We're here to talk | 24-hours a day
08088 010 444FREE from landlines & most major mobile networks
Providing support to anyone affected by blood cancer
By Dr. Andrea Stevens
Consultant Clinical Oncologist, Queen Elizabeth Hospital Birmingham.
Radiotherapy – for some it is a scary word, thinking about friends and family who have had radiotherapy and had a difficult time; for others, it is a mystery, unlike other treatments. So what is it really all about?
Radiotherapy uses high energy X-rays to treat cancers, including haematological malignancies. It is used in a variety of settings, both as part of curative treatment and also to palliate symptoms e.g. bone pain arising from myeloma lesions in bones, where it is often very effective. We also use it in the conditioning (preparing) regimens ahead of bone marrow/stem cell transplants where total body radiotherapy (single treatment or multiple treatments over three to four days) and total nodal radiotherapy remain important components of treatment in specific settings.
Radiotherapy has acquired something of a bad press due to concerns about its late effects, especially to the lung and heart, but the areas treated with modern radiotherapy are usually far smaller than they used to be and the radiotherapy is much more tightly conformed to the treatment area, meaning that these concerns no longer apply. We use techniques such as intensity modulated radiotherapy (IMRT) along with image guided radiotherapy (IGRT), where CT scans are taken as part of treatment delivery to make sure the radiotherapy is being delivered exactly where it is required.
Total body radiotherapy, however, means exactly that – we treat the whole body, so we look to ensure an even dose across the body rather than being able to create tightly conformed areas of radiotherapy treatment.
Clinical oncologists (radiotherapy specialists) are integral parts of the haematology multidisciplinary team. Patients are discussed in the weekly team meeting to agree a treatment plan for each individual patient. When this is to include radiotherapy, a referral to the clinical oncologist is made and an appointment to be seen in their clinic is made at the appropriate point in the treatment pathway.
The clinic appointment allows the clinical oncology team to explain radiotherapy – what it will involve, number of treatments (or fractions) and possible side effects. It’s your opportunity to ask questions as well, although these can be asked at any point during treatment, of either the doctors you have met in clinic or the therapy radiographers who will actually deliver the treatment and who are highly expert in this area.
The next step is preparing the radiotherapy plan, which is done for each individual patient. Depending upon where in the body we are treating, we may need to start by making what is known as an immobilisation device – this is to keep that part of the body to be treated very still during that treatment. It is also known as a radiotherapy mask or shell – they are made out of a thermoplastic material which becomes floppy and stretchy when soaked in warm water. It can then be pulled to fit exactly before being cooled back down, when it becomes rigid again but now is an exact fit for the patient.
Most patients will need a CT scan of the part of the body we are going to treat, in the exact position we are going to treat you. This allows us to draw out on the CT scan exactly where we are going to treat and see the areas we want to be careful about the dose received – known as Organs at Risk (OARs). There are clearly defined safe doses that we work to for these, which are well established and used throughout the world.
There are also clearly defined protocols for the total dose to be given and in how many treatments, which depend on the haematological malignancy being treated and the setting, such as for the treatment of lymphoma. Palliative radiotherapy is often given as a single treatment or five treatments as we want to get the dose in quickly to hopefully then get on top of symptoms promptly. If you have had radiotherapy before and we are re-treating the same area, this will also potentially influence the dose and/or number of treatments given. This is because there are limits to how much radiotherapy can be given before serious side effects would be seen. This varies according to the area of the body being treated and the OARs being irradiated.
Once the clinical oncologist has done this part of the process, it goes to the planning team who create a plan that will give an even dose of radiotherapy to the area being treated, whilst keeping the dose to the OARs within the specified limits and always as low as possible without compromising the coverage of the area being treated. During this part, there are ongoing discussions between the planners and clinical oncologists about how best to do this.
The final plan is then checked by a different planner before being signed off by the clinical oncologist. It then goes through further checks and is loaded onto the treatment machine ahead of the first treatment.
Having your first radiotherapy treatment can be an anxious time but it will feel like having an ordinary X-ray. Some people say the area feels a bit tingly where we have treated but often people report feeling nothing.
Side effects depend very much on where we are treating. We talk about acute (short term) effects and late (long term) effects. Acute effects start usually as radiotherapy is finishing and last a few weeks after and are fairly common. They include tiredness and some skin redness and soreness where we have treated. Late effects are normally rare but occur several months to years after radiotherapy. These will all be discussed with you at the clinic appointment with the clinical oncologist.