RADIOTHERAPY FOR BREAST CANCER: PROCEDURE, BENEFITS & RISKS
Radiotherapy for breast cancer provides excellent results. It goes hand in hand with surgery to help eradicate cancer.
Breast radiotherapy kills cancer cells responsible for the tumor and cells that can cause a relapse. Hence, there is less chance of cancer coming back. However, radiation can kill both cancer and normal cells. So, newer techniques aim to reduce the total radiation dose without losing effectiveness.
External beam radiotherapy uses radiation from outside the body to destroy cancer cells. This is the best-known type of radiation therapy for breast cancer. However, newer treatment options include intraoperative radiotherapy and brachytherapy.
Whichever your case, remember that the course of treatment you decide is something you should deeply discuss with your oncologist to ensure that it is as effective as possible.
What Is Radiotherapy?
Radiotherapy uses high-energy radiation or x-rays to kill tumor cells.
How does it work? Large but controlled doses of radiation can effectively damage the DNA inside the cancer cells. Then, when the DNA gets damaged, the cancer cells fail to divide successfully and die. Also, they can’t regenerate fast enough, just as healthy-normal cells do.
The treatment area may include your breast, armpit lymph nodes, or other parts of your body if cancer has spread (metastasized.)
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If I Have Breast Cancer, Will I Receive Radiotherapy?
The treatment plan will depend on the type of breast cancer, the stage, and the surgery you have. Breast-conserving surgery is the best treatment option for early-stage breast cancer. However, your doctor most likely will put you on radiotherapy to the breast afterward.
When having breast-conserving surgery, the tumor and a little surrounding breast tissue are removed. This can go from a lumpectomy or wide local excision to a partial mastectomy, where a significant part of the breast can be removed.
Surgery helps remove the tumor, and radiation is applied to destroy any remaining cancer cells. This is also called adjuvant radiotherapy and helps diminish the risk of recurrence.
Some patients have a low risk of cancer coming back after surgery. If so, your doctor may consider not giving you radiotherapy.
Now, if you have a mastectomy (removal of the breast) and a high risk of cancer coming back, you may need radiotherapy to the chest. This may happen if the pathology report shows that there are cancer cells at any of the edges of the surgery (positive margins.)
Most probably, you will have radiotherapy if:
- Cancer has spread to one or more lymph nodes under the arm.
- You have a large tumor (greater than 2 inches.)
The therapy can also be given to the lymph nodes located around your collarbone or the breastbone (sternum).
Ultimately, radiation therapy can treat unresectable breast cancer that “can’t be removed with surgery.” It can also treat breast cancer that has metastasized. This would help ease pain and symptoms caused by cancer that has spread to other parts of the body.
What are the Side Effects of Radiotherapy for Breast Cancer?
Radiotherapy effectively reduces the risk of breast cancer coming back. However, normal cells can also be damaged in the process.
Hence, newer techniques and treatment protocols have reduced the risk of damage to healthy tissue with fewer side effects. After all, cancer cells cannot repair themselves after radiotherapy, whereas normal cells can.
Among radiotherapy side effects, skin irritation is pretty common. Your skin in the treatment area may experience redness, itchiness, and peeling. Also, dark skin may get darker. Hence, you need to avoid exposing the treated area to the sun for at least a year after you finish the therapy. Also, you will have to wear high SPF sunscreen at all times.
You may also experience tiredness, shooting pains, or swelling in the treated area. These effects usually improve quickly, 1 to 2 weeks after treatment.
Other side effects may present later on, months or even years after finishing protocol.
With time, you may notice changes in your breast appearance. They may feel firmer, change color, or shrink slightly in size. So, if you had breast reconstruction with implants before having radiotherapy, you may need to replace them.
Also, radiotherapy to the breast may damage some of the nerves in your arm, known as brachial plexopathy. You may experience pain, numbness, and muscle weakness in your arm or hand.
Additionally, radiotherapy aimed at the armpit lymph nodes might later cause lymphedema, with pain and swelling in the arm and shoulder. It is rare for radiation to cause lung or heart problems, though. This can happen if you had treatment to your left side.
How Many Radiotherapy Sessions for Breast Cancer?
Radiotherapy, or external beam radiation (EBRT), is an outpatient procedure. It is given by a giant x-ray machine called linear accelerator.
You will have the therapy as a series of short, daily sessions. They will be scheduled five days a week, from Monday to Friday. Usually, you will start 4 to 6 weeks after surgery. If chemotherapy is necessary, radiotherapy is given after you finish chemotherapy.
In past years, radiation protocols could last five or six weeks. Nowadays, radiation plans are shorter. According to clinical trials, these hypofractionated treatment protocols are just as effective and may reduce the risk of some side effects.
For whole-breast irradiation, you will have radiotherapy for 3 to 4 weeks (hypofractionated treatment).
Conversely, partial breast radiation (just to the area where the cancer was located) can be completed in 1 to 3 weeks. And with extreme hypofractionated irradiation protocols, sessions may be completed in five days or less.
The decision to receive whole-breast or partial-breast irradiation will depend on your cancer stage. Partial-breast irradiation may apply for some early-stage breast cancers.
Patients who had breast-conserving surgery could receive an extra dose (booster dose) to the area where the cancer was (tumor bed.)
You could receive the booster dose at the same time as radiotherapy to the rest of the breast, or it could be scheduled at the end of the three weeks. In the last case, you will need four to five additional days of treatments.
Some patients can receive intensity-modulated radiotherapy (IMRT). In this case, different doses can be directed to different areas. Hence, you will receive lower radiation to healthy tissue surrounding the tumor.
Whichever your case, your cancer doctor will explain the treatments options available for you.
Before The Session
You will have an appointment to plan your treatment. First, you must have a CT scan of the area to be treated. During this scan, you will have to lie very still, in the exact position you will be in for your sessions. Pads or other tools can help you hold the position.
The radiographer will make small, semi-permanent pinpoint size markings (tattoo dots) on your skin to delimit the area to be treated. The markings will ensure you are in the correct position for each session.
Additionally, the oncology team might make a mold for you. It is like a plastic shell of your breast and chest that you must wear during the treatment sessions.
At the beginning of the session, the technician will explain the process. He will make sure you are in the correct position. This step ensures precise radiation therapy delivery.
Before starting, it’s essential that you have regained your arm movement and can raise it above your head. Thus, radiation can be given to the whole breast or chest. If your muscles feel stiff or painful, a physiotherapist can teach you exercises that may help.
During The Session
Once you are in the correct position, the radiographer will leave the room, and the treatment will begin. The machine may stop and move into a new position during the session, making whirring and beeping noises. This proves you are receiving radiotherapy from different directions.
Although the radiographer won’t be in the room with you, he will monitor you from a television screen. Also, through an intercom, you can talk, and he will answer any doubt you may have.
When having radiotherapy to your left breast, you will be instructed to take a deep breath and hold it briefly (between 2 to 17 seconds.). This respiration technique is known as deep inspiration breath-hold (DIBH).
DIBH keeps you still and moves your heart (behind your left breast) away from the radiation zone. Hence, DIBH helps protect your heart during the therapy and reduces the risk of late side effects.
Radiation is painless, and every session only takes 15 minutes to an hour.
After The Session
After the session, you can resume your regular activities. Take any self-care steps at home, especially in case of skin reactions.
If you didn’t know, external radiotherapy does not make you radioactive. After your treatment, you can safely be with other people, including your children.
What Is Brachytherapy for Breast Cancer?
With brachytherapy, also known as internal radiation, radioactive seeds or pellets are delivered to tiny tubes or a small balloon (radiation delivery device) placed inside your body.
Indeed, the device lies directly in the area from which the cancer was removed. Then, the radioactive material is placed for a short time each day, or it may be left in place for a few days.
This technique is highly effective but is not for everyone. Tumor size, staging, and location may limit who can receive brachytherapy. For certain patients who had breast-conserving surgery, brachytherapy can be used instead of whole-breast radiation. It would be a form of accelerated partial breast irradiation.
Depending on the type of brachytherapy prescribed, you may receive the treatment during a hospital stay or be given over a few sessions (5 days) as an outpatient procedure. The radioactive material will be removed each time before you go home, though.
After the treatment is finished, the radiation delivery device is removed. The breast area may feel slightly sore and tender as the tissue heals from the surgery and radiation.
What Is Intraoperative Radiotherapy for Breast Cancer?
Intraoperative radiotherapy for breast cancer is performed when the tumor is removed during breast-conserving surgery, right before the breast incision is closed. This type of radiation is given from inside the body, hence the name.
With this technique, a single large dose of radiation is applied where the tumor was removed, while still being in the operating room. In short, intraoperative radiotherapy ensures the patient´s healing with fewer noticeable side effects.
In an interview with the Spanish newspaper La Vanguardia (with a circulation of 230,000 copies per day), Doctor Benjamí Guix, director of the IMOR Hospital in Barcelona, answers several questions about the effectiveness of intraoperative radiotherapy for breast cancer.
What Are the Advantages of Intraoperative Radiotherapy for Breast Cancer?
Intraoperative radiotherapy has several advantages. The main benefit is that the specialist applies the treatment directly to the tumor’s exact location, avoiding tissue irradiation in areas of difficult access.
Another benefit is to prevent the proliferation of tumor cells once the wound is healed. It provides excellent results and dramatically shortens treatment time because it is performed in one session at the time of surgery.
Which Patients Are Candidates for Intraoperative Radiotherapy for Breast Cancer?
All women who have had breast cancer surgery are candidates for intraoperative radiotherapy.
In some cases, other treatments are unnecessary after this therapy. This applies to tumors less than one centimeter in diameter, without carcinoma, and with a non-positive sentinel node.
A third of patients meet these conditions and can undergo a single session of intraoperative radiotherapy. In the rest of the cases, it will be necessary to supplement the treatment with external radiotherapy.
How Long Does Recovery Take After Intraoperative Radiotherapy for Breast Cancer?
Patients can return home after 24-48 hours. Recovery is not complicated. Quarterly checkups are advised.
Can Intraoperative Radiotherapy Be Applied to Other Types of Tumors?
Intraoperative radiotherapy is mainly used for cases of breast tumors. But this technique can also be used in tumors of the colon, rectum, pancreas, and liver lesions.
Intraoperative radiation therapy can be applied in any surgically accessible location, but you should discuss this possibility with your doctor.
FACILITIES OF THE IMOR RADIOTHERAPY HOSPITAL (BARCELONA, SPAIN):
A center specialized exclusively in the care of oncology patients.
A center area of 700 m2 distributed over four floors.
Latest technologies in radiation oncology, including brachytherapy equipment.
Three-dimensional digital imagery.
Comfortable rooms with natural light.
Doctor Benjamín Guix Melcior
Specialist in Radiotherapy for Breast Cancer
More than 35 years of experience in breast cancer treatment.
Director of the IMOR Institute (Barcelona, Spain).
American Brachytherapy Society (ABS) Award 2009
Languages: Spanish, English, French
Bibliography – More recent publications:
Moderate hypofractionation remains the standard of care for whole-breast radiotherapy in breast cancer: Considerations regarding FAST and FAST-Forward. Krug D, Baumann R, Combs SE, Duma MN, Dunst J, Feyer P, Fietkau R, Haase W, Harms W, Hehr T, Piroth MD, Sedlmayer F, Souchon R, Strnad V, Budach W; Breast Cancer Expert Panel of the German Society of Radiation Oncology (DEGRO).Strahlenther Onkol. 2021
Long-term results of hypofractionated radiation therapy for breast cancer. Whelan TJ, Pignol JP, Levine MN, Julian JA, MacKenzie R, Parpia S, Shelley W, Grimard L, Bowen J, Lukka H, Perera F, Fyles A, Schneider K, Gulavita S, Freeman C.N Engl J Med. 2010
Modern Approaches for Breast Brachytherapy. Shah C, Martinez A, Kolar M, Vicini F.Semin Radiat Oncol. 2020
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