Radiation is a localized cancer treatment that works by damaging DNA to kill cancer cells and shrink tumors. Unlike chemotherapy, radiation is not a systemic therapy since it does not act on the whole body. The delivery of radiation does not hurt. It feels much like receiving an x-ray and is not felt by the body. The most common form of radiation (photon) is the same type of radiation that is used in x-rays, but the doses are higher and focused on the treatment area. Typically radiation happens daily for about 4-6 weeks and begins 4-8 weeks after chemotherapy or surgery. It takes approx 15 minutes after the patient is settled on the radiation table.
For breast radiation the patient may be placed in either the supine (on your back) or prone (on your belly) position. In order for radiation to be delivered with accuracy, patients must be perfectly aligned on the table day after day. In order to facilitate this, patients are typically tattooed in approximately 5 places on the upper body in order to align them. Tattoos are placed at the time of your treatment planning. They are typically blueish/grayish and about the size of a small freckle. For those patients who have strong objections to permanent tattoos, non-permanent options exist and can be discussed with your medical team beforehand.
Immediate side effects of breast radiation include skin irritation. This might feel like a sun burn or discolor to red or brown, breast tenderness and/or swelling. Some patients feel tired. Most side effects are worse at the end of the radiation treatments. Within six months you might get a cough that may be accompanied by a fever called radiation pneumonitis, this is rare but the signs are important to recognize and to know that it’s not bronchitis or a cold. It is very important to see your radiation oncologist right away if this develops.
Longer term side effects of radiation include increased density of breast tissue and discoloration of the skin. There is a very small risk of rib fracture and extremely small risk (1 in 500) that radiation may lead to the development of other cancers decades later. There may be a very small risk of heart disease if your cancer is on the left hand side. If lymph nodes are being treated simultaneously, additional risks include lymphedema and brachial plexopathy (damage to the nerves which is extremely rare).
If your doctor feels it is safe for you to have a lumpectomy, radiation to the breast would be part of the standard protocol if you are under the age of 70 so that you will be able to preserve your breast with the same possibility of a cure after surgery as a mastectomy. With other types of surgery, radiation is advised in the following cases:
- Stage 3
- 4+ positive nodes
- 1-3 positive nodes may require radiation after considering other tumor factors
- tumors greater than 5 cm
Radiation and reconstruction: It is always best to consult with your radiation oncologist and plastic surgeon before having a mastectomy or immediate reconstructive surgery. Although this may be something that seems second to treating your cancer, it needs consideration at the time of surgery and diagnosis. Radiation can affect reconstruction in varying degrees from minor infection to major complications such as loss of implant or loss of flap.
There are two main types of reconstruction, implant based and autologous tissue transfer. Since it is difficult to expand skin and underlying muscle following radiation, many plastic surgeons prefer to get started on the reconstruction before radiation occurs. Results are much better when the skin is stretched over an expander or implant before radiation therapy begins. Please note that skin expanders and permanent implants can be radiated. There are, however, sometimes strong institutional preferences on this point and radiation is slightly better tolerated on tissue expanders and for delayed reconstruction. Delayed reconstruction should not be attempted until one year after completion of radiation to ensure healthier skin and a successful reconstruction.