Oxford University Hospitals NHS Trust The Radiotherapy Department Radiotherapy to the chest wall and lymph nodes Information for patients
Introduction This leaflet is for people who have had surgery for breast cancer and have been recommended to have treatment with radiotherapy to the chest wall and lymph nodes Breast cancer is more common in women but can affect men. The General Radiotherapy Leaflet will explain what having the treatment involves, common side effects and some general information about the department. The leaflet Radiotherapy to the chest wall and lymph nodes will provide more detail, specific to the type of treatment planned for you and how you can help yourself during and following treatment. It is intended as a guide because the timing and effects of treatment may vary from one person to another. This leaflet will highlight the key points of the discussions you will have had with your doctor and treatment team. Family members and friends may also find it helpful. Treatment plan There is a small chance of a recurrence in the area of the chest wall where the breast used to be, after a mastectomy. The size of this risk depends on the extent of the initial cancer, and in some cases radiotherapy is recommended to reduce the risk to the smallest possible extent. Trials have shown that this is an effective treatment to minimise the chance of having any problems from recurrence of the cancer in the chest wall area. If chemotherapy is also recommended the radiotherapy is usually given after the chemotherapy has been completed. The extent of surgery carried out in the armpit area varies with each person. When the tests show that the cancer has spread to the lymph glands removed at surgery, there may be a need to treat the remaining lymph glands with radiotherapy. This will page 2
depend on the size of the surgery. The aim of such treatment is to prevent the recurrence of the cancer in any of the lymph glands which have not been removed by your surgeon. The position of patient on couch during treatment A tattoo page 3
Side effects Radiotherapy treatment is painless. However, there are some side effects which are associated with radiotherapy and you may notice one or more of them gradually developing over the course of treatment. Please note that it is rare for one patient to experience all of these side effects. If anything is worrying you, however small, during your treatment, please tell your therapy radiographer or radiotherapy nurse practitioner, either at your visit or by phoning the department. Lung Heart Liver page 4
Skin Almost everyone will experience some skin changes in the area being treated, which can vary from mild pinkness and itching (similar to mild sunburn), to quite marked redness and blistering. For most the extent of the irritation is mild and can be effectively eased with the use of aqueous cream. More detailed advice can be found in the General Radiotherapy Leaflet to reduce this reaction. The more severe reactions are uncommon and the radiotherapy nurse practitioners will assess the reaction and provide appropriate dressings and lotions. If your skin is very sore at the end of treatment, then a district nurse will be arranged to help you with skin dressings. Sometimes your skin reaction may worsen after your treatment has finished. During treatment wear loose fitting clothing preferably in natural fibres eg cotton, which are more comfortable and less irritating to the skin. Shoulder straps from vest or bra or wired bras can cause irritation if they rub against the skin. If your breast area is being treated, you may be more comfortable not wearing a vest or bra. Ladies may prefer to wear a soft, non wired, cotton bra, wearing a cropped top or vest or using some soft padding within the bra. Tiredness You may feel tired especially toward the end of a course of treatment. Listen to your body and if necessary allow yourself extra time to rest. You can continue working if you want. Gentle exercise and drinking more fluids can help reduce the tiredness too. The tiredness wears off over a few weeks once the treatment ends. Pain Some people do experience discomfort or describe the breast and treatment area as feeling different. Occasionally it becomes swollen during treatment. It may be a sharp pain post surgery page 5
and related to the re-growth of nerves. This is usually a mild symptom and can be treated with mild pain killers if needed. Nausea (feeling sick) It is rare to experience nausea during this treatment, but if it happens is usually mild. You may wish to try eating and drinking small amounts a little more often than usual. The side effects you have experienced during treatment may become worse for a short while after treatment finishes, and slowly settle over the next few weeks. Please do not worry as this is quite normal. During this time you should continue to follow the advice you have been given during your treatment. Continue to take any prescribed medication for the side effects until they settle down. page 6
Possible long term side effects Long term side effects can occur many months to years after radiotherapy has finished. These late side effects are hard to predict and unfortunately if they do occur can be permanent. In most people these effects are mild and do not interfere with everyday activities. However a small proportion of people (less than 1 in 10) develop more marked effects which can be troublesome. It would be extremely rare for someone to develop several of the side effects. We plan the treatment to avoid the surrounding areas around the tumour as much as possible to reduce these side effects. Skin You may notice dilated capillaries (tiny blood vessels) under the skin. This is called telangiectasia. It can look displeasing but doesn t cause problems. This occurs in less than 10 in 100. Chest wall The chest wall area may become firmer to the touch compared to the surrounding untreated skin and muscle in about 30 in 100. The change is marked in less than 10 in 100. Shoulder movement Some restriction in the range of shoulder movement may occur on the side which has been operated on or received radiotherapy in about 10 in 100 of women. This is marked in less than 5 in 100. Your breast nurse practitioner will give you a leaflet of helpful exercises. These and using your arm normally will help keep your shoulder more flexible. Lymphoedema Some swelling of the arm (lymphoedema) may develop in less than 20 in 100. It is caused by scar tissue which may form after an operation in the armpit or radiotherapy to the armpit. Lymphoedema is marked in less than 5 in 100 and can be managed with combinations of exercise and massage as advised page 7
during radiotherapy. In severe cases, help from a specialist lymphoedema team can be obtained. Lung Up to 10 in 100 develop dry cough and breathlessness due to the effect of radiotherapy on the lung. This is due to inflammation of the lung (radiation pneumonitis). It usually occurs one to three months after radiotherapy. It usually gets better within two to four weeks without any treatment or it may be treated with a short course of steroids. This condition usually resolves so the symptoms are often temporary. Occasionally radiotherapy can also affect the cells lining the lungs causing a hardening and thickening (fibrosis) of the tissue, which can cause some degree of breathlessness in a small amount of patients Every effort is made to limit the amount of lung included in the treatment area to minimise this risk. If this happens please contact your doctor. Bones Radiotherapy can make bones brittle and more likely to break. With this treatment the bones at risk are ribs. Rib fracture is very rare (less than 5 in 100 of women), but is painful. A fracture usually heals without any treatment. Occasionally healing is delayed and pain persists. This happens in less than 1 in 100. You should speak to your family doctor if you feel you have damaged a rib in some way. Heart Radiotherapy to the left breast may include a small amount of heart tissue and make a person more susceptible to heart disease. Every effort is made to exclude the heart from the treatment area to minimise this risk. The risk of a heart attack is estimated to be less than 1 in 100. If you experience any symptoms please contact your family doctor. In an emergency please attend the Emergency Department of your local hospital. page 8
Nerve damage Damage to the nerves supplying the arm (brachial plexus neuropathy) is a rare and serious side-effect. It can cause pins and needles, numbness, pain and weakness (paralysis) in the arm and hand. These changes occur in less than 1 in 1000. If this happens please contact your doctor. Second malignancy Radiotherapy is associated with a small risk of developing a second cancer many years later. This risk is much less than the risk of not treating the tumour. page 9
How to contact us If you have any queries during your radiotherapy please do not hesitate to ask a therapy radiographer treating you or contact the radiotherapy nurse practitioner on 01865 235472 during normal working hours or Oxford triage assessment team on 01865 572192 out of hours. Following treatment you can contact Breast Nurse Practitioners 01865 235773 (Mon- Fri 09:00-17:00 / answerphone) Helpful Webpages Breast Cancer care Helpline on 0808 800 6000 (text relay: 18001) Monday to Friday 9am - 5pm Saturdays 9am - 2pm The Helpline is a free and confidential service staffed by experienced nurses and specially trained workers with a personal or professional experience of breast cancer. You could also use the nurse email system. Helpful leaflet: Radiotherapy for primary (early) breast cancer (BCC26) Macmillan website Helpline 0808 808 00 00 www.macmillan.org.uk Helpful leaflet: Fatigue page 10
page 11
If you need an interpreter or need a document in another language, large print, Braille or audio version, please call 01865 221473 or email PALSJR@ouh.nhs.uk AuthorsT Rees, B Lavery, S Oliveros, G Stoker, S Smith Version 2, June 2012 Review, June 2015 Oxford University Hospitals NHS Trust Oxford OX3 9DU www.ouh.nhs.uk/patientinformation OMI 4518P