Radiation Induced Fibrosis
Radiation-Induced Fibrosis : “The Gift That Keeps on Giving”

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Radiation therapy is an important and common component of cancer treatment. However, unlike chemotherapy, the side-effects of radiation therapy are frequently not immediate. This leads many to believe that radiation therapy is “no big deal”, which often couldn’t be farther from the truth.

Beyond the general initial side effects such as skin irritation and fatigue (amongst others), the impacts of radiation therapy can take months to appear and can even continue to progress for several years (1, 2)!  This is why I call radiation therapy “the gift that keeps on giving.”  

 

Although radiation therapy can be very effective at treating cancer cells, its long-term side effects are the unfortunate “gift” that few people are prepared for and none of us want.  Radiation-induced fibrosis (RIF) is one of these side effects and the topic of this blog.

Though we can’t stop RIF from happening, understanding what it is, what to look out for and what you can do to improve these symptoms will put you in a better position to keep the impact to a minimum. 

What is Radiation Therapy?

Radiation therapy (also called radiotherapy) is a form of cancer treatment that uses high doses of radiation to kill cancer cells (3).  The type of radiation therapy used will depend on several factors, including the type of cancer:

  1. External Beam Radiation
    • Radiation is delivered to a region of the body from the outside via a machine that moves around you
  2. Internal Beam
    • Radiation is put inside the body via either a solid source (called brachytherapy – use of seeds, ribbons, capsules) or a liquid source (via swallowing, IV line or injection).

What is Radiation-Induced Fibrosis (RIF)?

RIF is a long-term side effect of external beam radiation and some forms of brachytherapy. In general, it causes an excessive formation of fibrous connective tissue in any of the tissues where radiation was delivered (called the radiation field). 

Though the specific process is quite complicated to explain in this article, think of RIF like “wound healing gone wild.”  In other words, the impacted tissues go through an excessive and prolonged inflammatory process that eventually creates tissue thickening/loss of flexibility, reduced blood supply, and tissue scarring.  These tissue changes typically only begin 4-12 months after radiation therapy is complete, and can progress over several years (1, 2, 4).

Radiation fibrosis occurs months and even years after radiation treatment is complete.

Who’s at Risk of Developing RIF?

Since the development of RIF is dependent on many factors, the number of people living with RIF is different across cancer types.  For example, the literature shows that following radiation therapy, approximately 10-23% breast cancer survivors, 34% of head & neck cancer survivors, and 97% of cervical cancer survivors will experience RIF (5, 6, 7).  

 

Factors that influence the risk of developing RIF can be divided into treatment-related and patient-related:

  1. Treatment-related factors that increase RIF risk (1, 5):
    • Increased radiation dose & fewer fractions (called “hypofractionation”) 
    • Larger amount of tissue treated (called “field size”)
    • Longer therapy regime
    • Concurrent use of chemotherapy
    • Surgery close to the time radiation is received (either before or after)
  2. Patient-related factors that increase RIF risk (1):
    • Pre-existing connective tissue diseases (e.g. systemic scleroderma, systemic lupus erythematosus, Marfan syndrome)
    • Certain genetic variants (e.g. in breast cancer, the genetic variant in the ATM (ataxia-telangiectasis mutated) gene has been linked to a greater risk of developing RIF)

Though we can’t control the above risk factors, it can be helpful to identify your risk level so you can be ready to identify RIF early (if and when it happens), and get the help you need to minimize its impact.

Signs You May Have Radiation-Induced Fibrosis

By now I’m sure it’s no surprise to you that RIF can have a tremendous impact on how you feel and move.  It often causes (4):

  • A loss of joint mobility
  • Pain
  • Muscle weakness
  • Lymphedema
  • Slowed wound healing 

Also, depending on the specific area of the body that received radiation, RIF can lead to the following (1):

Area of Radiation Treatment: Side Effect

Head & Neck

  • Difficulty opening the jaw
  • Difficulty swallowing
  • Voice changes

Breast, Chest or Lung

  • Shortness of breath
  • Progressive muscle weakness
  • Urinary urgency (strong/sometimes sudden urges to pee)
  • Increased urinary frequency (needing to pee more often)
  • Diarrhea
  • Loss of reproductive function
  • Pain with sex (called dyspareunia)

Treatment for RIF

It’s beyond the scope of this article to outline all the Radiation Induced-Fibrosis treatment trials in the literature.  The research is ongoing, but the overarching agreement is that there is no cure for RIF and that treatment is aimed at diminishing symptoms and improving overall function and quality of life. 

Treatment for RIF is aimed at diminishing your symptoms and improving your overall function and quality of life.

In the case of physiotherapy, some research has shown that education, exercise (8) and manual therapy (especially tissue distraction techniques) has the potential to improve quality of life, joint mobility, muscle strength, posture, and fibrotic tissue mobility (8, 9).  In other words… Cancer Rehab Can Help!

3 Things YOU Can Do for Radiation Fibrosis*

  • Deep Breathing

If RIF has impacted your chest, abdomen, pelvis or even neck, diaphragmatic breathing practices can help.  The movements required of your body to breathe diaphragmatically help to encourage your tissues to “slide and glide” during this process. Take a look at this video to get started.


  • Daily Purposeful Movement

In case you haven’t heard me say it enough, Movement is Medicine!  Moving your body with awareness, in a way that is both enjoyable and purposeful for the impacted area, is absolutely crucial for encouraging your tissues to move more freely.  


  • Self Tissue Massage

Regular self-massage to the impacted tissues can be very helpful. Try placing your palm or fingers (if it’s a small area) over the area and gently stretch/move the tissues in a circular formation. 

 

*If you would like help learning the right exercises for you and/or how to perform other self-massage techniques at home, consider seeking out the help of a cancer rehab physiotherapist near you. (Feel free to contact me directly for assistance in helping find someone near you.)

Want to Learn More?

My new online program “The Breast Cancer Surgery Recovery Program” has over 70 exercises geared towards regaining shoulder and chest mobility.  Even though it’s geared toward those recovering from surgery, there are still many exercise videos and informational talks that can help you manage problems related to radiation fibrosis as well.  For more information about this self-paced program, I invite you to take a look here.

Disclaimer – These blogs are for general information purposes only.  Medical information changes daily, so information contained within these blogs may become outdated over time. In addition, please be aware that the information contained in these blogs is not intended as a substitute for medical advice or treatment and you should always consult a licensed health care professional for advice specific to your treatment or condition.  Any reliance you place on this information is therefore strictly at your own risk.

References

  1. Straub, J. M., New, J., Hamilton, C. D., Lominska, C., Shnayder, Y., & Thomas, S. M. (2015). Radiation-induced fibrosis: mechanisms and implications for therapy. Journal of cancer research and clinical oncology141(11), 1985–1994. https://doi.org/10.1007/s00432-015-1974-6
  2. Keskikuru, R., Jukkola, A., Nuutinen, J., Kataja, V., Risteli, J., Autio, P., & Lahtinen, T. (2004). Radiation-induced changes in skin type I and III collagen synthesis during and after conventionally fractionated radiotherapy. Radiotherapy and oncology : journal of the European Society for Therapeutic Radiology and Oncology70(3), 243–248. https://doi.org/10.1016/j.radonc.2003.11.014
  3. Website: https://www.cancer.gov/about-cancer/treatment/types/radiation-therapy
  4. Nogueira, R., Vital, F., Bernabé, D. G., & Carvalho, M. B. (2022). Interventions for Radiation-Induced Fibrosis in Patients With Breast Cancer: Systematic Review and Meta-analyses. Advances in radiation oncology7(3), 100912. https://doi.org/10.1016/j.adro.2022.100912
  5. Williams, N. R., Williams, S., Kanapathy, M., Naderi, N., Vavourakis, V., & Mosahebi, A. (2019). Radiation-induced fibrosis in breast cancer: A protocol for an observational cross-sectional pilot study for personalised risk estimation and objective assessment. International journal of surgery protocols14, 9–13. https://doi.org/10.1016/j.isjp.2019.02.002
  6. Ramia, P., Bodgi, L., Mahmoud, D., Mohammad, M. A., Youssef, B., Kopek, N., Al-Shamsi, H., Dagher, M., & Abu-Gheida, I. (2022). Radiation-Induced Fibrosis in Patients with Head and
  7.  

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2019-2022 © Beth Hoag Physiotherapist

MEDICAL DISCLAIMER

The information provided on this website is offered for educational purposes only and is based on the personal and professional knowledge of the author. Nothing on this website is offered as a substitute for medical care or to negate or replace any previously given medical instruction by a licensed or certified health care provider. Beth Hoag is Canadian-licenced physical therapist. By reading this material and/or registering or purchasing an online product or service, you acknowledge that you are not entering into an agreement for personal training, professional coaching, clinical health or direct physiotherapy care. You also acknowledge that you are free to make your own healthcare decisions.

By reading this and/ or purchasing any online products or services, you assume the liability and responsibility over how you utilize the information provided and will not hold Beth Hoag, Physiotherapist liable for any personal injury ensued in how you utilized this information. You are recommended to inform your current health care providers of any changes in your health status and discuss your health care decisions with them immediately upon deciding to change a prior prescribed plan of care.