Radiotherapy after breast surgery

This information is about radiotherapy after breast surgery. Please try to read it before your next appointment at The Christie. It is also important that your family and friends feel well-informed and understand what is happening. This can make it easier for them to help you.

Not all the information in here may apply to the type of treatment you are having. This will be discussed when you have your first meeting with a member of The Christie radiotherapy team.

What is radiotherapy?

Radiotherapy uses exact, carefully measured doses of radiation to treat the area specified by the specialist doctor called a clinical oncologist.

External beam radiotherapy can be delivered in many different ways using high energy radiation beams. These can either be photons, electrons or protons. Photons and electrons are delivered from a machine called a linear accelerator whilst protons are delivered from a machine called a cyclotron.

Please note: Mobile phones can interfere with the treatment equipment. Please look out for signs letting you know if it is safe to use your mobile phone. If you do have one with you, you may need to turn it off.

The Christie NHS Foundation Trust now provides a proton beam therapy service. Some patients may benefit from this type of radiation and are currently offered it as part of a clinical trial. This will be discussed with you by your clinical oncologist if appropriate.

Treatment is given by therapeutic radiographers who operate the treatment machines which direct high energy rays to the precise area needing treatment. The radiographers will be able to answer any questions or concerns you may have.

Radiotherapy works by targeting cells in the treatment area. If radiation hits a cell that is dividing, the cell will be damaged. Cancer cells are much less able than normal cells to repair the damage, so more of the cancer cells will be destroyed. The normal cells can recover. Although surgery will have removed all the visible cancer cells, there is a small risk that some remain, and the radiotherapy should destroy these cells. If you have had surgery to remove part of the breast, radiation is usually advised for the surrounding breast tissue, to destroy any possible remaining cancer cells.

If you have had a mastectomy, it is sometimes advised for the chest wall. The area treated may also include some small glands called lymph nodes that lie behind your clavicle (collar bone), in the armpit and behind your sternum (breastbone).

The aim of treatment following surgery is to reduce the chances of cancer coming back in the breast or chest wall and to improve survival.

When will radiotherapy begin?

Before your course of radiotherapy can begin, it is important for the scar from your surgery to be healed. Treatment can sometimes be planned before it has healed completely, but the treatment itself may be delayed slightly. You will have an appointment with a Christie doctor or nurse clinician to discuss the type of radiotherapy you need before you attend for treatment planning. This may take place at your local hospital or The Christie.

Your first visit to the radiotherapy department will be to plan your treatment. The Christie gives radiotherapy treatment at our main Withington site and at radiotherapy centres at Oldham, Salford and Macclesfield. Treatment usually begins 1 to 2 weeks after the planning visit.

Most people will have 5 or 15 treatments. Your clinician will discuss which treatment option is best for you. You may possibly have some additional boost treatments, depending on your age and factors relating to your cancer.

Agreeing to treatment

Consent to treatment

We will ask you to sign a consent form agreeing to accept the treatment that you are being offered. The basis of the agreement is that you have had The Christie’s written description of the proposed treatment and that you have been given an opportunity to discuss any concerns. You are entitled to request a second opinion from another doctor who specialises in treating this cancer. You can ask your own consultant or your GP to refer you. Your consent may be withdrawn at any time before or during this treatment.

Should you decide to withdraw your consent then a member of your treating team will discuss the possible consequences with you.

Exposure to radiation during pregnancy can be dangerous for the foetus (baby). The effects can be serious and may result in birth defects, childhood cancers, impaired growth and mental development. For these reasons we would advise against falling pregnant before or during radiotherapy.

Please inform the radiographers as soon as possible if you fall pregnant before or throughout your radiotherapy treatment.

If you find out you are pregnant after radiotherapy has completed and believe your dates overlap with treatment, please contact your consultant’s secretary.

Are there any alternatives to this treatment?

The doctor at your local hospital may have advised you about any other possible treatments before referring you to The Christie. Your consultant at The Christie will be happy to discuss any concerns you may still have.

What will happen if I do not have this treatment?

There is an increased risk that your cancer may return. You can discuss what to do next with your doctor.

Planning the treatment (marking up)

A therapeutic radiographer will explain to you exactly what is going to happen. You will not have any treatment on your first day in the radiotherapy department. Treatment planning (marking up) will be done on a CT scanner. The scans undertaken are solely aimed to give enough information to plan your radiotherapy accurately.

An image of a patient lying on their back on the CT scanner bed. The patient has their arms above their head placed in arm rests and the CT scanner can be seen behind them. To the side of the patient is a radiographer.

These scans are not diagnostic and therefore do not give sufficient information to assess the status of your cancer or any other abnormalities.

The radiographer will ask you to remove all your clothes above your waist and give you a special breast gown to keep and bring with you during your treatment. Please return this on the last treatment day.

The radiographer will help you on to the treatment couch for you to lie on your back on a special inclined board. We will help to make you as comfortable as possible although the board is very hard. Your arms will be raised above your head and supported on a special arm rest. You will need to lie still. This is the position you will be in for your treatment.

For patients receiving radiotherapy to the left breast/chest wall and for select circumstances when treating the right side, we will attempt a technique called Deep Inspiration Breath Hold (DIBH).

During the planning session, the radiographers will draw marks on your chest with a skin pen. The pen marks may rub off a little onto your clothes. Do not worry if they do – they will wash out – but it might be sensible to wear older underwear.

A photo of a patient on their back on the CT scanner bed. The patient has their arms above their head placed in arm rests and the CT scanner can be seen behind them. There are some lights from a laser beam projected on the chest of the patient which help line up the patient in the correct treatment position.

What happens during treatment?

On the day of your first treatment, the radiographers will discuss the treatment and how to minimise the associated side effects. They will also check that you are still happy to go ahead with treatment. This is the time to ask any remaining questions or discuss any concerns you may have, even if they seem like silly questions.

A photo of a patient lying on their back on the radiotherapy treatment machine called a linear accelerator (or linac). The patient has their arms above their head placed in arm rests. To the side of the patient is a radiographer. The treatment machine arm extends from the linac and is positioned above and to the side of the patient. There is an imaging board on the other side of the patient.

The radiographers will have the details of your treatment which the doctor and planning team have carefully planned. Just before your treatment, you will be asked to change into your gown. If you are asked to sit in the waiting area in your gown, and you do not feel comfortable about this, please tell a member of staff or bring something to wear on top of it (jacket, cardigan or shawl).

While you are on the treatment couch, the radiographers will adjust your breast gown and will make sure to keep you covered up as much as possible. The radiographers will then position you, the treatment couch and the radiotherapy machine until they are all in the correct position. This is to line up the marks already put on your skin at marking up.

Parts of the radiotherapy machine may come close to you and even touch you, but at no time will you feel any pain or pressure.

When all the adjustments have been made and you are in exactly the right position, the radiographers will make sure you are comfortable and then leave the room to switch the machine on. You may feel isolated however, cameras inside the room give the radiographers at the control desk a clear view of you. They will be watching you all the time.

There is nothing to feel and nothing to see during treatment. The radiotherapy machine makes a buzzing noise when it is giving treatment. It is important you stay as still as possible however should you require assistance, wave or shout and the radiographers will come in immediately. Please check your appointment time for the following day before you leave in case of any changes.

Can I expect any side effects?

The side effects of radiotherapy occur in 2 stages:

  1. Early reactions: These reactions usually start 1 week from the start of treatment and gradually worsen, peaking about 2 weeks after finishing treatment. They then gradually improve thereafter.
  2. Late reactions: It is possible for reactions or changes to occur long after the treatment has finished (months or years).

Not everyone will have all the side effects listed here. These depend on the type of treatment, and everyone reacts in differing degrees to the treatment. The side effects of radiotherapy are limited to the area of the body being treated, apart from tiredness.

Early reactions

Skin reactions

You will notice very gradual changes. The reaction usually starts 1 week from the start of your treatment. Your skin in the treated area becomes pink (similar looking to sunburn) or darker (if you have darker skin) and may feel itchy and sore. This may worsen 1 to 2 weeks after radiotherapy completes and your skin may begin to blister, break down and weep. Here are some things you can do to help:

Wash the treated area with warm water and a mild soap or shower gel and then pat dry with a soft towel.

It is advisable to moisturise the skin within the treated area. Use your usual moisturising lotion to help soothe and moisturise the skin. If you do not have a moisturiser, a simple cream such as E45, Aveeno or Aloe Vera is adequate. We may advise you to stop using the moisturiser if your skin becomes blistered or broken.

You may use a deodorant unless it irritates your skin. It is best to use a deodorant that does not contain any metal compounds such as aluminium.

Do not use talcum powder in the treated area as this may irritate your skin and have a drying effect.

Use an electric razor if possible. Avoid wet shaving, using wax or other hair removal creams.

Loose natural fibre clothing such as cotton or silk may be more comfortable and prevent irritation caused by the rubbing of tight clothing. You may want to avoid underwired bras as they can cause extra irritation.

Perfumes and aftershave should not be used within the treatment area.

Be cautious when swimming in a chlorinated pool as the water can have a drying effect on the skin. It is advisable to rinse the skin well afterwards and apply moisturiser. If the skin becomes sore or breaks down, stop swimming until the reaction has settled.

Do not apply ice packs or hot water bottles to the area being treated.

Cover the treatment area when exposed to the sun or in cold and windy conditions whilst on treatment, and until any reaction has settled following treatment. We recommend using a total sun block for at least a year after treatment.

Do not use adhesive tape or dressings on the treated area unless advised by your specialist team.

There is more information in our leaflet ‘Skin care during and after your radiotherapy treatment’. Please ask your radiographer for a copy or visit the cancer information centre.

Some people have a more severe reaction, such as skin peeling, cracking or blistering. We advise you stop using all cream in the area that skin has broken, and use a foam, non-adhesive dressing to absorb any fluid, and reduce friction. This is more likely to happen if you have large breasts.

Contact the radiotherapy team or your breast care nurse who will advise you about appropriate dressings and make an appointment for you to be seen if necessary.

The Christie Hotline is also available 24/7 in more urgent cases on 0161 446 3658. You should take extra care of your skin during the treatment as long as the reaction lasts.

Tiredness

Tiredness can be a general side effect of treatment and travelling for treatment every day. A small number of people describe feelings of extreme fatigue, but most patients can continue normal routines, and some continue to work and carry out busy lives as normal. This can vary between individuals.

People who have had chemotherapy before radiotherapy may experience tiredness earlier because of the lasting side effects from chemotherapy. It is a good rule of thumb to listen to what your body is telling you, and if you feel tired then rest. Try to maintain a normal sleeping routine.

For people in good general health, it may be beneficial to do some gentle exercise such as walking . Please ask for a copy of The Christie booklet ‘Exercising during and after treatment for cancer’. Your tiredness should start to gradually improve a couple of weeks after completing your radiotherapy.

If tiredness is a problem, it is wise to take your time when doing jobs around the house and to follow that by periods of rest. If someone else can do the chores for a few weeks, this would help to speed your long-term recovery.

This largely depends on the type of work you are doing and individual circumstances. Discuss this with your doctor at an early opportunity and work out a plan for return, perhaps part-time or reduced hours, to begin with.

Hair loss in armpit (if you are having treatment to the axillary (armpit) lymph node area)

Radiotherapy only causes hair loss in the treated area. The sweat glands may also stop working for a while so sweating on that side should not be a problem.

Throat reaction (if you are having treatment to the lymph nodes at the bottom of your neck)

Some people can develop a sore throat, or it can feel uncomfortable when swallowing for a short time towards the end or just after treatment. We do our best to protect as much of the throat as possible. This does not usually last for more than a week. If this happens, we can give you liquid paracetamol to take before main meals. Take this for as long as the symptoms last. You can also help by drinking plenty of fluids. If it is uncomfortable when you swallow, eat soft but moist foods. More information is available in our booklet ‘Eating well for breast cancer’.

Stiffness of shoulder joints and muscles (from holding the treatment position or if you are having treatment close to the shoulder, treating the nodes)

Your shoulder can become stiff or uncomfortable if you have had lymph glands removed or may already be stiff since surgery. This can sometimes occur when treatment has finished. You may not think you have a problem with movement now, but doing some specific exercises during your radiotherapy treatment will help to prevent or minimise stiffness or discomfort. The exercises are different from those given to you following surgery and are taught by a physiotherapist in a class setting.

If you are having treatment at Withington, the physiotherapy department should contact you either before or shortly after starting your treatment to book you into a session. Alternatively, you can call them on 0161 446 3795.

If you are having radiotherapy at The Christie at Oldham, Salford or Macclesfield, you will automatically be booked into one of the exercise classes during the course of radiotherapy treatment. We strongly recommend that you join a class as near to the beginning of your treatment as possible. It is a good idea to continue with the exercises at home for several months after the treatment has ended to prevent any muscle stiffness.

Swelling of the breast (if you have had a lumpectomy)

You may notice a change to the size or shape of the breast. Some women say that the breast feels different and has changed in texture. At first, the breast may seem a little swollen (oedema). This should settle once treatment has finished but might take a month or more to do so. Women with large breasts have a greater tendency to changes in breast size. Also, patients having a 5-treatment course may notice more breast swelling due to treatment.

Pain

Some women have discomfort, pain (shooting pain or dull pain) or tenderness in the treated area, in the breast, or under the arm. Painkillers such as paracetamol or ibuprofen can often relieve this. If not ask your Christie doctor for further advice.

Lung inflammation (pneumonitis)

Rarely (about 1 in 100), part of the lung behind the treatment area can become inflamed causing a dry cough and shortness of breath. This is usually mild and temporary and resolves within a week or 2. If these symptoms persist, please contact your treatment team.

Smoking can increase radiotherapy side effects. For support to cut down or stop, contact the smoking cessation team on 07392 278 408 or 0161 956 1215.

Late or permanent reactions

It is possible for reactions or changes to occur long after the treatment has finished, although this is becoming less common because of improvements to treatment techniques. In some cases, discomfort can persist after treatment.

You may have changes to the colour of your skin in the treated area. This is particularly likely if you are dark skinned.

Several months after radiotherapy, some women may notice that their treated breast continues to feel firmer to touch. Occasionally, your breast might also change in size or shape. The change can be permanent but is usually only slight. Please contact your breast care nurse if you are worried about this.

The breast/chest wall/armpit and scar area may remain tender or sensitive for some time following surgery and radiotherapy resulting in some longer-term discomfort. Tiny permanent red spider marks may appear on your skin in the treated area several years after treatment. These are called telangiectasia and do not affect your general health.

Localised tenderness can occur over the ribs within the treated area, sometimes causing a weakening in the bone, and very rarely a rib fracture (about 1 in 100). The risk of rib fractures in patients having proton radiotherapy is possibly slightly higher which is currently being evaluated in trials. Rib fractures can be uncomfortable but will gradually improve.

As we may treat through a small amount of lung, in some cases this can cause scarring. It is highly unlikely to cause symptoms but rarely (1 in 100) can cause breathlessness and cough. If in the future, you have any medical imaging on your lungs, please inform them that you have had radiotherapy.

If the left breast or chest wall is being treated, there is some evidence with older radiotherapy techniques that there could be an increased risk of heart problems following radiotherapy. With modern and improved techniques and equipment, we minimise the radiation dose to the heart, thereby reducing the risk to your heart.

Using radiotherapy or chemotherapy to treat cancer carries a very small risk of causing a secondary cancer in the body. The risk is small (about 1 in 1000) and is greatest 10 to 20 years after treatment.

Radiotherapy can worsen cosmetic outcome after breast reconstruction surgery, particularly after an implant-based reconstruction. This is because the scarring around the implant can become more pronounced. This may cause pain and distortion of the reconstruction possibility needing further surgery to correct. Up to 1 in 5 patients may experience implant failure leading to replacement or removal of the implant.

The muscles in the shoulder and treated area can become stiff again. If this happens, please contact the physiotherapy department on 0161 446 3795 for further advice.

Please discuss your individual risk of lymphoedema (swelling in the body’s tissues) with your Christie doctor. Lymphoedema can occur due to surgery and/or radiotherapy to the armpit. Some patients notice a slight swelling of the arm or hand, and in a small number of cases it can be more severe (and can occur many years later). Our physiotherapy classes give advice regarding reducing the risk of lymphoedema, as well as stretching exercises. Please tell your breast care nurse or doctor if you develop any swelling or are concerned about this, as you may need a referral to a specialist.

Very rarely, radiotherapy to the breast/chest wall and lymph glands areas can cause nerve damage (brachial plexopathy) which may result in pain, weakness, numbness or tingling affecting nerves of the arm and shoulder. These symptoms are more likely if re-treatment of the same area is required.

Emotional support

You may feel low or depressed, and mood swings can occur from time to time. Sometimes these feelings can come out of the blue, during, or even after treatment. You are not alone at this time. Ask to speak to someone on the radiotherapy team (doctor or radiographer) or contact your breast care nurse.

Coming to terms with breast cancer can be traumatic, so don’t be afraid to ask for help. There are complementary therapy drop-in sessions including massage, reflexology and relaxation classes at The Christie at Withington, Oldham, Salford and Macclesfield. Please ask a member of staff about the dates and times of these services.

Breast care nurse support

Your local breast care nurse will remain your point of contact and source of advice for ongoing care.

Breast care nurses in the North West

  • Bolton: 01204 390494
  • Crewe: 01270 612130
  • The Christie: 0161 446 3996 or switchboard: 0161 446 3000
  • Macclesfield: 01625 663079
  • North Manchester: 0161 720 2558 or switchboard: 0161 795 4567
  • Oldham and Rochdale: 0161 627 8459 or switchboard: 0161 624 0420
  • Salford: 0161 206 1173/5676 or switchboard: 0161 789 7373
  • Stockport: 0161 419 5665/4752 or switchboard: 0161 483 1010
  • Tameside: 0161 922 6658/6088/6685 or switchboard: 0161 922 6000
  • Wigan: 01942 774720 or switchboard: 01942 244000
  • University Hospital South Manchester (Wythenshawe) and Trafford: 0161 291 3113 or switchboard: 0161 998 7070

Some questions you may have

No. You will feel no pain at all while you are actually having your treatment.

Radiation used in medical treatment is given in controlled, carefully measured doses. The aim is to include all tissues that could possibly contain cancer cells while minimising the dose to the normal tissue. No X-rays are given outside of the treatment area.

No. Patients treated by X-rays do not become radioactive. The radiation does not stay in your body after treatment, so you cannot do anyone else any harm. It is safe for you to mix with other people.

Not usually. The treatment may make you feel more tired than normal. Please tell your treatment team about any existing medical conditions and continue with any medication you may be taking. Ask your Christie doctor if you are worried about any other health problems.

Please discuss treatment times with the radiotherapy department support workers on the machine (blue uniform). The radiographers will give you an appointment time for the first treatment when you attend for your planning session. Please try and be as flexible as possible and give priority to your treatment sessions over other general appointments.

The time you prefer may not be available at the start of your treatment because of the large patient numbers being treated. If you need a specific time, please give the treating team as much notice as possible, though the department cannot guarantee to meet all requests.

The time we give you may vary half an hour each way due to emergencies. Please check your appointment time for the following day before you leave, in case of any changes.

During your treatment, you may be seen by the review team – this could be a doctor, specialist nurse or radiographer. This will be to review any side effects from your radiotherapy. This appointment will be made for you and will be arranged around your treatment appointment time.

If you require medical support during your treatment, please let the treatment radiographers know and they will organise this for you.

Many patients can bring themselves or can ask a friend or relative to help them out. If you think you may need ambulance transport, please discuss this with a radiotherapy support worker or radiographer on your first visit to the radiotherapy department.

Ambulance transport can be arranged subject to eligibility criteria based on medical need. There also needs to be a medical need for you to bring an escort on hospital transport.

There can be delays for some time either side of your appointment because of the high demand for transport. Please take this into account when you are deciding whether to use transport or not.

Hospital transport is provided by North West Ambulance Service and West Midlands Ambulance Service. Contact the transport liaison office at The Christie directly on 0161 446 8114 or 8143 for advice and bookings. Patients attending The Christie at Salford can contact 0161 918 7800, patients attending The Christie at Oldham can contact 0161 918 7700 and patients attending The Christie at Macclesfield can call 0161 956 1719 for advice about transport.

After treatment ends – follow-up

It is not always necessary to have a routine follow-up appointment after a course of radiotherapy. A follow-up appointment maybe arranged as necessary which usually takes place 6 to 12 weeks after your course of radiotherapy is completed. This appointment may be with a doctor, radiotherapy team or breast care nurse.

Alternatively, you may be given a contact number to call if you are experiencing significant problems after radiotherapy or the side effects do not settle as expected. Please contact this number and we will arrange an appointment for you.

If you have any problems after radiotherapy finishes related to side effects of the treatment, please contact the radiotherapy department, The Christie Hotline on 0161 446 3658, your breast care nurse, or the secretary of your Christie doctor via the switchboard on 0161 446 3000.

If you change your address, please let the health records department know your new address and the address of your new GP on 0161 446 3346 or 3347. If your follow-up appointment is inconvenient, please contact the hospital on the number on your appointment letter.

Last updated: August 2024

© 2024 The Christie NHS Foundation Trust