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Radiation Therapy

Radiation Therapy is a big maybe in breast cancer treatment. It is a possibility for all stages of breast cancer, but it is not always necessary. 

Purpose of Radiation Therapy 
-In STAGES 0-3 breast cancer, radiation is usually coupled with surgery in order to reduce cancer recurrence risk.
        -Radiation therapy is almost always given after a lumpectomy, to reduce local recurrence risk       
       -radiation therapy is sometimes given after a mastectomy to reduce chest wall recurrence risk
-In STAGE 4 breast cancer, radiation therapy can be used to shrink cancer in certain organs and/or in the bones. It also may be used to relieve pain caused by metastatic breast cancer (palliative radiation). 

Types of Radiation Therapy 
 
Breast irradiation can be given externally (external beam radiation) or internally (brachytherapy). External beam radiation can be directed at the whole breast or only at the part of the breast where the tumor is/was. Brachytherapy irradiates only the part of the breast where the tumor was.
 
External Beam Radiation (EBR)

Whole Breast Irradiation:
 Irradiation of the entire affected breast. 
 
Types: 
   -usually given for 15 minutes, 5 days a week, for 6 weeks 
   -another option is Canadian Hypofractionation, in which radiation is given in larger doses for only 3-4 weeks. Hypofractionation is usually an option for women who had a lumpectomy (still have their native breast with no implants) and negative lymph nodes. It may also have fewer side effects than the traditional six weeks of radiation. 


Accelerated Partial Breast Irradiation (APBI): 
APBI is radiation therapy directed only at the area where the breast cancer was. Not all doctors offer APBI, as more data is needed to determine if it is as effective as whole breast irradiation. 
However, select women may qualify for APBI: for example, most women who receive APBI are post menopausal (over 50 years old). Post menopausal women with small, node negative, HR+ breast cancers are very good candidates for APBI.  
 
Types: 

     -intraoperative radiation: radiation is administered in the operating room during a lumpectomy; the radiation is administered while the incision is still open, treating the area where the tumor previously was. However, this method is not common because it requires special equipment.

    -3D Conformal: Unlike whole breast radiation, 3D conformal uses a special machine that directs beams only at the affected area in order to spare as much surrounding healthy tissue as possible. 

    -Intensity Modulated Radiation Therapy: different doses of radiation are given to the breast relative to where the tumor is (the tumor gets a higher dose than the surrounding healthy tissue). 

  -Brachytherapy is also a type of APBI, but it is a type of internal radiation rather than external (see more below)

   -lymph node radiation is also a type of external radiation that may be beneficial to prevent local recurrence

   -chest wall irradiation may be given after a mastectomy to reduce risk of chest wall recurrence 
​
Possible Side Effects of External Breast Irradiation 
-skin irritation (resembling a sunburn) (those with larger breasts will experience more irritation)
-swelling 
-fatigue 
-cosmetic changes in the radiated breast (smaller, firmer skin, etc.) 
-lymphedema (if nodes receive radiation) 
-breast implant complications, such as loss of implant and capsular contraction (unusually hard scar tissue around the implant that may cause pain) if given after reconstruction
 
Very rare side effects: 
-pneumonitis or inflammation of the lung (only .7% risk, very treatable)

-fractures in the ribs (1-2% risk) 

-very rarely, radiation could lead to lung or heart damage if the beams hit these organs; however, now there are new techniques and technologies such as special machines, prone positioning (see more to the right), intensity modulated radiation therapy, and more, that make this 'bystander effect' very rare. 

-secondary malignancies/cancers; developing a second cancer is extremely rare; a 1/1000 chance or less. However, smoking can add to this risk. 
​
Internal Breast Irradiation or Brachytherapy
(only for those who had a lumpectomy)
In brachytherapy, the radioactive device is placed inside the breast (in the place where the tumor was previously) for a short amount of time.

Most Common Types: 

    -balloon brachytherapy: a catheter that expands into a balloon is placed in the cavity of a partial mastectomy, and left until the treatment is completed; a iridium (radioactive) seed is placed in the tube 2x a day for 5 days. 

    -catheter brachytherapy: catheters (tubes) are inserted into the tumor bed, and left there for a few days. A radioactive pellet is placed in the tube for a short amount of time on each day of the treatment. 
​
Side effects of Internal Breast Irradiation: 
-skin irritation 
-fatigue
-redness or bruising 
-infection 
- fluid buildup in the breast 

Radiation Therapy for Lumpectomy vs. Mastectomy vs. Metastatic Cancer 
 
Radiation Therapy for Mastectomy 
-Radiation therapy may be given after a mastectomy to reduce the risk of recurrence in the lymph nodes and/or chest wall 
Who is a candidate for Post Mastectomy Radiation Therapy? 
-those with node positive breast cancers
-those with large tumors (greater than 5cm)
-positive tumor margins (cancer in the skin or muscle of the chest). 

Radiation Therapy for Lumpectomy 
-Most women who receive a lumpectomy often need radiation therapy to reduce the risk of cancer recurrence. However, in rare cases, radiation is not necessary; women with a very low recurrence rate (for example, women with low grade, small DCIS) may not need radiation therapy. 

Radiation Therapy for Metastatic Breast Cancer
Cancer is classified as metastatic when it has spread to the bones or other organs via blood or lymph vessels. 
Although the main line of treatment for metastatic cancer will most likely be systemic therapy (hormone therapy, targeted therapy, chemotherapy, and/or immunotherapy), radiation therapy can be used to shrink and help control cancers in certain areas and manage pain caused by distant metastasis. 

Who qualifies for metastatic radiation therapy? 

-brain metastasis: local therapies such as radiation therapy can be used to treat symptoms caused by brain metastasis and to help contain the cancer. 

-bone metastasis: If breast cancer cells have metastasized to the bones, radiation therapy can often be used to help shrink or kill the cancer cells in the bones, therefore preventing or treating fractures by allowing the weakened bones to heal. 

-when cancer is compressing the spinal cord: If cancer cells have metastasized to the backbone, they can compress the spinal cord, causing pain, weakness, and more. Radiation can help alleviate this pain by killing the cancer cells responsible. 

-to help alleviate pain in other areas of the body

Newer Techniques that Help Prevent Organ Damage
In the past, the "innocent bystander effect" (the damage of organs such as the heart and lungs following breast irradiation) was a large risk in radiation therapy. However, today, there are new techniques and technologies that make organ damage very unlikely. 

-CT Planning:  Before you undergo radiation therapy, you will most likely have a CT scan that will allow your treatment team to accurately plan your radiotherapy and avoid vital organs. This planning may include tiny tattoos on your skin that ensure that you will be in the exact same position when you receive radiation. 

-Prone Positioning: Especially those for those who have larger breasts, prone positioning can be very effective in the prevention of the innocent bystander effect. This technique involves lying on your stomach. This position pulls your breasts away from your chest wall, lungs, and heart, protecting your organs while allowing the radiation to hit the breast. 

-Intensity Modulated Radiation Therapy (IMRT): IMRT is an advanced software in which different doses of radiation are given to the breast relative to where the tumor is (the tumor gets a higher dose than the surrounding healthy tissue). Therefore, IMRT allows the radiation to be administered very precisely, protecting organs and healthy tissue. 

-Deep Breath Hold: Sometimes, your radiographer will ask you to hold your breath while radiation is given, in order to help shelter the lungs and heart from the beam field. 

References: Yale Online. (2016). Introduction to Breast Cancer. https://online.yale.edu/courses/introduction-breast-cancer
American Cancer Society. (2021). Radiation for Breast Cancer.  Retrieved from: https://www.cancer.org/cancer/types/breast-cancer/treatment/radiation-for-breast-cancer.html
MD Anderson Cancer Center. (2023).  Radiation Treatment for Breast Cancer: What to Expect. https://www.mdanderson.org/cancerwise/radiation-treatment-for-breast-cancer--what-to-expect.h00-159621012.html
Breast Cancer.Org. Breast Radiation Side Effects. Retrieved from: https://www.breastcancer.org/treatment/radiation-therapy/side-effects
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