Breast cancer patient support and resources

By the time you hit my age, odds are you’ve been touched by cancer, either yourself or someone close. By age 85, every second Australian will develop it. But what if I were to tell you there’s a medicine that may double your chance of survival and cause your own body to attack the cancer? It’s exercise, but not as you know it.

I’m here at a clinic where, in a groundbreaking move, people are being prescribed specific targeted exercises designed for their own tumour and treatment on the same day as they get their chemo or radiation. The evidence is so strong now that cancer patients deserve this medicine.

You’ve literally this minute come from K?

Yep, straight from the hospital to here.

In this program, we’ll show you what professionally prescribed exercise is doing for a group of Australians with cancer.

It was the best thing I ever did. It made me feel better. I felt better at the end of each session.

And present startling new research that reveals the secret of how it works.

The muscles are producing chemicals and they’re actually destroying tumour cells.

The trial is still ongoing, but the early results are so impressive, the doctors think it will be a game changer.

This is our exercise medicine clinic here at the Cancer Care Centre. As far as I know, this is a world first, to have that close to the actual chemotherapy and radiation therapy suites.

The man behind this audacious new program, which includes a gym built inside the cancer treatment centre, is Professor Robert Newton. Director of the renowned Exercise Medicine Research Institute here in Perth, Western Australia.

A lot of our research is actually driven by the oncologists, because they’re right there working with the patients and they see what’s happening. And they came to us and said, why are we actually waiting until these patients are so deconditioned and they’re feeling so unwell, and then we try and rehabilitate them? Wouldn’t it be a way better, much more effective approach if we actually intervene with the exercise at the same time that they commence their therapy?

At the time, this team were already at the forefront of providing exercise programs for patients once they’d finished cancer treatment, with good scientific reason.

We now have a growing number of research studies showing that if people hit a certain level of physical activity, which is relatively modest to be honest, then they’ll more than double their chances of surviving their cancer. In other words, they halve their risk of dying.

But the idea to start the exercise program at the same time as starting punishing cancer treatment? Well, that’s still pretty radical.

It was a little bit of a step into the unknown, because chemotherapy, as most people would know, is a very difficult journey for the patient. And to put exercise on top of that, you know, is that a good idea? Will they tolerate it? Will it be safe? What about the muscle strength?

How are you going with the gym work?

So, to actually go against that mould and say to people, right, you’re having chemo today, that’s fine. Now we want you to get an exercise bike, and now we want you to start doing some weights. Because it is, you know, a new concept.

Yeah, of course. We’re all nervous about it.

Okay, two more reps, mate, and then you can have a rest. So push, push, push, all the way.

Convinced though they had a great team of oncologists and exercise physiologists on board, they began. One of their first recruits was Natalie.

I was diagnosed with breast cancer on the 11th of February last year. It was already spread through my milk ducts in my breast, on my left breast. It was quite serious and it was quite advanced, so we needed to get on top of it quite quickly.

Here you go. Are you ready?

I’ve got a four and a six-year-old, and a busy husband at work, and it just turned our lives upside down. Absolutely upside down.

Natalie knew to brace herself for heavy-duty chemo, but she never expected to be asked to exercise at the same time.

At the time, I wasn’t very fit and healthy anyway, so why not try it, you know. And so I did. I went along and pretty much straight away it started. K joined up, got a phone call, had to commit.

It works like this. On chemo or radiation days, patients book in here to the in-house exercise clinic. In between, three times a week, they come here to Exercise Medicine HQ at Edith Cowan University, under the direction of a team of expert exercise physiologists.

When I first met Natalie, she was struggling quite hard with her chemotherapy. It was hitting her hard. But she’s such an awesome woman, determined to exercise whenever she could.

And down another three reps.

It’s the exercise physiologist’s job to tailor the program for each cancer patient’s special circumstances.

Keep that breath going.

It’s really important. Natalie got some really bad peripheral neuropathy in her feet, so it really hurt to walk. So obviously the treadmill was out of the question, and so we moved her on to a recumbent bike.

Still, as Natalie was one of the first, many were understandably nervous about whether it would ultimately prove too much, including Natalie’s kids.

I didn’t think I should do it. They were a bit scared, because I looked so frail, and I looked so bald, and I looked different. And I was getting my gym gear on and dropping them off to school, and off I’d go.

And then, you’re going to gym again, Mum?

Yeah.

But when they’d see me come home still going, and not laying on the couch, and not having some of those symptoms that typical patients get, I think they could see the benefit.

That’s it. Good.

Natalie often dragged herself in, but by the end of the session she’d be feeling so much better than when she came in. And that’s a huge change in an hour, let alone over six months.

Stop. Stop.

And as time went on, everyone started to see the benefits.

And believe it or not, it did. It made me feel better. I felt better at the end of each session. I walked out with that extra bit of energy, a little bit less fatigue. The nausea was curbed, or kept at the same level.

Three quarters of the way through her punishing treatment, Natalie even managed a four-kilometre fundraising walk.

It was hard and I was tired. Nobody wanted me to do it, my husband, including. You’re just going to, it’s just going to be too much. And I just did it, and it was amazing that you could do it.

Everyone, including her oncologist, were very surprised with how well Natalie went through her treatments, because she was going through particularly hard chemotherapy regimens to try and kill this cancer.

But it wasn’t just Natalie who was doing well.

I’m probably surprised by how good people’s blood counts are. I’m surprised by their wellbeing, by how well they feel on chemo.

Anecdotally, all the patients on the exercise program seem to be getting less of the expected side effects of chemo, particularly less nausea and fatigue.

I can be very fatigued, but if I make the effort and have even the walk, then it lifts my energy.

It’s been pretty good, actually. The chemo is not as bad as I thought it was going to be.

And this is where our DEXA scanner is. I just want your head at this end here, and your feet at that far end.

But the evidence that blew the clinicians away came from this machine, the DEXA, which was used to track the fat, muscle and bone composition of each of the patients in the trial.

So how much decline do you typically see in muscle mass when people go on chemo?

Somewhere between 10 and 15%, depending on the length of duration that they’re actually undergoing chemotherapy. That’s the normal. That’s expected.

Yet in the 38 patients who’ve gone through the exercise program, that muscle wastage was almost completely blocked. Some even gained.

If we take Natalie, for example, she’s actually, which is quite astounding, increasing her muscle mass over the course of chemotherapy. And that’s just a really fantastic outcome, because it not only improves their health and function, but it likely improves their capability to complete the full course of chemotherapy. That means they’re much more likely to survive.

We’re really excited about this. I believe it will actually change the management of cancer patients.

To understand quite how extraordinary this is, let’s visit someone who had a very different experience of chemo. This is The Science Show, 2065. Hello, I’m Robin Williams.

This is Robin Williams, known to ABC Radio National listeners as the legendary voice of The Science Show. And in the interest of full disclosure, he’s also my long-term partner.

You ready for your trip down memory lane?

I think so.

Eighteen months ago, Robin was told he had two large tumours in his bowel.

Do you remember when that was?

Oh, dancing.

Yeah, that was the day after you got your diagnosis.

The next day, the treatment steam train started.

Gradually, you stop feeling like yourself. Your body is not yours to control. You kind of get smaller. Literally smaller, of course, because the effect of the chemo was, for me surprisingly, for them as well, devastating. I was then with a colostomy bag and I was losing weight.

Along with the weight loss came damage to the peripheral nerves, which meant he kept bumping into things. And a rapid loss of Robin’s ability to run, which he’d previously done daily.

At one point, I remember I couldn’t even walk around the block.

How much weight did you lose in the end?

I was just over 85 kilos when I started, and I was 59, under 59, at the, if you like, the base of the experience.

That’s why I took a photo.

Robin was hospitalised for five weeks, and his chemo had to be terminated two months early. Though Radio National listeners will be pleased to note he still insisted on making The Science Show.

The first ever computer program. I did things from the hospital bed. We never missed a program.

Robin’s experience was particularly bad, but it does help show why the fact the patients on the exercise trial are maintaining their muscle mass is so significant.

A scientific paper is currently being prepared. The benefit in terms of muscle mass is absolutely extraordinary, because we know that there’s no pharmaceutical intervention that can actually stop that decline in muscle mass. The only thing which will do that is highly targeted, prescribed exercise.

It certainly appears as though something here is working, which begs the question. How?

One likely mechanism is pretty straightforward. It’s all about blood flow. One of the troubles of getting chemo into a tumour is that tumours often have a really poor blood supply. But exercise increases blood flow, potentially allowing more chemical to get inside the tumour where it’s needed.

That’s why I believe that the greatest effectiveness of exercise is when you actually exercise either immediately before or after the actual session of receiving the chemotherapy. Because either before or after, you’re still influencing the circulation of blood into the tumour. So you have to be delivering more of the chemotherapy agent, targeting the specific cancer cells.

But the science gets way cooler than that. In the last three years, some fascinating discoveries have been made about what exercise does to the immune system.

Our bodies are making potential cancer cells all the time, but our immune system regularly finds them and destroys them. Crucial to our tumour defence force are so-called natural killer cells. They’re one of the only cell types that can recognise threats generated by our own bodies and call in an attack.

It’s one of life’s great mysteries why some cells slip past our defences and begin to grow. So our own immune system is still one of the best ways to fight the cancer.

The trouble with chemo is, at the same time as it’s poisoning our tumour cells, it’s also wrecking our immune system.

Which brings us to a small but remarkable study conducted in Sweden and published in 2013. A group of 10 average healthy young men were exercised on a bike for 60 minutes. Their blood was taken before the exercise and also straight after. The before and after bloods were then spun down to extract the clear serum and poured over laboratory lines of prostate cancer cells to see if they would grow.

Incredibly, the serum taken straight after exercise suppressed the cancer cell growth by 30%.

That particular study is landmark, because what it has done is it’s woken up the scientific community to say there is something produced during exercise systemically. So the muscles are producing chemicals which are going to all parts of the body, and they’re actually destroying tumour cells.

Then in early 2016, another study in Denmark gave us an even clearer picture of what’s going on. The study involved mice with cancer. They were split into two groups. One was given unlimited access to a running wheel. The other was not. And just to be thorough, the researchers tried this experiment in five different kinds of mouse cancer models, from lung cancer to liver cancer to melanoma.

You can see clearly here what happened. These are from the lung cancer mice. The black stain is cancer. Look at the difference when they’ve exercised. Across all five experiments, exercise reduced tumour growth by 60 to 70%.

Then when they looked inside the tumour cells, they saw this. The tumours of the exercising mice were chock-full of natural killer cells.

Now, that’s amazing. What is changing in the body through exercise that makes these natural killer cells more active, able to seek out the tumour and then attach to the tumour and destroy it?

The result would be striking enough, but the Danish researchers went much further. They were able to demonstrate how exercise did it. What sort of signal it was releasing to make the natural killer cells attack the cancer.

First signal: adrenaline.

Adrenaline produced during exercise activates the natural killer cells to be released into the bloodstream. They’re now primed for surveillance and looking for a target.

That information then comes via the muscles. Exercise causes muscles to release a chemical signal called interleukin 6. Interleukin 6 not only seeks out the tumour cells directly, informing them to cease and desist, it also tells the natural killer cells what to target.

There are many other physiological mechanisms involved, but this study shows so clearly exactly how exercise can upregulate the immune system and make it better at fighting cancer.

The exciting thing is that it’s actually the body generating its own chemotherapy, if you like. It’s generating its own anti-cancer drugs.

But is all exercise the same, or can some treat specific cancers better than others?

Lee has prostate cancer.

Well, I was put on an anti-testosterone drug that, of course, depleted my testosterone down to nothing. What normally happens there is, from a man’s perspective, you grow boobs, you put on weight, you become lethargic.

The problem with anti-androgen therapy, whilst it’s fantastic for slowing the progression of prostate cancer, it does have a lot of side effects. And one of the key ones is that it actually causes a dramatic loss of bone. And so these men rapidly become osteoporotic. They develop osteoporosis. So we had to do something to try and address that.

Seven years ago, Professor Newton’s team took a group of men who were on anti-androgen therapy and prescribed them three different types of exercise. One group of participants did aerobic exercise only. Another group did aerobic exercise plus resistance training. The third group did resistance work plus jumping impact training.

Lee was assigned this treatment.

So this was quite radical, to have men in their 70s and some in their 80s actually doing jumping, bounding and skipping.

I didn’t want to do it to start with. I thought, no thanks anyway. I decided that I’d go ahead and try it. It was the best thing I ever did.

Was that hard?

To everyone’s surprise, for the men who were doing aerobic and resistance, it didn’t help the osteoporosis at all. They still lost three percent of their bone mineral density in six months. But in the jumping group, the bone loss was prevented.

This is actually Lee. So this is his data. And what we see here, bone density is actually improved.

It gave me new lease of life. I met a whole bunch of fantastic people. I got healthy. I got fit. Probably the best thing that ever happened to me, getting cancer, as strange as that may sound.

It was only the combination of resistance exercise and the impact loading that totally obliterated the bone loss. So it was a world first and an outstanding outcome. It also showed clearly how important it is to know which exercise to prescribe for each condition.

The results of this study, presented at the Australasian Prostate Cancer Conference in 2011, were so significant they changed the national guidelines for prostate cancer treatment in the US and Australia.

Yeah, it was so positive. If we hadn’t have all gone on that journey, we would never have met.

The message where, as Natalie and her fellow survivors show, it does seem we’re on the cusp of a turning point. A shift away from some vague recommendation to exercise, toward a more sophisticated targeted exercise prescription for cancer patients.

And while Rob’s team will likely be one of the first in the world to publish their findings on exercise during cancer treatment, at least two other teams we’re aware of, in Sweden and Denmark, are running similar trials. There are also individual oncologists here who are starting to prescribe it, and more trials are underway of patients with different types and stages of cancer.

The evidence is so strong now that cancer patients deserve this medicine. It’s a very powerful medicine. It actually increases their survival and it has no side effects. So what we need now is for the medical and health professions to embrace it and actually make it an integral component of the overall management of the cancer patient.

Natalie, having just finally been given the all clear, can only agree.

I just know it did. I just know it helped. It helped me bounce back. It helped me get back on my feet quicker too. Yeah. Absolutely. It meant everything. I’m alive.

It is a great result for Natalie. However, at this point, we do need to stress this is a limited and ongoing scientific trial. Anyone with cancer should seek professional medical advice before embarking on an exercise program.

I’d advise someone with cancer who’d like to exercise, who doesn’t have access to a program such as this, find an exercise physiologist.

Hold on. When you have cancer, you need an exercise physiologist?

They know about the drugs and all the different things that can be going on in your life when you’re having serious chemotherapy.

And even after chemo is over, exercise can be crucial. As I experienced firsthand last year with my own partner, Robin Williams.

This is the day I dragged you into hospital.

Ah, not exactly Mr Atlas, really, is it?

Months after his treatment finished, Robin still wasn’t recovering from the fatigue and nerve damage. Until finally, he tracked down an exercise specialist, started his own targeted program, and turned things around.

That’s great. I’m working on...

When Robin first did this exercise, he was literally falling flat on his face. Weight training, treadmills, you name it. Boxing even.

I hadn’t done that since I was 13.

That’s way...

Everyone’s cancer experience is different, but appropriate exercise, before, during or after treatment, seems to substantially improve our odds.

And that’s two months later. The zombie rises. Long may the remission last.

Breast reconstruction is major surgery. It's important to allow your body time to heal. An important part of that healing process is introducing movement as soon as possible. The right type of movement will have a big impact on your recovery.

Some everyday activities could actually compromise your healing. It's important to know how to prepare your home environment and find other ways to perform tasks you might find difficult in the first weeks after surgery. This video will suggest some simple adjustments around the home that can make a big difference.

Good sleep is important to the healing process, but finding a comfortable position can be difficult. Position pillows so you're more upright in the bed. A higher or firmer bed, even a recliner chair, might make it easier to sleep. Using a pillow on the surgical side will stop you rolling and provide support for your affected arm.

Getting up from a lying position requires several slow movements. It's easier if you lie with your non-surgery breast nearest the side of the bed. Support your reconstruction by placing a small pillow under your armpit on the side of surgery, and put your arm across your chest.

Bend your knees, shift your pelvis to the side of the bed, and in one movement roll your knees over the side of the bed and push yourself up with your unaffected arm. For a double reconstruction, cross both arms across your chest.

Bend your knees, walk your feet to the side of the bed, then lower both legs to the ground. Reverse this movement to get into bed. It's a good idea to practise these manoeuvres prior to your surgery.

After surgery, you'll find a front-clasp bra and button-up shirts easier to get on and off because your shoulder movement will be restricted. When dressing, put your affected arm in first. Be careful not to pull on your drains.

In the first few weeks, the strength of your shoulder muscles will be limited. Do not pick children up. Get them to stand on a chair or bed so they're at your shoulder height. To shower, use a chair. It's safer and will make washing yourself much easier. To wash your hair, lean over your knees and tilt your head down. Stay seated in this position to also wash your feet. To dry or straighten your hair, sit down and again lean forward over your knees.

Remember, none of your activities should hurt or pull on your drains or stitches. It's important to check your wounds daily to ensure they're healing. Standing in front of a mirror is a good way to do this. Viewing them with your nurse or surgeon before leaving hospital can be helpful so you know what to look for. Taking photos is a good idea to help track any changes. If you're concerned, send a photo to your breast care nurse or surgeon.

Keep an eye on the fluid coming from your drains. It should become lighter in colour and consistency. After your drains are removed, there might still be some soft swelling and fluid. This is normal, but you should contact your surgical team if the swelling or your wounds become red-hot, hard, painful, or produce a discharge.

Before surgery, look around your home for items that you use often or that are heavy, and move them to below shoulder level. In the laundry, where possible, move appliances to a lower height. Use a stick or tongs to remove clothes. It's important that you don't lift heavy baskets. Consider a clothes rack. It's a better height than a clothesline.

When seated, you'll find that an upright chair is much easier to get up from than a low chair or lounge. For women who have had a reconstruction using tissue from their tummy, climbing stairs might be an issue. Walk up sideways with your back against the wall or handrail.

In the first two weeks at home, your activities should be interspersed with sufficient rest. Walking is ideal. It's important to do shoulder and circulation post-op exercises every day, four times a day. Balance your activity level to ensure you have sufficient energy to do these. When the balance of activity and rest is right, you'll feel a little better each day. Avoid the temptation to do too much too soon, and avoid any exercise or movement that pulls on your drains or stitches. If you feel that you are deteriorating day to day, contact your surgical team.

Effective pain management is also essential. Medication will allow you to get good sleep and perform your exercises. Both are vital for healing. Take pain relief around 20 minutes before exercise, and only as prescribed by your doctor. Writing out all your prescribed pain medication and ticking it off as you take it each day can help you avoid overmedicating or missing medication. Ideally, you should slowly wean off pain medication over the first few weeks, starting with the strongest pain medication. But if your pain is increasing or affecting your movement or sleep, contact your surgical team.

Avoid activities that may cause pain. Common activities that are painful are opening jars, chopping food, mopping, vacuuming, and pushing doors open. Check with your surgeon when you can drive.

You need a plan. You cannot go home and resume your normal duties and activities. Some forward planning will make those first weeks much easier. Stock the freezer with meals. Organise deliveries or shop online. Arrange home cleaning. Contact your local council for help. If you have small children, you'll need assistance for up to six weeks. Arrange transport. Community apps can help schedule getting children to activities and to appointments.

Ask for help. Family and friends need to be told how they can help. Designate tasks. If you live alone or have young children, arrange to have someone come and stay with you. Speak to your breast care nurse about any government-paid assistance programs for which you may be eligible.

The content of this video is a general guide only. Every surgery is different. It's recommended that you discuss your specific circumstances with your doctor first.

If you'd like, I can also lightly clean up the wording where the transcript seems inaccurate, such as "front class bra", "line position", and "some Forde planning".

Good evening and welcome to the final Breast Cancer Network Australia webcast for 2021. My name is Kirsten Pilatti, and it is fantastic to have you with us tonight.

Before we get underway, I would like to acknowledge the traditional owners of the land on which we all meet tonight. For us here, it is the Wurundjeri people from the Kulin Nation. I pay my respects to Elders past and present and acknowledge the emerging leaders who are making such a big difference in our network.

There is so much more we still must do for our First Peoples to ensure their breast cancer outcomes are just as good as those for non-Indigenous Australians. BCNA will not stop until we achieve equitable and accessible care for all Australians.

Tonight it is fantastic to have so many of you joining us to talk about a topic that many people do not discuss enough, and that is radiotherapy. We will cover early breast cancer and DCIS. We know that radiotherapy is an important part of the treatment plan.

Tonight we will talk about the benefits of radiotherapy, some of the side effects, and what developments are coming in the future. Most importantly, we will hear from some very skilled speakers who will help increase our knowledge and understanding of breast cancer treatment and radiotherapy.

I want to encourage you all to submit your questions. We will answer as many as we can tonight. You can also chat with each other through the chat function. If you want to remain anonymous, please make sure you tick that option when submitting your question.

We have some amazing speakers tonight. We are very lucky at BCNA to have so many specialists who are willing to share their expertise on topics that matter to you. Tonight we will hear from Associate Professor Jillian LaMore, Sue Manx, and Sophie Andrews.

Let us begin by hearing from Associate Professor Jillian LaMore. Jillian, could you introduce yourself and tell us about your experience in radiotherapy before we hand over to your presentation? Thank you for being with us tonight.

Thank you, KP. It is my absolute pleasure to participate in this forum. BCNA are absolute trailblazers in serving the support and information needs of breast cancer patients and their carers. It has been my privilege to be involved with BCNA over the last five years.

I hope my audio is clear as I introduce myself. I will let you give me a thumbs up if everything sounds okay.

My name is Jillian LaMore. I am a radiation oncologist at Royal North Shore Hospital here in Sydney. I am also a Clinical Associate Professor at the University of Sydney. In my private practice I work at the Mater Hospital, which is a GenesisCare facility.

I am also Director of the Genesis Foundation, one of the pillars of which is equitable access to cancer care for all.

Upfront I would like to declare some conflicts of interest. I am a visiting medical officer at GenesisCare at the Mater Hospital, as mentioned. I will also reference Prolio DX for those of you who have joined tonight, because the DCIS Decision RT assay has been rolled out in Australia through a global partnership with GenesisCare. I have no financial disclosures to declare.

It will be a busy 15 to 20 minutes with me, so I will give you an overview of what we will cover.

We will talk about the role of radiotherapy in early breast cancer and in DCIS. I know that among the participants tonight, a little over a quarter have experience with DCIS. This will therefore be an important part of our discussion, particularly regarding the emergence of new genomic assays such as Decision RT, which has been available in Australia since July.

I will also introduce some technological innovations, because radiotherapy is very much driven by technology and the resources we have available to improve outcomes. The aim is always to keep cancer control as high as possible while minimising effects on normal tissue.

I will also discuss hypofractionation, which means abbreviated or shorter radiotherapy schedules. These are now standard care across many stages of cancer.

Finally, I will briefly talk about the financial cost of radiotherapy and how this impacts patients in both the public and private systems.

You may already know that Australia, like many OECD countries, has one of the highest rates of breast cancer. The current statistic is that one in seven women will develop breast cancer or DCIS at some point in their lifetime.

The reassuring news is that survival rates are also increasing. For all stages of breast cancer, five year survival is now approximately 92 to 95 percent. An even more reassuring point is that Australia ranks at the top internationally for outcomes. While breast cancer is common, there is no better place to receive treatment than here in our country.

There is increasing demand for radiotherapy. This is partly due to the rising incidence of breast cancer and improved screening programs, which detect cancers earlier. Surgeons are also moving toward less invasive approaches. Radiotherapy often acts as an additional safeguard following surgery.

Radiotherapy is almost always recommended after a lumpectomy or breast conserving surgery. For DCIS, it is also commonly used after surgery. In some cases, radiotherapy may also be recommended after a mastectomy, especially when lymph nodes are involved or when the tumour is larger.

Radiotherapy uses high energy X rays delivered by machines called linear accelerators. These beams damage tumour DNA at a cellular level, preventing cancer cells from reproducing. Healthy cells can repair themselves between treatments, which is why radiotherapy is delivered in fractions over several sessions.

There are decades of evidence supporting lumpectomy followed by radiotherapy as being equivalent to mastectomy in many cases. Radiotherapy significantly reduces the risk of cancer returning.

We are also seeing advances in personalised medicine. Genomic tools are helping us identify which patients truly benefit from radiotherapy and which may safely avoid it.

For example, some genomic tests can estimate the likelihood of DCIS returning and whether radiotherapy will reduce that risk for an individual patient. These tools are not a simple yes or no decision maker, but they provide valuable information to guide treatment decisions.

Technological innovations are also improving radiotherapy delivery. One example is surface guidance technology, which allows treatment without permanent tattoos by using optical imaging systems.

Another important advancement is deep inspiration breath hold. This technique moves the heart away from the treatment area when treating the left breast, reducing radiation exposure to the heart.

Short term side effects of radiotherapy may include skin reactions, breast swelling, and fatigue. These effects usually resolve within a few weeks of treatment finishing.

Long term side effects are uncommon but can include changes in skin pigmentation, fibrosis, or very rarely effects on the heart, lungs, or development of a second cancer. Modern techniques have significantly reduced these risks.

Finally, it is important to consider financial costs. In the public system, radiotherapy is generally provided with no out of pocket cost. In the private system, Medicare typically covers around 70 to 80 percent of treatment costs, with patients paying the remaining gap.

Some centres offer transparent bundled costs to help patients understand their financial responsibilities before treatment begins.

I will stop there and look forward to answering your questions later in the session.

Thank you.