A.1.2 Radiotherapie

Zie ook noot 5 - Radiotherapie bij borstkanker wordt meestal toegepast in combinatie met andere medische interventies en kan curatief of palliatief van opzet zijn. Adjuvante radiotherapie na een mastectomie of lumpectomie is gericht op het verkleinen van het risico op een recidief. Bij sommige patiënten wordt radiotherapie als een palliatieve behandeling toegepast, bijvoorbeeld ter bestrijding van pijnklachten veroorzaakt door uitzaaiingen elders in het lichaam. Curatieve en adjuvante bestralingsbehandelingen bestaan meestal uit ongeveer 16-35 bestralingen die gedurende 3-7 weken, 4 à 5 dagen per week worden gegeven. Radiotherapie met een palliatief doel beperkt zich meestal tot enkele sessies met een hoge dosis per bestraling, gericht op een specifiek afgebakend gebied.

Bestraling vernietigt niet alleen kankercellen, maar beschadigt ook gezonde cellen in het bestraalde gebied. De bijwerkingen hangen af van de locatie van het bestraalde gebied, de techniek van de bestraling, de bestralingsdosis en het aantal -sessies. De bijwerkingen op korte termijn (tijdens en direct na afloop van de bestralingsperiode) zijn huidreacties (bijvoorbeeld roodheid, gevoeligheid, teleangiëctasieën, fibrose), futloosheid en vermoeidheid. Op de lange termijn zijn de bijwerkingen vermoeidheid, risico op stralingsfibrose, spieratrofie en lymfoedeem (met name na radiotherapie van de oksel).

Uit veel studies kwam niet duidelijk naar voren of radiotherapie op de borst of in combinatie met de oksel was gegeven. 
De wetenschappelijk bevindingen ten aanzien van radiotherapie zijn opgenomen in noot 5.

 


Aanbevelingen tijdens/na radiotherapie 

  • Het wordt aanbevolen er rekening mee te houden dat de gevolgen van radiotherapie van de oksel en/of supraclaviculair groter zijn dan die van radiotherapie van de borst en/of borstwand.
  • Er moet rekening mee worden gehouden dat na radiotherapie in grotere mate sprake is van schouderbeperkingen (met name abductie), pijn, fibrose, krachtsvermindering van de bovenste extremiteit en adl beperkingen.
  • Het wordt aanbevolen na afloop van de radiotherapie te controleren op mobiliteitsbeperkingen en op lymfoedeem.
  • Het wordt aanbevolen om 6 en 12 maanden na de radiotherapie opnieuw te controleren of er sprake is van mobiliteitsbeperkingen en/of lymfoedeem. Deze controle kan worden uitgevoerd  in combinatie met een controle op de mammacare poli of door de behandelend fysiotherapeut.
  • Het wordt aanbevolen dat patiënten met toenemende klachten van bewegingsbeperkingen en lymfoedeem opnieuw contact opnemen met de fysiotherapeut.
  • Er moet tijdens de behandeling in gedachten worden gehouden dat patiënten tijdens en na radiotherapie meer last hebben van vermoeidheid. Na de radiotherapie is het risico op pulmonale fibrose, ischemische hartziekten en ribfracturen verhoogd.
  • Er moet rekening mee worden gehouden dat ook op de lange termijn (20 jaar) na radiotherapie nog lymfoedeem kan ontstaan, zeker bij een BMI > 25, een trauma of een infectie.
  • Het verdient aanbeveling alert te zijn op een verminderde kwaliteit van leven en het stoppen met vrijetijdsactiviteiten, sport en werk. De fysiotherapeut kan desgewenst een coachende rol vervullen ten aanzien van het hervatten van bewegingsactiviteiten.

 

Noot 5 Radiotherapie

Noot 5 Belangrijke gegevens over radiotherapie en de indicatie voor fysiotherapie werden gevonden in 2 meta-analyses van Tsai et al. (2009) en Lee et al. (2008), 5 RCT’s (Collette et al., 2008; Rietman et al., 2004; Chetty et al,, 2000; Hojris et al., 2000; Whelan et al., 2000), 6 cohortstudies (Hwang et al., 2008; Lauridsen et al., 2008; Jones et al., 2007; Langer et al., 2007; Blomqvist et al., 2004; Ververs et al,, 2001) en 1 narratief review (Jung et al., 2003).

Tsai et al. toonden aan dat elke vorm van radiotherapie (onafhankelijk van locatie en dosis) het risico op lymfoedeem vergrootte (RR = 1,92); het risico op lymfoedeem was hoger bij bestraling van de oksel (RR = 3,06 als lymfoedeem objectief was gemeten). Daarnaast bleek radiotherapie te leiden tot meer schouderbeperkingen (met name abductie, endo- en exorotatie) en krachtvermindering van de bovenste extremiteit. Dit alles werd bevestigd in studies van Blomqvist et al. (2004) en Hwang et al. (2008).

Lee et al. (2008), Langer et al. (2007) en Lauridsen et al. (2008) vonden dat chirurgie in combinatie met radiotherapie (oksel/fossa supraclavicularis/borst/borstwand) bij 1-67% van de patiënten schouderbeperkingen gaf. De grote spreiding hield verband met de verschillen in meetmomenten en -manieren. Na radiotherapie was het risico op beperkingen (zowel mobiliteit als lymfoedeem) 1,67 keer groter, wat ook door Rietman et al. (2004) werd gevonden.

Rönkä et al. (2004) beschreven een risico van 34% op het ontstaan van lymfoedeem in de borst na radiotherapie, met als risicofactoren het aantal verwijderde lymfeklieren en de totale dosis radiotherapie. Radiotherapie van de borst had geen invloed op schouderbeperkingen en lymfoedeem in de arm (Chetty et al., 2000). Hwang et al. (2008) en Whelan et al. (2000) toonden verder aan dat door radiotherapie de kwaliteit van leven verminderde en de vermoeidheid toenam. Late bijwerkingen van radiotherapie werden beschreven in studies van Højris et al. (2000), Jones et al. (2007) en Collette et al. (2008). Deze onderzoekers beschreven als risico van radiotherapie chronische pijn, lymfoedeem, (pulmonale) fibrose, ischemische hartziekten, ribfracturen en vermoeidheid. Colette et al. (2008) beschreven dat het risico op fibrose toenam bij een hogere totale stralingsdosis en bij concomitante chemotherapie.

Jung et al. (2003) concludeerden dat patiënten die radiotherapie en chemotherapie kregen een verhoogd risico hadden op chronische neuropathische pijn. Vier typen pijn werden hier beschreven: fantoompijn, intercostobrachiale neuralgie, neuroompijn (inclusief littekenpijn) en overige pijn. De incidentie van pijn lag op circa 50%. 
Als langetermijnbijwerkingen beschreven Ververs et al. (2001) dat ruim 4 jaar na radiotherapie van de oksel en/of supraclaviculaire radiotherapie het risico op lymfoedeem 3,6 keer zo hoog was. Dit leidde ertoe dat de patiënten stopten met hun activiteiten in hun vrije tijd en met sporten. Lymfoedeem correleerde significant met okselklierdissectie én radiotherapie. Daarnaast was het litteken bij vrouwen na radiotherapie gevoeliger. Vrouwen jonger dan 45 jaar hadden 6 keer zo veel risico op sensibele stoornissen van de arm en problemen met adl dan vrouwen ouder dan 65 jaar.

 

Niveaus van bewijs

Niveau 1. Het is aangetoond dat radiotherapie van de oksel en/of supraclaviculaire radiotherapie het risico op lymfoedeem in de arm verhoogt, dat radiotherapie leidt tot meer schouderbeperkingen (met name abductie) en krachtvermindering geeft van de bovenste extremiteit. Gepoolde studies over okselklierdissectie én radiotherapie van de borst of de borstwand lieten een zwakke associatie zien tussen radiotherapie en het risico op lymfoedeem en schouderproblemen. (A1: Tsai et al., 2009; Lee et al., 2008. A2: Chetty et al. , 2000. B: Hwang et al., 2008; Lauridsen et al., 2008; Langer et al., 2007; Blomqvist et al., 2004; Rietman et al., 2004; Rönkä et al., 2004.) Het is aangetoond dat late bijwerkingen van radiotherapie kunnen zijn: chronische pijn, lymfoedeem, pulmonale fibrose, ischemische hartziekten, ribfracturen en vermoeidheid. (A2: Collette et al. , 2008; Højris et al., 2000
B: Hwang et al., 2008; Jones et al., 2007; Whelan et al., 2000.) 

Niveau 2. Het is aannemelijk dat patiënten die radiotherapie én chemotherapie krijgen een verhoogd risico hebben op chronische neuropathische pijn (fantoom borstpijn, intercostobrachiale neuralgie, neuroompijn inclusief littekenpijn). De incidentie van pijn in deze groep is ongeveer 50%. (A2: Jung et al., 2003.) 

Niveau 3. Er zijn aanwijzingen dat ruim 4 jaar na de radiotherapie het risico op lymfoedeem 3,6 keer zo hoog is en dat dit lymfoedeem erin resulteert dat patiënten stoppen met hun activiteiten in hun vrije tijd en met sporten. Het litteken bij jonge vrouwen (< 45 jaar) is gevoeliger na radiotherapie en jonge vrouwen hebben meer problemen met adl dan oudere vrouwen. (B: Ververs et al., 2001.)

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