As a radiation oncologist, I find that many breast cancer patients and their family members are anxious when they meet me for the first time. Patients have often already undergone surgery, and many have already met with a medical oncologist to discuss the possibility of chemotherapy and/or hormonal therapy. An initial visit with a radiation oncologist can be another scary step in an already overwhelming process. My goal in this post is to share some basic information about radiation for breast cancer, including what to expect during your first and subsequent visits as well as potential side effects that breast cancer patients may experience during and after radiation. Hopefully this information will help ease your mind throughout the radiation process.
Initial Consultation with a Radiation Oncologist
The first thing to know about the initial visit with a radiation oncologist is that there will be no tests or radiation delivered on that date. Your job during the first visit is simply to gather information. Your radiation oncologist will discuss with you whether or not radiation is recommended, what are the potential benefits of radiation in your care, and what are the possible side effects. It can often be helpful to bring a family member or friend as a second set of ears. Writing out a list of questions for your doctor prior to your visit can also be useful in organizing your thoughts.
In most patients with breast cancer, radiation is used after surgery. The goal of radiation, whether it is delivered after lumpectomy or mastectomy, is to decrease the risk of cancer recurrence in the local area (i.e. in the remaining breast or chest wall), and in some cases, to also decrease the risk of cancer recurrence in the nearby lymph nodes. Often, a breast surgeon will say “I got it all” when discussing the pathology results after breast cancer surgery. However, even in the setting of clean surgical margins, there is a risk that individual tumor cells may have been left behind, and these could possibly lead to cancer recurrence down the line. The job of postoperative radiation is to kill these cancer cells, thereby reducing the risk of recurrence.
Radiation is essentially targeted x-ray treatment. X-rays are generated in a treatment machine called a linear accelerator and then aimed at the part of the body at risk. Radiation kills cancer cells by causing double-stranded breaks in their DNA. Radiation is typically delivered 5 days per week, Monday through Friday, and a treatment course can be as few as 5 treatments or as many as 30 or more treatments, depending on the clinical situation.
CT Simulation for Radiation Planning
After consultation, the next visit with a radiation oncologist will be for a CT scan, called a CT simulation, to help plan the radiation. Diagnostic CT scans done in a radiology facility are for separate purposes and do not replace a CT simulation. At the time of CT simulation, you will be asked to change into a gown from the waist up. Planning and treatment are typically done with the patient lying on a customizable breast board or a customizable mold. A CT of the chest is performed in the treatment position, which can be with the patient lying on the back or the stomach, with the arms above the head. The goals of CT simulation are to select the best position for treatment and to make that position reproducible within millimeters for treatment each day. Once the scan is complete, a patient is typically given a few small tattoos on the chest area to allow for proper positioning each day.
There is no need to fear the CT simulation process. Typically, the scan is performed without injection of contrast. You eat and drink normally before and after the scan (as well as before and after radiation treatments). Your job is mainly to hold still, and your radiation team should explain what is happening throughout the process, which usually takes 45-60 minutes. It is normally 1-2 weeks between CT simulation and starting radiation treatments, and you should be given your daily treatment schedule at the time of simulation so that you can plan your life for the coming weeks. Many patients continue to work throughout radiation and/or have responsibilities at home, and it is helpful to know your treatment schedule in advance.
During the next 1-2 weeks, your radiation oncology team will be hard at work on your treatment plan. The CT images taken during simulation allow your physician to see all of your anatomy. Your physician can see the breast tissue, the tumor bed, and the regional lymph nodes (i.e. all areas that may be at risk for harboring microscopic cancer cells). Your physician can also see your normal tissues, most critically your heart and lungs. This information is used to optimally plan your radiation, so that that areas at risk are properly treated, while the normal tissues are adequately spared. A lot of work goes into creating your individual treatment plan and to ensure that treatment is delivered safely.
Radiation Treatments
Your first visit after CT simulation is for what we call a dry-run or safety check. Patients are set up on the radiation treatment table in the same position that was used during CT simulation. X-rays are taken to confirm positioning on the table and safety. Once your physician has reviewed and approved these images, you are ready to start your radiation.
Patients are typically in the office less than 30 minutes each day. Much of that time is for the preparation. Patients change into a gown and then need to be set up in the precise treatment position, which can take some time to ensure accuracy. Once in the proper position, the treatment is started. Radiation treatments are typically broken up in to a few pieces, each taking a few minutes to deliver. Your job during treatment is to relax and hold still. As with any other x-ray, you do not feel anything while the treatment is being delivered. Once the treatment is complete, you get down from the table, get changed into your clothing and head home, or to work, or to take care of kids or grandkids, whatever you normally do. You are not radioactive after treatment. You can drive yourself to and from treatments (and free, convenient parking is often available at radiation treatment centers).
Side Effects of Radiation Treatment
Most breast cancer patients tolerate radiation treatments very well. The main side effects during treatment are some fatigue and irritation of the radiated skin. Tiredness typically starts in the third week of radiation, peaks at the end of treatment and resolves in the 4-6 weeks after completion of therapy. Fatigue is generally manageable, with most patients continuing normal activities. However, fatigue can hit older or more debilitated women harder.
With regard to skin irritation, we typically start to see some pinkness of the radiated skin toward the end of the second week of treatment. Skin irritation increases throughout the treatment course, peaking at the end. Pink skin can become red. There can be an associated “rash” and itchiness. There can be some peeling of the skin. Radiation causes inflammation in the treated area, which can be associated with breast swelling and discomfort. Your radiation oncology team will recommend a cream for you to use on the treated skin throughout the radiation course. They will review additional skin care recommendations, including appropriate soaps, deodorants, bras, etc. And your team will be there to support you throughout the treatment course, answering your questions along the way and managing side effects as they arise.
Skin redness, itchiness, and irritation tend to resolve in the few weeks after radiation. Your radiation oncologist will typically see you 3-6 weeks after completion of radiation to ensure resolution of acute side effects. At this point, the treated area should no longer be red, but there is often residual darkness/tanning of the skin of the breast, which will fade over time, particularly with long-term use of a daily moisturizer.
Long-term side effects of radiation include potential for damage to heart and/or lung, cosmetic changes, rib fracture, lymphedema, and a small risk of induction of secondary malignancies. The risk of long-term side effects due to radiation is generally low but is dependent on the tissues targeted and the radiation dose prescribed. Technology for the delivery of radiation has improved over time, resulting in decreased side effects. Furthermore, as a field, we are focused on de-escalation of therapy whenever possible, which may translate to fewer treatments, smaller radiation targets, and possibly omission of radiation all together. Whenever a radiation oncologist recommends treatment, it is because he or she believes that the benefits of treatment far outweigh the risk of side effects.
Final Thoughts
I hope this post has offered some valuable information and helped to put your mind at ease. Please know that your radiation team will be there to answer questions and support you throughout the treatment process.
