Dr Williamson graduated from the USC School of Medicine in 1989, and completed her residency as chief resident in radiation oncology at USC in 1994. Dr Williamson talks about why her medical career became focused on breast cancer following the loss of her sister to the disease. In her in-depth interview, she talks about the importance of radiation and how it significantly reduces the rate of recurrence for her patients. You will learn about the preparation for radiation, the various forms of radiation therapy treatment and the side effects that a patient can expect with treatment.
My name is Dr. Ruth Williamson. I graduated from USC medical school and my residency in radiation oncology was also at USC.
When I went into radiation oncology, I was not going to sub specialize. I was working with two male radiation oncologists and I found that women with breast cancer just wanted to be treated by a female physician. And then my sister, as well as my mother, was diagnosed with breast cancer, and my sister actually passed away of breast cancer. And at that point I didn't think that I'd be able to take care of breast cancer patients, but now I'm very happy that that's what I do. I'm highly motivated to take care of the patients. I understand what it's like to be a family member of a breast cancer patient.
So radiation is a high-energy x-ray, and breast cancer cells are very sensitive to radiation. As a matter of fact, whatever your risk is, we see a 75 percent risk reduction from the radiation itself. So, we're really good at getting rid of microscopic breast cancer cells.
Radiation therapy always comes at the end. Chemotherapy sometimes is before or after surgery, and radiation therapy is always at the end of treatment. That is because, if you delay the chemotherapy, it's not as effective, but delaying the radiation does not make the radiation less effective.
So I think it's very important that a woman be informed as well as she can be beforehand and understand the reason for having the radiation. Otherwise, it's scary. I mean you actually want the woman going into it wanting to have the radiation if she needs to have it. I mean if there's a survival benefit or if it's allowing her to keep her breast, she should understand those issues and understand why it's being offered and how much it protects you actually from having a recurrence.
I think it takes a lot of time for your initial consultation. I'm usually spending 45 minutes to an hour just discussing the radiation therapy. A lot of patients that are going to go ahead with neoadjuvant treatment, or if they're making a decision to have a mastectomy, and they don't know if they're going to have the radiation, sometimes that can be tough. And some patients need to know about the radiation even before going ahead with chemotherapy or surgery, so they want to know up front what the overall treatment plan might be.
Most patients that have a lumpectomy have radiation. Early-stage breast cancer…if you are node negative after a mastectomy you would not need to have the radiation in general. But that threshold for post-mastectomy radiation therapy has gone down. If you have multiple-risk factors, a large tumor, you're young, invasion in the lymphatic… sometimes we even treat patients that are node negative after mastectomy with radiation. And there's a benefit in survival whether you have radiation after lumpectomy or after mastectomy by preventing recurrences.
If it's a patient with lumpectomy and sentinel node biopsy, in general they're usually ready to go about four to six weeks after the surgery. If they've had reconstruction with implants or tissue being placed in the chest area that takes a lot longer to recover from. So I would say in those cases it's usually about two months or so before we get started. Whenever they've healed adequately, that's when we usually get started. It's very important to make sure the patient is healed before we get started because radiation can interfere with the healing.
Then we're ready to do the planning for treatment, and what we do is we have a woman in the same position that they'll be treated in, with their arm up, lying on a table, and we do a CT scan through the area that we're going to treat. That's how we determine the angles for treatment, and we determine what we need to cover, what we don't need to cover. We want to block out the structures that we don't want to treat. We want to treat the breast but we don't want to treat the heart. We don't want to treat the lung. Sometimes we want to treat the lymph nodes; sometimes we don't; so we want to target the area that we want to treat.
Planning usually takes about 30 minutes, and we do put some tattoos on the skin; they look like little dots, very small, a little bit blue so we can tell the difference between the tattoo and maybe a freckle, but they're very, very small, and that's actually very important to align the treatment field. It's also important, god forbid you need to have radiation in the future the only way to reproduce your treatment field is actually on your skin, so we do recommend having tattoos.
We're usually ready to start you a few days after the planning for treatment, and we always want to do the planning right before starting treatment so it's very accurate.
The first day that the woman starts treatment I think it's really important to make sure she's feeling comfortable. I usually check the patient on the table; it's kind of a clinical set-up; and then we also have the woman work with the nurse who can answer any questions that she might have especially about skin care.
As I'm checking the woman on the table to make sure everything is lining up, we might make some adjustments. We take films to document the field that we're planning to treat. We want to make sure everything is completely aligned, and in general those films are taken once a week to make sure that the field has not shifted in any way.
Actually, the course of treatment now, the length of treatment, has changed for a lot of our patients for very early-stage low-grade breast cancer. Now they're randomized trials showing that we can treat in three weeks or six weeks. That's called hypofractionated treatment. A lot of my women are being treated with hypofractionated treatment. It's a larger dose per day, about an equivalent total dose, but we actually now have randomized trials looking to see if it might be slightly better with low-grade cancers to be treated faster. I really like the three-week course of treatment but It's not appropriate for everybody. If we need to treat the lymph nodes, we can't do it. If it's a high-grade tumor HER2 positive or if it's a triple-negative fast-growing cancer, it may not be better so we usually treat those patients with six weeks of treatment
Whether or not you're treated for six weeks, or whether you're treated for three weeks, you're here about 20 minutes a day for treatment. It's actually just a couple minutes that you're actually receiving the treatment, but the woman has to get in the treatment position; everything has to line up perfectly; that takes a little time just to get you on the table lined up.
So it's not a long time in the radiation department but it's daily, Monday through Friday, whether it's three weeks or six weeks. And sometimes if it's three weeks, we still give a boost at the end to adjust the area where the tumor was, and so it might be three weeks and a few extra days for treatment. It's not appropriate for everybody. If we need to treat the lymph nodes, we can't do it. If it's a high-grade tumor HER2/neu-positive or if it's a triple-negative fast-growing cancer, it may not be better so we usually treat those patients with the six weeks of treatments.
There's also intraoperative radiation, which is somewhat investigational and is falling a little bit out of favor because there's higher recurrence rates for the intraoperative radiation. There’s a device that is placed into the lumpectomy cavity, and localized radiation is given internally right into the lumpectomy cavity, and it's a very superficial radiation. It might be something that can be used more as a boost for treatment, but it has been shown to be somewhat inferior in terms of recurrence rate. And then those women with the intraoperative radiation were getting a lot of fluid collections, permanent fluid collections, because you're giving radiation before the woman has been able to heal, and radiation does interfere with healing. There's also…it's like a .7 percent recurrence rate versus 1 percent so it's getting into the realm of being unacceptable.
Watching the skin closer is super important, so you want to go and see your doctor once a week; don't avoid that appointment because sometimes we can see something that's about to happen and prevent it. So if I see it's red or rashy, I can often give a steroid cream and then that will reverse that reaction.
Radiation fatigue doesn't come on until about maybe the third week of treatment if you're going to get it. It's kind of a strange fatigue in that if you can rest and you can take it easy, you tend to feel better, not unlike chemo where you might have a more profound fatigue. So I usually tell my ladies that the last two weeks of treatment, the two weeks after that, that's the timeframe that you might get tired. My nappers always do great, and actually my 80-plus ladies do a lot better than my 40 or younger patients because there life is not as busy as it was at 40.
Six weeks after you're done, you should be back to normal. You shouldn't have long-term fatigue. In general where we see the long-term fatigue, it's my women that have had some chemotherapy.
At the end of treatment you tend to get depressed. That's why we get blamed for everything because we're always at the end of treatment. All the emotional stuff happens at the end of treatment. I think it's because women go into a survival mode. Women are built to survive so women put everything into compartments so it's surgery, the chemo; it's the radiation…you're kind of getting through it. And when you get to the end of treatment, that's when you realize, oh my god, I had breast cancer. And so we've developed all sorts of programs for women at the end of treatment because of that.
You have to redefine who are you. Am I a breast cancer survivor? Am I cured? How do I think of myself? After you've had cancer you have to sort of redefine yourself. That takes a lot of emotional energy. And then how do I know I'm okay? Every time you go to the doctor, they're checking you; how do you know? Well, it's a blood test; we examine you; there's no special study to tell you you're okay. That's a hard thing to deal with. You have to learn to accept that and there's a lot of anxiety with that first mammogram that first breast check, and all of that. And it gets better over time.
We have a post-treatment stress management program with a psychologist that's a specialist in cancer coping. It is nice to be around other women going through the same thing, and usually you find someone that's coping in a way that you'd like to cope. Everyone copes in a different way. I think it helps to talk to somebody that is coping in the way that you would like to move forward. So support groups are great, I think. They're not for everybody, though, so some women do better with individual counseling. Some women do much better in support group situations.
There's the women that have advanced disease and we have to treat after mastectomy; we have to treat all of the lymph nodes; we have to treat that skin to a high dose; and then it might even spread. And then they're dealing with chronic medications, whether it's chemotherapy, whether it's hormonal treatments, and that's very difficult. And the women that have hormone receptor positive disease, they can have long periods of time where they're fine. I mean I have a lot of women that are dealing with metastatic disease; you wouldn't even know; you'd see them out there, beautiful women out there living their lives, a completely perfect quality of life, and the medications are working for them. At some point it's probably going to come back so they have to deal with that.
Every year there are new treatments for breast cancer and huge improvements.
That's why I love treating breast cancer actually because it's always changing. Women decide where all the money goes so it goes into pediatric research and breast cancer research. Nothing for prostate.
So radiation is improving the survival for those advanced cases. And I've seen ladies with inflammatory breast cancer, very advanced stage 3 with 20 out of 20 nodes positive, and they are fine, and that's because of the radiation because without the radiation, they'd have about an 80 percent risk of recurrence and then it could spread from there. So by controlling this disease locally, we're improving survival, and the reason that we're seeing that is because these chemotherapies are doing such a good job getting rid of the cancer in the rest of the body.
Twenty years ago we didn't think that radiation would benefit you in terms of survival, and that's true after a lumpectomy, too. By reducing that risk down to such a low risk, we're preventing recurrences. If in studies looking at radiation versus no radiation, even for very early-stage breast cancer, if you don't get the radiation and four women recur because of that, one of those four will die because of it. So, it's very important to control it locally. And that's what's important for the women to know.
Recent data has also shown that even if you have a node that's positive with your sentinel node, now we can treat with radiation; you don't have to have the nodes removed because we know radiation gets rid of any disease in those lymph nodes. So, radiation is equivalent to a node dissection and clinically negative, meaning you can't feel a node or we didn't see one or it wasn't biopsied. So, that's also a wonderful thing because doing those node dissections causes a lot of problems so you have chronic pain or lymphedema, radiation to those lower left nodes doesn't do that. So, there have been a lot of huge advancements in radiation therapy in the last 20 years.
I just think that no matter what your situation with breast cancer, there's hope, whether you're stage one or even stage four. Every year we have new drugs, new advancements and even for Stage IV patients, it's becoming more like a chronic disease. It's not a death sentence anymore.
I also think we've come a long way with support. I've been incredibly impressed with acupuncture supporting our patients; with hypnotherapists with self-guided meditation; with our support groups. I don't think it has to be a torture chamber emotionally, either. I think that you can get the support and get through this gracefully. And actually what I like about what I do more than anything is that I see women transform and improve their lives from going through this situation.
Sometimes it takes dodging the bullet to actually change your life and make it better and change things that you think you have all the time in the world to change. So I love to see that. I see women that come in like a deer in the headlights and they're so afraid and they leave this process a better person with a better life.