Survivorship: Late Effects After Radiation for Lung Cancer

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 in your bowel or bladder after radiation.

Late effects can be physical or emotional, practical, financial or spiritual.

This article focuses on the late effect of radiation treatment for lung cancer.

Late Effects After Radiation for Lung Cancer

The physical side effects of radiation treatment are directly related to the area of the body being treated. Any area in the treatment field has a risk of being damaged, causing side effects. As radiation techniques have improved over the years, the risk of late effects has decreased.

Lung Problems

Radiation that includes your lung(s) can lead to scarring (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 scarring 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 right away by a healthcare provider, either in the office or the emergency room.
• At your yearly physical your provider will check your lungs and ask about possible symptoms (cough, shortness of breath, wheezing).
• Have a flu vaccine every year and the pneumococcal vaccine.
• Don't smoke. This can cause more lung damage.

Swallowing Problems

Radiation to your chest can cause scar tissue in your throat and esophagus (the tube from the mouth to the stomach). This can happen many years after radiation treatment. This scar tissue can make the throat or esophagus narrow, making it hard to swallow or cause heartburn. If you develop these issues, you should see your provider. You may benefit from seeing a gastroenterologist (GI doctor) or surgeon. They may be able to use a stent or balloon to stretch the scar tissue and open the throat/esophagus.

Heart Problems

Radiation treatment to your chest can affect your heart. This can lead to different types of heart problems, including heart failure, high blood pressure, valve problems, and scarring or inflammation of the heart tissue.

• Your risk of heart failure depends on the amount of radiation you got and what other cancer treatments you had.
• When radiation treatment is planned, it is designed to avoid the heart as much as possible, but in many cases, it cannot be avoided altogether.
• 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 try to live a heart-healthy lifestyle, including 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 suggest an echocardiogram (heart ultrasound) to check heart function.

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.

Skin Problems

Radiation can lead to permanent changes in the skin.

• You may develop new scars or notice changes in the color or texture of your skin. Radiation can also change the color and texture of your hair or can cause permanent hair loss in the treated area.
• The soft tissue and muscles under the skin can develop scarring and/or shrinkage, which can lead to a loss of flexibility and movement or chronic swelling in this area.
• You may develop chronic or recurring ulcers of the skin in the area treated. Blood vessels of the skin may become dilated and more visible, although this is not harmful.
• If the skin feels tight or sore, you can apply vitamin E to the skin.
• Use fragrance and dye-free soaps and moisturizers in the area if your skin is sensitive after radiation.

Sun Safety

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 to avoid being 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 anywhere on your body, you should contact your provider for an assessment.

Thyroid Problems

Your thyroid gland is in your neck, just below the larynx (voice box). Radiation fields that include the thyroid gland can lead to thyroid problems, including hypothyroidism, hyperthyroidism, and thyroid nodules or tumors. Most often, thyroid issues caused by radiation happen 2-5 years after treatment. Thyroid nodules are most often seen 10 years or more after treatment. Risk is higher with higher doses of radiation.

• You should see your primary care provider every year for a checkup. You should also have your thyroid checked each year by your provider.
• If your thyroid was directly in the radiation field, TSH (thyroid-stimulating hormone) levels should be checked every 6-12 months. This is done using 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. This is 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.

Spinal Cord Damage

Occasionally, the spinal cord is in the field of lung radiation treatment. This can cause damage to the nerves in the spine.

• Signs include loss of strength, feeling, or coordination of the arms or legs, paralysis, or not being able to hold your bladder (urine) or bowels (stool). Sometimes nerve damage can cause a feeling of electric shock spreading down the arms or legs.
• If you develop any of these issues, you may need imaging tests or to be seen by a neurologist to find the cause.

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

Nerve Damage

Survivors who received radiation to the chest or underarm area can experience nerve damage (brachial plexus nerve). This damage is often a result of scar tissue in the area compressing on the nerves or blocking the blood supply to the muscles served by these nerves.

• Radiation injury to the nerves and muscles is sometimes called radiation fibrosis syndrome. It tends to develop in the years following treatment and slowly worsens over time.
• Symptoms can include pain, loss of strength, decreased feeling (sensation), loss of coordination, or loss of movement or function of the muscle. The area affected will depend on the area that was in the radiation field.
• In rare cases, the autonomic nervous system (ANS) can be affected. The ANS controls things you don’t think about, such as blood pressure and bowel and bladder control. Symptoms of ANS dysfunction can cause lightheadedness, fainting, extreme constipation, urinary incontinence, and erectile dysfunction.
• If you develop any of these symptoms, report them to your provider. Some of these concerns can be caused by other health issues, so your provider will need to determine the cause.
• If radiation fibrosis is determined to be the cause, you may benefit from seeing a cancer rehabilitation physician or physiatrist, and physical or occupational therapists. These specialists can help manage symptoms through therapy, medications, and assistive devices.

Managing Late Effects

If you experience any concerning or lasting symptoms, contact your care team. Some side effects require specialized care from healthcare providers experienced in working with cancer survivors. Interdisciplinary survivorships clinics are available at many cancer treatment sites. If a clinic is not available near you, talk with your oncology care team about resources for managing your late effects.

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