Breast Cancer Care Advice

Breast and arm changes after breast cancer treatment

Surgery and radiotherapy to the breast can cause a number of changes. These can include pain, problems with movement, changes to the breast tissue or appearance, and swelling of the arm. On this page, we explain these effects and what you can do.

Always let your cancer doctor or nurse know if you have any of these symptoms. Women sometimes worry that their symptoms are caused by the cancer coming back. Your doctor or nurse will be able to reassure you or arrange to have them checked, if necessary. There are different ways that these effects can be managed, and they’ll be able to advise you on what may be helpful in your situation.

Changes in sensation in the breast and arm

Surgery and radiotherapy can cause changes in sensation in the chest area, the armpit, and the shoulder and arm on the affected side.

These can include:

  • sharp, shooting or burning pain
  • aching pain
  • sensitivity to touch or to the cold
  • numbness or pins and needles.

These symptoms happen because the nerves in the chest area or armpit are cut or injured during surgery. It‘s not unusual to experience these symptoms, particularly after surgery to remove all the lymph nodes in the armpit. Symptoms usually improve with time, but in some women they may take months or years to get better.

If you have an aching pain in the breast, wearing a support bra during the day and a soft bra (no underwire) at night may help. Describing your symptoms clearly will help your doctor to prescribe the right painkiller for you. Simple painkillers such as paracetamol, or anti-inflammatory drugs such as ibuprofen, can often control the pain. But if you have nerve pain (shooting or burning pain), you may need other types of painkillers.

Rarely, radiotherapy to treat the lymph nodes in the armpit or an area above the collarbone (clavicle) can damage the nerves to the arm causing pain, numbness and, in extreme cases, loss of movement (brachial plexus neuropathy). As radiotherapy techniques have improved, this problem is now much rarer.

Although this condition can’t be reversed, the symptoms can be improved with drug treatment and physiotherapy. Physiotherapy involves doing exercises to strengthen the muscles and keep them supple. The physiotherapist will also be able to show you how to use slings or splints to support your arm, if needed.

You can read more information about peripheral neuropathy on the macmillan website, which could be helpful.

Changes in movement and strength in your arm/shoulder

Radiotherapy and surgery, especially to the armpit, can affect the range of movement and strength in your arm and/or shoulder. This may affect your ability to do everyday activities, such as household chores. It may interfere with some types of exercise, such as swimming or tennis.

After breast surgery, a physiotherapist usually gives you exercises to do to help improve recovery of shoulder movement. Arm and shoulder movement gradually improves after treatment. If you continue to have problems, here are some suggestions that may help:

  • Ask your doctor to refer you to a physiotherapist who will assess you and show you exercises to help improve movement and strength. Exercises you were given previously may not be right for you now. Having good posture is also important and your physiotherapist can give you advice on this.
  • Having your pain controlled will help to improve movement and relieve stiffness. Problems with pain may mean that you’re not using your arm or shoulder properly, which can make things worse.
  • Taking painkillers half an hour before you exercise or having a warm bath to relax your muscles can help. If you can’t do your exercises or you find them painful, then stop.
  • Avoid lifting or carrying heavy things with the affected arm/shoulder or reaching out or lifting if it’s painful. Use a shopping trolley instead of a basket, shop online and get heavy things delivered. Try to make sure that objects you use often are low down and in easy-to-reach places.
  • Ask to be referred to an occupational therapist (OT) if you’re having difficulty carrying out daily tasks. They can assess your needs and recommend aids or equipment to help you.
  • Accept offers of help. Let people know what kind of practical help you need. They could help you with things like shopping, taking the rubbish out or mowing the lawn.
  • Complementary therapies, such as relaxation or deep breathing exercises, may be helpful. Ask your doctor or physiotherapist for advice on this.

Cording

After surgery for breast cancer, some women have an uncomfortable sensation that feels like a tight cord running from their armpit to the back of their hand. This is called cording. It may develop weeks or months after surgery and is thought to be due to hardened lymph vessels. Sometimes it makes it difficult to move the arm, but it usually gets better gradually over a few months. Some women may need physiotherapy and massage to improve it.

Changes to the appearance of the breast

Women who have a breast removed (mastectomy|) may find it hard to come to terms with the change in their appearance. This may affect how you feel about yourself as a woman and your sex life. It may also result in problems with depression|. Some women choose to have breast reconstruction (see below).

Most women who only have a small part of the breast removed followed by radiotherapy don’t find there are too many changes in the appearance to adjust to. However, there are some changes that can develop over time.

Radiotherapy can cause dilated blood vessels under the skin (telangiectasia). Although this affects how the breast looks, it shouldn’t cause any other problems. Rarely, prominent blood vessels in the skin of the breast or chest can be a sign of more serious conditions so it’s always important to get any changes like this checked out. After radiotherapy, a woman’s breast may shrink slightly over time. Some women also develop a hardening or thickening of the breast tissue (fibrosis). This can cause the breast to become harder and smaller than it was. Breast shrinkage is worse in women who smoke, so doctors strongly advise women who smoke to give it up.

If you notice changes to the appearance or feel of your breast, it’s best to have it checked by your doctor or breast care nurse.

Women’s breasts often get bigger with age or weight gain. But if you have had radiotherapy, the treated breast won’t always increase in size in the same way as the other breast.

Keeping to a healthy weight can help to make sure that you don’t have too much of an imbalance between breasts. Wearing a shell or partial breast prosthesis in your bra can help to add symmetry. This is a silicone insert that can be worn inside one cup of a bra to give you a more balanced appearance.  Some women choose to have surgery to reduce the size of the larger breast if the imbalance in their appearance is a problem. Your doctor or breast nurse can tell you more about this.

Breast reconstruction

Breast reconstruction is one or more operations to make a new breast shape. It can be done after a mastectomy or to improve the shape of the breast after a lumpectomy.

Newer procedures, developed from liposuction techniques (lipomodelling), may be used to fill in dents in the breast. Fat cells are removed from the tummy area (abdomen) or the thighs by gentle liposuction. The whole fat cells are then separated and injected into the breast.

For some women, breast reconstruction can help to restore self-confidence, feelings of femininity and sexual attractiveness. There isn’t a time or age limit on when the operation should be done, just as long as you’re fit enough. Many women have reconstruction years after their initial breast operation.

Lymphoedema

Lymphoedema| (swelling) of the arm or hand, and occasionally the breast, can develop at any time after treatment for breast cancer. It happens because surgery to remove the lymph nodes in the armpit, or radiotherapy to the nodes, has affected the way that lymph fluid drains from the arm.

Lymphoedema is more likely to happen if you’ve had all, or a large number, of lymph nodes removed together with radiotherapy to the armpit. It usually develops gradually, months or years after treatment. If you’ve only had a sentinel lymph node biopsy (checking just one or two of the lymph nodes), the risk of getting lymphoedema is low.

Reducing the risk of lymphoedema

The following steps could help to prevent lymphoedema. If you already have lymphoedema, this advice may stop it getting worse.

Skin care

Any cuts in your skin can allow bacteria to enter your body and may quickly develop into an infection. So good skin care and protecting your arm and hand are important.

Here are some things you can do to prevent skin damage and reduce the risk of infection:

  • Keep your skin clean and moisturise every day with unperfumed cream or oil. Lymphoedema can make the skin dry and itchy, and it may crack. Good moisturising can help prevent this and keeps your skin supple and in good condition.
  • Treat even small grazes and cuts straight away. Wash the area thoroughly and cover it, if necessary. See your GP immediately if you develop any signs of infection around the cut, for example if it becomes red, hot or swollen.
  • General advice is to avoid needles (blood tests, injections, drips or acupuncture) and having your blood pressure taken in the arm on the side that has been treated. However, there is limited medical evidence in relation to this and lymphoedema.
  • Protect your arm and hand by wearing gloves and long sleeves when doing household tasks, DIY, gardening or working with animals.
  • To avoid burns, use oven gloves or pot holders and long sleeves when cooking and baking.
  • Use insect repellent to prevent insect bites. If you’re stung on or near the affected area, get medical advice.
  • Use nail clippers instead of scissors to cut your nails and never push back or cut the cuticles – use cuticle cream instead.
  • Use an electric razor if you shave under your arms. Numbness under the arm is not uncommon. It can be easy to cut yourself with a blade razor, especially if you have a bumpy scar.
  • Protect your skin from the sun. Cover up or use a high factor suncream (at least SPF 30) and avoid getting sunburnt.

Treating lymphoedema

Lymphoedema is a long-term condition but the earlier it’s diagnosed, the more effective and straightforward treatment is. If you notice any swelling in your arm or chest, always get it checked by your doctor or nurse.

If lymphoedema is diagnosed, you’ll be referred to a specialist lymphoedema nurse, breast care nurse, doctor or physiotherapist for a full assessment.

The aim of treatment is to relieve discomfort by reducing swelling and to prevent more build-up of fluid.

Possible late effects of breast cancer treatment on the heart

Some treatments for breast cancer may increase the risk of getting heart problems years later. Small changes to your lifestyle can help to reduce the risk of these problems and of other health problems.

You will have been monitored closely during and after treatment to reduce the risk of heart problems developing. Most women won’t ever experience any effects on the heart. But it may help to understand more about them and how you can help look after your heart.

Treatments that can affect the heart are:

  • Chemotherapy
  • Radiotherapy
  • Hormones
  • Early Menopause

The standard chemotherapy for early breast cancer usually includes drugs known as anthracyclines (epirubicin or doxorubicin). This is an effective treatment for breast cancer as evidence shows that these drugs are better at reducing the risk of it coming back.

In some women, treatment with anthracyclines may result in slight damage to the heart muscle. Because these changes are slight, they usually don’t cause any immediately noticeable effects. But, they may lead to an increased risk of heart problems developing much later in life.

The most important risk factors for heart problems developing in the future are pre-existing heart disease, including high blood pressure. Women at risk are carefully monitored before and during their treatment to find out if their treatment needs to be changed. And many women who have these drugs won’t ever experience heart problems.

After radiotherapy to the chest, there is a very small risk of damage to the heart muscle or the major blood vessels around the heart. This is only a potential problem if you’ve had cancer in your left breast, as the heart is on the left side of the chest. Radiotherapy is now very carefully planned, so that the heart is either not within the radiation area or only a small amount of the heart will receive any radiation. As a result, the risk of developing any heart problems is now very   low.

Having an early menopause due to your treatment may also increase the risk of heart problems. This is because oestrogen and progesterone help protect the heart. Hormonal drugs, called aromatase inhibitors, may also increase the risk of high cholesterol, which can lead to heart problems.

Trastuzumab (Herceptin) can cause changes in the heart, particularly in women who already have heart disease. Because of this, it’s not given to women with some types of heart conditions. Tests are done before treatment and women are checked regularly throughout and after treatment.

If heart problems occur during treatment with trastuzamab, they are usually temporary, improve with medication and get better after treatment finishes.

Symptoms

We’ve included a list of symptoms that can be linked with heart problems. But they can be caused by lots of other things.

Let your doctor know if you have any of these symptoms:

  • Feeling your heart beating fast or irregularly
  • Pain or discomfort in your chest
  • Getting breathless for example if you walk up some stairs
  • Feeling weak or dizzy
  • Getting tired very easily
  • Swelling of your feet or lower legs

What you can do

Making small changes to your lifestyle can reduce your risk of developing heart problems. And, even if you already have problems, small changes can help to reduce your risk of further problems.

Look after yourself by keeping physically active, eating a healthy diet, not smoking, reducing your stress and being aware of the dangers of drinking too much. The British Heart Foundation has lots of information and advice on keeping your heart healthy.

Keep physically active

Physical activity can help your heart health and has other benefits too. It helps you to keep to a healthy weight and reduces your risk of bone thinning (osteoporosis). It can reduce stress and improve fatigue and you’ll look and feel better.

There’s also some evidence that regular exercise may help to reduce the risk of breast cancer coming back as well the risk of getting some other cancers.

Eat healthily

This helps to protect your heart and keeps your weight healthy as well. Try to eat five portions of fruit and vegetables a day, more chicken and fish (especially oily fish) and high fibre foods. Eat less saturated fats (such as pastries, cakes, cheese), less red and processed meat and cut down on salt.

After breast cancer, some women want to know if they should avoid dairy foods or if there’s a particular diet they should follow. Studies that have looked for a connection between diets that are high in dairy products and breast cancer haven’t shown a clear link. So cancer experts don’t recommend following a dairy-free diet. Dairy products are also a good source of calcium, which is important for bone health.

There’s also a lot of publicity about alternative diets for treating cancer, but there’s no evidence that they increase a person’s chance of survival. Some of these diets may lack important nutrients or be unbalanced in other ways and may even be harmful.

Cut down on alcohol

Too much alcohol can cause heart problems and it’s also high in calories. There’s some evidence that drinking small amounts of alcohol might help to reduce the risk of heart disease, at least in middle-aged people. Stick to sensible drinking. Current guidelines recommend that men drink less than 3 units of alcohol per day, or 21 per week, and women drink less than 2 units per day, or 14 per week.

Give up smoking

If you smoke, stopping is the healthiest decision you can make. It’s one of the major risk factors for heart disease. Stopping smoking also reduces your risk of developing lung disease, bone thinning (osteoporosis) and smoking-related cancers. You’ll also feel and look better.

Possible late effects of breast cancer treatment on the bones

Oestrogen helps keep bones healthy and strong. All women have an increased risk of bone thinning (osteoporosis) after the menopause. But after breast cancer, some women are at a greater risk because some breast cancer treatments also increase the risk of bone thinning.

Occasionally Radiotherapy can weaken the bones in the ribs or collarbones

Bone thinning

The following treatments for breast cancer can increase the risk of bone thinning:

  • chemotherapy, if it brings on an early menopause
  • stopping the ovaries from working by removing them or by giving radiotherapy,
  • or using drugs called LHRH analogues, such as goserlin (Zoladex®)
  • Hormonal therapy with aromatase inhibitors.

Before treatment with an aromatase inhibitor, national guidelines recommend that women have their bone health (density) checked by a DEXA scan using a very low dose x-ray. DEXA is short for dual energy x-ray absorptiometry.

These scans only take about 15 minutes. You lie on a couch while the scan is done. There are no injections involved and you don’t have to undress, as long as there aren’t any metal fastenings, such as zips, in the area to be scanned.

Your bone density can be monitored during and after treatment. Depending on the results, you may be prescribed calcium and vitamin D supplements and/or bone strengthening drugs (bisphosphonates) to minimise the risk of problems. If you have a history of osteoporosis in your family, ask your cancer specialist about using bisphosphonates to help prevent osteoporosis.

What you can do

Taking regular exercise, eating a healthy diet and stopping smoking can help to keep your bones healthy.

Exercise makes your bones stronger. Regular exercise that forces you to work against gravity (weight- bearing) is best. For example, walking, climbing stairs, dancing, hiking and gentle weight-lifting. Swimming isn’t so helpful, as your bones aren’t supporting your weight while you swim. If you already have osteoporosis, avoid exercises that put too much strain on your bones, such as jogging.

It’s important to make sure that you get enough calcium and vitamin D in your diet. Low-fat dairy products, eggs, green leafy vegetables, nuts, and whole fish (such as whitebait, and sardines) are good sources of calcium. Vitamin D is essential to help the body absorb calcium. It’s found in oily fish, eggs and food with added vitamins, but we mainly get it from sunlight.

Most people get enough vitamin D by getting out and about in the summer months. If you have naturally dark skin, you need more sunlight to make vitamin D because of the pigment in your skin.

A well-balanced diet and exposure to enough sunshine will usually give you all the calcium and vitamin D you need. If you’re not getting enough calcium or vitamin D, taking supplements may be helpful. Your specialist can advise you about this.

Drinking too much alcohol can interfere with the balance of calcium in your body, so stick to sensible drinking guidelines.

Radiotherapy damage to bones

Rarely, radiotherapy results in a reduced blood supply to bones in the treatment area (ribs and collarbone). This makes them thinner and increases the risk of a bone becoming infected or breaking, but this is very rare. If you have any symptoms, such as pain, always get them checked by your doctor, but there will usually be a simpler cause.

Treatment can involve taking painkillers or anti-inflammatory drugs. Sometimes calcium supplements, vitamin D, or bisphosphonates and antibiotics are given.

Pain in the joints (arthralgia)

Women taking aromatase inhibitors (such as anastrozole, letrozole and exemestane) may have joint pain, which is probably caused by a fall in oestrogen levels. Joint pain is also a common symptom of the menopause..

Pain is most common in the hands and feet but may also affect the knees, hips, lower back and shoulders. It may be there all the time or come and go. Some women notice that their joints are stiffer in the morning, when they first get up.

If you’ve recently started taking an aromatase inhibitor, the pain may settle over the next few months as your body adjusts to changes in hormone levels. Doctors can prescribe several different painkillers for joint and muscle pain. These range from simple painkillers such as paracetamol; to anti-inflammatory painkillers, such as ibuprofen; to opiate-based medicines, such as codeine; or for severe pain, morphine.

If the pain is difficult to cope with, switching to a different type of aromatase inhibitor may be effective. If that doesn’t work, switching to tamoxifen, which causes fewer problems with joint pain, usually helps most women. There is evidence that after taking an aromatase inhibitor, switching to tamoxifen doesn’t increase the risk of breast cancer coming back.

Aromatase inhibitors are effective in reducing the risk of breast cancer coming back. It’s important not to stop taking them without talking things over with your cancer specialist. There’s usually something that can be done to improve the pain.

Small studies suggest that for women with lower levels of vitamin D, taking vitamin D3 supplements may improve symptoms. Talk it over with your doctor before taking a supplement.

Research is going on to discover if a drug called glucosamine, often used to treat arthritis, may help some women. You can buy this over the counter in health shops and pharmacies, but it’s not suitable for everyone. It may affect blood sugar levels, so may not be suitable for people with diabetes. Talk to your GP or cancer specialist before taking it.

What you can do

It’s important to let your doctors know if joint or muscle pain is a problem for you. Don’t stop taking your hormonal therapy without discussing it with your cancer specialist. Hormonal therapy is an effective treatment that reduces the risk of breast cancer coming back. Your doctor can prescribe drugs to help control the symptoms and look at other ways of improving them.

Regular exercise can help to strengthen the muscles around your joints, keep them flexible and reduce pain. Non-weight-bearing exercises, such as swimming and cycling, may feel less uncomfortable and will help keep your joints healthy.

If you’re having lots of problems, a referral to a physiotherapist for advice and treatment is sometimes helpful. Your doctor can arrange this for you. If you’re having difficulty carrying out daily tasks, you can ask to be referred to an occupational therapist. They’ll be able to assess your needs and recommend aids and equipment to help you.

Some women find complementary therapies, such as massage, helpful. Some hospitals offer massage on the NHS.

CLICK HERE to download the Breast Cancer Patient Resource Pack

 

Please do not hesitate to contact your breast care nurse for any further information which you might find helpful:

Lorraine Walker
Macmillan Breast Care Nurse Consultant
01480 363516

Mel Robinson
Macmillan Breast Care Nurse Specialist
01480 416416 x 8249

“If you are considering reconstruction then please follow this link which provides some very useful information”. Mel
Keeping abreast at www.keepingabreast.org.uk