Intensity Modulated Radiation Therapy
Intensity modulated radiation therapy, or IMRT, is a specialized form of 3D-CRT that allows radiation to be more exactly shaped to fit the tumor. With IMRT, the radiation beam can be broken up into many âbeamlets,â and the intensity of each beamlet can be adjusted individually. Using IMRT, it may be possible to further limit the amount of radiation that is received by healthy tissue near the tumor. In some situations, this may also allow a higher dose of radiation to be delivered to the tumor, potentially increasing the chance of a cure.
Starting With Neoadjuvant Therapy
Most often, these cancers are treated with neoadjuvant chemotherapy. For HER2-positive tumors, the targeted drug trastuzumab is given as well, often along with pertuzumab . This may shrink the tumor enough for a woman to have breast-conserving surgery . If the tumor doesnt shrink enough, a mastectomy is done. Nearby lymph nodes will also need to be checked. A sentinel lymph node biopsy is often not an option for stage III cancers, so an axillary lymph node dissection is usually done.
Often, radiation therapy is needed after surgery. If breast reconstruction is planned, it is usually delayed until after radiation therapy is done. For some, additional chemo is given after surgery as well.
After surgery, some women with HER2-positive cancers will be treated with trastuzumab for up to a year. Many women with HER2-positive cancers will be treated first with trastuzumab followed by surgery and then more trastuzumab for up to a year. If after neoadjuvant therapy, any residual cancer is found at the time of surgery, ado-trastuzumab emtansine may be used instead of trastuzumab. It is given every 3 weeks for 14 doses. For women with hormone receptor-positive cancer that is in the lymph nodes, who have completed a year of trastuzumab, the doctor might also recommend additional treatment with an oral targeted drug called neratinib for a year.
What Are The Implications
There may be various reasons why a woman is not ready to start chemotherapy within four weeks. This study suggests there are compelling reasons to avoid non-essential delays.
However, absolute risk will vary depending on cancer stage and characteristics. For example, if a womans 10-year risk of death is 20%, with prompt chemotherapy this could increase to 21% with four-week delay. A 60% risk could increase to 65%. Therefore risks need to be balanced for the individual and electronic tools, such as Predict, are available to help with this.
The key message for hospitals and commissioners is to manage waiting lists and clinics in a way that minimises unnecessary delays in starting chemotherapy after surgery.
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Radiation Therapy Timing And Breast Reconstruction
The timing of radiation treatment in your overall breast cancer treatment plan depends on your individual situation and the characteristics of the breast cancer.
In many cases, radiation therapy is given after surgery. If chemotherapy is planned after surgery, radiation usually follows chemotherapy.
If youre having mastectomy and have decided to have breast reconstruction, its important to know that radiation can cause a reconstructed breast to lose volume and change color, texture, and appearance.
In particular, radiation therapy is known to cause complications with implant reconstruction. Research also suggests that a reconstructed breast may interfere with radiation therapy reaching the area affected by cancer, though this can vary on a case-by-case basis.
For these reasons, some surgeons advise waiting until after radiation and other treatments, such as chemotherapy, are completed before breast reconstruction surgery is done.
Other surgeons may recommend a more staged approach, which places a tissue expander after mastectomy to preserve the shape of the breast during radiation treatments. Once radiation is completed and the tissues have recovered, the expander that was used to maintain the shape of the breast is removed and replaced with tissue from another part of the body or a breast implant.
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Summary Of Surgery Timing
Though we don’t have a solid answer on how soon surgery should be done after a diagnosis of breast cancer , it would seem earlier surgery is ideal .
Delaying for a lengthy period of time can be dangerous, with studies finding that those who delay over six months are twice as likely to die from the disease. This is important to keep in mind for those who have breast lumps they are “observing” without a clear diagnosis. Any breast lump needs to be explained.
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Radiation Therapy For Early Stage Node Negative Breast Cancer
- Original: Oct 21, 2020
Standard local treatment for early-stage breast cancer involves either a mastectomy or a lumpectomy. A mastectomy involves removal of the entire breast, whereas a lumpectomy involves removal of the cancer and some surrounding tissue. Because a lumpectomy alone is associated with a higher rate of cancer recurrence than mastectomy, patients who elect to have a lumpectomy are also typically treated with radiation therapy. The combination of lumpectomy and radiation is referred to as breast-conserving therapy. Breast-conserving therapy and mastectomy decrease the risk of a local cancer recurrence and produce similar rates of long-term survival.1,2
Radiation therapy is often delivered to the whole breast from a machine outside the body . This treatment was historically delivered on a daily basis for 5-7 weeks. Doctors are increasingly using other methods to deliver radiation over shorter time intervals to reduce the inconvenience of treatment and its side effects.2-6
Delaying Chemotherapy After Breast Cancer Surgery May Reduce Survival Chances
Delaying chemotherapy after breast cancer surgery may slightly decrease a womans chances of survival. A review found about a 5% increase in the relative risk of death.
Many women are offered chemotherapy soon after breast cancer surgery, called adjuvant chemotherapy. Chemotherapy is usually started after the surgical wounds have healed but the effect of any delay to this was unclear. These researchers calculated the risk from outcomes for almost 30,000 women treated with adjuvant chemotherapy, from studies in Europe and North America.
The absolute risk of death for any woman will depend on her individual cancer stage and characteristics. A four week delay could add several percentage points to her overall risk of death. This could have meaningful impact for the individual, but may not be enough to remove the benefit entirely. The review didnt examine delays longer than four months.
NICE recommend adjuvant chemotherapy for breast cancer should be started within 31 days of surgery. This review reinforces that guidance.
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Late Effects Of Radiotherapy For Breast Cancer
Radiotherapy to the breast may cause side effects that happen months or years after radiotherapy. They are called late effects.
Newer ways of giving radiotherapy are helping reduce the risk of these late effects happening. If you are worried about late effects, talk to your cancer doctor or specialist nurse.
The most common late effect is a change in how the breast looks and feels.
Radiotherapy can damage small blood vessels in the skin. This can cause red, spidery marks to show.
After radiotherapy, your breast may feel firmer and shrink slightly in size. If your breast is noticeably smaller, you can have surgery to reduce the size of your other breast.
If you had breast reconstruction, using an implant before radiotherapy, you may need to have the implant replaced.
It is rare for radiotherapy to cause heart or lung problems, or problems with the ribs in the treated area. This usually only happens if you had treatment to your left side.
Tell your cancer doctor if you notice any problems with your breathing, or have any pain in the chest area.
How Long Is Chemo For Breast Cancer
Chemotherapy is often administered after surgery to remove any undetected breast cancer cells. Chemotherapy can also help reduce your risk of the cancer returning.
Chemotherapy should usually be given within 30 days of surgery and less than 120 days from the initial diagnosis. One study showed women who started chemotherapy two months after surgery had a 19 percent lower chance to survive compared to women who began chemotherapy a month after surgery.
Treatment comes in cycles that can occur once a week or once every three weeks. Following a period of recovery, this process can continue for up to six months. Women with more aggressive forms of cancer may receive chemotherapy for longer than that.
Not all stages of cancer require chemotherapy. Depending on the results of pathology from surgery, your doctor will decide the best plan for adjuvant treatment. You may also be a candidate for hormonal therapy.
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How Is Radiation Therapy Delivered
- Radiation therapy uses high-energy X-rays or other types of radiation to kill the cancerous cells within the breast tissue. Radiation may be delivered through external radiation, which uses a machine to deliver the rays from outside the body or internal radiation therapy, which utilizes radioactive substances placed in needles, seeds, or thin tubes directly into or near the cancer this method often requires less time.
Take Care Of Yourself During Treatment
Radiation affects each person differently. To help keep your energy up during radiation treatments:
- Get enough rest.
- Eat a well-balanced, nutritious diet.
- Pace yourself, and plan frequent rest periods.
Good nutrition will also help you recover from side effects, heal, and fight off infection. It may give you a sense of well-being, too. If you have a hard time eating, work with a dietitian to find ways to get the nutrients you need.
Many people feel fatigued after several weeks of treatment. Most often, this is mild. But some people feel more tired and may need to change their daily routines. Your doctor will let you know if they think you should limit your activities.
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Will The Nhs Fund An Unlicensed Medicine
It’s possible for your doctor to prescribe a medicine outside the uses it’s licensed for if they’re willing to take personal responsibility for this ‘off-licence’ use of treatment.
Your local clinical commissioning group may need to be involved, as it would have to decide whether to support your doctor’s decision and pay for the medicine from NHS budgets.
Page last reviewed: 28 October 2019 Next review due: 28 October 2022
Radiation For Metastatic Breast Cancer
Sometimes breast cancer spreads to other parts of the body. When this happens, the breast cancer is called metastatic or stage IV.
If youve been diagnosed with metastatic breast cancer and are having symptoms, your doctor may recommend radiation therapy to:
- ease pain
- lower the risk of a cancer-weakened bone breaking
- open a blocked airway to improve breathing
- reduce pressure on a pinched spinal cord or nerve that might be causing pain, numbness, or weakness
- treat cancer that has spread to the brain
The radiation dose and schedule to treat metastatic breast cancer depends on a number of factors, including:
- the level of pain or amount of function lost
- the size of the cancer
- the location of the cancer
- the amount of previous radiation youve had
- the schedule for any other treatments
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What Kind Of Treatment Follow
The major goal of follow-up is, if possible, to detect and treat recurrences in the irradiated breast or lymph nodes and new cancers developing later in either breast before they can spread to other parts of the body. Theroutine use of bone scans, chest x-rays, blood tests and other tests to detect the possible spread to other organs in patients without symptoms does not appear to be useful. Your physician will determine a follow-upschedule for you. This may include a physical exam every few months for the first several years after treatment and then every six to 12 months or so after that. Annual follow-up mammograms are an important part of your care. If symptoms or clinical circumstances suggest a recurrence, diagnostic tests such as blood tests, ultrasound,computed tomography , magnetic resonance imaging , chest x-ray , or bone scan may be needed.
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How Long Is Too Long To Wait
How soon you might need to have surgery after a cancer diagnosis can vary. It depends on the type of cancer and other factors. Sometimes cancer surgery needs to happen as soon as possible. Other times, waiting a while is not a problem. And sometimes you might need chemotherapy or radiation before having surgery. It’s not unusual for patients to wait a few weeks after learning they have cancer to have surgery. Talk to your doctor and others on your health care team about how long to wait before having surgery. Don’t be afraid to ask questions! You might want to ask if you have time to think about other options or get a second opinion.
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Changes To The Look And Feel Of The Breast
Radiation therapy may cause the breast to feel firmer and to be slightly smaller in volume. There may be some permanent discolouration of the skin in the treatment area and visible small red blood vessels may develop.
Your radiation oncologist will discuss with you the very small risks of long-term damage to normal tissue in the treatment area, such as changes in the lungs underlying the chest wall, rib fracture, heart problems if you have a left-sided breast cancer, nerve damage causing weakness in the arm, or lymphoedema of the arm or breast. There is an extremely small risk of inducing a second cancer in the treatment area many years after your breast cancer radiotherapy.
It is felt that the benefit of radiation therapy using modern radiation techniques outweighs the potential risks of treatment and your radiation oncologist will discuss this with you.
How Effective Is Radiation Therapy
If early-stage breast cancer hasnt spread, radiation therapy after a lumpectomy significantly reduces the risk of cancer coming back by approximately 50%. Studies show that a lumpectomy followed by radiation therapy is as effective as a mastectomy without radiation therapy.
People who undergo a lumpectomy have a 20% to 40% chance of the cancer coming back at 10 to 20 years. With the addition of postsurgical radiation therapy, that risk drops to 5% to 10%. However, there are some patients who derive less benefit from radiation including patients 65 years or older with small cancers.
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Internal Beam Radiation Or Brachytherapy
Brachytherapy is a type of radiation therapy that generates radiation from within the body. In comparison with external beam radiation, which projects particles of radiation from outside the body, brachytherapy can deliver higher doses of radiation in a precise fashion, resulting in fewer side effects and shorter treatment times.
The type of brachytherapy that doctors use depends on the location of the tumor, how much the cancer has spread, and the persons overall health.
The doctor will use a tube or cylinder to deliver a radioactive substance into the body and place it in the tumor.
The doctor will use a needle or catheter to place radioactive material within a cavity either a natural one or one that surgery has created. For breast cancer, they will place it in the breast.
Brachytherapy can also involve either high-dose-rate or low-dose-rate treatments.
High dose rate
This type consists of multiple treatment sessions in which doctors place radioactive material in the body for about 1020 minutes before removing it.
Low dose rate
This type uses substances that release a constant, low dose of radiation over 17 days, during which time a person will likely stay in the hospital. Doctors will remove the radiation source after a designated amount of time.
Signs Breast Cancer Has Spread
Your doctor may use several imaging tests to determine if your cancer has spread. An ultrasound, CT scan or MRI are the most common tests to see if cancer has spread to other organs. You may also receive a chest x-Ray to see if the cancer has reached your lungs.
For more advanced imaging, your doctor can order a PET scan in which a radioactive sugar travels through your body before images are taken where the sugar collects. Similarly, a bone scan uses a radioactive substance to determine if cancer has spread to your bones. Bone scans can pick up cancer cells that may not show on other scans.
However, it is not uncommon to not need any additional imaging to check for tumor spread. You should work with your doctor to decide which imaging, if any, is best.
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Radiation Therapy And Sun Exposure
During radiation treatment, its best to keep the treated area completely out of the sun. This can be especially difficult if youre having radiation therapy in areas or seasons with warmer weather. To help avoid sun exposure:
- Wear clothing or a bathing suit with a high neckline, or wear a rash guard top.
- Try to keep the area covered whenever you go outside. An oversized cotton shirt works well and allows air to circulate around the treated area.
- Avoid chlorine, which is very drying and can make any skin reactions youre having worse. Chlorine is used to disinfect most pools and hot tubs.
- If you do want to swim in a pool, you might want to spread petroleum jelly on the treated area to keep the chlorine away from your skin.
After your radiation treatment is completed, the treated skin may be more sensitive to the sun than it was in the past, so you might need to take extra protective steps when you go out in the sun:
- Use a sunblock rated 30 SPF or higher on the area that was treated.
- Apply the sunblock 30 minutes before you go out in the sun.
- Reapply the sunblock every few hours, as well as when you get out of the water.
Written by: Jamie DePolo, senior editor
This content was developed with contributions from the following experts:
Chirag Shah, M.D., breast radiation oncologist, director of breast radiation oncology and clinical research in radiation oncology at the Cleveland Clinic in Cleveland, Ohio
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