Is Radiation Necessary After Breast Cancer Surgery

Risks And Benefits Of Mastectomy Versus Lumpectomy Plus Radiation Therapy

The main benefit of lumpectomy plus radiation therapy is the breast is preserved as much as possible.

A potential benefit of mastectomy is radiation therapy may be avoided. Although some women will need radiation therapy after mastectomy, many will not.

Radiation therapy has some side effects and requires daily trips to a treatment facility. If you live far away from a radiation treatment centre, or if you cannot have radiation therapy, mastectomy may sometimes be a better option for you than lumpectomy.

The table below outlines some things to consider when choosing between mastectomy and lumpectomy plus radiation therapy.

Total mastectomy versus lumpectomy plus radiation therapy

Research Table: Radiation Therapy After Mastectomy For Invasive Breast Cancer

Introduction: Radiation therapy isnt often used after mastectomy for women with early stage breast cancer. However, its recommended for women with 4 or more positive lymph nodes to improve overall survival .

Radiation therapy after mastectomy is also strongly considered for women with 1-3 positive lymph nodes and for those who have positive tumor margins .

A meta-analysis that combined the results of 22 randomized clinical trials found radiation therapy after mastectomy lowered the risk of breast cancer recurrence and the risk of dying from breast cancer .

Radiation therapy after mastectomy is also considered for women with negative lymph nodes who have :

• A tumor larger than 5 centimeters
• A tumor 5 centimeters or smaller, but the tumor margins are close

How Radiotherapy Is Given

Radiotherapy can be given in several ways and using different doses, depending on your treatment plan.

The total dose is split into a course of smaller treatments , usually given daily over a few weeks.

Its carried out by people trained to give radiotherapy, known as therapeutic radiographers.

Radiotherapy is not available in every hospital, but each breast unit is linked to a hospital that has a radiotherapy department.

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Shorter Course Apbi Radiation Therapy

The most recent research suggests shorter course APBI to the breast results in equivalent outcomes among patients with node negative breast cancer who have undergone breast conserving surgery compared to the standard longer course and higher dose.2,3,10,14-16

Accelerated partial breast irradiation after surgery is as effective as whole breast irradiation for preventing recurrence among patients with early stage node negative breast cancer, according to 10-year follow-up results from the APBI IMRT Florence clinical trial presented at the 2019 San Antonio Breast Cancer Symposium.

The Florence clinical trial included 520 women aged older than 40 years with stage I or stage II breast cancer. Half of the women were treated with accelerated partial breast irradiation, which consisted of a total 30 Gray of radiation to the tumor bed in five daily fractions. The other half of women received whole breast irradiation, which consisted of a total of 50 Gray administered in 25 daily fractions to the whole breast, plus a 10-Gray boost to the tumor bed in five daily fractions.

The findings support previous studies demonstrating that shorter course less invasive partial breast irradiation is an acceptable alternative to whole breast irradiation.

At eight years, the risk of cancer recurrence in the breast was very low and similar for the two groups. For patients treated with APBI the risk was three per cent and for patients treated with whole breast radiation the risk was 2.8 per cent.

External Beam Breast Cancer Radiation

External beam radiation is the most common kind of radiation treatment for breast cancer. Its a painless treatment, like getting an X-ray. A doctor will place a machine on the outside of your body and aim the radiation beams at the area of the cancer. Your doctor will figure out where to aim the rays and how much radiation to use before each treatment. They will mark the area with temporary or permanent ink.

Each treatment only lasts a few minutes. The session setup will take longer. External radiation treatment happens five days a week for about five to seven weeks. Its the longest type of radiation treatment available.

Short-term side effects of external radiation include:

• fatigue

• swelling and pain in the arm or chest
• weakened and fractured ribs
• future cancer in the inner lining of your blood vessels

External radiation does not leave radiation in your body. You will not be radioactive during or after treatment.

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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.

Are Routine Mammograms Necessary After Breast Surgery

As long as there is breast tissue present, there is a risk of breast cancer. Most breast surgeries do not remove the breast tissue, and that tissue may still harbor any abnormalities.

Getting mammograms after breast surgery is especially smart if youve had breast augmentation or a breast lift. These procedures often entail repositioning or removing the breast tissue, which changes both the internal and external image of the breast. Because of these changes, any previous mammograms become void, since the breast tissue no longer looks the same.

A mammogram after breast surgery will be necessary to get a clearer idea of what the healthy breast looks like and to create a baseline to compare all future mammograms to. In the case of double mastectomies, future mammograms may not be necessary, because this procedure removes both breasts, leaving no tissue for examination.

Generally speaking, the experience of getting a mammogram wont change much after breast surgery. It will still consist of the same examination with the technologist taking two images of each breast. Specific breast surgeries, like having breast implants, for example, may require more imaging or further testing to better see the breast tissue.

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Travelling To Radiotherapy Appointments

You might have to travel a long way each day for your radiotherapy, depending on where your nearest cancer centre is. This can make you very tired, especially if you have side effects from the treatment.

You can ask the therapy radiographers for an appointment time to suit you. They will do their best, but some departments might be very busy. Some radiotherapy departments are open from 7am till 9pm.

Car parking can be difficult at hospitals. You can ask the radiotherapy staff if they can give you a hospital parking permit for free parking or advice on discounted parking. They may be able to give you tips on free places to park nearby.

The radiotherapy staff may be able to arrange transport if you have no other way to get to the hospital. Your radiotherapy doctor would have to agree. This is because it is only for people that would struggle using public transport and have no access to a car.

Some people are able to claim back a refund for healthcare travel costs. This is based on the type of appointment and whether you claim certain benefits. Ask the radiotherapy staff for more information about this.

Some hospitals have their own drivers and local charities might offer hospital transport. So do ask if any help is available in your area.

When Does Someone With Breast Cancer Get Radiation Therapy

The timing for radiation therapy depends on several factors. The treatment may take place:

• After a lumpectomy: A lumpectomy removes the cancerous tumor, leaving most of the breast. Radiation therapy lowers your risk of cancer coming back in the remaining breast tissue or nearby lymph nodes as well as reduces your chance of passing away of breast cancer.
• After a mastectomy: Most people dont get radiation therapy after a mastectomy . Your provider may recommend radiation if the tumor was larger than 5 cm if theres cancer in surrounding lymph nodes, skin tissue or muscle or if all the cancer can’t be removed .
• Before surgery: Rarely, healthcare providers use radiation to shrink a tumor before surgery.
• Instead of surgery: Sometimes, providers use radiation therapy to shrink a tumor that they cant surgically remove . A tumor may be unresectable due to its size or location. Or you may not be a candidate for surgery because of concerns about your health.
• To treat cancer spread: Stage 4 breast cancer is cancer that spreads to other parts of the body. Your provider may use radiation therapy to treat cancer that spreads to other parts of the body.

If you had surgery, radiation therapy typically starts about one month after the incision heals if chemotherapy is not received. Some individuals receive chemotherapy after surgery, followed by radiation therapy. You may get the two treatments at the same time.

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Making Your Own Decision

Your breasts may be such an important part of your identity your sense of who you are that youll go to great lengths to preserve them. Thats a completely acceptable approach to take, no matter what your age or figure as long as it doesnt endanger your overall health and chances for a full recovery.

Over the past decade, women with early-stage breast cancer are increasingly opting for mastectomy or double mastectomy removal of both breasts. The increased availability of advanced breast reconstruction techniques has contributed to the trend.

Things to consider

There are no right or wrong answers when you are making a decision between treatments. Women each feel very differently. You need to decide what feels best for you.

Some women want to keep their breast if at all possible, so they choose a lumpectomy and radiotherapy.

Other women feel that once they have breast cancer they would rather have the whole breast removed because it makes them feel it is more likely to remove all of the cancer. They can then choose to have a new breast made .

Some women feel strongly that they dont want radiotherapy. Others welcome it if it means keeping their breast.

Factors affecting which surgery might be best for you:

• the size of your cancer
• where the cancer is in your breast
• whether there is more than one area of cancer
• the size of your breasts
• your general health

What to take into account

To help you decide, you might want to think about:

Radiation Therapy Side Effects

The side effects of radiation therapy depend on the type of radiation therapy youre having. In general, the side effects tend to develop as treatment goes on and may be more troubling toward the end of treatment. Overall, the most common side effects are redness, swelling, and skin peeling in the area being treated.

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The Types Of Radiotherapy

The type of radiotherapy you have will depend on the type of breast cancer and the type of surgery you have. Some women may not need to have radiotherapy at all.

Types of radiotherapy include:

• breast radiotherapy after breast-conserving surgery, radiation is applied to the whole of the remaining breast tissue
• chest-wall radiotherapy after a mastectomy, radiotherapy is applied to the chest wall
• breast boost some women may be offered a boost of high-dose radiotherapy in the area where the cancer was removed however, this may affect the appearance of your breast, particularly if you have large breasts, and can sometimes have other side effects, including hardening of breast tissue
• radiotherapy to the lymph nodes where radiotherapy is aimed at the armpit and the surrounding area to kill any cancer that may be in the lymph nodes

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What Are The Types Of Radiation Therapy For Breast Cancer

There are different ways to receive radiation therapy. Your healthcare provider will choose the best method based on the cancer location, type and other factors.

Types of radiation therapy for breast cancer include:

• External beam whole-breast irradiation: During external beam whole-breast radiation therapy, a machine called a linear accelerator sends beams of high-energy radiation to the involved breast. Most people get whole-breast radiation five days a week for one to six weeks. The time frame depends on factors including lymph node involvement. In some cases, intensity-modulated radiation therapy may be used.
• External beam partial-breast: This treatment directs radiation to the tumor site only, not the entire breast over 1 to 3 weeks with 3-dimensional conformal radiation or IMRT.
• Brachytherapy: Some people get internal radiation therapy or brachytherapy. Your provider places an applicator or catheter. A radioactive seed is moved into the tumor site. The seeds give off radiation for several minutes before your provider removes them. You receive two treatments every day for five days.
• Intraoperative:Intraoperative radiation therapy takes place in the operating room before your provider closes the surgical site. Your provider delivers a high dose of radiation to the tumor area of the exposed breast tissue.

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Radiotherapy To Part Of The Breast

Less commonly, some women are given radiotherapy to part of the breast instead of the whole breast. There are different ways of doing this.

Your cancer doctor or specialist nurse will explain if any of the following treatments are options for you. They will tell you what the possible side effects are and any risks involved.

It is important to have information about all your treatment options. They can explain how these treatments compare with external radiotherapy.

Ovarian Ablation Or Suppression

In women who have not yet experienced the menopause, oestrogen is produced by the ovaries.

Ovarian ablation or suppression stops the ovaries working and producing oestrogen.

Ablation can be done using surgery or radiotherapy. It permanently stops the ovaries from working and means you’ll experience the menopause early.

Ovarian suppression involves using a medicine called goserelin, which is a luteinising hormone-releasing hormone agonist .

Your periods will stop while you’re taking it, although they should start again once your treatment is complete.

If you’re approaching the menopause , your periods may not start again after you stop taking goserelin.

Goserelin comes as an injection you have once a month.

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If Youre Getting Radiation Therapy To The Abdomen

If you are getting radiation to your stomach or some part of the abdomen , you may have side effects such as:

• Nausea
• Diarrhea
• Constipation

Eating or avoiding certain foods can help with some of these problems, so diet planning is an important part of radiation treatment of the stomach or abdomen. Ask your cancer care team about what you can expect, and what medicines you should take to help relieve these problems. Check with your cancer care team about any home remedies or over-the-counter drugs youre thinking about using.

These problems should get better when treatment is over.

Managing nausea

Some people feel queasy for a few hours right after radiation therapy. If you have this problem, try not eating for a couple of hours before and after your treatment. You may handle the treatment better on an empty stomach. If the problem doesnt go away, ask your cancer care team about medicines to help prevent and treat nausea. Be sure to take the medicine exactly as you are told to do.

If you notice nausea before your treatment, try eating a bland snack, like toast or crackers, and try to relax as much as possible. See Nausea and Vomiting to get tips to help an upset stomach and learn more about how to manage these side effects.

Managing diarrhea

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Ductal Carcinoma In Situ

Randomized Data

One randomized study comparing lumpectomy alone to lumpectomy plus radiation therapy-the National Surgical Adjuvant Project for Breast Cancer B-17 trial-has been published . Overall, in this trial, the addition of radiation reduced the annual breast failure rate from approximately 5% to 2%.

In a retrospective subset analysis, the addition of radiation decreased the annual breast recurrence rate in all subgroups, regardless of margin status and the presence or absence of moderate/marked comedo necrosis. In the subgroup of patients with the most favorable risk profile, ie, those with clear margins and absent/minimal comedo necrosis, the absolute reduction in the annual breast failure rate was less than 1%. In the “highest-risk” group, ie, those with positive margins and prominent necrosis, the addition of radiation reduced the absolute annual breast failure rate by 7% .

Additional randomized data are available from NSABP B-06. This study was intended to include only patients with invasive cancer. However, on histologic review, a small subset of patients were judged to have DCIS. In NSABP B-06, as in the larger NSABP B-17 study, the addition of radiation reduced the breast failure rate from approximately 6% to 1%.

No differences in overall survival were reported in the NSABP B-17 trial.

Nonrandomized Data

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