This is a section from the Book, What To Do If You Get Breast Cancer by Lydia Komarnicky, MD, Anne Rosenberg, MD with Marian Betancourt

Radiation Therapy

Radiation is standard procedure following a lumpectomy, to wipe out any remaining cancer cells from the tumor site. If you have a lumpectomy, you probably have no detectable cancer left, but there may be microscopic disease left in the lumpectomy site. Even if the surgeon says, "I got it all," experience shows it is difficult to "get it all" with any real degree of certainty.

In cases of extensive cancer, radiation might also be used with mastectomy. Then it treats the chest wall or the chest wall and skin after mastectomy and reconstruction to reduce the chance of recurrence. Radiation is also used to treat Iymph nodes under the arm, beneath the breastbone, or above the collarbone, when the cancer has spread. Depending on the type and extent of your cancer, radiation may be used with chemotherapy or surgery or both.

Generally, if you have a single small cancer no bigger than 1~/2 inches in diameter (about the size of a peach pit or a Ping-Pong ball), you can probably save your breast with lumpectomy and radiation treatment. Radiation to the breast can be given safely and accurately with an excellent cosmetic result in at least 90 percent of patients treated. In other words, your breast will look and feel very much the way it does now.

Once it has been decided that you may keep your breast, you must weigh the pluses and minuses of each treatment and consider how important it is for you to keep your breast. You are empowered to make that decision. But feel assured that keeping your breast does not mean your treatment is less effective than mastectomy.

Radiation is meant to mimic mastectomy. Mastectomy removes the whole breast. Therefore, the entire breast is treated with radiation, usually for five weeks, or twenty-five times. At the final phase, treatment is localized to the tumor bed. It is not standard therapy to treat only the tumor area.

Radiation treatment after a lumpectomy (and usually a Iymph node dissection) for early breast cancer is just as effective as mastectomy in preventing the tumor from coming back where it was. This is accepted scientific fact! Yet some patients and even some doctors still have a hard time understanding this.

There is still a strong belief that the breast must be removed to get all the cancer out. But it has been proven over and over -in radiation and surgical literature, including surveys by the National Institutes of Health-that lumpectomy followed by radiation has the same cure rate as mastectomy. We cannot stress this enough!

How Long Has Radiation Treatment Been in Use?

Radiation therapy has been around for a hundred yearssince the discovery of X rays and radium. In fact, breast canc~ was one of the first types of cancer to be treated with radi~ tion. But in the early years only low-energy equipment e' isted, leading to a high complication and low cure rate. Du ing the following years, especially after the 1940s, great strid~ were made in the development of equipment for treatir cancer. Eventually, powerful high-energy radiation machines in proved cure rates, and complications decreased.

Since the 1960s, developments in electronics and compu ers have led to some amazing equipment for diagnosing ar treating cancer patients. Normal tissues can now be visualiz~

in relation to cancer in three dimensions. The treatment area can be aligned and positioned for the highest accuracy.

Lumpectomy with radiation has been used to treat breast cancer for the past thirty years. However, it is still more commonly used in the northeastern United States than other areas.

How Radiation Works

Radiation has two functions: to cure cancer and preve~ return, and as a palliative treatment-that is, to kill pai~ slow the progress of the disease if it has metastasized t~ bone, liver, or brain. It can be used by itself or in combin with surgery, either before or after. Approximately 5( 1,000 times more energy is used in radiation treatment with regular X rays. Thi,s high dosage from high-energy e ment kills all the cells ~ts path, good and bad, so cannot grow and multiply. However, new, healthy cell replace those lost.

Before Beginning Radiation Treatment

Before your surgery, you will have had a series of tests t whether the cancer has spread. These may involve a chest 2 blood tests to check your red and white blood cell and h globin counts, and to determine whether blood liver en2 are elevated, which could be an early warning of cane other parts of the body. A bone scan may also have been

Your radiologist will review results of all these tests, a' as the tissue slides from your biopsy and your mammc films. She or he will need to know your medical histor find out if you've had radiation before. Your breast w physically examined many times in the process. Then yo your doctor can discuss your treatment.

Who Should Not Be Treated with Radiation?

If you have had radiation in the past, or if your canc~ calcifications are widespread in your breast, or if you ha large tumor in a small breast, radiation may not be the treatment. For example, removing a large tumor from a s~ breast would involve too much resectioning to restore contour of the breast. Cosmetic results would generall~ poor in these cases.

So, radiation therapy might be inappropriate in these cumstances:

• If you have had radiation to the same breast radiation to the other breast in the past. Past would not rule you out.
• If you have had radiation treatment for Hodgkin's disease or have a connective tissue disease like scleroderma, or lupus.
• If you have very large breasts, which may result in less satisfactory cosmetic results with radiation. These patients tend to have some shortening and contracture on the treated side.
• If you have multiple tumors in several areas of your breast.
• If you have extensive calcifications in your breast.

Preliminary Steps: Simulation and Planning

As mentioned, radiation is standard procedure following I ectomy and/or Iymph node dissection. Sometimes it i~ given after a mastectomy to make sure all the cancer cell might have lingered on the chest wall or skin are wipec

It's common to wait two weeks after surgery for skir tissue to heal so there is no onenine in thc~ inricir~n 1

beginning radiation treatment, because radiation can slow the healing process. During that waiting time it is important to exercise your arm so that you have good range of motion before beginning the simulation process. Your surgeon or radiation therapist will show you exercises to do at home.

Your first visits (usually three) to the radiation treatment center will be for simulation, a process of measuring and marking-usually with an ordinary felt-tip marker-the precise area to be treated. You may be asked not to wash off the marks for a day or two. The technicians will have you lie on a table with your hand over your head (this is one reason the arm exercises are important) and make sure that you are in the correct position so the oblique beam will treat the breast and not the arm unnecessarily.

You may also be fitted for an alpha cradle, so that each time you lie on the table for treatment, you will be in exactly the same position. This cradle is molded by filling a large plastic bag with a liquid material that solid)fies to fit your body contours. Such immobilization devices are not used everywhere. Some hospitals simply use a wedge under your body.

Your physician will probably take Polaroid photos of your breast several times during the process. Such documentation helps follow any changes in the size and appearance of your breast.

A CAT scan may be necessary in the treatment-planning process so that a two- or three-dimensional picture of your breast can be re-created in the computer. This helps the radiologist decide exactly how the radiation will penetrate the breast to avoid exposing too much tissue around your rib and lung.

The next visit is usually for an X ray on the same machine where you will be treated. This documents the treatment area. After the X ray, tattoos will be placed on your breast to mark the pathway for the radiation beam. This does not hurt. The tattoos are permanent, but they are so tiny that you'll hardly notice them. Usually about a dozen tattoos are placed, but this can vary from one institution to another.

However they are done, these markers guide the doctors and technicians in directing the radiation to the proper spot. The radiation will treat you from your collarbone to the fold under your breast and from your breastbone to an area near your underarm.

Minor adjustments may be necessary periodically during your treatments if your breast has swelled. Don't be alarmed. This is only to ensure accuracy. During the treatment period, your radiation doctor will see and examine you and check your dosages. Breaks in treatment may be necessary if your skin becomes irritated too quickly.

If you have any Iymph nodes that have tested positive, your underarm may also be treated.

How Often Do I Receive Radiation and How Long Does It Take?

You will be treated daily from Monday through Friday for fivf to seven weeks. It takes five weeks to treat the whole breas~ and then two more weeks for the boost, a dose of radiatior directed into the tumor bed.

Your daily treatments last less than five minutes and ar~ administered by highly trained and state-licensed technicians With your upper body bare, you will lie down in your cradl' and the technicians will set up the machinery and administe the dose of radiation.

Radiation therapy is strictly regulated by federal and stat' nuclear regulatory commissions. The total dose of radiatio~ delivered to the breast at most institutions is between 4,50 and 5,000 reds, or cGy, which means centigrays. The dail dose will be between 180 and 200 cGy. A boost dosage of aadditional 1,000 to 2,000 cGy is delivered directly to th tumor bed in the last part of the treatment. Dosage varies wit the philosophy of the institution. It is believed, however, th~ a total dose to the tumor bed should be in the range of 6,00 to 6,500 cGy. Increasing the dose beyond this increases cor~ plications, and cosmetic results are not as good.

Your doctor will visit you periodically to monitor your tree meet. At least once a week your doctor should also examir your breast thoroughly and see how you are feeling. She or may also photograph your breast to keep a record of yo, progress.

Does Radiation Treatment Burn?

No. It's painless. You may feel some discomfort Iying in the cradle, or in the particular position you must maintain while the radiation is penetrating. Technicians will help you lie down. They will set up the machine to the proper angle. They will look at you once or twice from the computer monitor to be sure you are correctly positioned. Then they will ask you to lie still while they turn on the machine. It is just like getting an X ray. You won't feel a thing. The radiation is sent into your breast for only a few seconds, although you may be in position for five minutes or more. After one to two weeks of treatments your breast may swell and the skin in the treated area may redden, turning any shade from slightly pink to deep red.

What Is the Boost?

The boost is the final phase of radiation treatment, u given during the last two weeks. A boost delivers a d~ radiation directly to the tumor bed. There are two ways this: externally, using the radiation machine, or interna implanting radioactive pellets in your breast. Cost an~

External boost. Most women get the external boost, because not every radiation oncologist has the experience to do implants. As was mentioned in the surgery chapter, small metal clips- like staples-are inserted at the margins of the surgical bed (the edges of the area where the tumor was) during the lumpectomy. Don't worry, these clips won't set off metal detectors at the airport! But they will remain in your body forever. These clips define the tumor bed to help the radiation oncologist determine where to deliver the boost. When a CAT scan is done as part of the treatment planning, these metal clips can be seen on the scan and a final radiation field can be very accurately placed, based on their position. The boost dose uses the same type of radiation as your previous treatments. It is just more focused.

The interstitial implant is used more often at university hospitals. It is not a new procedure, nor is it any more or less effective than the extemal boost. While you are in surgery for your lumpectomy, your radiation oncologist will insert small, hollow plastic tubes in your breast tissue where the tumor was- the area surrounded by the clips. These are conduits for radioactive pellets that are placed the day of surgery and provide the local boost dose. The pellets are left in place for about forty-eight hours and removed before you leave the hospital. Then, two weeks later, overall radiation treatment of the breast starts.

The amount of the radiation dose with the implant is usually the same as with the external boost. Once the boost dose is delivered, the implant can be removed in your room without anesthesia in about ten minutes. However, you are considered radioactive for the forty-eight hours the implants are in your breast. This will not cause sterility or affect any part of your body, but the number of visitors to your room will be limited. Since the isotope is emitting some low-energy X rays, no children under eighteen or pregnant women can come to your room. Other visitors can stay for an hour. Some hospitals place a waist-high lead shield at the side of the bed for the protection of nurses who often deal with radiation and try to limit their exposure. Once the implant is out, there are no restrictions.

The tubes are removed as easily as sutures are removed. This may cause some local discomfort during the removal process. Usually an analgesic such as acetaminophen and codeine is suffficient to alleviate this local discomfort

Can I Continue to Work While Getting Radiation Treatment7

Most women do, and if you can schedule treatment for mornings or late in the afternoon, you can work with little interruption to your day. It is always best to lead as normal a life as possible during the weeks of treatment. However, radiation can make you tired, so don't expect to function at your full capacity. Rest when you need it.

What Side Effects Can I Expect?

Most women have no problem receiving radiation t, breast. The most common side effects are:

• itchy, dry skin in the treatment area
• reddened skin (mild to deep red)
• breast swelling
• blisters under the breast where the bra rubs

All are temporary and are treated with mild creams and sometimes a break in treatment.

Breast swelling usually resolves itself in up to six months in most women. This is related to the extent of the Iymph node dissection and occurs to some extent in most women. This is usually a short-term condition.

How Can I Offset These Side Effects?

Here are some things you can do to feel more comfortable.

• Avoid shaving your underarm on the treatment side.
• Don't use antiperspirant, deodorant, or powder on that side.
• Do not use creams or solutions that contain perfumes, alcohol, or aluminum or other metals.
• Use a mild, aloe-based cream after treatment to soothe dry, itchy skin.
• If blisters form, ask your doctor to recommend treatment for this.
• Wear soft cotton clothing and go braless as often as possible.

Are There Any Long Term Effects of Radiation.?

With careful treatment planning and appropriate doses, fewer than 5 percent of patients experience any long-term side effects, such as rib fracture, a scar on the lung, or inflammation of the lung. Some people are more sensitive than others to radiation, and a future trauma, such as a fall or an auto accident, could cause a rib to fracture more easily than it would normally. There is no way to prevent this, but always X-ray any injury to your chest or ribs.

A few women have developed a sarcoma, a tumor of the soft tissue of the breast, as a result of treatment, but most of these women had been treated on old, low-energy equipment. There is no way of knowing if the malignancy was already developing in their breast, or if it developed because radiation injured the underlying soft tissue of their breast.

When radiation hits the part of the lung directly under the chest wall, it can leave a scar on your lung. This part of the lung needs to be included in the radiation field to make sure all of your breast is treated. This scar shows up in X rays in about 5 percent of patients but is symptomatic in less than this. Someone reading your chest X ray might think you had had pneumonia in the past. Careful treatment planning with CAT is important to minimize the amount of lung area in the radiation field.

Radiation's effect on the heart is extremely rare. It occurs in less than 1 percent of patients, and only if the heart is
directly within the radiation field. It could cause some scarring or possibly increase the risk of atherosclerosis.

The risk of getting cancer again as a result of radiation is negligible. There is no evidence that radiation on one breast will increase the risk of breast cancer on the opposite side. Nor is there any evidence that it increases the risk of any other cancer, such as Iymphoma.

If you are receiving chemotherapy with certain cytotoxic drugs, such as Adriamycin or methotrexate, at the same time as radiation, your skin may react to radiation more intensely and this could result in a less than perfect cosmetic effect. But these drugs can be omitted while you are receiving radiation treatment.

If Iymph node areas are treated with radiation, there is a possibility of damage to the nerves underlying the arm, but this is also rare. Tingling sensation and weakness can occur in the arm and hand. Another risk of treating the underarm Iymph node area is the increased likelihood of arm swelling, or Iymphedema. There is a 20 percent risk of swelling as a result of radiation, and it may become a long-term condition. However, it can be treated and kept in check so that it does not disrupt your life-or your appearance. (See Chapter 14.)

What Will My Breast Look Like After Radiation?

With state-of-the-art radiation equipment, 90 percent of E tients believe their breast looks and feels similar to the u treated breast, though the treated breast usually seems sligh~ firmer. As one fifty-year-old woman quipped, "Now I have twenty-year-old breast and a fifty-year-old breast!" The majc ity of patients report excellent cosmetic results.

It may take as long as a year for the breast to return to i normal state. It may remain slightly red for a few months, ar larger than normal. As mentioned earlier, cosmetic resul depend largely on how much breast tissue is removed. If large tumor is removed from a small breast, the cosmetic results can be less satisfactory, because a greater proportion of the breast will have been removed.

With any size breast the cosmetic results can be less than satisfactory if too much of the tissue has been removed. That is why it is so important to find a surgeon with experience in treating breast cancer. Determining just how much tissue to remove without compromising either your recurrence rate or the cosmetic result requires precision and sensitivity.

What Follow up Care Will I Need?

When radiation therapy is completed, expect to have a ~ tine checkup within two months. This will include phys examination of the breast to check the aftereffects of tr meet. Then visit your radiation oncologist at regular month intervals for five years.

You should also see your surgeon at six-month intervals, be sure to stagger your appointments so you receive a br. examination every three or four months. You may also al nate with your medical oncologist if you are taking horm' or cytotoxic chemotherapy. This close follow-up proced continues for five years, while the potential for recurrenc highest. After that you visit everyone-radiologist, onc~ gist, surgeon-annually.

Six months after completing radiation therapy you sho have a bilateral (both breasts) mammogram. The mamr gram of the treated breast will continue at six-month inter\ for two years and then once a year. The mammogram of untreated breast can continue at regular yearly intervals.

Ask your radiation oncologist, your surgeon, or your me cal oncologist if you will need a bone scan at yearly interv; along with tumor marker studies, including a CA15-3 a CEA. These are blood tests that detect certain antigens m~ by tumor cells. Routine pelvic and rectal examinations your gynecologist are also important. You may want to se/ physical therapist if you need more mobility in your arm. Al always, always do your monthly breast self-exams.

Obviously, the extent and frequency of follow-up testing depend upon the extent and degree of your breast cancer. A11 of this testing may turn out to be negative for the rest of your life. And in the majority of early breast cancer cases it does. But the point is, never leave it to chance. If you monitor your health, you will find any recurrence early enough.to treat it and save your life.

How Do I Find the Best Place to Have Radiation Therapy?

Radiation therapy is most often done in big city hospita teaching hospitals, and comprehensive cancer centers (hos tals that treat only cancer); and it is more commonly done the Northeast, although excellent centers can be found in parts of the United States. There are many ways to find radiation oncologist and radiation center. Your physician cc refer you, or you can call the American Cancer Society, tl National Cancer Institute, or the American College of Rac ology. Support groups, libraries, and hotlines are also goc sources of information. (See Appendix 4.)

Big city teaching hospitals and comprehensive cancer cel ters often provide better treatment because they treat so mar more patients, attract more experienced physicians, and u~ up-to-date equipment. Ask if a simulator is available for tree ment planning, along with a high-energy 4-6 megavolt phr ton beam with electron capability. You'll want to know th' there is a CAT scanner available and a physicist on staff t handle problems that may arise with the equipment. If yot surgeon does not feel the need to send you to a radiatio oncologist experienced in breast cancer, it may be wise t go find one yourself. You may feel better with a second opir ion. Call the breast cancer information groups listed in AF pendix 4.

Look around. The treatment is not an emergency. So move with deliberate speed, and don't make any snap judgments based on emotions. Learn as much as you can first, so you will feel more comfortable and be ready to make an educated decision. Take a friend or loved one with you on interviews and consultations. Take notes. Bring a tape recorder!

What Does Radiation Therapy Cost?

A complete program of radiation therapy for breast cance cost as much as $30,000 in a large medical center ir Northeast. This includes treatment planning and shirt' treatments. Most of that is a technical fee, and about a is the professional fee. Most medical insurance covers cost. Medicare covers 80 percent of the cost and Med covers it all.

Questions to Ask Before Deciding on Radiation Therapy

These questions are meant to help you interview physicians and other healthcare professionals so that you can feel secure about your treatment decisions. Some of these questions have no clear-cut answers, some do. But ask anyway! For instance, you don't need to understand how the machinery works, but there are manufacturing standards. Most hospitals conform to these standards, but sometimes there are exceptions. Take this book with you and ask the questions you want to know about. It is your responsibility to get the best treatment you can. So don't be bashful!

Do you have high-energy machinery (4~6 megavolts) with electron capability?

If the machinery is new, it probably meets these standards; however, it is still wise to ask.

Do you have CAT simulation and planning and a physicist on staff?

If the answer is no, it means they cannot get the optimum precision required for applying radiation to your breast.

Is the radiation delivered by licensed technicians?

Radiation technicians must be licensed by the state.

What is the dosage of radiation used for breast cancer?

It should be somewhere between 4,500 and 5,000 ra

What type of boost will you use?

Electron (external) boost and implant (internal) boost are equally effective, but not all hospitals are equipped to handle the internal boost.

How often will I see my radiation oncologist during the course of treatment?

At least once a week during the course of treatment for a thorough visit. But a resident or attending physician should be available to you anytimeyou need one or have a question.

How long will I have to wait for treatment every day?

Scheduling should be done so that you wait no longer than half an hour, and more commonly, only a few minutes.

May I see some photos of other women who have been treated here?

There should be no objection, because faces are not usually photographed and no privacy is invaded. Look at the cosmetic results; note any deformity, skin changes, asymmetry with the other breast, and placement of incisions.

What kind of follow-up care can I expect?

Be sure the reatment center provides thorough follow-up care. Ask if they include blood tests like the CA15-3 and CEA. These test for antigens in your blood that may indicate remaining cancer cells.

Will my insurance take care of simulation and planning, treatment, follow-up care, and ny related expenses?

It's very important that you understand the cost of everything, so that you don't get billed later for things like the cost of making the cradle,or find out that your insurance does not cover follow-up exams. Always check with your insurance company, too.