Radiotherapy for breast cancer

This leaflet has been given to you in addition to the information you will receive from your clinical oncologist (who is a specialist in cancer treatment) or consultant radiographer. Their team will be caring for you during your treatment. This team includes therapeutic radiographers and may also include radiotherapy review clinic nurses, your breast care nurse specialist, Macmillan support radiographers and physiotherapists.

This leaflet describes radiotherapy planning and treatment. It also explains the side-effects which you may experience during and after treatment.

Each person’s treatment will vary, so the information given is a general guide. The healthcare team looking after you will explain your treatment and the side-effects in detail.

You may have already had surgery with a lumpectomy or mastectomy, and/or chemotherapy/hormone therapy.

Occasionally radiotherapy may be the first and only treatment for breast cancer. If you have any questions after reading this leaflet, please speak to the team looking after you or ring the numbers at the end of leaflet.

Staff will make every effort to meet your individual needs or will direct you to the person who can help.

Please do not bring any valuables into hospital with you as the Trust cannot accept liability for loss or theft.

What is radiotherapy?

Radiotherapy is the use of high energy X-rays and other types of radiation, to treat cancer and pre-cancerous changes (referred to as ‘ductal carcinoma in situ’ or ‘DCIS’).

The radiotherapy causes damage to cancer cells in the treated area. Although normal cells are also affected, they can repair themselves and are able to recover.

Radiotherapy is a local treatment that reduces the chance of breast cancer returning in the areas that are treated. This means it only affects the part of the body that is treated.

When you are having your radiotherapy you do not feel anything and it does not make you radioactive.

It is perfectly safe for you to be with other people, including children and anyone who may be pregnant, throughout your treatment.

You may hear a buzzing noise when the machine is switched on. You will have your radiotherapy on a treatment machine, called a linear accelerator, shown here in the photograph.

You will see your radiographers at each treatment session and they will be happy to answer any questions you may have.

How often is it given?

Radiotherapy is given once daily, Monday to Friday, as an outpatient appointment. The number of treatments required varies from 5 to 23 treatments. Where possible radiotherapy is given consecutively on weekdays, although it may not start on a Monday.

If there are bank holidays within your treatment course the staff will advise you. Your radiographer will be able to explain the details of your individual radiotherapy appointments. Your treatment will usually be given as an outpatient.

Visiting us before your treatment

If you would like to visit the radiotherapy department before starting treatment, please call 0113 206 7603. This visit can be very useful as you can find out more information about radiotherapy and ask questions.

Who will I meet?

Therapeutic Radiographers

Radiotherapy is given by therapeutic radiographers of any gender who are highly trained in the accurate planning and delivery of radiotherapy treatment. You will see your radiographers at each treatment session and they will be happy to answer any questions you may have.

Student radiographers

The radiotherapy department is a training centre for therapeutic radiographers. They are supervised at all times. If you do not wish students to be present please speak to a member of staff. This will not affect your treatment or care.

Important advice before your treatment

Pregnancy

It is very important that patients of childbearing potential are not pregnant at the start of a course of radiotherapy and that they do not become pregnant during a course of radiotherapy because it can have an effect on the unborn child. You should use an effective form of barrier contraception and avoid hormone based contraceptives. Please discuss this with your clinician if you require further information or guidance.

For more information see the ‘Contraception and pregnancy during cancer treatment’ leaflet. Please do not hesitate to ask your oncologist / consultant radiographer or breast cancer nurse specialist if you have any questions or concerns.

Planning your treatment

Your first appointment for radiotherapy will be a planning appointment. This will be used to gather all the information we need to accurately plan your treatment. We will contact you by phone, with an appointment for your radiotherapy planning session. Directions to the hospital and transport arrangements will be discussed with you at this point.

You may see your clinical oncologist / consultant radiographer (or a member of their team) at this appointment.

This is an ideal opportunity for you to ask questions. If you have not previously consented to your treatment you will be asked to sign a consent form.

What to bring with you:

• a list of all questions you may have;
• an up-to-date list of all the medications you are taking (including inhalers, sprays, vitamins or herbal products);
• any medication that you may need during your visit;
• something to eat and drink and something to occupy yourself with, as this first visit may be quite lengthy (up to two hours).

Your planning scan

In order to plan your treatment you will have a planning CT scan. This is done on a machine called a CT Scanner, shown here.

It allows the images from the scan to be sent to the radiotherapy computer planning system.

There will be several members of staff present at your scan, such as therapeutic radiographers, and possibly a mould room technician and a dosimetrist (the person who will produce the computer plan for your treatment).

If you wear a head covering you may be required to remove it for your radiotherapy planning scan and also for treatment.

If your comfort or the reproducibility of the position for radiotherapy is going to be affected the radiographers will discuss this with you before you have your scan.

You will be asked to undress to the waist and given a gown to wear. You can bring your own dressing gown from home if you prefer. The radiographers will help you into the correct position for planning and treatment. The scan will be done with you lying in the same position that you will also be in for your treatment. You will be asked to lie as still as you can during this process. The actual scanning process will only take a few minutes.

To define the treatment area, the radiographers draw four small crosses on your chest; two on your front (breast bone) and one on either side of your chest. At the end of the scan these crosses will be replaced by permanent marks (tattoos), as shown in the picture on the next page.

These permanent marks help us to ensure that you are in the same position each day. It also means that you can wash without worrying about your marks coming off.

Following the scan the radiographers will give you the time of your first appointment on the treatment machine which is most likely to be a couple of weeks after the planning visit. The radiographers will talk to you about any further appointments you have. You will be able to drive your car or go to work after your scan.

All of the information taken at this stage is used to produce your treatment plan. We plan your treatment carefully to make sure we are treating all of the areas necessary, whilst avoiding other structures such as your heart and lungs as much as we possibly can. The radiotherapy plan is tailor made to your shape and size.

Seroma

A seroma is a collection of fluid that can develop after your surgery. Small seromas are common after breast surgery and the fluid is usually reabsorbed by the body, often over a number of months. If you have a large seroma your surgical team may remove some of the fluid from it using a needle and a syringe. This is called ‘aspiration’. The fluid can build up again after it has been aspirated.

Voluntary Deep Inspiratory Breath Hold (vDIBH) technique

If you are having your left breast, left chest wall or the lymph nodes running alongside your breast bone treated, we may advise that you are treated using vDIBH.

vDIBH is a technique where you hold your breath for short periods of time during your radiotherapy planning CT scan and for treatment. We use vDIBH because the heart sits behind the left breast and chest wall. When you hold your breath, your lungs fill with air and your chest wall moves away from your heart. Therefore, this minimises the amount of heart that will be in the treatment area.

You will have a planning CT scan with you breathing normally. This will be followed by a second CT scan whilst holding your breath.

When you have your second CT scan, you will be asked to hold your breath for the whole scan (usually 15 seconds). The radiographers will talk to you through an intercom. They will let you know when to hold your breath and when to breathe normally again.

Your radiotherapy will start a couple of weeks later. This process will be repeated so that the radiotherapy is delivered whilst you are holding your breath for short periods (usually about 25 seconds).

The radiographers will monitor your breathing and positioning from outside the room using CCTV cameras. If you release your breath without being told to, the radiographers will see this and switch off the treatment. The radiographers will explain this to you in more detail before your first treatment.

You may find it helpful to view the information video on the website below. This national resource is available due to collaboration between several radiotherapy centres in the UK. The video was filmed in the radiotherapy department in Leeds.

www.respire.org.uk/

Having your treatment

When you arrive for your treatment you should go to the radiotherapy main reception desk at the entrance of the radiotherapy department. On the first occasion you will be given all your appointments and be escorted to the waiting area for your machine. The radiographers will explain what will happen and answer any questions that you may have.

Treatment is usually given daily, Monday to Friday, however your treatment may start on any day of the week. Whenever possible you will be treated at the time of day that suits you, but this cannot always be arranged or guaranteed. There may be occasions when you may have a longer stay in the department or be asked to attend at a different time, for example to see your oncologist / consultant radiographer.

You may need to partly undress and put on a gown; the radiographers discuss this with you when you first attend the department.

Although you have the small permanent marks on your skin, the radiographers may need to draw around them each time you come for treatment. This is part of the quality checking procedure for your treatment.

If you have pen marks on your skin please do not scrub at them to remove as this may irritate your skin.

You may prefer to wear older clothing as the marks may discolour fabric. It is also generally advisable to wear loose clothing around the treated area.

The radiographers will carefully position you and adjust the treatment couch and machine to the correct positions. They will also take images to check the accuracy of the treatment, and to check your shape hasn’t changed significantly. This takes a few more minutes. Images are usually taken for the first few treatments, and also intermittently during treatment.

You will be asked to stay as still as possible during the treatment but you should breathe and swallow normally.

Once you are in the correct position the radiographers will leave the room to switch on the machine. You will only be alone for a few moments at a time. The radiographers will be watching you on a closed circuit TV (CCTV) monitor during treatment. The CCTV camera is not recording or saving any images. There is also an intercom system so the radiographers can talk to you. If you would like to listen to music during your treatment please let us know.

The treatment only takes a few minutes but you will be in the treatment room for about 10-20 minutes. The machine stops automatically after your prescribed dose of treatment has been given. The radiographers can stop the machine at any time if needed. The treatment machine makes a buzzing sound when switched on. You do not feel anything.

The radiographers may need to come in and out part way through each treatment. After the treatment is complete the radiographers will come back into the room and help you off the couch.

On some days the radiotherapy department may be busy and there may be a delay before your treatment. We will keep you informed of any delays, please see the delay signs in the waiting areas. It may be a good idea to bring something to eat and drink with you, including any supplement drinks you have been asked to have and any medication you may need.

Your treatments will generally be on the same machine, although there may be days when this machine is being serviced and your treatment will be in a different room.

It is very important that you do not miss treatment days as it may make your treatment less effective. If you feel you are unable to attend for any reason please telephone us so that we can discuss this with you. If you have any queries about your appointment times please discuss these with the radiotherapy co-ordinators on your treatment unit.

Nutrition

It is important that you are well nourished and drink plenty of fluids during your treatment in order to keep yourself healthy and to help your body to heal.

When outside in the sun

Please do not expose the treatment area to the sun whilst you are having radiotherapy treatment. Please make sure it is covered completely. Once treatment has finished, you will still need to use sun cream factor 50 if you are exposing the treated area to the sun. This applies to any skin tone.

Side-effects of radiotherapy

Side-effects can be divided into short term (acute) effects that happen during or soon after treatment and long term effects, occurring months or years later. Some side-effects are common, whilst others are rare. The area and amount of treatment given to you will affect which side-effects are most likely to happen to you. Your oncologist / consultant radiographer will have discussed these with you, before taking your written consent. If you develop any radiotherapy side-effects you will be given advice and support by your healthcare team.

Short term side-effects from radiotherapy

Most side-effects are common and are temporary. Side- effects tend to build up from two weeks after the treatment starts and are usually worse after treatment has finished. They generally last a number of weeks or months after the treatment has finished.

Please tell us how you are feeling, particularly if your symptoms worsen, so that we can advise and treat you.

Swelling

Your breast or chest wall and underarm may become a little swollen during and after the radiotherapy treatment. Fluid drainage from the tissues can be slower after you have had any type of surgery to the armpit. Radiotherapy can cause a build-up of fluid in the tissue being treated, which results in temporary swelling. Sometimes the scar area can feel hard and irregular and can take some months to settle.

Tiredness (fatigue)

Nearly all patients having radiotherapy will feel tired. Be prepared to take things easy during treatment and allow for extra rests. There is a Macmillan information leaflet available and if you would like a copy, or support with your fatigue please ask a member of staff.

Fatigue usually improves in the weeks to months after treatment.

Things you can do to help yourself:

• Gentle exercise can help reduce the symptoms of fatigue.
• Having enough to drink can prevent tiredness from dehydration.
• Small meals or snacks eaten more than three times a day may be easier to face.
• Try to get a good night’s sleep where possible.
• Try to ‘pace’ yourself and listen to what your body is telling you. Rest if you need to.
• Pick out the things that you enjoy and try to accept help with other tasks.
• Little and often is the rule of thumb.

Skin reaction

The skin in the treated area starts to redden or darken about seven days after your radiotherapy started. It may become dry and itchy. Later it may peel and become weepy.

Avoid hair removal where possible, including shaving, waxing, cream and lasers unless advised otherwise by your consultant, nurse or radiographer.

Before you go in for your treatment the radiographers will explain what is likely to happen to your skin and how to look after it. They will also give you a leaflet to take home.

If you are concerned about your skin reaction please talk to your radiographers or contact the review clinic nursing staff in the Princess Royal Suite 0113 206 7587.

Hair loss

Armpit and/or chest hair is the only hair that could potentially be affected by the radiotherapy. It will temporarily stop growing and may fall out. Sometimes the hair will not grow back after treatment.

Pain

After radiotherapy you may have some discomfort in the treated area. This is not usually severe. You may also get a sharp pain that lasts only for a few seconds. This is quite common and thought to be due to healing nerves. Please tell your radiographer or nurse if the pain becomes severe.

Cough

If you are having the lymph nodes that run alongside your breast bone treated, there is a small risk that you may develop a cough in the 6-8 weeks after radiotherapy. This may require treatment so please report it to your oncologist / consultant radiographer or breast clinical nurse specialist.

Long term side-effects from radiotherapy

Long term side-effects can happen months to years after your radiotherapy. We believe that the benefits of your radiotherapy treatment outweigh the risks involved. The list below can seem alarming, but please remember serious late side-effects are very rare. The effects can vary from person to person and not all reactions occur in all people.

Skin changes

It is common to notice a slight change in the colour of your skin some months after treatment has finished. This is usually very mild and does not cause any problems, but may last. A minority of patients have increased pigmentation long term.

A less common change in the skin is called ‘telangiectasia’. This is where tiny blood vessels called capillaries are visible under the skin. This appears to be more common in patients following lumpectomy where a ‘boost’ is given. Although these changes are permanent, they do not cause any health risk or problem.

Scar tissue

After surgery and radiotherapy scar tissue (fibrosis) may form. This tends to be more noticeable around your surgical scar. In the months and years following treatment you may notice an alteration of the shape around the treated area. For example, after a lumpectomy and radiotherapy, the treated breast may become a little firmer, smaller and higher.

If you are at all unsure about any changes to your breast area please contact your breast care nurse specialist for advice.

Lymphoedema

A swelling of the arm or hand may develop due to a build-up of fluid. This is called ‘lymphoedema’.

If this occurs, it is usually mild and comes and goes. Sometimes the problem is more severe. The chances of developing this are related to the type of surgery you have had in the armpit. It is also related to whether the armpit or lower neck is included in the radiotherapy treatment area.

There are simple precautions you can take to help prevent lymphoedema occurring.

These include:

• regular gentle stretching exercise of the arm;
• avoiding heavy lifting with that arm (e.g. heavy shopping bags);
• use the opposite arm where possible for blood tests, blood pressure readings and injections;
• wear protective clothing and gloves when gardening etc. to avoid cuts and grazes;
• if you have a cut or graze to the affected arm, wash immediately and apply an antiseptic cream. If the cut or graze appears infected please seek medical advice;
• if symptoms persist your oncologist / consultant radiographer may refer you to the specialist lymphoedema nurses for assessment and management.

Pain or discomfort

A rare side-effect is a general ache and tenderness in the breast, ribs or chest wall. These pains usually respond to painkillers such as paracetamol. If the pain continues your oncologist / consultant radiographer or breast care nurse specialist can provide advice and further medication if needed.

Shoulder stiffness

If your armpit and lower neck are included in the radiotherapy treatment area there is a risk that your shoulder will become stiffer in the long term. It is important to maintain movement of your shoulder. Continuing with the exercises you were given after surgery or the exercises in the back of this booklet is helpful.

Very rare long term side-effects from radiotherapy (risk between 1 in 200 and 1 in 1000)

After radiotherapy your ribs, breast bone or collar bone in the treated area may become more brittle. Although this may cause some pain, you may also be completely unaware of it.

There has been worry in the past about the effect of radiotherapy on the heart and lungs. The likelihood of such problems is now very low, because modern techniques reduce the dose of radiotherapy to the heart and lungs.

Very rarely radiotherapy can cause tumours to develop in the skin and connective tissue of the breast or in the lungs. If you notice sudden changes in your skin (in the area that was treated) in the years after radiotherapy please seek prompt medical advice. Any new persistent cough for three weeks or more should also be discussed with your GP.

These are possible serious side-effects of your treatment but it is important to bear in mind that these are very rare. If it does happen, it is likely to be many years after your treatment.

It is important to maintain a healthy lifestyle as this is likely to reduce the chance of developing some of the longer term complications. There is also increasing evidence that it is helpful in reducing cancer recurrence, although this is not yet proven. Ensure you are eating a healthy balanced diet and keep alcohol consumption to the recommended weekly allowance.

It is very important that if you smoke you look for a way to STOP – there is a lot of help available. Please ask your breast care nurse specialist for more information.

www.nhs.uk/live-well/quit-smoking/

It is also very important to look after your skin, especially the skin that has been treated. Be aware of sun safety.

• Spend time in the shade when the sun is strongest
  (11am and 3pm);
• Make sure you never burn;
• Cover up with suitable clothing;
• If you are exposing the skin to the sun, use factor 50 sunscreen (applies to any skin tone).
  www.nhs.uk/live-well/healthy-body/sunscreen-and-sun-safety

Exercises to help you with your radiotherapy

Following your breast surgery your chest and arm on the affected side may feel very tight. Gentle exercises will help to give you more freedom of movement. At first you will experience discomfort as the tight structures begin to stretch. If you exercise carefully, gradually increasing the range of movement, you will not harm yourself and you will regain normal use of your arm.

Regular short sessions of approximately five minutes every 2-3 hours, are best for effective stretching. All the exercises should be done slowly. Do not force movement, instead gradually try to increase it. It is OK for the stretch to feel tight or a little uncomfortable but not painful. You should receive examples of appropriate exercises following your surgery. The following exercises will be helpful for your radiotherapy position.

You will not be able to have your radiotherapy unless you can reach this position, please see the following photo.

This may seem very difficult at first but becomes easier with repeated exercise and gentle stretches. It is important to do these exercises regularly even if you feel you are moving normally for you.

You will naturally feel protective towards your scar area but try not to carry your arm across your chest. It makes you round shouldered and leads to tightening in the armpit and elbow.

Take your shoulders backwards without lifting them. Try to let your arms swing naturally when you walk.

The following are stretching exercises. To gain maximum benefit these positions should be held. Gradually increase the hold for each exercise as much as you can tolerate, 20-40 seconds will give you maximum benefit.

Lying on your back, grasp a stick with both hands apart.
The non-affected arm can help control the movement.
Raise both arms overhead as far as possible.

Lie on your back. Take your arms over your head. Let your arms relax back onto the pillows with arms slightly bent and your palms facing the ceiling.

Gradually increase the hold as much as you can tolerate, 20-40 seconds will give you maximum benefit. Repeat 5-10 times. Start gradually and increase the amount you do as your stamina and arm movements improve. Even when radiotherapy is completed, continue a short daily programme of stretching exercises to help maintain good arm movements. A five-minute session will be most helpful.

When radiotherapy has finished

Your side-effects may get worse in the first few weeks after treatment and will then gradually settle. You should start getting back to normal about 4-6 weeks after treatment but it may take a little longer. Tiredness can last for several months and you may need to continue to rest more than usual.

You may be asked to attend the hospital where you were first seen by your oncologist for follow-up checks at regular intervals. This will vary according to the area you have had treated. Please discuss this with your doctor if you have any concerns.

Planning a return to work

If you find that you are tired after your treatment has ended you may consider taking a break from work or working part- time. It can be useful to talk to your employer about returning to work gradually, i.e. shorter or fewer days at first. Your GP can recommend this on your fitness to work note. There are Macmillan booklets available which offer help and advice on all areas of work during your cancer treatment.

Research at Leeds Cancer Centre

Leeds Cancer Centre is a major centre for cancer research. You may be asked if you would like to participate in clinical studies or trials. You are under no obligation to take part in any trials and your treatment will not be affected in any way if you do not wish to take part.

If you do take part in a clinical trial you may meet a research nurse or radiographer who will be helping to run the trial.

Further information and support

If you have any questions please ask your hospital team. We all have our own ways of coping with difficulties.

Some people have a close network of family and friends who provide emotional support. Others would rather seek help from people who are not involved with their illness.

The following are also available as sources of information and support that you may wish to use.

Breast Care Nurses (BCN)

Your BCN is available to discuss any aspect of your treatment with you. This is to offer support and advice about the practicalities and effects of your treatment and answer any questions you may want to ask.

Your BCN will also assess and discuss any physical, psychological, social, occupational and spiritual needs that you may have. They can refer you to other services if needed, for instance, benefits advice.

You should be given a ‘key worker’ as a contact for support through your treatment; this is usually your BCN.

Review Clinic Nurses

These nurses look after radiotherapy outpatients’ general needs, give information and advice, manage difficult side- effects and apply dressings.

Physiotherapists

Physiotherapists are available at the hospital if required.

Lymphoedema Service

This is a team of specialist physiotherapists and nurses you can be referred to by your oncologist / consultant radiographer. If you are aware of more swelling on the treated side after you have received treatment, discuss this with the doctor, nurse or radiographer you see in clinic or when you see your breast care nurse.

Macmillan Specialist Radiographer and Macmillan Radiotherapy Nurse Specialist

Sometimes people need more help if they are feeling depressed, very anxious or are having problems with their Radiotherapy. If this is the case you may benefit from seeing the Macmillan radiographer or nurse specialist, also known as the Radiotherapy patient support team.

Your clinical oncologist, radiographer or nurse can refer you at any point before or during your treatment.

Local Support Services

Leeds Cancer Support

Leeds Cancer Support complements care provided by your clinical team. We offer access to information and a wide range of support, in a welcoming environment for you, your family and friends.

We can be found in the information lounges in Bexley Wing and also in the purpose built Sir Robert Ogden Macmillan Centre.

The Sir Robert Ogden Macmillan Centre

This centre offers a variety of free health & wellbeing and supportive therapies for patients, their family members and carers. These include hypnotherapy, mindfulness coaching, acupuncture (for hot flushes) and pilates.

Contact numbers for Leeds Cancer Support

All the above services can be emailed on:
[email protected]

Maggie’s Centre

If you or someone you love has cancer you may have lots of questions. Maggie’s is a warm, welcoming place where you can meet people who are experiencing similar things to you.

You may also be able to find support groups specific to your needs and get advice and information from their professional staff.

You don’t need an appointment and all support is free.

Open Monday to Friday 9.00 am – 5.00pm.
Tel: 0113 457 8364

Address: St James’s Hospital (next to the multi-storey car park), Alma Street, Leeds LS9 7BE

Email: [email protected]

Website: www.maggiescentres.org

MY (Mid Yorkshire) Breast Cancer Support Group

This is a closed Facebook group offering online support for the whole of Yorkshire (i.e. even if you live in other parts of Yorkshire).

We offer Cancer rehab gym sessions, craft, Crocodile walks, guest speakers, benefits advice and social events, many of these are online.

Tel: Sara 07842 140381 or Alison 07939 702262

National support organisations

Hotel Bexley Wing

The hotel is located on the 8th floor of Bexley Wing and offers 19 twin rooms and 1 single room. All have en-suite, tea and coffee making facilities, a mini-fridge, towels, hairdryer and digital television. There are two rooms with wheelchair access and a wet room.

Patients are able to stay free of charge. There is a charge for relatives if they are staying in their own room.

Meals can be purchased (at breakfast and lunch) if you are able to make your way to the restaurant in the Bexley atrium. At other times you will need to have something you have brought from home or purchased. There is a very small fridge for your personal use. There are no staff after 4pm until the next morning in this facility.

For further details please contact the Hotel Co-ordinator on 0113 206 7687. Out of hours please contact the Non-Surgical Oncology Nurse Practitioner through main switch board on 0113 243 3144.

Car Parking

When you are coming for radiotherapy planning and treatment your parking is free in the on-site multi-storey car park. Please ask for more information at the radiotherapy main reception desk.

How to find us

St James’s University Hospital – site plan