With an empathetic face, she leaves an office in one of the corridors of the Santa Maria Hospital that nobody wants to cross – the Radiotherapy corridor.
She’s as reserved as she’s gentle. Vera Mendonça is now a specialist in Radiotherapy and says she’s a “daughter of this house;” she studied at the Faculty of Medicine of the University of Lisbon and she stayed at the Santa Maria Hospital were she specialised. While she was an intern and a new mother of twins – the first 2 out of a total of 6 children -, she chose Pneumology in her second year of general internship, but her experience in internal emergency room soon showed that it was not the right choice for her. It was a conversation with two of her best friends that aroused her curiosity to learn more about Radiotherapy. A department that didn’t have a central emergency room, was very innovative from the technological point of view, and offered more stable schedules for someone who was also a mother, was the choice she deems to have been the right one.
That’s when she met her tutor, Marília Jorge, who had always worked with breast cancer and Gynaecology; she wanted to stay with her in Pathology and that’s where she’s spent the last 8 years.
She’s at the emergency room one day a week, from 8 a.m. to 9 p.m.; there they receive patients from the hospital and referral areas and deal mainly with 3 clinical situations: the vena cava syndrome (obstruction of blood flow through the superior vena cava), bleeding (which stops with radiotherapy), and spinal cord compression (lesions and illnesses that put pressure on the spinal cord). Her role is to decide what dose of radiation to administer starting at 24-48h, single dose or divided into several days (with a smaller dose per fraction).
What brought us together to talk was the issue of breast cancer and what happens to a woman who undergoes radiotherapy. We were looking for simple questions for those who are faced with bad news for the first time and we realised that when we open doors with answers, everything seems to become less dark.

Please demystify radiotherapy for us.
Vera Mendonça: It’s one of the therapeutic modalities used to treat cancer. About 50% of cancer diseases are currently treated with radiotherapy. This treatment is associated with surgery, used as a single therapy, or associated with surgery and chemotherapy.

And how is radiotherapy applied?
Vera Mendonça: It’s applied using a machine known as linear accelerator; one of the great technological advances was the replacement of the cobalt pump by the linear accelerator, and it was from that point on, in the mid-1990s, that it was possible to do 3D radiotherapy; that’s because treatments are now being planned by CAT (in some Centres they are planned by RMI or PET – Positron-emission tomography, a nuclear medical imaging technique that uses molecules which include a radioactive component). The advancement in imaging techniques has also improved treatment planning, and that is a great advantage because we are able to irradiate our target organ more effectively and evaluate the doses of radiation that reach the organs at risk precisely because we design them individually.

When we do a treatment with radiations we are killing bad cells, of course, but we are also hitting healthy cells. In this difficult balance, is it still better to kill bad cells, even if you’re hitting good cells?
Vera Mendonça: Yes, of course; partly because the radiobiology of radiation treatments allows it, “healthy cells” are able to recover because radiation acts in a phase of the cell cycle in which malignant cells cannot recover from the damage that is done to their DNA, but benign cells can. And that’s why treatments are fractionated and we don’t give the full dose of radiation in a single day (with a few exceptions); we divide the radiation into several daily fractions, so cells can recover in the meantime. It’s 5 days of treatment, 2 days of rest. This break is very important to recover from damage.

We know there is collateral damage to the cells, but that’s on the inside. And on the outside, what happens to a patient subject to radiotherapy?
Vera Mendonça: They feel more tired, and that happens in general to patients who receive radiation. From the pathophysiological point of view there’s no specific reason for that. Maybe the fact that they come and go every day is exhausting, as these are curative treatments. The total dose is divided into small daily fractions, but they must come every working day. Currently we have more condensed breast treatment schemes that are equally effective in terms of local control and cosmetic outcome, and so instead of offering patients 5- or 6-week-long treatments, we are offering 3- to 4-week-long treatments, which means that we’re slightly increasing the dose per fraction. This has all been studied and confirmed, of course. But it’s important to note that even these women who undergo 3-week-long treatments mention fatigue. On the other hand, when it comes to toxicity, and according to the area we are dealing with, it’s a problem that emerges as the weeks go by; in the case of the breast, the skin will become progressively redder and wounds may appear. The degree of toxicity depends on the type of skin, hydration, adherence to the requested care, previous therapies, co-morbidities. These are ways to minimise cutaneous toxicity, which is the only one that the patient can see. We can’t see pulmonary or cardiac toxicity; we only detect it and diagnose it when there are complaints.

But if there are no obvious complaints, they will not undertake medical examinations to screen for collateral lesions, is that it?
Vera Mendonça: Yes, if there are no complaints we don’t conduct further tests to assess the surrounding toxicity. With regard to chronic cardiac toxicity, several international recommendations are being developed for the follow-up of patients irradiated for left-sided breast cancer.

Do patients stick to the recommendations they are given?
Vera Mendonça: In most cases; in the summer it’s a bit more difficult.

In the summer? Why?
Vera Mendonça: It has to do with clothes, because it’s not advisable to wear a bra directly on skin that is being irradiated on a daily basis. You should always wear a cotton sweater under your bra to minimise the risk of wound; elastics, lace, all of these can increase the risk of wound. With warmth patients feel more reluctant to adhere to this recommendation and therefore we see more grade-2 toxicity, perhaps because they’re less careful. In the winter we see mostly grade-1 toxicity, which is the same as an erythema, oedema, or pruritus on the breast.

Can you trace the profile of a woman with breast cancer?
Vera Mendonça: That’s an interesting question because this is an issued we discuss with oncologists. Of course there are exceptions, but I think that all cancer patients have a certain psychological profile; breast cancer patients also have a profile, and they are usually more anxious, some more depressed, generally more stressed women. Please note that this is not a label, and it doesn’t rely on any established evidence, but rather our perception of the sample we treat annually.

Can this speed up the disease process?
Vera Mendonça: In women who have experienced traumatic situations and were left with emotional damage, these can affect the disease, because they affect their immune system. On the other hand, each of us has a specific genetic profile, and that makes us more prone to certain diseases. And when all these intrinsic and extrinsic factors come together, “get in tune” and combine themselves, that’s when the disease reveals itself. So, I believe that in some cases the disease may actually be triggered by a life event. All these women often mention this, you know, the fact that they believe they experienced stressful situations at home or at work, which may have been responsible for triggering the disease. And many of them – some who are still very young, they are 30/40 years old and have breast cancer – say “I’ve always been healthy, I don’t smoke, I don’t drink, I even exercise, why did this happen to me?”

And why did it happen to them?
Vera Mendonça: I don’t think anyone can answer that. Because there’s genetic cancer and non-genetic cancer, and most of the cancer is not genetic; the disease happens when all the factors, both extrinsic and intrinsic, come together in the same person. According to literature, it’s a multifactorial question.

If it’s not genetic, is it worth investing in prevention?
Vera Mendonça: Of course, because the earlier we find it, the better the prognosis. There’s a difference in finding a stage-1 tumour or a stage-3 tumour, because that has a great impact on survival.

But, in preventive exams, don’t you receive signs from the body saying “hold on, there might be a disease here?”
Vera Mendonça: No, we don’t. We can’t predict it.

Is breast cancer as aggressive in an 80-year-old woman as in a 40-year-old woman? In other words, do cancer cells slow down as metabolism slows down?
Vera Mendonça: It depends on the biology of the tumour. We’ve had cases of patients over 80 whose breast cancer had an aggressive biological profile. The problem is that, because many of them have several co-morbidities (quantification of various diseases), that forces us to exclude some therapeutic modalities. As treatment we have radiotherapy, surgery and hormone therapy (chemotherapy and immunotherapy are used in selected cases), for women who are hormone-dependent and have a better prognosis; for the triple negative profile we have fewer therapeutic options. We have to adjust the treatment to the patient we have before us.

I know that you’re a doctor and you’re used to dealing with this reality every day, but you’re also a woman. Do you struggle with this disease as a woman, or can you filter this reality and don’t allow these issues to affect you?
Vera Mendonça As time goes by, we manage to stand more and more on the side, but at the same time we have a different bond with the patient. I’m able to see past the disease but, at the same time, I try walking in the patient’s shoes. I try to understand what she’s feeling and establish an emotional relationship. To get more of them, we also have to give them more. Breast cancer patients need to be emotionally touched in order to better correspond to what we ask of them next. Radiation frightens them, but when their doubts have been cleared, they are calmer and less afraid of toxicity.

Is there still room for advancements in radiotherapy?
Vera Mendonça: Of course, imaging techniques are constantly evolving and each time they do we can offer more possibilities to the patients. Planning associated with the technological evolution of the treatment has been amazing.

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After all, walking across the corridors of a Hospital as huge as Santa Maria may not be as terrifying as we’d imagined, as if we were terrified children in the dark, facing the unknown.
Trusting in the physician we have before us and in therapeutic and technological progress may be the second most important tool to overcome a disease such as breast cancer.
Because the first of all is the inner confidence that every woman must grasp and never want to give up.
And if, along the rockiest road, you receive the news that you have cancer, when you find a physician like Vera Mendonça you can be sure that the odds are more in your favour.