What Should Lupus Patients Know About Radiation Treatment for Cancer and Elective Cosmetic Enhancement Procedures?


Doruk Erkan, MD, MPH

Doruk Erkan, MD, MPH

Associate Attending Rheumatologist, Hospital for Special Surgery
Associate Professor of Medicine, Weill Cornell Medical College
Associate Physician-Scientist, Barbara Volcker Center for Women and Rheumatic Disease

Michael D. Lockshin, MD

Michael D. Lockshin, MD

Attending Rheumatologist, Hospital for Special Surgery
Professor of Medicine, Weill Cornell Medical College
Director, Barbara Volcker Center for Women and Rheumatic Disease

Introduction

If you have lupus and also have cancer, you are apt to receive misinformation about your treatment options. If you wish to undergo a cosmetic enhancement procedure, from Botox injections to breast enlargement, receiving misinformation is also quite likely.

This brief review provides some correct information -- but also acknowledges that very little solid science is available to answer many questions.

Radiation Treatment for Cancer

Lupus, as well as other systemic autoimmune illnesses such as rheumatoid arthritis or scleroderma, are chronic, lifelong diseases. Although not unusually susceptible to develop cancer, some patients with rheumatic diseases, in natural course of events, do develop other illnesses such as breast cancer. 

To the surprise of patients and their rheumatologists, rheumatic disease patients who develop cancer are often told that they cannot receive radiation therapy, breast reconstruction, or certain kinds of chemotherapy because of their disease.

There is very little basis for these restrictions. Most papers on the topic do not show important complications resulting from radiation therapy in patients with systemic autoimmune diseases.(1, 2, 3, 4) A retrospective review published in 2008 speaks of a higher frequency (compared to patients without connective tissue diseases) of late complications - primarily intestinal perforation - in patients receiving radiation to the pelvis, possibly a result of long-term steroid and immunosuppressive therapy weakening this area.(5) However, in even this group of patients, the frequency of acute or late complications was low, and many factors that might have increased the complication rate could not be analyzed.

Ironically, radiation therapy was once touted as a treatment for lupus, rheumatoid arthritis, and ankylosing spondylitis.(6, 7) Rarely used today, it was abandoned because of long-term toxicity of radiation, but it was effective.

Since cancer treatment often involves chemotherapy, treatment of autoimmune illness with immunosuppressive drugs must be altered; generally the cancer chemotherapy also treats the lupus, so it is possible to withdraw most lupus treatment when a patient undergoes chemotherapy.

Chemotherapy regimens for cancer sometimes have to be modified for patients who have taken other chemotherapeutic agents for autoimmune disease, particularly cyclophosphamide. Aromatase inhibitors and other estrogen analogues usually cannot be used in patients with antiphospholipid antibodies since these agents are capable of inducing blood clotting, a considerable risk in such patients.

Cosmetic Enhancement Procedures

Breast reconstruction and implants

This issue involves two questions: 

  1. Is there a higher rate of complications in patients with rheumatic disease who receive breast reconstruction or implants?
  2. Do such procedures worsen the rheumatic disease?

Regarding the first question, there are no systematic studies, but the authors have personally cared for many such patients (whether the implants were done for elective cosmetic or post-cancer therapy) and none had unusual complications. Thus our personal experience suggests that there is no heightened risk for a woman to undertake such a procedure.

Regarding the second question, there was a concern in the 1990s that silicone breast implants led to the development of scleroderma, but a meta-analysis (combined analysis of all available studies) in 2000 demonstrated no association between silicone implants and any connective tissue disorders (8), a feeling shared by most physicians today. Furthermore, there is no evidence that disease worsens if implants are performed.

Hair dye

One study long ago found an association between hair dye and lupus (9, 10), but other systematic studies have not found this association.(11) For instance, in a recent 12-year longitudinal lupus case series, there was no difference in disease flares and activity between hair dye users and non-users.(12) 

Botulinum Toxin (Botox)

There are no reports of new onset lupus or flares of lupus following Botox (botulinum toxin) injection. Botox is a very dilute preparation of a powerful muscle poison that causes the potentially fatal neurologic disease, botulism, most often encountered from improperly canned foods. At cosmetic or treatment doses the toxin relaxes muscles, thus reducing the appearance of a frown on the forehead or relaxing muscle spasm in cases of migraine.

Surprisingly, literature about drugs available to doctors lists an interaction between Botox and hydroxychloroquine (Plaquenil). The report of the interaction apparently comes from an experiment published in 1982, in which a diaphragm muscle was removed from a rat and placed in a flask, and made to contract over the course of an experiment that lasted between 30 and 120 minutes.(13) The diaphragm was less paralyzed if a very high amount of hydroxychloroquine was also in the flask. This experiment probably has no relevance to patients at all. In the authors' experience, many patients have received Botox without complication.

Tattoos

Although discoid lupus skin lesions appearing directly on tattoos have been reported.( ) there is no evidence that tattoos trigger flares in lupus patients. However, patients considering getting a tattoo should think about both general risks (such as infection) and medication-related risk (such as immunosuppressive drugs slowing healing or blood thinners increasing the risk of bleeding).

Obviously, if a person has an active rash, it is not a good idea to get a tattoo when the skin is inflamed.

Body Piercing

Patients taking corticosteroids may have delayed healing, and are at higher risk for infection, after the piercing. However, pierced ears, navel rings, etc., are nearly universal in young women these days; the authors have not seen unusual complications from these procedures in patients with autoimmune illnesses.

Collagen injections, Restylane, and Other Fillers

No reliable information exists regarding these enhancements. Once thought to trigger autoimmunity and worsen existing autoimmune disease, these enhancements are widely used and have not convincingly made any patient known to the authors worse. Websites on these products refer to experiments conducted under the auspices of the Food and Drug Administration which have not shown unusual complications. These experiments have not been published in the formal medical literature.

References

1. Kontos M and Fentiman IS. Systemic lupus erythematosus and breast cancer. Breast J. 2008;14:81-86.

2. Ross JG, et al. Acute and late reactions to radiation therapy in patients with collagen vascular diseases. Cancer. 1993;71:3744-3752.

3. Morris MM and Powell SN. Irradiation in the setting of collagen vascular disease: acute and late complications. J Clin Oncol. 1997;15:2728-2735.

4. Phan C, et al. Matched-control retrospective study of the acute and late complications in patients with collagen vascular diseases treated with radiation therapy. Cancer J. 2003;9:461-466.

5. Lin A, et al. Toxicity of radiotherapy in patients with collagen vascular disease. Cancer. 2008;113:648-653.

6. Strober S, et al. Treatment of lupus nephritis with total lymphoid irradiation. Observations during a 12-79-month follow-up. Arthritis Rheum. 1988;31:850-858.

7. Tanay A, et al. Effect of total lymphoid irradiation on levels of serum autoantibodies in systemic lupus erythematosus and in rheumatoid arthritis. Arthritis Rheum. 1986;29:26-31.

8. Janowsky EC, et al. Meta-analyses of the relation between silicone breast implants and the risk of connective-tissue diseases. N Engl J Med. 2000;342:781-790.

9. Reidenberg MM. The chemical induction of systemic lupus erythematosus and lupus-like illnesses. Arthritis Rheum. 1981;24:1004-1009.

10. Hardy CJ, et al. Systemic lupus erythematosus and hair treatment: a large community based case-control study. Lupus. 1999;8:541-544.

11. Sánchez-Guerrero J, et al. Hair dye use and the risk of developing systemic lupus erythematosus. Arthritis Rheum. 1996;39:657-662.

12. Jiménez-Alonso J, et al. Hair dye treatment use and clinical course in patients with systemic lupus erythematosus and cutaneous lupus. Lupus. 2002;11:430-434.

13. Simpson LL. The interaction between aminoquinolines and presynaptically acting neurotoxins. J Phamacol Exp Ther. 1982;222:43-48.

14. Jolly M. Discoid lupus erythematosus after tattoo: Koebner phenomenon. Arthritis Rheum. 2005 ;53:627

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