One of the hardest things about starting radiation can be the fear of the unknown. Many patients have high levels of anxiety prior to starting radiation, only to realize after a few treatments that it was not as frightening as they expected. It is useful to familiarize yourself with the treatment machine, your team, and the potential side effects as much as possible before starting to ensure that you’re feeling confident and ready. Making sure your skin is well healed from surgery and well moisturized is another important preparation to make. Be sure to discuss any supplements you’re taking with your treatment team prior to starting, as some supplements have the potential to make radiation less effective and should be avoided during treatment. A healthy, balanced diet with enough protein will give your body the building blocks it needs to heal from radiation on a day-to-day basis. Practical issues such as double checking your radiation schedule and making sure you have transportation can make things go smoother during the weeks of treatment. Patients can drive themselves to treatments, but those who don’t drive may need friend/family assistance. Your department’s social worker may be able to assist with other transportation options, financial assistance, as well as helping with forms related to getting time off work.

Radiation Bolus

You may hear your radiation oncologist or radiation therapists talk about “bolus” during your treatment course. Bolus is most commonly used in women who have had a mastectomy for breast cancer. Photon beam radiation penetrates through the body because of its high energy. Because of this, the dose at the surface (i.e., your skin) may not be as high as it is deeper inside the chest wall. However, the skin is considered to be at risk for containing cancer cells. Bolus is a technique we use to make sure the radiation dose to the skin is close to the prescription dose.

There are two main types of bolus. Brass bolus, because it is made of metal, causes more scattering at the skin surface, which increases the dose. Plastic bolus is made to be the same density as your skin but is thicker, thus providing a place where the dose can “build up” and then deposit the prescription dose to the skin.

Proton Beam Radiation

Therapeutic radiation can be given with a number of different types of particle. The most common of these is photon beam radiation. Photons are X-rays and are very light but very high energy. They travel through your tissue and deposit dose by interacting with water molecules in your body, creating electrons. Protons are heavier than photons. While they deposit dose in much the same way, they don’t travel as far through the body as photons. Thus the “dose fall off” is sharper with proton therapy, i.e., there is less low dose spread throughout the nearby tissues. Ask your radiation oncologist whether proton therapy is appropriate for your case.

Skin Side Effects

The most common side effect during radiation therapy for breast cancer is a skin reaction. This effect takes time to develop and is often not visible for the first couple of weeks of treatment. After that, the skin will gradually start to change color (pink/red/tan for patients with lighter skin tones; tan/dark/red for patients with darker skin tones). This can be accompanied by feelings such a burning sensation, shooting pains, stinging, or itching. Occasionally, people can have areas of peeling or rash. Your radiation oncologist will recommend skin creams to use starting from your first day of treatment. They will also meet with you weekly to check your skin during treatment. After treatment is over, the pain recedes within several days and the skin becomes tan. You may notice some dry flakiness as the skin sheds its top layer. Over time the skin typically returns to its normal color, but some people, especially those with darker skin tones, may have longer lasting or permanent discoloration. In the long term, you may also notice change in the texture of the skin, sometimes feeling subtly thicker in some areas.

Fatigue

Fatigue is another commonly reported side effect. Like the skin reaction, it may not be noticeable for the first couple of weeks, though some people notice it right away. For most, it reaches a peak about 3 weeks into treatment and stays constant until around 2 weeks post-treatment, at which point it begins to gradually improve. Most patients describe the fatigue as feeling “blah” or unmotivated in the evenings after their usual day of activity. Some patients report sleeping extra hours at night or taking naps during the day. Some notice feelings of irritability or moodiness with the fatigue. Most people can continue to do their usual activities throughout radiation, but it’s normal to need extra rest. Getting exercise or fresh air may help to mitigate the fatigue.

 Patient Reported Symptoms, Side Effects, Comments

It’s common to feel other sensations in the treatment area during radiation therapy. Patients describe shooting pains, aching, heaviness, or a burning sensation. For the most part, these resolve fairly quickly after radiation is over. Less commonly, people sometimes notice queasiness or insomnia.

In addition to the color and texture change of the skin, there can be other subtle long term cosmetic changes. The breast tissue itself may feel slightly different when compared to the other breast. That can result in asymmetry, where the treated breast may sit up higher on the chest wall. Telangiectasias (spider veins) can occasionally develop in the skin; these are more common in women who have had a mastectomy. Also in the long term, there may be some fibrosis (scarring) in the treatment area. This may present as a sensation of pec muscle tightness or pulling in the breast tissue/chest wall, underarm, or around the expander/implant. Scar tissue in the area can also be tender, and this tends to be most pronounced at the surgical site (near the lumpectomy scar). Physical therapy can be very helpful to relieve these symptoms, and most patients are not limited in their activities following completion of radiation.

Content supplied by Dr. Kiri Cook, Radiation Oncology, Oregon Health & Sciences University