Radiotherapy

This section describes radiotherapy, one of the treatments that patients with breast cancer may be offered. In this section we aim to give information that will be helpful to you and your family and friends regarding radiotherapy treatment.
We hope this will help you discuss your radiotherapy treatment with the doctors, nurses and therapeutic radiographers involved in your care. It is important to understand that there may be some differences between radiotherapy centres. Remember not to compare treatments with other patients, as each person’s treatment plan is tailor-made for them as an individual.

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What is radiotherapy?

Radiotherapy is the use of high energy x-rays to treat cancer. These high-energy rays are produced by a machine called a linear accelerator and are able to damage and destroy cancer cells within the treatment area. Radiotherapy also affects normal cells in the area being treated, but they are generally better able to recover than cancer cells. Treatments are usually given regularly over a period of time to have the greatest effect on the cancer cells whilst limiting the damage to normal cells.

When is radiotherapy given?

It is important to remember that patients’ treatment plans vary. In most cases it is given after surgery to reduce the risk of cancer coming back by getting rid of any possible remaining cancer cells in the area. If you have a lump removed or a part of your breast removed you will most likely receive radiotherapy to the remaining breast tissue. If you have a mastectomy (removal of the whole breast) you may receive radiotherapy to the chest wall area if the tumour was large or cancer cells had spread to lymph nodes under the arm.

If you are to have chemotherapy a decision will be made as to when radiotherapy will be given. Radiotherapy may be given before, during or after chemotherapy, depending on the type of chemotherapy given.

Radiotherapy cannot be given at the same time as some chemotherapy drugs. Your doctor will arrange your schedule according to which chemotherapy drugs you are on.

Radiotherapy may also be used in more advanced stages of breast cancer. It can help to control previously untreated disease in the breast or help relieve cancer-related symptoms, such as pain caused by the cancer spreading secondary breast cancer to other parts of the body. In these situations, the extent of treatment will depend on individual circumstances, but would usually be given over a much shorter period of time.
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What about treatment arrangements?

It is recommended that radiotherapy starts about four to six weeks after surgery. It will usually be given daily, Monday to Friday, for a total of three to six weeks. Some centres treat patients on alternate days, rather than every day.

First you will see the radiotherapy specialist (radiation oncologist) in the outpatient department to talk about your treatment. A further appointment will be made to plan the treatment, and you will then be given a starting date.

Radiotherapy is a specialised treatment and so is not available in every hospital. However, each breast unit will have a link with a hospital that has a radiotherapy department. You will usually be treated as an outpatient. If you think you will have problems attending appointments, tell the radiotherapy staff. Sometimes transport can be arranged. It is important that treatment continues as planned and that you don’t miss any appointments. If, for example, you have a holiday booked, tell the specialist or radiographer who is treating you so that s/he can decide what arrangements to make.

The staff treating you will check how you are each day, but if you have any problems tell the therapeutic radiographer or nurse. An appointment can then be arranged with your specialist and/or breast care nurse if necessary.
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Treatment planning

Treatment is individually planned for each patient, so do not compare treatment sites and number of treatments with other patients.
Treatment planning, also known as simulation, identifies the exact area to be treated, using the maximum dose of radiation, while causing the fewest possible side effects to the patient.

A special x-ray machine called a Simulator is used for treatment planning. Each patient will be called to their radiotherapy centre for this planning. We understand that you may be nervous on this day, as it may be your first visit to your radiotherapy centre. Try to bring someone with you on this day for company and support. Remember to wear an old bra or vest as the markings from the treatment planning may stain your underwear and often these stains are difficult to remove.

You are also advised to have enough arm movement after your operation to allow you to raise your elbow to at least shoulder level so that you are comfortable in your treatment position. If you find this difficult ask to see a physiotherapist prior to starting treatment. If you are on pain medication take your painkillers before you go to your appointment.
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Simulation

Simulation is not painful. However, you will lie on a hard table in a room with machines above you, which maybe uncomfortable. You will have to partially undress to expose the skin in the breast area. Your planning session may last from half an hour to an hour.
During this time you will need to lie still while x-rays and measurements are taken by the doctor and therapeutic radiographer. At some stages you will be alone in the room but you can be seen and heard at all times. The area to be treated will be marked with a pink/purple marker and/or permanent tattoos.
If marker is used you are advised not to rub it off prior to starting treatment and to return to the radiotherapy centre for top up markings if they fade. The tattoos are small pinprick size black/purple marks, tattooed onto the skin, and will remain on this area for life. These are not painful and are barely noticeable. Top

How is radiotherapy given?

When you go for treatment you will be asked to undress to the waist and lie on the treatment bed. The therapeutic radiographer will position you so that you are in the exact position each time you have treatment.
Again you will be in the room alone but can be seen and heard in the outside room by the therapeutic radiographers at all times, and you can speak with staff via an intercom.
When you are in the correct position you will be asked to stay very still and breathe normally. The therapeutic radiographer will position the machine to different angles to direct the treatment to the areas required.
You will not feel any pain while treatment is been given but you may feel some discomfort in your arm from keeping it in the same position during treatment. The treatment only takes a few minutes after which you will be asked to get dressed and will be given an appointment for the next day. This will be the routine until treatment finishes.
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What are the side effects of treatment?

Side effects happen because radiotherapy affects normal cells as well as cancer cells. Normal cells are able to recover but they may be damaged in the short or long term by the effects of radiation. Most side effects are temporary, but some may be permanent.
Some side effects may even occur months or years after treatment. Each person reacts differently to treatment but certain side effects are more common than others.
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Common side effects

You may develop a skin reaction during or after treatment to the breast. The extent of this reaction depends on a number of factors including the dose of treatment given and the sensitivity of your skin. Skin reactions may be present with tenderness and itching of the skin in treatment area 10-14 days after treatment begins.
There may be some flaking of the skin as treatment goes on and the skin may become red, sore and weepy. Each person’s skin reacts differently so while one person’s skin may react and become sore another person’s skin will remain intact. Your skin will be monitored frequently by your healthcare team and appropriate treatment will be given for the reaction.

Now and then you may have some aches, pains, twinges and swelling in the breast area while you are on treatment. These symptoms may continue for some time after treatment is finished.

If treatment includes the centre of the chest or collarbone area, a small area of your gullet may be affected causing some heartburn and discomfort this can usually be relieved with medication.

Your body does use a lot of energy over the weeks of treatment so you may feel more tired than usual especially as treatment goes on. The stress of a cancer diagnosis, and the journey to hospital may all add to this tiredness. Research would suggest that a balance between exercise and rest might help with this feeling of fatigue, prioritising tasks at home; a healthy diet and fresh air may be helpful.

For more information please contact Action Breast Cancer and ask for our Coping with Fatigue booklet Coping with Fatigue .
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Less common side effects

These side effects would not appear until treatment was finished. Radiotherapy to the breast and armpit may cause hardening of the tissues. This is known as fibrosis and is caused by build up of scar tissue.

Sometimes part of the lung behind the treatment area may become inflamed causing a dry cough or shortness of breath. This usually heals by itself.

Rare side effects

There are some rare side effects, some of which can be serious and permanent.
If the fibrosis of the breast becomes severe the breast may become noticeably smaller and harder. You may notice tiny dilated blood vessels under the skin. This is known as Telangectasia. Severe fibrosis can also block lymph drainage of the arm and cause a swelling in the arm called Lymphoedema.

Fibrosis of the upper lung can cause side effects such as dry cough or shortness of breath.

Other side effects that can occur later include:

• Weakness of the bones in the area, for example, the ribs and collar bone
• Damage to nerves in the arm, which may cause tingling, numbness, pain, weakness and possibly some loss of movement.

It is important to remember that serious side effects are rare and the experts agree that the benefits of the treatment outweigh the risks of these possible side effects.
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How to take care of yourself during treatment

It is important to take care of your skin in the area being treated. We would suggest the following:

• Avoid using any perfumes, deodorants, dressings, creams or lotions in the treatment area unless advised to do so by the radiotherapy staff.
• Wash the area gently with lukewarm water either in a bath or shower and pat dry with a soft towel. Do not rub the area. Some departments allow you to use a gentle non-perfumed soap.
• If having radiotherapy to under the arm the hair may fall out under the arm.
• Avoid exposing the treated area to direct sunlight for one year after treatment. When treatment is finished the skin in the treatment area will be more at risk of burning, so it is important to keep this area covered or regularly apply a sun block to the area. Avoid extreme temperatures such as heat pads, saunas, hot water bottles or cold packs while on treatment.
• Soft cotton bras or vests are more comfortable to wear while on treatment but we would advise people to leave them off as much as possible.
• If wearing a prosthesis, a soft lightweight one is advisable instead of your silicone prosthesis while on treatment.
• A well-balanced healthy diet with plenty of fluids can help your body to cope with the effects of treatment.
• Try not to expect too much of yourself during treatment as your energy levels will be low.
• Breast tissue on the treated side may feel firmer than before. It is important to note what is normal for you. Continue to be breast aware after treatment. For a free breast awareness information pack call the National Cancer Helpline on Freefone 1800 200 700.
• If you develop a skin reaction it should be fully healed about four weeks after treatment. You will be advised by nursing staff in the radiotherapy centre on how to care for your skin.
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What can I expect after treatment?

Although completing radiotherapy treatment is usually a relief, many people still feel quite vulnerable. It may take some time before you feel you are ‘getting back to normal’. Try not to expect too much of yourself in the early days and weeks after your treatment. You may go on feeling tired for some time, but gradually you should begin to feel better. For some, this can mean several months and sometimes up to a year.

You will be given regular follow-up appointments to monitor your progress, but if at any time you have a concern or worry, contact the radiation department doctor so that an earlier appointment can be arranged.

After radiotherapy the breast tissue on the treated side may feel firmer than before. From the point of view of breast awareness, it is important to know that this is normal and nothing to worry about.

Your skin may feel dry after radiotherapy, so using a moisturiser as recommended by the radiotherapy staff may help.
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Coping with radiotherapy

Some people may feel quite emotionally upset, frightened or have difficulty adjusting to what is happening to them. Fear of the unknown is common so finding out as much as possible about your treatment can help you to cope better. You may find it helpful to visit the department beforehand so you know what to expect.

If you are feeling low, tired, anxious or tearful at any point during or after your treatment, remember that you are not alone and that there are people who can help you. Try to let other people know how you are feeling, particularly your family and friends, so that they can be more supportive.
It can also help to discuss your feelings or worries with your breast care nurse or specialist. Alternatively, a counsellor or psychotherapist might be more appropriate if you want to talk through your feelings in more depth over a period of time.

For information on available counselling services call the National Cancer Freephone Helpline on 1800 200 700.

You might find it easier to share your feelings with someone who has had a similar experience to you. Reach to Recovery is a programme set up to help and support women who have recently had a breast cancer diagnosis. The programme works on the principle of personal contact between the patient and a Reach to Recovery volunteer – a woman who has had surgery for breast cancer.
Carefully selected and fully trained volunteers are available to provide advice and reassurance at a time when a woman is most in need of both. For more information on individual support or support groups in your area, call the Action Breast Cancer Freefone Helpline.
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Help from Action Breast Cancer