Radiotherapy tattoos could be a painful reminder of most cancers – however 3-D imaging may very well be the answer

Radiation therapy tattoos ensure that a patient is properly placed under the device. Photo credit: Mark_Kostich / Shutterstock

In the UK, over 150 women every day receive the devastating news that they have breast cancer. This is the beginning of a long journey of treatment, which usually includes surgery to remove the tumor – most likely followed by radiation therapy to the chest or chest wall. What many people may not realize, however, is that radiographers often use small permanent black ink tattoos to position a patient under the radiation therapy machine. These small tattoos are placed on the patient’s sternum and at points above the thorax. These tattoos, while small (about one to two millimeters in diameter), are permanent. The patient will have these tattoos for the rest of their life long after the surgical scars have faded.

The new technology, known as surface-guided radiation therapy (SGRT), uses three-dimensional imaging to help radiographers position patients and avoid tattoos. As part of the treatment planning, a 3D image is first recorded. This image is then used before each radiation therapy to ensure that the patient is in the correct position. This also means that patients without a tattoo can be positioned under the radiation therapy device. However, as with many new technologies, this can be costly.

Permanent ink

In the 1980s, it was common for patients receiving radiation therapy for breast cancer to be marked with semi-permanent ink. However, these can rub off on the patient’s clothing or while showering. If semi-permanent markings fade or need to be reapplied, the markings may be drawn differently, which can affect the accuracy of the radiation therapy. Concerns about the disappearance of these semi-permanent markings before the patient had completed all radiation therapy led to the gradual use of permanent tattoos as the standard. Most breast cancer patients currently use an average of three permanent tattoos for treatment.

However, in a study of over 300 women who were randomized to have either permanent tattoos or semi-permanent markings, no differences in accuracy were found between skin marking methods. When I was diagnosed with breast cancer in 2018 and had radiation therapy, I didn’t want permanent tattoos. I opted for a semi-permanent ink mark on my sternum that was covered with a waterproof bandage. Semi-permanent stains have the advantage that they disappear after the treatment is completed. However, their disadvantage is that they can wash off. This means that patients should be careful showering during the three to four weeks of treatment. Also, many patients are rarely given the option of receiving semi-permanent markings. By default, patients are tattooed.

Other skin marking methods have been tried including the use of ultraviolet tattoos which would only be visible in black light. These are not without drawbacks, as a recent experiment showed. The researchers found that UV tattoos were difficult to see on the two sub-Saharan patients with skin tones. UV tattoos can also be visible in bars or restaurants in black light, making it an undesirable option for many.

It has been shown that surface-guided radio therapy methods have better positioning accuracy than permanent tattoos. One study found that permanent tattoos required position corrections 28% of the time, compared with just 7.7% of the cases where surface-guided radiotherapy was used. Surface-guided radiotherapy also reduced the positioning time by an average of one minute and seven seconds per patient. Over the course of a day, this small time saving could mean that an additional four patients can be treated per radiation therapy device. This is important in that radiation therapy resources are limited.

Radiation therapy tattoos can be a painful memory of cancer - but 3-D imaging could be the solution
A similar permanent tattoo would be applied to the patient’s breastbones and rib cage. Photo credit: felipequeiroz / Shutterstock

Emotional experience

Most worrying, however, is the stress that tattoos can put on some women during what may be an already stressful treatment journey. In an online survey of breast cancer patients, 78% said they would choose treatment that did not require them to have skin spots or tattoos, even if that meant they had to travel further to receive radiation therapy.

As part of our ongoing research, we asked women who had had radiation therapy for their thoughts on getting tattoos. Women reported a range of different experiences, emotions, and knowledge about using tattoos. A couple of women didn’t mind having the tattoos. Others, however, often experienced a lack of choice, disempowerment, and recognition of the enormous scale of the cancer as this required permanent marking.

For me, a permanent tattoo in the center of my chest didn’t mean a permanent memory of the cancer. It was more about being able to get back into the clothes I always wore, going back to the gym, sunbathing on vacation, going to the spa without having to worry about getting a radiation therapy tattoo for others is visible for questions. Sometimes you don’t want to have to explain to curious people why you have a black dot on your chest, but just want to move on.

Surface-guided radiation therapy is a non-invasive technology that enables precise positioning of patients for breast cancer radiation therapy and does not leave permanent markers for cancer treatment. This gives many patients the opportunity to continue living after treatment is complete.

“Invisible tattoos” could improve the body’s self-confidence after breast cancer radiation therapy provided by The Conversation

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