Toxicities of Radiation Treatment for Breast Cancer : Risks and Management Strategies

"This book is a comprehensive guide to breast toxicity. Adjuvant radiation remains standard for a majority of women who undergo breast-conserving surgery for breast cancer, and indications for post-mastectomy and regional lymph node irradiation have also broadened with recent publications. At the same time, locoregional recurrence has declined and survival has improved in recent decades. In the current era of excellent breast cancer outcomes, then, considering the balance between toxicity and outcomes becomes paramount. Several recent editorials recommend considering toxicity against the potential benefit of adjuvant radiation in tailoring radiation decisions for individual patients. Thus, a clear understanding of the potential toxicities of adjuvant radiation for breast cancer is critical to optimizing outcomes in modern breast cancer management. Here, authors have collected recent data focused on toxicity of treatment that provide an opportunity for improving this optimization. Chapters cover both acute and late toxicity of radiation for breast cancer, including tailored risk assessment for each of these potential toxicities, considerations for including risk of toxicity in management decisions, and toxicity management strategies. This is an ideal guide for radiation oncologists, residents, and oncologists seeking to optimize care for their patients. ." -- Prové de l'editor Preface 6 Contents 8 Contributors 10 Including Toxicity Risk in Balanced Clinical Decision Making 12 References 14 Acute and Late Skin Toxicity from Breast Radiation 16 The Layers of Skin and Anatomy of the Breast 16 Composition of the Skin 16 Breast Anatomy 17 Radiotherapy-Related Skin Toxicity in Breast Cancer 17 General Principals of the Radiation Response and Breast-Specific Considerations 17 Acute Skin Toxicities 18 Diagnosis and Grading of Acute Skin Toxicity 18 Clinical Findings of Acute Radiation Toxicity 19 Erythema 19 The Desquamation Continuum 19 Late Skin Toxicity 20 Diagnosis and Grading of Late Skin Toxicity 20 Types of Late Skin Toxicity 20 Radiation-Induced Fibrosis 20 Atrophy 21 Hyperpigmentation 21 Telangiectasia 21 Morphea 21 Radiation Recall 22 Risk Factors for Acute and Late Radiation Skin Toxicity 22 Patient Predisposition to Skin Toxicity 22 Patient Characteristics 22 Genetic Predisposition via Altered DNA Damage Repair 23 Dysfunctional Immune Response 23 Radiation Delivery and Planning Risk Factors 24 Other Non-radiation Treatment Characteristics 24 Management of Acute and Late Skin Toxicity 25 Management of Acute Toxicity 25 Prevention of Acute Skin Toxicity 25 Treatment of Acute Skin Toxicity 26 Treatment of Late Toxicity 26 Considerations for Including Risk of Toxicity in Management Decisions 27 Conclusions and Future Directions 27 References 28 Fatigue Associated with Radiation Treatment for Breast Cancer 34 Introduction 34 Fatigue Prevalence During and After Breast Cancer Radiotherapy 35 Prevalence of Fatigue 35 Fatigue Severity 36 Fatigue Scales 36 Biological Mechanisms of Fatigue 37 Inflammation 38 Inflammation and Radiotherapy-Induced Dermatitis 38 Cellular Immunity 39 Anemia 39 Predictors of Fatigue 40 Demographic Factors 40 Clinical, Tumor, and Treatment-Related Factors 40 Behavioral Symptoms 41 Radiation Dose, Fractionation, and Fatigue 42 Treatments for Fatigue 43 References 44 Pain Associated with Radiation Treatment for Breast Cancer 50 Introduction 50 Epidemiology of Pain 51 Etiology and Pathophysiology of Pain 51 Acute Pain 52 Prevalence and Incidence 52 Symptoms and Pain Location 59 Risk Factors 59 Chronic Persistent Pain 60 Prevalence 60 Risk Factors 61 Delayed Radiation-Induced Brachial Plexus Neuropathy (RIBPN) 66 Incidence/Prevalence 66 Symptoms 66 Risk Factors 69 Assessment of Pain 69 Unidimensional Pain Scale 70 Multidimensional Pain Assessment 70 Neuropathic Pain (NP) Assessment 72 Management of Pain 74 Acute and Chronic Persistent Pain 74 The WHO Analgesic Ladder 74 Non-pharmacological Strategies 79 Neuropathic Pain (NP) 79 Radiation-Induced Brachial Plexus Neuropathy (RIBPN) 85 Risk Reduction 85 Pain Management 85 Conclusion 86 References 87 Considerations for Post-Mastectomy Radiation Therapy in the Setting of Breast Reconstruction 94 Introduction 94 Surgical Factors Impacting PMRT Outcomes 95 Patient Factors Impacting PMRT Outcomes 99 Radiation Planning Factors 100 Conclusion 103 References 104 Lymphedema After Breast Cancer Treatment 108 Incidence of BCRL 108 Detection of BCRL and Diagnostic Methods 109 Future Model for BCRL Diagnosis: Prospective Screening-Based Model 109 Methods of Quanitfying Arm Volume 110 Water Volumetry 110 Circumferential Tape Measurement 110 Perometry 110 Bioimpedance Spectroscopy (BIS) 111 Lymphoscintigraphy 112 Defining BCRL 112 Defining BCRL by Absolute Volume Difference 113 Defining BCRL by Absolute Volume Change Relative to a Baseline 113 Defining BCRL by Relative Volume Change 113 Established Risk Factors for BCRL 116 High Body Mass Index (BMI) at the Time of Breast Cancer Diagnosis 116 Subclinical Edema 116 Local Infection 117 Axillary Lymph Node Dissection 117 Regional Lymph Node Radiation 117 Lack of Breast Reconstruction 118 Chemotherapy 119 Impact of Radiation on BCRL 119 Clinical Significance of RLNR 123 Symptoms of BCRL and Impact on Patient Quality of Life 124 Treatment of BCRL 125 Complete Decongestive Therapy (CDT) 125 Exercise 126 Intermittent Pneumatic Compression (IPC) 126 Surgical Intervention 127 Precautionary Guidelines 128 Recommendations 129 References 130 Cardiotoxicity Associated with Radiation for Breast Cancer 138 Introduction 138 Radiation-Related Cardiac Injury 139 Studies Supporting Relationship Between RT and Cardiac Toxicity 140 Studies That Did Not Find a Relationship Between RT and Cardiac Toxicity 141 Impact of Treatment Era 142 Subclinical Cardiac Changes 143 Factors Influencing Cardiac Dose 143 Anatomy 143 Treatment Volume 144 Cardiac Risk Factors 145 Age 145 Systemic Therapy 146 Anthracycline-Based Chemotherapy 146 Herceptin 146 Endocrine Therapy 147 Methods to Reduce Cardiac Dose 147 Intensity-Modulated Radiotherapy (IMRT) and Arc Therapy 147 Deep Inspiration Breath Hold 147 Prone Positioning 149 Partial Breast Irradiation 149 Proton Beam 150 No RT 150 Cardiac Dose Constraints 150 Conclusion 151 References 152 Second Malignancies after Radiation for Breast Cancer 156 Definition of Second Malignancy 156 Risk of Second Malignancy 157 Lung Cancer 158 Sarcoma 160 Second Breast Cancers 162 Esophageal Cancer 164 Radiation Technique 164 Summary 166 References 166 Tissue Fibrosis after Radiation Treatment for Breast Cancer 169 References 180 Pulmonary Toxicity Associated with Radiation Treatment for Breast Cancer 185 Radiation Pneumonitis 185 Pulmonary Fibrosis 186 Radiation Considerations 187 Risk of Secondary Lung Cancer 188 Strategies for Risk Reduction 189 Discussion 189 References 190 Integrative Methods for Management of Toxicities Associated with Radiation Treatment for Breast Cancer 191 Overview 191 Exercise 192 Exercise for Fatigue 192 Exercise for Upper Limb Function and Lymphedema 193 Exercise for Pain 193 Summary 193 Nutrition 194 General Dietary Recommendations 194 Mindfulness-Based Interventions 195 Mindfulness-Based Stress Reduction 195 Cognitive-Behavioral Therapy 196 Meditation 196 Yoga 197 Art Therapy, Dance Therapy, and Guided Imagery 197 Conclusion 198 References 198 Index 202 Front Matter ....Pages i-xii Including Toxicity Risk in Balanced Clinical Decision Making (Jean L. Wright)....Pages 1-4 Acute and Late Skin Toxicity from Breast Radiation (Lindsey Sloan, Sara Alcorn)....Pages 5-22 Fatigue Associated with Radiation Treatment for Breast Cancer (Canhua Xiao, Mylin Ann Torres)....Pages 23-38 Pain Associated with Radiation Treatment for Breast Cancer (Eunkyung Lee, Shannon Snyder, Jennifer J. Hu)....Pages 39-82 Considerations for Post-Mastectomy Radiation Therapy in the Setting of Breast Reconstruction (Lisa Singer, Jean L. Wright)....Pages 83-96 Lymphedema After Breast Cancer Treatment (Kayla M. Daniell, Tessa C. Gillespie, Cheryl L. Brunelle, Alphonse G. Taghian)....Pages 97-126 Cardiotoxicity Associated with Radiation for Breast Cancer (Kara Lynne Leonard, David E. Wazer)....Pages 127-144 Second Malignancies after Radiation for Breast Cancer (Sarah Nicole Hamilton)....Pages 145-157 Tissue Fibrosis after Radiation Treatment for Breast Cancer (Kristin A. Plichta, Wenqing Sun, John M. Buatti)....Pages 159-174 Pulmonary Toxicity Associated with Radiation Treatment for Breast Cancer (Arti Parekh)....Pages 175-180 Integrative Methods for Management of Toxicities Associated with Radiation Treatment for Breast Cancer (Meghana Reddy, Gautam Krishna Koipallil, Amber Orman)....Pages 181-191 Back Matter ....Pages 193-197