Survivorship: Late Effects After Radiation for Sarcoma (Chest)

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 Sarcoma (Chest/Chest Wall)

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, causing side effects. As radiation techniques have improved over the years, the risk of late effects has decreased.

Risk of Breast Cancer

  • Radiation therapy fields that include breast tissue can lead to breast cancer later on in life. Because of this, the recommendations for breast cancer screening for you are different than the general public.
    • 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. You may also require a breast MRI.
    • Each case is unique and you will want to talk to your provider about what tests and how often you should have them.
  • Make sure that you are familiar with the normal feeling of your breasts. While monthly breast exams are no longer part of recommended screening tests, it is important to be familiar with your breasts and to report any changes to your provider. Changes to report 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 recommendations for screening tests for men who have had chest radiation. However, you should report any abnormal symptoms or findings, such as lumps, skin changes, or nipple discharge, to a healthcare provider right away.

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 completely avoided.
  • 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.

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 the 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 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.

Nerve Damage

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

  • Radiation injury to the nerves and muscles is sometimes called radiation fibrosis syndrome. 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.
  • In rare cases, the autonomic nervous system (ANS) can be affected. The ANS controls things you don’t think about, such as blood pressure and bowel and bladder control. Symptoms of ANS dysfunction can cause lightheadedness, fainting, extreme constipation, urinary incontinence, and erectile dysfunction.
  • 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.

Spinal Cord Damage

The spinal cord can be in the field of radiation treatment for “mantle field” therapy. This can cause damage to the nerves in the spine.

  • Symptoms can 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 feeling 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.

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, 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.

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

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.2016.07.003

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.

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

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

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