Radiation in Cancer Treatment

What is radiation therapy?

Radiation is a special kind of energy carried by waves or a stream of particles. It can come from special machines or from radioactive substances. When radiation is used at high doses (many times those used for x-ray exams), it can be used to treat cancer and other illnesses. Special equipment is used to aim the radiation at tumors or areas of the body where there is disease. The use of high energy rays or particles to treat disease is called radiation therapy. Sometimes it's called radiotherapy, x-ray therapy, cobalt therapy, electron beam therapy, or irradiation.

How does radiation therapy work?

High doses of radiation can kill cells or keep them from growing and dividing. Radiation therapy is a useful tool for treating cancer because cancer cells grow and divide more rapidly than many of the normal cells around them. Although some normal cells are affected by radiation, most normal cells appear to recover more fully from the effects of radiation than do cancer cells. Doctors carefully limit the intensity of treatments and the area being treated so that the cancer will be affected more than normal tissue.

What the benefits and goals of radiation therapy?

Radiation therapy is an effective way to treat many kinds of cancer in almost any part of the body. Half of all people with cancer are treated with radiation, and the number of cancer patients who have been cured is rising every day. For many patients, radiation is the only kind of treatment needed. Thousands of people are free of cancer after having radiation treatments alone or in combination with surgery, chemotherapy, or biological therapy.

Doctors can use radiation before surgery to shrink a tumor. After surgery, radiation therapy may be used to stop the growth of any cancer cells that remain. Your doctor may choose to use radiation therapy and surgery at the same time. This procedure is known as intraoperative radiation. In some cases, doctors use radiation along with anticancer drugs to destroy the cancer, instead of surgery.

Even when curing the cancer is not possible, radiation therapy still can bring relief. Many patients find the quality of their lives improved when radiation therapy is used to shrink tumors and reduce pressure, bleeding, pain, or other symptoms of cancer. This is called palliative care.

Are there risks involved?

Like many other treatments for disease, there are risks for patients who are receiving radiation therapy. The brief high doses of radiation that damage or destroy cancer cells also can hurt normal cells. When this happens, the patient has side effects. The risk of side effects is usually less than the benefits of killing cancer cells.

Your doctor will not advise you to have any treatment unless the benefits -control of disease and relief from symptoms -are greater than the known risks. Although it will be many years before scientists know all of the possible risks of radiation therapy, they now know that it can control cancer.

How is radiation therapy given?

Radiation therapy can be in either of two forms: external or internal. Some patients have both forms, one after the other.

Most people who receive radiation therapy for cancer have the external type. It is usually given during outpatient visits to a hospital or treatment center. In external therapy, a machine directs the high-energy rays or particles at the cancer and the normal tissue surrounding it.

One type of machine that is used for radiation therapy is called a linear accelerator.

The various machines used for external radiation work in slightly different ways. Some are better for treating cancers near the skin surface; others work best on cancers deeper in the body.

When internal radiation therapy is used, a radioactive substance, or source, is sealed in small containers such as thin wires or tubes called implants. The implant is placed directly into a tumor or inserted into a body cavity. Sometimes, after a tumor has been removed by surgery, implants are put into the area around the incision to kill any tumor cells that may remain.

Another type of internal radiation therapy uses unsealed radioactive sources. The source is either taken by mouth or is injected into the body. If you have this type of treatment, you will probably need to stay in the hospital for several days.

Who gives radiation treatments?

A doctor who has had special training in using radiation to treat disease -a radiation oncologist- will prescribe the type and amount of treatment that best suits your needs. The radiation oncologist is the person referred to as "your doctor" throughout this booklet.

The radiation oncologist works closely with other doctors involved in your care and also heads a highly trained health care team. Your radiation therapy team may include:

• The radiation physicist, who makes sure that the equipment is working properly and ensures that the machines deliver the right dose of radiation.
• The dosimetrist, who helps carry out your treatment plan by calculating the number of treatments and how long each treatment should last.
• The radiation therapy nurse, who provides nursing care and helps you learn about treatment and how to manage side effects.
• The radiation therapist, who sets you up for your treatments and runs the equipment that delivers the radiation.

You also may use the services of a dietitian, a physical therapist, a social worker, and other health care professionals.

Is radiation therapy expensive?

Treatment of cancer with radiation can be costly. It requires very complex equipment and the services of many health care professionals. The exact cost of your radiation therapy will depend on the type and number of treatments you need.

Most health insurance policies, including Part B of Medicare, cover charges for radiation therapy.

In some states, the Medicaid program may help you pay for treatments. You can find out from the office that handles social services in your city or county whether you are eligible for Medicaid and whether your radiation therapy is a covered expense.

If you need financial aid, contact the hospital social service office, the Cancer Information Service, or the local office of the American Cancer Society. They may be able to direct you to sources of help.

External Radiation Therapy: What to Expect

How does the doctor plan the treatment?

The radiation used in radiation therapy can come from a variety of sources. Your doctor may choose to use x-rays, an electron beam, or cobalt-60 gamma rays. Choosing which type of radiation to use depends on what type of cancer you have and on how deep into your body the doctor wants the radiation to penetrate. High-energy radiation is used to treat many types of cancer. Low-energy x-rays are used to treat some kinds of skin diseases.

After a physical exam and a review of your medical history, the radiation oncologist may need to do some special planning to pinpoint the treatment area. In a process called simulation, you will be asked to lie very still on a table while the radiation therapist uses a special x-ray machine to define your treatment port or field. This is the exact place on your body where the treatment will be aimed. You may have more than one treatment port. Simulation may take from a half hour to about 2 hours.

The radiation therapist often will mark the treatment port on your skin with tiny dots of colored, semipermanent ink to outline the treatment area. Be careful when you bathe because the marks must not be washed off until all of your treatment is over. If they start to fade, tell the therapist who will darken them so that they can be seen easily. Do not try to draw over faded lines at home unless they will be completely gone before your next visit. If you do replace the marks, be sure to tell the therapist at your next visit.

Using the information from the simulation, other tests, and your medical background, your doctor will meet with the radiation physicist and the dosimetrist.

Your doctor then decides how much radiation is needed, how it will be delivered, and how many treatments you should have. This process often takes several days.

After you have started the treatments, your doctor will follow your progress, checking your response to treatment and your overall well-being at least once a week. The treatment plan may be revised by your doctor, if needed. It's very important that you have all of your scheduled treatments to get the most benefit from your therapy. Unnecessary delays can lessen the effectiveness of your radiation treatment.

How long does the treatment take?

Radiation therapy usually is given 5 days a week for 6 or 7 weeks. When radiation is used for palliative care, the course of treatment lasts for 2 to 3 weeks. These types of schedules, which use small amounts of daily radiation, rather than a few large doses, help protect normal body tissues in the treatment area. Weekend rest breaks allow normal cells to recover. The total dose of radiation and the number of treatments you need will depend on the size and location of your cancer, type of tumor, your general health, and any other treatments you're receiving.

What happens during each treatment visit?

Before your treatment is given, you may need to change into a hospital gown or robe. It's best to wear clothing that is easy to take off and put on again.

In the treatment room, the radiation therapist will use the marks on your skin to locate the treatment area. You will sit in a special chair or lie down on a treatment table. For each external radiation therapy session, you will be in the treatment room about 15 to 30 minutes, but you will be getting your dose of radiation for only about I to 5 minutes of that time. Receiving external radiation treatments is painless, just like having an x-ray taken.

The radiation therapist may put special shields (or blocks) between the machine and certain parts of your body to help protect normal tissues and organs. There might also be plastic or plaster forms to help you stay in exactly the right place. You will need to remain very still during the treatment so that the radiation reaches only the area where it's needed and the same area is treated each time. You don't have to hold your breath just breathe normally.

The radiation therapist will leave the treatment room before the machine is turned on. The machine is controlled from a small area that is nearby. You will be watched on a television screen or through a window in the control room. Although you may feel alone, keep in mind that you can be seen and heard at all times by the therapist who can talk with you through a speaker.

The machines used for radiation treatments are very large, and they make noises as they move around to aim at the treatment area from different angles. Their size and motion may be frightening at first. Remember that the machines are being moved and controlled by your radiation therapist. They are checked constantly to be sure they're working right. If you are concerned about anything that happens in the treatment room, ask your therapist to explain.

You will not see or hear the radiation, and, most likely, you won't feel anything. If you do feel ill or very uncomfortable during the treatment, tell your therapist at once. The machine can be stopped at any time.

What are the effects of treatments?

External radiation therapy does not cause your body to become radioactive. There is no need to avoid being with other people because of your treatment. Even hugging, kissing, or having sexual relations with others poses no risk to them of radiation exposure.

Side effects of radiation therapy most often are related to the area that is being treated. Your doctor and nurse will tell you about the possible side effects and how you should deal with them. You should contact your doctor or nurse if you have any unusual symptoms during your treatment, such as coughing, sweating, fever, or unusual pain. Most side effects that occur during radiation therapy, although unpleasant, are not serious and can be controlled with medication or diet. They usually go away within a few weeks after treatment ends. However, some side effects can last longer. Many patients have no side effects at all.

Throughout your treatment, your radiation oncologist will regularly check on the effects of the treatment. You may not be aware of changes in the cancer, but you probably will notice decreases in pain, bleeding, or other discomforts you may have had, especially after your treatment is completed. You may continue to notice more improvements with time. Your doctor probably will recommend some tests to be sure that the radiation is causing as little damage to normal cells as possible. You may have routine blood tests to check the levels of white blood cells and platelets, which may be lower than normal during treatment.

What can I do to take care of myelf during therapy?

Each patient's body responds to radiation therapy in its own way. That's why the doctor must plan, and sometimes adjust, your treatment just for you. In addition, your doctor or nurse will give you advice for caring for yourself at home that is specific for your treatment and the side effects that might result.

Nearly all cancer patients receiving radiation therapy need to take special care of themselves to protect their health and help the treatment succeed. Some guidelines to remember are given below:

• Be sure to get plenty of rest. Sleep as often as you feel the need. Your body will use a lot of extra energy over the course of your treatment, and you may feel very tired. In fact, fatigue may last for 4 to 6 weeks after your treatment is finished.
• Good nutrition is a must. Try to eat a balanced diet that will prevent weight loss. For patients who have problems with eating or diet planning, the section titled "Managing Side Effects" offers practical tips.
• Avoid wearing tight clothes such as girdles or closefitting collars over the treatment area. It's best to wear older garments that feel comfortable and that you can wash or throw away if the ink marks rub off on them.
• Be extra kind to the skin in the treatment area:
  • Do not use any soaps, lotions, deodorants, medicines, perfumes, cosmetics, talcum powder, or other substances in the treated area without talking with your doctor.
  • Wear loose, soft cotton clothing over the treated area.
  • Do not starch your clothes.
  • Do not rub or scrub treated skin.
  • Do not use adhesive tape on treated skin. If bandaging is necessary, use paper tape. Try to apply the tape outside of the treatment area.
  • Do not apply heat or cold (heating pad, ice pack, etc.) to the treatment area. Even hot water can hurt your skin, so use only lukewarm water for bathing the treated area.
  • Use an electric shaver if you must shave the area - but only after checking with your doctor or nurse.
  • Do not use a pre-shave lotion or hair remover products.
    
  • Protect the area from the sun. If possible, cover treated skin (with light clothing) before going outside. Ask your doctor if you should use a lotion that contains a sunblock. If so, use a PABA sunscreen or a sunblocking product with a protection factor of at least 15. Reapply the sunscreen often, even after your skin has healed following your treatment. Continue to protect your skin from sunlight for at least 1 year after radiation therapy.

• Be sure your doctor knows about any medicines you are taking before starting treatment. If you need to start taking any medicines, even aspirin, let your doctor know before you start.
• Ask your doctor, nurse, or radiation therapist any questions you have. They are the only ones who can properly advise you about your treatment, side effects, at-home care, and any other medical concerns you may have.

Internal Radiation Therapy: What to Expect

When is internal radiation therapy used?

Your doctor may decide that very intense radiation given to a small area of your body is the best way to treat your cancer. Internal radiation therapy places the source of the high-energy rays as close as possible to the cancer cells so that fewer normal cells are exposed to radiation. By using internal radiation therapy, the doctor can give a higher total dose of radiation in a shorter time than is possible with external treatment. Instead of using a large radiation machine, the radioactive material is placed directly into (or as close as possible to) the affected area. Some of the radioactive substances used for internal radiation treatment include radium, cesium, iridium, iodine, phosphorus, and palladium.

Internal radiation therapy often is used for cancers of the head and neck, breast, uterus, thyroid, cervix, and prostate. Your doctor may recommend a combination of internal and external radiation therapy.

Implant radiation as described in this material means internal radiation treatment. You also may hear the terms interstitial radiation, intracavitary radiation, or brachytherapy; each is a form of internal radiation therapy. Some people use the term "brachytherapy" whenever they are talking about any form of internal radiation therapy.

When interstitial radiation is given, the radiation source is placed right in the affected tissue, usually in small tubes or containers. These implants may be temporary or permanent. When intracavitary radiation is used, a container of radioactive material is placed in a cavity of the body such as the uterus. In brachytherapy, the radioactive source, which is sealed in a small container, is placed on the surface of the body near the tumor or a short distance from the affected area. The radioactive source also may be delivered to the tumor through tubes; this is called remote brachytherapy. Internal radiation also may be given by injecting a solution of radioactive substance into the bloodstream or a body cavity. When the substance is injected, it is not sealed in a container and may be called unsealed internal radiation therapy.

How is the implant placed in the body?

For most types of implants, you will need to be in the hospital and have general or local anesthesia while the doctor places the container for the radioactive material in your body. In many hospitals, the radioactive material is placed in the container after you return to your room so that others are not exposed to radiation.

To get the radiation as close as possible to the cancer, doctors may use implants of radioactive material sealed in wires, seeds, capsules, or needles. The type of implant and the method of placing it depend on the size and location of the cancer. Implants may be put right into the tumor, in special applicators inside a body cavity, on the surface of a tumor, or in the area from which the tumor has been taken.

Does the implant spread radiation to others?

The radioactive substance in your implant may transmit rays outside your body. While you're receiving implant therapy, the hospital may require you to stay in a private room. Although the nurses and other people caring for you will not be able to spend a long time in your room, they will give you all of the care you need. You should call for a nurse when you need one, but keep in mind that the nurse will work quickly and speak to you from the doorway more often than from your bedside. In most cases, your urine and stool will contain no radioactivity. However, either one may contain some radioactive material if you have unsealed internal radiation therapy.

There also will be limits on visitors while your implant is in place. Most hospitals do not let children younger than 18 or pregnant women visit patients who have an implant. Visitors should sit at least 6 feet from your bed and stay for only a short time each day (10 to 30 minutes). Have visitors ask your nurse for specific instructions before thay enter your room.

Are there any side effects?

You are not likely to have severe pain or feel ill during implant therapy. However, if an applicator is holding your implant in place, it may be somewhat uncomfortable. If you need it, the doctor will order medicine to help you relax or to relieve pain. Some patients feel drowsy, weak, or nauseated after having the anesthesia to place the implant, but these effects do not last long.

Be sure to tell the nurse if you have any side effects such as burning, sweating, or other unusual symptoms.

How long does the implant stay in place?

The total amount of time that an implant is left in place depends on the dose (amount) of radioactivity with which the patient is treated. The implant may be low dose rate and left in place for several days, or it may be high dose rate and removed after a few minutes. Generally, low dose rate implants are left in place from 1 to 7 days. Your treatment schedule will depend on the type of cancer, where it is, your general health, and other cancer treatments you have had. Depending on where the implant is placed, you may have to stay in bed and lie fairly still to keep the implant from shifting.

For some cancer sites, the implant may be left in place permanently. If your implant is permanent, you may need to stay in your room away from other people in the hospital for a few days while the radiation is most active. The implant will lose energy each day, so by the time you are ready to go home, the radiation in your body will be much weaker. Your doctor will advise you if there are any special precautions you need to use at home.

High dose rate remote brachytherapy allows a person to be treated within a few minutes in inpatient or outpatient clinics. With remote brachytherapy, a very powerful radioactive source travels by remote control through tubes, or catheters, to the tumor. The radioactivity remains at the tumor for only a few minutes. This procedure is done by the brachytherapy team, who will watch you on a closed-circuit television. They will talk to you through an intercom. In some cases, several remote treatments may be required. Sometimes, the catheter stays in place between treatments and sometimes it is removed, depending on your condition.

High dose rate treatments are short (usually a few minutes) and result in less discomfort than other types of radiation therapy. Because radioactive materials are not left in your body, you can return home soon after you recover. Remote brachytherapy has been used to treat cancers of the cervix, breast, lung, pancreas, prostate, and esophagus.

What happens after the implant is removed?

Usually there is no need to have an anesthetic to take out the implant. Most can be taken out right in the patient's hospital room. If you had to stay in bed during implant therapy, you might have to remain in the hospital an extra day or so after the implant is removed. Once the implant is removed, there is no radioactivity in your body. The nurses and your visitors no longer will have to observe any special rules.

Your doctor will tell you if you should limit your activities after leaving the hospital. Most patients are allowed to do as much as they feel like doing. You may need some extra sleep or rest breaks during your first days at home, but you will feel stronger quickly.

The area that has been treated with an implant may be sore or sensitive for some time after therapy. Your doctor may advise you to limit sports and sexual activity for a while if they cause irritation in the treatment area.

This material was taken from the booklet "Radiation Therapy and You" published by the National Institutes of Health.

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