Survivorship: Late Effects After Radiation for Lung Cancer

Author: OncoLink Team
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What is a late effect?

A late effect is as a side effect related to a cancer diagnosis or treatment that happens months to years after treatment. Some side effects that you develop during treatment can last for months to years after treatment is completed (for example, fatigue or neuropathy). These are often called long term side effects.

Late effects can be health issues or psychological, emotional and practical challenges.

Late Effects After Radiation for Lung Cancer

 The physical side effects of radiation treatment are directly related to the area of the body being treated. Any area in the treatment field has a risk of being damaged, causing side effects. As radiation techniques have improved over the years, the risk of late effects has decreased.

Lung Problems

Radiation fields involving the lung can lead to scarring (fibrosis), inflammation (pneumonitis), and restrictive or obstructive lung disease.

  • The risk for these problems is higher with higher doses of radiation, if you also got certain chemotherapies (bleomycin, busulfan, BCNU, and CCNU), or if you had part of your lung removed (lobectomy).
  • Radiation can cause scarring in the lungs that may affect blood vessels. Damage to the blood vessels can lead to coughing up blood. If you cough up blood, you should be seen right away by a healthcare provider, either in the office or the emergency room.
  • At your yearly physical your provider will examine your lungs and ask about possible symptoms (cough, shortness of breath, wheezing).
  • You should get a flu vaccine every year and the pneumococcal vaccine. 
  • You should not smoke as this can cause further lung damage.

Swallowing Problems

Radiation to the chest can lead to developing scar tissue in the throat and/ or esophagus (the tube from the mouth to the stomach). This can happen many years after treatment. This scar tissue can make the throat or lower esophagus narrow, making it difficult to swallow or cause heartburn. If you develop these symptoms, you should be seen by your provider. You may benefit from seeing a gastroenterologist or surgeon. They may be able to use a stent or balloon to stretch the scar tissue and eliminate the narrowing.

Heart Problems

Radiation treatment to the chest can affect the heart. This can lead to different types of heart disease, including heart failure, high blood pressure, valve problems, scarring or inflammation of the heart tissue.

  • The risk of heart failure depends on the amount of radiation you received and what other cancer treatments you had.
  • When radiation treatment is planned, it is designed to avoid the heart as much as possible, but in many cases, it cannot be avoided altogether.
  • You should have a yearly physical by your primary care provider. They should listen to your heart, check your blood pressure, look for signs of heart trouble such as swelling in your legs/feet, and check your cholesterol and blood sugar levels with a blood test.
  • You should strive for a heart-healthy lifestyle, including regular exercise, not using tobacco and eating a healthy diet.
  • If you are at a high risk of heart problems based on your treatments, your provider may suggest a screening echocardiogram to evaluate heart function.

Damage to the Bones

  • Radiation can cause small cracks (fractures) in the bones that are in the treatment field. Try to avoid trauma including falls or accidents. If you do get hurt, ask your provider if you need an x-ray to check for bone damage.

Skin Problems

Radiation can lead to permanent changes in the skin.

  • You may develop new scars or notice changes in the color or texture of your skin. Radiation can also change the color and texture of your hair or can cause permanent hair loss in the treated area.
  • The soft tissue and muscles under the skin can develop scarring and/or shrinkage, which can lead to a loss of flexibility and movement or chronic swelling in this area.
  • You may develop chronic or recurring ulcers of the skin in the area treated. Blood vessels of the skin may become dilated and more visible, although this is not harmful.
  • If the skin feels tight or sore, you can apply vitamin E to the skin.
  • Use fragrance and dye-free soaps and moisturizers in the area if your skin is sensitive after radiation.
  • After radiation, the skin in the treated area is more sensitive to sunlight. This sensitivity will last for your lifetime. Practice sun safety, using plenty of sunscreen, wear a wide-brimmed hat, and keep skin in the treated area covered with clothing. Try to avoid being out in the sun between the hours of 10 am-4 pm when it is the strongest.

If you notice any new or worsening skin issues anywhere on your body, you should contact your provider for an assessment.

Thyroid Problems

The thyroid gland is located in the neck, just below the larynx (voice box). Radiation fields that include the thyroid gland can lead to thyroid problems, including hypothyroidism, hyperthyroidism, and thyroid nodules/tumors. Most often, thyroid issues caused by radiation develop 2-5 years after treatment, while thyroid nodules are more often seen10 years or more after treatment. Risk increases with the amount of radiation received to the area.

  • Survivors should have a thyroid exam and a physical performed each year by their provider to check for thyroid issues.
  • If the thyroid was directly in the radiation field, TSH (thyroid-stimulating hormone) levels should be checked every 6-12 months. This is done using a blood test.
  • If you develop thyroid problems, you should be seen by an endocrinologist.
  • Symptoms of hypothyroidism (underactive thyroid, the most common complication) include fatigue, weight gain, constipation, dry skin, brittle hair or always feeling cold.
  • Symptoms of hyperthyroidism (overactive thyroid) include weight loss, irregular or fast heartbeat, sweating and being irritable.
  • You may also be at risk for hypoparathyroidism, a condition resulting from damage to the parathyroid glands (located in the same area as the thyroid). Signs of hypoparathyroidism are tingling in your fingers, toes and lips, muscle aches, muscle spasms, and fatigue.

If you notice any of these symptoms, you should contact your care provider.

Spinal Cord Damage

Occasionally, the spinal cord is in the field of lung radiation treatment. This can cause damage to the nerves in the spine.

  • Symptoms include loss of strength, feeling, or coordination of the arms or legs, paralysis, or problems with bowel or bladder control. Sometimes nerve damage can cause a sensation of electric shock spreading down the arms or legs.
  • If you develop these symptoms, you may need imaging tests or to be seen by a neurologist for further workup.

Radiation can also cause damage to the bones of the spine. This can result in a reduction in height or change in the curvature of the spine. Radiation to these bones can also put them at risk for fracture. If you have any new back pain, you should call your provider right away. You may need x-rays or other imaging tests.

Nerve Damage

Survivors who received radiation to the chest or underarm area can experience damage to the brachial plexus nerve. This damage is often a result of tissue scar tissue in the area compressing on the nerves or interrupting the blood supply to the muscles served by these nerves.

  • Radiation injury to the nerves is called radiation-induced neuropathy. It tends to develop in the years following treatment and slowly worsens over time.
  • Symptoms can include pain, loss of strength, decreased feeling (sensation), loss of coordination, or loss of movement or function of the muscle. The area affected will depend on the area that was in the radiation field.
  • If you develop any of these symptoms, report them to your provider. Some of these concerns can be caused by other health issues, so your provider will need to determine the cause.
  • If radiation fibrosis is determined to be the cause, you may benefit from seeing a cancer rehabilitation physician or physiatrist, and physical or occupational therapists. These specialists can help manage symptoms through therapy, medications and assistive devices.

Managing Late Effects

If you experience any concerning or persistent symptoms, contact your care team. Some side effects require specialized care from healthcare providers experienced in working with cancer survivors. Interdisciplinary survivorship clinics are available at many cancer treatment sites. If a clinic is not available near you, talk with your oncology care team about resources for managing your late effects.

After treatment, talk with your oncology team about receiving a survivorship care plan, which can help you manage the transition to survivorship and learn about life after cancer. You can create your own survivorship care plan using the OncoLife Survivorship Care Plan.

References

American Thyroid Association, http://www.thyroid.org/

Boerma, M., Sridharan, V., Mao, X.-W., Nelson, G. A., Cheema, A. K., Koturbash, I., … Hauer-Jensen, M. (2016). Effects of ionizing radiation on the heart. Mutation Research/Reviews in Mutation Research770, 319–327. https://doi.org/10.1016/j.mrrev.2016.07.003Feuerstein, M., & Nekhlyudov, L. (2018). Handbook of Cancer Survivorship, 2nd. Ed. Springer,  https://doi.org/10.1007/978-3-319-77432

Cella, L., D’Avino, V., Palma, G., Conson, M., Liuzzi, R., Picardi, M., ... & Pacelli, R. (2015). Modeling the risk of radiation-induced lung fibrosis: Irradiated heart tissue is as important as irradiated lung. Radiotherapy and Oncology117(1), 36-43.

Giridhar, P., Mallick, S., Rath, G. K., & Julka, P. K. (2015). Radiation-induced lung injury: prediction, assessment, and management. Asian Pac J Cancer Prev16(7), 2613-7.Koontz, B. F. (2017). Radiation Therapy Treatment Effects: An Evidence-based Guide to Managing Toxicity. Springer Publishing Company.

Stephenson, R.O (2019). Radiation-induced brachial plexopathy treatment & management. Retrieved from: https://emedicine.medscape.com/article/316497. Dec. 12, 2019.

Stubblefield, Michael Dean. (2017). Neuromuscular complications of radiation therapy. Muscle & Nerve56(6), 1031–1040. https://doi.org/10.1002/mus.25778

Taunk, N. K., Haffty, B. G., Kostis, J. B., & Goyal, S. (2015). Radiation-Induced Heart Disease: Pathologic Abnormalities and Putative Mechanisms. Frontiers in Oncology5https://doi.org/10.3389/fonc.2015.00039

Wei, J., Meng, L., Hou, X., Qu, C., Wang, B., Xin, Y., & Jiang, X. (2018). Radiation-induced skin reactions: Mechanism and treatment. Cancer Management and Research11, 167–177. https://doi.org/10.2147/CMAR.S188655

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