Radiotherapy for breast cancer

What is radiotherapy?

Radiotherapy uses precise, carefully measured doses of high energy x-rays to treat cancer. Cancer cells are more sensitive to radiation than normal cells, so the aim of treatment is for the x-rays to either destroy the cancer cells or stop them from growing, whilst avoiding and protecting the normal cells as much as possible.

Radiation also damages normal cells in or around the area being treated which causes side effects, but these will usually recover and heal after treatment.

Using external beam radiotherapy to treat breast cancer

Radiotherapy is normally used to treat the whole breast/chest wall area. In some cases, your doctor may discuss with you treating only part of the breast tissue where it has been shown this is equally beneficial for your specific case.

You will need to attend the radiotherapy department as an out-patient, for a course of daily treatments (Monday to Friday), on weekdays. The number of treatments can vary but will commonly be for a period of one to three weeks.

You may also be given an extra dose to the original site of the tumour or scar area. This is known as a ‘boost’ and will usually be given during the last week of treatment, which will make your overall treatment course a little longer.

Each appointment should take around 15-30 minutes (although your hospital visit may be longer).

Preparing for your treatment

It is important that your surgical wound has fully healed, or any build-up of fluid (seroma), in the area has settled before treatment is started.

You will need to raise your arms above your head during your planning and treatment sessions. For this reason, it is important that you have regained movement in your arms after surgery and are able to comfortably raise your arms above your head.

After surgery, it can be difficult or painful to lift your arm above your head and keep it there for the duration of the planning or treatment session. Please continue doing the exercises given to you after surgery regularly. If you are struggling to hold your arm up, talk to your breast care nurse or radiotherapy review specialist. They may arrange for you to see a physiotherapist. You may also take some pain relief before your radiotherapy appointments to ease any discomfort.

If you are having any ongoing issues with your arm movement or healing after your surgery, please mention this to your doctor when you are being consented or to the member of the radiotherapy team who contacts you to book in your planning appointment.

Breath hold in radiotherapy

Depending on the exact area being treated, there is a chance that radiotherapy treatment may affect your heart. This is most commonly when the treatment area includes the left breast, left chest wall, or a group of nodes called the internal mammary chain (IMC) on either the right or left.

A technique called Deep Inspiration Breath Hold (DIBH) is used to minimise this. Not everyone will require this, and it is not suitable for every patient. If your doctor feels it is beneficial for you, they will discuss it with you when consenting you for your radiotherapy treatment.

An additional information leaflet “deep inspiration breath hold (DIBH) for radiotherapy” is available which will provide you with more information about this if it is applicable to you.

Radiotherapy to lymph nodes

Some patients require treatment to their axilla (the armpit region), supra clavicular fossa (the area above the collarbone), or the internal mammary chain (the area where your breast/chest wall meets your breastbone). If this is necessary for you, your doctor will discuss this when they are consenting you for treatment.

Planning your radiotherapy treatment

Before starting your treatment, we need to tailor it to your specific needs. You will need to attend the radiotherapy department for a planning scan. This is done using a CT scanner, which takes x-rays of the area to be treated which build up a 3D picture of your body.

You will be asked to undress above the waist and will be given a gown to wear. It may be helpful for you to wear a top that is easy to take off and put on. We will ask you to lie down on the couch of the machine and raise your arms above your head. You will be supported by a special piece of equipment designed specifically for this purpose.

For this reason, it is important that you have regained your arm movement following surgery and are able to comfortably raise your arms above your head before you start.

A specially trained member of the radiotherapy team or one of the doctors will put some pen marks on your skin around the area to be treated. At this stage they will assess your surgical site and then feel for the edges of your breast tissue. These marks will provide additional information for the planning process.

Treatment planning is a very important part of radiotherapy. Marks will be drawn on your skin by the radiographer. They will also stick markers on your skin that are visible on the CT scan to help the doctor when planning your treatment. At the end of the CT scan, three permanent ink markings will be made on your skin using a pinprick of ink. These are used to make sure that you are accurately positioned for your treatment each day.

Receiving your radiotherapy treatment

Treatment will usually start a few weeks after your planning appointment. Each session takes about 15-20 minutes.

The radiographer will carefully position you on the couch in the exact position you were in for your planning appointment. They will use the permanent marks to align you correctly.

The machine will move around you. Once the radiographers have completed their checks, they will leave the room to switch the machine on. The machine will move while the radiographers are outside of the treatment room, but it is important that you always keep still and follow the radiographer’s instructions. If you are being asked to hold your breath, the radiographers will inform you when to breath in and out.

The actual treatment lasts a few minutes, during which you will be alone in the room. The radiographers will be observing and if necessary, will be able to talk to you from the next room where they can always hear you. You will not feel anything when the machine switches on, but you will hear the machine buzzing.

Short term side effects of radiotherapy treatment

Some side effects are short term, or “acute”. Short term side effects typically reach their peak about two to three weeks after you finish your treatment and take a further two to three weeks to reduce, however this will not be the case for all patients. Examples of possible short term side effects from radiotherapy for breast cancer are listed below. 

Skin reaction

Initially, you may notice some redness (similar to sunburn) and if you have darker skin it may get darker or develop a blue or black tinge. Increased pigmentation (darkening), tenderness or itching of the skin in the treatment area usually occurs around 10-14 days after treatment has started, although this can sometimes occur later or after treatment has finished.

If you have a skin reaction, please apply plain water-based moisturisers to the area little and often. As the treatment continues, the skin may peel or flake and this may result in a red, sore, moist, and weepy skin reaction. If this happens, the radiotherapy review specialist team can advise on skin care. It is important to take special care of the skin on the area being treated.

Pain in the breast area

Occasionally you may have aches, twinges, or sharp pains in the breast area. Although these are usually mild, they can continue for some time after treatment is finished. In some cases, they can continue for months or even years, but they usually become milder and less frequent over time.

You may also experience stiffness and discomfort around the shoulder and breast area from lying in the treatment position. This may also happen after treatment has finished. Continuing with your arm and shoulder exercises during and after treatment can help minimise or prevent any stiffness or discomfort happening.

Tiredness

Radiotherapy may make you feel tired – this may continue for a month or two after it finishes. Gentle exercise can help but save your energy for activities you enjoy doing. You may experience some or all these side effects. Please always let the radiotherapy team know of anything worrying you, as we want to help you recover as soon as possible.

Long term side effects

Some side effects are long term. These usually occur more than three months, but sometimes much longer, after finishing your course of treatment.

Breathlessness

A few months after radiotherapy some women develop breathlessness because of radiotherapy on the lung. It usually gets better within two to four weeks without any treatment or with a short course of steroid medicines. Radiotherapy rarely causes any long-term damage to the lungs.

Side effects relating to the heart

Radiotherapy is very carefully planned to avoid including the heart in the treatment area. It very rarely causes heart problems, and only women who had cancer in their left breast may be at risk.

Rib weakness

Rarely, radiotherapy may weaken the ribs in the treated area, making them more likely to fracture than normal.

Lymphoedema

Lymphoedema is swelling caused by a build-up of lymph fluid in the tissues. This is usually because of damage to the lymphatic systems following surgery.

Radiotherapy to the lymph nodes under the arm and surrounding areas (such as neck or chest) can increase the risk of lymphoedema. If this is relevant to you, your doctor will discuss this with you.

After your treatment

Follow up from radiotherapy can vary depending on the treatment you have received. Sometimes you may be referred back to your surgeon or chemotherapy doctor for follow up and sometimes you will be followed up by your radiotherapy doctor.

Usually, you should expect a follow up from the radiotherapy review specialist team about 6 weeks after your final radiotherapy treatment. This may sometimes be a telephone appointment.

If you have concerns about your follow up If you have any concerns about your follow up, please speak to the radiographer team, or contact your clinical nurse specialist or your oncology team’s secretary.

Support available

We have several support services are available, for you to access. If you would like to know more about these, please read our leaflet titled “a patient’s guide to radiotherapy” or ask a member of the radiotherapy team.