they use something like magic markers.  They problem is that since it can all come off, they are very generous with the markings.  Marks like  these marks are all across about 1/2 of my chest.  And in different colors, some going up to the collar bone.  Very jolly.

Though in the intervening 24 hours I have come to realize why they said that one should wear old, dark clothes.  That’s because the stuff comes off on anything that touches it.Since the paint comes off, it will get drawn back on, and then rubbed off and put back on, etc.  Fortunately, I’ll just have 4 weeks of this routine, while some people get 7 weeks of it.  That’s five days a week, as I may have said.  The remarkable thing for me is that with all these millions and millions spent on these high tech machines, why can’t anyone come to a sensible solution to the paint problem.

The millions and millions getting spent are now being spent on a new approach, which is really interesting, but maybe not exactly for the squeamish to read about:

Breast intensity-modulated radiation therapy (IMRT) – a technique that delivers radiation equally throughout the breast tissue and avoids radiation ‘hot spots’ in which some areas of the breast receive higher doses than others – reduces the skin side-effects that commonly occur with standard radiation therapy, according to a study in women with early breast cancer.

Women with early-stage breast cancer are generally treated with breast-conserving surgery, or lumpectomy, which minimises the amount of breast tissue removed, followed by radiation therapy to the whole breast. Clinical studies have shown that this treatment approach is associated with a low risk of the cancer returning (recurrence) while maintaining the shape of the breast as much as possible. It provides an effective alternative approach to mastectomy, in which the breast is completely removed.

The problem with radiation therapy to the whole breast is that about one-third of women suffer acute side-effects to the skin where the radiation is concentrated. The top layers of the irradiated skin are broken down and the area becomes ‘weepy’ in a process referred to technically as ‘moist desquamation.’  [Of course, when one is told about radiation, no one describes this process.  Women to whom it happens talk about their skin coming off.  Wine is thought to help prevent the effect.  Drunken, that is, not poured on.] 

The complex, three-dimensional shape of the breast makes it difficult to deliver radiation at a uniform dose throughout the entire breast using conventional radiotherapy equipment. This results in radiation ‘hot spots’ that can cause skin damage. Wedges are used to try to protect narrower parts of the breast and various other approaches, such as creams, have been tried in efforts to reduce skin problems due to radiotherapy, but none have proved very effective.

Breast intensity-modulated radiation therapy uses a computerised planning system that calculates the dose of radiation delivered to each part of the breast allowing for changes in its shape. Essentially, it allows rapid blocking of the radiation beam in areas of the breast where the dose of radiation needs to be reduced to achieve more even dosing throughout the changing contours of the breast.  [The planning is very expensive and involves a team of specialists; see below.]

Using the new radiotherapy strategy did not significantly reduce pain or improve quality of life. The researchers thought this may have been because the measures they used for these factors were rather non-specific. However, their results showed that the occurrence of moist desquamation was significantly correlated with pain (P=0.002) and reduced quality of life (P=0.003).

The distribution of radiation dose within the breast was significantly improved with IMRT. Less than one-tenth (7.7%) of the volume of the breast received more than 105% of the prescribed radiation dose with the technique, compared to more than one-sixth (16.9%) with standard radiotherapy.

Commenting on the findings, the researchers, led by Jean-Philippe Pignol from the Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Toronto, Canada, said: “To our knowledge, this the first multicentre randomised trial demonstrating a successful reduction in acute radiation skin toxicity using an improved radiation technique, breast IMRT.”

“Our trial confirmed the dramatic improvement in the dose distribution homogeneity using breast IMRT, and demonstrated that it translated into a significant 17% absolute reduction in the frequency of moist desquamation.”

They considered that their results supported breast IMRT being offered to patients receiving adjuvant breast radiotherapy instead of the standard wedge technique.

US-based breast radiation therapy specialists agreed. Writing in an accompanying editorial, Bruce Haffty (Cancer Institute of New Jersey, New Brunswick), Thomas Buchholz ( M.D. Anderson Cancer Center, Houston) and Beryl McCormick ( Memorial Sloan-Kettering Cancer Center, New York) said that the study “may have a significant impact on the practice of breast radiation.” They recommended: “Most facilities that have the necessary planning equipment and technology available should strive for optimal homogeneity, which can be readily achieved with the techniques described.”

The editorial writers cautioned that the improvement in treatment planning needed for IMRT is not reimbursed by all healthcare insurers in the US, with technical costs for IMRT treatment being about three times those for non-IMRT treatment. They hoped that these economic issues can be resolved “so that clinical applications of this exciting technology can continue to move forward.”

4 thoughts on “Breast cancer: getting painted

  1. Medical treatment does not dignify.

    I suppose that medical personnel could try to treat patients in a more dignified manner, but they generally don’t, unless patients pay huge sums for it.

    Even when patients try to buy dignity, they end up buying only servility.

    I suppose that very few of us enjoy dealing with diseased bodies and that many medical staff resent having to do what they do to earn a living.

    In any case, in spite of what you have to go through, I hope that it is effective in technical terms.

  2. Yes, well, I am not sure I meant to whine and complain. Getting painted with all these codes over a significant part of one’s body appeals to a very distant longing. I’m not keen on the laundry problem, and I would have loved to do the other side myself, but these are small matters.

    The contrast between primitive body painting and multi- million dollar machines is also extraordinary. In my case the macinery was quite new and actually didn’t quite work. At the same time, it is important that one not move between the beginning ct scan and the final stage, though I am not completely clear why. So I was left somewhat frozen in place for well over an hour, but occasionally someone would rush in with, “you aren’t moving, are you?”. At one point i did say, “well, I’d really like to scratch an itch,” to which this very conscientious assistant replied, “don’t move; I’ll scratch it for you.”. I actually treasure the fact that a day’s experience can contain almost unbelievable bits like this.

  3. I don’t think that you are whining.

    Complaining, on the other hand, seems entirely legitimate to me. This isn’t a Stoic forum.

    When I’m in medical hands, I maintain my precarious sanity by trying to surmise who is behind the invariable masks of impersonal benevolence of the medical staff.

    Sometimes I’m even able to anticipate the reactions of the person behind the mask beforehand. It’s a game I play with myself.

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