Radiotherapy for breast cancer

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1 Page 1 of 13 Radiotherapy for breast cancer Introduction The Gloucestershire Oncology Centre at Cheltenham General Hospital is a specialist centre for the treatment of cancer. s come to the centre from Gloucestershire, Herefordshire, South Worcestershire and parts of Wales. We also have a Radiotherapy Unit at Hereford County Hospital treating patients from that region. This information has been specially written for patients receiving radiotherapy for breast cancer. By giving you some idea of what to expect, we hope to ease some of the worries that you may have. This booklet is a guide to the effects that you may have from the treatment, although this may vary from one person to another. If you have any questions or worries, however small, please speak to your doctor or radiographer. When you arrive at the Oncology Department it is important that you check in at the Radiotherapy reception so that we know you are here. Please take a seat and a radiographer will call you for marking-up or treatment. We have male and female staff working in our department and we also train students who are always supervised. What is radiotherapy? Reference No. GHPI0763_11_15 Department Radiotherapy Review due November 2018 Radiotherapy is the use of carefully measured doses of radiation to treat disease, usually cancer. Radiotherapy works by destroying cancer cells in the area that is treated. Although normal cells can be damaged by radiotherapy, they can usually repair themselves. Radiotherapy can cure some cancers and can also reduce the chance of a cancer coming back after surgery. It may also be used to control a cancer or improve the symptoms of it. You will not be radioactive.

2 Page 2 of 13 The machine used to give you your radiotherapy treatment is called a linear accelerator. The radiotherapy staff that will provide your treatment are specially trained in the delivery of the treatment. For female patients, if there is a possibility that you might be pregnant, please inform your doctor or radiographer when you arrive as there may be a risk to your unborn child. It is also important to avoid becoming pregnant during your course of treatment. Please speak to a member of staff if you have any concerns. Radiotherapy aims to treat the whole of the breast or mastectomy area it may be necessary to also treat the lymph nodes that lie in the armpit and neck. Radiotherapy may be used as a treatment on its own or with other treatments such as chemotherapy, hormone therapy and surgery. Other treatments Surgery If you have had surgery that may have involved removal of the lump or removal of the breast itself, radiotherapy can be used after either type of operation. Sometimes radiotherapy is given before surgery to reduce the size of the lump making surgery easier. Chemotherapy This may be given before or after surgery. It is often completed before starting radiotherapy but may sometimes be given alongside. If you are having chemotherapy alongside radiotherapy your chemotherapy nurse or doctor will ensure you have all the information you need and will see you regularly for blood tests. Hormone therapy Cancer cells removed at the time of your operation may have been tested to see if they respond to hormone therapy. If they do, your doctor may recommend you take hormone tablets to further prevent the cancer returning.

3 Page 3 of 13 The type of tablets you take will depend on your own hormone levels, for example whether or not you have reached the menopause. Usually hormone therapy starts after surgery or chemotherapy. If you are unsure of whether you should be taking these tablets please ask your doctor or radiographer. Treatment schedules Most patients receive their treatment as an outpatient and travel to the department for their appointment. For breast cancer, you may receive between 5 and 25 treatments. This may be daily or on alternate days. A number of factors affect the decision made by your consultant regarding how many treatments you will receive. It may depend on whether you are taking part in a clinical trial. The decision is not a reflection of how good or bad the outcome following treatment is likely to be. Please ask your doctor or radiographer if you are at all worried by this. Transport Most patients arrange their own transport either driving themselves or a friend or relative bringing them to hospital. An exemption parking permit is available on application, valid for the duration of the treatment. Please ask reception on arrival. In some cases, we may be able to arrange hospital transport for you, but we need to know in advance as this will affect your appointment times. There are a limited number of hostel rooms available for selfcaring patients who have long distances to travel. Planning your radiotherapy treatment In order to plan your treatment, a Computerised Tomography (CT) planning scan will be carried out at the Radiotherapy Department at Cheltenham General Hospital.

4 Page 4 of 13 Specialist radiographers carry out all of your planning and treatment appointments. A doctor may not be available at any of these appointments unless you have urgent issues to discuss. Whilst you may have had previous CT scans, we need to scan you whilst you are lying in the position required for your treatment. This scan is used specifically for the planning of your radiotherapy treatment. The CT scan is very quick and will only take about 10 minutes. The radiographers will explain the procedure and ask you to undress from the waist up. They will try to maintain your dignity and keep you covered as much as possible but your breasts or chest will have to be uncovered some of the time. You will be asked to lie on a sloping board on top of the bed with your arms supported above your head. The radiographers will make you as comfortable as possible in this position and will draw some marks on your skin. So that the radiographers can see the location of the marks on the scan, they will place thin pieces of wire over them. The Radiographers will then have to leave the room for a few minutes while you are being scanned but they will be monitoring you all of the time on the closed circuit television at the control desk. Whilst they are out of the room the bed you are lying on will move through the scanner. It is important to remember to breathe normally during the whole procedure but otherwise to keep as still as possible. As the marks on your skin will wash off, once the scan is complete the radiographers will ask your permission to do some permanent tattoo dots. The tattoos are small and look like dark freckles. The tattoos will give the radiographers precise points to accurately align the treatment to.

5 Page 5 of 13 After we have completed the CT planning scan, we will give you your appointments for the course of treatment, but if they are not available someone will contact you as soon as possible. It is therefore important we have all your contact details available. What happens during your treatment? Before your first treatment a radiographer will explain your treatment and its side effects to you, also answering any questions you may have. You may have a relative or friend with you for this discussion Before each treatment you will be called through from the waiting room and may be shown to a changing cubicle. You should remove clothing above the waist and put a dressing gown on, this can be one of ours or you may bring your own if you prefer You will be shown where to sit outside your treatment room When the room is ready for you, you will be taken into the room and asked to remove your gown and lie on the treatment couch as you did during your marking up session The radiographers will cover you up whenever possible to ensure your dignity is maintained The radiographers will then position the couch and treatment machine It may be necessary to draw over the small permanent dots with a pen each time you have treatment so the radiographers can see them when the treatment room lights are dimmed The radiographers may need to move you to line up the marks that were put on your skin during the planning session; this ensures you are in the correct position for your treatment The machines are large and you may find them a little alarming at first. The radiographers will only leave the room to switch the treatment on once you are in the correct position and they are sure you are alright Parts of the machine may come quite close, but you will feel no pain or discomfort

6 Page 6 of 13 Radiotherapy is used to treat the whole of your breast/chest area on the side of the cancer not just the area of the cancer itself. If you had lymph nodes removed from under your arm that also had cancer cells in them, then we may also treat an area at the side of your neck If you have had a mastectomy the radiographers will lay a pad over your chest for each treatment. This pad is called bolus and ensures the skin gets a full dose of treatment A closed circuit television on the control desk means the radiographers can monitor you at all times during your treatment. They also have an intercom system and can talk to you from outside the room The treatment lasts a minute or so and there is nothing to see or feel you will hear a buzzing sound when the machine is on. You should breathe normally The radiographers may enter the room during your treatment to move the machine to the correct position for the next part of your treatment, or the machine may be moved from outside of the room You will be told when your treatment has finished and you can get off the couch. At your first treatment, the whole procedure may take 20 minutes, after that, treatment sessions should take from 10 to 15 minutes It is important that you stay still during your treatment but the radiographers will tell you what to do if you need to cough, sneeze or move during your treatment Once your treatment is completed you may dress and leave the department On certain days of treatment the radiographers will take further images and X-rays. This is to ensure your treatment is accurate. Boost treatments Some patients will receive a boost treatment to the original site of the tumour. If boost treatment has been recommended for you, it is usually for your last 3 to 8 treatments. If you have had a mastectomy you will not need any boost treatments. The boost treatments will be given using the marks made for the CT scan so you will not need any additional marks.

7 Page 7 of 13 Boosts are slightly different to the other treatments in that the radiotherapy is only aimed at the scar on your breast or area where a tumour was removed from, instead of at the whole breast. The boost treatment can give a higher dose nearer the skin surface meaning that area may develop more of a skin reaction. Your boost treatment may be on a different machine but within the same department. Heartspare radiotherapy If you are to receive radiotherapy to your left breast your treatment is planned to avoid your heart this is called Heartspare radiotherapy. You may be asked to hold your breath at intervals during your planning scan and treatment. This will be explained to you in detail when you arrive for your planning appointment. Side effects of radiotherapy Each patient is an individual and may experience some or all of the following side effects to differing degrees. You may find it helps to get plenty of rest and sleep during the course of your treatment, especially if you start to get tired. It is important that you continue with your normal activities and routines as much as possible. Try to find a sensible balance between rest and activity Smoking during the course of treatment may worsen your side effects, so try to avoid this. Cutting down will help you if you cannot stop completely. Please ask a radiographer if you would like extra support with this. Friends and family often offer to help and accepting this can give you support as well as allowing them to feel involved with your treatment. Effects during your treatment Tiredness Some patients notice they feel more tired than usual during the course of their treatment, often after 2 to 3 weeks. Travelling to the department may also add to this tiredness Tiredness can last for a number of weeks after radiotherapy has finished. If you have also had chemotherapy you may find that you feel particularly tired. Some patients find that

8 Page 8 of 13 once their treatment finishes they feel better, but it can take a number of months before they feel back to normal. Skin The skin in the treated area may begin to feel sore or itchy and look pinker or darker as your treatment progresses. You may use your normal moisturiser sparingly - gently smooth it on and apply in the direction of hair growth. Please stop using if it irritates your skin and talk to your treatment team. If you are choosing a new moisturiser one that is sodium lauryl sulphate free is best In a minority of patients, the skin may become very sore and even blister or break. If this happens, stop using any moisturiser and your treatment team will advise you You may use deodorant under your arm on the side being treated and shave using an electric shaver unless the skin becomes sore or irritated You may bath or shower during the course of your treatment but do not have the water too hot or add anything to the water such as oils or bubble bath. Wash the skin gently using soap and pat your skin dry with a soft towel Please ask your radiographer if you have any other queries about your skin care products During the course of this treatment you may wish to wear looser cotton clothing next to your skin to minimise irritation. We recommend that women wear a bra that isn t tight and does not rub the skin this may be a loose softer bra, one without an underwire or a bra top if this is more comfortable than going without a bra If you have had a lump removed from your breast, rather than a mastectomy, you may find the skin in the fold under your breast gets sore. Occasionally the skin here may blister or peel a little. If you have had a mastectomy we may lay a pad over your chest when you have your treatment. This has the effect of increasing the amount of radiotherapy your skin receives and can result in a more severe skin reaction. This can be uncomfortable. Please be reassured that the radiographers are able to help you with this by providing advice alongside alternative creams, gels or dressing

9 Page 9 of 13 Any skin reaction should settle down within a few weeks of your treatment finishing. If you received boost treatment this area may develop slightly more of a skin reaction and can take a little longer to settle down. Throat If we are treating the lymph nodes at the side of your neck you may find that this causes a sore throat or the feeling of a lump in your throat or discomfort on swallowing. You may take pain relief or throat lozenges if needed. Swelling and pain It is quite normal for the treated breast to become a little swollen during radiotherapy. The radiographers sometimes need to adjust your treatment to account for this Often patients notice sensations in the treated area this may be a tingling, shooting pain or an ache. This may be uncomfortable please take pain relief if needed. Do not worry as the pain will settle once your course of treatment is completed. Shoulder The shoulder on the side you had your surgery may still feel a little stiff when you start your radiotherapy. It is important you carry on with the exercises you were given at the time of your operation. Some people notice that the stiffness gets a little worse during radiotherapy. This is possibly due to the position you lie in for treatment. The stiffness will settle following the end of your radiotherapy. Hair loss You will only lose hair if it grows in the treated area such as the hair in your armpit which may fall out and may or may not regrow. Lymphoedema This literally means fluid or water swelling. Lymph is the clear, water-like fluid which we all have inside skin tissues Swelling often occurs after damage to the lymph glands. This can be due to radiotherapy or surgery. Sometimes the fingers, hand or arm can swell on the side of surgery/radiotherapy

10 Page 10 of 13 Some patients may have had fluid drained from their breast or surgery site before starting radiotherapy but you may find the fluid returns during radiotherapy. If this happens do not worry, your radiographer will advise you on what to do There is information available about lymphoedema and if necessary we can refer you to a lymphoedema specialist. If you have any concerns, however small, please speak to your radiographer or doctor Lymphoedema may also occur in the future after treatment has finished. You will be seen at intervals in the review clinic to assess your side effects and give you a further opportunity to ask questions and discuss any concerns you may have. These appointments will be with a specially trained radiographer. You may also need to see a doctor during the course of treatment; your radiographers will arrange this. Effects after treatment Your doctor will have discussed with you the possibility of potential long-term side effects occurring after your treatment has finished The likelihood of these happening is often small and the advantage of receiving radiotherapy is believed to outweigh the risks of long-term problems. Skin colouring You may find that the area treated may always appear slightly darker than before treatment. This is not usually very noticeable. There may be the appearance of tiny red veins in the treated area, particularly if you ve had a mastectomy. This is called telangiectasia. Avoidance of sun exposure Once an area of the body has received radiotherapy it will always be more sensitive to the sun. We advise that you avoid exposing the treated area by covering up or using a high factor sun lotion in the future.

11 Page 11 of 13 Breast shrinkage It is possible that the treated breast may in future be slightly smaller than it was prior to surgery and radiotherapy. Please ask your consultant or radiographer if you have concerns about this. Tenderness Some patients notice that the breast remains tender or feels heavier for some time after the radiotherapy has finished. This is because healing after radiotherapy can be a slow process. More serious but rare side effects Damage to: the lungs (causing breathlessness) the ribs (making them fragile) the heart (if treatment has been given to the left breast). These occur in a very small percentage of patients. We take great care to treat as little of your lungs and heart as possible. It is extremely rare for treatment to damage the nerves (brachial plexus neuropathy), which may cause numbness, pain and weakness in the arm and hand. Finally, it is important to stress that the side effects mentioned are possible effects and that you may not experience all of them. After your treatment has finished On the day of your last treatment the radiographers will give you specific advice on what to do now your treatment has finished, including how to manage any side effects and what to expect. You will be also be given your first follow up appointment. This may be at Cheltenham General Hospital or at a hospital closer to your home and is usually between 4 and 8 weeks after your radiotherapy finishes. This time is given to allow the treatment to continue working, side effects to begin to settle and for you to recover.

12 Page 12 of 13 You will be seen by your oncologist or a member of their team who will want to check that your side effects are settling down and discuss with you what further appointments are needed. Most of the side effects that you experience from your radiotherapy treatment will take a few weeks to gradually settle down. Some people notice they initially worsen for a short while. Please do not worry as this is quite normal. Tiredness can take a while to pass. Most people find they notice a gradual improvement in how they feel in the days and weeks after treatment has finished. Although all patients are glad to have finished their course of radiotherapy it is quite normal to feel anxious as to what happens next. If you have any worries regarding your treatment or side effects you can phone the radiographers who treated you. You can also contact your GP if you have any other worries concerning your disease and / or treatment. Contact information Radiotherapy Reception Tel: Monday to Friday, 8:00am to 5:00pm Radiotherapy Appointments Tel: Monday to Friday, 10:00am to 3:00pm Your treatment machine: Telephone number: Your treatment team:

13 Page 13 of 13 Further information FOCUS Cancer Centre Oncology Outpatients Department Cheltenham General Hospital Tel: Open Monday to Friday, 8:30am to 4:30pm As well as information on treatments and support groups, the centre advises on how to obtain wigs and can supply scarves and turbans to patients, as well as a list of companies who may be able to help with holiday insurance. They also sell herbal sweets for nausea. Complementary Therapies Aromatherapy, massage and reflexology are available to patients and carers. The charity Look Good Feel Better run monthly beauty sessions at the centre for women undergoing treatment for cancer. Appointments can be booked through the information centre. Maggie s Cancer Caring Centre The local Maggie's Cancer Caring Centre is located close to Cheltenham General Hospital and offers support services. For further information visit the website, call or pop in to see them. Maggie s The Lodge Cheltenham General Hospital College Baths Road Cheltenham GL53 7QB Website: Tel: Content reviewed: November 2015