It is tragic when patients are permanently harmed by a complication of treatment. One such complication, which has recently received publicity, is brachial plexus neuropathy after radiotherapy for early breast cancer.1 A group of women who perceived themselves damaged in this way formed a pressure group called RAGE (Radiotherapy Action Group Exposure). In response the Royal College of Radiologists commissioned an independent survey by two senior oncologists funded by the NHS Executive.2
The committee of RAGE received more than 1000 letters after publicity surrounding litigation and formed an action group with 800 members. Of 556 women who thought they had sustained nerve damage the college contacted those who had been treated at 15 representative centres. These women were asked if they would agree to have their medical records reviewed in order to establish whether they were suffering from a condition related to the disease process or to previous treatment, or both. It was essential to identify factors in the delivery of the radiotherapy or its association with surgery or chemotherapy that might have contributed to the neuropathy.
Against advice from their solicitors, 126 of the women agreed to have their records examined, and 48 (38%) of them were found to have brachial plexus neuropathy due to radiotherapy. These patients had been treated during a 14 year period (1980-93) at 15 radiotherapy departments in England and Wales. These centres gave radiotherapy to about 65000 women with operable breast cancer during this period. (It is not known how many of these also developed side effects.) Although 41 cases occurred during 1980-6, only seven patients had received treatment since 1986. Since the median delay between treatment and the start of symptoms was 27 months, this implies a decline in incidence of neuropathy.
An extensive review of the factors associated with radiotherapy in breast cancer--associated surgery, chemotherapy, radiation dose, fractionation regimes, the position of the patient, the radiotherapy fields, and the treatment schedule--laid the main blame for the neuropathy on the planned movement of the patients' arms and bodies between radiotherapy to the breast and radiotherapy to the axillary and supraclavicular lymph nodes. Thirty four of 47 patients (72%) moved in this way developed neuropathy, compared with only 12 of 51 (24%) who were not moved. The high doses used to treat the axilla in the past were a secondary cause.3
While radiotherapy has an important effect in preventing local recurrence and thus improving quality of life, a recent overview shows no significant impact on 10 year survival.4 Indeed, a 5% reduction in deaths from breast cancer seems to be counterbalanced by an increase in deaths from other causes. However, studies with longer follow up have shown a significant trend towards improved survival, suggesting that modern radiotherapy may have a value beyond the clearly established improvements in local control.5 A 5% improvement in survival due to radiotherapy would rank in impact with that from adjuvant chemotherapy and hormone treatment. Surgical management of the axilla is used increasingly. This largely avoids the need for radiotherapy to that area and so prevents brachial plexus neuropathy due to radiotherapy, while a good cosmetic result is still achieved by irradiating the retained breast.
How big is the problem? The Royal College of Radiologists survey reviewed a self selected group of women who perceived themselves damaged, and thus the report cannot assess the absolute size of the risk. However, the report states that radiotherapy to the breast has dramatically improved in recent years. Written patient information, pain relief clinics, lymphoedema protocols, and palliative care services are now routinely available, and the aim is to manage patients in a multi-disciplinary team of breast specialists with a wide knowledge of the disease.
What more can be done now? A further multi-disciplinary committee of the college, chaired by Dr Jane Maher, has produced a report enumerating management plans for patients who have brachial plexus neuropathy.6 It lists named clinical oncologists at each radiotherapy centre who would act as a contact for such patients. In addition independent cancer support groups have formalised advice for patients who are concerned about late side effects of radiation.
A recent issue of Clinical Oncology described the audit of early breast cancer management by radiotherapy.7 The report from the college suggests proposals for research. The time has come for a national study to identify the optimum dose fractionation technique for appropriate, safe, effective, and economic management of early breast cancer. Clinical oncologists are anxious to continue to provide improved clinical outcomes for breast cancer patients. The Royal College of Radiologists has a nationally agreed protocol for assessing different radiotherapy regimes in early breast cancer, including quality assurance. This initiative must be funded.
Consultant clinical oncologist Middlesex Hospital, London W1N 8AA
Margaret F Spittle