Radiation Therapy

Radiation therapy is one of a number of treatments for breast cancer. It may be used in addition to surgery, chemotherapy or hormone therapy.

Like many aspects of cancer treatment, radiation therapy techniques have improved a great deal over the past decade. More accurate planning techniques and modern technology have improved the precision and safety of radiation treatment. Therefore, some of what you may have heard about radiation therapy in the past may no longer be true. The side effects of radiation therapy to the breast may also differ from the side effects of radiation therapy to other parts of the body.

How radiation affects cancer cells

Cancer cells grow and divide at a faster rate than healthy tissue. During radiation treatment, the breast is targeted with high energy X-rays. These X-rays are much more powerful than normal X-rays taken during a dental exam or for a broken bone. As a result, they are very effective at stopping cancer cells from dividing and growing. Radiation therapy is used to treat all stages and sizes of many types of cancers. It can be a treatment option for women with:

  • ductal carcinoma in situ (DCIS or stage 0)
  • early stage invasive breast cancer (stages 1 and 2)
  • advanced disease (stages 3 and 4)
Radiation therapy works best when the cancerous lump or area has been removed and only microscopic (very tiny) amounts of cancer remain in the breast. It is commonly recommended following breast conservation surgery (also called a lumpectomy, wide excision or partial mastectomy). After this type of limited surgery, the remaining breast tissue may contain undetectable cancer cells. Because these cells are too small to see even on a mammogram, your surgeon cannot detect and remove them. Radiation treatments are given to eliminate any cancer cells that may be in the remaining breast and surrounding tissue. The X-ray treatment is confined to the breast region and does not spread to other parts of your body.

Radiation therapy is sometimes given after mastectomy. If you are considering a mastectomy, talk with your surgeon about the possibility of needing radiation therapy after surgery.
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Medical conditions requiring special consideration

Women with certain medical conditions may not be good candidates for radiation therapy. Let your doctor know if you have any of the conditions listed below. Your doctor will need this information to determine the best treatment plan for you.

  • Scleroderma and systemic lupus are connective tissue disorders that might impair tissue healing after radiation therapy. Your radiation oncologist may need to talk with the doctor treating your connective tissue disease to determine if radiation therapy is safe for you.
  • Pregnancy usually rules out using radiation therapy since radiation may injure the fetus. However, if you are near the end of your pregnancy, it may be possible to postpone your radiation treatments for a month or two until after you deliver. Talk with your surgeon, obstetrician and radiation oncologist to discuss the best treatment options for you. It is important that you do not get pregnant during or immediately after receiving radiation therapy. If you are pre-menopausal, discuss your birth control plans with your radiation oncologist.
  • Prior radiation therapy to the breast or chest area on the same side as your breast cancer may prohibit further radiation treatments. It may not be safe for you to receive additional radiation therapy in the same area. Your radiation oncologist can obtain your records about your previous radiation treatment and determine if more radiation treatments are an option for you.

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The radiation therapy process

Your initial visit
Before beginning radiation therapy, you will consult with a radiation oncologist, a doctor trained to use radiation to treat cancer. During your first visit, the radiation oncologist will review your medical history, mammogram films and pathology report. He or she will also perform a physical exam and discuss the risks and benefits of radiation therapy with you. This is your chance to share your concerns and fears and ask your doctor and radiation oncology staff questions. (Refer to the “Questions to Ask Your Doctor” section in this notebook.) It is a good idea to bring another person to this appointment since you will receive a lot of information about your treatment plan. You can also write the information in your notebook or ask your doctor if you can tape record your visit.

The treatment planning or simulation appointment
Your second appointment will be your treatment planning or simulation appointment. During treatment planning, the exact area or treatment field will be identified. Your radiation oncologist will use various imaging techniques to identify structures in your chest, such as your heart and lungs. After analyzing the images, your radiation oncologist will determine the best way to treat your breast tissue while reducing exposure to the rest of your body.

Your skin will be marked to make sure that the radiation therapy is administered exactly as planned. Most treatment centers use a combination of tiny tattoos (about the size of a pinhead) and skin marks with semi-permanent ink to mark the treatment field. Do not wash these marks off when you bath until your radiation oncologist says that you can. Your doctor will also determine how to position you during your treatment, including your arm position. A special brace or Styrofoam mold may be made to cradle your arm or back in a special position.

Your simulation visit can last from one to two hours, and you will be lying on a firm surface most of the time. This can be uncomfortable. If you have difficulty lying on your back for this period of time, you may want to take some mild pain medication before your visit. Let your doctor know if you have difficulty raising your arm over your head. Exercising to increase the flexibility of your arm before the planning session can help with this. Ask the treatment staff for suggestions if arm mobility is an issue for you.

Some women find the process of being analyzed and measured impersonal and feel as if they are being worked on rather than worked with. Treatment planning is a very precise and technical process. Your doctor and the radiation center staff have not lost sight of you, but are concentrating on providing you with the safest and most effective treatment possible.

Radiation treatments
Usually within seven to 10 days after your simulation visit; you will begin your actual radiation treatments (some more complicated treatment plans will take longer). Your treatment sessions will occur daily, Monday through Friday, for five to seven weeks. It is important not to interrupt your treatment schedule or to skip appointments. If you know that you will not be available during part of the time you are scheduled to receive your treatments, let your radiation oncologist know before you start your treatments. Some adjustments to the start time may be acceptable. It may be better for you to start your treatments a little later rather than interrupt your schedule.

After checking in at each visit, you will normally be asked to change into a hospital gown from the waist up. You may then have to wait a bit before being called to the treatment area. The radiation technologist will position you exactly as planned during your simulation appointment. A high-energy X-ray machine called a linear accelerator will be used to deliver the radiation to your breast, a process called external beam radiation therapy (EBRT). No one can be in the treatment room with you during the actual treatment, but the technologist can hear you through a microphone and see you via television cameras.

You need to remain very still during your treatment, but you do not need to hold your breath. Just breathe normally. You may receive radiation treatment from two or more different angles, so don’t be surprised if the technologist positions the machine differently during the course of your treatment. Although it takes just a few minutes to do the EBRT, you should plan to spend about 45 minutes at the treatment center. Most centers will schedule your visits for the same time each day.

After completing several weeks of radiation to the whole breast, you may receive additional EBRT targeting just the area where the tumor was removed. This is called boost radiation. The technologist will adjust the equipment so that the radiation field is much smaller and centered on part of your breast. Boost radiation uses the same machine as EBRT, so you may not notice this change in your treatment. Boost radiation is administered daily, Monday through Friday, for one to two weeks.

You will meet with your radiation oncologist once a week during your treatment period. Each week you will have another opportunity to ask questions, discuss side effects and their management, and share your concerns. You can also meet with other members of the radiation oncology team. Many centers have nurses, social workers and dieticians available to help.
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HDR Brachytherapy for breast cancer

High-dose rate (HDR) brachytherapy is another method of administering radiation therapy to women with breast cancer. During HDR brachytherapy, tiny radioactive pellets are implanted into catheters in the breast. The pellets deliver high doses of radiation to a specific area in the breast and are removed when the treatment session is completed. Nothing radioactive is left behind to expose the patient or others to radiation. Each treatment session usually takes only a few minutes. As a result, the total treatment dose is delivered in about five days of outpatient treatment. HDR brachytherapy is carefully planned, and the radiation placement is controlled to avoid high doses to the skin, ribs and lungs while treating a specific area of the breast. If your physician refers you for brachytherapy, you will be provided with additional information at that time.
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Radiation side effects

While each woman is unique and will respond differently to breast radiation treatments, there are a number of common side effects that many women experience. The most common short-term side effects are generalized fatigue and skin changes to the treated breast.

Fatigue
It’s hard to appreciate how radiation affects your body. Every day, the radiation works on both healthy and cancerous cells in your breast, and your body is expending energy as it heals. The effect of this work isn’t noticeable at first. Around the third week of treatment, you may notice that you become more tired by the end of the day. Since the healing process continues after you finish your treatments, the fatigue may also continue for several weeks after completing radiation therapy.

Ways to improve your energy level

  • Drink plenty of fluids and eat a healthy diet.
  • Take a nap in the afternoon.
  • Don’t cut out all physical activity even though you have less energy. Try small amounts of exercise. Some physical activity, such as walking, can energize you and help you feel better.
  • Find a balance between activity and rest. You will feel most tired during the last few weeks of your treatment, so plan on taking extra time to rest during this time.
  • Women receiving chemotherapy before their radiation treatments will feel more fatigued than those receiving only radiation therapy. Make sure to get enough rest so you don’t become exhausted.
  • Accept offers of help, such as cooking meals or cleaning your house. Think of what others can do for you, and don’t be afraid to ask for help.
  • Cut back on extra activities and commitments during these few weeks. Many women continue to work outside the home while undergoing radiation therapy by adjusting home and work commitments.
  • If you become very fatigued, talk with your work supervisor about cutting back your hours or using some sick time until your energy returns.
Temporary skin changes
At first you may not notice any skin changes. Around the second or third week, you may find that the skin in the treatment area is red and irritated, similar to sunburn. Your breast skin may also become very dry. You need to be very gentle with the skin in the treatment area during radiation therapy.

Skin care tips
  • Avoid irritating the treated skin. Do not scrub, scratch or rub the treated area.
  • Talk with your medical team about how to care for red, dry skin. If your center recommends a specific gel do not apply these immediately before your treatment. Remember to wash these gels from your skin before your daily radiation treatment sessions.
  • If the area itches, apply a cool compress or one of the gels your medical team recommends.
  • Use only warm water and a mild soap, such as Dove or pure glycerin, when you wash. Pat the area dry. Do not rub.
  • Avoid constricting clothing, including bras. Instead wear something soft and loose, such as a cotton camisole. If you feel you need a bra for support, ask your nursing staff about special bras available.
  • Heat and cold can damage the skin. Do not apply hot items to the area, such as hot packs or the rice packs that can be heated in the microwave.
  • Do not get in a hot tub or sauna during your treatment.
  • Do not apply ice or very cold items to the treatment area.
  • Avoid shaving under your arm on the side of your treatment. If you must shave, use an electric razor.
  • Do not use any deodorants, powders, creams, perfumes, body oils, ointments, lotions or home remedies in the treatment area while you’re being treated and for several weeks afterward unless approved by your doctor or nurse.
  • Continue to confer with your radiation treatment team regarding all skin care products. You can also develop another type of skin reaction called a moist reaction. This is caused by friction and irritation where two surfaces rub together. The most common sites are under the breast and the underarm area. When a moist reaction develops, the skin breaks down and becomes very sore. If you or the radiation technologist notices any skin breakdown, talk with your doctor or nurse. They will tell you how to care for this type of skin condition.
Other short term side effects
After surgery or radiation therapy, the breast may be tender or sore, especially when you have a mammogram or when your breast is examined. You may also experience a sharp stabbing or burning sensation occasionally. These sensations will lessen in intensity and frequency over time. They are most common during the first months after surgery or radiation therapy. Some women may have these random sensations for years.

Radiation therapy usually does not affect your blood count. If you have chemotherapy prior to radiation therapy, your blood count may be monitored. If you are anemic or have a low blood count, it is a good idea to work with your doctor to correct such problems before starting radiation treatment. It will help you feel better.

Ribs in the treatment area can also break for no apparent reason, but this is very rare. A broken rib may cause some discomfort or pain when breathing deeply. Broken ribs will heal on their own and do not require treatment.

Long term side effects
Radiation therapy can cause a change in the feel, look or size of your breast. Breast swelling during treatment is common for the first one to four months. In some cases, your breast may become smaller over time. The shape and size of your breast is mostly determined by the amount of tissue removed during surgery. Most breasts are firmer and appear more uplifted after the radiation treatment.

Many women worry that radiation therapy will harm their heart and lungs. Injury to the heart can occur when the left breast is irradiated; however, this is much less likely to occur with modern radiation therapy planning. If you are concerned about this, or have a history of heart disease, discuss your concerns with your radiation oncologist. There are treatment techniques that can reduce the exposure of your heart to radiation.

Lung tissue can also become inflamed (swollen) if the lungs are in the beam of radiation during your treatment. This condition (called radiation pneumonitis) is not common but can occur within the first few months of treatment. If this happens, you may develop a dry cough, have a harder time breathing during activity, and a low-grade fever at times. Radiation pneumonitis will usually go away on its own. If it persists, your radiation oncologist may prescribe anti-inflammatory drugs to reduce the severity of the symptoms.

You are at greater risk of developing lymphedema (swelling of the hands or arms) if you have a lymph node dissection in the underarm area and then have radiation therapy to the underarm area. This is caused by fluid that can build up when underarm lymph nodes are removed during breast cancer surgery or damaged by.

On very rare occasions, radiation treatment to the breast can cause a second cancer, such as leukemia, lung cancer or angiosarcoma (cancer of a blood or lymph vessel). The risk of developing these cancers is extremely small and is far out weighed by the benefits of treating your breast cancer.

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