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Intimate Apparel

2011-04-01 13:55:00

I’ve got breast cancer – series (for the first two articles in this series, please refer to the Feb. ’11 and Mar. ‘11 issues)

Question: I’ve just been diagnosed with breast cancer. I’m frightened. I have lots of questions and concerns. If I ever needed a “coach,” I need one now. Can you help me?

Answer: As you might recall from my first two articles in this series, most women, like you, have dozens of questions. Some of these questions might deal with: a second opinion, method of treatment, alternative treatments, radiation, chemotherapy, stigmas, depression, support groups, going out in public, clothes, wigs, bras, swimsuits…and a host of other topics. To know that they all fit in one of five areas, is part of the organization that will help you go about handling this challenge. These areas are: physical, mental, social, spiritual and material. This article, as did last month’s article, will deal with the physical side of cancer, and one of the most common of all treatments…radiation therapy. While there is much that can be written on this subject, in this series I will attempt to provide an overview. In doing so, I have sought the help of information supplemented by www.cancer.org and a host of other sites. Local versus systemic therapy Local therapy is intended to treat a tumor at the site without affecting the rest of the body. Surgery and radiation therapy are examples of local therapies. Systemic therapy refers to drugs which can be given by mouth or directly into the bloodstream to reach cancer cells anywhere in the body. Chemotherapy, hormone therapy, and targeted therapy are systemic therapies. Adjuvant and neoadjuvant therapy Patients who have no detectable cancer after surgery are often given adjuvant (additional) systemic therapy. Doctors believe that in some cases cancer cells may break away from the primary breast tumor and begin to spread through the body by way of the bloodstream even in the early stages of the disease. These cells can’t be felt on a physical exam or seen on x-rays or other imaging tests, and they cause no symptoms. But they can go on to become new tumors in other organs or in bones. The goal of adjuvant therapy is to kill these hidden cells. Not every patient needs adjuvant therapy. Generally speaking, if the tumor is larger or the cancer has spread to lymph nodes, it is more likely to have spread through the bloodstream. But there are other features, some of which have been previously discussed that may determine if a patient should get adjuvant therapy. Some patients are given treatment, such as chemotherapy or hormone therapy, before surgery. The goal of this treatment is to shrink the tumor in the hope it will allow a less extensive operation to be done. This is called neoadjuvant therapy. Radiation therapy Radiation therapy is treatment with high-energy rays or particles that destroy cancer cells. This treatment may be used to kill any cancer cells that remain in the breast, chest wall, or underarm area after breast-conserving surgery. Radiation may also be needed after mastectomy in patients with either a cancer larger than 5 cm in size, or when cancer is found in the lymph nodes. Radiation therapy can be given in 2 main ways. External beam radiation This is the most common type of radiation therapy for women with breast cancer. The radiation is focused from a machine outside the body on the area affected by the cancer. The extent of radiation depends on whether a lumpectomy or mastectomy was done and whether or not lymph nodes are involved. If a lumpectomy was done, most often the entire breast gets radiation, and an extra boost of radiation is given to the area in the breast where the cancer was removed to prevent it from coming back in that area. Depending on the size and extent of the cancer, radiation may include the chest wall and underarm area as well. In some cases, the area treated may also include supraclavicular lymph nodes (nodes above the collarbone) and internal mammary lymph nodes (nodes beneath the breast bone in the center of the chest). When given after surgery, external radiation therapy is usually not started until the tissues have been able to heal, often a month or longer. If chemotherapy is to be given as well, radiation therapy is usually delayed until chemotherapy is complete. Before your treatments start, the radiation team will take careful measurements to determine the correct angles for aiming the radiation beams and the proper dose of radiation. They will make some ink marks or small tattoos on your skin that they will use later as a guide to focus the radiation on the right area. You may want to talk to your health care team to find out if these marks will be permanent. Lotions, powders, deodorants and antiperspirants can interfere with external beam radiation therapy, so your health care team may tell you not to use them until treatments are complete. External radiation therapy is much like getting an x-ray, but the radiation is more intense. The procedure itself is painless. Each treatment lasts only a few minutes, but the setup time – getting you into place for treatment – usually takes longer. The most common way breast radiation is given is 5 days a week (Monday thru Friday) for about 5 to 6 weeks. Accelerated breast irradiation: The standard approach of giving external radiation for 5 day a week over many weeks can be inconvenient for many women. Some doctors are now using other schedules, such as giving slightly larger daily doses over only 3 weeks. Giving radiation in larger doses using fewer treatments is known as hypofractionated radiation therapy. This approach was studied in a large group of women who had been treated with breast conserving surgery and who did not have cancer spread to underarm lymph nodes. When compared with giving the radiation over 5 weeks, giving it over only 3 weeks was just as good at keeping the cancer from coming back in the same breast over the first 10-years after treatment. Newer approaches now being studied give radiation over an even shorter period of time. In one approach, larger doses of radiation are given each day, but the course of radiation is shortened to only 5 days. Intraoperative radiation therapy (IORT) is another approach that gives a single large dose of radiation in the operating room right after lumpectomy (before the breast incision is closed). Other forms of accelerated radiation are described below in the section, “Brachytherapy.” It is hoped that these newer approaches may prove to be at least equal to the current, standard breast irradiation, but few studies have been done comparing these new methods directly to standard radiation therapy. It is not known if all of the newer methods will still be as good as standard radiation after many years. This is why many doctors still consider them to be experimental at this time. Women who are interested in these approaches may want to ask their doctor about taking part in clinical trials of accelerated breast irradiation now going on. 3D-conformal radiotherapy: In this technique, the radiation is given with special machines so that it is aimed better at the area where the tumor was. This allows more of the healthy breast to be spared. Treatments are given twice a day for 5 days. Because only part of the breast is treated, this is considered to be a form of accelerated partial breast irradiation. Possible side effects of external radiation: The main short-term side effects of external beam radiation therapy are swelling and heaviness in the breast, sunburn-like skin changes in the treated area and fatigue. Your health care team may advise you to avoid exposing the treated skin to the sun because it may make the skin changes worse. Changes to the breast tissue and skin usually go away in 6 to 12 months. In some women, the breast becomes smaller and firmer after radiation therapy. Having radiation may also affect a woman’s chances to have breast reconstruction. Women who have had breast radiation may have problems breast feeding later on. Radiation to the breast can also sometimes damage some of the nerves to the arm. This is called brachial plexopathy and can lead to numbness, pain and weakness in the shoulder, arm and hand. In rare cases, radiation therapy may weaken the ribs, which could lead to a fracture. In the past, parts of the lungs and heart were more likely to get some radiation, which could lead to long-term damage of these organs in some women. Modern radiation therapy equipment allows doctors to better focus the radiation beams, so these problems are rare today. A very rare complication of radiation to the breast is the development of another cancer called angiosarcoma. These rare cancers can grow and spread quickly. Brachytherapy Brachytherapy, also known as internal radiation, is another way to deliver radiation therapy. Instead of aiming radiation beams from outside the body, radioactive seeds or pellets are placed directly into the breast tissue next to the cancer. It is often used as a way to add an extra boost of radiation to the tumor site (along with external radiation to the whole breast), although it may also be used by itself (see below). Tumor size, location, and other factors may limit who can get brachytherapy. There are different types of brachytherapy. Intracavitary brachytherapy: This method of brachytherapy consists of a small balloon attached to a thin tube. The deflated balloon is inserted into the space left by the lumpectomy and is filled with a salt water solution. (This can be done at the time of lumpectomy or within several weeks afterward). The balloon and tube are left in place throughout treatment (with the end of the tube sticking out of the breast). Twice a day a source of radioactivity is placed into the middle of the balloon through the tube and then removed. This is done for 5 days as an outpatient treatment. The balloon is then deflated and removed. This type of brachytherapy can also be considered a form of accelerated partial breast irradiation. Like many forms of accelerated breast irradiation, there are no studies comparing outcomes with this type of radiation directly with standard external beam radiation. It is not known if the long-term outcomes will be as good. Interstitial brachytherapy: In this approach, several small, hollow tubes called catheters are inserted into the breast around the area of the lumpectomy and are left in place for several days. Radioactive pellets are inserted into the catheters for short periods of time each day and then removed. This method of brachytherapy has been around longer (and has more evidence to support it), but it is not used as much anymore. While these methods are sometimes used as ways to add a boost of radiation to the tumor site (along with external radiation to the whole breast), they are also being studied in clinical trials as the only source of radiation for women who have had a lumpectomy. In this sense, they can also be considered forms of accelerated partial breast irradiation. Early results have been promising, but long-term results are not yet available, and it’s not yet clear if irradiating only the area around the cancer will reduce the chances of the cancer coming back as much as giving radiation to the whole breast. The results of studies now being done will probably be needed before more doctors recommend accelerated partial breast irradiation as a standard treatment option. Next month will be the final article of this series dealing with the physical area of breast cancer. It will be dealing with chemotherapy, the most used of all systemic therapies.