Understanding Radiation Therapy
After receiving her breast cancer diagnosis, Patti Scalia, of Tarpon Springs, Florida, considered whether to have radiation therapy. Diagnosed at age 55 with stage II A triple-negative disease, Patti was told she had a high risk of breast cancer returning. Her doctors recommended radiation treatment to lower that risk, but “they gave me a choice,” she says.
She went for a second opinion at a major cancer center. Those doctors agreed with the recommendation. Patti will start radiation after completing chemotherapy.
“I want to get upfront the treatment that will give me the best outcome,” she says.
Who Gets Radiation Therapy?
Radiation therapy uses high-energy x-rays to kill cancer cells in specific places chosen by your doctor, unlike treatments that kill cells throughout the body. It is most often used after breast surgery.
“Radiation is a critically important component of managing breast cancer for many women,” says Thomas A. Buchholz, MD, FACR, FASTRO, professor of radiation oncology, and executive vice president and physician in chief at the University of Texas MD Anderson Cancer Center, in Houston, Texas.
“When we use radiation, we do it on the basis of there being a probability of some residual [remaining] cancer cells,” he says.
Radiation is recommended for most people who have a lumpectomy. It lowers the chance of recurrence in the breast, called local recurrence, and improves survival. It also can be used after mastectomy for disease in the lymph nodes and for those treated for locally advanced or inflammatory breast cancer.
“Radiation can go in areas that surgery can’t,” says Dr. Buchholz. While many think mastectomy is more aggressive treatment, he notes, with lumpectomy and radiation “we’re actually targeting a bigger volume of tissue…compared to just doing mastectomy alone.”
Is Radiation Needed?
Not everyone needs or can have radiation therapy. Those having mastectomy for ductal carcinoma in situ (DCIS) or stage I disease may not need radiation. It might not be advised for the frail elderly. In pregnant women, radiation is usually delayed until after delivery.
When radiation is needed can be a grey area. Some people are told they won’t need radiation but later, after further testing, are advised to have it. Talking with a radiation oncologist can help sort out your risk of recurrence and how much you may benefit from radiation therapy.
Even when doctors recommend radiation, some people decide to skip it. They may lack information, fear side effects, worry that breast reconstruction will be affected, or have concerns about overtreatment.
Jennifer Stringer, of Grants Pass, Oregon, was told she wouldn’t need radiation if she had a double mastectomy. After surgery and chemotherapy for stage II, triple-negative disease, her doctor said she should have radiation because she had cancer in two lymph nodes. He said more doctors are using it after mastectomy for even a few positive lymph nodes.
They talked about how radiation might affect her recurrence risk and could impact reconstruction. Jennifer, then 29, had already started reconstruction and was to have implant surgery soon. She chose no radiation.
“I’m OK with the decision I made,” she says, although she still wonders. “Recently, I had a lump in my armpit. It was benign, but the first thing that came to my mind was, ‘Should I have done it?’”
Side Effects of Radiation
Radiation therapy is painless but can cause side effects. Fatigue is common. Skin may redden, blister or become dry. Pain may develop. Symptoms usually take a few weeks to begin and often peak about a week after treatment ends. Skin problems usually heal 3 to 4 weeks after treatment ends.
Radiating lymph nodes can cause lymphedema, swelling of the arm, torso or chest. In rare cases, radiation can damage the heart, lungs or nerves, or cause a second cancer called sarcoma.
Barbara M. Lefkowitz was diagnosed with stage IB disease in both breasts. She had lumpectomy and 33 rounds of radiation to each breast.
“It was a long, hard journey,” says Barbara, who is 74 and lives in Jacksonville, Florida. “The skin just below my breast was very raw. My nipples were peeling. It was extremely sensitive.” She used creams and prescription pain medicine.
During 28 days of radiation for stage IIB breast cancer, Kim Jennings, 50, of Maidens, Virginia, walked daily, ate healthy meals and participated in a clinical trial of melatonin, a hormone used to combat fatigue. She slept well and went to work.
At the end of treatment, painful skin effects and fatigue began. “I was absolutely miserable,” says Kim. She took over-the-counter pain medicine and rested. “By day 14, my skin was back to normal.”
How It’s Given
Radiation is given in fractions, or portions, most often once a day over several weeks. Conventionally fractionated or CF radiation therapy to the whole breast has long been used to treat breast cancer. It’s given 5 days a week for about 5 to 6 weeks.
A newer method, called hypofractionated or HF radiation therapy, delivers about the same dose as CF but in about 3 to 4 weeks. Results are similar to CF.
The American Society for Radiation Oncology (ASTRO) supports using HF in people diagnosed at age 50 or older, with early-stage, hormone-positive, node-negative breast cancer, who have not had chemotherapy. Some doctors use HF for other people, including those who are younger.
Adoption of hypofractionation in the U.S. has been slow. “We’re hoping it will be used in patients deemed appropriate more often. It lessens fatigue and skin reactions and the long-term cosmetic results in treated but unreconstructed breasts are comparable, if not better, than longer course treatment,” says Melissa Rasar Young, MD, PhD. Dr. Young is a clinician and assistant clinical professor of radiation oncology at Smilow Cancer Hospital, Yale Cancer Center, in New Haven, Connecticut.
Dr. Buchholz also wants to see more HF use. At MD Anderson, he says, “We use it as a default standard. There are some cases of breast conservative treatment where I still feel more comfortable with the conventional approach, but that’s probably only about 15 percent of the patients treated with radiation after lumpectomy.”
Partial breast radiation gives treatment from inside or outside the body after lumpectomy. It reduces treatment time and avoids radiating healthy tissue but may miss cancer cells that started to travel away from the tumor. The internal method, brachytherapy, delivers radiation via catheter-based systems that allow for radioactive sources to be temporarily placed in the breast. External treatment uses techniques called 3D-conformal or intensity-modulated radiation to shape the radiation beams to the tumor site. Both methods are still being studied.
Most people receive radiation while lying face up. When treating the left breast, that position exposes the heart and lungs to the radiation, which can cause problems such as weakening the heart muscle. Some doctors now treat people with left-sided breast cancer in a face down or prone position.
“Lying on their tummy gives them no toxicity of the skin, heart and lungs. The heart and lungs are completely avoided in that position,” says Beatriz E. Amendola, MD, FACR, FASTRO, FACRO, a radiation oncologist in South Miami, Florida. Using intensity-modulated radiation shortens treatment time and targets radiation, Dr. Amendola says. She uses a prone position table to deliver therapy more comfortably. Lying face down also helps women with very large breasts, by pulling breast tissue away from the body.
Deep inspiration breath hold, or holding one’s breath when lying face up, also may protect the heart. For many people, the breath hold can help push the heart deep into the body and away from the chest wall and breast, Dr. Young explains. Breath holds may last up to 20 seconds and several are needed each session.
Another heart protecting method, sometimes called a heart block, interrupts rays and shapes radiation around the heart.
Radiation for Metastatic Breast Cancer
In metastatic disease, radiation is used to ease symptoms, treat pain and shrink tumors. Focused radiation called radiosurgery can destroy individual metastases in the brain, liver, bone, spine and lungs. It may be used again if new metastases appear, Dr. Amendola notes.
Treating individual metastases in the brain avoids whole-brain radiation, which can cause hair loss and may affect brain function.
If metastases disappear after other anticancer treatment, there may be a role for surgery and radiation. Dr. Buchholz says research is exploring such possibilities.
Colleen Yanco, 54, of Dana Point, California, was told she would not have surgery or radiation for metastatic breast cancer. After chemotherapy and while receiving an anti-HER2 medicine, a scan showed she had no evidence of disease. Her doctors suggested surgery, but her surgeon saw nothing to remove and suggested radiation.
With her daughter’s wedding approaching, Colleen talked with her doctors about declining radiation. “Nobody thought I was making a bad choice,” she says. “My thought process was maybe someday I’ll need it, but as long as I don’t need it, I don’t want to have it.”
Reconstruction and Radiation
Receiving radiation after starting or having implant reconstruction could cause an increase in complications, Dr. Young says. There may be capsular contracture, scars around the implant that develop and change the shape and feel of the breasts. More surgery could be needed.
There is a lot of interest in natural tissue reconstruction at the time of mastectomy, and the safety of radiation to these reconstructed breasts is being studied. At Dr. Young’s center, complication rates for tissue reconstructions receiving radiation are similar to no radiation. But she says tissue reconstructions could have size changes, need revision surgery or be damaged by poor blood flow.
If you need radiation therapy, you can delay reconstruction until after healing from the treatment. “Wait for radiation to be done, then wait 6 months,” Dr. Amendola says. “Because then your surgeon can do a much better job and the results will be better, with less risk of complications."
It’s important to understand how radiation therapy may fit in your treatment. There’s time to consider. These suggestions may help with decision-making.
- Discuss radiation therapy options for your situation with a radiation oncologist.
- Ask how much your recurrence risk might improve for each option.
- Talk about scheduling, side effects or other issues that concern you.
- If having reconstruction, ask what type might work best with radiation and find out if you are eligible. Check with your health insurer about coverage for delayed reconstruction.
- Consider getting a second opinion before deciding.