Left Breast Radiation May Increase Heart Disease Risk in Breast Cancer Survivors

Radiation therapy is a cancer treatment that uses high energy x-rays to kill cancer cells and shrink tumors. It is often used after breast cancer surgery to reduce the risk of the cancer coming back.

Radiation therapy is routinely recommended for most patients after a lumpectomy. It is sometimes also recommended after a mastectomy depending on the stage of disease and other factors.

Possible Side Effects of Radiation

Radiation therapy is a very effective and widely used treatment for breast cancer. It is very well tolerated by most patients, but as with any treatment, it can have side effects.

Short-term potential side effects which usually resolve within two weeks of completing treatment include:

Swelling to the breast
Skin changes to the treated area, eg sunburn, redness, flaking, color changes
Fatigue
Pain to the treated area
Hair loss to the treated area
Sore throat (if the supraclavicular lymph nodes are treated)

Radiation therapy can also have long-term side effects:

Breast and skin changes such as discoloration, firmness or shrinkage of the breast
Can increase the risk of complications after breast reconstruction, especially implant-based reconstruction
Lymphedema – if lymph nodes under the arm are treated, fluid may collect in the arm causing it to swell

Very rare long-term side effects can include:

Rib fracture
Lung inflammation or fibrosis
Heart problems
Increased risk of a second cancer (eg angiosarcoma)

Coronary Artery Disease

A recent study specifically evaluated the risk of heart problems in breast cancer survivors who had undergone radiation therapy. The study analyzed 972 women under the age of 55 when diagnosed with stage I or II invasive breast cancer between 1985 and 2008. The study found that women who had radiation therapy to their left breast, the same side of the body as their heart, had twice the risk of coronary artery disease (10.5%) compared to those who had radiation to their right breast (5.8%).

Coronary artery disease leads to decreased blood flow to the heart muscle. This can lead to chest pain (angina), shortness of breath, an abnormal heartbeat, heart failure, and even a heart attack (myocardial infarction).

“Our study adds to the growing evidence that left-sided radiation therapy is an independent risk factor for future heart disease after treatment for breast cancer”, said study co-author, Dr Gordon Watt. “It is important that clinicians caring for younger breast cancer patients communicate the importance of radiation therapy for breast cancer while explaining the need for long-term attention to the risk of heart disease, particularly for women receiving left-sided radiation therapy. Radiation therapy is an indispensable part of breast cancer care, and the good news for breast cancer patients is that modern techniques and computerized treatment planning have reduced the amount of radiation that reaches the heart, thereby reducing the risk of developing heart disease.”

There have certainly been several major advances in the technology and techniques used to administer radiation therapy since the beginning of this study. There are also ways to avoid radiating parts of the chest that don’t need it, like body positioning and breath holding. These techniques and maneuvers weren’t used in the 1980’s. When combining all the advances, the dose of radiation delivered to the heart today is significantly less than during the early years of this study.

Despite the advances, if you are a patient with a left-sided breast cancer, we still strongly recommend you ask your radiation oncologist what techniques they’re using to protect your heart. This will ensure you are decreasing your risk of heart disease as much as possible.

Single-Dose Intraoperative Radiation Therapy Improving Breast Cancer Care

Single dose intra-operative radiation therapy associated with fewer side effects than external beam radiation therapy (EBRT)

Many breast cancer patients may be able to avoid lengthy radiation treatment according to research published in the British Journal of Cancer. As an alternative to standard external beam radiation therapy (EBRT) performed after a lumpectomy, TARGIT-IORT is a single-dose intraoperative radiation treatment targeting the tumor site immediately following the lumpectomy. The treatment occurs while the patient is still asleep under general anesthesia. This protocol means patients can have their breast cancer surgery and radiation treatment all at the same time.

By targeting the radiation just to the tumor site at the time of the surgery, patients may be able to avoid potentially harmful effects traditional radiation treatments can have on nearby organs. According to the study, delivering TARGIT-OIRT during the lumpectomy also makes the site of the original tumor less conducive for future cancer growth. Other studies show the benefits of this type of radiation treatment including less pain, better cosmetic results after surgery, and fewer changes to the breast shape and skin compared with whole breast EBRT.

For the study, 2,298 women with invasive breast cancer and a tumor size of up to 3.5 cm in diameter were randomly assigned to receive either TARGIT-IORT during lumpectomy or post-operative extended radiation. The trial was run in 32 hospitals across 10 countries.

Intraoperative radiation is safe and effective

The study showed no difference in local recurrence-free survival between the two methods of radiation treatment. Unlike with EBRT, local recurrence with TARGIT-OIRT was not associated with a higher risk of death.

The study found “no statistically significant difference between EBRT and the approach of risk-adapted TARGIT-IORT during lumpectomy, for local recurrence-free survival, invasive local recurrence-free survival, mastectomy-free survival, distant disease-free survival or breast cancer mortality. The mortality from other causes was significantly lower in the TARGIT-IORT arm”.

Based on these study results, single-dose TARGIT-IORT during lumpectomy is an effective and safe alternative to several weeks’ course of post-operative EBRT. Patients who are candidates for single-does radiation can therefore benefit from less time spent in treatment and a faster recovery without comprising their cancer care.

Please remember, it is important to discuss all treatment options thoroughly with your healthcare team before undergoing surgery.

Confused about your options?

Confused about your breast cancer treatment options? Get the help you need with evidence-based information in the palm of your hand – download Breast Advocate® FREE here.

Breast Cancer Patients Needing Radiation Therapy Face Higher Risk of Implant Reconstruction Complications Requiring Additional Surgery

Implant-based breast reconstruction is the most commonly performed method of reconstruction in the United States today. While the procedure can be performed in one surgery (known as ‘direct to implant’), most women have a 2-stage approach beginning with tissue expanders. These are replaced with a permanent implant a few months later at a second surgery (stage 2).

Radiation therapy increases complications after breast reconstruction with implants

Implants are a good option for many women but may not be the best choice for some patients. In particular, patients needing radiation therapy as part of their breast cancer treatment should know that radiation increases the risk of complications after reconstruction with implants. Potential complications include infection, capsular contracture (breast hardening), asymmetry, seroma, pain, implant rupture, and implant exposure. In many cases, additional surgery is required to address the complication.

Implants often need to be removed

A recent study published in The Breast Journal found that 44% of women with locally advanced breast cancer who had implant reconstruction needed unplanned implant removal when radiation therapy was part of their treatment plan.

The study followed 52 patients who had mastectomy, implant-based breast reconstruction, and radiation therapy from 2010 to 2017. 44% of the patients in the study had stage III disease, 77% were estrogen receptor positive, and 75% were HER2 positive.

Patients were followed for just over 3 years following surgery and treatment. The average time between treatment and implant removal was only 5 months. In this study, implant removal was required before starting radiation in 17% of the patients, and after radiation was completed in 27% of the patients.

Reasons for implant removal before radiation began were infection (44%), wound breakdown (33%), hematoma (11%), and concern about planned radiation (11%). Reasons for implant removal after radiation included significant breast asymmetry (57%), infection (21%), a deflated expander (14%), and seroma (7%). Some women had bilateral mastectomy and reconstruction – most of the complications in these cases occurred in the breast that underwent radiation therapy.

This study is yet another example of why it is important for patients to be fully informed of the potential risks associated with surgery they choose. Fully-informed patients also tend to have more realistic expectations, which in turn can also improve recovery and the overall satisfaction with the final outcome.

You have other options!

Fortunately, implants are not the only reconstructive option and most women are candidates for alternative procedures. These include other types of breast reconstruction using the patient’s own tissue (known as ‘flaps’), and aesthetic flat closure (going flat).

“Despite the relatively high rate of implant removal reported in this study, salvage reconstruction is feasible,” the study authors noted. “Of the 23 patients who experienced unplanned implant removal, 78% were able to undergo salvage reconstruction with only 5 patients pursuing no further reconstruction at the time of last follow-up.”

If you are facing a similar situation and would like to learn more about your options, the Breast Advocate app can help – download it today!