Survivorship: Late Effects After Radiation for Non-Hodgkin Lymphoma (Chest/Mediastinum/Neck)

Side Effects After Cancer Treatment?

There are different types of side effects you may have during or after cancer treatment.

• Short-term: side effects that happen while you are on treatment and end shortly after treatment. Example: mouth sores that heal within a few weeks after treatment is finished.
• Long-term: side effects that happen while you are on treatment and last for months to years. Some of these side effects will not go away. Example: neuropathy.
• Late effects: side effects that happen months to years after you have finished treatment. Example: scar tissue forming and causing health issues.

This article focuses on the late effects of radiation treatment to the chest, mediastinum, and/or neck for Non-Hodgkin Lymphoma.

Late effects can be health issues or psychological, emotional, and practical challenges.

Late Effects After Radiation to the Chest, Mediastinum, or Neck for Non-Hodgkin Lymphoma

Side effects from radiation treatment affect the area of the body in the treatment field. The treatment field includes the cancer and in some cases nearby healthy tissue. The way radiation is given has changed over the years, leading to a lower risk of late effects. Talk with your radiation oncologist to find out which areas were in your treatment field.

Late effects of radiation treatment to the chest, mediastinum, or neck for Non-Hodgkin Lymphoma can include:

Risk of Breast Cancer

Radiation therapy fields that include breast tissue can lead to breast cancer later in life. Because of this, the recommendations for breast cancer screening are different for you than for people who have not had chest radiation. 

• Women who received radiation to the chest should have annual mammograms starting 8-10 years after radiation, or at age 40, whichever comes first. 
• If you received radiation to the chest wall between the ages of 10 and 30, your mammograms may start earlier, and you may also need a breast MRI. 
• Each case is unique, and you should talk to your provider about what tests you need and how often you should have them. 
• Make sure that you are familiar with the normal feeling of your breasts. Tell your provider about any changes. Changes can include a new lump or mass, a change in the look and feel of the skin on your breast, or any discharge coming out of your nipple.
• If you are a man who has had radiation to the chest, you also have an increased risk of getting breast cancer. There are no screening tests done for men who have had chest radiation. However, you should tell your provider about any unusual changes, such as lumps, skin changes, or nipple discharge.

Heart Problems

Radiation treatment to the chest can affect the heart. Heart problems caused by radiation can include heart failure, high blood pressure, valve problems, and scarring or inflammation of the heart tissue.

• Your risk of heart failure depends on how much radiation you got, what other cancer treatments you had, and your heart health before treatment.
• Radiation treatment is designed to avoid the heart as much as possible, but in many cases, it cannot be completely avoided.
• You should have a yearly physical by your primary care provider. They should listen to your heart, check your blood pressure, look for signs of heart trouble such as swelling in your legs/feet, and check your cholesterol and blood sugar levels with a blood test.
• You should strive for a heart-healthy lifestyle, with regular exercise, not using tobacco, and eating a healthy diet.
• If you are at a high risk of heart problems based on your treatments, your provider may order an echocardiogram (heart ultrasound) to look at your heart function before treatment.

Lung Problems

Radiation fields involving the lung can lead to scar tissue (called fibrosis), inflammation (pneumonitis), and restrictive or obstructive lung disease. 

• The risk for these problems is higher with higher doses of radiation, if you also got certain chemotherapies (bleomycin, busulfan, BCNU, and CCNU), or if you had part of your lung removed (lobectomy). 
• Radiation can cause scar tissue in the lungs that may affect blood vessels. Damage to the blood vessels can lead to coughing up blood. If you cough up blood, you should be seen by a healthcare provider right away, either in the office or the emergency room. 
• At your yearly visit, your provider will examine your lungs and ask about symptoms (cough, shortness of breath, wheezing). 
• You should get a flu vaccine every year and the pneumococcal vaccine. 
• You should avoid smoking, secondhand smoke, vaping, and hookah products, as these can cause further lung damage.

Throat and Swallowing Problems

Radiation to the throat area can cause scar tissue in the throat. This can happen months to years after treatment.

• This scarring can make the throat narrow, making it difficult to swallow, feel like food gets “stuck”, or cause heartburn. If you have these problems, you should be seen by your provider. You may need to see a gastroenterologist (GI Doctor) or surgeon. They may be able to use a stent or balloon to stretch the scar tissue and widen your throat.
• This scar tissue can also make breathing and speaking hard. Talk with your provider if you are having issues like a hoarse voice or a lasting cough. If you are having trouble breathing or are coughing up blood, contact your care team right away or go to an emergency room.

Thyroid Problems

The thyroid gland is in the neck, just below the larynx (voice box). Radiation fields that include the thyroid gland can cause hypothyroidism (low/underactive thyroid), hyperthyroidism (high/overactive thyroid), and thyroid nodules or tumors. Under and over active thyroid caused by radiation happens 2 to 5 years after treatment. Thyroid nodules happen 10 years or more after treatment. Your risk increases with the amount of radiation given to the area.

• You should have a thyroid exam and a physical each year by your provider to check for thyroid issues.
• If the thyroid was directly in the radiation field, your TSH (thyroid-stimulating hormone) level should be checked every 6-12 months. This is done with a blood test.
• If you develop thyroid problems, you should be seen by an endocrinologist.
• Signs of hypothyroidism (underactive thyroid, the most common complication) include fatigue, weight gain, constipation, dry skin, brittle hair, or always feeling cold.
• Signs of hyperthyroidism (overactive thyroid) include weight loss, irregular or fast heartbeat, sweating, and being irritable.
• You may also be at risk for hypoparathyroidism, a condition caused by damage to the parathyroid glands (located in the same area as the thyroid). Signs of hypoparathyroidism are tingling in your fingers, toes, and lips, muscle aches, muscle spasms, and fatigue.

If you notice any of these signs, you should contact your care provider.

Stomach Problems

Indigestion and heartburn can be late effects of radiation that include the stomach. You may also be at risk for gastritis (irritation of the stomach wall), ulcers, and gastric outlet obstruction.

• Signs include new or worsening belly pain, frequent vomiting or heartburn, or blood in your vomit or stool. Call your care team right away if you have any of these problems.
• You may need a referral to a gastroenterologist (GI Doctor) to find the cause.
• If you are having heartburn, your care team may prescribe medicine to lessen the amount of acid being made or to coat/protect your stomach.

Damage to the Bones

Radiation can cause small cracks (fractures) in the bones that are in the treatment field. Try to avoid trauma including falls or accidents. If you do get hurt, ask your provider if you need an x-ray to check for bone damage.

Spinal Cord Damage

The spinal cord can be in the field of radiation treatment for “mantle field” therapy. This can cause damage to the nerves in the spine.

• Signs of this can include loss of strength, feeling, or coordination of the arms or legs, paralysis, or problems with bowel or bladder control. Sometimes nerve damage can cause a feeling of electric shock spreading down the arms or legs.
• If you have any of these issues, you may need imaging tests or to be seen by a neurologist.

Radiation can also cause damage to the bones of the spine. This can cause you to be shorter or have a change in the curve of your spine. Radiation to these bones can also put them at risk for fractures (breaks). If you have any new back pain, you should call your provider right away. You may need x-rays or other imaging tests.

Skin Changes

Radiation can lead to permanent changes in the skin.

• You may find new scars or changes in the color or texture of your skin. Radiation can also change the color and texture of your hair or can cause hair loss in the treated area. Your hair might never grow back.
• The soft tissue and muscles under the skin can cause scarring and/or shrinkage, which can lead to a loss of flexibility and movement or chronic swelling in the area treated.
• You may get chronic or recurring ulcers of the skin in the area treated. Blood vessels of the skin may become dilated (larger) and more visible,  but this is not harmful.
• If the skin feels tight or sore, you can put vitamin E on the skin.
• Use fragrance and dye-free soaps and moisturizers if your skin is sensitive after radiation.

After radiation, the skin in the treated area is more sensitive to sunlight. This sensitivity will last for your lifetime. Practice sun safety, use plenty of sunscreen, wear a wide-brimmed hat, and keep skin in the treated area covered with clothing. Try not to be out in the sun between the hours of 10 am-4 pm when it is the strongest.

If you notice any new or worsening skin issues, you should call your provider for an assessment.

Managing Late Effects

Tell your care team about any new or worsening symptoms. Some side effects need care from healthcare providers who specialize in working with cancer survivors. There are interdisciplinary survivorship clinics at many cancer centers. If there is not a survivorship clinic near you, talk with your oncology care team about support for managing your late effects.

After treatment, talk with your oncology team about getting a survivorship care plan, which can help you in your transition to survivorship and learn about life after cancer. You can build your own survivorship care plan using the OncoLife Survivorship Care Plan.