Maher Committee. Management of Adverse Effects following Breast Radiotherapy

Summary
Background
Patients treated for breast cancer may suffer a range of upper limb problems, from mild oedema and inner arm sensation changes related to surgery, to the rare but severely disabling brachial plexus neuropathy associated with radiation damage brought to public attention by a group of patients, Radiotherapy Action Group Exposure (RAGE), who claim to have suffered such damage.

Axillary tunnel damage
The term axillary tunnel damage (as used in the terms of reference) is not commonly used in the literature. The Maher Committee interpreted it as describing the spectrum of problems associated with damage to tissues adjacent to the clavicle and under the armpit due to treatment with ionising radiation. The most serious complication is generally acknowledged to be damage to the nerve cords, i.e. radiation induced brachial plexopathy (RIBP). Review of the literature revealed no completely unambiguous guidelines as to diagnosis or management of RIBP; most studies were based on small series of selected cases considered retrospectively rather than large prospective randomised trials. There is thus no solid research base. The committee has been guided by the priorities identified by RAGE.

Guidelines

1. Information after radiotherapy - While the chance of axillary tunnel damage is small, all those who have received radiotherapy to the supraclavicular fossa and/or axilla should be given information to allow them to recognise and report significant symptoms so that they can obtain rapid expert assessment and management When patients complete radiotherapy details of symptoms to watch for should be given to both patients and GP. Included in this should be the information that persistent tingling of the fingers, particularly if it is associated with shoulder pain or weakness of the hand, should result in urgent assessment by the treating oncologist, as it can sometimes be an early symptom of recurrent cancer, or of a complication related to surgery or radiotherapy.
2. Diagnosis - Diagnosis of RIBP rests on demonstrating brachial plexopathy in an irradiated site in the absence of other causes, particularly recurrent cancer. Even in the absence of a negative biopsy, recurrent cancer cannot be absolutely excluded particularly during the first two years from presentation. Key elements of diagnosis include:

• Recognition of presenting symptoms.
• Physical examination.
• X-ray of the chest and cervical spine.
• CT/MRI scan of supraclavicular fossa, axilla and cervical spine.
• Biopsy of suspicious lesions.
• Electrophysiological studies (including both nerve conduction studies and needle studies) to localise the lesion in the brachial plexus.

3. Surveillance - Patients with a provisional diagnosis of RIBP should be followed three-monthly for two years and thereafter 6-12 monthly depending on symptoms.
4. Management - Management involves a multidisciplinary team coordinated by a clinical oncologist designated in every cancer centre. The coordinating consultant oncologist is responsible for liaising with the following to make sure they are aware of protocols:

• Breast care nurse.
• Breast surgeon.
• GP and District Nurse.
• Occupational therapist. Pain clinic (anaesthetist, psychologist/psychiatrist).
• Palliative care clinic.
• Physiotherapist and, if possible, complementary therapists.

Key elements of management include:

• Information and explanation to empower patients to help themselves.
• Systematic management of pain.
• Assistance with functions of daily living.
• Psychological support including access to voluntary groups.
• Regular surveillance to detect and treat cancer.

Access to services
The designated oncologist in each cancer centre will take referrals where no oncologist has been consulted so far (or relationships have broken down). Where there are problems gaining access to a clinical oncologist, GPs and district nurses are extremely important points of contact, but may not be familiar with RIBP. A breast care nurse may be better able to facilitate the referral. Patients who do not currently have a breast care nurse can contact the RCR's Clinical Audit Unit for the name and address of a regional representative of the British Cancer Nurses Network (BCNN), who can put patients in contact with a local nurse, or of the British Lymphology Interest Group (BLIG), who may be able to offer advice as to where to seek help concerning lymphoedema.