Pros And Cons Of Radiation After Lumpectomy
Many women who have had a lumpectomy for breast cancer are given the option of receiving either a mastectomy with reconstruction, or postoperative radiation therapy to prevent the cancer from returning in the chest wall area where it was removed. For many years, radiation has been used to treat small areas of residual disease left behind by the surgeon during breast conserving surgery (BCS). However, recent studies indicate that radiation does not appear to prolong survival when compared to no treatment at all. One such study looked at 4,000 women with early stage breast cancer who were treated with BCS alone or with BCS plus a limited amount of radiation. The researchers found that there was no significant difference between the two groups regarding five year overall survival rate. In addition, women who received radiation did experience higher rates of serious complications than those who did not receive radiation.
For this reason, some doctors now do a “less is more” approach when treating patients with very small amounts of tumor remaining after their initial treatment. This means that they will only use radiation if the tumor size falls below 1 cm or so as measured on MRI scans. If the tumor measures larger than about 2-2.5cm, the patient will be offered chemotherapy instead of radiation.
The decision whether to use radiation depends upon several factors including how large the original tumor was before removal, whether the margins around the surgical site were clear, whether lymph nodes were affected, what type of breast tissue was present at the time of the diagnosis, and whether the woman wants to consider additional treatments like chemotherapy later. In addition, most insurance companies will cover radiation up to 5-6 weeks following BCS, but not longer than 8 weeks. It’s important to note that radiation can cause scar tissue formation and other side effects. Women should discuss these issues with their doctors prior to making any decisions.
So why would any woman choose to get radiation? There are several reasons, including:
To decrease the chance of the cancer coming back
To decrease the risk of developing future cancers
Because radiation works faster than systemic therapies like chemotherapy
Radiation also helps reduce pain caused by lymphedema
It reduces the number of surgeries needed to repair asymmetrical breasts
In order to properly evaluate which women should receive radiation therapy, medical professionals must first determine exactly where the cancerous mass started. A mammogram can help identify the location of the cancer. Once the site of origin has been determined, then the next step is to decide whether the cancer originated inside the breast itself or outside the breast. The latter case involves a sentinel lymph node biopsy. During this procedure, a few tiny bits of radioactive material are injected into the fatty tissue surrounding the underarm lymph nodes. These nodes serve as filters for circulating cancer cells. When cancer cells reach them, however, they become activated and release substances called cytokines that attract white blood cells. As these cells travel through the bloodstream, they pick up and distribute cancer cells throughout the body. If cancer cells are seen within the sentinel lymph nodes, then the entire lymphatic system needs to be taken apart and examined further. If no cancer cells are found in the sentinel lymph nodes, then the surgeon will simply take out the rest of the lymph nodes. Only one third of cases require a sentinel lymph node biopsy.
Once the site of origin has been identified and the extent of the cancer has been established, radiation planning begins. At this point, the radiologist takes images of the breast using special equipment to create a three dimensional map of the breast. From this map, he or she determines the exact placement of the radiation beams. Most women undergo four views – each image representing a different view of the breast. The first set of images shows the position of the breast in relation to the chest wall. The second set shows the breast lying flat against the chest wall. The third set shows the breast standing upright while the fourth set shows the breast hanging down over the chest wall. Each set consists of multiple images.
After determining the position of the radiation beams, the radiologists then plan the dose distribution to ensure that the target volume receives enough energy to destroy the cancer cells without damaging normal breast tissues. Dose calculations vary depending upon the individual situation. Some women need a high dose of radiation to eradicate the cancer cells; others need a low dose. The goal is to prescribe the lowest possible dose without compromising the health of the normal breast tissues. To accomplish this, the physician uses computer software programs. He or she inputs information about the patient’s age, height, weight, lung capacity, race, gender, medications and smoking history, and family history. Based on the calculation results, the physician decides upon the recommended dose and schedule. After the actual radiation therapy session, another set of pictures are taken to see how well the treatment worked.
Most women begin radiation therapy approximately six weeks after their lumpectomy. They usually continue treatment until 6 months following their surgery. Treatment length varies based upon the prescribed total dose. Treatment generally lasts for 4-8 hours per day, Monday through Friday for eight weeks. Over the course of the entire week, women will spend 3-4 days in the hospital. Because radiation treatment requires daily visits to the clinic, it cannot be done over the weekend. Patients are required to wear a custom internal mammary shield designed to protect the heart and lungs. The shield is made of lead and contains slots of perspex that allow the beam to pass through. The shields are worn over the bra, and they weigh less than one pound.
Women undergoing radiation therapy should avoid strenuous activity for 24 hours prior to beginning treatment. They should also refrain from eating heavy meals because this could slow gastric emptying and make it harder to empty the bowel during the treatment. Also, since radiation affects healthy tissues, women should drink plenty of fluids during treatment. Many hospitals provide free water and soft drinks, but juice and alcohol are off limits. Some women find that ginger ale helps settle their stomachs.
As part of their preparation for radiation therapy, most women are asked to attend weekly sessions with a therapist. Therapy sessions are intended to help women cope with the physical changes they will undergo. Some therapists also incorporate relaxation techniques like meditation and hypnosis.
Following completion of radiation therapy, women are often encouraged to resume normal activities. They are advised to exercise moderately, limit sun exposure, and to avoid hot showers. Women are also told not to smoke cigarettes or to drink alcoholic beverages. They should check with their physicians as to whether they should return to work sooner rather than later.
Although radiation appears to have lost favor among surgeons lately, it still plays an important role in helping women recover from certain types of breast operations. While the choice to pursue radiation therapy remains personal, it is wise to consult with a qualified professional in order to make informed decisions about your care.
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