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What does a GP need to know about radiotherapy?

Ayla Cosh and Helen Carslaw
InnovAiT 2014 7: 349 originally published online 28 October 2013
DOI: 10.1177/1755738013484908

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 InnovAiT, 7(6), 349–355 DOI: 10.1177/1755738013484908

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What does a GP need to

know about
radiotherapy?
I
n 1895 the German physicist, Wilhelm Rontgen discovered electromagnetic
radiation in a previously unknown wavelength. He later named this wavelength
‘X-ray’ (X referring to an unknown quantity). Since this discovery and through
the hard work of many others, most prominently Pierre and Marie Curie and
Alexander Graham Bell, radiotherapy has developed into an integral part of the
treatment of cancer. Approximately 320 500 people were diagnosed with cancer
in the UK in 2009, which equates to around 519 cases for every 100 000 people.
Roughly one-half of all patients diagnosed with cancer will receive radiotherapy
treatment at some point during their journey. The aim of this article is to provide
a brief overview of the background of radiotherapy, some of the more frequently
occurring side effects that GPs need to be aware of and the role of the GP in
patients receiving radiotherapy treatment.

The GP curriculum and radiotherapy

Although radiotherapy is not specifically mentioned in the curriculum, management of patients who experience severe
side effects would come under clinical example 3.03, Care of acutely ill people. GPs should be able to:
. Recognise the signs of illnesses and conditions that require urgent intervention
. Work effectively in teams and coordinate care
. Prioritise problems and establish a differential diagnosis
. Make patient’s safety a priority
. Consider the appropriateness of interventions, according to the patient’s wishes, the severity of the illness and
any chronic or comorbid diseases
. Be able to make mental state assessments and ensure the safety of others
. Accept responsibility for your actions, at the same time recognising your need for involving more experienced
personnel
. Act calmly in emergency situations and follow agreed protocols
. Know the process and arrangements for commissioning and delivering urgent and unscheduled care in your
community
. Be aware of how the management of patients with continuing conditions affects the need to give urgent and
unscheduled care

and charged particles such as electrons and less com-

What is radiotherapy
..............................

monly protons. There are four main situations in which

and how does it work?
...........................................................
radiotherapy is used in the context of cancer manage-
ment and they are described in Box 1.
The term ‘radiotherapy’ describes the use of ionising
radiation to control or destroy cancer cells. At present There are two principal types of radiotherapy; external
the forms of radiation used include X-rays, gamma rays beam radiotherapy and brachytherapy. External beam

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Box 1. How radiotherapy is used in the The planning of radiotherapy treatment requires the use
treatment of cancer. of three-dimensional imaging to ensure that the required
radiation field is properly treated but that the dose to the
. Used to destroy abnormal tumour tissue - aiming non-target surrounding tissues is minimised. The pos-
for radical treatment itioning of the patient is extremely important and effect-
. Used in the neoadjuvant setting to shrink the ive immobilisation is essential. In certain situations such
tumour making it easier to surgically remove as head and neck cancers, patient-specific thermoplastic
. Used in the adjuvant setting after surgery to des- masks are used to ensure there is no movement during
troy small amounts of tumour that may be left delivery of the treatment.
following surgery
. Used to control symptoms and for use in palliative
situations, e.g. to relieve pain/prevent bleeding General side effects
...........................................................
Fatigue
radiotherapy is usually delivered by a linear accelerator. Fatigue is a general side effect that can present during
Kilovoltage X-rays are used for treating superficial struc- radiotherapy and in the weeks that follow. Certain types
tures and megavoltage X-rays are used for treating of radiotherapy carry a higher risk of causing fatigue such
deeper structures such as the bowel or bladder. A as whole brain radiotherapy. However, radiotherapy
linear accelerator has the ability to deposit the maximum fields that include a large proportion of bone marrow
dose of radiotherapy beneath the surface and therefore can cause anaemia due to the temporary destruction of
when treating deep structures is thought to be skin- haematopoietic stem cells. Therefore, it is important to
sparing. The radiation dose or exposure is measured in check a full blood count in patients undergoing radiother-
units of absorbed radiation per unit of tissue. One Gray apy who present with fatigue if anaemia is thought to be
(Gy) represents one J/kg of tissue. External beam radio- the cause. After eliminating anaemia, reassure patients
therapy is given in what are called ‘fractions’, when the that fatigue is a normal part of receiving radiotherapy
total dose of radiotherapy is split up and spread out over treatment and is likely to pass. Patients should be encour-
time. This could range from daily over a number of days aged to pace themselves and plan activities with regular
or weeks to weekly. Fractionation of radiotherapy maxi- rest periods during this time.
mises the treatment effect and also minimises the side
effects to the surrounding healthy tissues by allowing Depression
normal cells time to recover. Depression is multifactorial in origin, often being caused
by a combination of tiredness, anxiety and potentially
The second form of commonly used radiotherapy is difficult social circumstances that can arise when patients
brachytherapy, or internal radiotherapy. This technique go through intensive treatment. It is important for mood
involves putting radioactive material in close proximity to be considered when assessing patients undergoing
to the tumour (common when treating prostate and cer- radiotherapy. Treatment is with antidepressants and/or
vical cancers). Techniques include implantation of radio- psychological therapies as appropriate.
active ‘seeds’; a radioactive liquid being ingested and
then absorbed by the cancer cells; or an intravenous
injection of radioactive material which is also then
Nausea and vomiting
Nausea and vomiting are other general side effects of
absorbed by the cancer cells (for example, in treating
radiotherapy. The larger the area of the body being trea-
thyroid cancers).
ted then the higher is the risk of the patient experiencing
these symptoms. Nausea and vomiting can also be pre-
Stereotactic radiotherapy is used to treat brain tumours
dicted from the specific site to which the radiotherapy is
by delivering radiotherapy precisely to the diseased area.
delivered, for example, irradiation of the brain or parts of
In order to accurately treat the lesion, a head frame is
the upper gastrointestinal tract are more likely to cause
made to ensure that there is no movement during treat-
nausea and vomiting. Although the exact mechanism by
ment, therefore protecting surrounding brain tissue. The
which these symptoms occur is unclear, they usually
term ‘stereotactic radiosurgery’ is used to describe a pro-
respond to treatment with 5HT3 antagonists such as
cedure involving a single episode of stereotactic radio-
ondansetron. It is better if nausea and vomiting are pre-
therapy treatment.
vented by giving anti-emetics prophylactically rather than
treated once symptoms have started.
There is still much to be learnt about the exact mechan-
ism of cell death resulting from radiotherapy. There is
evidence that radiation treatment causes the production
of free radicals and the ionisation of oxygen molecules,
Common site-specific
this causes damage to deoxyribonucleaic acid which then side effects
...........................................................
leads to cell death or inhibition of reproduction via mech-
anisms such as inducing tumour cell apoptosis or causing Other than fatigue and depression, side effects which
permanent cell cycle arrest. develop as a result of radiotherapy tend to be related

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to the treatment site. Early side effects usually present
and are generally treatable. However, late side effects
(developing 6 months or more after treatment) are
often permanent.

Skin
Although in recent years, with the usage of megavol-
tage equipment, skin reactions are less commonly seen,
a portion of skin is irradiated in all patients treated with
external beam radiotherapy, and clinically significant
skin reactions can still pose a big problem. Acute and
chronic skin changes are detailed in Table 1.

It is important to advise all patients to apply an emollient

at least daily while undergoing radiotherapy as it is diffi-
cult to predict how the skin will be affected. Patients
undergoing radiotherapy need to have their skin exam-
ined regularly so that if side effects present, appropriate
dose reductions can be made. Figure 1 shows an exam-
ple of a patient with radiotherapy-induced skin erythema.
Figure 1. Example of erythema caused by radiotherapy.
Dr P Marazzi/SPL.
Brain
Radiotherapy to the brain is administered for treatment
of a primary tumour or for the palliative treatment of
metastases. Whole brain radiotherapy is very difficult to
tolerate, and patients often feel unwell for weeks after
treatment with fatigue, memory loss, hair loss, nausea
and possible skin irritation. Figure 2 gives an example
of radiotherapy-induced hair loss.

Memory loss and hair loss commonly resolve over time.

However, in some patients they will persist and become
long-term side effects. There is usually a good support
network patients can access through their oncology
department to help with memory problems and finding
wigs or head scarves to help with such side effects.

Nausea and vomiting can also be problematic in patients Figure 2. Hair loss after treatment with radiotherapy.
receiving radiotherapy to the brain. It is important to Reprinted from International Journal of Radiation
identify the cause and the mechanism of the nausea or Oncology  Biology  Physics, 72(3), Rosenthal DI,
vomiting. The vomiting centre in the brain can receive Chambers MS, Fuller CD, Rebueno NC, Garcia J, Kies MS,
Morrison WH, Ang KK, Garden AS., Beam Path Toxicities
to Non-Target Structures During Intensity-Modulated
Radiation Therapy for Head and Neck Cancer, Pages 747–
755, Copyright (2008), with permission from the American
Table 1. Skin reactions to radiotherapy. Society for Radiation Oncology.

Early changes Late changes

Erythema Fibrosis
Dry and moist Loss of pigment signals from the vestibular apparatus, the cerebral cortex,
desquammation Telangiectasia the chemoreceptor trigger zone and the vagus and
Pigmentation Loss of skin appendages splanchnic nerves. There are different receptors in
Epilation Loss of connective tissue these areas to which the various anti-emetics bind, or
Loss of sweat gland have affinity for, therefore it is important to work out
function via which pathway the vomiting centre is being activated
Tissue oedema so that the most appropriate anti-emetic can be given
Reproduced from Souhami, R., Tobias, J. Cancer and its man- (see Table 2 and Fig. 3). Nausea and vomiting are usually
agement. Third edition, (1998), with permission from Wiley- acute side effects which resolve a few weeks after com-
Blackwell. pletion of treatment.

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Table 2. Anti-emetics. not all side effects can be wholly attributed to the radio-
therapy itself.
Commonly used Neurotransmitter site
anti-emetic at which it is effective
Nervous system
Radiotherapy involving the spinal cord can potentially
Cyclizine Ach/H1
cause a myelitis which may cause altered sensation,
weakness and even irreversible paraparesis. Great cau-
Metoclopramide D2/weakly at H1
tion and care is taken to give the appropriate exposure of
radiotherapy to patients, and consideration will be given
Haloperidol D2/weakly at H1 to the length of the spinal cord being treated, the frac-
tionation and the total dose. A possible long-term side
Domperidone D2 effect from radiotherapy to the spinal cord is that of
Lhermitte’s or barber’s chair syndrome (paraesthesiae
Ondansetron 5HT of the extremities on flexing of the neck), this is often
reversible over time.
Levomepromazine Affinity for most receptors but
weaker, tends to be used as a
Head and neck
second- or third-line treatment Epithelial cells lining the mouth and upper gastrointes-
tinal tract have a high turnover and therefore are readily
affected by radiotherapy. A sore mouth or throat can be a
common problem leading to eating and swallowing diffi-
culties. The problem can usually be managed by pain
Patients receiving radiotherapy to the brain are usually relief, mouthwashes and adjusting eating habits appro-
given oral steroids to accompany the course of treatment priately. In severe cases, ulceration and infection can
to minimise brain swelling. At high doses the steroids can develop and patients may have to be fed via nasogastric
cause significant side effects such as gastric irritation, tube until symptoms settle.
sleeplessness and uncontrollable blood sugars.
Therefore, it is important to remember the side effects Osteonecrosis of the jaw is another potential side effect of
of concomitant medications when assessing patients as radiotherapy to the head and neck and is termed

Figure 3. Nausea and vomiting pathways.

Reprinted from Anaesthesia & Intensive Care Medicine, 13(13), Iqbal IM, Spencer R, Postoperative nausea and vomiting,
Pages 613–616., Copyright (2012), with permission from Elsevier.

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osteoradionecrosis. Radiotherapy can cause reduce blood chronic. Diarrhoea can often be managed with anti-
flow and poor healing ability which can lead to necrosis. diarrhoeal medications, antispasmodic medications and
This is a serious side effect and often requires surgery. a change in diet. Nutritional deficiency and significant
weight loss can occur and so it is important that this is
If radiotherapy is directed at or if the field includes the monitored and supplements are given as necessary. If
salivary glands, then patients will develop a dry mouth as bloody diarrhoea persists after radiotherapy, referral to
the amount of saliva produced is markedly reduced. In exclude other causes is indicated.
some patients this can be a permanent change. This is a
significant side effect as it can cause problems with Radiotherapy to the pelvis can affect the bladder causing
speech, taste, the enjoyment of food and recurrent infec- cystitis. This can present with dysuria, urinary frequency, a
tions. Various artificial saliva sprays or gels are available feeling of incomplete voiding and occasionally bleeding.
as well as medications to stimulate the production of These can be short- or long- term side effects. Patients
saliva such as pilocarpine. Tooth decay is a further side with persistent urinary symptoms will need a referral for
effect of radiotherapy involving the head and patients cystoscopy to eliminate any other causes and to poten-
must be encouraged to have regular dental check ups. tially cauterise any vessels that may be bleeding. Patients
should be advised to drink more water and avoid bladder
Chest irritants such as tea, coffee and alcohol.
Radiotherapy to the chest can cause swelling and sore-
ness of the throat. If the treatment area is close to or Radiotherapy to the pelvis can cause sub- or infertility in
includes the stomach radiotherapy can also cause nausea both males and females of reproductive age. This should
and vomiting. This is usually a short-term side effect and be discussed in depth during the consenting process and
clears within a few weeks of completing the radiotherapy.
Nausea and vomiting can often be controlled with regular
anti-emetics and the careful timing of meals or snacks. It
is important to ensure patients are getting adequate
nutrition during and after radiotherapy, as losing signifi-
cant amounts of weight can affect the ability of the
patient to tolerate further treatments. Early referral to a
dietician is imperative.

As well as affecting the gastrointestinal tract, radiother-

apy to the chest also affects the lungs. One of the more
serious short-term side effects is pneumonitis, which is
inflammation of the lung tissue, and may present with
breathlessness, cough and hypoxia. Patients are often
treated with steroids but at times require hospital admis-
sion if symptoms are severe and oxygen is needed. If
assessing patients who are undergoing radiotherapy and
experiencing breathlessness it is also important to con-
sider other potential differential causes such as pulmon-
ary emboli or infection. Figure 4 shows an X-ray of a
patient with radiotherapy-induced pneumonitis.

Radiotherapy can also cause longer-term damage to the

lungs with fibrosis and scarring, particularly with radical
radiotherapy to the chest. This can cause long-term
reduced exercise tolerance, breathlessness, cardiac prob-
lems and the need for supplemental oxygen therapy. It is
often managed with oral steroids and pulmonary rehabili-
tation can be helpful.

Abdomen and pelvis

Radiotherapy-induced diarrhoea results from a number
of different pathological mechanisms which include: a
Figure 4. X-ray example of radiation pneumonitis (A
change in gut motility, a decreased absorption of bile being initial X-ray and B showing radiation pneuonitis).
salts due to epithelial cell damage and imbalances in Reprinted from Makimoto T, Tsuchiya S, Hayakawa K,
local bacterial flora. Patients may also experience Saitoh R, Mori M. Risk Factors for Severe Radiation
bloody diarrhoea. This is often a short-term side effect Pneumonitis in Lung Cancer, 1999, 29(4), 192–197, by
but occasionally, symptoms can persist and become permission of Oxford University Press.

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often patients choose to have gametes stored. Female prevent fracture. Radiotherapy given for the relief of
patients receiving treatment to the pelvis may experience bone pain is usually given as a single fraction and has a
vaginal dryness or irritation. Advising use of lubrication if good response.
sexually active can help alleviate dyspareunia associated
with vaginal dryness.
Reduction of tumour bulk to reduce pain
Radiotherapy can be effective in reducing the size of the
tumour and therefore controlling symptoms it is causing.
Radiotherapy in Reducing the tumour bulk can be effective in improving
pain symptoms.
palliative situations
........................................................... Treatment of haemorrhage
Radiotherapy is widely used in palliative situations to aid Some tumours extend to and involve the skin causing
in the relief of symptoms and to reduce the growth of the ulceration. This can lead to bleeding which in some
neoplasm. Radiotherapy used in the context of palliative cases can be severe and distressing. Radiotherapy can
care accounts for at least one-half of all radiotherapy be given to problematic areas to try to control bleeding.
treatment administered. The dose given will be the
lowest effective dose in order to minimise the potential
side effects.
The GP’s role
...........................................................
Bone collapse leading to spinal cord
GPs have an important role in the provision of continuity
compression
of care to patients undergoing cancer treatment. Patients
The sequelae of unrecognised or untreated spinal cord
receiving radiotherapy will no doubt have seen many
compression are potentially devastating and can render a
different healthcare professionals during the diagnosis
patient completely immobile depending on the level of
and treatment of their cancer, but the GP remains a con-
the compression. Patients who have bone metastases are
stant in their care. GPs often have unique insight into
at a high risk of cord compression and so it is important
their patient’s psychosocial situation which enables GP to
to have a greater index of suspicion if back pain or neuro-
provide appropriate input and can aid decision-making
logical symptoms occur. Patients who present with symp-
regarding which other services may be of benefit to the
toms that create suspicion of spinal cord compression
patient. It is important for patients undergoing cancer
need immediate referral for a magnetic resonance ima-
treatment to have easy access to medical attention.
ging scan depending on how local referral pathways are
GPs can provide easily accessible care.
arranged. Starting oral steroid treatment as soon as pos-
sible is important as this can improve overall prognosis.
The GP is involved in patient education and can provide
information to patients and answers to questions they may
Relief or improvement of symptoms have regarding their treatment. After seeing specialists
of obstruction patients may have questions they had forgotten to ask
Cancers can cause obstruction such as superior vena or issues they may wish to discuss further. Advising and
cava obstruction (SVCO), tracheal or oesophageal clarifying details of radiotherapy treatment to patients is
obstruction. Often stents are used to relieve the symp- important particularly at a stressful point in their lives.
toms of tracheal or oesophageal narrowing but it is some-
times more appropriate to treat with radiotherapy. SVCO Having knowledge of side effects of radiotherapy is
is treated with radiotherapy and steroids and it is import- important as GPs will be called upon should problems
ant that symptoms and signs are recognised as early as arise. Being able to advise patients of what to expect
possible to improve prognosis after treatment. and how side effects can be managed is helpful. GPs are
particularly likely to encounter the chronic side effects of
radiotherapy that can present at any time from weeks to
Brain metastases years after treatment and unfortunately tend to be per-
Radiotherapy to the brain is often difficult to tolerate.
manent and potentially progressive. As cancer survival
Therefore, patient fitness or performance status need
rates improve more patients with chronic side effects
to be assessed to try and predict the patient’s ability to
will be seen.
cope with the treatment as it may not be appropriate in
all cases.
It is important that GPs recognise some of the symptoms
that can be relieved or partially relieved by radiotherapy
Bone pain and refer promptly for treatment. Being able to access
Pain from metastatic bone disease is often well localised help is important in the emergency setting, for example,
and worse on movement. At times lytic lesions can be so in patients with spinal cord compression. Prompt action
severe that the risk of fracture is high and patients will reduce potential neurological complications
undergo prophylactic surgery to stabilise the bone and and improve the patient’s symptoms and therefore quality

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aiming to provide a high standard of care for people. cancer treated with palliative radiotherapy.
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. Halkett, G. K. B., Jiwa, M., O’Shea, C., Smith, M.,
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patients. Management of cases that might benefit from
radiotherapy: a standardised patient study in pri-
Macmillan Cancer Support: www.macmillan.org.uk – mary care. European Journal of Cancer Care, 21,
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and treatment people. Retrieved from www.rcgp.org.uk/gp-train
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exams/Curriculum-2012/RCGP-Curriculum-3-03-
Acutely-Ill-People.ashx
. Schreiber, G. J., Meyers, A. D., Calhoun, K. H., &
Key points Talavera, F. (2011). General principles of radiation
. Approximately one-half of patients with cancer will therapy. Retrieved from http://emedicine.meds
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. Radiotherapy is widely used in both the treatment . Souhami, R., & Tobias, J. (1998). Cancer and its
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References and further information
. Ahmad, S., Duke, S., Jena, R., Williams, M., &
Burnet, N. (2012). Advances in radiotherapy.

Dr Ayla Cosh
Clinical Assistant, Breast Oncology, Velindre Cancer Centre, Cardiff
GP, Saltmead Medical Centre, Cardiff
Email: aylacosh@gmail.com

Dr Helen Carslaw
GP Retainer, Sunny Meed Surgery, Woking

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