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 Table of Contents  
ORIGINAL RESEARCH REPORT
Year : 2020  |  Volume : 17  |  Issue : 2  |  Page : 30-37

Side effects of radiotherapy on breast cancer patients in the Department of Radiotherapy, Lagos University Teaching Hospital, Idi-Araba, Lagos, Nigeria


1 Radiotherapy, Radiodiagnosis and Radiography College of Medicine, University of Lagos, Lagos, Nigeria
2 Department of Radiotherapy, Lagos University Teaching Hospital, Lagos, Nigeria

Date of Submission14-Sep-2018
Date of Acceptance06-Jan-2020
Date of Web Publication14-May-2020

Correspondence Address:
Dr. Anthonia C Sowunmi
Department of Radiation Biology, Radiotherapy, Radiodiagnosis and Radiography, College of Medicine, University of Lagos, Lagos
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcls.jcls_79_18

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  Abstract 


Background: Side effects of radiotherapy (RT) could be temporary or permanent, can be severe, and affect quality of life. An investigation into the side effects of RT on breast cancer patients would help evaluate the incidences and associated risk factors in the low-income countries for patients undergoing RT in order to ensure maximum treatment with very minimal side effects. Objective: To assess the side effects of RT in patients with breast cancer undergoing RT in Lagos University Teaching Hospital. Materials and Methods: This was a descriptive, cross-sectional study. Self-administered questionnaires were distributed to breast cancer patients on RT that have received treatment for at least 2 weeks at the RT Department between March and August 2016. A total of 146 questionnaires were distributed, whereas 139 were completely filled and returned for the evaluation and analysis, given a response rate of 95.2%. Results: The common side effects noticed from the analysis of this research work included skin erythema (87.1%), fatigue (74.1%), telangiectasia (69.1%), pain (89.9%), breast swelling (45.3%), and loss of hair in the armpit and chest area (87.1%), and the less common ones were breast shrinkage (20.1%), lymphedema (41.0%), cardiac complications (30.9%), lung problems (12.9%), sore throat (7.9%), brachial plexopathy (24.5%), and damage to the bones (ribs; 3.6%). Management of the side effects by patients revealed that 30 (21.6%) used analgesics, 28 (20.1%) used steroidal cream, 27 (19.4%) avoided deodorants and antiperspirant, 22 (15.8%) exercised, 15 (10.8%) took antibiotics, 10 (7.2%) took herbs, and 7 (5%) had to stop treatment temporarily for minimum of a week due to severe morbidity. Conclusion: A large percentage of breast cancer patients undergoing RT experience painful side effects (89.9%), of these 87% experience skin erythema, 74% experience fatigue, and 69% experience telangiectasia.

Keywords: Breast cancer, radiotherapy, side effects


How to cite this article:
Sowunmi AC, Onuoha PC, Alabi AO, Okoro US. Side effects of radiotherapy on breast cancer patients in the Department of Radiotherapy, Lagos University Teaching Hospital, Idi-Araba, Lagos, Nigeria. J Clin Sci 2020;17:30-7

How to cite this URL:
Sowunmi AC, Onuoha PC, Alabi AO, Okoro US. Side effects of radiotherapy on breast cancer patients in the Department of Radiotherapy, Lagos University Teaching Hospital, Idi-Araba, Lagos, Nigeria. J Clin Sci [serial online] 2020 [cited 2020 Jul 12];17:30-7. Available from: http://www.jcsjournal.org/text.asp?2020/17/2/30/284280




  Introduction Top


Cancer of the breast is the most common malignancy affecting women in many parts of the world. Globally, it accounts for 18.4% of female cancers.[1] It is estimated that one in 8 Caucasian women (one in 14 African Americans) in the USA (double the risk in 1940) and one in 12 in Britain will develop cancer of the breast in their lifetime and the incidence is rising.[2]

In the USA, the incidence since 1982 has been rising by 4.5% per year[1] and about 185,000 new cases are diagnosed and about 46,000 die of it every year.[1] In Britain, the corresponding numbers are 25,000 and 16,000.[3] There are 45 cases per 1000 women aged 50–70 years. Of the developed countries,[2] Japan has the lowest incidence one in 60 women in their lifetime and the death rate is about 30% of that in Britain. However, as in other developed countries, it is rising rapidly.[3]

On the burden of cancer in Nigeria, Lambo (2007)[4] explained that there is likely to be 100,000 new cases each year, and that by 2010, there may be 500,000 new cases. Understanding the challenges encountered by Nigerian cancer patients,[4] it is worthy of note that the survival rate for breast cancer in the Unites States of America is 85% while it is a dismal 10% in Nigeria. Olopade (2004)[5] and Durosimi (2004)[5] reported a survival rate of 1.9% for Nigeria and over 50% for East Africa and other countries. The Lagos State Ministry of Health documented that the annual 15% of the cases occur in women <30 years. In Nigeria, between 1960 and 1980, cervical cancer had 19.9% prevalence whereas breast cancer had 11.2%, but between 1981 and 1995, breast cancer has taken over the lead with 25.7% whereas cervical cancer followed closely with 22.7%.[6] These statistics which are the most recent show breast cancer to be rated first among all other cancers and majority of cases occurred in premenopausal women, with the mean age at occurrence ranging between 43 and 50 years across the regions.[7] The youngest age recorded in Lagos State was 16 years (Adebamowo and Ajayi, 2000).[6] In Accra, Ghana, it accounts for about 16.0 of all female cancers, being now diagnosed yearly in Korle Bu Teaching Hospital. In Kenya, it constitutes about 9.4% of all cancers in women, in Zimbabwe 8.5%, in Tanzania about 8.1%, in Sudan 26.0%, in Malawi 5.5%, in Liberia 15%, and in Uganda 4.0%.[6],[7]

With the rising life expectancy and the increasing standard of living, cancer of the breast is likely to become a major problem in Africa. In the far East generally, carcinoma of the breast is rather common.[3]

At present, radiation therapy is used in somewhat more than half of all cancer treatments, and in some cases, it is the preferred and most effective treatment. In other cases, it is used in combination with chemotherapy or surgery.[8] Radiotherapy (RT) has been used as an adjuvant therapy in patients with breast cancer submitted to conservative surgeries in initial stages. It aims to diminish locoregional recurrence and favor survival.[9],[10]

Acute side effects of RT, although temporary in nature, can be severe and affect quality of life. These effects occur during treatment and up to 6 months after treatment has finished, and chronic side effects occur months or even years after treatment ends. The side effects that develop depend on the area of the body; it can also cause pain and discomfort, limit activities, and delay treatment.[11] Although avoidance of skin reactions caused by radiation therapy would be preferred, it often is not possible, such as in the treatment for inflammatory breast cancer where an intense skin reaction is expected.

Objective of the study

Major objective

To identify the side effects associated with the treatment of breast cancer using RT among patients in Lagos University Teaching Hospital (LUTH).

Specific objectives

  • To determine the side effects of RT on breast cancer patients
  • To assess the knowledge of breast cancer patients treated with RT
  • To determine the major risk factors for RT side effects
  • To review the various management practices of breast cancer patients undergoing RT in LUTH.



  Materials and Methods Top


This research work was a descriptive, cross-sectional study that was carried out among breast cancer patients undergoing RT treatment either alone, with chemotherapy, postsurgery, or presurgery in the RT Department in LUTH. Interviewer-administered questionnaires alongside survey of their case file were used. Satisfactorily completed questionnaires were collated and analyzed using the SPSS software (version 20, Chichago, Illinois, United State of America).


  Results Top


A total of 146 self-structured questionnaires were distributed to assess the side effects of RT on breast cancer patients in the RT Department of LUTH, Idi-Araba, Lagos. 139 of the questionnaires were returned and found adequate for analysis given a response rate of 95.2%, whereas the remaining 7 (4.8%) were not adequately filled or returned.

[Table 1] shows that majority of the respondents (137; 98.6%) were female, whereas only 2 (1.4%) were male. Most of the respondents (104; 74.8%) were Christians, whereas only 35 (25.2%) were Islam. Seventy-three (52.5%) respondents were married, whereas 49 (35.3%) were single. 64 (46.0%) and 60 (43.2%) respondents were civil servants and traders, respectively. Majority of the respondents (63; 45.3%) were secondary school holders, whereas 52 (37.4%) had tertiary education.
Table 1: Sociodemographic characteristics of the participants

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[Figure 1] shows that majority of the respondents (46; 33.1%) were within the age group of 56–65 years, followed by 42 (30.2%) who were within the age group of 46–55 years. Twelve (8.6%) and 13 (9.4%) respondents were within the age group of 26–35 years and above 66 years, respectively.
Figure 1: A bar chart showing age distribution of the participants

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[Figure 2] shows that most of the respondents (79; 56.8%) were Yorubas, 23 (16.5%) were Igbos, only 12 (8.6%) were Hausas, and 25 (18%) were from other ethnic groups.
Figure 2: A pie chart showing ethnicity of the respondents

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[Table 2]a shows that 44 (31.7%) respondents said that their first point of presentation was a spiritual house, whereas 41 (29.5%) said that it was a modern medicine. Forty-one (29.5%) respondents said that they received their treatment from modern medicine, whereas 17 (12.2%) said that they received their first treatment from traditional doctors. Seventy-six (54.7%) respondents said that they have family history of breast cancer, whereas 63 (45.3%) said that they do not have. Fourteen (10.1%) respondents have not had any pregnancy, whereas 63 (45.3%) have had between 3 and 4 pregnancies. Majority of the respondents (127; 91.4%) said that they had children.


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[Table 2]b shows that majority of the respondents (85; 61.2%) said that they breastfed their children <6 months, whereas 35 (25.2%) said that they breastfed their children for 6 months. Seventy-six (54.7%) respondents said that they had been on pills for birth control. Eighty-eight (63.3%) respondents said that they had been on hormone therapy. Majority of the respondents (63; 45.3%) said that they had been on combined hormone therapy. Ninety (64.7%) respondents said that they had no history of breast cancer, whereas 49 (35.3%) respondents said that they had history. Twenty-three (16.5%) respondents said that their presenting complaints have lasted for <5 years. Only 8 (5.8%) respondents said that they had been diagnosed of other types of cancer.

[Figure 3] shows that majority of the respondents (44; 31.7%) presenting complaints were swelling or lump in the breast region, while 42 (30.2%) complained of breast pain. Eleven (7.9%) respondents presented complaint of nipple discharge other than breast milk, whereas 4 (2.9%) respondents presented all the complaints.
Figure 3: A bar chart showing the presenting complaints of the respondents

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[Figure 4] shows that 40 (28.8%) respondents' complaint duration has lasted within 6 months, 22 (15.8%) had lasted within a year. Thirteen (9.4%) respondents' complaints had lasted for more than 2 years.
Figure 4: A pie chart showing duration of their complaints

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[Table 3]a shows that majority of the respondents(105; 75.5%) said that RT involves the use of radiation for the treatment of cancer. Fourteen (10.1%) respondents said that it involves the use of chemotherapy drugs for the treatment of cancer, whereas 8 (5.8%) said that they do not know.


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[Figure 5] shows that majority of the respondents (121; 87.1%) said that the side effect they experienced was skin erythema and loss of hair in the armpit and chest area, respectively, and pain 125 (89.9%). One hundred and three (74.1%) respondents experienced fatigue.
Figure 5: A bar chart showing some of the most common side effects of radiotherapy experienced by the respondents

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[Table 3]b shows that 50 (36.0%) respondents said that they knew about surgery for the treatment of cancer, 34 (24.5%) said that they knew about chemotherapy, and 25 (18.0%) said that they knew about RT. Eighteen (12.9%) respondents said that they knew about surgery and chemotherapy, whereas 9 (6.5%) respondents said that they knew about all the modes of treatment.

[Table 4] shows that majority of the respondents (79; 56.8%) with side effect of skin erythema said that the onset is in the 2nd week after receiving radiation therapy, whereas 41 (29.5%) said that it is in the 3rd week. Forty-seven (33.8) respondents said that they experience breast swelling 4th week and after, whereas 8 (5.8%) respondents said that they do not know. Forty-three (30.9) respondents said that they experienced fatigue in the 1st week of the radiation therapy, whereas 27 (19.4) respondents said that they experience it in the 2nd week. Fourteen (10.1%) respondents said that they experienced breast shrinkage in the 4th week and after, whereas 4 (2.8%) said that they do not know. Only few of the respondents said that they experienced 2 (1.4%) and 5 (3.6%) of the respondents had sore throat in the 3rd week and the 4th week respectively.
Table 4: Onset of the side effect after receiving radiotherapy

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[Figure 6] shows that majority of the respondents (79; 56.8%) with side effect of skin erythema said that the onset is in the 2nd week after receiving radiation therapy, whereas 41 (24.5%) said that it is in the 3rd week.
Figure 6: A bar chart showing the onset of skin erythema

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[Table 5] shows that majority of the respondents (88; 63.3%) said that they do not visit nutritionist when on RT, whereas 51 (36.7%) said that they do. Most of the respondents (91; 65.5%) said that they bath with lukewarm water when receiving RT, whereas 120 (86.3%) respondents said that they do wear soft or loose clothing. Majority of the respondents (82; 59.0%) said that they visit doctor weekly for review when on RT.
Table 5: Personal hygiene and care of patients during radiotherapy

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[Figure 7] shows that 30 (21.6%) respondents managed their side effects using pain killers, followed by 28 (20.1%) respondents who managed their side effect using hydrocortisone cream. Twenty-two (15.8%) respondents said that they undertook exercise to manage the side effects, whereas only 7 (5.0%) respondents said that they suspended their RT.
Figure 7: A line graph showing how the respondents managed the side effects

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  Discussion Top


A transient early erythema can be seen within a few hours after radiation and subsides after 24–48 h.[11] This is believed to be an inflammatory response, i.e., histamine-like substances are released that cause dermal edema and skin erythema from the permeability and dilatation of capillaries. The main erythematous reaction occurs 3–6 weeks after the radiation begins and reflects a varying severity of loss of epidermal basal cells. A useful prospective study was done that carefully documented the skin reactions each week of 126 breast cancer patients receiving breast radiation after lumpectomy and axillary node dissection.[12] This demonstrated that during weeks 1–2, skin reactions are uncommon. During week 3, almost 50% of the patients had developed mild erythema, and for up to 12%, more severe erythema was seen. By week 4, about 80% of the patients demonstrated skin changes, with 20% of these being more severe.

A Canadian study evaluated the impact of not washing versus washing the skin on the acute skin reactions for 100 breast cancer patients.[13] The washing patients had less side effects and as a result, the Radiation Therapy oncology Group (RTOG) acute toxicity scores was low and less frequently developed moist desquamation (14% vs. 33%, P < 0.03). No significant difference between arms for the occurrence of dry desquamation was seen (74% no washing and 56% washing arm). On univariate analysis, washing, chemotherapy, concomitant chemotherapy schedule, weight >165 lb, and dosimetric hotspot were all predictors of worse acute skin toxicity. On multivariate analysis, concomitant chemotherapy schedule, weight >165 lb, and dosimetric hotspot remained the strongest predictors of increased skin toxicity. Nonwashing was weakly associated (P = 0.06).

Another study from Norway evaluated no cream versus the use of Bepanthen® cream during RT in 86 patients with each patient serving as his/her own control.[14] Concurrent chemotherapy with breast radiation has also been associated with worse acute skin toxicity in many series.[10],[15],[16],[17],[18],[19]

Fatigue in breast cancer patients receiving radiation seems to be mild to moderate in intensity and develops in a characteristic pattern. This is illustrated in a small study that reported on 15 women who demonstrated mild fatigue (2–4 on a 10-point scale) during a course of radiation for early-stage breast cancer. The intensity of fatigue peaked at the 4th week, plateaued through the 7th week, and then dropped beginning with the 11th week.[20] Similarly, a different study in thirty breast cancer patients receiving radiation reported that fatigue peaked at weeks 4–6 and returned to baseline level 1 month after treatment.[20] Another study examining fatigue using a fatigue subscale tool amongst breast cancer patients undergoing radiotherapy to the breast and chest wall demonstrated that 43% of 52 women receiving breast radiation developed significant fatigue (score >37) and in 54% minimal or no fatigue was found. They reported that fatigue increased during the first few weeks of breast radiation, peaked at week 4 and then remained stable until 2 weeks after RT, and was beginning to return to the baseline levels by 6 weeks posttreatment.[21] A different study evaluated fatigue in 76 breast cancer patients at 5 time points: pre treatment, 2 weeks into treatment, end of RT, 3 months post RT and 6 months post RT using Pearson–Byars Fatigue Feeling Checklist.[22] This study, in contrast to previous ones, demonstrated fatigue onset in the 1st week of treatment, stabilizing thereafter, and resolving by the end of RT. During a course of breast radiation, patients should be guided about self-management of fatigue, that is, prioritizing essential activities and deferring, postponing, or delegating activities that are nonessential. Patients who work full time are advised that they may need to reduce their work hours during the last 2 weeks of breast radiation and for 2 weeks afterward. A discussion about what type of documentation a patient needs to reduce work hours if necessary may be in order. Treatment of specific causes related to fatigue should be done, e.g., anemia, depression, anxiety, and insomnia.[23] One such study examined the effect of exercise on fatigue levels by randomizing 46 women aged 35–64 years receiving breast radiation after lumpectomy[24] to an exercise program versus usual care during treatment. In the exercise group, 86% of patients reported exercising for at least 30 min ≥3 times per week and the usual care tended to decrease their activity level as the treatment progressed. One hundred percent of patients in the study reported fatigue during treatment, but the fatigue scores were lower for the exercise group. Anxiety, depression, and difficulty sleeping were common for both groups; however, greater symptom intensity was found in the usual care group. On the basis of this, we guide our patients to rest when they feel tired and to be active when they feel good. All the patients are counseled about the benefits of exercise for minimizing fatigue symptoms during treatment. Patients are encouraged to maintain their exercise routines when they feel well and given support if they express interest in beginning the exercise programs during treatment.

A survey of 127 breast cancer survivors who were on average 3 years posttreatment was done and revealed that 27% reported chronic pain.[25] The pain was rated mild in severity for 90% of patients. The sites of pain affected were breast 86%, ipsilateral arm 69%, and ipsilateral axilla 81%. Pain in all three sites was reported in 58%. The prevalence of pain was 27% after lumpectomy with RT and 23% after mastectomy alone. The impact of irradiation on breast pain has been reported from two randomized studies. A companion study to assess breast pain was done at Princess Margaret Hospital during a prospective trial that randomized breast cancer patients older than 50 years to tamoxifen alone or tamoxifen and breast RT after lumpectomy.[26] This study found that radiation did not adversely affect breast pain up to 12 months posttreatment. Another quality of life study that accompanied a randomized trial of observation versus breast RT after lumpectomy demonstrated that patients did have increased breast pain during irradiation and up to 2 years posttreatment. At 2 years, no difference between the treatment groups could be detected in the rates of skin irritation, breast pain, and being upset by the appearance of the breast.[27]


  Conclusion Top


This research has been able to show that the treatment of breast cancer with RT is strongly associated with side effects, and due to the presence of critical organs in the breast region, damage to these structures will have negative impact on quality of life. In conclusion, the side effects of RT commonly experienced by the respondents include skin erythema, fatigue, pain, lymphedema, breast swelling, telangiectasia, and loss of hair in the armpit and chest area. Side effects that were not so commonly experienced by the respondents in this research were lung problems, sore throat, breast shrinkage, cardiac complications, and brachial plexopathy.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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