Facing Radiation Therapy for Breast Cancer After Breast-Conserving Surgery

Authors:
Lydia Komarnicky, MD
Pramila Rani Anne´, MD
Barbara Levy, R.N.

Department of Radiation Oncology
Bodine Center for Cancer Treatment
Thomas Jefferson University Hospital

Table of Contents

• Introduction
• Breast-Conservation Therapy
• Boosting Your Treatment
• Treatment Planning
• Radiation Treatment
• Your Radiation Therapy Program
• Radiation Therapy and Your Personal Care
• Protecting Your Skin From the Sun
• Guarding Against Infection
• Helping You Stay at Your Best During Treatment
• Exercise #1
• Exercise #2
• Exercise #3
• Exercise #4
• Meeting Special Needs
• After Your Treatments are Over
• Resource Personnel

Introduction

One out of eight women in the United States will develop breast cancer. The good news is that there are a variety of treatment methods available to help fight this cancer. You have chosen radiation therapy treatments after your breast-conserving surgery.

To help prepare you for your radiation oncology care at Jefferson's Bodine Center, we have developed this booklet to explain your radiation therapy. We want you to understand what to expect during your radiation therapy planning, treatment and recovery.

In addition to this booklet, we offer a video presentation that further explains what you will experience as a patient in the Bodine Center. We suggest you view this program, just ask one of our staff members to arrange for you to see it. This presentation will help you understand more about our facilities and the equipment used in your treatment.

The staff at the Bodine Center realizes that each cancer patient has special needs. That's why we encourage you to talk to us about them and to discuss with us any questions you have that are not answered in this booklet.

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Breast-Conservation Therapy

Breast-conservation therapy is one of the newer ways to treat breast cancer. With breast-conservation therapy you will have a lumpectomy (removal of the tumor), a lymph node dissection and radiation treatments. Following your lumpectomy, we will treat your entire breast with radiation for approximately five weeks. The lumpectomy site will receive a higher dose of radiation, called a booster dose, than the rest of your breast. This booster dose is delivered either through radiation implants or by external radiation. Your surgeon and radiation oncologist will decide the best type of booster dose for you, based on where the tumor was located and other findings at the time of surgery.

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Boosting Your Treatment

• Boost with Radiation Implants

Some women can have a radiation implant at the time of their lumpectomy. Small hollow tubes are placed in the breast tissue and are later filled with radioactive pellets. The number and location of the tubes depend on the size and location of the tumor that was removed.

After surgery, we take X-rays and a CT (computed tomography) scan to make sure the tubes are in the correct position. A CT is an X-ray seen in cross section that gives your doctor an accurate view of your internal tissues and organs. While you are recovering from surgery, the radioactive pellets are placed inside the tubes in your breast. This is a painless procedure, and you won't feel anything while it's being done.

The implant usually stays in place for 40 to 60 hours, to deliver the radiation dose. You'll need to stay in the hospital for about three days while you're receiving the radiation.

While the implants are in your breast, certain people will not be allowed to visit you. This includes pregnant women and people under the age of 18. These restrictions are necessary to limit the amount of radiation babies and young people are exposed to.

Your breast may be sensitive around the area of the implant, but you should not feel pain. A nurse from the Bodine Center will visit you daily and go over the exercises that you will be asked to do in the two-week interim before starting your five weeks of external radiation treatments.

The implant is removed once the prescribed radiation dose is delivered. No anesthesia is required for this. Removing the implant takes no longer than 10 minutes and is done right in your room. Once the implant is taken out, you may go home at the discretion of your surgeon.

The number of radiation treatments you'll need depends on the stage of your cancer, but is usually 25 to 35 treatments. Before your radiation therapy begins, you must come to the Bodine Center several times for treatment planning.

 

• Boost with External Radiation

Some women are not candidates for a booster dose with an implant because of the location of the tumor and how much breast tissue was removed during surgery. For those who aren't, the booster dose is delivered by external radiation instead. This is usually done after your entire breast has been treated with radiation for about five weeks.

Your external radiation therapy will begin approximately two weeks after your lumpectomy. The number of radiation treatments you'll need depends on the stage of your cancer. Before your radiation therapy begins, you must come to the Bodine Center several times for treatment planning.

Following your five weeks of external radiation to your entire breast, you will receive a booster dose for the next two weeks. Your scheduled treatment time will remain the same each day for the duration of your radiation therapy program.

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Treatment Planning

• What is Treatment Planning?

Treatment planning helps us create an individual, customized radiation therapy program for you. During treatment planning, we do technical calculations to help us develop your treatment plan.

Treatment planning requires two to three sessions; please allow about two hours for each of these sessions. During this time you will become acquainted with our staff, facilities and the medical equipment used during your therapy.

• Your First Day of Treatment Planning

A radiation oncologist will decide the best way to position your body for treatment. An upper body foam mold may be made to help keep you in the correct position during the course of your radiation therapy. This serves as a cradle to rest and support your back and upper arm during therapy. The foam mold feels much like a pillow filled with liquid, which becomes warm, then hot, and finally solidifies to the contour of your body.

Once you are in the correct position, your breast area is marked with a temporary dye that indicates the exact treatment area. We suggest you do not wear your best clothing or undergarments, as this dye will stain clothes. You may prefer to wear a white T-shirt under your clothing or a hospital gown to prevent damaging your clothing. Bring along a scarf in the event the markings extend to your neck. This way you may cover these marks if you wish.

It is important that you do not wash off the dye markings until you are told to do so. You may take sponge or tub baths, but you must keep this area dry.

After these temporary marks are made, a CT scan of your body is taken. You may have X-rays taken as well.

We enter the results from these studies, measurements and calculations into a computer and generate your treatment plan. The treatment plan helps your physician determine how to best position the treatment machine during your therapy.

• Your Second Day of Treatment Planning

While your first day of treatment planning is devoted to gathering data, your second visit is for simulating your actual treatment plan. You are placed on a simulator, an X-ray machine used solely for treatment planning, in the same position as the day before. The simulator is designed to duplicate the exact treatment plan that will be used during your radiation therapy.

If a foam cradle was made the previous day, we make sure that it corresponds to your computerized treatment plan. We also confirm that your body is in the proper position.

During simulation, you can see the simulator move above you and turn at different angles. You will see laser lights which are used to increase the precision of your positioning.

You can also hear a low murmur from the machine when it's in operation. Your skin may be marked again to ensure that the radiation beams correspond precisely to your computerized treatment plan. Blocking devices that shape the radiation beam to the exact area to be treated, are specially created. We may also take more X-rays, if necessary.

Your first and second days of planning also give you the opportunity to meet some of the members of your treatment team. This team is responsible for customizing your treatment plan so that your radiation therapy program can begin. Feel free to discuss any questions you may have about your therapy with them.

• Your Third Day of Treatment Planning

The third and final step in treatment planning involves your set-up, or your final positioning on the radiation therapy machine itself. Again, we verify that your body position matches the computerized treatment plan, and make any modifications or adjustments recommended by your radiation therapy team during simulation.

Once your positioning and treatment plans are finalized, you are ready to begin your first radiation treatment. In some cases, radiation therapy can begin on the last day of treatment planning. To prepare

you for treatment, a therapist marks your skin with a few small permanent dots or tattoos. These "radiation freckles" feel like pin pricks and serve as guides to help the therapist set up the treatment machine quickly and accurately each time you visit the Bodine Center. You are also told how to wash the area around these permanent markings.

It's common for patients to feel nervous during the three days of treatment planning. As your treatment progresses, you will become more familiar and relaxed with the procedure and the equipment. However, this may affect the body measurements taken on the first day of treatment planning, which could alter the actual treatment field on your breast. If this occurs, you may be asked to return to the Bodine Center for additional visits to correct your positioning.

Treatment Machine

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Radiation Treatment

What Happens During Radiation Treatments?

Your radiation treatments are similar to having an X-ray, except that they take a few minutes longer. During each treatment, you lie on your back while the therapy machine delivers the proper dosage of radiation to your breast. Each treatment lasts about five minutes.

Our therapists watch you on a television monitor, and you can talk to them during your treatment. You can't see or feel anything while the equipment is in operation; however, you can hear the machine being turned on and off.

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Your Radiation Therapy Program

Your radiation therapy program lasts for five to seven weeks, depending on the type of booster dose you receive. Each of your treatment appointments are scheduled for the same time and usually take about an hour. If, for some reason, you are unable to keep your scheduled appointment, please call us at (215) 955-6702 to let us know. If you have to miss a treatment appointment because of inclement weather or other reasons, the appointment will be rescheduled.

One of our physicians will examine you thoroughly at least once a week. Your skin is checked weekly for any reaction, and we take a photograph of the treatment area. In addition, a blood count is obtained every other week or more often, if necessary.

• What Reactions Can I Expect During Radiation Therapy?

Most women who receive radiation therapy for breast cancer do not experience severe reactions. Breast radiation treatments do not cause hair loss, nausea, vomiting, or other adverse side effects. However, some women do suffer a skin reaction, occasional fatigue or a sore throat.

If you experience a reaction to the radiation therapy, don't be alarmed. Your physician will see you on a regular basis to monitor you. Here are some suggestions that may provide relief for common radiation therapy reactions:

• Skin reaction

A skin reaction to radiation therapy is usually gradual, occurring over several weeks. At first you may notice that the skin of the treated area becomes slightly dry, itchy, and, depending on your skin-tone darker or red in color. Some women with larger breasts may also notice blistering under the fold of the breast. Patients on chemotherapy may notice a skin reaction that is more severe and which may appear several weeks earlier than women who are only receiving radiation.

A skin reaction is a temporary side effect of the radiation treatments. Most women notice that their skin tone returns to normal several months after their final radiation treatment.

Before using any lotions to counteract a skin reaction, check with the Center's staff. In addition, please let them know about any changes in your skin condition.

• Fatigue

Most patients experience some fatigue during their treatment period. However, this side effect should gradually subside after the treatments are over. Most patients have the stamina to continue to work, although some people become more tired than usual. The best way to fight fatigue is to get an extra hour or two of sleep until you return to your normal level of energy.

• Sore Throat

This reaction occurs only if the treatment area includes the lymph nodes as well as a breast. If you have a sore throat from your radiation treatments, you may want to avoid alcoholic beverages, very hot or very cold drinks and liquids that are high in acid, such as citrus and tomato juices.

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Radiation Therapy and Your Personal Care

Many women wonder what to do about skin care and hygiene during radiation treatments. You may have to slightly alter the way you bathe and protect the skin around the treatment area while you receive radiation therapy. Keep in mind the following guidelines about personal care:

• Once your treatment begins, you can continue to bathe or shower, but use a mild soap around the area being treated. Do not use a deodorant soap. Ask one of our staff members about products which are hypoallergenic.
  
• If you choose to shave your underarms while you are receiving radiation therapy, use an electric razor.
  
• Be gentle with the skin surrounding the treated area. Pat dry, rather than rub, the skin.
  
• If possible, avoid wearing a bra for a short time after bathing or showering to allow air to circulate around your breasts. Consider wearing a loose-fitting T-shirt, rather than a bra, around the house.
  
• Do not use any astringent products such as rubbing alcohol around the area being treated.
  
• Nonallergenic, non-aerosol deodorant products are less irritating to the skin around the treated area.
  
• You should continue taking any medication your physician prescribed. If, after taking these precautions, you still notice your skin becoming excessively dry or itchy, you should consult your physician. Quite often, skin irritation can be relieved with a vitamin-enriched cream.

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Protecting Your Skin From The Sun

You can enjoy the outdoors while you receive radiation treatments, but it's essential that you limit the amount of time the treated area is exposed to the sun. Overexposure may worsen any skin reaction caused by radiation treatments. Use a protective garment or a sunscreen with a sun protection factor (SPF) of 15 or more.

Once your radiation treatments have ended, you must continue to take special care of the treated skin when you go outdoors. Cover the treated area with clothing or use a sun block product with an SPF of at least 15.

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Guarding Against Infection

If you've had underarm lymph nodes removed, your body is less able to fight infections in that arm. Therefore, it's important that you minimize your risk of infection. We recommend you take these precautions:

• Avoid cuts, scratches, pin pricks, and insect bites. Apply an insect repellent before going outside if you might be exposed to bites on the arms. Any break in the skin, even if very small, can lead to infection and swelling of the arm.
  
• Wear gloves when gardening to avoid thorn pricks, and also when washing dishes or doing housework.
  
• Wear oven mitts when reaching into an oven to avoid burns, which may lead to infection.
  
• Use a thimble when sewing.
  
• Be careful when manicuring your nails; use a cream cuticle remover rather than scissors.
  
• Avoid any injections or vaccinations in the arm on the operated side. Do not have blood drawn from that arm, if possible.
• 
  Ask someone else to move heavy objects or perform strenuous tasks for you.
  
• Try to avoid tight clothing and elastic dress sleeves.
  
• Wear loose jewelry.
  
• Use a hand cream to prevent dryness and chapped skin.
  
• Use an electric razor to avoid cuts if you shave under your arm.

If your breast or arm becomes red or swollen, call your surgeon or Jefferson's radiation oncology department immediately!

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Helping You Stay at Your Best During Treatment

Jefferson is sensitive to the special concerns of women receiving radiation therapy for breast cancer. We encourage you to maintain your physical and emotional well-being during the course of your treatment.

To help you stay at your best, we suggest you practice the following exercises to improve your mobility prior to your treatments. Patients who exercise following surgery and before radiation therapy begins, often experience minimal discomfort during treatment planning and therapy.

We suggest you do these exercises before you come to the Bodine Center for your initial day of treatment planning. Do each exercise three times a day in sets of 10, and then gradually increase the number of sets.

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Exercise #1 - Make an "O"

• Position your arms in front of you, so that both hands are touching, and form an "O" shape with your arms and hands. (Fig. 1)
  
• Keep this position and slowly raise your arms and hands above your head. (Fig. 2)
  
• Return your arms and hands to the starting position.

Make an "O"

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Exercise #2 - The Backhand Reach

• Using the hand on the side of your body that had breast surgery, place your hand, palm open, behind your head. (Fig. 1)
  
• While maintaining this position, alternately move your elbow in front of and behind you. (Fig. 2)

The Backhand Reach

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Exercise #3 - Walk the Wall

• Face a wall and stand a few steps away from it. Stretch the arm on the side of your body that had breast surgery straight in front of you. Make sure your open palm touches the wall surface. (Fig. 1)
  
• Slowly let your fingers "walk" up the side of the wall until your hand is above your head.
  
• Slowly let your fingers creep back down the wall until you reach the starting position. (Fig. 2)

Walk the Wall

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Exercise #4 - Walk to the Other Ear

• Raise the arm on the side of your body that had breast surgery and bend your elbow. Let your fingers touch the ear on that side. (Fig. 1)
  
• Slowly "walk" your fingers across the top of your head until they reach the other ear.
  
• Slowly "walk" fingers in the reverse direction across the back of your head until they reach the starting position. (Fig. 2)

Walk to the Other Ear

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Meeting Special Needs

Jefferson's department of radiation oncology has developed special programs to meet the particular needs of women like yourself who are fighting breast cancer. We can help you modify your diet to reduce your risk of other cancers; help you deal effectively with stress and anxiety; and help you find emotional support, counseling, and other services.

Here is a description of the many ways Jefferson can assist you and your family:

• Dietary Counseling

This program is designed to identify foods and dietary habits that may increase the risk of breast and gynecologic cancers. Our registered dietitian offers individual counseling to help you establish healthy eating habits and control your weight, and can recommend changes in your diet. Group classes in nutrition counseling are free and are conducted at the Bodine Center. Special cooking classes are also available.

• Biofeedback

Learning that you have cancer can be one of life's most stressful experiences. Jefferson's biofeedback program is designed to help you overcome your anxieties. Biofeedback uses electronic equipment to measure muscle tension, heart rate and other physiological factors which indicate how your body reacts to stress. Our certified biofeedback therapist shows you techniques, such as deep breathing and relaxation exercises, to help you reduce your anxieties and cope with stress. For more information about biofeedback, contact Jefferson's biofeedback specialist at (215) 955-8227.

• Cancer Support

To help you and your family deal with the diagnosis and treatment of cancer, Jefferson offers three unique programs free of charge. For more information about these cancer support groups, contact radiation oncology social work at (215) 955-8370.

• Jefferson's "Care, Share, and Learn" cancer support group helps patients and their families cope with cancer by encouraging them to discuss their experiences and offering emotional support during treatment. The group meets every other week throughout the year.
  
• An "I Can Cope" support group, sponsored by the American Cancer Society, is held at Jefferson. A Jefferson nurse and social worker meet with the group at the Bodine Center for eight one-hour sessions in the fall and spring. Membership is open to cancer patients and their families.
  
• Jefferson's Cancer and Recovery Encouragement Support Group (CARE) is designed specifically for women with breast cancer. Sponsored by Jefferson's department of radiation oncology and nuclear medicine, CARE meets once a month to provide participants with the opportunity to share common concerns and experiences, and to meet with guest speakers.

Jefferson's social workers are also available to help you find services beyond those offered at the Bodine Center and Thomas Jefferson University Hospital. Our social workers can help you find temporary housing near Jefferson or home nursing care, prescriptions, and medical equipment. Our staff can also assist you with financial matters and act as a liaison between you and the resources in your community. In addition, Jefferson's social workers offer emotional support and counseling as needed.

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After Your Treatments are Over

After you have completed your radiation treatments, you will have follow-up examinations at the Bodine Center. The first is scheduled one to three months after your final radiation treatment. Then, we suggest alternating further examinations between the radiation oncologist and your surgeon. Once a year, you should have a mammogram, chest X-ray, and blood tests.

During your follow-up visits you are given a thorough physical examination. The radiation oncologist will examine the skin around your treatment area and perform a breast examination. Any concerns you may have about your recovery will be addressed. If you have any problems between your follow-up visits to the Bodine Center, please call us at (215) 955-8668 Monday through Friday from 9 a.m. to 5 p.m.

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Resource Personnel

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