In the fight against breast cancer there is a lot of talk about surgery and drugs, but little about radiotherapy. Yet it is a fundamental strategy. With the help of Cinzia IottiDirector of the Complex Structure of Radiotherapy at the AUSL-IRCCS of Reggio Emilia and President of the Italian Association of Radiotherapy and Clinical Oncology (AIRO), we then tried to answer the doubts about this important treatment against breast cancer, both in the initial stage and in the metastatic stage.
What is the role of radiation therapy in breast cancer?
In early (non-metastatic) breast cancer, surgery is the most important therapeutic act: without surgery it is impossible to cure the disease. But alone, in most cases, it is not enough: radiotherapy and systemic medical therapy play a very important role in increasing the chances of survival and recovery. In general, there is almost never an absolute “protagonist” and cancer treatment is done by multiple people and multiple approaches which, combined, reduce the risk that the disease may recur over the years. Radiation therapy of the breast and / or lymph nodes is performed, in the vast majority of cases, in women treated with conservative surgery.
Is it true that radiotherapy “burns”?
Until a few years ago, radiotherapy was seen as the treatment that “burns” and “destroys” the tissues. This view has diminished somewhat, although many patients still have this fear. It is therefore important to remember today that radiotherapy is a very well tolerated treatment, compatible with a normal life and not burdened by major toxicities. It even happens that some patients finish the course of radiotherapy without affecting the skin.
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Can moisturizers be used to reduce the risk of erythema?
Not only is it possible, but recommended. There are products designed to prepare the skin for the action of radiation, and which can also be used in the morning before starting the radiotherapy session, as long as they are well absorbed. There is no scientific evidence of their effectiveness, but they certainly have the function of keeping the skin trophic and hydrated. Whether you use an ad hoc cream or a normal moisturizer, the important thing is to choose products free of perfumes and substances that can irritate the skin. If a skin rash appears (such as the one that occurs when you expose us too much to the sun), cortisone creams are recommended by specialists. For the rest, it is important not to wear synthetic fabrics and to keep the skin clean.
Is there a risk related to the radiation you receive?
The fear of radiation and side effects today is not supported by data, thanks to the progress of technology and knowledge.This fear is linked to the fact that the ionizing radiations used can be carcinogenic: it is certainly right to take this into consideration, but the benefit ratio The risk, for those who have a tumor, is strongly shifted in favor of the first: there is, in fact, an enormous clinical benefit in the face of an infinitesimal risk.
Do you become radioactive after radiotherapy?
No, this is a false myth. Radiotherapy consists in the administration of radiations that interact with the tissues, but when the beam is turned off the effect ends, just like when a CT scan or an X-ray is done. You can safely pick up a baby as soon as you leave the hospital. There are other cases in which there may be residual radioactivity: for example after a Pet or a bone scan, two tests that involve the administration of radioactive substances that remain for a few hours in the body.
Is it true that if the left breast radiates there can be heart problems?
Cardiotoxicity is the adverse effect of most concern and has been extensively studied. It is a late effect, which can appear many years after the treatment: from 10 to 20, in general. It must be said that the study data we have relate to a time when radiotherapy was not as accurate as it is today. Now we are able to control radiation distribution and doses much better than in the past, and specific devices are used to reduce the dose that reaches the heart. The anatomy of the heart itself is also better known, in particular of the structures that can be most damaged by radiation and that must be preserved. It is a legitimate concern, especially for young patients, also due to the fact that radiotherapy is often associated with other systemic cardiotoxic therapies, but precisely for this reason radiotherapy centers implement many different precautions to reduce this risk.
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How many sessions are needed?
Many studies have now shown that radiotherapy for breast cancer can be done in 13-15 sessions. With some exceptions: for example in patients who have undergone mastectomy and reconstruction it is recommended to dilute the radiation doses in 25 sessions. In most cases, however, the treatment ends in about three weeks.
This time could be reduced in the future to just one week for a total of 5 sessions, as data from a recent study that could change clinical practice show. Unfortunately, despite the recommendations of national and international scientific associations on the dose fractionation schemes to be used, in many centers they continue to practice 25 sessions, if not 30. This is a problem for two reasons: on the one hand, the patients to make many more visits to the hospital, when they could return to their normal life two weeks early; on the other hand, machinery is taken care of and waiting lists are lengthened. The final dose of radiation administered is the same (it is a standard of care) whether 15 or 30 sessions are performed, and it has been shown that the effect is comparable both in terms of disease control and for the risk of toxicity.
How long after surgery should radiotherapy be started?
It depends on whether the treatment plan includes chemotherapy or not. In this case, the standard pathway involves surgery, chemotherapy, and then radiation therapy. When chemotherapy is not planned (or when it is given only before surgery, in the neoadjuvant phase), the optimal timing for starting radiotherapy is within three months of surgery. In the case of tumors with a low risk of recurrence and in older people, it can wait up to 4 months, while when the tumor is aggressive it is recommended to start treatment after 2 months. In any case, there is a necessary waiting time, linked both to the complete healing and normalization of the tissue (the breast must return to its final appearance), and to the results of the complete histological examination.
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What happens if there is a recurrence in a breast that has already been treated with radiotherapy?
Until a few years ago, the rule was to perform a mastectomy. Now this paradigm is changing: techniques have improved and even re-irradiation is no longer a taboo. Some cases can be managed again with conservative surgery and radiotherapy. This possibility must be discussed by the multidisciplinary team, carefully evaluating the characteristics of the disease and the patient.
Is it true that radiotherapy can worsen the aesthetic result of a prosthetic reconstruction?
Yes, it is a possibility that must be explained to the patient and discussed, because radiotherapy can make the tissue fibrotic and cause retractions. Also in this case, techniques have been developed to affect the aesthetic aspect as little as possible, but the worsening of the outcome is a possibility that can occur.
What is intraoperative radiotherapy and for whom is it indicated?
It is a type of radiotherapy that is performed directly during the operation, after the removal of the tumor, when the patient is under anesthesia. In addition to requiring particular devices, it does not run very frequently, because it is reserved for a few selected cases. Careful evaluation is required of patients, who must have a low risk of cancer recurrence.
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What role does radiotherapy play in metastatic cancer?
A large number of radiotherapy treatments have a palliative purpose, that is to prevent or eliminate the symptoms due to the disease. The emblematic example is the treatment of pain from bone metastases. But radiotherapy today also has an important role in the treatment of oligometastatic disease (i.e. with a limited number of metastases, from 3 to 5): it is possible to carry out very short treatments (from one to 5 sessions), effective and safe, to eliminate these injuries. These treatments, often carried out in combination with medical therapies with innovative drugs, are proving to be able to improve the overall survival and quality of life of patients.