Intraoperative Radiotherapy (IORT)
What is Intraoperative Radiotherapy (IORT)?
Intraoperative Radiotherapy (IORT) is a single dose of radiotherapy delivered at the time of breast conserving cancer surgery and can eliminate the need for External Beam Radiotherapy (EBRT), which is typically administered five days a week, over the course of three weeks. Breast conserving surgery involves the removal of the tumour and a small area of surrounding tissue from the breast.
Following removal of the tumour, a single dose of IORT is applied directly to the tumour bed while patients are still under general anaesthetic helping to destroy any remaining cancerous cells.
For most patients, IORT eliminates the need for post-operative EBRT, avoiding the inconvenience, disruption and expense of attending daily hospital appointments for 3 weeks at a radiotherapy centre.
What type of diagnosis is it used for?
IORT may be suitable for patients that are 50 years or older with early stage breast cancer (low grade disease) and small tumours. Based on current clinical data available, strict selection criteria must be met before patients can be offered IORT as a treatment option by their doctor.
How does IORT work?
Once the surgeon has removed the tumour during the breast conserving surgery procedure, a specially designed inflatable balloon-shaped applicator is placed into the breast tissue in a space called the tumour bed. The balloon applicator is inflated with water to ensure it fits snugly into the breast tissue. A small shield is often placed on the chest wall to protect the heart, ribs and lungs from radiation dose and a special x-ray shield is placed over the breast tissue to protect the patient from radiation dose. A miniaturised X-ray tube, which delivers the radiotherapy, is then threaded through the water filled applicator inside the breast. The single dose of radiotherapy is delivered in 10 minutes. Once the treatment has finished; the surgeon removes the water filled applicator from the breast and finishes the operation as normal. The treatment radiographer who delivers the radiotherapy and the anaesthetist remain with the patient for the duration of the treatment. When the patient wakes up from surgery, the tumour has been removed and their radiotherapy treatment has been completed. The majority of patients can go home on the same day following their treatment.
Would it work for me?
IORT may not be suitable or beneficial for all early stage breast cancer patients; patients must meet strict criteria, which will be evaluated by their doctor. Information should be provided to patients to aid shared decision-making that informs the patient of the evidence available on the range of treatment options available and their associated risks and benefits.
Quality of life, patient satisfaction and convenience can be improved by giving patients the choice of IORT. IORT also enables patients to receive treatment promptly and reduces exposure of surrounding healthy tissue to radiation.
It must be stated though that the NICE (National Institute for Health and Care Excellence) appraisal committee is currently reviewing IORT following NHS England. Click here to view the draft guidance released in January 2015. Click here to connect to the documents that show all the research and evidence that is being considered by NICE in 2017.
NICE also acknowledged uncertainties about the long-term results. There are uncertainties that IORT may not be as effective at preventing cancer returning as traditional treatments and women will be asked to weigh up convenience against this risk. NICE issued a press release on 8th Feb 2017 recommending IORT for patients with early breast cancer in limited circumstances with additional data collection. Click here to view this press release.
Carole Longson of NICE said: “This is a promising new way of providing radiotherapy but the evidence needs to develop and the committee therefore recommended that its use is carefully controlled and accompanied by gathering additional information on its clinical effectiveness.”
The charity Breast Cancer Now said: “It is vital that the risks versus the convenience are fully discussed with patients.”
What are the risks?
In a clinical trial, IORT was better tolerated overall than daily radiotherapy. Adverse reactions are mostly related to wound related complications and radiotherapy-related complications. As NICE acknowledges, there are some uncertainties about long term results.
Are there any alternatives?
The current UK standard practice and alternative to IORT follows NICE guidance for early and locally advanced breast cancer whereby patients with early invasive breast cancer who have had breast-conserving surgery with clear margins would have a standard course of EBRT of 40 Gy in 15 fractions over 3 weeks.
Where is IORT available?
There are 4 UK NHS hospitals with the equipment to offer IORT.
- The Royal Free, London
- Royal Hampshire County Hospital, Winchester
- Great Western Hospital, Swindon
- University College London
NB These hospitals however do not currently offer IORT to NHS patients as there is no reimbursement code for IORT in the NHS yet (this will hopefully change soon).
IORT is currently available at the following various private centres throughout the UK.
- Spire Healthcare Hospitals (Brighton, Chatham, Thames Valley, Worcester, Bristol, Wrexham, Manchester)
- BMI Healthcare Hospitals (Northwood, Nottingham, Orpington)
- Nuffield Health Hospitals (Brighton, Cheltenham)
To find out more about IORT, please click here to view a video interview with an IORT patient, her surgeon and clinical oncologist. To learn more about IORT or contact your doctor.