RADIOTHERAPY IS A cancer treatment that uses high-energy X-rays. The X-ray beams release pockets of energy as they pass through your body that damage and kill cancer cells. The X-rays also have an effect on healthy cells but most of these cells recover and repair themselves. Radiotherapy doesn’t make you radioactive, and it’s safe for you to be around pregnant women and children during your treatment.
If you have primary breast cancer, radiotherapy is given after you have finished surgery to reduce the risk of your cancer coming back and to improve your overall survival from breast cancer. If you have secondary cancer, radiotherapy is used to treat secondary deposits, for example in your brain or your bones, and for symptom control (see Chapter 23).
This chapter focuses on radiotherapy for primary breast cancer (for secondary cancer, see Chapter 23). There are four groups of people who will benefit:
Radiotherapy reduces your risk of a local recurrence (cancer in the breast tissue, skin or chest wall muscles). Together with a lumpectomy, it gives the same risk of recurrence and survival as those women having a mastectomy. If you are under 50, or over 50 with a large or Grade 3 cancer, you may also be given an additional boost to the tumour bed (the area of your breast that surrounded the breast cancer) to further reduce the risk of recurrence.
You have a higher risk of getting a local recurrence if your cancer is large (over 4–5cm), Grade 3, has grown directly into the skin or the muscle underneath the breast, or if you have cancer in some of the lymph nodes in your armpit. Radiotherapy is given to your chest wall to reduce this risk.
If you have cancer in four or more nodes, radiotherapy is given to the area above your collar bone (the ‘supraclavicular fossa’) to reduce the risk of local recurrence in the lymph nodes there. It may also be given if you have cancer in one to three axillary nodes and your cancer is large or a high-grade.
If your sentinel lymph node biopsy was positive, your doctor may discuss radiotherapy to your armpit instead of further lymph node surgery. Trials have shown that surgery and radiotherapy are both equally effective at reducing the risk of recurrence. Your oncologist will help you decide which treatment to have.
QUESTIONS TO ASK YOUR ONCOLOGIST
● Why do I need radiotherapy?
● What are the side effects?
● Are there any alternative treatments?
● What might happen if I don’t have it?
● How could it affect my surgery?
● What will my breast look like afterwards?
If you are over 70, with a small ER-positive, HER2-negative cancer and negative lymph nodes, your benefit from radiotherapy is small, and there are ongoing clinical trials investigating whether people like you can avoid radiotherapy.
You have radiotherapy after you have recovered from your surgery, and ideally it should be given within a month or two after your surgery. It may have to be delayed if you have a wound infection, a large seroma that needs draining, you need further surgery or you can’t lift your arms above your head. This is why it is important to do your shoulder exercises so your treatment isn’t delayed. If you need to have chemotherapy, you will have this first, followed by radiotherapy once chemo has finished. If you are having Herceptin as well, your injections will continue while you have radiotherapy, and carry on until you have finished the course of treatment.
Radiotherapy is measured in Grays (Gy). In the UK, most women get 40Gy given in 15 sessions over 3 weeks, from Monday to Friday. If you need a boost, this will involve an extra five to eight sessions. Most units run from early in the morning to late in the evening. You can ask for your sessions to be at a certain time to fit in around work and other commitments. You should be able to carry on working during treatment.
Most patients have External Beam Radiotherapy. The beams are delivered by a machine called a ‘linear accelerator’ (LINAC). Radiotherapy beams can also now be modulated (IMRT or Intensity-Modulated Radiotherapy) which means that stronger beams are sent to the target area, and the healthy surrounding tissues get a smaller dose. This can be done using the LINAC machine or another machine called a TomoTherapy machine.
If you have a left-sided cancer or heart problems you might be asked to hold your breath during treatment which reduces the effect of radiotherapy on the heart. This is called ‘respiratory gating’ and you will be coached how to hold your breath by the radiotherapy team.
A new technique has recently been introduced in a small number of UK hospitals called Intraoperative Radiotherapy (IORT) as part of a trial for women with small, node-negative cancers. Radiotherapy is given after your operation, while you are still asleep, using a ball-shaped probe that sits inside the breast. It has fewer side effects and avoids radiation damage to the skin, ribs, heart and lungs. Early results are promising, and we hope that the survival and recurrence rates will be the same as those women who have traditional radiotherapy.
Your first appointment is a planning appointment for a CT scan to plan your radiotherapy and precisely map out the areas to be treated. You’ll meet some of the radiotherapists who’ll be looking after you. If you want female radiotherapists, you can ask at your planning scan, although it might not be possible. The CT scan takes 15–30 minutes to do, and the appointment can take up to an hour in total.
For the CT scan, you lie topless on a table with one or both your arms above your head resting on a support. Once the scan is done, you need to be marked so the radiotherapists can accurately position you each time. The marks are blue-black in colour, and look like a full-stop made with a pencil. You have three in total – one in your low cleavage area, and one on either side of your chest. You will feel a sharp scratch when they are done, and they are permanent.
Once you are correctly positioned, the radiotherapists will go into an adjoining room. They watch you through a window with an intercom so they can talk to you. Depending on which machine is being used, the machine will either move around you, or you may be moved inside the machine. It can be quite noisy, but it doesn’t last for long – only five to ten minutes. Having radiotherapy is completely painless. You may find that the room is cold because of the air-conditioning. There will be blankets to put over your legs, but your arms may get cold.
Liz used an old pair of thick woolly tights cut in two to keep her arms warm, with a pair of gloves for her hands as well.
It can be very emotional having radiotherapy. There is something quite unsettling about lying topless in a tunnel with your arms above your head in an empty room with nothing but your thoughts for company. However, each treatment only takes a couple of minutes, and the radiotherapists are wonderful at reassuring you and cheering you up afterwards. Liz even got hugs from hers.
Not every hospital has a radiotherapy department, and you might need to travel quite a distance, particularly if you live in a rural area. You may find the travelling exhausting, especially if you have to rely on public transport. If you drive, you may be entitled to reduced car parking charges, and this will be explained at your first appointment. If you’re worried about how to get to the hospital, your doctor may be able to arrange hospital transport for you.
Radiotherapy causes side effects that happen in the first few weeks and months of treatment (immediate), and some that happen several months or years later (late).
These are very common after external beam radiotherapy, because the radiotherapy beams have to go through your skin to get to your breast. Your skin may become dry and sore, it might peel and flake, or turn red like a sunburn. Your skin can also change colour and darken like a deep suntan. Certain things make it worse, such as eczema, being overweight and smoking. You will be told to use non-perfumed moisturisers, soaps, shower gels and natural deodorants while you are having treatment, and for the first few weeks afterwards, until your skin settles down again. After radiotherapy, you are at a greater risk of getting burnt in the sun, so you should stay out of the sun during treatment and use a high factor sunscreen in the future. Wear loose clothing and you might want to stop wearing a bra for a while. Most skin reactions settle in a month or two.
The breast can swell and feel tight and uncomfortable because of a build-up of fluid in the breast and skin. Regular breast massage can help: firmly rub your breast in a circular motion using a gentle moisturiser or non-perfumed massage oil for a couple of minutes every day.
It is normal for your breast to change in size or shape after radio-therapy. Your breast may feel firm to the touch and shrink in size. There are surgical options to improve the look of your breast after radiotherapy, such as lipofilling (see here), but you’ll have to wait at least 6–12 months until the final effects of radiotherapy have developed.
Your shoulder might feel sore, stiff and difficult to move, especially if you are having your armpit treated. You should keep doing your shoulder exercises for several months after radiotherapy has finished to combat this.
If you’ve had your collarbone treated, you may get a sore throat and find it difficult to swallow for a couple of weeks. Simple painkillers and throat sweets can help, as well as eating softer foods. This gets better after a week or two.
You may experience sharp aches or pains in your breast or chest wall which are normally mild and don’t last very long. Sometimes these can continue for months or years, but should get better in time.
Radiotherapy causes your armpit hair (and chest hair, if you’re a man) to fall out. It normally starts to grow back after a month or two, but sometimes it never grows back.
If you have radiotherapy to the armpit, you can develop a swollen arm because the lymph nodes have been damaged. Lymphoedema is fully explained here.
Radiotherapy can speed up the development of a capsule around your implant (see here). You may need surgery to correct this.
You may notice little red dots appearing on your skin due to tiny broken blood vessels. These are called ‘telangiectasia’; they are harmless, but permanent.
Some people have tender ribs during treatment, and this can last for a long time. You may also be more likely to break a rib if you have an accident, so it’s important to take extra care after treatment. If you do break a rib, the treatment is regular painkillers like paracetamol and ibuprofen to help with the pain and to let you take deep breaths, and the bone will repair itself over a couple of months.
Sometimes, either due to your body shape or the position of the cancer within your breast, a small part of your heart and lungs may be damaged if they lie in the path of the X-ray beams, although newer techniques mean that your heart and lungs now receive very little radiation. There is a small chance that you might develop heart failure or inflammation of the lungs in the future. Your radiotherapy team will tell you if this applies to you, and also what signs to look out for.
Some people are scared of radiotherapy, but we hope we’ve been able to reassure you that it’s not as bad as you think it is. It can be tiring, especially if you have to travel a long way for each session, so take it easy, and remember to look after your skin.