Since 2007, Jodi Winicour PT, CMT, CLT-LANA, has treated patients with lymphedema, cancer-related dysfunction, and orthopedic issues at Longmont United Hospital in Colorado. In addition to her work as a full-time clinician, Jodi serves as a class instructor for Klose Training & Consulting’s Lymphedema Therapy Certification course. She is the author and instructor for one of Klose Training’s most successful continuing education courses, “Breast Cancer Rehabilitation.”
I Thought Radiation Therapy Was Behind Me
Radiation therapy is a necessary treatment for many women with breast cancer. If you received radiation therapy as part of your breast cancer treatments, you may be familiar with the saying, “radiation is the gift that keeps on giving.” A significant proportion of issues that I address in physical therapy for breast cancer survivors are influenced by tissue changes caused by radiation therapy (RT). Some of the side effects of RT are short lived, and some develop over time, frequently becoming long-term problems. Without specialized care, ongoing radiation tissue changes can contribute to significant chest, axillary and shoulder stiffness, lymphedema, decreased rib and shoulder movement, limited function and reduced quality of life.
Effects of Radiation Therapy
During RT and immediately following its completion, the effects to the breast, chest and other radiated tissues are inflammatory in nature. Redness, warmth, swelling and pain are common signs and symptoms of inflammation in these regions. Inflammatory effects generally begin 3-4 weeks into radiation treatments, typically last for up to 4-6 weeks after radiation is completed and vary greatly in severity depending on the type and the dose of the radiation prescribed.
American Society for Radiation Oncology guidelines recommend hypofractionated whole breast radiation therapy for most breast cancers treated with a lumpectomy. This type of external radiation delivers a lower overall dose in a shorter period of time than conventional RT, lessening the days needed for treatment, but it delivers a higher daily dose of radiation to the breast at each visit. This higher daily dose can contribute to more extreme inflammatory responses in some women, leading to more pain and swelling than with the older, more conventional dosing recommendations.
Internal breast radiation therapy (IBRT) and accelerated external beam partial breast irradiation (APBI) limit these inflammatory side effects by specifically treating where the cancer was in the breast. IBRT is either given during breast lumpectomy surgery or through a catheter(s) inserted into the lumpectomy cavity once surgery is completed. Those with earlier stage breast cancer who qualify for these more localized types of radiation will likely have fewer inflammatory and long-term side effects.
ASTRO guidelines for those undergoing mastectomy suggest any patient with one or more positive axillary node taken during surgery receives post-mastectomy RT. While these guidelines have significantly reduced arm lymphedema risk by eliminating the need for further axillary nodes to be removed during surgery, they have resulted in many more long-term side effects for many more women.
Long-Term Effects of Radiation Therapy
Late and long-term effects of RT typically begin 3-4 months after completion. Stiffness of the skin, connective tissues, muscles and joints within the radiation treatment field is common and can contribute to pain and lymphedema of the arm and breast or torso. Those who had a mastectomy or who have less body fat in the radiated areas tend to experience more stiffness. Women who are sedentary tend to have more tissue and joint stiffness as compared to those who were fit at the time of their diagnosis and exercised during their medical treatments.
What Can I Do About Early and Late Radiation Effects?
Therapy with a qualified physical, occupational or massage therapist can be helpful to address pain and the soft tissue and joint stiffness expected from RT. Hands-on techniques such as massage, myofascial release, the use of negative pressure suction devices, joint mobilization and stretching can be very soothing. Look for a qualified therapist who has taken a Breast Cancer Rehabilitation. Being lymphedema certified does not ensure adequate knowledge of how to treat the late effects of radiation therapy, so be sure to ask!
Your therapist can help safely treat early inflammatory effects of radiation with manual lymphatic drainage (MLD), a gentle massage technique, though it may need to be applied outside of the radiation treatment region while tissues are irritated and inflamed.
Lymphedema of the chest, breast or arm can be well treated with MLD and compression once the inflammatory effects of radiation have resolved. Manufacturers, like Juzo, offer “off the shelf” sized garments, as well as made-to-measure (or custom) garments which Juzo knits based on the patient’s specific measurements (see products). Patients can also wear body shaper tank tops and shirts or shape wear products, to help reduce truncal and breast edema and lymphedema.
Gentle arm and chest stretching that is not painful and cardiovascular exercise such as walking, hiking and cycling are helpful to do during RT, though should be stopped if painful. Compression therapy in the form of gradient compression sleeves and torso compression tank tops are generally avoided in the inflammatory phase of RT due to fragile tissues within the treatment field.
Late radiation effects can be improved with moderate cardiovascular exercise –anything that gets your heart rate up and makes you a little out of breath and start sweating (scary movies during Halloween probably do not count!). Work up to at least 150 minutes/week, then up to a minimum of 180 minutes/week of at least 10-minute intervals at a time for health benefits such as reduced breast cancer recurrence risk and weight control.
Good luck in your recovery, and I hope you have a meaningful Breast Cancer Awareness Month!
Learn more about a lymphedema diagnosis after cancer treatment. View the variety of arm sleeves and gloves Juzo has available to help manage swelling. Follow along with our posts throughout Breast Cancer Awareness Month on Instagram, @JuzoCompression and Facebook.