Preparing for breast cancer radiation therapy on the left side with Karen Winkfield, MD, PhD

Radiation therapy is an important part of treatment for many people diagnosed with early-stage breast cancer. High-energy beams are used to destroy cancer cells that were not removed during surgery and to lower the risk of cancer returning to the breast. But the chest is home to other vital organs, including the heart, which can sit very close to the chest wall in many people. Delivering effective radiation treatment while protecting the heart from the effects of radiation is one of the highest priorities for your healthcare team.

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Living Beyond Breast Cancer CEO Jean A. Sachs, MSS, MLSP, spoke with radiation oncologist Karen Winkfield, MD, PhD, about the importance of protecting the heart during radiation therapy, and the technology and techniques that have been developed to make radiation therapy safe.

Jean A. Sachs, MSS, MLSP:

Hi, everyone. It is Jean Sachs. I'm the CEO of Living Beyond Breast Cancer. Today, we are talking to Dr. Karen Winkfield. She is a radiation oncologist and executive director of the Meharry-Vanderbilt Alliance. She is also part of an incredible podcast called 3 Black Docs. If you haven't checked it out, I really encourage you to go to wherever you listen to your podcasts and download it. It's full of really great information.

Today we are going to talk to Dr. Winkfield about radiation therapy, which she is an expert in, and we want to focus a lot on what happens when your breast cancer is on the left side of your chest, your body. What does that mean? What are the impacts that everyone should be aware of in terms of protecting their heart?

So, first of all, welcome, and thank you for joining us.

Karen Winkfield, MD, PhD:

Thank you, Jean. Thank you so much. I appreciate the invitation and am so grateful for your warm welcome.

Jean A. Sachs, MSS, MLSP:

We are proud to have you with us. Let's just start by telling everyone, what is radiation therapy? When is it used and why?

Karen Winkfield, MD, PhD:

Radiation is one of the treatment modalities that we have for cancer. It is a type of local treatment, similar to surgery, but instead of using a knife, radiation therapy uses energy. In this case — in most cases — it's going to be x-rays, although there are other types of energy that could be used. Most people, particularly patients with breast cancer, will be delivered radiation therapy locally to the breast, in cases where they may have had a lumpectomy.

So, radiation therapy really is a way to provide more local treatment than surgery. Surgery can be pretty invasive, right? You're cutting the body open and you may not be able to clear out as much of the area that you'd want, so radiation therapy provides what I say is the “extra insurance,” especially for breast cancer patients.

You have a tumor that's found on a mammogram. The surgeon goes in and cuts out that area. But then you're also concerned about the risk to the rest of the breast. Radiation therapy can be delivered to the entire breast in a way that's safe.

Now, it's not just [for] women who've had lumpectomy. Studies in the past have shown that doing a lumpectomy with radiation therapy [leads to] the same overall survival as a mastectomy. So some women say, “Oh, well, I've had a mastectomy, so I don't need radiation therapy,” but that's not the case. And this is why it's important to make sure that if you have been diagnosed with breast cancer, you have an opportunity to talk with a radiation therapist or radiation oncologist before you've actually gone for treatment. The reason why is that if you have a very large tumor, or if you have any evidence that the breast cancer has spread to your lymph nodes, you may indeed still need radiation therapy. In this case it wouldn't be to the breast or the intact breast. It would be to the chest wall or, for women who have undergone reconstruction, it could be to the reconstructed breast.

Jean A. Sachs, MSS, MLSP:

That is very comprehensive, thank you, and very important for people to know. We know there are several side effects from radiation therapy, but we really want to focus on today are the concerns [of radiation] to your left chest and how you protect your heart. So tell us, what can you do if your breast cancer happens to be on the left side?

Karen Winkfield, MD, PhD:

This is an area where there's certainly been more and more research that's being done on ways that we can protect men and women who have breast cancer diagnosis and who may need radiation on the left side.

As you know, your heart is there on the left. In some people, their anatomy is such that the heart is really plastered right up against the chest wall. And you mentioned the side effects of radiation. Certainly, there are acute side effects, which include some fatigue and skin irritation. But I'm always more concerned about the late side effects of therapy. Women, in particular with breast cancer, have been extraordinarily generous with their time, have enrolled in clinical trials, and we've gathered all this data over time. There was a study that was done that is generally referred to as the Oxford Overview that had some data collected from over 40,000 women.

It showed that, if there's even just low dose radiation therapy to the heart, it can actually impact heart function over time, it’s not something that happens right away. Although there is more evidence to suggest that even as soon as 6 months there might be some changes in terms of how the heart functions now, most women will recover. For most people, the heart will recover. But for those who may have doses to their whole heart that are more than five units of radiation therapy, then there certainly can be some risks. So what we say, when you have a left-sided cancer, is if you're not going to be treated by me, make sure you ask the next treating doctor, how are you going to protect my heart?

Radiation therapy is not a laser. It's not something that you scan in and things like that. But there are things in the head of the treatment machine that are called multileaf collimators, and those little devices can come in and be used to protect the heart. So, even for women where they're just free-breathing, just lying on the treatment table, usually with their arms over their head, they're able to protect their heart.

Now, for other women, particularly if they're large breasted, one way that we can protect the heart is to treat women in the prone position, which is on their belly. What that can do is allow the breast tissue to hang away from the chest wall and allow for the radiation to be directed so that they are staying away from the heart. But that's not always possible. So, this is where other techniques, like deep inspiration breath hold, come in. It's really important. If you have a breast cancer diagnosis and you need radiation therapy to the left side, please ask your doctor, well, how are you going to protect my heart?

Jean A. Sachs, MSS, MLSP:

I want to get into the deep inspiration breath hold, but before I do that, do you feel like most women are told about this when they start radiation? Are they routinely told if it's on your left side, you need to be concerned? Or is this something women really need to proactively talk about?

Karen Winkfield, MD, PhD:

Most radiation oncologists have this conversation with their patients, but I always believe that more information is best, right? More information is more information. And there are some places that don't have deep inspiration breath hold, or may not be able to do treatment in the prone position.

I'm so excited that Living Beyond Breast Cancer is talking about this. This information is vital for patients because knowing there are different techniques available is great.

So, remember I talked about those little leaves that are in the machine called the MLCs, or multileaf collimators? Sometimes that's the only way that the heart can be shielded, and it may not protect the entire heart. This is why knowing what options are available at the radiation site near you can be helpful.

Jean A. Sachs, MSS, MLSP:

Great. So tell us about the deep inspiration breath hold, because I think some people are like, what is this? Am I going to breathe? Am I going to pass out? I don't know if you want to demonstrate it, or just [explain] how you talk about it with your patients.

Karen Winkfield, MD, PhD:

Yes, you breathe, and hopefully you won't pass out, but it is something that does take practice. When I talk to my patients about, I say, look, it's really important to make sure that you can take a deep breath in and hold it for up to 30 seconds. It doesn't seem like a lot, but it is. Take a deep breath in, and hold it. And then release, right? It does sometimes take a little practice.

I often tell patients that I'm a yogi. It's almost like taking a deep yoga breath and holding it in. What that does is by taking that deep breath, it increases the pressure inside your rib cage. Remember, you have your lungs on both sides, your heart is there, but those lungs inflate and push the heart away from the chest wall. It is really cool. You have to think about it, if you're breathing, you’re just breathing normally, you have the motion of your heart, your heart's beating, but you also have this motion of your chest wall going up and down. And that could, believe it or not, put the heart closer into the [radiation] beam. By taking that deep inspiratory breath and holding it, you're holding your chest wall stable. There's no movement, and it pulls the heart back from the chest wall. It's a great technique.

Jean A. Sachs, MSS, MLSP:

What I’ve heard from patients is, it feels like a lot of responsibility for them to protect their heart. Some people have said, “Really? This is the best you can do? Just tell me to take a deep breath?” I know there are also technologies called surface guided radiation therapies that can help a patient. They're not available everywhere, but it might be something that's available where you're going or somewhere nearby. Tell us about that.

Karen Winkfield, MD, PhD:

When I was practicing in Boston, we had surface guided radiation therapy and patients found it quite easy to do. If you had asthma or some other sort of pulmonary disease where you couldn't hold your breath for a long time, then obviously [deep inspiration breath hold] is not a technique that's appropriate.

Using surface guided techniques, it is a series of lasers or cameras that are set up in a room that can look at the surface of a patient's body to make sure that [the machine] is getting into the same position when you take that deep breath each and every time. What that does, is it allows for the radiation oncologist, the treating physician, to be certain that the plan that they've created to spare dose to the heart is exactly what is being delivered. So, while it is some responsibility on the patient's part, [surface guided radiation therapies] have a way to make sure that things are reproducible.

So, they had the surface guide, and there are other types of optical devices that are being utilized to help patients make sure they're doing what they're supposed to do, and the therapist delivering the radiation. Sometimes there are people who have to wear goggles. It kind of looks like they're snorkeling. I've had patients be treated that way. Others, it might be just a signal that they can see on the wall in front of them, just to encourage them and say, “Oh, you're doing a great job, you know, continue to hold your breath.” And then sometimes it's really just the radiation therapist’s voice that says, “Keep holding your breath, keep holding your breath, and now you can release.” It gets easier with time. And I must say that most patients actually do quite well with it.

Jean A. Sachs, MSS, MLSP:

It's really important for people to know. before we end, is there anything else you want to share about either preparing for your first radiation visit or just anything you, as someone who's so knowledgeable in this area, think patients should know to really advocate for themselves?

Karen Winkfield, MD, PhD:

I must say, one of the first things is, please make sure you get a chance to see your radiation oncologist. If you have a breast cancer diagnosis, please do not have surgery until you've had a chance to speak with a radiation oncologist, because it might actually impact, the type of surgery that's done, or your decision-making process. So please, please, please, if there's any way for you to have an appointment to see a radiation oncologist before you have surgery for your breast cancer, please do so.

I know there's a lot of fear associated radiation. Our techniques and technologies have changed, similar to the SGRT that we're talking about today, and we're doing everything we can to not only reduce the late side effects of radiation, such as the heart effects, but even the acute side effects of treatment that include the skin changes and things like that. It's really changed. We've revolutionized the way we do radiation therapy. And again, a lot of it is due to the generosity of women who have decided, “Hey, I want to enroll in a cancer clinical trial because not only do I want to do what's right for me, but I also want to make things better for people in the future.” So, thank you.

Jean A. Sachs, MSS, MLSP:

I just want to do one follow-up. If you are meeting with your surgeon and you haven't been referred to a radiation oncologist, they usually work in teams, right? In most centers, they would easily be able to refer you to someone. Is that correct?

Karen Winkfield, MD, PhD:

Correct. It depends on the type of center. Sometimes there are freestanding surgical centers, but if they are treating breast cancer, they will know who the radiation oncologist is. They've worked with a radiation oncologist and it could be a simple matter of saying, “Hey, am I going to get a chance to meet with a radiation oncologist before I have to decide what surgery I'm going to take?”

Jean A. Sachs, MSS, MLSP:

That's great. Really helpful information. Next time we bring you back, I want to talk about radiation scars and burning because we hear a lot about that.

So we'll bring you back to discuss that, but thank you so much, Dr. Winkfield, for your time today and all you are doing every day to help the breast cancer community. We really appreciate it.

I want to thank everybody for tuning in. Remember Living Beyond Breast Cancer is here all the time to support you. If you want to talk to one of our Helpline volunteers or join one of our closed Facebook pages for support, just go onto our website, lbbc.org. Take care and stay well.