Breast radiotherapy

What is radiotherapy?

Radiotherapy is often used in the treatment of breast cancer adjuvantly (after surgery). It is a preventative treatment and the aim is to reduce the chances of it coming back in the breast or chest wall and improve overall survival. We know through many trials that have been done that it is effective at reducing the risk of recurrence and it uses high energy x-rays to do this. Treatment is carried out using machines called Linear Accelerators and it is safe for you to be around people after you have had your treatment.

Oncology appointment

Informed consent

After having received the results of your surgery, you will receive an appointment to discuss radiotherapy with the oncologist and / or advanced clinical practitioner. At this appointment, the reason for radiotherapy will be explained to you and you will have a discussion around the risks and benefits of treatment specifically for you.

This appointment is for you to ask questions about the treatment and how it may impact you. The oncologist will discuss the logistics of radiotherapy and any possible side-effects and they will go through the nationally devised consent form with you. This will allow you to make an informed decision about the radiotherapy treatment.

It is important if you unsure about radiotherapy that you take the time to read and understand the information. You are welcome to ask for more time to consider your recommendations to ensure you make the right decision for you.

The oncologist will discuss with you about having radiotherapy to the following areas:

• Whole breast
• Partial breast
• Chest wall

You may also be advised about having radiotherapy to include some of the lymph nodes and this may be highlighted on your consent form as any of the following;

• Lymph nodes in the armpit (axilla)
• Lymph nodes in the lower neck (supraclavicular fossa)
• Lymph nodes behind the breast bone (internal mammary chain)

You may also be advised that you will be having a boost to where the tumour was removed, this will be highlighted as;

• Tumour bed boost

If you have any further questions after this appointment, please contact the advanced clinical practitioner in Breast Radiotherapy on the number below. We can provide you with a copy of your consent form for treatment so that you can refer back to this before you start the radiotherapy process, or you can refer back to the example found within this pack below.

Advanced practice radiographer contact details:

Poppy Howe: 01223256710

E-mail Poppy Howe

What happens next?

Treatment planning

After your initial consultation (approximately 1 to 2 weeks), you will receive an appointment at the Radiotherapy Department. This is located in the Outpatients Department, Level 2 and can be found down the corridor from Oncology.

This appointment will involve having a CT scan of your chest only. We are using this scan to visualise the location of your anatomy and design the radiotherapy specifically for you.

This appointment lasts approximately 30 minutes. The CT scan itself will only take a few minutes; the rest of the time is spent finding a position that you will be able to manage for the radiotherapy.

During the planning session, you will be required to lie still on the couch in a position with both arms raised above your head and supported by the equipment. This position will be exactly the same for your treatment, therefore; it is important that you let the radiographers know if this is uncomfortable.

The CT couch will move you through an opening which is where the scan will gather information to help design your treatment.

You will need to remove the top half of your clothing to allow the treatment area to be marked. Vest tops are ideal garments to wear but gowns / covers are available. It is important to highlight here that we are not an ALL female department and you may come across male radiographers. Everyone is trained to treat you with dignity and respect and we understand that some people may find this uncomfortable. If this is applicable to you, please discuss this with the radiographers or call the advanced practice radiographer on the number identified earlier.

Radiotherapy is tailored to deliver the best treatment for you. Sometimes a second CT scan may be required as part of the planning process so do not be concerned if you get called back for another planning CT scan.

During planning, reference points on the skin will be defined using several small skin marks (usually three small permanent tattoos). The tattoos are made with dark ink and feel like a pin prick when each tattoo is done. They are usually about the size of a pinhead and permanent but may fade with time. These points are an important element of this process as they are used to ensure you are in the same position for each treatment. Wall mounted laser lights are used to help align these points for each treatment session. An identification photograph and a positioning photograph may also be taken to aid the radiographers for your treatment on a daily basis.

As we are using this CT scan to design your individual radiotherapy plan if you are concerned about any of the following please contact the Advanced Practice Radiographer (01223 256710) before attending your appointment:

• Restricted arm movement
• Wound healing problems
• Regularly having fluid drained from the breast

Surface Guided Radiotherapy

In the future we would like to move away from using tattoos. We can do this by using a system called surface guided radiotherapy or SGRT for short. This system gathers information from your skin surface which is collected at your radiotherapy planning CT appointment. It is used to help monitor your position before we deliver the radiotherapy and during the treatment.

For the system to work correctly, your chest will need to be exposed so that the system can see your skin to assess your position accurately. The system requires you to have two radiotherapy CT planning scans. The first scan will be with you holding your breath, and the second scan will be with you breathing normally. This second scan will be a low dose CT to minimise exposure to radiation and is safe to do as part of the preparation for treatment. The next section talks about how you can practice holding your breath for the scan and the treatment.

The Oncologist or Advanced Practice Radiographer will talk to you about the system if it is appropriate for you and your treatment. If you have concerns regarding the system please speak to the Advanced Practice Radiographer who can discuss this with you.

Finally, this system is helping us move towards a ‘tattooless’ radiotherapy treatment process. However, we still require you to have permanent marks or tattoos until the system is fully established in the department.

Voluntary breath hold technique

During your initial appointment with the Oncologist or Advanced Practice Radiographer you may be told about a technique called voluntary deep inspiration breath hold.

This technique is where you would take a deep breath in and hold your breath for a set period of time whilst we plan and deliver the radiotherapy treatment. This is because we pay close attention to the position of your heart in relation to the radiotherapy beams.

It is important to highlight that this is not the only method that is used to shield the heart from radiotherapy so if this is something that you find difficult and you will not be able to manage, please do not worry about this as we always review the plan very closely in order to ensure side effects are minimised.

Ideally, if this is discussed with you, we would strongly recommend practising holding you your breath before your planning CT scan appointment. This is to allow you to build up your confidence in doing this and will help you to build your stamina in holding your breath.

There are some freely available online resources that you can use to help you practice this gradually.

Please visit the respire website (opens in a new tab) where you will find 3 short videos that take you through ‘How to prepare for holding your breath for radiotherapy’.

This will give you some advice and guidance on practising this and once you have reviewed these resources, we would recommend allocating 10-15 minutes a day to give you time to practice this.

We would advise you to begin practising as the videos suggest holding for 5,10,15, 20 seconds to build your tolerance up to 30 seconds (if this is manageable for you). We suggest practising up to 30 seconds as this is close to the length of the time you will be required to hold your breath during your CT scan appointment.

During treatment, we will tailor this more appropriately for you and you will be asked to hold your breath for intervals of 20 or 25 seconds. Please discuss this with the radiographers who are delivering your treatment if you are worried about doing this.

There may be times where you will have a ‘free-breathing’ scan first and we will ask you to wait outside the scanning room whilst we see whether you will benefit from doing this. If so, then we will ask you to come back in and give this a try. For the majority of people this will not be necessary.

Radiotherapy treatment

It takes time to produce the individualised plan so there will be a gap of approximately 2 to 3 weeks between the treatment planning appointment (CT scan) and the start of treatment. This is an important part of the process as many checks are completed to make sure the plan is safe for you. This delay will not impact the effectiveness of the treatment.

The appointments for your radiotherapy treatment are usually sent out by post following your treatment planning appointment and will be available on MyChart if you have access to this.

Treatment is carried out by therapy radiographers. The procedure will be explained to you before the first treatment. You will be in the treatment room between approximately 15 to 40 minutes, depending on the treatment technique you are having, but the treatment will not take as long as this.

The treatment is delivered from several directions with the machine moving around you. It comes quite close but will not touch you. The treatment is the same every day, but you may feel like some days it takes longer for the radiographers to set up than on other days which is not unusual.

Once you have been positioned by the radiographers, they will leave the treatment room to deliver the radiotherapy treatment. Whilst you will be alone in the room during treatment, the radiographers are watching you on a monitor throughout the procedure. You should not feel anything, but the machine does make a noise. You must keep still but continue to breathe and swallow normally unless you are asked to hold your breath for the treatment whereby the radiographers will communicate with you through the intercom system. The radiographers can speak to you via an intercom. If you need help you can raise your arm if needed and the radiographers will switch off the machine and return to the room to assist you.

Number of treatments

Like the treatment plan, the number of treatments can be different person to person. Treatment can be given for 15 days over 3 weeks, 5 treatments over one week or 5 or 6 treatments once a week over five / six week. There are lots of different factors that determine the most appropriate schedule for you so this will be discussed with you individually.

Radiotherapy trials

We are a leading centre in developing treatments for breast cancer and you may be approached by our trials team to discuss a clinical trial that you may be eligible for as part of your radiotherapy treatment.

It is important to note that you will have the opportunity to discuss a trial if it is available to you and you will be given relevant information to read if you would like to participate. You will be given plenty of time to consider if this is the right option for you and you can withdraw you consent at any time.

Clinical trials are not available to everyone and are constantly changing so if you are not approached it is likely we do not have a study available to you at this time.

Possible side-effects of treatment

Early / Short-term

These side effects tend to start during the radiotherapy or shortly afterwards and usually resolve within two to six months of finishing radiotherapy. It is important to note that we have to discuss all of the ‘possible’ side-effects with you as it is to ensure you are fully informed of what ‘could’ happen. It does not mean that you are going to get every side effect that are discussed here.

Expected (50% - 100% chance)

• Tiredness
• Temporary hair loss in the treatment area

Common (10% - 50%)

• Skin soreness, itching, blistering and colour changes in the treatment area

Redness in white skin tones and subtle darkness, yellow / purple / grey appearance in brown and black skin tones.

Less common (less than 10%)

• Breast / chest wall / axilla discomfort
• Breast swelling
• Change in breast texture

Rare (Less than 1%)

• Sore throat
• Skin blistering
• Lung inflammation (pneumonitis) – which can lead to a cough / breathlessness

Late / Long-term

These are side-effects that may happen many months or years after radiotherapy and may be permanent.

Expected (50% - 100%)

• Breastfeeding – after breast radiotherapy (and or surgery), you may not produce milk in that breast but the other breast will not be affected.

Common (10% - 50%)

• Skin colour change in the treatment area including; lighter / darker or pinker
• Subtle changes to the breast appearance including; changes to breast size, shape and texture
• Breast / chest wall / axilla discomfort including; aching and shooting pains
• Worsened cosmetic outcome after reconstruction surgery – may require the implant to be replaced

Less common (Less than 10%)

• Marked change to breast appearance including; change to breast size, shape and texture
• Breast / chest wall swelling
• Shoulder stiffness
• Swelling (Lymphoedema) of the arm – fluid collecting in the arm which may cause swelling, pain and or movement difficulties

Rare (Less than 1%)

• Skin changes (Telengiectasia) in the treatment area – these are small visible blood vessels that look like spidery marks
• Rib fracture
• Fibrosis (scarring) of the underlying lung – can cause breathlessness, cough or changes on x-ray
• Increased risk of heart disease later in life
• Brachial plexopathy – nerve damage which may cause pain, numbness or tingling affecting the arm and shoulder
• A different cancer in the treatment area

It is important to note that whilst some of these side effects sound worrying, the benefit of giving you radiotherapy outweighs any of these risks above. Individual risks are considered in detail and will be discussed with you if they are different from the above.

Advice and guidance on side-effect management

Reactions to your skin cannot be prevented. However, there are things you can do to help yourself feel more comfortable.

Tell your radiographers and clinical nurse specialist about your usual daily skin care routine and keep note of any differences. They will let you know if any changes are advised to your skin so you can share these with your radiographers and clinical nurse specialist. Please tell them if your skin reaction is painful, so they can recommend pain relief. Talk to them about any worries you have.

Health and well-being

It will help your overall health if you:

• Keep up an intake of 6 to 8 glasses of water a day
• eat a nutritionally well-balanced diet

A diet that included fruit, vegetables whole grains and lean protein. You can ask your radiographers and clinical nurse specialist to provide examples and to explain the importance of staying hydrated and eating a healthy diet in more detail.

If you are receiving treatment to your abdominal are they may recommend a different diet.

• You may go swimming if your skin is not blistered or peeling. It is best to shower immediately afterwards to wash off the chlorine and then apply moisturizer. Please stop swimming if it irritates your skin.
• You may find it more comfortable to wear loose-fitting clothing made of natural fibres, such as cotton or silk.
• Please avoid sun exposure and protect the area from direct sunlight. You can wear a brimmed hate and / or cover up with clothing. Continue to protect the treated area from the sun for at least one year after you have finished treatment. Because your skin will be more sensitive, use sunscreen with SPF 50 (sun protection factor 50).

Hygiene and moisturising

1. Please continue to use the moisturizer you prefer and like to use. No specific moisturizer can be recommended for use during and after treatment as there is not sufficient evidence to support the use of one product over another.
2. Use moisturizer frequently; gently smooth it onto your skin until it is absorbed. The aim is to help your skin supple.
3. If you do not currently use a moisturizer, speak with your radiographers and clinical nurse specialist and they will be able to suggest a few options for you.
4. You do not need to wipe your moisturizer off before receiving treatment, but please do not apply moisturizer immediately before your treatment.
5. Please stop using your moisturizer if it irritates your skin and talk to your radiographers and clinical nurse specialist.
6. If your skin blisters or peels, stop using moisturizer in that particular area and ask your radiographers and clinical nurse specialist for more advice.

Washing and bathing

Make sure the water is not too hot; wash the skin gently with products you would normally use and gently pat dry.

Deodorants / sprays

Please continue to use the deodorant you normally use, unless it irritates your skin; stop if your skin blisters or peels.

Dont's for the treatment area

Please avoid:

• Rubbing the area
• Using sticky tape on the area (such as Elastoplast or Micropore)
• Shaving - Reduce shaving if possible, unless advised differently by your radiographers and clinical nurse specialist)
• Using wax, cream or lasers for hair removal on or close to the treated area
• Using make -up: Hair dye, perfumes and aftershave on or close to the treated area

After your treatment has finished

• Your reaction may worsen for the next 10 to 14 days before starting to improve
• Most patients find that their skin has improved around 4 weeks after treatment
• If skin has blistered or peeled it may take longer to heal
• The treated area will continue to be more sensitive than the rest of your skin, even once you have completed your radiotherapy, especially to heat and sunlight

This guidance was developed by The Society and College of Radiographers and was last updated in 2020. If you have any questions about skincare management, please contact the advanced clinical practitioner.

Fatigue

You may find that you have less energy to do things that you normally would do during and in the weeks following radiotherapy. This can be very variable person to person, ranging from none at all to extremely tired. Some people describe this tiredness as feeling weary, weak, worn out or just slower than usual. You may not have the same energy as before. This is normal.

There can be many factors that contribute to your fatigue. The effort and sometimes stress associated with attending for radiotherapy can contribute. Your routine may be disrupted and sleep pattern disturbed. You may also be coping with side-effects related to other treatments and medications.

• Regular physical activity during and after treatment can help reduce treatment related fatigue
• Good-quality sleep may help with fatigue. Some people do need to rest at times during the day but be aware how naps affect you. Some people find that day time naps help them sleep better at night, while others sleep less well.
• You may find that you do not have enough energy to do all the things you want to.
• You may want to prioritise the activities that are most important to you and perhaps

do others at another time this can be called ‘Pacing’.

• This may be a time to let others help you. Letting family members or friends help with chores, errands, transport etc. may give you more time to look after yourself while you are coping with the radiotherapy effects and help with the management of fatigue.
• Fatigue can affect your working pattern. Some people are able to continue to work throughout the radiotherapy process with little interruption. For others it may be much more difficult. This is very individual and you must do what is right for you.
• Sometimes after a period of time away from work, some people benefit from a phased return or changes to their work pattern.

Breast changes

Some people experience some breast tenderness either during or after radiotherapy treatment and occasionally the breast can feel swollen. If you have had a mastectomy, you may feel some tightness over the chest area. These are a normal part of the healing process and should settle within a few weeks after treatment. For some people this may continue for a bit longer than this (a few months). Aching, twinges and sharp pains within the treated area.

It is important to remember that everyone is different and if you have any concerns over this then to get in touch with the advanced clinical practitioner or the breast care nurses.

What happens now that I have finished my radiotherapy?

End of treatment information

Follow-up appointments

You will have an end-of-treatment appointment either during your final week of radiotherapy (if you are having 15 treatments) or within 2 weeks of completing your radiotherapy treatment (if you have 5 treatments). This will be either a face-to-face or a telephone appointment.

During this appointment you will have the opportunity to discuss any side-effects that you may be experiencing and we will discuss what to expect after the treatment finishes. We know that the radiotherapy continues to work for approximately two weeks after treatment and that this can mean that side-effects can get worse before they get better.

You will be given some information on your final day of treatment including giving advice on what to expect and how to manage any concerns you have. It is important to remember that you can always call the advanced practice radiographer if you have any questions.

We will also discuss with you patient-initiated follow-up, and you will be advised of any further appointments that may be booked for you. We will discuss surveillance imaging and any other treatments that may be recommended to you.

If you do not receive an appointment after 2 to 3 weeks following your end of treatment radiotherapy appointment, please contact either the Breast Unit (01223 217627) or advanced clinical practitioner (01223256710).

It is quite common to feel quite overwhelmed after the treatment finishes and this is where you may find help through other supportive services. Please note that this feeling does improve but if you are concerned about this please do reach out for further support and take a look at the information in the section below.

Support information

There are plenty of support services available to you during this journey. These are available either as face-to-face, a telephone call or online. It is important that you review what is available and consider what is appropriate to you. You may not feel that you need any extra support but is important to know that you are able to contact these services at any point after you finish treatment.

The Maggies Centre in Cambridge

Maggies are a charity run support and information centre for people diagnosed with Cancer. They offer a range of freely available services that may assist you with your journey. They are available to help manage emotions, manage practicalities and assist in the management of symptoms and side-effects. For further information please visit the Maggies Centre website (opens in a new tab) or give them a call on 01223 249220 (Monday to Friday, 9am - 5pm).

You can visit them at:

Maggie's Cambridge
Addenbrooke's Hospital
21 Milton House
Puddicombe Way
Cambridge
CB2 0AD

Or email the Maggies Centre Cambridge to enquire about how they could help you.

If you would like a bit more information or an example schedule to highlight what is on offer, then please ask your advanced clinical practitioner or the treatment radiographers.

Macmillan Cancer Information and Support Service Pod

The Macmillan Cancer Information and support services or ‘The Pod’ is located within the Oncology department. This is a drop-in service, so no appointment is necessary and they are available to offer support, advice and guidance to anyone affected by cancer. This service can help give advice and guidance with grant applications and referral and signposting to benefits advice.

Online websites

• Macmillan Cancer Support (opens in a new tab)
• Breast Cancer Care (opens in a new tab)
• Breast Cancer Now (opens in a new tab)
• Cancer Research UK (opens in a new tab)

Mobile apps

Macmillan's Sleepio (opens in a new tab) (for poor sleep and insomnia, addresses unique needs with a personalised programme, featuring sessions with step-by-step guidance through evidence-based techniques, available night or day. In a clinical trail, 76% of patients experienced improvement in their sleep).

Macmillan's Daylight (opens in a new tab) (for worry and anxiety, helps people gain control over their anxiety with personalised therapeutic content. Its available when it's needed the most, providing you with evidence-based techniques to cope in the moment. In a clinical trial, 71% patients experienced reductions in anxiety).

REACT program

Rehabilitation and Exercise during Addenbrooke’s Cancer Treatment is a service freely available to all patients undergoing cancer treatment at Addenbrooke’s. It is led by a Specialist Team of Physiotherapists and Cancer Exercise Specialists.

The programme offers supervised exercise opportunities for patients and aims to keep patients physically active throughout their cancer journey. It can also reduce the likelihood and severity of side-effects associated with cancer treatments.

The REACT programme includes individual exercise assessments / exercise counselling, group cardiovascular circuit style classes, standalone education sessions and short course to include;

• Breast Cancer Recovery
• Lymphoedema Prevention
• Boost your bones (Exercise for Healthy Bones)
• Strength and Balance
• Pilates
• Tai Chi
• Yoga
• Zumba
• Nordic walking / outdoor exercise

To find out more information about this service please speak to the breast care nurses or advanced clinical practitioner who can place a referral for you.

Useful information and contacts

Radiotherapy

• Poppy Howe - Advanced Clinical Practitioner in Breast Radiotherapy

Telephone: 01223 256710

• Radiotherapy reception

Telephone: 01223 216634

Breast Unit Reception

Telephone: 01223 217627

How to get involved

We believe that involving patients and carers can help us improve the services we provide.

There are many ways that you can get involved and help us improve the services we provide. For further information you can visit the CUH website to read more about the following;

• Patient and Carer User Groups
• Cancer Participation Group
• My Chart Stakeholder Group
• Outpatient Experience Group
• Reader Panel – Patient information
• The CUH PPI Panel

Just want to say thank you? How you can support Addenbrooke’s and the Rosie hospitals

In our busy hospital, our dedicated staff do amazing things every day. Of course, they never expect thanks, however, we know that many patients want to express their gratitude for the wonderful care they have received.

Here are five ways to do just that.

Make sure great work gets recognised

Our Patient Advice and Liaison Service (PALS) would be delighted to receive your thanks for a job well done and will share your feedback with the staff involved.

Telephone: 01223 216756

12:00 to 16:00, Monday to Friday

e-mail CUH PALS

You can help us make Addenbrooke’s and the Rosie hospitals even better

Did you know we have our own charity, Addenbrooke’s Charitable Trust (opens in a new tab)? Whether you can donate, fundraise or volunteer your time, you can help change and save lives every day.

Telephone: 01223 217757

e-mail ACT

Staff awards

Nominate an individual or a team for our monthly You Made a Difference Award, a little public recognition goes a long way.

Telephone: 01223 274775

e-mail the You Made a Difference team

Become a member of the Foundation Trust

Become a member of the Foundation Trust and have your say about the issues that matter to you and help shape the future of patient care at Addenbrooke’s.

Telephone: 01223 216756

e-mail CUH Foundation

Become a hospital volunteer

Our volunteers occupy a special place in our hearts. If you have time to give, there’s a volunteer role for you.

Telephone: 01223 586616

E-mail CUH Volunteers

Privacy and dignity

Same sex bays and bathrooms are offered in all wards except critical care and theatre recovery areas where the use of high-tech equipment and / or specialist one to one care is required.