March 2004: Radiation Therapy Updates

Daily work during radiation?

Question from leslie: Hello. I start radiation tomorrow. Will I be able to tolerate my daily work? What will be the side effects? I am very nervous. Thank you.

Answers —Lydia Komarnicky, M.D.: Yes, you should be able to work. Most people have mild fatigue if getting radiation only. The fatigue may be a little greater if getting chemo and radiation. Therefore, you should be able to work without any problems.

Marisa Weiss, M.D., president and founder: If there are things that you're worried about, write down your questions and report your concerns. Tomorrow, before you get started with your planning and treatment, ask the nurse and doctor about your questions and share your concerns. Most of the time, the things you're nervous about are just anticipated fears, rather than what's actually going to happen.

Future radiation to another body part?

Question from Lisa: I've read that once you've received radiation, you cannot have it again, even on a different part of the body. Is this true, and why?

Answer —Lydia Komarnicky, M.D.: No, this is not true. If you get radiation to one breast, you can still get radiation if needed to the other breast or any other part of the body. In rare situations, some patients may be able to have re-irradiation to a breast that has been previously treated.

Radiation as a precaution?

Question from AnnieP: Would it not be beneficial to irradiate both breasts as a precautionary measure?

Answer —Lydia Komarnicky, M.D.: No. Radiation only works where there are potentially cancer cells, or where we know there are cancer cells. In addition, the side effects do not warrant treating the other breast if there are no signs of cancer or no history of cancer in that breast.

How long does treatment take?

Question from Xana: How long does each treatment take?

Answers —Lydia Komarnicky, M.D.: Each treatment only lasts a couple of minutes. Most patients are in the treatment room about 10 minutes to make sure they're lined up correctly. I usually tell patients to plan on being in the Radiation Department about one-half hour a day.

Marisa Weiss, M.D., president and founder: This may vary from one department to another. And even within the same department, there can be variation from day to day. Sometimes there are emergencies that throw off the schedule. Your doctor and your nurse will usually get to see you about once a week.

Lydia Komarnicky, M.D.: Periodically, the doctor may ask to take a special x-ray to check and make sure that the setup is still perfect.

Good vs. bad radiation?

Question from PatCA: I don't understand how radiation, per se, helps with cancer treatment, yet radiation exposure as a whole is bad. Please explain the difference. Also, what is the gold standard for the RAD exposure?

Answers —Lydia Komarnicky, M.D.: The goal of radiation therapy is to stop the growth of cancer cells, and that's how it helps. When radiation is dangerous is if it's given to the whole body and not just to a small part of the body.

Marisa Weiss, M.D., president and founder: Radiation used for treatment is delivered with very fancy machines. The doctor can manipulate all kinds of factors to make sure that the radiation only goes to the area of the body that's at risk and to avoid or minimize dose to any adjacent normal tissues that are not at risk.

Lydia Komarnicky, M.D.: As part of the treatment, there are behind-the-scenes people that check the doses and set-ups to ensure its accuracy on a daily basis. These include physicists, dosimetrists, and therapists, all of whom check plans and doses.

IMRT, thin-beam radiation?

Question from Friday: When are the new thin-beam radiation techniques going to be the standard?

Answers —Lydia Komarnicky, M.D.: I assume you're talking about IMRT (Intensity Modulated Radiation Therapy) by thin-beams. These specialized beams—which may be 4, 5, or 6 beams of radiation—treat the breast and provide a very accurate beam of radiation to the breast. Not all centers are using these types of beams for the treatment of breast cancer. These beams may be considered controversial still.

Marisa Weiss, M.D., president and founder: Just because it's new does not mean it's better. In my practice, we have the ability to use IMRT as well as another state-of-the-art treatment approach. Most of the time, the non-IMRT plan looks better.

Lydia Komarnicky, M.D.: One thing people need to realize, and don't hear on the advertising, is that sometimes when you use these IMRT beams, you are actually by necessity having to treat normal breast tissue on the other side.

Marisa Weiss, M.D., president and founder: That is a significant concern. We don't know if that is safe or dangerous. There are some IMRT approaches that do not involve exposure to the other side. All these new techniques need to be carefully studied further before they are commonly used.

Lydia Komarnicky, M.D.: We're still in uncharted territory with IMRT for breast. IMRT is being used a lot for prostate cancer and brain tumors, but I think this still has to be evaluated for the treatment of breast cancer a little more.

Marisa Weiss, M.D., president and founder: IMRT is best suited for treating cancers that are deep inside the body where it is very challenging to limit the dose only to the area at risk and spare normal tissue. But when it comes to treating women with breast cancer, the breast is on the surface. The challenge of restricting the dose to normal tissue is not the same. It is easier.

Lydia Komarnicky, M.D.: There are some that would use IMRT especially for left-sided breast cancers to try to spare the heart and even the lungs, but there is a tradeoff for treating normal tissues like breast tissue on the other side.

Choosing facility by radiation machine?

Question from Marion: Should we be aware of the different kinds of radiation machines in choosing a treatment center?

Answers —Lydia Komarnicky, M.D.: Most newer radiation oncology centers will have state-of-the-art radiation therapy equipment; however, it would be important to ask what kind of treatment planning systems they have. Does the radiation oncologist use 3-dimensional treatment planning systems? Are there certified physicists involved with the planning? What kind of experience does the radiation oncologist have? Is there a certified dosimetrist?

There are many people behind the scenes who help the radiation oncologist determine the treatment plan. It's not just all about the radiation oncologist. There are many people involved. Not all centers are the same, but there are many centers with excellent radiation oncologists and good equipment.

Marisa Weiss, M.D., president and founder: You definitely need to find the best team approach.

Lydia Komarnicky, M.D.: Team approach is always best. If they all work together well to formulate a plan, that's the best scenario.

Marisa Weiss, M.D., president and founder: You may find the best of each of these types of doctors in different hospitals, but you can still get them all working on your team in a coordinating fashion.

What exactly does radiation treat?

Question from Tina: If surgery has removed my breast, and chemo has chased down the cancer cells in my body, then what is left for radiation to get?

Answers —Lydia Komarnicky, M.D.: That's a good question. We know that—based on tumor size and the number of lymph nodes involved— there are patients who still require radiation therapy after other combined modalities, such as surgery and chemotherapy.

Our literature shows that there may be an increased risk for having the tumor come back in certain scenarios, and your radiation oncologist can help make a recommendation for this. Based on tumor size—usually over 4 cm and multiple positive nodes—is a scenario where radiation therapy after chemotherapy and mastectomy would be recommended.

Marisa Weiss, M.D., president and founder: One area we're still waiting for a clear answer is in pre-menopausal women after mastectomy and chemotherapy, with only a few positive nodes. The New York Times just did an article about this 'gray area.' Each of you is unique and different and deserves individualized guidance from a top-notch radiation oncologist to find out if radiation is likely to benefit you.

Lydia Komarnicky, M.D.: You have to weigh the side effects of the radiation vs. the benefit of the treatment.

Marisa Weiss, M.D., president and founder: In your particular situation.

Brachytherapy and IORT procedures?

Question from Katie JM: What about brachytherapy and IORT (intraoperative radiation therapy) procedures?

Answers —Lydia Komarnicky, M.D.: Brachytherapy, also known as radiation implant therapy, has been around for many, many years. In the early 1900s, brachytherapy was actually the main mode of treatment for breast cancer, because we did not have the wonderful equipment we have today. So the concept is not new.

It started back in the 1900s with radium needles and has progressed to other forms of radiation materials. Now, there is a special technique called high-dose rate radiation, which is a form of brachytherapy. Potentially, all the radiation treatments can be given in one week through this brachytherapy implant.

There are different ways to do the brachytherapy implant. The most advertised way these days that you hear about is MammoSite. In this method, a catheter with a balloon on the end is placed in the cavity where the tumor was located and a small radioactive wire is placed in the balloon. This then retracts out of the balloon. It is done twice per day, as an outpatient, for five days.

The results are still early, but very promising. The recurrence rates appear to be very low. There should be strict criteria for the types of patients accepted for this type of therapy. Acceptable types are those with small tumors, patients with negative lymph nodes, and older women.

Marisa Weiss, M.D., president and founder: In addition, this study, so far, only accepts women with non-lobular cell types and with negative margins of resection. The information available so far is really only in women with invasive breast cancer. Studies are just getting started looking at the use of partial breast radiation in women with DCIS, or non-invasive breast cancer.

Lydia Komarnicky, M.D.: The results are very promising. The cosmetic results are looking quite good along with the low recurrence rates. This may become the wave of the future, but we're still obtaining data from the studies.

Marisa Weiss, M.D., president and founder: The side effects of partial breast irradiation are less, because only a part of the breast is treated. Still, at this time, the standard of care is still whole breast radiation after the cancer has been completely removed. Later this year, a new study will open that compares whole breast radiation to partial breast irradiation in women with early-stage breast cancer.

Lydia Komarnicky, M.D.: Another type of partial breast radiation is where small tubes are actually placed into the breast instead of the balloon. So there are other techniques available for partial breast irradiation rather than MammoSite.

Intraoperative radiation (IORT) is a technique not so much used for breast cancer, but for other types of malignancies, like pancreatic cancer or even recurrent rectal cancer.

Marisa Weiss, M.D., president and founder: At the past San Antonio meeting, early results were presented on the possible role of intraoperative radiation as the technique to deliver full partial breast irradiation. The results are too early to base treatment decisions on at this time.

What do physicists and dosimetrists do?

Question from Janet: What do physicists and dosimetrists have to do with radiation? What is a dosimetrist?

Answers —Lydia Komarnicky, M.D.: Physicists and dosimetrists are critical to any radiation therapy department. They make sure the equipment is functioning correctly, that the dose delivery is correct, the charts are checked on a regular basis, and the quality of the radiation beam is intact. They are responsible for the quality of the radiation equipment and the correct functioning of that portion of the department.

Dosimetrists help the physician actually work out the radiation treatment plan--the 3-dimensional treatment plan—and help us to determine the angles of the beam. A good dosimetrist is hard to find and keep, but they're worth their weight in gold.

Marisa Weiss, M.D., president and founder: Keep in mind that radiation is a physical phenomenon that is controlled in a predictable way using all kinds of parameters. The physics and dosimetry staff are experts in how to best utilize radiation together with the doctor, who understands more about the disease itself and how to control the disease.

Lydia Komarnicky, M.D.: So it really is a team approach of not just the radiation oncologist, but also the physicist and the dosimetrist.

External or internal radiation?

Question from Berneil: What determines the decision for external or internal radiation?

Answer —Lydia Komarnicky, M.D.: Standard therapy is still considered to be external radiation. Some radiation oncologists may employ the internal or brachytherapy type of radiation, depending upon the circumstance. Whole breast irradiation is still considered standard, and that is the external form of radiation.

Why isn't radiation spaced out?

Question from RavenW: Why must radiations be given so close together if it causes so much skin irritation? Wouldn't it be better to space it out some?

Answers —Lydia Komarnicky, M.D.: We know that radiation given daily five days per week over six to seven weeks works best. Spacing it out or skipping days is not the best way to deliver radiation.

We know that from giving radiation daily, the risk of recurrence in the breast is low. So most radiation oncologists are not willing to change that pattern, because we know it works.

Marisa Weiss, M.D., president and founder: Radiation works best when one dose builds on the next dose. In between doses, normal tissue is better able to repair the effects of radiation, because they have their 'act together' better, whereas cancer cells grow in a more erratic and uncontrolled way. They're not as good at repairing radiation damage in between treatments.

So when one treatment is given close to the next treatment, the damage adds up more in the cancer cells and you're more likely to kill those cancer cells.

Lydia Komarnicky, M.D.: From historical studies looking at radiation biology—the effect of radiation on cells—we know that giving daily doses of radiation works best, as opposed to one dose a week or two doses a week. You need to give daily radiation for at least five days.

Marisa Weiss, M.D., president and founder: If you have a four-day week because of a holiday or another important reason, don't worry. Your treatment is still effective when the rest of the weeks of treatment are given in a more continuous fashion.

Lydia Komarnicky, M.D.: An occasional interruption would be OK. Continued interruptions on a weekly basis would not be recommended. You can make up an occasional interruption at the end.

How to protect skin from radiation?

Question from Shandy: What can radiation patients do for their skin to help guard against irritation or burning from radiation?

Answers —Lydia Komarnicky, M.D.: This probably varies from one radiation oncologist to another. Typically, we ask our patients not to use anything harsh on the skin during radiation treatments. Use only mild moisturizing soaps. Do not use harsh deodorants. Your radiation oncologist can tell you what kind of cream to use during a course of therapy.

For women who have very large breasts, they tend to get more treatment reaction, and keeping the folds underneath the breasts as dry as possible is important. We tell our patients to use cornstarch to keep that area nice and dry.

Marisa Weiss, M.D., president and founder: You can take cornstarch from your kitchen and pour it into a thin sock. Put a knot at the top and you have a ball of cornstarch that you can use to apply under the breast in the armpit. After putting the creams on, you can dust the surface just like flouring a pan after you've buttered it. This can make the skin surface smooth and cut down on friction.

In women with big breasts, it's good to avoid skin against skin under the breast. And for any woman, it's good to avoid skin against skin in the armpit area. Whenever you can, try to keep the arm away from the breast so it doesn't move through the armpit area. You want to avoid tight bras or ones with underwires that rub too much under the breast.

I tell patients that when they get home they should take off the bra and put fabric under the breast to avoid skin against skin. Keep a space between the breast and the area where it might rest on the top of your abdomen.

Lydia Komarnicky, M.D.: For some patients a hand-held fan can also be a great idea a couple times a day, especially if you have a large breast. Get the fan to get air moving underneath.

Marisa Weiss, M.D., president and founder: You might have a hair dryer that you can put on "cool." This, too, can help keep air moving and can make you feel better.

Lydia Komarnicky, M.D.: I only use hydrocortisone cream when the skin gets quite red.

Marisa Weiss, M.D., president and founder: Each radiation oncologist has a different set of recommendations. I use a low-strength hydrocortisone cream a few weeks into treatment and then move up to a higher strength steroid cream towards the end of treatment, as needed.

Each week during treatment, your doctor will see you and look at your breast and skin carefully. That's a good opportunity to modify the skin care instructions based on your individual situation and how you're doing.

Lydia Komarnicky, M.D.: If you think that your skin is getting too red too quickly, don't wait for your weekly assessment with your doctor to point that out. Feel free to call him or her earlier if necessary, or point it out to your radiation therapists and they will call the doctor.

Lying on stomach during radiation?

Question from Anna: My mom is getting radiation lying on her stomach with her breast hanging. Is this just as effective as the more usual way?

Answer —Lydia Komarnicky, M.D.: Yes, it is. I've used this technique in women who have large breasts. It's called the prone position way of treating breast cancer, and it's an innovative way to do it if someone is large-breasted. Technically challenging, but there is nothing wrong with this technique. It's used in many parts of the country.

Will radiation aggravate swelling?

Question from Janet: I have swelling that comes and goes under my arm after my mastectomy. Will radiation aggravate the swelling?

Answer —Lydia Komarnicky, M.D.: Radiation should not aggravate the swelling necessarily. It sounds like you probably have a seroma (fluid buildup). It should probably be pointed out to your surgeon, but the radiation should not make this worse. Eventually, with time, this fluid collection will stop forming when your lymphatic channels have opened and are flowing more easily.

Blood clots after radiation?

Question from Jamie: I have recently developed blood clots under the breast that was radiated. Is this normal?

Answers —Lydia Komarnicky, M.D.: I think you are probably referring to Mondor's disease. This happens sometimes after surgery alone without radiation and is usually more a complication or side effect after surgery. You can also see this happen underneath the arm.

I have seen it on occasion, but much less frequently now that more women are getting sentinel lymph node procedures done as opposed to a standard dissection. This eventually will go away, but can be uncomfortable for a while. If you have any concerns, please point this out to your doctor.

Marisa Weiss, M.D., president and founder: Even though it's called a "disease," it just has that name because someone noted it and assigned it a name. As Dr. Komarnicky said, it's usually mild and does go away.

Does radiation cause hair loss?

Question from Gwen: Does radiation cause hair loss as chemo does?

Answers —Lydia Komarnicky, M.D.: Radiation is very site-specific so that the symptoms and side effects are related to where you aim the beam. If someone is having their head treated by radiation, they will lose their hair. However, if they are having their breast radiated, the hair on their head will not fall out. They may lose a little bit of the hair underneath the arm, however, but that's it.

Marisa Weiss, M.D., president and founder: If you have hair around your nipple and areola, this hair may come out and may or may not regrow.

Lydia Komarnicky, M.D.: It will not cause you to lose your eyebrows, eyelashes, or hair on your head.

Marisa Weiss, M.D., president and founder: Most forms of breast radiation do not make you radioactive. It's only when the radiation sources are placed during brachytherapy that there is radioactivity within the breast. No one can catch radiation from you.

It's important to let people close to you know this so they do not avoid you during your radiation therapy. I had a patient whose husband avoided touching her breast during their sexual activity because he was afraid that he would get radiation from her. In addition, radiation to the breast does not cause any nausea or vomiting. This is another concern that you don't have to worry about.

Lasting discomfort after radiation?

Question from Sally: I finished 33 treatments of radiation in August 2003. Is it normal to have redness, discomfort, and pain down the one side of my breast seven months after the treatment finished?

Answers —Lydia Komarnicky, M.D.: This would be unusual, but, occasionally, I've had patients with tenderness in the breasts and swelling up to seven months after treatment, with still mild redness. However, make sure you ask your radiation oncologist to take a look at this for you.

I have had a number of patients continue to have tenderness even after the surgery and radiation is done for a few years, and there may always be a little tenderness in the breast. Some women have no tenderness, and some women do have tenderness and swelling.

What I tell my patients now to do, after the radiation, is to massage the breast with a nice moisturizing cream a few minutes a day to try to disperse the fluids in the breast. I think this helps decrease a little bit the swelling and some of the tenderness, but it is an ongoing process, so don't be discouraged by it.

The other thing I would recommend is that if there is tenderness and swelling of the breast, go to a larger bra or cup size. Sometimes, if the bra is too tight, this almost acts like a tourniquet around the breast, keeping the fluid in or making the breast feel engorged or heavy. So trying this is a simple way that can help reduce some of the tenderness.

When you're wearing your bra and you take it off, if you see indentations in the skin on the treatment side, this probably means that you have some fluid in the skin and the bra may be too tight for you. This can keep the breast engorged and feeling tender.

Marisa Weiss, M.D., president and founder: Also, if you tend to sleep on your stomach or on the same side as you were treated, then the fluid buildup that might happen during the day doesn't get a chance to drain back into the body.

If you sleep on your back, without a bra at night, the fluid does tend to drain away from the breast during the nighttime. In the morning, you will probably notice some improvement. But by the end of the day, you'll probably notice fluid buildup along the lower part of the breast where gravity puts it.

Lydia Komarnicky, M.D.: The nipple may feel a little bit hard when the breast is swollen because of the fluid in the breast. Because of the gravity, the bottom portion of the breast may feel firmer.

There are changes in the breast that go on for a year, if not two years, after the radiation therapy is complete. And even though the skin may look normal and the breast starts to feel normal, you can still see these changes ongoing in a mammogram for almost up to two years.

Marisa Weiss, M.D., president and founder: Sometimes, it can feel confusing because many of the side effects from radiation go away quite quickly, like the redness. But the side effects like the diffused swelling of the breast take longer to go away.

During the first few years after radiation has been completed, the swelling does tend to very slowly improve. From day to day, it's hard to notice the difference. But Dr. Komarnicky and I can usually see improvement in between our checkups, several times a year. 

I have been quite impressed by how much the swelling can go away within the first few years. Even patients who do have a lot of swelling for, let's say, one to three years, can really have substantial improvement after that period of time.

Tolerating radiation well?

Question from Carol: I tolerated chemotherapy very well; does this mean I should tolerate the radiation treatment as well, or is that up for grabs?

Answers —Lydia Komarnicky, M.D.: Most people tolerate radiation therapy very well and it really has no bearing on how well or not well chemotherapy was tolerated.

Marisa Weiss, M.D., president and founder: These days, chemotherapy is generally given first, followed by radiation. By the time you get to radiation, many women are dealing with a cumulative or buildup of fatigue because they've been pushing and pushing through all the diagnostic steps, surgery, then multiple cycles of chemotherapy. They might already feel worn down by the time they start radiation.

In this situation, adding the demands of daily radiation can feel burdensome. It's important to keep well rested during your treatment. Don't expect too much of yourself. Hang out with people that make you feel good and give you energy. Leave the housekeeping to somebody else, or let the dust build up, and order out some good food rather than do all the shopping and cooking every day of the week.

Does radiation affect eggs, ovaries?

Question from Kelly: Does radiation affect eggs in the ovaries of pre-menopausal women? The numerous x-rays and scanning machines used during treatment concern me, as my husband and I will not be able to try to have children for a while yet.

Answers —Lydia Komarnicky, M.D.: After radiation therapy, usually within about two years, we recommend our patients can try to get pregnant. This varies, and I understand is controversial. Some expect their patients to wait longer or have families earlier.

During the course of radiation, we would certainly never treat someone who is pregnant because of the tiny scatter dose to the baby and to the ovaries. This would not be enough to disturb a menstrual cycle or affect fertility, but it's a precautionary measure more than anything.

Marisa Weiss, M.D., president and founder: The recommendation to wait two years after finishing treatment is separate from the concern about any small scatter to the ovaries. This delay until trying to get pregnant is more related to getting past the highest risk period of recurrence just to make sure you're OK, cancer-free, and ready to take on the responsibility of being a parent.

Editor's Note: For more information about fertility and breast cancer treatment, see Breastcancer.org's section on Fertility, Pregnancy, and Adoption.

When is armpit radiated?

Question from BJW: What determines whether the axilla (armpit) will be radiated?

Answers —Lydia Komarnicky, M.D.: There are certain characteristics that we look for on the pathology report that would indicate whether the axilla should be radiated or not. This has to do with the number of lymph nodes involved, how large the lymph nodes were, and even if there's some extension outside of the lymph node into the soft tissue.

We look at these characteristics very carefully, because there are risks to treating the lymph nodes underneath the arm along with surgery, especially if a large number of lymph nodes have been removed.

Radiation to the lymph-node-bearing areas can increase the likelihood of lymphedema of the arm, as well as some potential damage to the nerves that come through the armpit area, although this is certainly rare. Therefore, we evaluate pathology reports very carefully before we make this recommendation.

Marisa Weiss, M.D., president and founder: All of these treatment decisions are individualized for each patient.

Lydia Komarnicky, M.D.: Now that more and more patients seem to be getting the sentinel lymph node procedure, we are seeing less in the way of arm swelling, which is a wonderful thing.

When is radiation boost given?

Question from Kaye: When is radiation boost given? I am worried because I didn't have boost. I had bilateral mastectomy; main tumor was in upper inner quad—pleomorphic invasive lobular. Also had tumor in nipple with dermal lymphatics and high-grade DCIS with extensive comedo necrosis.

Answer —Lydia Komarnicky, M.D.: If someone has a mastectomy and radiation therapy is necessary, typically the chest wall is treated, but not necessarily with a boost. The patients who typically receive a boost as part of their radiation treatment planning are those patients who have an intact breast.

In other words, those patients who've not had a mastectomy will require whole breast radiation plus a boost to where the tumor was located. If a mastectomy has been performed, there is no need to have a boost. Although rare circumstances happen where you may, but usually where a mastectomy is performed, a boost is not performed as part of the treatment plan.

Long-term effects of radiation?

Question from Jen315: What are the long-term effects of radiation? I am having a lot of anxiety re: late effects, combined with anxiety of a recurrence.

Answers —Lydia Komarnicky, M.D.: Long-term side effects from radiation that I usually tell my patients about include the possibility of a small scar on the lung which is infrequent and asymptomatic—in other words, no symptoms. Another long-term side effect may be that the ribs on the treatment side may become more fragile and a small fracture can result. This is also not frequent.

Radiation oncologists, as part of their initial treatment plan, try to avoid the lungs and heart at all costs. But even the best treatment plan will incorporate a small sliver of the lung in the treatment field.

In the 18 years I've been practicing, I've only seen about four patients with a fracture of the ribs. A very small percentage of patients may develop a cancer related to radiation, and I've only seen two to three during the whole course of my career. So, certainly, the benefits of radiation outweigh these long-term side effects.

Marisa Weiss, M.D., president and founder: The treated breast does tend to stay a little perkier than the other side. Some women say it looks a little bit more youthful. Ten years after breast radiation, if you're standing naked in front of the mirror, the untreated side usually hangs lower than the treated side. In a bra, you usually look pretty even.

As we grow older, we also tend to gain weight naturally. The treated breast may not gain as much weight as the untreated side. This can accentuate any asymmetry that you may already have.

These are very subtle long-term effects, but you may notice them. We tend to be focused on a lot of the little things that can happen to our bodies, and it's always easier when you know what to expect. But, again, many of the changes that Dr. Komarnicky mentioned are uncommon, and your doctor checks for them when you go back for your follow-up visits. If you notice anything that's new or different about your body, and you're concerned about it, bring it to your doctor's attention.

Tamoxifen during radiation?

Question from CJ: Why is it that some doctors recommend waiting until after radiation before starting tamoxifen, while others say it is not a problem to do both at the same time?

Answers —Lydia Komarnicky, M.D.: That's an area of controversy. I personally do not have much of a problem with tamoxifen given during radiation. I think that there are some radiation oncologists that may be concerned about the cosmetic results of tamoxifen during radiation treatment.

Marisa Weiss, M.D., president and founder: We don't have the 'right answer' on this. My personal preference is to delay the start of the hormonal therapy until after radiation is finished for most women. The reason why I have this preference is because we know that anti-estrogen therapy slows down the growth of hormone-receptor-positive breast cancer cells. When these cells are slowed down and dormant, they are less vulnerable to the effects of radiation, theoretically. In order to maximize the potential benefit of radiation, it's theoretically best to have the cells be active, not inactive. I keep mentioning 'theoretically' because these concerns are based on laboratory observations rather than clear findings from clinical studies. We do know from a recent NSABP (National Surgical Adjuvant Breast and Bowel Project) study that chemotherapy works better when it's separated from the hormonal therapy.

The other reason why I like to delay the tamoxifen is because I prefer to do one thing at a time and to separate out any potential side effects from each of the treatments if there's no compelling reason to do it otherwise. Women are on the anti-estrogen therapy for five years, so I figure that it's OK to delay it for the six to seven weeks of radiation. Again, this is just a preference. It's not known to be the 'right answer.'

There are situations, however, where a woman may be at high risk for recurrence. For example, she has multiple positive lymph nodes or other factors that put her at high risk for recurrence. Then, as soon as her chemotherapy is done, her medical oncologist might want to put her immediately on anti-estrogen therapy to get that immediate protection and to keep it going during her radiation. This is perfectly acceptable, based on what we know at this time. There have been plenty of studies that have shown that radiation together with tamoxifen is very effective.

Lydia Komarnicky, M.D.: I have reviewed our data looking at patients receiving tamoxifen and radiation therapy over the past 17-18 years, and it was apparent that there was no effect on the cosmetic results. We did not notice any difference in the survival. We are still awaiting studies to define this, so there's not a right or wrong answer to this question right now.

Marisa Weiss, M.D., president and founder: Both Harvard and Penn also looked at this question. One institution prefers one way, the other institution prefers the other way. Again, there is no 'right answer' at this time.

Why use tattoos to mark area?

Question from Sandy: Why are tattoos used instead of markers, which will eventually wash off?

Answers —Lydia Komarnicky, M.D.: Most radiation oncology facilities will use the initial marking pen for the initial setup. However, when the field has been defined, tattoos will be placed in the corners of the field to make sure that the field is as accurate as possible each day.

Occasionally, if patients refuse tattoos, I have been coerced into allowing marking pen marks only, but it's not my preference. It's always nice to have a permanent map by virtue of using tattoos so that you know where the previous radiation field was in case you need to treat the other side. There is no question as to where the prior field went.

Marisa Weiss, M.D., president and founder: Tattoos are really, really tiny, and magic marker marks tend to be thick and imprecise. If you're finished treatment and you have a tattoo that shows and gets in the way of your wearing a low-cut dress or your favorite bathing suit, then it's OK to go to a dermatologist or a plastic surgeon to have the tattoo at the top center of the chest paled or removed with a laser.

Some doctors prefer to make a teeny incision to remove it, if it really is unacceptable to you. We can use the rest of the tattoos to reconstruct prior radiation if that ever needs to be determined.

Reconstruction how long after radiation?

Question from LeslieB: I am headed for radiation for six and one-half weeks and want to know first, how long should I wait before reconstruction and is it going to be difficult to have implants?

Answers —Marisa Weiss, M.D., president and founder: If you have mastectomy with placement of a tissue expander, and then you finish radiation to that area, most plastic surgeons want the area of the redness and swelling to heal before they go in to remove the expander and put in the permanent implant. At some places, like at Memorial Sloan-Kettering in New York, they tend to switch the expander for the implant before radiation to the chest wall is delivered.

Lydia Komarnicky, M.D.: Sometimes, a plastic surgeon and certainly the radiation oncologist will want the saline expander expanded to its fullest before starting radiation. The reason is that once you start radiation, you can't continue expanding during the treatment. This will throw off the very accurate beam that was set up to the breast in the initial time in the department. Then, after the radiation is complete, the expander can be replaced with the actual implant.

Marisa Weiss, M.D., president and founder: The coordination between the plastic surgery reconstruction and the radiation requires good communication. For example, sometimes the expander is expanded too much before the radiation, distorting the chest wall and other normal tissues in the area that needs to be radiated. It then could push the chest wall down towards the heart. In this situation, the radiation oncologist may request that some fluid be removed from the expander to improve the radiation distribution to the area at risk and to avoid dose to the adjacent normal tissue.

Each of you needs to work closely with your own radiation oncologist to find out how the information we provided tonight can be useful for you, based on your unique circumstances.