November 2015 Ask the Expert: Radiation Therapy

November 1, 2015

Radiation therapyinfo-icon is a common treatment for breast cancer. It can lower the risk of cancer returning. Whether you’ve heard other people talk about radiation therapy, your doctor has recommended it, you’re receiving it now or you’ve finished receiving it, you may have questions. 

This November, Living Beyond Breast Cancer expert Rachel Rabinovitch, MD, answered your questions about radiation therapy, from how it works and when it’s needed to what side effects it may cause.

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 providerinfo-icon because treatment varies with individual circumstances. The content is not intended in any way to substitute for professional counselinginfo-icon or medical advice.

I had radiation, which I tolerated well, with few side effects, 9 months ago. I’m wondering when I can expect the remaining redness and occasional itchiness to go away. I have the kind of skin that sunburns easily and tends to react to various allergens, if that's relevant.

The skin redness associated with breast radiationinfo-icon usually resolves within 6 to 8 weeks. Radiation can cause darkening of the treated breast skin which can persist for months or years.  Redness from breast radiation 9 months after treatment is exceedingly unusual. I’d suggest meeting with your doctor to be sure nothing else is an issue.  

Does radiation have an effect on the lungs?

Breast radiationinfo-icon always results in a small amount of radiation being delivered to a small percentage of the lung on the treated side. This doseinfo-icon is lower and delivered to a much smaller area than radiation treatments that are used to treat lung or esophagus cancer, for example. Very rarely, a woman can develop “pneumonitis,” inflammationinfo-icon of the treated lung tissueinfo-icon, in the first 6 months after treatment. Symptoms of pneumonitis are new onset of cough and shortness of breath. This conditioninfo-icon is treated with steroids and the symptoms always resolve. Even more rarely, radiation can increase the risk of lung cancer in the treated area decades after treatment.

Keep in mind that it is possible for changes to be seen on a chest CT scaninfo-icon in the small area of radiated lung tissue, even in a completely healthy women. 

Does radiation therapy extend overall life expectancy for someone with early-stage breast cancer? I spoke with an oncology nurse who said that is the question that should be addressed, not “How likely is this to prevent recurrence?”

Radiation therapyinfo-icon to the breast after lumpectomyinfo-icon for early-stageinfo-icon invasive breast cancerinfo-icon reduces the likelihood of in-breast recurrenceinfo-icon by about 20 percent. That in turn reduces the risk of death from breast cancer by 5 percent at the 15-year mark. So if all early stage breast cancer is lumped together, the answer is: Yes. But all breast cancer and all patients with breast cancer are not the same. A woman’s age and the tumorinfo-icon’s estrogen receptorinfo-icon status are important factors which might change these statistics. For example, while radiationinfo-icon always reduces the risk of breast cancer recurrence after lumpectomy, there is no evidence of increased risk of death in women over 70 with early-stage estrogen receptorinfo-icon-sensitive tumors if treated only with lumpectomy and anti-estrogeninfo-icon therapyinfo-icon. Individualized treatment options should be designed with your oncologistinfo-icon.  

My aunt was treated with radiation therapy and she was treated with something called AccuBoost. It sounds much less invasive than other methods. Could you explain the process? It seemed like such an obvious choice compared to the other options.

AccuBoost is a specific machine designed to deliver radiationinfo-icon treatment to the tissueinfo-icon around the surgical bed, not the entire breast. It uses breast compression (like a mammograminfo-icon) and x-ray imaginginfo-icon before treatment. In general, the gold standard of breast radiation is whole breast treatment, which has the best cancer outcomes, longest track record and the fewest complications. Adding a “boost,” or additional treatment to a small area of the breast after whole breast radiation, can be done effectively with other techniques on standard machines or with an AccuBoost. Partial breast radiation therapyinfo-icon alone (instead of whole breast radiation) can also be done with the AccuBoost.  It is only one of several techniques designed to accomplish this goal. Talk to your doctor about your options and your personal preferences.

I am undergoing radiation now on my left breast. I am concerned about the long-term effects, namely to my heart and lungs. Do you have any statistics as to the percentage of people who have radiation and then develop heart or lung problems later? And are the numbers different depending on what side is radiated?

Minimizing radiationinfo-icon exposure to the heart is an important focus of treatment planning by your radiation oncologistinfo-icon if you have left-sided breast cancer. This issue is not relevant for right sided breast cancers. In the 21st century, radiation treatment planning is accomplished with the help of CT scans, which allow your doctor to identify the location of your heart, lungs and breast/chest wallinfo-icon. With modern planning techniques, there are numerous ways to spare the heart muscle and coronary arteries from radiation exposure. Recent analyses have demonstrated an extraordinarily low to no risk of radiation-caused heart disease. For example, a study in 2013 looking at more than 5,000 women showed no increased risk of death from heart disease 15 years after radiation for breast cancer. Another study showed an increased risk of death from heart disease of less than 1 percent with well-planned left breast radiation. Smoking, high blood pressure and high cholesterol increase the risk of heart disease after breast radiation. 

Similarly, lung injury from modern treatment is rare, with a rate of 1 to 4 percent in some studies.  Symptomaticinfo-icon lung injury causes cough and shortness of breath in the first 6 months after treatment, but it responds to steroidinfo-icon medications and always resolves with treatment.

Do you recommend radiation for someone who is metastatic at original diagnosis?

This is an area of much discussion among breast cancer specialists. We certainly recommend radiationinfo-icon to sites of metastaticinfo-icon disease that cause pain or other symptoms. For patients who are diagnosed with a few sites of metastatic disease that are not bothersome, there is a lot of controversy as to whether or not the breast or the metastatic lesions should be treated. There are ongoing clinicalinfo-icon trials, in which such a patient might be eligible for enrollment. An individualized discussion with your oncologistinfo-icon is recommended.  

About 14 months after my last radiation treatment the area where the tumor had been became hard and very tender to touch, even hurting sometimes when my arm would brush against it. What can be done to soften the tissue and reduce pain?

The most important thing to do first is see your radiation oncologistinfo-icon or other cancer doctor for evaluation. We would certainly want to rule out a tumorinfo-icon recurrenceinfo-icon, though this is unlikely given your symptoms of pain. The more likely cause is fat necrosis, a painful swelling of fatty breast tissueinfo-icon. Fat necrosis can be caused by traumainfo-icon or radiationinfo-icon to the breast. Sometimes fat necrosis can be recognized on a mammograminfo-icon, and certainly with a needle biopsyinfo-icon, but these interventions aren’t always needed.   For most women, these symptoms can be managed with ibuprofeninfo-icon or Tylenol and patience. It may take several months for the symptoms to resolve. In severe cases, steroids or even surgical removal is recommended.  

How does radiation affect my breast reconstruction surgery options?

Plastic surgeons vary greatly on how they choose reconstructive options in the setting of breast radiationinfo-icon. As a general rule, if a patient will have implants (saline or siliconeinfo-icon), the expanders should be maximally filled prior to radiation. Radiation can be performed with the expanders in place, and the final implantinfo-icon can be inserted about 6 months after completion of radiation therapyinfo-icon, once swelling has completely resolved. If a flap is planned, most centers prefer to complete the radiation first and then perform the flap reconstruction, to protect the transferred tissues from unnecessary radiation exposure.  Working with radiation oncologists, plastic surgeons and surgical oncologists who communicate well with each other or work as a team is ideal.