Radiotherapy.
Dr. Sayeed Ahmad D. I. Hom. (London)

 

What is radiotherapy?

Since the discovery of x-rays over one hundred years ago, radiation has been used increasingly in medicine, both to help with diagnosis (by taking pictures with x-rays), and as a treatment (radiotherapy). While radiation obviously has to be used with care, doctors and radiographers have great experience in its use in medicine.

Radiotherapy treatment can cure some cancers and can reduce the chance of a cancer coming back after surgery, but can cause side effects. It can be used to reduce cancer symptoms.

The benefits and possible side effects are discussed in detail below.

Radiotherapy is the use of x-rays and similar rays (such as photons) to treat disease.

Many people with cancer will have radiotherapy as part of their treatment. This can be given either as external radiotherapy from outside the body, using x-rays or cobalt irradiation, or from within the body as internal radiotherapy.

Radiotherapy works by destroying the cancer cells in the treated area. Although normal cells are also sometimes damaged by the radiotherapy, they can repair themselves more effectively.

 

Effect of radiotherapy on fertility

Most radiotherapy treatment has no effect on your ability to enjoy sex or to have children. Many healthy babies have been born to parents who have had radiotherapy, and the risk of having an abnormal baby is not increased if you have had treatment in the past. Many specialists recommend that women wait for about two years after having radiotherapy before trying to get pregnant, to give the body a chance to get over the effects of the cancer and its treatment. However, where the ovaries cannot be excluded from the radiation field, temporary or permanent infertility (inability to have children) is likely.

In men, sperm production can be reduced if the testicles are in the area being treated, and this can lead to temporary or permanent infertility. Fortunately, it is usually possible to avoid giving radiotherapy to the testicles in the cancers that are most common in younger men. Radiotherapy for prostate or bladder cancers is likely to cause permanently low sperm counts.

Before you have radiotherapy, your specialist will discuss the possibility that it may lead to infertility with you, and will normally ask you to sign a form consenting to treatment. Understandably, this can be a traumatic time, particularly for young people who were planning to have children. If you have a partner, he or she will be encouraged to join in this meeting, giving both of you a chance to express any fears or worries you may have, and talk them through.

Sometimes, it may be possible for men to store sperm before they have their radiotherapy. The sperm are frozen and can be stored for several years until a couple is ready to have children. This is known as sperm banking. It is now sometimes possible to store a woman's eggs as well, although this is still at a very early, experimental stage and not widely available. You should use a reliable method of contraception throughout your treatment.

Even if your treatment is likely to make you infertile, you may be strongly advised to use a form of birth control. If pregnancy occurs during or shortly after radiotherapy, there might be a slight possibility of damage to the baby. It isn't easy to come to terms with the prospect of infertility, or any of the side effects of your treatment. It can take a while for you to sort out your emotions and be able to talk about them. When you are ready, it may be helpful to talk openly to your partner or a friend about these feelings. If they can understand how you feel it is often easier for them to offer help and support.

 

Sexuality

For women

External and internal radiotherapy to the pelvis usually affects the function of the ovaries. Radiotherapy to the ovaries will cause the menopause. This may happen gradually over a few months. The normal signs of the menopause will develop, such as hot flushes, dry skin and dryness in the vagina. This can be very distressing, particularly for younger women who are not prepared for the menopause. Depending on your type of tumour, your doctor may prescribe hormone replacement therapy, which can help to overcome these problems. Occasionally -- for example, when treating some types of cancer called lymphomas - the ovaries may be moved out of the treatment area by an operation before radiotherapy begins.

Radiotherapy to the vaginal area can occasionally cause the vagina to become narrower. The radiotherapy staff will show you how to use vaginal dilators and a lubricant to keep the vagina supple once you have finished treatment.

At first you may find sex uncomfortable, and it may be helpful to use a lubricant such as KY jelly, which you can buy at your local chemist. Regular sex may help to prevent narrowing of the vagina, but many women will not feel ready to return to a regular sex life while they are experiencing the side effects of radiotherapy. This is very natural; your interest in sex will usually return as the effects of the treatment wear off, and in the meantime, using a dilator will be an effective way of keeping your vagina healthy.

It may help to talk over your fears and worries with your partner, and the radiotherapy staff, if you are having problems. Although it can be embarrassing to talk to the hospital staff about such intimate things, remember that they are used to dealing with these issues and can suggest things that will help you.

 

For men

Men who have radiotherapy may experience some problems with sex. It may be that you have lost interest in sex or become temporarily impotent because of your anxiety about your illness, or worries about the future, or because the treatment is making you too tired to think about sex. These effects may last for a few weeks after radiotherapy has finished, and can be very distressing.

Talking openly to your partner about your problems may help, and you can ask the radiotherapy staff about any problems.

Radiotherapy to the pelvis -- for example, to treat bladder or prostate -- may cause impotence (inability to have an erection). This side effect may develop months or years after your radiotherapy is finished.

 

Contraception.

It is very important for women of childbearing age to use effective contraception throughout their radiotherapy treatment. Radiotherapy could cause a miscarriage or cause a child to be born with abnormalities. If you think that you may be pregnant when you are told that you are to have radiotherapy treatment it is extremely important to let your clinical oncologist know. The oncologist will discuss with you whether the treatment can be delayed until the baby is born.

If appropriate, you should use a reliable method of contraception throughout your treatment.

 

Internal radiotherapy

Internal radiotherapy is used mainly to treat cancers in the head and neck area, the cervix, the womb, the prostate gland or the skin.

Treatment is given in one of two ways: either by putting solid radioactive material (the source) close to or inside the tumour for a limited period of time, or by using a radioactive liquid, which the patient takes either as a drink or as an injection into a vein.

If you have internal radiotherapy, you may have to stay in hospital for a few days and some

special precautions will have to be taken while the radioactive material is in place in your body. Once the treatment is over there is no risk of exposing your family or friends to radiation.

The process of putting solid radioactive material close to or inside the tumour is called brachytherapy.

Giving a radioactive liquid, either as a drink, a capsule, or as an injection into a vein is called radioisotope treatment. Your specialist will discuss your particular treatment with you.

Before having your treatment you will be asked to sign a form to say that you give your permission (consent).

 

What safety measures are taken with your treatment?

Because of the possibility of unnecessary radiation exposure to the hospital staff and your friends and relatives, certain safety measures are taken while you are being treated with the radioactive source, or after you have been given a liquid radioisotope. Depending on the type of treatment you are receiving, this means the restrictions may be needed for a few days. But sometimes they are only needed for a few minutes.

The staff looking after you will explain these restrictions to you in more detail before you start your treatment. Each hospital has different routines, and it is worth visiting beforehand to discuss what will happen with the nursing and medical staff.

You may be admitted to the ward the day before your treatment so the staff can go over the procedure with you. This is a good time to ask questions and it may help to make a list beforehand so you don't forget something important.

 

While the radioactive source is in place, or after treatment with a liquid radioisotope:

" You will probably be nursed in a side room, away from the main ward.
" You may be nursed alone or with someone else having similar treatment.
" Lead screens may be placed on either side of your bed to absorb any radiation that is given out.
" The doctors and staff on the ward will only stay in your room for short periods at a time.
" Staff and visitors will be asked to stand away from your bed to reduce their exposure to the rays.
" An instrument called a Geiger counter can be used to monitor the level of radiation in the room. The nurses may wear a small counter.
" Visitors will be restricted, and only allowed to stay in the room or sit at the end of the bed for a short time, if at all. Visitors will be able to talk to you from outside the room through an intercom.
" Children and women who are pregnant will not be allowed to visit.

These precautions can make you feel very isolated, in addition to the fears you may already have about your treatment. People are different in the way they handle their fears; some find it easier to know everything about their treatment, while others prefer to know as little as possible. If you want any explanations the staff on the ward will be happy to help you. It often helps to bring any fears or worries you have into the open by talking to the staff or to family and friends. You will probably only be in the single room for a short time, sometimes only one or two days. You can bring books and magazines into your room, watch TV or listen to the radio.

If you are being treated with a radioactive source, the safety measures are only necessary while it is in place. Before and after your treatment, your visitors can come at normal visiting times.

Some people worry that they will remain radioactive once the treatment is over, and be dangerous to their family and friends. If you have been treated with a radioactive source, this is not so.

As soon as the radioactive source has been removed, all traces of radiation disappear.

If you have been given a liquid treatment, however, the radioactivity will disappear gradually. Before you leave hospital the staff will check that most of the radioactivity in your body has gone, and that your belongings are free of any signs of radioactivity. After you leave hospital you should be able to carry on your life almost as normal, but there may be a few restrictions about meeting people - especially children and pregnant women - for a few more days.

Caesium insertion

This type of internal radiotherapy treatment is used for treating cancer of the cervix, uterus or vagina. The radioactive source most commonly used is called caesium-137. The advantage of caesium insertion treatment is that it gives a high dose of radiotherapy directly to the tumour, but gives a low dose to normal tissues.

The caesium source has to be put inside an applicator (there may be more than one) to keep it in place. The applicator, is inserted into the vagina, while you are under a general an�sthetic or sedation in the operating room. At the same time, a flexible tube called a urinary catheter may be put into your bladder to drain off urine. This means you don't have to get on and off bedpans and risk moving the applicators. Once the applicators are in place an X-ray will be taken to check they are in the correct position. Sometimes the radioactive source is put into the applicator while you are in the operating room, but more commonly it will be put in place once you are back on the ward. You may hear this referred to as 'afterloading'.

The applicators are kept in place by a pack (cotton/gauze padding) inside your vagina. This can be uncomfortable and you may need to ask your nurse for regular painkillers.

Once the source is put into the applicators you have to stay in bed. This helps to keep them in the correct position. If you need anything, you can call a member of staff by using the call bell by your bed. If the source does get dislodged, you should call the staff on the ward immediately.

 

Curitron/Selectron machine

In some hospitals a machine, which may be called a Curitron or Selectron or similar name, is used to put the radioactive material into the applicators. The machine is attached by tubes to the applicators. When the machine is switched on it passes small radioactive sources into the applicators. If the machine is switched off, the source is pulled back inside the machine. The machine is kept switched on throughout your treatment, except when someone needs to go into your room. It can then be turned off, so reducing their exposure to the rays. However, safety measures and visiting restrictions are still necessary. The time you spend on the machine varies but it is usually between 12 and 48 hours.

 

Microselectron

Sometimes a machine called a Microselectron can be used to give internal radiotherapy. This gives the radiotherapy more quickly, so the treatments last for only a few minutes and you can go home the same day.

After the treatment

Once you have received your dose of radiation the sources and the applicators will be removed. This is usually done on the ward. As it can be a little uncomfortable, you will be offered some painkillers beforehand. Sometimes a few breaths of the gas Entonox will help you to relax. The staff on the ward check that all the applicators and sources have been removed. Your catheter may be removed at the same time.

Your doctor may suggest you use vaginal douches for a few days after the insertion has been removed to keep the vagina clean. Your nurse will show you how to use these.

You will probably be able to go home the same, or the following, day. Once the radioactive sources are removed, all traces of radioactivity will immediately disappear.

 

Side effects

Many women will be treated with both internal and external radiotherapy to ensure the area is treated in the most effective way.

There is a slight risk of infection following caesium insertion but this is very rare. If you do develop a high temperature or heavy bleeding after your treatment you should contact your doctor as soon as possible. You will be prescribed antibiotics to deal with the infection.

 

Caesium or iridium implants

These can be used to treat a number of tumours including those in the mouth, lip and breast. Very fine needles, wires or tubes carry the radioactive source, and are inserted while you are in the operating room under a general an�sthetic.

An X-ray may be taken to ensure that they are in the correct position. You will be nursed in a separate room, and safety measures will be applied until the wires are removed, usually between three and eight days. Sometime this is done under general an�sthetic.

Implants in the mouth can be uncomfortable, and can make eating and talking difficult. A soft or liquid diet may be necessary while the needles are in place. Your nurse will show you how to keep your mouth clean, using regular mouthwashes. If eating is a problem you may be fed through a thin tube (nasogastric tube) which is passed via your nose and into your stomach.

The implant is removed once the correct dose of radiation has been received. This may be after two days, if the treatment is given as a booster after external treatment, or up to one week if given as the only form of treatment.

Once the implant has been removed the area will feel sore for up to two or three weeks afterwards. Your specialist will prescribe pain killers that you can take regularly until this improves.

Radioactive seed implants are occasionally used to treat small tumours of the prostate gland.

 

Radioactive isotopes

These are given as liquids, either through the mouth (in capsules or as a drink) or by injection into a vein (called an intravenous injection). The commonest form of radioisotope treatment is radio-iodine. It is used to treat tumours of the thyroid gland, and is given in the form of an odourless and colourless drink.

The same safety precautions will be taken with this type of treatment as with implants.

Any radio-iodine which is not absorbed by your thyroid will be passed from the body in sweat and urine. You should drink plenty of fluids during your treatment as this helps to flush the iodine out of the body. The amount of radiation in your body will be checked regularly and as soon as it falls to a safe level, after about four to seven days, you will be able to go home. You may need to take some special precautions for a short time after going home - particularly with young children and pregnant women. The hospital staff will explain these to you.

Radioisotope treatment can also be given when certain types of cancer have spread to the bones (secondary cancer in the bone). A radioisotope is injected into a vein and this is normally given as an out-patient. Before you go home you will be given some simple advice to follow as your urine and blood are slightly radioactive for a few days.

 

Side effects of external radiotherapy to specific areas of the body

This section deals with the side effects of radiotherapy to different areas of the body:

" the head and neck
" the chest area
" the stomach and pelvis area.

As radiotherapy treats only the affected area of the body, you only need to read the section that relates to your treatment area

 

Radiotherapy to the head and neck

Radiotherapy to the mouth can make you more likely to get tooth decay and you will need more frequent check-ups at the dentist. Fluoride treatment can often help to protect your teeth against the effects of radiotherapy, and your clinical oncologist may refer you for special dental treatment before your radiotherapy starts.

Gently brushing your teeth with a soft toothbrush and fluoride toothpaste as many as five or six times a day will help. It is important to tell your dentist that you have had radiotherapy before having any dental work later on.

 

Radiotherapy to the chest (thorax)

Difficulty in swallowing

About two to three weeks (but sometimes only a few days) after the radiotherapy to this area has started, you might notice that your chest feels tight, which makes it difficult to swallow solid foods. This is a common reaction to treatment. It may help to try a soft, plain diet supplemented by high-calorie drinks such as Build-Up and Complain. By trying different foods, you will find out which ones are easiest to swallow. Your specialist may prescribe painkillers or liquid medicines (such as Asilone, Maalox or Altacite plus) to be taken before meals to make eating less uncomfortable. The discomfort will usually get better on its own in about five to eight weeks.

Feeling sick

Some people find that their treatment makes them feel sick, and sometimes they may actually be sick. This is most common when the treatment area is near the stomach. Your specialist will prescribe anti-sickness drugs (called anti-emetics) if this happens. These drugs are also commonly provided to prevent nausea (feeling sick) and vomiting, if the specialist thinks this is likely, and are usually very successful.

Tell your specialist if you have any nausea or vomiting, and remember that it usually stops once treatment is over.

Weight loss

If you are having problems with eating or sickness you may begin to lose weight. This can make you feel tired and weak. At times you may not feel like eating. The dietitian or your specialist will be able to give you advice if eating is a problem.

Breathlessness

After radiotherapy to the chest you may notice that you develop a dry cough and breathlessness. This side effect may not occur until several months after your treatment. Whenever it happens you should report it to your doctor who may treat it with a course of steroids and possibly antibiotics.

It is important to let your doctor know if you notice any changes in your breathing at any time during and after your treatment.

 

Radiotherapy to the stomach and pelvis

Diarrh�a

Diarrh�a is a fairly common side effect of treatment to this area, and stomach cramps and wind may also occur. Your specialist can prescribe anti-diarrh�a drugs for you. If a large area of the abdomen or pelvis is being treated you may be advised to drink lots of fluid. You will normally be advised to eat a normal healthy diet, and to take the anti-diarrh�a drugs as prescribed by your doctor. The diarrh�a may continue for some weeks after your treatment. As well as being unpleasant, diarrh�a can make you feel weak and tired. Don't hesitate to contact the radiotherapy department or your doctor if it doesn't seem to be getting any better.

Discomfort around the back passage

The rectum (back passage) may become irritated by the radiotherapy if the area being treated is in the lower pelvis, such as in prostate or bladder cancer. If this is likely you may be advised to follow a high-fibre diet to avoid becoming constipated as this can worsen the irritation of the back passage (proctitis). Piles may also become more irritating, and local an�sthetic, steroid creams or suppositories may be prescribed to ease this discomfort.

Sometimes, after radiotherapy to the pelvic area, there may be a mucus discharge or some bleeding from the back passage. Let your specialist know if you have any of these problems.

Feeling sick

Some people find that their treatment makes them feel sick and they may actually be sick. Your specialist can prescribe anti-sickness drugs (called anti-emetics) for you. Any feeling of sickness usually stops once your treatment is over.

Loss of appetite and weight loss

These side effects may occur as a result of diarrh�a and nausea. At times you may not feel like eating, and the idea of preparing food may make you feel sick. If you can, ask someone else to prepare your meals for you. You may find it easier to eat little and often - having small, more frequent meals or snacks rather than conventional larger meals at set times.

Food supplements such as Build-Up and Complain can be used in place of meals to add necessary calories. The dietitian or your specialist will be pleased to advise if eating becomes a problem for you.

Occasionally, if your weight continues to fall, it may be necessary for you to spend a short time in hospital so that you can be fed in alternative ways. Liquid food can be given intravenously (into a vein) or by a tube through your nose and into your stomach (a nasogastric tube) until you are able to eat properly again.

Pain while passing urine

Inflammation of the bladder, known as cystitis, may develop during radiotherapy to the lower abdomen, usually after several treatments have been given. You may notice a burning sensation or discomfort when you pass urine and feel that you need to pass water more often than usual, including during the night. Increasing the amount of fluid that you drink will help to relieve these symptoms, but try to avoid coffee, tea, alcohol and acidic fruit juices such as orange juice, as these irritate the bladder and will make the symptoms worse. Some people find that cranberry juice or lemon barley water help to reduce the symptoms. If necessary, medicines may be given to treat these symptoms. You may also have your urine checked regularly to make sure there is no infection.

 

General side effects

While radiotherapy can destroy cancer cells, it can also have an effect on some of the surrounding normal cells. The side effects that may occur are described below. It is important to remember that no person will have more than a few of them, and for many people they may be very mild.

As radiotherapy affects people in different ways, it is difficult to predict exactly how you will react to your treatment. Before you start your treatment the staff will discuss with you any likely side effects of the particular treatment you are having, and can give tips on how to deal with them and how they can be treated. Being aware of side effects in advance can help you to cope with any problems that arise.

Most side effects of radiotherapy disappear gradually once the course of treatment is over. However, side effects may continue for a few weeks.

Tiredness

You may find that you feel very tired during your radiotherapy. This can often be made worse by having to travel to your treatment each day. Listen to your body, and if necessary, allow yourself extra time to rest, perhaps by taking a nap in the afternoons. It may help if you spread chores out over the week, sit down to do them, wherever possible, and accept any offers of help. Tiredness can be a problem for some months after your treatment has finished.

Eating and drinking

As always during treatment of any kind, it is important to maintain a healthy diet and drink plenty of fluids. At times you probably won't feel like eating, or you may find that your eating habits change. It may be easier to have small snacks throughout the day rather than large meals. It is not unusual to lose a little weight during radiotherapy, but if you are having any problems with eating it is important to tell the radiotherapy staff. They can arrange for you to talk to the dietitian.

Changes in your blood

Radiotherapy to some parts of the body can sometimes affect bone marrow, which produces the different types of blood cells. If this is thought likely to happen in your case you will have regular blood tests during your treatment to check your blood counts (the number of cells in your blood). If your blood counts are low, you may feel tired and `run down'. If your blood count becomes very low (which is unlikely), it may be necessary to have a short rest from treatment so that your blood cell level can return to normal. You may also need to have a blood transfusion.

It is very important to let your doctors know if you feel very unwell, or if your temperature goes above 38�C (100.4�F), or if you start feeling cold and shaky.

Skin care

Some people develop a skin reaction, similar to sunburn, while having external radiotherapy. This normally happens after three to four weeks. People with pale skin may find that the skin in the treatment area becomes red and sore or itchy. People with darker skin may find that their skin becomes darker and can have a blue or black tinge. The amount of the reaction depends on the area being treated and the individual person's skin. Some people have no skin problems at all. Your radiographers will be looking for these reactions but you should also let them know as soon as you feel any soreness.

Do not apply creams or dressings unless they have been prescribed or recommended by your specialist.

Occasionally, if the skin reaction is severe, your treatment may have to be delayed for a short time to allow the area to recover.

Staff at your radiotherapy department will be able to give you advice on how to look after the skin in the area that is being treated. The care of the skin varies according to the part of the body that is being treated and the dose of radiotherapy that the skin is receiving. You may be asked not to wash the treatment area at all while you are having treatment. Alternatively, you may be advised to use only tepid water to wash the area (and not to soak too long in the bath), and then to dry it by patting gently with a soft towel. Instead you could dry your skin with a hairdryer on the coolest setting. Do not rub the area as this may make it sore.

Soaps, talcs, deodorants and perfumes may also make your skin sore and should not be used. The staff at the hospital may suggest that you gently apply simple moisturisers, such as E45 cream or aqueous cream, to the area. After your treatment, simple soap and simple moisturisers are often recommended. Aloe vera cream or arnica cream can sometimes help the skin to heal. Always check with the radiotherapy staff before applying anything to your skin.

It is very important that any marks put on your skin to mark the treatment area are not removed. If the marks do fade or disappear, do not try to replace them yourself but let the radiotherapy staff know.

Men who are having radiotherapy to the head and neck should use an electric razor, rather than wet-shaving.

These restrictions apply only to the treatment area, and the rest of your skin can be treated normally. Your skin may peel after the redness has faded, but it should heal quickly. Skin reactions usually settle down two to four weeks after the treatment has finished, but the skin area may remain slightly darker than the surrounding skin.

Avoiding the sun

Because the treated area is so sensitive it should not be exposed to the sun or cold winds. If you are having radiotherapy to the head or neck, try wearing a silk or cotton scarf when you go outside.

It is very important to cover the treated area if you go out in strong sunshine for at least the first year after your radiotherapy. Wear clothing made of cotton or natural fibers which have a closer weave and offer more protection against the sun. Even after this time the skin will be more delicate, so extra care should be taken. Use a sun-screen (of at least factor 15) and wear a hat and a long-sleeved shirt. It is important to remember that you can burn even through clothing if you are out in hot sun for a long time.

You can swim as soon as any skin reaction has settled down, usually within a month of finishing treatment. But if you are swimming out of doors, do not stay in the water too long, and do not forget to use a waterproof sunblock.

Clothing

Loose-fitting clothes, preferably in natural fibers rather than man-made materials, are more comfortable and less irritating to the skin. If you are having radiotherapy to your neck you should avoid tight collars and ties.

Shoulder straps and bra straps can also cause irritation if they are rubbing treated skin. If your breast area is being treated, you may be more comfortable not wearing a bra or wearing a cropped top or vest.

Smoking

Stopping smoking during and after radiotherapy is very worthwhile. Research has shown that it may make the radiotherapy more effective as well as reducing the side effects. It will also improve your general health and reduce your risk of developing other cancers. Stopping smoking or even cutting down at such a stressful time can be very difficult, but do your best. If you want help or advice talk to your specialist.

 

External beam radiotherapy

About your treatment

External radiotherapy is normally given as a series of short daily treatments in the radiotherapy department, using equipment similar to a large x-ray machine.

The treatments are usually given from Monday to Friday, leaving patients to rest at the weekend. Each treatment is called a fraction. Giving the treatment in fractions ensures that less damage is done to normal cells than to cancer cells. The damage to normal cells is mainly temporary, but is the reason why radiotherapy has some side effects.

The number of treatments you have depends on several factors, including:

" your general health
" the site and type of cancer being treated
" whether or not you have had, or are going to have, surgery, chemotherapy or hormonal therapy as part of your treatment.

For these reasons, treatment is planned for each patient individually, and even people with the same type of cancer may have different treatments.

External radiotherapy does not make you radioactive, and it is perfectly safe for you to be with other people, including children, throughout your treatment.

A course of curative (radical) treatment may be given every weekday from two to six weeks. Instead of having one treatment a day or having a rest at the weekend, some people will have different treatment plans. They may have more than one treatment a day or treatment every day for two weeks. Giving radiotherapy in this way is known as continuous hyperfractionated radiotherapy (often called CHART). Sometimes treatment may be given on only three days each week (for example, on Mondays, Wednesdays and Fridays).

Palliative treatment (for symptom control) may involve only one or two sessions of treatment, or up to five sessions.

The different types of radiotherapy machine work in slightly different ways. Some are better for treating cancers near the surface of the skin, while others work best on cancers deeper in the body.

The type of radiotherapy machine used will be carefully chosen by your specialist and physicist to give you the most appropriate treatment. Some machines are quicker than others and may give treatment in a very short time, such as a few seconds. Usually, radiotherapy treatment (including the time taken to position you) takes 10-15 minutes or less, on any machine.

The radiotherapy machine does not normally touch you and the treatment itself is painless, although it may gradually cause some uncomfortable side effects. If you have a specific type of radiotherapy known as electron treatment, a small applicator may be used, which touches a small area of skin.

People react to radiotherapy in different ways: some find that they can carry on working, taking time off for their treatment, while others find it too tiring and prefer to stay at home. If you have a family to look after, you may find that you need extra help. Don't be afraid to ask for help, whether it's from your employer, family or friends, social services, or the staff in the radiotherapy department. As your treatment progresses, you will have a better idea of how it makes you feel so you can make any necessary changes to your daily life.

The radiotherapy staff will try to give you an appointment for the same time each day. This gives your body a chance to recover from any side effects between treatments and also allows you to get into a daily routine.

 

Getting to your appointment

If you have to do a lot of traveling each day to get to your appointment you may feel very tired, particularly if you are feeling some side effects from your treatment.

If the treatment makes you feel tired, you could ask a family member or friend to drive you to the hospital, or ask for hospital transport if friends or family cannot easily drive you there.

If you rely on your own or public transport you can usually arrange an appointment which suits both you and the radiographers. Some hospitals provide transport, and if necessary, this can be arranged for you by the radiotherapy staff. Some local support groups and charities also provide hospital transport. If transport is very difficult, or you live a long way from the hospital, you may need to be admitted to the ward, or a hostel ward in the hospital or nearby.

Giving your consent

Before you have your radiotherapy treatment, you will be asked to sign a form saying that you give your permission (consent) for the hospital staff to give you the treatment. No medical treatment can be given without your consent, and before you are asked to sign the form you should have been given full information about:

" the type and extent of the radiotherapy you are advised to have
" the advantages and disadvantages of the treatment
" any possible alternative treatments that may be available
" any significant risks or side effects of the radiotherapy

If you do not understand what you have been told, let the staff know straight away so that they can explain again. Some radiotherapy treatments are complex, so it is not unusual for people to need several explanations.

It is often a good idea to have a friend or relative with you when the treatment is explained, to help you recall the discussion more fully. You may also find it useful to write down a list of questions before you go for your appointment.

People often feel that the hospital staff are too busy to answer their questions, but it is important for you to be aware of how the treatment is likely to affect you and the staff should be willing to make time for you to ask questions.

You can always ask for more time to decide about the treatment, if you feel that you can't make a decision when it is first explained to you. You are also free to choose not to have the treatment, and the staff can explain what may happen if you do not have it.

You can also change your mind and stop the treatment at any time, even if you have signed a consent form. It is important to tell a doctor, or the nurse in charge, immediately so that he or she can record your decision in your medical notes. You do not have to give a reason for not wanting to have treatment, but it can be helpful to let the staff know your concerns so that they can give you the best advice.

It is true that the hospital staff are busy, but the more you understand about your treatment, the easier it is for you and them.

 

Planning your treatment

Your first appointment at the radiotherapy department will be a planning session. This is a very important part of your treatment, as the results of this session will be used to finalise your treatment plan. Radiotherapy treatment is planned very carefully to ensure that the x-rays are aimed precisely at the cancer and cause minimal damage to surrounding healthy tissues. It is important for you to feel that you are involved in your treatment, so feel free to ask as many questions as you like.

Your specialist may plan your treatment by drawing temporary ink markings directly onto your skin. Alternatively, you may need to be x-rayed or measured on a machine called a simulator. This moves in exactly the same way as the treatment machines, but rather than giving treatment it takes x-rays to help the radiographer plan the correct position for your treatment. This procedure takes about 15-45 minutes and may be quite tiring.

Women of childbearing age will be asked whether they could be pregnant, as x-rays given during pregnancy could harm a baby. If you think that you may be pregnant, let the doctors and radiographers know immediately and you will be offered a pregnancy test.

During the treatment planning you will be lying on a fairly hard couch that can be slightly uncomfortable. If it is, let the radiographer know: you can be made more comfortable by having foam pads placed underneath you. You have to lie very still for a few minutes so that accurate measurements can be taken and your exact position recorded. The radiographer can then make sure that you are lying in the correct position each time you have treatment.

Some special procedures may be necessary to make sure the radiographers get a clear picture. The radiographers will explain these to you. For example, to plan treatment to the pelvic area, a liquid that shows up on x-ray may be passed into your back passage or into your bladder, or a vaginal tampon may be used to show the exact position of the vagina. These procedures may be slightly uncomfortable but are not painful and take only a few minutes. They are used only for planning the treatment, and not during the treatment sessions.

Sometimes a CT (computerised tomography) scan is taken of the area to be treated and this may be done in the hospital scanning department before your planning session appointment. A CT scan is a series of x-rays that gives a detailed picture of part of your body. The scanning department staff will explain the scanning process to you beforehand. Again, the scan is not painful, but you need to lie still for up to 10-30 minutes, which can be uncomfortable.

Sometimes more than one planning session is necessary - it depends on the size and position of the tumour. You may have your first treatment on the same day as your planning session, but often it is necessary to wait a few days while the physicist and specialist prepare the final details of your treatment.

 

Skin markings

Once the treatment area has been finalised, ink markings are usually made on your skin to pinpoint the exact place where the radiation is to be directed. The staff will explain how to look after these markings. If the marks begin to rub off, tell your radiographer. Do not try to redraw them yourself. Since they can rub off onto clothing, some people choose to wear older clothes next to the skin during their treatment.

Sometimes two, three or more permanent pinpoint tattoo marks are also made on the skin. This will be done only with your permission. It is a little uncomfortable while it is being done, but is a good way of making sure that your treatment machines are set up in the right way each day. The tattoo marks are also useful once treatment has finished, as they show where the radiotherapy was given and prevent further radiotherapy being given to that area in the future.

 

Mould room

As radiotherapy is planned very precisely, to treat exactly the right area, it is important to keep that part of the body as still as possible during treatment. For radiotherapy to some parts of the body, a see-through Perspex device called a `mould' or `shell' may be made, to prevent movement during treatment. This is often used for treatments to the head and neck area. Any necessary marks can be made on the mould instead of on your skin. Your

mould will be made before your treatment is planned.

In the mould room a plaster cast mould is made of the body part. Some people may find this claustrophobic or a little frightening, particularly if the mould is of the face and neck, but it takes only a short time.

After you leave the department, perspex is moulded on to the cast to form a mask. This mask fits snugly to your face and neck, with holes cut for your eyes, nose and mouth. The mould is ready to wear at your first planning or treatment session. Again, this may feel claustrophobic for some people, but try to remember that you will only have it on for a few minutes at a time.

Sometimes a mould of your leg or arm is used to keep the area still while your treatment is in progress.

 

Having your treatment

Before your first treatment your radiographers will explain to you what you will see and hear. It is quite normal to feel anxious about having your treatment, but as you get to know the staff and understand what is going on it should become easier. The sight of large machines can be frightening, especially for children. Don't be afraid to talk about any fears or worries to the staff; they are there to help you, and the more you understand about your treatment the more relaxed you will be.

Radiotherapy itself is painless and each session may take anything from a few seconds to several minutes. Because your positioning is so important, however, the radiographers may take a little while to get you ready (they may call this `setting up'). The room may be in semi-darkness while this is happening.

 

Try to relax as much as possible.

Once you are in the correct position the staff will need to leave you alone in the room, to prevent them from being exposed to any unnecessary radiation. Don't worry if the staff seem to rush out of the room once they have positioned you, this is just to keep your treatment time to a minimum, as radiotherapy units have many patients to treat and the staff need to keep appointments on time.

Some treatment rooms have tape players so that you can listen to music while having your treatment, to help you to relax. During treatment you will be alone for a few minutes but there will be an intercom so that you can talk to the radiographers. They will be watching you carefully from the next room, either through a window or on a closed-circuit television screen. To protect your privacy, no one else will be able to see you. If you have any problems you can raise your hand to attract the radiographers' attention and they will come in to help you.

Most radiotherapy machines will be able to rotate around your body to give the treatment from several different directions. At first, this and the sound of the machine, can be unsettling.

 

Positioning of radiotherapy machine

The radiographers may have to come into the treatment room and change your position slightly in the middle of your treatment. Also, small changes sometimes have to be made to your treatment plan. There may be a number of reasons for this and your specialist will explain these changes to you and keep you up to date with your progress.

 

Why is radiotherapy given?

Curative treatment

Radiotherapy is often prescribed with the aim of destroying the tumour, and, it is hoped curing the cancer. When radiotherapy is given in this way it is described as radical radiotherapy. Radiotherapy may be given before or after surgery or before or after chemotherapy (the use of anti-cancer drugs to destroy cancer cells). If radiotherapy and chemotherapy are given at the same time, this treatment is known as chemo radiotherapy.

Palliative treatment

Sometimes, when it is not possible to cure a cancer, radiotherapy may be given to relieve symptoms - for example, to lessen pain. This is called palliative treatment. Lower doses of external radiotherapy are given than for curative treatment, usually over a shorter period of time (sometimes just a single treatment).

Total body irradiation

This type of radiotherapy is used much less commonly than the other types of radiotherapy, but is often given to patients who are having a bone marrow or stem cell transplant for example, as treatment for leuk�mia. A large single dose, or six to eight smaller doses of radiation is given to the whole body to destroy the cells of the bone marrow. Very high doses of chemotherapy are also given, followed by new bone marrow given by a drip into a vein, to replace the bone marrow that has been destroyed. This type of radiotherapy is described in the section on stem cell and bone marrow transplants.

 

Children and radiotherapy

Radiotherapy can be a frightening experience for both children and their parents, but once everyone understands what is involved this fear should disappear. The radiotherapy staff are used to treating children and they can offer help and support.

Young children, especially if they are aged three or younger, may have their treatment under a mild general an�sthetic. As your child can't eat or drink for at least four hours before his or her treatment, you will probably have a morning appointment. The an�sthetic is usually given in the radiotherapy department by an an�sthetist. You can stay with your child until he or she is asleep.

Although you won't be able to stay in the radiotherapy room during your child's treatment, you can watch through the window or on the TV screen. The nurses will look after the child until he or she wakes up, usually after 20 minutes to an hour, and then you will both be able to go home, unless your child is an in-patient, in which case a nurse will take them back to the ward.

Older children may take a while to get used to the size and sound of the machines, but this should get easier once they come to know the staff and the surroundings. If you are finding it difficult to cope with your child's illness, you may find it helpful to contact one of the children's cancer groups. Sharing your experiences with other parents can help you to cope with your own problems and fears.

 

Reference: Cancer BACUP, U. K.

 

 

© Copyright with Dr. Sayeed Ahmad 2004