Survivorship: Late Effects After Radiation for Esophageal Cancer

What is a late effect?

A late effect is a side effect that is caused by cancer treatment but happens months to years after cancer treatment has finished. 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 called long-term side effects. 

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

Late Effects After Radiation for Esophageal Cancer

Side effects from 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 by radiation, causing side effects. The way radiation is given has changed over the years, leading to a lower risk of late effects.

Esophageal cancer can be treated with surgery, chemotherapy, radiation, or a combination of these therapies. 

• Radiation therapy for esophageal cancer can cause scar tissue months or years after therapy. This can make the esophagus narrow (called a stricture), making it hard to swallow or causing a chronic feeling of food being "stuck" in your throat. You may also feel like you have heartburn. Esophageal dilatation is a procedure that stretches the area that has narrowed. This can help with the feeling of food being stuck. If you have signs of a stricture, you should be seen by a gastroenterologist (GI Doctor) or surgeon.
• Your weight and nutrition should be checked by your care team. If you are losing weight and/or not eating enough, you should see a registered dietitian. A dietitian will work with you to stop your weight loss and to gain some weight back.
• Because the heart is behind the esophagus, radiation can damage the sac around the heart. This can cause it to tighten or have scar tissue. This can happen many years after radiation. Surgery can be done to fix this problem. Signs of this can include difficulty breathing, racing heart or palpitations, lightheadedness, chest pain, and/or feelings of anxiety.
• In addition, cardiac (heart) disease can develop at a younger age and without other risk factors (such as diabetes, high cholesterol levels, family history). You should maintain a healthy lifestyle including regular exercise, having a healthy weight, eating a healthy diet, and not smoking. These can all help lower your risk of heart disease.

Risk of Breast Cancer

• Radiation therapy fields that include breast tissue can lead to breast cancer later in life. Because of this, the recommendations for breast cancer screening for you are different than people who have not had chest radiation. 
  • Women who received radiation to the chest should have annual mammograms starting 8-10 years after radiation, or at age 40, whichever comes first. 
  • If you received radiation to the chest wall between the ages of 10 and 30, your mammograms may start earlier, and you may also need a breast MRI. 
  • Each case is unique, and you should talk to your provider about what tests you need and how often you should have them. 

• Make sure that you are familiar with the normal feeling of your breasts. Report any changes to your provider. Changes can include a new lump or mass, a change in the look and feel of the skin on your breast, or any discharge coming out of your nipple.
• If you are a man who has had radiation to the chest, you should be aware of your increased risk of getting breast cancer. There are no screening tests done for men who have had chest radiation. However, you should report any unusual findings, such as lumps, skin changes, or nipple discharge, to a healthcare provider right away.

Lung Problems

Radiation fields involving the lung can lead to scar tissue (called 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 the lung removed (lobectomy). 
• Radiation can cause scar tissue 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 checked out 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 avoid smoking, secondhand smoke, vaping, and hookah products, as these can cause further lung damage.

Skin Changes

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, use 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. 

Managing Late Effects 

If you experience any concerning or lasting symptoms, contact your care team. Some side effects require specialized care from healthcare providers experienced in working with cancer survivors. Interdisciplinary survivorships clinics are available at many cancer centers.  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.