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NetWellness provides the highest quality health information and education services created and evaluated by faculty of our partner universities.
Sunday, March 21, 2010
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NetWellness provides the highest quality health information and education services created and evaluated by faculty of our partner universities.
Sunday, March 21, 2010
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- How long does the numbness last after a modified radical mastectomy?
- I would appreciate it if you could explain why you should not have your blood pressure taken in the arm of your mastectomy side.
- While reading a list of preventive measures regarding lymphedema, I was puzzled with this measure: Consider wearing a compression stocking on the extremity when flying in an airplane. What is the need for this?
- A friend had a lumpectomy and an axillary dissection, and the doctor reported only four lymph nodes were removed. Is it normal to have fluid build up in this still after one week has past since the surgery? A drain had been in place for 7 days. The doctor had to drain the area with a syringe.
- I am supposed to take care of my mom after her mastectomy. I will be changing bandages and taking care of the drainage tubes. Is that hard to do, if you have a weak stomach? About how long before she will be able to do things on her on?
- I underwent a prophylactic mastectomy nine days ago. My doctor placed a pressure bandage around my chest for the first two weeks. What is the purpose of this? He does not want me to sweat at all. Why? Also, I have a burning sensation that radiates underneath my left arm. What could that be?
- I had a lumpectomy and 8 nodes were removed. Afterward, I had a hematoma. How long will it be there?
- What are some of the side effects of chemotherapy?
- Have you heard of a method of decreasing hair loss during chemotherapy by applying a cold cap to the head? Is it helpful?
- When I underwent lumpectomy and chemotherapy along with radiation therapy, I stopped having my periods all of a sudden. I'm wondering if this is just the beginning of menopause, or if the radiation or chemo caused my periods to stop.
- My sister is about to begin chemotherapy treatment. Her oncologist has told her she needs to stay away from thin skinned fruits because of the risk of bacteria. Is this true?
- Is chemo dependent on the number of treatments or the length of time the chemo is working? Also, if a patients' blood count drops below a healthy level does that mean the chemo is working well or not well?
- I was diagnosed with Stage I breast cancer and had a left modified radical mastectomy. They removed 19 lymph nodes, which showed no cancer. I have chosen to just take Tamoxifen without chemotherapy. My tumor size was 1.5 cm. and 0.7 cm. Am I putting myself in danger if I do not take the chemotherapy?
- What are the long-term effects of radiation therapy? I have heard that the immune system is seriously affected. Is this so?
- I was diagnosed with breast cancer and had a lumpectomy, chemo and radiation. Since I finished radiation, I have noticed a "peau d'orange" look to the lower half of my breast. Is this a late side effect of the radiation? During radiation, my breast was red and swollen and blistered, but that has since healed.
- Can treatment for breast cancer (full chest wall radiation, Cytoxin and Adriamycin) cause fatigue and shortness of breath? Also, when I walk outside on a cool or damp evening my hands turn purple and sometimes my heart beats very hard.
- What is the evidence on survival rate after lumpectomy with radiation versus no radiation for a small (1 cm) tumor?
- If you have a non-invasive in situ carcinoma, is radiation a good thing to go through after lumpectomy?
- I am three weeks into radiation, following lumpectomy, I've had a sore throat & cough for the last two weeks and am starting to feel tired all the time. My doctor says these are side effects of radiation. How long will these last? Also I have trouble sleeping at night and trouble staying awake during the day. Is this a side effect too? I was very upbeat and optimistic at first but now I am grouchy all the time. How can I keep up my spirits until this is done?
- I have had a lumpectomy and radiation - how will this affect my breasts during pregnancy and post delivery?
- I have had a lumpectomy followed by radiation and am now on Tamoxifen. Eight lymph nodes were removed and the pathology report was negative. It has been over four months since the last radiation treatment and I am still very sore and somewhat swollen. Do you see anything to be concerned about?
- If a person gets lung damage from radiation, is the damage permanent, or does lung tissue heal/regenerate? I have been having episodes of excruciating stabbing pains just beneath my lower ribs on the side that was radiated, and also shortness of breath. Temporary prescriptions of Prednisone relieve the symptoms, but then they return. Will I heal with time?
- Is it possible to repeat radiation to the same breast? What possible ill effects might occur? Have you ever heard of this being performed before?
A modified radical mastectomy is a surgery in which all of the breast tissue and the pectoralis minor muscle are removed, and the axillary nodes are removed. The nerve supply to the breast is cut, resulting in permanent numbness around the scar. The outer borders of the surgery should still have sensitivity to touch like a tingling sensation. As time goes on the numbness should lessen in severity.
Your question is an important topic that I am pleased to address. The surgical procedures used for individual women who have breast cancer may be mastectomy, partial mastectomy, or lumpectomy. Along with the actual breast surgery for cancer is the removal of regional lymph nodes and axillary (under the arm) lymph nodes to be tested for cancer cells. The nodes are examined by a pathologist to see if the cancer has invaded the lymph nodes. It is the way to see if the cancer has spread to other parts of the body.
Normally, lymphatic fluid circulates through the lymph vessels, passes through the lymph nodes and enters the bloodstream near the heart. Lymph nodes filter or catch foreign matter and bacteria. If the nodes are removed as in breast cancer surgery, the normal drainage is impaired or causes a reduced capacity to carry the lymph fluid. If there is pressure on the affected arm with taking a blood pressure, the fluid backs up and can cause swelling in the arm called lymphedema. Lymphedema is an accumulation of lymphatic fluid that causes swelling in the arm of the surgical side. This condition is painful and is a continuous risk for the development of infections.
Lymphedema can be a normal consequence or side effect of lymph node removal in breast cancer surgery. Therefore, anyone who has had either a mastectomy, lumpectomy, partial mastectomy, or modified radical mastectomy in combination with axillary node dissection should be educated about how to avoid lymphedema.
There are other precautions to take to avoid lymphedema besides having blood pressure checked only in the unaffected arm:
It is very important that women who are at risk for lymphedema report any slight increase of swelling in the arm, hand, finger, neck or chest wall to her physician immediately. Also, an infection in the affected arm could be the beginning of lymphedema. See your physician for any rash, blistering, redness or heat in the arm or hand.
Lymphedema is a threat to women who have had any treatment that involved axillary node dissection or radiation to the axillary lymph nodes. This can occur immediately after treatment or anytime in your lifetime (years later) because normal drainage of lymph from the arm is compromised and fluid can build up. Normally, lymph fluid that circulates through lymph vessels passes through lymph nodes and returns to the bloodstream near the heart. If the nodes are removed or scarred from radiation, the lymph fluid does not drain as it should and may back up in the tissues with changes in pressure or infection. When flying, the pressure is somewhat different in the cabin and the lack of exercise over an extended flying time allows arterioles to dilate and protein leakage in the tissues. The outcome is swollen ankles and legs as well as the risk of fluid accumulation in the affected arm. Prevention of lymphedema is a primary concern for women who have had axillary node dissection or radiation to the axilla.
The drain is left in as long as needed to collect the fluid accumulation. The time varies with each patient. It is not unusual for a drain to be in for a week. Some women get so much fluid, it is necessary to aspirate the area like the doctor has done. Tell your friend to be patient as the condition will lessen. She should ask her doctor about physical therapy and exercise after the drain is out to reverse the swelling while there is still elasticity in the skin.
Your mother will return from surgery with a hemovac or other type of drainage tubes coming out of the dressing. The system drains the fluid in the tissue that accumulates under the incision and creates a suction so that the skin in held down against the muscle to heal. At first, the drainage looks very bloody but clears a little every day. Some surgeons remove the drains in 3-4 days, others wait a week. Usually, the dressing stays intact until the first post-operative visit to the surgeon when the drains are removed. While in the hospital, you and your mother will be taught how to empty the drainage vac. Your mother can learn to do it herself from the beginning. You can be with her for support for the first few times. Your mother will receive instructions from the surgeon about any exercise and types of movements of the affected side. The important thing is that you both understand her self care instructions before you leave the hospital. Keep asking for directions and clarifications until you feel comfortable about being alone with the care of the surgical area. You both will do fine with the post-operative care.
The presence of a pressure bandage around the chest and how long it is on depends upon the style of the surgeon. Some surgeons remove the big bulky dressing after the drains are removed in 3 to 7 days. Some surgeons do not use a pressure dressing when they use suction drains. The suction drains are in place post-operatively to remove the fluid that builds up where the breast tissue was removed. The pressure dressing or the drains hold the skin down against the muscle until it heals, relieving the suture line of any pressure from fluid build-up and ensures better circulation to the operative site which allows for wound healing.
It is important that the dressing is dry post-operatively to avoid wound infection. Moisture harbors organisms from the environment that could cause an infection or cellulitis. Therefore, it is important to avoid activities and environmental heat that would cause excessive perspiring.
Possible changes in chest wall sensation and phantom breast syndromes was probably part of your education before the mastectomy. Women complain of all sorts of pains: moveable pain, deep pain, surface pain, strong and weak pains. They report throbs, stabs, burning, tickles and itches during the healing process and sometimes long after. I think, too, it is the nerve endings regenerating and reprogramming themselves.
A hematoma is caused be some bleeding inside the area where the nodes were removed. It is a collection of blood, usually clotted, in the tissue of the breast due to a break in the wall of a blood vessel. The drain helped remove most of the old accumulated blood. Your body will absorb any blood and fluid that remained that caused the swelling, just as it does with a bruise. The time it takes varies with individuals. It may be several weeks for all the swelling to disappear. Since the blood is clotted in that space (hematoma), the doctor cannot aspirate it. Your body will absorb it slowly over the next few weeks which does no harm to you. Keep in contact with your surgeon if any other problems occur. Exercise will help but you must get explicit instructions from your doctor on the exercises you should do. If any sign of infection occurs, such as, redness, pain or fever, call your doctor right away.
The side effects of chemotherapy depend upon what specific drug or combination of drugs is being given, the dosage and the frequency of drug treatment. The common side effects may include nausea, vomiting, fatigue, susceptibility to infection, and hair loss with some drugs (but not all). If you are a candidate for chemotherapy or already receiving chemotherapy, the physician and health care providers should inform you of possible side effects of your particular drug program.
The rationale of a cold cap to the head is to decrease the blood flow to the hair root. The chemotherapeutic drugs, especially Doxorubin and Cyclophosphamide, cause partial or complete atrophy of the hair root bulb and constriction of the hair shaft. Other drugs used to treat breast cancer may cause milder degrees of hair thinning. The hair breaks very easily with any tension. The cold cap can be somewhat helpful. Other things one should do for hair loss include the following:
The side effects of radiation treatment depend upon the area of the body that is being treated. Radiation to the breast may cause rib fractures, a cough associated with bronchitis, breast skin changes such as sunburn effects or rash, a thickening and/or darkening of the radiated skin after treatment, and fatigue. If the armpit is radiated, the effect can be some numbness from the arm to the hand. However, this is rare. There could be some swelling of the affected arm called lymphedema. A later effect could be an inflammation and pain where the ribs and the breast bone connect. This is called costochronditis. Tenderness, soreness and swelling in the radiated breast may last for a long time. There is no evidence in the literature that I have seen that indicates early menopause is a result of radiation of the breast. However, chemotherapy along with radiation can be a reason for early menopause. Chemotherapy can cause premature menopause, which may be very sudden and cause hot flashes, sweating, dryness in the vagina or mood swings.
As you mentioned, thin skinned fruits present a risk of bacteria - there may be bacteria on the skin from many possible sources. During chemotherapy the white blood cells, red blood cells, and platelets are often decreased due to the toxicity of the chemotherapy. The white blood cells fight bacterial invasion of the body. When there are not enough white cells to fight bacteria, a person becomes susceptible to infection, fever and sometimes severe illness. Therefore, health care providers educate patients about how to avoid bacterial and viral infection. You sister can also avoid infection by:
The kind of drugs used and the time frame for chemotherapy is a decision of the oncologist based on the individual type and size of the tumor, the lymph node involvement or status, and whether the woman is pre or post menopausal. The usual time for chemotherapy is six months but that can differ from woman to woman depending upon the individual side effects. The doctor adjusts the chemotherapy dosage of drugs according to the bone marrow recovery rate. The white cells are the most vulnerable to the chemotherapy drugs. A blood sample is taken before each treatment. When the count is too low, the patient has to wait for the marrow to recover. Especially the white count has to be at a safe level so the body can fight against infection. This can result in the treatment being reduced or put off. The outcome is that the number of months increases until the patient receives the prescribed dosage of the drugs for a successful treatment.
The cytotoxic drugs find and kill cancer cells anywhere in the body. They also damage other healthy cells in the body that multiply rapidly like the cancer cells. The most worrisome is the bone marrow damage. When the blood count is low, it is an indication that the treatment is working. There are drugs that help the bone marrow to recover more rapidly. They stimulate the marrow to make white cells, red cells and platelets.
The decision whether chemotherapy is indicated for a tumor less than 2 cm and node-free is very difficult. There is controversy and no right answer. The issues include the side effects of chemotherapy, which are unpleasant and can be permanent. To be exposed to the side effects of chemotherapy may not be indicated in stage I. The chemotherapy decision depends upon your age and other issues that your oncologist has assessed and hopefully discussed with you. Find out what your chances of recurrence are, or percentage of recurrence that applies to you. It may be such a small percentage that the systemic treatment of chemotherapy is not necessary. Find out what your chances of recurrence are with Tamoxifen alone and with chemotherapy followed by Tamoxifen. You may get a second opinion, and ask the oncologist about clinical trials that have been done. Ask for a definite answer as to whether chemotherapy is recommended as a precaution against recurrence and spread (or just in case) or whether it really will make a difference. Chemotherapy is drastic if you get the same results with Tamoxifen alone.
Radiation therapy is local treatment delivered to structures located within the target area. Most side effects are confined to tissues and organs within the path of the radiation beam. Side effects that occur 6 months after treatment is finished are called late or chronic effects. These late effects include SPECIFIC organ damage. Examples of late effects on specific organs may include cataract formation or blindness, chronic anemia, permanent taste alteration, permanent loss of saliva, malabsorption or strictures in the gastrointestinal tract, fibrosis in the lungs, bladder, or heart. These mentioned effects depend upon where and what organs the radiation was beamed. The concept of local treatment-local effect is very important in understanding side effects of radiation as well as planning and providing care during and after radiation. There is no documentation in the literature that radiation affects the overall immune system. To my knowledge, no one can say the immune system is seriously affected by radiation therapy.
After radiation to the breast, there can be changes in the breast tissue. There may be fluid collection or changes in lymphatic drainage that cause the breast to enlarge and appear as a pitted skin surface (peau d'orange). Other breast changes may include skin thickening or breast edema.
The pectoralis major muscle will need to regenerate after full chest wall radiation. The radiation caused some inflammation in the muscle, which causes soreness and stiffness but disappears with time and healing. Some of the radiation may have affected your lung, causing coughing or shortness of breath with exertion. This, too, is due to a temporary inflammatory condition in the lungs. The inflammatory process and swelling in the area of treatment is also likely to account for the feeling at the base of your throat.
The drug Adriamycin may cause a heart problem that causes shortness of breath, fast or irregular heart beat, and swelling of feet or lower legs. This can occur one to six months after the start of treatment. Fatigue is associated with both types of treatment and worsens with the extent of treatment, or toward the end of treatment. Fatigue may not even start until after radiation is over and may last several months after treatment is finished. These symptoms should subside with time. Keep in constant communication with your radiation oncologist and the oncologist who manages the chemotherapy about the side effects you are describing. These physicians have established protocols to treat and manage these side effects so that you may experience more comfort.
Irradiation of the breast after a lumpectomy does not influence survival. It only serves to reduce recurrence of cancer in the breast. Certain types of cancer are associated with a high risk of breast cancer recurrence that indicates the need for irradiation with excision. And, there are certain conditions or criteria that indicate that excision only (no irradiation) is treatment of choice. If a person has a lumpectomy with no irradiation and recurrence does happen later on, either local re-excision followed with irradiation or a mastectomy will be done.
Noninvasive carcinoma means it has not metastasized or spread to other areas of the body. "In situ" means "in place" or "has not grown beyond the place of origin." It is also called pre-cancer. There are two kinds of pre-cancer: the lobular carcinoma in situ (LCIS) and the ductal carcinoma in situ (DCIS). They differ in where they originate, which can either be the ducts of the breast or the lobules of the breast. But they have quite different characteristics.
The LCIS does not grow into cancer. Studies have shown that women with LCIS have as much as 25% risk of breast cancer developing in some other part of the breast. The treatment frequently used for LCIS is mastectomy or some variant surgery or no treatment at all with close follow-up. Close follow-up means a clinical exam by a physician every six months and a yearly mammogram. If a woman chooses no treatment with follow-up, and cancer does occur later in life, it is found at a very early stage and can be treated successfully. If cancer does not develop, the woman's breasts have been preserved. Radiation and chemotherapy have not been considered necessary treatment for LCIS because it is not cancer.
Treatment for ductal carcinoma in situ (DCIS) is quite a different approach. DCIS is a lesion that can grow into a cancer. Studies show about 25% of untreated DCIS will grow into cancer in years to follow. The three types of treatment for DCIS are surgery called lumpectomy or wide resection, wide resection with radiation, or mastectomy. The reason radiation is done following a lumpectomy is to kill any micro cancer cells that were left behind that cannot be detected.
Sometimes, the ductal cancer in situ (DCIS) is on the border of being invasive. The radiation may prevent the cancer from becoming invasive and that is what the doctor is trying to prevent. Or, the radiation may help prevent cancer from occurring in the first place. There have been studies since the 1980's that show there is less recurrence within 5 years with the use of radiation following DCIS surgery than those who did not have radiation. A large study that was published in 1993 again showed approximately 16% recurrence in groups with no radiation compared to 7% recurrence in the radiation group. Even though the noninvasive in situ may be precancer, it is thought by many physicians that radiation helps prevent cancer from occurring. There are varied opinions about treatment for DCIS.
Your physician will review with you various options based on the extent of DCIS in your breast. Ask your physician about the latest research and information that will help you make a decision. You will make the final decision about the best treatment for you. Some women do not want a mastectomy and choose less surgery while others do not want to take a chance and decide upon a mastectomy.
The side effects of radiation do bring major changes into your life and threaten your sense of well-being. These feelings of unsettled emotions are natural responses to having cancer and to the treatment. Concerns about your health, body changes and uncertainty of the future can lead to insomnia, changes in eating, and less exercise. This results in feeling tired and feeling out of sorts. You can try some of the following coping behaviors, which will help keep your spirits up:
If you had radiation and lumpectomy, the non-radiated breast will go through normal post delivery changes. The radiated breast has some damage to the breast glands and will not keep up with the other breast. It will not grow as large as the non-radiated breast and will have less or no milk. The only problem is the breasts will not be the same size. But again, it is fine to nurse on one side only.
The soreness you are experiencing is not unusual. The muscle behind and above your breast, called pectoralis major, can get very sore and stiff between 3 to 6 months after radiation treatment is completed. The soreness is due to inflammation caused by radiation. As the muscle is regenerating and healing it gets sore and stiff like any muscle that has been strained or injured. The soreness will gradually subside. Some women report they have occasional sharp and shooting pains in the radiated breast for a long time. The swelling in the breast is to be expected also. A large amount of radiation can cause permanent swelling. Your swelling may go away since you describe it as very little swelling. Continue to see your radiation oncologist for follow-up during recovery.
This question is frequently asked because a few months after treatment is finished a woman does not expect to have lingering side effects. Radiation especially has delayed side effects because the treatment causes inflammation in the muscles and bones. The relief you receive with Prednisone indicates that the discomfort or pain is due to inflammation. The soreness will start to decrease and should be relieved after 6 months. You probably have been informed that you will heal with time. It is important to keep your follow-up appointments with your radiation oncologist.
This is a very important question. Local recurrence is definitely treatable but not with more radiation. The area formerly treated with radiation can only be radiated one time. Your physician(s) will discuss the steps of care. The first step is usually to do tests, such as, bone scans, chest x-ray, and blood tests. The physician then has to determine if this is leftover cancer or a new cancer. All the possible alternative treatment plans will be presented to you. A mastectomy may be discussed. If you have not seen a physician yet, it would be wise to see a breast specialist at this time. Also, you can request a second opinion if you desire.
This article is a NetWellness exclusive. 
Last Reviewed: Jun 12, 2002
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Janet Trigg, RN, MSN, EdD Formerly: College of Nursing University of Cincinnati |
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