November 2015 Ask the Expert: Radiation Therapy
Radiation therapy 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 provider because treatment varies with individual circumstances. The content is not intended in any way to substitute for professional counseling or medical advice.
The skin redness associated with breast radiation 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.
Breast radiation always results in a small amount of radiation being delivered to a small percentage of the lung on the treated side. This dose 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,” inflammation of the treated lung tissue, in the first 6 months after treatment. Symptoms of pneumonitis are new onset of cough and shortness of breath. This condition 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 scan in the small area of radiated lung tissue, even in a completely healthy women.
Radiation therapy to the breast after lumpectomy for early-stage invasive breast cancer reduces the likelihood of in-breast recurrence 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 tumor’s estrogen receptor status are important factors which might change these statistics. For example, while radiation 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 receptor-sensitive tumors if treated only with lumpectomy and anti-estrogen therapy. Individualized treatment options should be designed with your oncologist.
AccuBoost is a specific machine designed to deliver radiation treatment to the tissue around the surgical bed, not the entire breast. It uses breast compression (like a mammogram) and x-ray imaging 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 therapy 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.
Minimizing radiation exposure to the heart is an important focus of treatment planning by your radiation oncologist 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 wall. 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. Symptomatic lung injury causes cough and shortness of breath in the first 6 months after treatment, but it responds to steroid medications and always resolves with treatment.
This is an area of much discussion among breast cancer specialists. We certainly recommend radiation to sites of metastatic 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 clinical trials, in which such a patient might be eligible for enrollment. An individualized discussion with your oncologist is recommended.
The most important thing to do first is see your radiation oncologist or other cancer doctor for evaluation. We would certainly want to rule out a tumor recurrence, though this is unlikely given your symptoms of pain. The more likely cause is fat necrosis, a painful swelling of fatty breast tissue. Fat necrosis can be caused by trauma or radiation to the breast. Sometimes fat necrosis can be recognized on a mammogram, and certainly with a needle biopsy, but these interventions aren’t always needed. For most women, these symptoms can be managed with ibuprofen or Tylenol and patience. It may take several months for the symptoms to resolve. In severe cases, steroids or even surgical removal is recommended.
Plastic surgeons vary greatly on how they choose reconstructive options in the setting of breast radiation. As a general rule, if a patient will have implants (saline or silicone), the expanders should be maximally filled prior to radiation. Radiation can be performed with the expanders in place, and the final implant can be inserted about 6 months after completion of radiation therapy, 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.