Julie Reiland, MD, and Avera’s Breast Care Innovators

By Alex Strauss

Since 2011, Julie Reiland, MD, and her partners at Avera Medical Group Comprehensive Breast Care have treated nearly 200 patients with electron-based intraoperative radiation therapy (IORT), making them one of the highest-volume centers for this technique in the country. In appropriate patients with small, non-aggressive tumors, IORT may allow for a single “one-and-done” dose of radiation. In other cases, post-surgery radiation can be dropped to just three weeks instead of the usual six with a “boost of IORT.

The American Society for Radiation Oncology now recommends IORT as a standard treatment for breast cancer. By combining it with oncoplastic surgery, Reiland and her team have achieved some remarkable results and added to the understanding of how this approach can preserve both lives and quality of life. She and her colleague Kyle Arneson, MD, of Avera Medical Group Radiation Oncology, spoke with MED about the evolution of Avera’s innovative, holistic approach to breast cancer care.

MED: What led to the development of IORT?

JR: About 85 percent of breast cancers recur within 2 centimeters of the original tumor. So we started to think, maybe we don’t have to irradiate the whole breast. At first, we were delivering accelerated partial breast irradiation with brachytherapy by putting balloon catheters in the breast. But you have to keep a space open for that, so it left patients with a deformed breast. IORT is the next evolution because it does not require that space.

MED: There are different approaches to breast cancer radiotherapy. How did Avera settle on IORT with the Mobetron?

JR: In 2011, we received a 2.5 million dollar grant grant from the Leona M. and Harry B. Helmsley Charitable Trust and Avera said ‘you pick the machine that you want to buy’. One device delivers electrons and the other delivers low-dose X-rays. I knew that we had been using electrons every day since the 1960s, so I decided that my best bet was to use the best energy source that we knew about. So that’s what we did, even though the Mobetron was six times the price of the other machine.

KA: Treating cancer with electrons has a very long track record. It has been battle-tested in the clinic for decades, although it is fairly new to bring it into the OR. Using electrons allow us to define that tumor bed very specifically, keeping radiation away from skin, lungs, and heart.

MED: How is electron-based IORT different from other approaches?

KA: Our ability to shape the beam and to control the depth of the electrons allows us to be very specific and target that critical 2 centimeter area around where the tumor was with a full dose of radiation. Also, we don’t have to go through any tissue to reach the bed, so we are able to spare the skin.

JR: X-rays lose energy the further out they go. With the linear accelerator, we can dial in exactly when the electrons drop off their energy into the tissue. The electrons come from above and go 2 or 3 centimeters deep in a six-inch radius. It’s like dropping a bomb. We put a copper plate below the breast so no electrons go further than we want them to.   

MED: Why would a patient consider lumpectomy and IORT over mastectomy?

JR: Some women come in and say ‘I want the breast gone so I don’t have to worry about it again’. But your risk comes from your tumor biology, not your surgery type. Lumpectomy with radiation has about a 10 to 15 percent chance of recurrence at 10 years compared to a 10 percent chance with mastectomy. To me, it just doesn’t make sense to be removing breasts on both sides for a five percent benefit. If you keep your breasts and you don’t have significant risk factors, you have a ½ percent chance per year of developing another breast cancer in either breast. And you have the benefit of feeling good about yourself and how you look.

When I explain this to eligible patients, there are very few who don’t take me up on the “one-and-done” option. We recently completed our 100th single-dose case.

KA: I tell patients that, here at Avera, they have several good options. We are always working together as a team to maximize the benefits and minimize the risks. IORT can maximize that risk to benefit ratio, especially for rural patients who may be looking at weeks of travel for treatment. 

MED: Can you explain the IORT procedure?

JR: The tumor must be smaller than 2 centimeters. Once we’ve removed it, we loosen up all the tissue around the defect and pull it together into one tight circle and bring the radiation tube over that circle. This is exactly the way I repair the breast when I’m doing oncoplastic surgery anyway, so it is a beautiful combination.

KA: It only take about two minutes to deliver the radiation, but it adds about 30 minutes to the surgery time just because of the preparation.

MED: What kind of outcomes are you seeing?

KA: Ultimately time will tell. We have to follow these patients for multiple years in order to show the value for breast cancer control. At this point, everyone is very pleased with the cosmetic outcomes and with the convenience of this approach.

JR: We have three trials running because we want all of our patients to be part of a protocol. We want to be good stewards of the technology. Even now, I have patients who come in and say ‘I feel kind of guilty, I feel like I never had breast cancer.’ Their breasts are lifted and perky and there is none of the hardness and tanning of the skin that you can get with radiation.