Survivorship: Late Effects After Radiation for Breast 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 occurs months to years after treatment. Some side effects that you develop during treatment can last for months to years after treatment is completed. These are often called long term side effects. 

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

Late Effects After Radiation for Breast 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.

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. 

Lymphedema Risk

Surgery to remove lymph nodes or radiation to lymph nodes can cause damage to lymph nodes and lead to lymphedema. Lymphedema is swelling that can occur in the chest, underarm, arm, and hand after treatment for breast cancer. It can cause pain, be disfiguring, make activity difficult and increase the risk of infection in the area. Your provider should teach you about lymphedema risk reduction

  • Talk to your provider if you are having any new swelling. This can be as simple as your clothing or jewelry feeling tighter.
  • A Certified Lymphedema Therapist should be consulted at the first sign of swelling to try to keep the lymphedema from worsening.
    • You are at risk of infection in any area with lymphedema or that is at risk for lymphedema. If you experience any signs of infection, contact your care team right away or go to the emergency room. These signs include a sudden increase in swelling, an increase in pain, redness, the area is warm to the touch, or fever. 

Heart Problems

Radiation treatment to the chest can affect the heart. You may be at increased risk of cardiac (heart) complications, particularly if you had left-sided breast cancer. 

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

  • 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.
  • The risk of heart failure after radiation for breast cancer is generally low. This risk depends on the amount of radiation you received and what other cancer treatments you had.
  • 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 and/or family history, your provider may suggest a screening echocardiogram or electrocardiogram 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.

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. 

Cancer After Cancer

Unfortunately, having breast cancer once does not mean you cannot have it again. Breast cancer survivors are at risk of developing new cancers in the breast that was treated, or in the opposite breast. Radiation also increases the risk of skin cancer in the treatment area.

  • Yearly mammograms are important after breast cancer and should be performed on both breasts in survivors treated with lumpectomy or partial mastectomy. Women who had single mastectomy should have annual mammograms on the remaining breast after treatment for breast cancer.
  • Patients who have had a mastectomy are also at risk for developing breast cancer recurrence in either the chest wall, a reconstructed breast, or the axilla (armpit). Notify your provider if you notice any changes in the skin in this area or discover any new lumps.
  • Reduce the risk of developing skin cancer by practicing sun safety, as discussed above.
  • In addition, talk to your provider about other cancer screenings to help you stay healthy. 

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

Celii, F. G., & Beckmann, N. M. (2019). Radiation-induced insufficiency fracture of the femur 18 years after radiation therapy. Radiology case reports14(2), 179-183.

Feuerstein, M., & Nekhlyudov, L. (2018). Handbook of Cancer Survivorship, 2nd. Ed. Springer,  https://doi.org/10.1007/978-3-319-77432 

Koontz, B. F. (2017). Radiation Therapy Treatment Effects: An Evidence-based Guide to Managing Toxicity. Springer Publishing Company.

National Lymphedema Network, https://lymphnet.org/

Shaitelman, S. F., Cromwell, K. D., Rasmussen, J. C., Stout, N. L., Armer, J. M., Lasinski, B. B., & Cormier, J. N. (2015). Recent progress in the treatment and prevention of cancer-related lymphedema. CA: A Cancer Journal for Clinicians65(1), 55–81. https://doi.org/10.3322/caac.21253

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

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

Yusuf, S. W., Venkatesulu, B. P., Mahadevan, L. S., & Krishnan, S. (2017). Radiation-Induced Cardiovascular Disease: A Clinical Perspective. Frontiers in Cardiovascular Medicine4https://doi.org/10.3389/fcvm.2017.00066

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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