CLEVELAND, Ohio -- Intraoperative radiation therapy, or IORT, is a procedure in which a patient receives radiation immediately following surgery before leaving the operating room. For years, it has been a treatment option for patients with certain types of cancer, including colon, pancreas and prostate.
More than a dozen years ago, surgeons began the limited use of IORT in breast cancer patients. But it wasn’t until June 2010, when the journal Lancet published online the results of an international, randomized clinical trial called the TARGIT-A Trial, that large, academic hospitals, including those in Cleveland, began offering the procedure to more patients. Data collected over four years from the TARGIT-A Trial showed that IORT was as effective as standard, whole-breast radiation in preventing a recurrence of breast cancer.
Buoyed by encouraging data from its own recent study, the Cleveland Clinic this year has expanded its use of IORT in breast cancer patients.
From November 2010 through December 2012, 78 breast cancer patients underwent IORT at the Clinic. More than 90 percent of patients had no recurrence of disease at the 12-month follow-up. The results of the study were published in April in the journal American College of Surgeons.
IORT for breast cancer patients usually follows a lumpectomy to remove cancerous tumors. A radiation oncologist inserts a probe that delivers radiation to a targeted area where the tumor was removed, all while the patient is still under anesthesia.
At roughly one-fifth of the cost for standard whole breast radiation, which runs around $10,000, IORT is less expensive, said Dr. Stephanie Valente, one of four breast surgeons at the Clinic that performs the procedure for breast cancer patients.
IORT takes about 30 minutes, cutting down on treatment time. Standard radiation of the whole breast typically begins one month after surgery and takes five to seven weeks.
“That would have been a lot of time and energy involved,” said Joanne Duffy of Avon Lake, who had IORT at the Clinic last October. “It [also] shortened my time of recovery.”
Physicians diagnosed Duffy, 71, with early-stage breast cancer in September 2012. The tumor was spotted during a CT scan in advance of another operation that had already been scheduled to reconstruct her sternum, which had not healed well after heart bypass surgery.
Duffy’s cardiologists were anxious for her to have that surgery as soon as possible. So her oncologists suggested IORT, which she recovered from well enough to have the other surgery three months later.
At University Hospitals Case Medical Center, a clinical trial looking at the effectiveness of IORT in patients who undergo oncoplastic surgery -– a lumpectomy and reconstructive surgery in the same session -– is drawing to a close.
IORT also is available to patients as part of other studies, as well as to patients with a recurrence of breast cancer. Because the recurrence rate is so low in women who have had radiation in the past, there are only a handful of patients in that category in a year, said Dr. Janice Lyons, director of Breast Cancer Services at University Hospitals Case Medical Center and associate professor of radiation oncology at Case Western Reserve University School of Medicine.
“[IORT is] an opportunity to help women who felt like they didn’t have other options,” she said. "We're doing this in a population of patients with no other option other than mastectomy."
The standard of care for the majority of women remains whole-breast radiation, said Dr. Rahul Tendulkar, a radiation oncologist at the Clinic.
“But we're looking at ways to find alternative options for patients,” he said.
Choosing the right patient for IORT is a collaborative effort, Tendulkar said. The patient who is a good candidate for the therapy is typically over age 50 with early-stage breast cancer that hasn’t spread beyond the initial site.
“We want to make sure that we’re not putting patients at risk,” he said. “It’s less radiation, less volume. We want to make sure we’re not compromising care.”
One disadvantage to IORT, said the Clinic’s Valente, is that lumpectomy comes with the risk that not all of the cancerous tissue is identified and removed during surgery. About 15 percent of patients require a follow-up surgery and radiation, but previous IORT still helps to significantly reduce the treatment, she said.