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September 2013 Ask the Expert: Understanding Radiation Therapy

During the month of September, Living Beyond Breast Cancer Expert Jennifer Bellon, MD, answered your questions about what radiation therapy is, what to expect during treatment, what side effects may be associated with radiation therapy and how to manage them.

Remember: we cannot provide diagnoses, medical consultations or specific treatment recommendations. This service is designed for educational and informational purposes only. The information is general in nature. For specific healthcare questions or concerns, consult your healthcare provider because treatment varies with individual circumstances. The content is not intended in any way to substitute for professional counseling or medical advice.

About halfway through my radiation treatment for breast cancer, I developed excruciating joint pain all over my body. Have you come across this before?

Is there anything that I can do to help myself survive radiation better, such as nutrition or skin care?

I'm just 6 treatments in and started seeing noticeable swelling and pain in the radiated breast after the second day. Is this normal?

What is the relationship between radiation and risk of lymphedema?

Do you think supplements can help with some of the side effects of radiation?

What are long-term side effects of radiation therapy?

Are there any successful treatments for radiation-induced fibrosis and radiation-induced neuropathy?

What can I do (exercises, behavior changes, etc.) to avoid lymphedema from radiation therapy? 

What is the current recommended treatment for breast lymphedema and to whom do you refer patients who might return seeking treatment after 2 years? 

I had a lumpectomy in 1987 followed by 28 radiation treatments at the age of 40.  At the age of 55 the cancer recurred and a mastectomy followed. I have been fine since, at the age of 67. What side effects could I have from the radiation therapy? Would a cough be one? 

I finished my treatment at the end of June, so why am I still sore periodically?

After I completed my radiation regimen, I was diagnosed with achalasia. One GI doctor attributed the achalasia to my radiation treatments, though others feel there's no connection. Have you heard of other cases of achalasia following radiation treatment? 

You mentioned in a previous answer: "In addition, the side effects of chest wall radiation after mastectomy differ from that of breast radiation." Given that each case can be different, what would the general differences be? 

What is the general recommended time frame within which radiation therapy should be started when the treatment plan is:  chemo - surgery - radiation versus surgery - chemo - radiation? Is the order of treatment ever: surgery - radiation - chemo? 

Is there any general cutoff time after which it is too late to do radiation?

Question: About halfway through my radiation treatment for breast cancer, I developed excruciating joint pain all over my body. Nobody seemed to know why. Have you come across this before?

Dr. Bellon: All-over body pain is highly unlikely to be related to radiation therapy to the breast or chest wall. It is possible that it is a leftover side effect from chemotherapy, or possibly related to starting hormonal therapy.

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Question: Is there anything that I can do to help myself survive radiation better, such as nutrition or skin care?

Dr. Bellon: A well-balanced healthy diet seems prudent, although this has not been clearly linked to a lower rate of radiation-related side effects. Radiation-related skin side effects (redness and/or peeling) are more likely related to the clinical situation and body habitus, the way your body responds to sickness and disease.  Your radiation nurse can recommend creams that hydrate the skin and keep the area more comfortable. If there is peeling, covering the area with a gauze pad or bandage can reduce rubbing. This typically heals quickly after a person has finished radiation therapy.

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Question: I'm just 6 treatments in and started seeing noticeable swelling and pain in the radiated breast after the second day, but the radiation oncologist doesn't seem concerned. Is this normal?

Dr. Bellon: Radiation can cause inflammation in the breast, which can result in swelling and pain. It is important to make sure that there is no underlying infection (which would typically require antibiotics), however. If your physician does not feel there is an infection, it is likely the swelling will go away on its own. 

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Question: What is the relationship between radiation and risk of lymphedema?

Dr. Bellon: Radiation can increase the risk of lymphedema if the lymph nodes under the arm or around the clavicle are included. The risk is higher if there was axillary surgery (particularly a full dissection, and less so after sentinel node surgery), and also seems to be higher in women who are overweight.

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Question: Do you think supplements can help with some of the side effects of radiation?

Dr. Bellon: There is no proven role for supplements, and no evidence that they decrease radiation-related side effects. 

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Question: What are long-term side effects of radiation therapy?

Dr. Bellon: This is highly dependent on the specific treatment being given, and can’t be generalized to all breast cancer patients.  Sometimes the breast alone is treated, and sometimes the regional nodes are also included.  In addition, the side effects of chest wall radiation after mastectomy differ from that of breast radiation.

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Question: Are there any successful treatments for radiation-induced fibrosis and radiation-induced neuropathy?

Dr. Bellon: Unfortunately, there are no known curative treatments for radiation-related nerve injury.  The medicine gabapentin can help if there is pain, but there is no known treatment to reverse the injury.  Fibrosis can often be helped by massage, stretching (yoga or swimming) and physical therapy. 

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Question: What can I do (exercises, behavior changes, etc.) to avoid lymphedema from radiation therapy? 

Dr. Bellon: Prevention of lymphedema has not been well studied. There is some evidence that moderate exercise can help. In addition, most studies have shown that obesity contributes to the risk of lymphedema, so keeping a healthy weight is likely important here as well.   

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Question: What is the current recommended treatment for breast lymphedema and to whom do you refer patients who might return seeking treatment after 2 years? 

Dr. Bellon: We would generally refer someone to a physical therapist for massage, range of motion exercises and manual drainage.   

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Question: I had a lumpectomy in 1987 followed by 28 radiation treatments at the age of 40.  At the age of 55 the cancer recurred and a mastectomy followed. I have been fine since, at the age of 67. What side effects could I have from the radiation therapy? Would a cough be one? 

Dr. Bellon: It would be highly unlikely that a cough would have any relation to radiation given over 25 years ago. Long-term side effects can include thickening or fibrosis of the breast, red discoloration of the treated area (telangiectasias), a heightened risk of heart disease (if treated on the left side) and an extremely small risk of a cancer caused by radiation.  

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Question: I finished my treatment at the end of June, so why am I still sore periodically?

Dr. Bellon: I’m not sure why this occurs, but it is not at all uncommon. Breast discomfort typically improves over time. If you tolerate it, ibuprofen can be helpful.

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Question: After I completed my radiation regimen, I began to have difficulty with food moving down my esophagus. Eventually I was diagnosed with achalasia and have since had surgery (myotomy) to improve the food passage process. My symptoms remain, though to a lesser extent.  One GI doctor attributed the achalasia to my radiation treatments, though others feel there's no connection. Have you heard of other cases of achalasia following radiation treatment? If so, are any studies underway to determine the cause and whether this might be preventable? 

Dr. Bellon: I’ve never heard of achalasia following radiation. Radiation fields are typically planned to avoid the esophagus, but this may not always be the case. You may want to speak directly with your radiation oncologist.

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Question: You mentioned in a previous answer: "In addition, the side effects of chest wall radiation after mastectomy differ from that of breast radiation." Given that each case can be different, what would the general differences be? 

Dr. Bellon: In general, there is more skin toxicity (redness, peeling) following chest wall radiation than following radiation to the breast.

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Question: What is the general recommended time frame within which radiation therapy should be started when the treatment plan is:  chemo - surgery - radiation versus surgery - chemo - radiation? Is the order of treatment ever: surgery - radiation - chemo? 

Dr. Bellon: Generally, we like to start radiation approximately 3–5 weeks after the last cycle of chemotherapy.  The time frame after surgery is similar, with the exception that a few more weeks of healing is often necessary after mastectomy, particularly if there has been reconstruction. 

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Question: Is there any general cutoff time after which it is too late to do radiation?

Dr. Bellon: We do worry that radiation may be less effective when it is delayed for several months, but there are no absolute cutoffs. 

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Denver, CO  ·  September 13, 2014

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