Does radiation after lumpectomy usually include the chest wall?

Whole breast radiation after lumpectomy includes the chest wall and is standard of care for all except women over 70 with small low grade tumors who commit to taking AIs. Radiation to the chest wall after mastectomy is done when the tumor is large and the patient is younger. There are breathing and prone positioning techniques which are sometimes used if there are concerns about the heart and lungs, but there is no way of eliminating all risk. My RO drew a sketch showing why this is the case.

Sarahnh, I did a lot of research before I had surgery since I have an underlying medical condition (Barrett's esophagus) that makes radiation more dangerous. Also, having autoimmune conditions like scleroderma and RA can cause adverse reactions. My RO understood my concerns and spent time explaining why any radiation would be more risky for me and what he could do to minimize the risks. I chose lumpectomy since my only alternative was skipping rads altogether. I had opted out of chemo for other medical reasons and decided radiation was the lesser of two evils in my situation.

The actual radiation treatment (whole breast and axilla) went fine. Six months later I did develop late stage grade 3 radiation pneumonitis causing pulmonary fibrosis and resulting low oxygen levels. My RO immediately got me in with a pulmonologist who specializes in interstitial lung disease. I was treated with corticosteroids and supplemental oxygen. The pulmonologist was really good about getting me off of oral steroids which have terrible side effects and onto inhaled steroids which target the lungs as quickly as he could. I had a scary couple of months but I'm doing fine now. There is permanent scarring and atelectasis in my right lung, but the fibrosis stopped progressing and my pulmonary function tests have returned to normal range.

This happens pretty rarely and generally to those with pre-existing conditions. I don't want to scare you off, but all treatments have potential side effects and doctors are used to dealing with them. The worst happened to me but I would do it again since breast cancer can be deadly, too. You had surgery on your right breast so your heart should not be in the radiation field. If there are specific lung conditions you are worried about, ask the RO how radiation might affect them and what your individualized risk might be.

I read all kinds of research papers (my math/chem/physics background was useful here) but this article has a pretty good easy to understand summary: https://www.oncolink.org/cancers/breast/treatments...

Best wishes for making the right decision for you from a fellow granite stater.

Sarahnh, There are many doctors, including pulmonologists, who are not familiar with pulmonary fibrosis. The genetic IPF you are worried about is eventually fatal even though there are now meds to slow its progression. Since there is no test that can be done you are definitely tempting fate no matter which type of radiation you have since a small area of the lung will be in the portal. Once the PF starts it can stay in the portal, spread throughout the affected lung as mine did, or spread to the other lung as well (about a 20% chance of this occurring from what I read.) You could contact a pulmonologist who specializes in interstitial lung disease. MGH, Beth Israel, and St. Elizabeth's are Boston PF centers of excellence. A link for other centers in the US is

https://www.pulmonaryfibrosis.org/researchers-heal...

My ILD pulmonologist is wonderful, but he freely admitted that there are many unknowns and even though he is an expert in the field he often doesn't have any answers. His job is helping people live longer since he usually can't cure them. With your academic background you will appreciate the story he told me when I initially asked about my prognosis. He said his daughter in fifth grade came home from school one day and told him, "Daddy, math is magic, you can use it to solve all kinds of problems!" I chuckled, and he then said to me, "Math is magic, but medicine is not," a math related version of the "We don't have a crystal ball" answer. He was not surprised at my bad reaction since an upper GI bleed and the Barrett's esophagus in my medical record made it highly probable that I already had occult ILD from chronic microaspiration of acid and pepsin. Going into this I knew cancer could be triggered in my esophagus but didn't know my lungs were at so much risk.

One thing to keep in mind is that many of the treatments for MBC have ILD as a listed side effect. However, even if there is a recurrence, it is often many years down the road. Given your good response to chemo and the dire consequences of IPF being triggered by radiation, you seem to have an argument for deviating from the standard of care, skipping radiation altogether, and (at worst) buying time. It might be worth consulting an ILD specialist but it's probable that s/he won't be able to give you a good answer.

Best wishes for making the right decision for your situation. Keep our state motto in mind (lol!)

Hi Sarahnh - My pulmonologist is Dr. Robert Hallowell in the Interstitial Lung Disease Program at MGH. There are six other pulmonologists in the program and it is considered a center of excellence by the Pulmonary Fibrosis Foundation.

Appealing for proton radiation is a good idea. Hopefully I'll never have to worry about this again, but that is my planned course of action if I have a local recurrence in the future.

All the best for finishing your treatment with no adverse effects!

I had five weeks of radiation to my right breast after a lumpectomy. I was in the hospital three times soon after and was diagnosed with Pneumonia three times until I was seen by an infectious disease specialist who determined it was not Pneumonia nor were all the different antibiotics (horrible side effects) were not the appropriate treatment. He put me on IV Steroids (arghh) and sent me home on Prednisone (double arghh). He determined it was Pneumonitis and inflammation, not infection and after two CT scans and three Chest xrays that it was radiation fibrosis. I know that they do all they can to prevent damage to the lungs, but in my case, that wasn't the outcome. I wish you all the best with your treatment

Maggie15, I am outraged that your RO said the odds of RP are so low. My RO told me there was a 1-2% chance of pulmonary fibrosis for non-smokers. Of course he didn’t tell me the odds double when the internal mammary nodes are included in the radiotherapy treatment plan (Poortman. EORTC. 2015 NEJM.)

Almost anyone having radiotherapy will show lung changes on CT after treatment, and most cases have no clinical symptoms and resolve on their own. So CT imaging alone may not be a concern. But for those who do have symptoms, prompt treatment with steroids is critical. So sorry yours was not caught earlier. Nor was mine, despite my reporting of symptoms.

Reshma Jagsi of U Michigan has written on radiation therapy and physicians missing patient-reported symptoms, especially in younger and non-white patients.