Medically reviewed by C.H. Weaver M.D. Medical editor 12/2018
Often, one or more treatment modalities may be used in order to provide the most complete treatment for the patient. Increasingly, it is common to use several treatment modalities concurrently (together) or in sequence. This is referred to as multi-modality treatment of the cancer and the modalities may include surgery, chemotherapy, biological therapy, and/or radiation therapy. For the majority of newly diagnosed cancer patients, the optimal treatment may be a multi-modality approach composed of standard therapies that have been established through extensive medical research. For other patients, the most appropriate therapy may still be under investigation and may be available only through a clinical trial.
Radiation therapy works by damaging the DNA in the cancer cell, thereby disabling the cancer cells from reproducing and growing. The cancer cells then die and the cancer shrinks. The objective of radiation therapy is to kill enough cancer cells to maximize the probability of cure and minimize the side effects. Under some circumstances, radiation therapy may also be used as palliation, or palliative care, which is aimed at reducing symptoms but not curing the underlying disease.
Radiation is usually administered in the form of high-energy beams that deposit the radiation dose in the body where cancer cells are located. Radiation therapy, unlike chemotherapy, is considered a local treatment. This means that cancer cells are only killed at the location in the body where the radiation is delivered, called the radiation field. If cancer exists outside the radiation field, those cancer cells are not destroyed by the radiation.
The following is a general overview of radiation therapy, covering:
Techniques for Delivering Radiation Therapy
Radiation therapy may be delivered externally or internally. External radiation delivers high-energy rays directly to the cancer from a machine outside the body. Internal radiation, or brachytherapy, is the implantation of a small amount of radioactive material (seeds) in or near the cancer. Radiation can also be delivered as an isotope into a vein, as in the use of radioactive iodine for the treatment of thyroid cancer.
External Beam Radiation Therapy (EBRT)
EBRT is given via machines called linear accelerators, which produce high-energy external radiation beams that penetrate the tissues and deliver the radiation dose deep in the areas where the cancer resides. These modern machines and other state-of-the-art techniques have enabled radiation oncologists to significantly reduce side effects while improving the ability to deliver radiation.
EBRT is typically delivered on an outpatient basis for approximately 6 to 8 weeks. EBRT begins with a planning session, or simulation, during which the radiation oncologist places marks on the body and takes measurements in order to line up the radiation beam in the correct position for each treatment. During treatment, the patient lies on a table and is treated with radiation from multiple directions. The actual area receiving radiation treatment may be large or small, depending on the features of the cancer. Radiation can be delivered specifically to an organ or encompass the surrounding area, including the lymph nodes.
Three-dimensional conformal radiation therapy (3D-CRT)
EBRT can be delivered more precisely by using a special computed tomography (CT) scan and a targeting computer. This capability is known as three-dimensional conformal radiation therapy, or 3D-CRT. The use of 3D-CRT appears to reduce the chance of injury to nearby body structures. Since 3D-CRT can better target the area of cancer, radiation oncologists are evaluating whether higher doses of radiation can be given safely and with greater cancer cures.
Intensity Modulated Radiation Therapy (IMRT)
IMRT is an advanced form of 3-D conformal radiation therapy that allows doctors to customize the radiation dose by modulating, or varying, the amount of radiation given to different parts of the area being treated. The radiation intensity is adjusted with the use of computer-controlled, moveable “leaves” which either block or allow the passage of radiation from the many beams that are aimed at the treatment area. The leaves are carefully adjusted according to the shape, size, and location of the tumor. As a result, more radiation can be delivered to the tumor cells while less is directed at the normal cells that are nearby.
An analogy for IMRT is a shower nozzle that shoots many different streams of water from different directions, except that each stream can be turned on or off, or set to deliver different intensities. This is unlike standard radiation techniques that allow only a constant flow of radiation from each beam.
Image-guided Radiation Therapy (IGRT)
IGRT is a new approach to delivering radiation therapy that allows for more accurate delivery of radiation to the target tissue. IGRT involves imaging during the course of radiation treatment. A computer compares images taken at the time of treatment to images taken during the planning phase. Through this process, IGRT is able to account for changes in the patient’s body or position that may shift the exact location of the cancer. This allows increased accuracy of very complex treatment approaches. It also provides documentation of the degree of accuracy. IGRT is used in conjunction with EBRT, 3D-CRT or IMRT.
Intraoperative radiation therapy (IORT)
Intraoperative radiation therapy (IORT) refers to radiation therapy that is administered directly to the area of the cancer during surgery. Potential benefits of IORT include increased doses of radiation delivered to the cancer and reduced exposure of normal tissue (normal tissue can be moved or shielded during the procedure). IORT has been used in the treatment of several types of cancer, and may be particularly useful for localized cancers that are difficult to remove completely or that have a high risk of local recurrence (recurrence near the original cancer site).
Two different approaches to delivering IORT are intraoperative electron beam radiation therapy (IOERT) and high dose rate brachytherapy (HDR-IORT).1 The choice of which approach to use depends on the nature of the cancer and the facilities available. Thanks to improvements in technology, such as the development of mobile IOERT units, treatment may be provided directly in the operating room. This avoids the need to transfer the patient from the operating room to the radiation oncology department during surgery.
Internal radiation is known by a number of names, including “brachytherapy,” “seeds,” or “implants.” These terms refer to treatment in which radioactive material is placed directly into or near the cancer. Brachytherapy may be used to provide an additional boost of radiation to an area also being treated with external radiation therapy, or may be used as the only type of radiation therapy.
Brachytherapy may be permanent or temporary. In permanent brachytherapy, radioactive seeds are inserted and permanently left in place. After the procedure, the patient will temporarily contain a small amount of radiation from the seeds, although this amount is not generally dangerous to most other people. Some physicians may advise patients to avoid close contact with young children or pregnant women for several weeks. Over time, the radioactivity diminishes.
In temporary brachytherapy, the radioactive material is inserted for a specified period of time and then removed before the patient goes home. Temporary brachytherapy may be administered at a lower dose over a longer period of time (low dose rate, or LDR) or a higher dose over a shorter period of time (high dose rate, or HDR). During LDR brachytherapy, patients are generally hospitalized for as long as the radioactive implants are in place (often two to three days). In contrast, it may be possible to receive HDR brachytherapy on an outpatient basis.
Brachytherapy has proven to be useful in the treatment of several different types of cancer, including prostate, cervix, uterus, vagina, head and neck, and breast.
Breast brachytherapy is an alternative to traditional EBRT for women who choose breast conservation rather than a mastectomy. Breast conservation therapy involves removing the tumor in a procedure called a lumpectomy, and is followed by radiation therapy to reduce the likelihood of recurrence. Traditional EBRT following a lumpectomy consists of five to six weeks of radiation treatment, five days per week. With breast brachytherapy, a site-specific, prescribed dose of radiation is administered during a five-day course of therapy. Because of the relatively short duration of the treatment course, breast brachytherapy is an attractive option for women who choose lumpectomy over mastectomy, but do not wish to undergo 6 weeks of EBRT.
The procedure for breast brachytherapy involves inserting a deflated balloon into the cavity where the tumor was removed. An applicator shaft, or catheter, connects the balloon to the outside of the breast. The balloon is filled with saline, and both the balloon and the catheter remain in place during the time the woman is undergoing treatment. The radiation therapy is performed on an outpatient basis in a five-day-long, twice-per-day sequence of treatments. During the treatment, a radioactive “seed” is inserted into the catheter within the balloon in an exact dose, minimizing radiation exposure to the rest of the breast, skin, ribs, lungs, and heart. No source of radiation remains in the patient’s body between treatments or after the final procedure. The catheter and balloon are removed after the final procedure. Conventional brachytherapy for breast conservation requires the insertion of 14 to 20 catheters per procedure and is much more complex than the breast brachytherapy procedure described here.
Stereotactic Radiosurgery (SRS)
Stereotactic Radiosurgery (SRS) allows non-invasive treatment of brain tumors, arteriovenous malformation, and other selected conditions. It is an outpatient treatment that delivers a high dose of radiation to a highly defined target. Treatments can be prescribed to deliver the total dose of radiation in a single treatment or in a fractionated manner over a course of several weeks.
What to Expect During Radiation Treatment
Radiation treatment must be individualized for each patient depending on the size and location of their cancer. In order to tailor radiation treatment to meet the specific needs of individual patients, the radiation process involves several components, including consultation, simulation, treatment planning, and finally, the actual treatment.
The consultation is an important visit that allows both you and the radiation oncologist to gain more information. During the consultation, the radiation oncologist will obtain a medical history and perform a physical examination. Many patients find it helpful to prepare for the consultation by bringing x-rays, medical records, a list of medications, insurance information, and referral forms.
During the consultation, the radiation oncologist may communicate a great deal of information in a short period of time. You may find it useful to prepare a list of questions prior to the consultation to assure they are all answered. You may also find it beneficial to bring another person to the consultation to help understand the information from the physician.
After the consultation, the radiation oncologist may order additional tests, await results of other pending tests or consultations, or obtain additional records and reports. Multidisciplinary care is increasingly important for optimal cancer care, therefore the radiation oncologist will typically communicate with any other treating physicians to determine the appropriate course of treatment. In addition, the radiation oncologist will likely send a complete report of their evaluation to the referring physician and any other physicians requested by the patient. Once all of the necessary information has been gathered and the treatment team has communicated, a decision may be made to use radiation treatment. At this point, the radiation oncologist will discuss the treatment plan and alternatives with you and will present a consent form for you to sign prior to treatment. It is important to read and understand the consent form prior to signing it.
After the initial consultation and decision to use radiation treatment, the next session is usually a planning session, which is called a simulation. Simulation is used to determine the radiation treatment fields and most of the treatment planning. Of all the visits to the radiation oncology facility, the simulation session may actually take the most time.
The CT simulator does not deliver radiation treatment, but instead allows the radiation oncologist and technologists to see the area to be treated. Images are obtained and transferred to the planning system where a virtual 3-dimensional image of the patient is created and the treatment delivery plan is developed.
For the simulation session, temporary marks are made on your skin with magic markers to identify the treatment areas. The room is periodically darkened while the treatment fields are being set. Alignment is critical during simulation and is facilitated by lasers mounted on the wall and ceiling. Special individually constructed immobilization devices may be used to help achieve this alignment. While you may see red lines of light, the low energy lasers are for alignment purposes only and you will not feel burning or anything else from the laser light.
Once the aspects of the treatment fields are set, the technologist will take special simulation x-rays representing the treatment fields. In most centers, the patient is given multiple “tattoos,” which mark the treatment fields and replace the marks previously made with magic markers. These tattoos are not elaborate and consist of no more than pinpricks followed by ink, appearing like a small freckle. Tattoos enable the radiation technologists to set up the treatment fields each day with precision, while allowing you to wash and bathe without worrying about obscuring the marks that indicate where treatment will be delivered.
Sometimes several simulation sessions are necessary in order to optimize treatment and are often performed prior to planned “boost” or “reduced field” treatments as part of the overall treatment plan.
Several steps occur after simulation and prior to treatment; however, you do not need to be present during most of these procedures. The simulation x-ray may be used to design special lead alloy blocks that are used to block normal tissues from the effects of radiation. These lead alloy blocks are placed on a plastic tray and will be attached below the head of the linear accelerator, the machine that emits the radiation, prior to each treatment. These blocks are designed to minimize the amount of radiation that is delivered to normal tissues, while maximizing the dose to the cancer site. You may need to return after simulation and prior to treatment to verify the placement of these blocks and accuracy of the treatment plan.
During treatment planning, the technologists also perform special calculations to help assure that the proper radiation dose will be delivered. Computerized treatment planning may facilitate these calculations. Computers have become extremely sophisticated in planning radiation therapy delivery. Some computers are even capable of extremely complex three-dimensional representation of the treatment area and surrounding normal tissues. If such computerized planning is necessary, the patient may be asked to have a special CT scan (a special type of x-ray device with a donut shaped opening).
It may take several days for treatment planning to be completed after simulation and prior to treatment. After all treatment planning is complete, radiation therapy treatments are ready to begin.
Radiation treatment is usually given in another room separate from the simulation room. The treatment plans and treatment fields that result from the simulation session are transferred over to the treatment room, which contains a linear accelerator focused on a patient table similar to the one in the simulation room. The treatment plan is verified and treatment started only after the radiation oncologist and technologists have rechecked the treatment field and calculations, and are thoroughly satisfied with the “setup”.
During radiation treatment, you must lie very still on the treatment table while the radiation beam is targeted to the exact area of the tumor. The machine and treatment table may rotate up to 360 degrees if the treatment requires the radiation to hit the tumor from all angles. The technologists will not be in the room during the treatment, but they will be monitoring the treatment via a video camera and an audio connection with the treatment room. You will not feel the radiation as it is being delivered.
Radiation therapy is generally given once a day, five days a week, usually at the same time each day. Occasionally, treatment is given less frequently or twice a day. The number of treatments depends on multiple factors and varies from 5-10 to 40 or more, which means that treatment may last anywhere from one to eight weeks or more. Radiation treatments are generally given as outpatient treatments and involve relatively little time each day. While the first few visits might last for an hour or more, typically a daily radiation treatment will take about 15-30 minutes in the treatment room and the actual treatment only lasts a few minutes. It is important not to miss treatments. Extending treatments beyond the recommended time period may reduce the chance of controlling the cancer.
Side Effects of Radiation Therapy
Although patients do not feel anything during a radiation treatment, the effects of radiation gradually build up over time. Most patients have very few initial side effects; however, many patients experience fatigue as treatment continues.
The vast majority of patients are able to complete radiation therapy without significant difficulty. Side effects and potential complications of radiation therapy are infrequent and, when they do occur, are typically limited to the areas that are receiving treatment with radiation. The chance of experiencing side effects, however, is highly variable. A dose that causes some discomfort in one patient may cause no side effects in other patients. If side effects occur, you should inform the technologists and radiation oncologist, because treatment is almost always available and effective. Side effects are usually temporary and resolve once the radiation is completed.
The most common side effect of radiation are:
- Skin reaction
Side effects that commonly occur with radiation to the head and neck are:
- Changed sense of taste and/or smell
Other less common side effects are:
- Hair loss
- Loss of appetite
- Low blood counts (myelosuppression)
While not as common with the advent of modern radiation delivery techniques, side effects that may occur with radiation to the chest are:
- Lung fibrosis
- Heart complications
In addition to the above temporary side effects, in certain cases, patients may develop long-term side effects, also called “late complications”, such as:
- Secondary cancers
These long-term side effects are also less common with the advent of modern radiation techniques.
Most Common Side Effects of Radiation Therapy
Skin reaction: A common side effect of radiation therapy is skin irritation in the area of the body that is being treated. The skin reaction can range from mild redness and dryness (similar to a sunburn) to severe peeling (desquamation) of the skin in some patients. The majority of skin reactions to radiation therapy go away a few weeks after treatment is completed. In some cases, the treated skin will remain slightly darker than it was before and it may continue to be more sensitive to sun exposure.
It is important to notify your nurse or physician when your skin becomes irritated because redness and dryness can eventually progress to peeling with oozing of fluid in the area. They can suggest measures to relieve your discomfort and possibly minimize further irritation. There are effective topical medications for treatment of radiation induced skin irritation, as well as a number of precautions that may minimize skin irritation during radiation therapy, such as:
- Keep the treated area dry and free from irritation. Cornstarch, gently patted on with a powder puff, will keep the skin dry.
- Wash the skin in the treatment area only with mild soaps.
- Use a mild shampoo, such as baby shampoo, if the head is being treated.
- When using a towel, pat the area dry instead of rubbing.
- If you must shave in the treated area, use an electric razor to prevent cuts.
- Avoid using shaving lotions or scented creams.
- Do not use perfumes, deodorants, or makeup in the treated area.
- Avoid using heating pads or ice packs on the skin in the treated area.
- Wear loose-fitting clothing that does not rub on the skin in the treated area.
- Avoid harsh fabrics over the treatment area, such as wool, corduroy, or starched cloth. Lightweight cotton is recommended.
- Avoid sun exposure in the treated area. If you expect to be in the sun for more than a few minutes, wear protective clothing (such as a hat with a broad brim and shirt with long sleeves) and use a sunscreen. Ask your doctor or nurse about using sunscreen lotions of SPF 15 or higher.
- Check with your nurse or physician regarding the use of creams or lotions. Usually, samples of safe topical medications are available in the radiation clinic.
- Unless necessary, do not use adhesive tape, including band aids and paper tape on the treated area.
- Breast cancer patients should not use deodorant if the axilla is in the treatment field. Create your own non-irritating deodorant: 1/4 cup baking soda and 1/4 cup of corn starch mixed together and applied with cotton balls.
- Do not swim in salt water, lakes, pools, or ponds.
- Always report any discomforts or concerns to your nurse or doctor.
Fatigue: Fatigue is a feeling of tiredness, weariness, weakness, exhaustion, or a profound lack of energy. Fatigue is one of the most common side effects of radiation therapy. Patients are not restricted from normal activity during radiation therapy; however, they should balance normal activity with periods of rest. Fatigue is typically more severe 2-4 hours after treatment. The feeling of fatigue should wear off several weeks after the completion of radiation therapy. The following suggestions may help you manage fatigue resulting from radiation therapy:
- Limit your activities, if possible.
- Exercise each day to maintain your strength.
- Prepare meals ahead of time and freeze them.
- Use convenience foods that are ready to eat.
- Accept offers of help from friends and relatives.
- Drink three quarts of fluid each day to avoid the build-up of cellular waste products.
- Increase rest by getting more sleep at night and taking naps during the day.
- Try to eat even when you are tired. Sometimes a little food will increase energy.
Side Effects Associated with Radiation Therapy to the Head and Neck
Mucositis (sore mouth or throat): Radiation therapy that is delivered to the head and neck area may cause mucositis. Mucositis is inflammation of the lining of the mouth and throat, called the mucus membranes. When radiation is administered directly to or near the head and neck region, chest, abdomen, or anal-rectal regions, it may cause damage to the mucosal lining of the entire gastrointestinal tract. This results in inflammation and sloughing of the mucosal cells, causing pain and increasing the risk of infection.
Patients who have a sore mouth or gums need to take special care of their teeth, as they are a primary site for infection and pain. These patients may need to utilize frequent oral hygienic measures and antiseptic mouthwashes. In addition, some patients find it helpful to rinse the mouth with water frequently in order to remove food and bacteria and promote healing.
Patients with mucositis should also select foods that will not further irritate an already tender mouth, for example:
- Choose soft foods that are easy to chew and swallow.
- Avoid foods that irritate the mouth such as citrus fruits and foods that are spicy, salty, rough, coarse, or dry.
- Cook foods until they are soft and tender.
- Cut foods into small pieces.
- Mix food with butter, thin gravies or sauces to make it easier to swallow.
- Puree food in a blender or food processor.
- Use a straw to drink liquids.
- Eat foods cold or at room temperature, as hot food can irritate a tender mouth.
- Use anesthetic lozenges and sprays to numb the mouth and throat long enough to eat meals.
Xerostomia (dry mouth): Radiation therapy that is delivered to the head and neck area may also result in xerostomia. Xerostomia is a chronic dry-mouth condition, which is caused by damage to the salivary glands as a result of radiation therapy. Xerostomia can have a negative effect on quality of life by greatly impairing a patient’s ability to speak, chew, swallow, and taste. Coping with a dry mouth can be difficult, but the following tips may help.
- Try consuming sweet or tart foods or beverages, such as lemonade, to help your mouth produce saliva. (Avoid these, however, when experiencing a sore mouth or throat.)
- Suck on sugar-free, hard candy or popsicles or chew sugar-free gum; this may also help to produce more saliva.
- Eat soft and pureed foods that are easier to swallow.
- Keep lips moist with lip salves.
- Eat foods with sauces, gravies, and salad dressings to make them moist and easier to swallow.
- Sip water every few minutes to make swallowing and talking easier.
- If the dry mouth problem is severe, ask your physician or dentist about products that coat and protect the mouth and throat, and if you don’t have one, you could find a good dentist at westairdriedental.ca.
Changed sense of taste and/or smell: Radiation therapy or cancer itself may cause a change of taste or smell that typically goes away once treatment is complete. Foods may have a bitter or metallic taste, or simply less taste. The following is a list of suggestions that may help to make food taste better.
- Stop eating foods that cause an unpleasant taste and choose foods that look and smell good to you.
- Serve foods at room temperature.
- Try using small amounts of flavorful seasonings.
- Try tart foods such as oranges or lemons that may have more taste (unless you are experiencing a sore mouth or throat).
- Marinate meat, chicken, or fish in sweet sauces.
- If red meat tastes or smells strange, switch to chicken, turkey, eggs, or dairy products.
Less Common Side Effects of Radiation Therapy
Hair loss: Radiation therapy only causes hair loss in the area being treated. Hair loss typically begins 2-4 weeks after the initiation of treatments. Some individuals experience thinning of the hair, while others experience complete hair loss. Hair loss caused by radiation is temporary. Typically, regrowth of hair begins 6-8 weeks after completion of radiation therapy. The best way to deal with hair loss is to prepare for it before it happens. Your physician will inform you of your chances for hair loss before your treatments begin. Consider the following tips for coping with hair loss:
- Get a short, stylish haircut prior to beginning radiation in order to prepare yourself for the change in your appearance.
- If considering a wig, see a wig stylist before radiation treatment begins so that the stylist can match a wig to your natural hair color and texture.
- Ask your doctor for a prescription for a wig, as some insurance companies will cover this cost.
- Once radiation treatments begin, use a mild shampoo, pat the hair dry, and comb the hair carefully, without tugging.
- Only use a hairdryer if necessary and keep it on a low heat setting.
- Avoid hair dyes, rollers, curling irons, or perms.
- Sleep on a satin pillowcase to avoid friction between hair and scalp.
- Consider scarves, turbans, or wigs.
- Some patients feel more in control if they shave their head completely, rather than dealing with the hair falling out.
Nausea/vomiting: Sometimes radiation therapy causes nausea (feeling queasy or sick to your stomach) and/or vomiting (throwing up), especially when the radiation is delivered to the abdominal area. Nausea/vomiting can happen immediately after radiation, can be delayed, or can occur in anticipation of receiving treatment. Several drugs, called antiemetics, are FDA approved for the prevention of nausea and vomiting.
If you do experience nausea immediately after radiation, you may find it helpful to refrain from eating several hours prior to the treatment and for 1-2 hours afterward. In contrast, if you experience anticipatory nausea, it might be helpful to eat a bland snack, such as toast or crackers, before treatment. The following is a list of suggestions for coping with nausea:
- Eat small meals.
- Eat and drink slowly.
- Eat often.
- Avoid foods that are fried or high in fat.
- Drink cool liquids between meals.
- Eat foods that have only a mild aroma and that can be served cool or at room temperature.
- Stick to any special diet that your doctor or dietician gives you.
- For a severely upset stomach, try a clear liquid diet (broth and juices) or bland foods that are easy to digest, such as dry toast and gelatin.
- If nausea/vomiting persists, your physician can prescribe an antiemetic to prevent nausea.
Diarrhea: Radiation treatment that is delivered to the abdominal area can cause diarrhea, which usually begins in the third or fourth week of radiation therapy. Your physician may recommend that you change your diet and/or prescribe medicine to help with the diarrhea. The following may help you manage diarrhea:
- As soon as diarrhea starts, switch to a clear liquid diet.
- Avoid foods that are high in fiber or can cause cramps or a gassy feeling (raw vegetables, coffee, beans, cabbage, spicy food).
- Eat small, frequent meals.
- Avoid dairy products.
- Eat foods that are high in potassium, such as bananas, potatoes, and apricots, because diarrhea causes potassium loss.
Loss of appetite: Loss of appetite is a common factor with cancer and its treatment. Nausea, vomiting, and depression can contribute to a loss of appetite. While you may not want to eat, it is important to maintain proper nutrition throughout treatment. The following suggestions may help you maintain your nutritional intake:
- Eat whenever you are hungry. Several smaller meals throughout the day might be more appropriate than three larger meals.
- Eat often. Taking just a few bites of food every hour can ensure that you get more protein and calories.
- Have a calm, relaxed mealtime.
- Add variety to your menu.
- Create a calm and appealing ambiance with music, candles, and friends.
Low blood counts (myelosuppression): Blood counts, or the number of blood cells in circulation, can be affected by radiation therapy. Many radiation therapy institutions make it a policy to check the blood counts at least once during the radiation treatments. Low blood counts may cause changes in sleep or rest patterns during the radiation therapy period and some patients describe a sense of tiredness and fatigue. Notify your nurse or doctor if you experience any of these symptoms because treatment is available for low blood counts.
Other less common side effects may occur in certain situations and will be discussed with you as appropriate.
Possible Side Effects with Radiation to the Chest
Lung fibrosis: Lung fibrosis is scarring of the lung tissue and causes difficulty breathing. Fibrosis can be a significant long-term (late) complication following radiation treatment for Hodgkin’s disease and other cancers requiring radiation to the lungs. However, this decrease in lung function appears to improve over time and is thought to be reversible.
Heart complications: Heart disease is also a late complication of radiation to the middle portion of the torso, called the mediastinum. The risk of heart disease increases with higher radiation doses and larger field sizes.
Possible Long-Term Side Effects of Radiation Therapy
Secondary cancers: A second cancer can be induced by cancer treatment, including radiation, chemotherapy, or the combination of radiation and chemotherapy. Treatment for Hodgkin’s lymphoma at a young age will ultimately result in a higher incidence of second cancers.
Hypothyroidism: Hypothyroidism (abnormally low levels of thyroid hormone) is one of the more frequently encountered late complications of radiation therapy in patients where the radiation field includes the neck. This may occur in up to one-third of patients receiving radiation therapy. It is important for patients who have received radiation therapy to be tested on a regular basis because signs and symptoms of hypothyroidism occur very late and are subtle.
Prevention and Management of Radiation Side Effects
There are several methods being utilized for the prevention of radiation therapy side effects. These mainly include altering the manner in which radiation is delivered and administering drugs that protect normal cells from radiation damage.
Radiation Delivery Methods
Two delivery methods that were originally used to reduce radiation side effects include dose fractionation, or splitting the total dose of radiation therapy into multiple doses and physical shielding with lead blocks to reduce the area of exposure.
Fractionation and hyperfractionation: Radiation therapy was originally given in one large dose. More than a half-century ago it was found that it was less toxic and more effective to administer radiation on a daily basis, a method called dose fractionation. Fractionation allows the delivery of a larger total dose of radiation to the cancer than would have been possible as a single dose. Currently, most radiation treatments are administered daily, 5 days a week. The 5 days per week is strictly for the convenience of maintaining a normal work week. The 24-hour interval and the two-day interval between doses allows for recovery of normal tissues between doses while cancer cells, in general, have less capability for recovery. There is no doubt that using fractionation has reduced side effects compared to single-dose delivery.
While cancer cells tend to be less resilient than normal tissues, there is a chance that the intervals between fractionated doses of radiation may allow cancer cells to recover. Recent findings indicate that some cancers are best treated by reducing the 24-hour interval between doses to 6-8 hours, in order to enhance the toxic effects on cancer cells, while still preserving an adequate time interval for the recovery of normal cells. This technique, called hyperfractionation, is being widely used to treat a variety of cancers. Hyperfractionation requires sophisticated equipment and therefore it is important for patients to be treated at specialty medical centers that have experience and staff trained in this technique.
Intensity modulated radiation therapy (IMRT): IMRT delivers varying intensity of radiation with a rotating device. The intensity is varied by the placement of “leaves,” which either block or allow the passage of radiation. The rotating component of this technique allows for more specific targeting of the cancer, sparing normal tissues from damage due to radiation exposure. In conventional radiation therapy, the beam is usually delivered from several different directions, possibly 5-10. The greater the number of beam directions, the more the dose will be confined to the target cancer cells, sparing normal cells from exposure. IMRT delivers radiation from every point on a helix, or spiral, in contrast to only a few points.
IMRT is similar to CT scanning. In CT, a beam rotates around the patient, creating a sequence of cross-sectional images. IMRT also uses a rotating beam, except the beam delivers radiation. IMRT also delivers treatment one cross-section at a time.
Three-dimensional conformal radiation: Three-dimensional conformal radiation therapy is a promising approach for the treatment of some cancers with decreased toxicity to normal tissues. Using computerized tomography (CT) scans and other scans, radiation oncologists have developed methods for determining the tumor size and shape in 3 dimensions. This allows high-dose external beam radiation therapy to be delivered primarily to the cancer with less damage to normal cells. For example, three-dimensional conformal radiation has allowed radiation oncologists to reduce the amount of radiation to the breast by 50%, which should decrease the risk of secondary breast cancer. It is important for conformal radiation to be administered at special cancer centers with sophisticated equipment and trained staff.
While preventing radiation side effects from occurring is the ideal approach to management, sometimes side effects are inevitable. In these situations, several types of drugs can be used to decrease the side effects of radiation. Drug therapies for radiation-induced side effects fall into two categories:
- Those that protect the non-cancerous tissue from radiation damage through systemic administration.
- Those that are applied topically to mucus membranes to decrease or treat radiation damage.
Radiation protectors: Radioprotectants are drugs that selectively protect normal cells, but not cancer cells, from the effects of radiation. Over the past 50 years, many radiation protectors have been tested in laboratories to determine their efficacy in preventing radiation damage to normal cells and tissues.
Ethyol®: Ethyol® is a radiation protector and the only drug that has been approved by the FDA for xerostomia (dry mouth) in patients receiving radiation therapy for cancers of the head and neck. Xerostomia is a chronic dry-mouth condition, which is caused by damage from radiation therapy to the salivary glands. Xerostomia can greatly impair a patient’s ability to speak, chew, swallow and taste and therefore, can have a negative effect on a patient’s quality of life. Results from a clinical trial indicated that the incidence of severe xerostomia for patients receiving Ethyol® was 51%, compared to 78% for patients receiving radiation therapy alone. One year following completion of radiation therapy, only 35% of patients who had received Ethyol® were still experiencing symptoms of xerostomia, whereas 57% of patients who had received radiation therapy alone were still experiencing symptoms.
Steroids: Steroids are naturally occurring hormones produced by the adrenal glands. As part of your radiation therapy treatment, your physician may prescribe steroids such as Prednisone® or Decadron® (generic name is dexamethasone). These drugs help decrease swelling in body tissues. Dexamethasone has also been shown to prevent radiation-induced vomiting, especially in treatment of cancers of the abdomen.
Topical agents: Some drugs can be applied topically to mucus membranes to decrease or treat radiation damage. The topical agent sucralfate may protect mucus membranes by several mechanisms and is often used during and after radiation therapy for the prevention and treatment of mucositis (mouth sores).
Topical antiseptics, such as chlorhexidine or benzydamine, have been used for the prevention of mucositis, but recent research indicates that these are not effective. In a Mayo Clinic study involving 52 patients with head and neck cancers who received radiation therapy, chlorhexidine was found to be more toxic, and no more effective than placebo in the prevention of mucositis. German researchers reported that chlorhexidine mouthwashes were not effective in treating mucositis in patients with a low white blood cell count. Despite a significant decrease in the aerobic and anaerobic bacterial flora on the oral mucous membranes, the risk of mucositis seemed to be enhanced. The patients treated with chlorhexidine seemed to have more problems with inflammation, resulting in mucositis.
Strategies to Improve Prevention and Management of Radiation Side Effects
The development of more effective cancer treatments requires that new and innovative therapies be evaluated with cancer patients. Clinical trials are studies that evaluate the effectiveness of new drugs or treatment strategies. Future progress in the prevention and management of radiation side effects will result from the continued evaluation of new treatments in clinical trials. Participation in a clinical trial may offer patients access to better treatments and advance the existing knowledge about treatment of this cancer. Patients who are interested in participating in a clinical trial should discuss the risks and benefits of clinical trials with their physician. Areas of active investigation aimed at improving the prevention and management of radiation side effects include the following:
- Keratinocyte growth factor (KGF, palifermin)
- Interleukin 11
Keratinocyte growth factor (KGF, palifermin): This is a growth factor that has been shown to stimulate growth of epithelial cells, which make up the mucus membrane and line the mouth and throat. Keratinocyte growth factor is currently being tested in patients to prevent chemotherapy damage to the mucus membranes of the gastrointestinal tract.
Antioxidants: The antioxidant agent Cu/Zn superoxide dismutase (SOD) has shown promise in reducing early and late radiation-induced tissue injury. In one clinical trial, 448 patients with bladder cancer were randomly allocated to receive either SOD or placebo after each radiation treatment. The patients who received SOD experienced fewer rectal problems and less bladder inflammation and skin toxicity than those who received placebo.
Interleukin 11: Interleukin 11 is a growth factor that is similar but not identical to what the body normally produces. Interleukin 11 has been approved by the FDA to stimulate platelet recovery in patients with low platelet counts due to chemotherapy. Clinical trials are currently underway to determine if Interleukin 11 will prevent side effects, especially to the mucus membranes and gastrointestinal tract, associated with chemotherapy and radiation therapy.
Prostaglandins: Prostoglandins are a group of compounds that affect the healing of inflammation and wounds. Misoprostol is a prostaglandin that is effective in treating complications that arise in patients with prostate cancer who receive radiation treatment. Inflammation of the rectum (radiation proctitis) is a known complication of radiation therapy in the treatment of prostate cancer. Available medical treatment is usually ineffective and has focused on relieving symptoms after damage has occurred. One clinical study evaluated the effects of misoprostol in patients undergoing radiation therapy treatment for prostate cancer. In the study, nine patients received misoprostol rectal suppositories and seven patients received placebo. The results indicated that misoprostol rectal suppositories significantly reduced acute and chronic radiation proctitis symptoms in patients receiving radiation therapy for prostate cancer.
Frequently Asked Questions About Radiation Therapy
What is radiation therapy?
Radiation therapy, or radiotherapy, is the treatment of cancer and other diseases using ionizing radiation. This radiation can be delivered externally or internally.
How does radiation work?
Radiation therapy works by damaging the DNA in the cancer cell, thereby disabling the cancer cell from reproducing and growing. The cancer cells then die and the cancer shrinks.
Will I feel the radiation or will it hurt?
No, external beam radiation treatments are painless, like having an x-ray taken. Although radiation therapy is not painful, it can cause unwanted side effects. The skin where radiation is aimed may feel like it has been sunburned and will need to be protected from the sun.
Will I become radioactive?
External beam radiation does not cause you to become radioactive, and you pose no risk of radiation exposure to people near you. If you have a radioactive implant in place, some visitors, such as pregnant women and small children, will not be allowed to get too close and visiting time may be limited or restricted until the implant is removed. Your doctor or nurse will tell you when these precautions are necessary.
Are there risks involved with radiation therapy?
The radiation used to damage or destroy cancer cells can also damage normal cells. When this happens, you may experience side effects. However, the risk of side effects is usually outweighed by the benefits of killing cancer cells. Any side effects will be carefully monitored by the radiation oncologist.
What should I know about the risks of radiation therapy?
The risks, problems, and side effects that can occur with radiation therapy depend on the type and the dose and the part of the body that is being treated. Radiation that involves the abdomen may cause diarrhea; radiation involving the head and neck can cause mouth sores. The most common side effects of radiation are fatigue, mouth sores, and skin problems. Before your treatments, your doctor will explain ways to help prevent or reduce potential side effects.
What are the typical side effects of radiation therapy?
The most common side effects of radiation therapy reported by patients are fatigue and skin irritation at the site of treatment. Other side effects depend on the area of the body being treated and the dosage being given, such as:
- Dry or sore mouth or throat may occur when treatment is being given in the mouth, throat or neck area.
- Some coughing and excess mucus production may occur if treatment is given to the lung area.
- Mild nausea and/or diarrhea may occur if treatment involves the abdominal area.
Most of these side effects will go away on their own within 4 to 6 weeks after treatment is completed. Some long-term effects may include changes in the color and elasticity of skin in the treatment area. Discuss any concerns you may have about side effects and ask about medications to counteract them with the radiation oncologist before the start of your treatment.
Will the radiation therapy make me sick?
Most patients do not experience any nausea with radiation therapy, unless the area being treated with radiation is around the stomach. If you experience nausea, report this and any other symptoms to your doctor. Effective medications exist to reduce and/or prevent your symptoms.
Will I lose my hair?
No, you will not lose the hair on your head unless that is the area being treated. Hair loss only occurs in the area that is being treated with radiation therapy. For instance, if the area being treated is your arm, you can expect to lose the hair on that arm during the treatment.
How long will my radiation treatment take?
Most of the time, external beam radiation is delivered in daily treatments, or fractions, over a period of 5 to 7 weeks. The patient will generally receive these treatments Monday through Friday, and then have the weekend off. A daily fraction will take about 15-30 minutes in the treatment room; however, the actual treatment only lasts a few minutes.
Who will administer my radiation treatments?
A doctor who specializes in radiation therapy is called a radiation oncologist. The radiation oncologist will prescribe the type and amount of radiation treatment that is appropriate and work closely with a team of healthcare professionals in determining the best way to deliver that treatment. Those healthcare professionals may include the following:
- Radiation physicists are experts who make sure the machines are working properly and that they deliver accurate radiation doses. The physicist also works closely with the doctor in planning your treatment.
- Dosimetrists are specialists who work with the doctor and physicist to create the treatment plan and calculate the radiation dose delivered to the tumor and the surrounding normal tissues.
- Radiation therapists are professionals who position you and operate the machines to deliver the radiation treatment on the linear accelerator.
- Radiation oncology nurses are caregivers who will help coordinate your care, manage side effects, and help you and your family learn about your treatment.
Can someone come to my treatments with me?
Friends or family are welcome to accompany you to your treatments. However, federal regulations prohibit anyone who is not a patient or a person wearing a film badge monitor to be in the radiation controlled area during the time radiation equipment is being operated. Those accompanying you will likely be asked to wait in the reception area during the treatment. This also serves to protect the privacy of other patients. Only patients and staff are allowed in the treatment area during treatment hours.
Can I continue my regular routine/activities while undergoing radiation treatments?
You should continue with your normal routines. Most patients continue full-time occupations or leisure activities through the course of treatments. When you feel tired, do not over exert yourself; take time to rest when needed. Try to get plenty of sleep and maintain a healthy diet.
Will I be alone during my treatments?
Because radiation effects are accumulated and radiation therapists treat many patients each day, it would be a long-term health risk for them to be in the room during the radiation treatments. To ensure that you are okay and your treatment delivery is going well, you will be in voice contact with your radiation therapists and constantly monitored by a video camera. If you should need assistance, simply tell the therapists and they will terminate the treatment and immediately tend to your needs.
What cancers are treated with brachytherapy?
Brachytherapy is used predominantly to treat early stage prostate cancer; however, it may also be used in breast, cervical, head and neck, and other cancers.
What is involved in the implantation of a radioactive seed into the prostate (brachytherapy)?
For most of these patients, radioactive seed implantation into the prostate is a one-time, non-surgical, low-impact procedure. Radioactive seed implantation into the prostate is typically performed in an outpatient hospital setting by a team of physicians consisting of a urologist, radiation oncologist, and a radiation physicist. Spinal anesthesia is typically performed, but general anesthesia may occasionally be utilized. Some centers perform this procedure in their hospital operating rooms. Both outpatient and inpatient settings are acceptable. Most patients can return to normal activity, including work, within one to three days, with little or no pain.
Will radioactive seeds be painful?
After the implantation of radioactive seeds into the prostate, there typically is some soreness underneath the scrotum. Occasionally patients describe feeling like they are “sitting on a golf ball”. This is due to the slight swelling and bleeding associated with the surgery. It gradually resolves. Most patients require only mild analgesics like acetaminophen (Tylenol®). Narcotic pain medications are rarely required.
How soon after implantation of radioactive seeds into the prostate can I resume exercise or other vigorous activities?
The insertion of the needles causes some trauma to the vessels surrounding the prostate. Therefore, immediately after the implant, any exercise or activity that puts pressure on the prostate should be avoided. You should avoid lifting heavy objects or doing vigorous exercise for at least three to four days after the implant. Very vigorous exercise after this period may cause some minor bleeding in the bladder. This is not harmful, but you should limit your exercise until the bleeding stops. Activities such as bike riding, horseback riding, motorcycle riding in which there is pressure on the prostate should be avoided for at least six months. The repetitious jarring of the prostate with these activities can cause some swelling and impair urination.
Will I be radioactive after the seed implantation?
No. Although the seeds are radioactive, patients are not. Because the radioactivity is so low and the placement is so precise, virtually all the radioactivity is absorbed into the prostate. However, special precautions should be taken when a patient is in contact with small children and pregnant women in the first two months after treatment. You nurse or doctor will advise you what precautions are necessary and when.
Does the radiation from seed implants pose any danger to my sexual partner?
No, the seeds are of low energy and pose little risk to your partner. The semen is not radioactive. You may resume sexual activity very soon after the procedure. Occasionally, there may be blood in the semen or some slight pain at climax.
- Willett CG, Czito BG, Tyler DS. Intraoperative Radiation Therapy. Journal of Clinical Oncology. 2007;25:971-977.
- Brizel DM, Wasserman TH, Henke M, et al. Phase III Randomized Trial of Amifostine as a Radioprotector in Head and Neck Cancer. J Clin Oncol 2000;18:3339-3345.
- Sanchiz F, Milla A, Artola N, Julia JC, et al. Prevention of radioinduced cystitis by orgotein: a randomized study. Anticancer Res 1996;16(4A):2025-8.
- Foote RL, Loprinzi CL, Frank AR, et al. Randomized Trial of Chlorhexidine Mouthwash for Alleviation of Radiation Induced-Mucositis. J Clin Oncol 1994;12:2630-2633.
- Pitten FA, Kiefer T, Buth C, et al. Do cancer patients with chemotherapy-induced leukopenia benefit from an antiseptic chlorhexidine-based oral rinse? A double-blind, block-randomized, controlled study. J Hosp Infect 2003;53:283-91.
- Khan AM, Birk JW, Anderson JC, Georgsson M, et al. A prospective randomized placebo-controlled double-blinded pilot study of misoprostol rectal suppositories in the prevention of acute and chronic radiation proctitis symptoms in prostate cancer patients. Am J Gastroenterol 2000;95(8):1961-6.