{'fraction_non_alphanumeric': 0.016371681415929203, 'fraction_numerical': 0.0017699115044247787, 'mean_word_length': 5.331932773109243, 'pattern_counts': {'":': 0, '<': 0, '<?xml version=': 0, '>': 0, 'https://': 0, 'lorem ipsum': 0, 'www.': 0, 'xml': 0}, 'pii_count': 0, 'substrings_counts': 0, 'word_list_counts': {'cursed_substrings.json': 0, 'profanity_word_list.json': 0, 'sexual_word_list.json': 0, 'zh_pornsignals.json': 0}}
Regarding the "Rising incidence of tumorectomies without breast radiation in patients treated for invasive breast cancer in Caribbean nations".

The paper by Braverman et al 1 reports on the rapid increase in tumorectomies (breast conserving surgery) without adequate supply of radiation therapy facilities in the Caribbean nations and the resulting high rate of local recurrence in breast cancer. Whereas in the United States 88% of patients receive radiation therapy after breast conserving surgery, only 18% of the patients receiving breast conserving surgery in this study from the Caribbean nations had radiation therapy, and 70% had local recurrence at a median follow up of eight months. The main reason for the breast cancer patients in this study not receiving radiation therapy after breast conserving surgery is the lack of access to radiation centers. This lack of access to radiation facilities is related to inadequate number of centers, centers being too far for patients to go to, lack of state of the art radiation equipment, and long delays before the patients can receive radiation therapy. Building new stateof-the-art radiation centers is the obvious solution, but this is probably not economically viable. These problems are similar to those of breast cancer patients in the rural United States. However, breast cancer patients in rural areas of the United States often elect to have a mastectomy when radiation therapy is unavailable or very inconvenient. These mastectomies prevent a very large percentage of local recurrences in the United States. The outcome of breast conserving surgery without radiation therapy is better in early stages of breast cancer and in small-sized tumors. This can be done by improving both the availability of screening mammography and the participation of women in screening programs. It is well known that early stage breast cancer (Stage I and II) has a lower local recurrence rate than more advanced Stage III breast cancer; therefore, by reducing the number of breast cancer patients that are Stage III at presentation in the Caribbean nations, the rate of local recurrence after breast conserving surgery without radiation would be significantly reduced. Considering tumor biology is very important when choosing treatment options for breast cancer patients. Triple negative patients (negative estrogen, negative progesterone, and negative Her2 receptors) have a poor prognosis that is related to the fast growth rate of these tumors, their propensity to be metastatic, their lack of response to adjuvant hormonal therapy, and monoclonal antibody therapy, and their higher recurrence rate after adjuvant chemotherapy. Therefore patients with triple negative tumors are at greater risk of recurrence and may be taking an unacceptable risk of recurrence if they do not receive radiation therapy after breast conserving surgery. Given the number of patients that do not receive radiation therapy after breast conserving therapy in the Caribbean nations, clinical studies that define subgroups according to lower incidence of recurrence when radiation therapy is omitted, instead of just according to age group, would be beneficial. Integrating accelerated partial breast irradiation (APBI) into the treatment of breast conserving surgery would shorten the treatment time and make radiation therapy after breast cancer surgery more available to patients due to the shorter treatment time necessary to complete the radiation. However, the APBI equipment is quite costly and not widely available. Although not the standard of care in either Europe or the United States, intraoperative radiotherapy is a promising technique that could be made widely available in the Caribbean nations. The Intrabeam (Carl Zeiss Meditec, Inc., Jena, Germany) intraoperative radiotherapy method is an example of a method that would be feasible in the Caribbean nations. If ongoing trial data confirms the Intrabeam ’s efficacy, then the high patient acceptance and satisfaction, ease of operation, along with being the most convenient, flexible, inexpensive, and versatile intraoperative APBI system available, will make it a candidate for standard of care in areas lacking adequate radiation facilities. In conclusion it seems apparent that achieving breast cancer radiation therapy after breast conserving surgery is not likely to occur in the Caribbean nations for a variety of reasons. Therefore a new paradigm will have to be developed that could include some of the above ideas.