Why Radiation is a risk for LE

kira66715 · September 2012

I've been doing some research about radiation and LE, and looking at whole breast radiation, with current techniques, NOT with additional radiation delivered to the nodes--axillary or supraclavicular, and I found that with standard whole breast radiation, even with normal "tangents" (the upper line), most of the level I/II nodes get a full dose of radiation--which will irreversibly damage them.

I became aware of this during my radiation and was told "not to worry"

Here is information to arm yourselves with and discuss with your radiation oncologists.

I do understand that radiation therapy decreases local recurrence and is standard of care with breast conservation, but I don't think we are--I certainly wasn't--informed that whole breast radiation will involve many of our axillary nodes--and I think we should be discussing this with our radiation oncologists.

And, "radiation to the level 1/2 nodes has never been proven to cause LE" as I was told--is a flat out lie.

From this week's Oncology: a Review Article http://www.cancernetwork.com/breast-cancer/content/article/10165/2101226

ONCOLOGY. Vol. 26 No. 9
REVIEW ARTICLE
Irradiation in Early-Stage Breast Cancer: Conventional Whole-Breast, Accelerated Partial-Breast, and Accelerated Whole-Breast Strategies Compared
By Kent W. Mouw, MD, PhD1, Jay R. Harris, MD2 | September 12, 2012
1Harvard Radiation Oncology Program, Boston, Massachusetts, 2Dana-Farber Cancer Institute and Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts

WBI is usually delivered via tangent fields using high-energy x-rays. Forward planning techniques allow addition of sub-fields to optimize dose homogeneity; intensity-modulated radiotherapy (IMRT) is typically not required. Standard tangent fields cover a substantial percentage of level I and II axillary nodes. “High tangent” techniques can be used to treat a greater percentage of the axilla.

http://www.ncbi.nlm.nih.gov/pubmed/15667953 This article argues that tangents should be planned to get more radiation to the axilla

http://www.ncbi.nlm.nih.gov/pubmed/21088091 This article also suggests that radiation planning be adjusted to get full coverage of the axilla--in early breast cancer

http://www.ncbi.nlm.nih.gov/pubmed/20853176 This article argues that radiation after SNB will treat occult mets in the nodes, with minimal LE

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Binney4 · September 2012

Frown Surprised Yell Tongue out

Thanks, Kira. Who knew?
Binney

carol57 · September 2012

I'm still wondering why there is no way to shield the axilla, whenever the intent is to capture the breast tissue only. No protection device to cover it, or unlike an X ray, would the radiation penetrate regardless?

kira66715 · September 2012

Carol, it's quite easy to shield the axilla, there are lead shields, and Andrea Cheville did a study where she identified the nodes that drain arms with SPECT and had them shielded--about a year ago. It has NOT become standard of care, unfortunately.

She specifically addressed radiaition to node negative women:

"In an effort to deliver therapeutic doses of radiation to the breast, lymph nodes under the arm are innocent bystanders that often are irrevocably harmed. Minimizing harm to these nodes during breast cancer treatment is the most effective way we have seen to reduce women's risk of developing lymphedema," says the study's lead investigator, Andrea Cheville, M.D., a consultant in Physical Medicine and Rehabilitation at Mayo Clinic in Rochester, Minn., who specializes in lymphedema management.

Also, radiation is planned on a CT, and the tangents can be modified.

http://www.mayoclinic.org/news2010-rst/6084.html

And, position can make a difference: the prone position gets less lung/heart/nodes.

Guidelines for radiation are not prescribed, ASTRO does studies and makes recommendations, but it comes down to the individual rad onc, and the global standard of care is not to shield the axilla--at this time.

But, I feel, women should know that their axillary nodes are being irradiated, not JUST the breast. As well as their hearts and lungs.

Informed consent should include the details, IMO--mine was like "radiation can make you tired, irritate your skin and lower your blood count" No details at all.

cider8 · September 2012

This is very timely info for me. I just had some random DCIS cells show up in some tissue removed from breast recon. My breast surgeon says I'm looking at breast radiation. I'm still waiting on final pathology before I can go on to my RO. I got out of rads a year ago because my margins were clean from MX and only one positive node. I did have 21 nodes removed and experience latent signs of LE. I'm disappointed I'll be needing radiation, but this will help me grill my RO. She was VERY open to my questions and concerns last time, so I am hopeful the SE can be minimal. I wonder if protecting my already dissected axilla will prevent more LE. Last time she said the axilla wouldn't be radiated, but this stuff says other wise.

kira66715 · September 2012

Cider, in the rad onc's thought process,the axilla isn't radiated, because they're not doing a special field to include it. But, as we're figuring out, "just" whole breast radiation hits the axilla.

It's great that you have a responsive rad onc.

Good luck,and let us know how you're doing.

kira66715 · September 2012

Quess what just showed up on BreastCancer.org, information about the NYU study that showed that laying prone reduced radiation to the heart and lungs, and I've seen the CT images in JAMA, and can't help but think it reduces radiation to the axillary nodes as well.

http://www.breastcancer.org/treatment/radiation/new_research/20120911.jsp

carol57 · September 2012

The list of studies on that page includes one titled 'Mammosite System Seems Just as Good as Whole-Breast Radiation' --so are we headed toward no whole-breast radiation when treatment does not need to include the axillary nodes?

kira66715 · September 2012

Carol, mammosite has largely been replaced by newer devices, like savi. To qualify for brachytherapy which is quite expensive, you need to have a low grade tumor and a breast and depth to handle the device. Last year there was a review of brachytherapy in Medicare patients and cosmesis was not good, and I think there were more subsequent mastectomies. I need to re read it. I couldn't have had brachytherapy due to smaller breast size.

Ah, here it is on bc.org--brachytherapy causes more complications/mastecomies in older women (they used medicare data--so they just looked at older women)

http://www.breastcancer.org/treatment/radiation/new_research/20120502.jsp

When I worked for the rad onc, there was one breast surgeon who pushed brachytherapy on practically all his patients, and one was a high risk triple negative person, who did not meet guidelines, and she relapsed within months. Other women had terrible scars and hematomas. And the one week business--it's more like 2 weeks as you have surgery, get the device put in a few days later, start on a subsequent Monday-Friday, have to wait a few days for the incision to heal after the device is out, and then they could shower. Due to the open wound/device, everyone is on antibiotics. But, in two weeks or so, you're done....

Hypothetically, and for the right person, it would totally spare the nodes. It just delivers radiation to the surgical cavity.

BeckySharp · September 2012

I had mammosite and still have LE! My radiologist says the radiation did not cause it because of mammosite. Said I fit the profile for mammosite perfectly. Time will tell.

carol57 · September 2012

Becky, you had just 2 nodes removed, and ruling out radiation as an LE contributor, I guess you're one of our poster children for why even just one or a few nodes out puts us at real LE risk. My count was 5 nodes; zero radiation.

Kira, my mother-in-law had BC in 1970, with a radical mx followed by weeks of radiation. it scarred her lungs and though she lived until 2011, it was the scarring that truly sent her into a downward health spiral in the end--every minor upper respiratory infection seemed to morph into pneumonia, because she had a very difficult time exhaling as she became more frail with age, and repeat pneumonia bouts simply depleted her.

My own mother also had BC at about the same time, with the same treatment. Her radiation therapy is the primary suspect for cataracts that were fully developed by age 43, necessitating surgery and seemingly setting her up for the surgery sequela of a detached retina--and more surgery.

I take great comfort in radiation advances that allow the field to be chosen purposefully today. In my mom/mom-in-law's BC generation, that was not really the case and their experiences bear witness to the consequences. Mom is and M-i-L was a 40-year+ survivor, before the advent of chemo and any understanding of hormones and cancer, so radiation must have been key to their survival. What a double-edged sword, but your posts here make me optimistic for more effective rads, with less collateral damage now and in the future.

purple32 · September 2012

Not disagreeing with anything here or disputing, but just a note ..I have had NO radiation at all. Oooops...unless you count a good half dozen chest x rays due to my lung disease!

kira66715 · September 2012

Purple, Jane Armer showed a photograph of a woman with a hugely swollen arm and hand and said she had not had radiation--clearly some of us are at higher risk. And it doesn't take much to bring it on.

But for those of us who had whole breast radiation, I personally was never informed that most of my axillary nodes were getting radiated and I told the rad onc I'd gotten LE right after surgery and before rads.

If I knew then, what I know now, I would have asked her to minimize the amount of radiation delivered to my negative node axilla.

Informed consent means to really inform the patient. I would have liked to know about the axillary radiation, the benefits and the risks, and the rad onc not to lie and say that radiation to the nodes never causes LE. Seriously misinformed/uninformed.

Carol, my MIL was offered a lumpectomy, in the Bernie Fisher trial in Pittsburgh, and declined due to fear of rads. She was a 40+ year survivor, but with LE.

I saw some impressive radiation pulmonary fibrosis during my time with the rad onc....

I truly just assumed it was just my breast getting radiated. Knowing how much of the axilla gets radiated, it makes my think of the Guiliano trial, where 1-2 positive nodes and a T2 tumor did just as well with SNB without ALND. They had "standard" treatment--and many likely got a good dose of radiation to the axilla. I need to look at the trial again.

Why Radiation is a risk for LE

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