Breast Cancer and Radiation Therapy

Chances are, if you are reading this article, you or someone you love has breast cancer. You are not alone. The numbers of women with breast cancer are staggering. In 1998, over 200,000 women were newly diagnosed with the disease. One in seven women will develop it some time in their lives and it is second only to lung cancer in the number of new cases. Fortunately with advances in diagnostic procedures the cancers are being diagnosed earlier, meaning that current treatments are more effective.

One treatment for breast cancer is radiation therapy. Traditional concepts through most of the 20th century held that breast cancer was a local disease best managed by radical mastectomy. Over the past 20 years many clinical trials worldwide have shown that for women who chose to keep their breast, lumpectomy and radiation therapy is as effective as mastectomy. This, of course, is determined by your oncology team upon your final staging. More advanced cancers may need mastectomy, chemotherapy and hormonal manipulation.

Radiation therapy has been used on breast cancer for almost 100 years. Because a surgeon can only remove what he can see, there are many instances where radiation therapy is needed. Microscopic disease left after surgery in the form of unclear surgical margins or microscopic disease that didn't appear on the pre-surgical mammograms can, in time, grow and cause a recurrence. Postoperative radiotherapy is given to kill any residual disease and cure a woman of her breast cancer. Prospective randomized trials, with a maximum follow up of 17 years comparing breast conservation treatments (lumpectomy and radiation) with mastectomy, have demonstrated equivalent results as measured by overall patient survival. This is extremely important because to many women, breast conservation is almost as important as the cure. Women who receive radiation therapy seem very satisfied with their cosmetic results.

The first day of treatment is your longest. The doctor and technologists will spend this day devising the best treatment for you. X-rays and measurements will be done to make sure that everything that needs to be treated is included in the fields of treatment and as much healthy tissue as possible is avoided.

There are four basic areas of concern. The breast itself will be treated along with the internal mammary lymph nodes, the axillary (armpit) lymph nodes and the supraclavicular (around the collarbone) lymph nodes. Whether your lymph node dissection at the time of surgery shows disease or not, the lymph nodes are treated just in case. The idea is that if the cancer is going to spread out from the primary site, the lymph nodes should be the first place for it to go.

The areas the doctor wants treated are verified and documented by x-rays. Once the x-rays are approved, the technologist will draw big bold ink marks on your skin to map out where they will be treating everyday. These marks are critical to your treatment. You cannot wash them off! Without the marks the technologists will not know where to aim the radiation. It is ok to get the marks wet. You can still take a bath or shower. In the shower, stand with your back against the water and wash normally. Be careful to wash between the marks, then quickly turn towards the water and rinse. Use an old bath towel to dry off because some of the ink may come off. When the marks begin to fade, your technologist will darken them up. Unless directed by your technologists, do not try to help remark the lines yourself. They have the skill it takes to be accurate and you wouldn't want to accidentally alter the treatment. The daily treatment should take about fifteen minutes.

The time the machine is actually on will be around 1-2 minutes. You won't see or feel anything during your treatment. The machine will make a buzzing noise while on. You can breathe during your treatment. You will never have to hold your breath. The only thing the therapists will require of you is that you hold still and not move until they tell you.

After the first treatment, the only thing you should feel is relief that you have finally started. There are side effects to the treatment, but they do not generally begin until the third or fourth week. The first side effect that you will notice is your skin getting tight and dry. Gentle hand lotion can be used a few times a day. Just make sure not to remove the marks! Don't waste your money on any expensive lotions. Excessive perfumes and colors might irritate your skin so keep with something like baby oil or Keri lotion. You should also buy a tube of hydrocortisone cream and a box of regular kitchen cornstarch. Around week 5-6 your nipple, underarm and under your breast will get itchy and might crack. If the lotion doesn't work any longer switch to cortisone. It might sting a little at first, but it will numb the area nicely. If your skin eventually peels (just like a sunburn) you might notice that your skin is moist in some areas. This is normal fluid and nothing to get alarmed about. In these areas use the corn starch to dry up the moisture. Bacteria love warm moist places so keeping it dry will promote healing. The goal of caring for your skin is to keep wet places dry with cornstarch and dry places wet with lotion. If there are spots that itch and burn and are wet, apply the cortisone cream first then cover it with cornstarch. Don't worry about coming to treatment with lotion on. It will not interfere with your treatment.

The next side effect of treatment is fatigue. The fatigue is cumulative. You will notice it most by the end of the week. Because you will have no weekend treatment, your energy will come back by Monday. Unfortunately, by the following Friday you will be tired again. Some ladies hardly notice the fatigue while others are fairly worn out. Adjust your activities accordingly, but do not just lie around. The lazier you are, the more tired you will get. So keep as active as possible.

As a side note, during surgery, the surgeon sometimes damages regional nerves. There may be some numbness in the breast and armpit. A few weeks to a few months after surgery the nerves will begin to "wake up." Because they have been temporarily damaged, they may misfire and send tingling down the arm and pins and needles in the breast. This coincidentally begins during radiation and some confuse this with radiation side effects. Radiation does not affect nerve tissue in this manner. Its manifestation during radiation is purely coincidental.

Also, if you have large breasts and unfortunately gravity has taken its toll and your left breast is being treated there is a small chance of nausea. Large peoples' stomachs are usually high in their abdomen and if your breast hangs low a portion of your stomach might get some radiation. There should not be any vomiting, but an upset stomach for six or seven weeks is still difficult. If an adjustment in your diet doesn't work, ask your doctor for anti-emetics such as Compazine and you should have no problems.

Lastly, because the ribs under the breast are going to be treated too, they will become brittle. For older patients with osteoporosis, this might lead to the possibility of a fracture. You will need to be careful of any aggressive activities that might cause a blow to the ribs. Even a hard hug from an overzealous husband or grandson can cause pain, so be careful.

The bone will eventually become strong again, but it can take up to a year after treatment. While the skin irritation and the fatigue usually last about 4-6 weeks after treatment, there are some side effects that last longer. Besides the bone problems mentioned earlier, the breast itself might change. Some ladies complain that their breast gets slightly smaller and firmer. (Actually some ladies like this!) Also, because a slight amount of normal lung tissue will be in the field of radiation, there will be a thin line of scar tissue on the affected side's lung. This should never give you any problem, but it might cause stress if you are not prepared.

Eventually, after treatment, you might need a chest x-ray. If the radiologist does not know about your previous radiation therapy, they might be alarmed by this new and confusing shadow on your lung. If they call your doctor and get him or her all worked up, they in turn will get you worked up over nothing. To nip this in the bud, make sure to let everyone know that you've had previous breast irradiation. In addition, occasionally the breast may become firm and globular making mammographic follow up difficult. This is one reason for regular yearly mammograms so that comparisons can be readily available.

If breast conservation was the deciding factor in choosing radiation, you should be quite happy with the results. You will have a scar from your surgery plus or minus any denting or defect from the lumpectomy, but your skin will recover nicely from surgery and you will still have your breast.

Any statistical cure rates should come from your radiation oncologist. It is too difficult to give cure rates when there are many different factors. These include tumor size, differentiation (maturity of the cancer cells), estrogen or progesterone response, lymph node staging, etc. However, as stated earlier, post lumpectomy radiotherapy is as effective as mastectomy and if keeping your breast is a concern, radiation therapy is a solid choice.

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