RADIATION THERAPY

and SIDE EFFECTS

Jo Tuaine
May 2017
OVERVIEW

• What is radiation therapy

• How it works
• Impacting factors
• Assessment
• Skin reactions
• Treatment
• Potential for the future
RADIATION THERAPY

• The medical use of high energy x-rays

primarily for cancer treatment
• 60% of cancers are treated with radiation
therapy
• Intent can be both curative or palliative
• Combined modality treatment is increasing
• High energy x-rays damage the DNA of the
cancer cells in the area being treated

• The radiation can be very accurately

targeted to treat only the required area
How does radiation therapy work?
Radiation is particularly lethal during mitosis and cell
division – the cell’s most sensitive processes - and can
delay the onset of cell division
Cell death

"G2 "
Most resistant
phase in the phase Most sensitive
"S" phase
cell cycle (DNA phase in the
"M" phase
synthesis) cell cycle
(mitosis)

"G1 " "G0 "

phase cell resting
How does radiation therapy work?
Interference with normal cell function can result in either
immediate cell death or in a series of events leading to
cell death, although affected cells may go through a few
more divisions before dying
Cell death

"G2 "
Most resistant
phase in the phase Most sensitive
"S" phase
cell cycle (DNA phase in the
"M" phase
synthesis) cell cycle
(mitosis)

"G1 " "G0 "

phase cell resting
 Single strand breaks are of little
consequence to treatment – cells
have evolved efficient repair
mechanisms
Photons of radiation
impinging on the
DNA resulting in
single strand breaks

Photons of radiation
impinging on the
DNA resulting in
double strand breaks

Double strand breaks – difficult for the

cell to repair and can cause irreversible
damage. There will be no template for
the cell to use to repair the damage
 The aim of radiation therapy
Usually described as being given with either curative or
palliative intent

Curative intent – aims to cure or at very least achieve local

control of the cancer whilst causing minimal damage to
normal, ‘healthy’ tissue which is in or close to the treated
area
 Curative radiation therapy
 Treatment courses can continue five days a week for 7 or
even 8 weeks – patients could have up to 35 or 40
treatments (fractions) altogether
 The total dose of radiation given is usually high – side
effects tend to be acute
 Treatment techniques tend to be complex
 Patient comfort can be sacrificed to achieve pinpoint
accuracy
FRACTIONATION –the number
of treatments
The total prescribed dose is divided into a
specific number of treatments

Different malignancies require different

prescriptions. This is determined by the cells
sensitivity to XRT and the ability of the
healthy cells to repair
 How fractionation works
 A given amount (or dose) of radiation
will kill a certain % of cells. The cells
that are killed are those that are in
their most sensitive phase i.e.
Day 1: tumour cell population
mitosis and cell division – a state
reduced by 50%
known as radiosensitivity
 Once the radiosensitive cells have
been killed, those cells that remain
will be radioresistant – in other
words, they will be in a phase of the
Day 2: tumour cell population
reduced by 50% cell cycle that is not sensitive to
radiation
 How fractionation works
Day 3: tumour cell population
reduced by 50%
Day 4: tumour cell population
reduced by 50%
Day 5: tumour cell population
reduced by 50%
 Cells are programmed to respond to
injury and death. Within 24 hours
new ‘recruits’ will have been brought
in from the resting phase of the cell
cycle
 Other cells will also be progressing
through the cell cycle  a new
supply of radiosensitive cells
 Critical dose ~ 200 cGy (2Gy)
 If the same amount of radiation is
given each day, the same
percentage of remaining cells will be
killed each day
Critical criteria for curative RT
 Tumour repopulation is minimised by
limiting breaks in treatment
 Treatment is given five days a week
(generally Monday to Friday)
 Cancers are prioritised into 3 groups
– P1, P2, P3. P1 cancers must have
~ 5 fractions per week. This may
necessitate giving treatment twice a
day to achieve this
 Completion of a course of curative
treatment is vital if the patient is to
have the best chance of a ‘cure’
 Palliative radiation therapy
 Aim – to improve quality of life through symptom relief
 Typically treatment courses are shorter because doses
are lower – can be as short as a single #
 Treatment techniques are simpler
 Try to avoid compromising patient comfort
Palliative radiation therapy
Typically used to relieve:
 Pain
 Obstruction
 Bleeding
 Ulceration
 Neurological symptoms (e.g. cord compression)
Pathophysiology of Skin

• Skin composed of 2 main layers

– Epidermis (superficial layer)
– Dermis (deep layer)

• Basal layer of the epidermis; proliferates rapidly

and particularly sensitive to Radiation Therapy
RADIATION THERAPY

• Ionizing radiation damages the mitotic

ability of the stem cells within the basal
layer preventing the process of
repopulation and weakening the integrity of
the skin. Repeated radiation impairs cell
division within the basal layer and skin
reaction develops
• Skin is very sensitive to radiation. Basal cell
loss begins at 20-25Gy(visible at 2 – 3
weeks)
• Erythema – 20-40Gy
• Dry desquamation – 45 Gy
• Moist desquamation – 45 Gy
• Maximum depletion occurs at 50Gy peaking
at the end of treatment
INCIDENCE

• SEVERITY DIFFICULT TO PREDICT

– Breast cancer 87% - 95%
– Head and neck cancer 94.3%
– Use of EGFR inhibitor increases to 98.1%
– Increasing use of concomitant chemotherapy
and high dose radiation increases the
incidence on skin reaction even more
ASSESSMENT
• Pre treatment assessment
– Comorbidites
– Medications
– Previous sun exposure
– Smoking and alcohol intake
– Nutritional status
– Skin type (Fitzpatrick scale)
– Treatment area
ASSESSMENT TOOLS

• EviQ radiotherapy Nursing Assessment

Form
• Fitzpatrick Skin Assessment Tool
• RISRAS Scale
IMPACTING FACTORS

• Treatment related
– Type of energy (electrons v photons)
– Use of parallel opposed fields (2 skin surfaces
are proximal)
– Bolus (gel-like sheets which increase radiation
dose to the skin)
– The location of the lesion eg: close to the skin
surface
IMPACTING FACTORS

• The treatment technique used eg more

treatment beams, less dose to the
periphery
pt’s with a deep seated tumour will often
not receive a skin reaction such as bladder
cancer, prostate cancer
whereas rectal cancer will likely receive a
skin reaction between buttocks due to the
proximity of the lesion to the skin surface
IMPACTING FACTORS
– Skin types (the scalp has a higher tolerance
than the trunk or groin)
– More oxygenated cells than hypoxic cells
– Size of the txt field
– Radiation dose
– Previous radiation
– Use of radiation sensitizer
IMPACTING FACTORS

• Non-treatment related
– General skin condition – moist areas of the
body causing friction (axilla, inframammary
areas, groin, perineum
– Skin folds and bony prominences
– Age and nutritional status
– Prior exposure to chemotherapy (radiation
recall - doxorubicin)
IMPACTING FACTORS
– Healing may also be affected in people with
elevated blood pressure
– Smoking
– Underlying medical conditions (scleroderma,
lupus, diabetes
SKIN REACTIONS

• There are three distinct manifestations of

skin reactions
– Erythema
– Dry desquamation
– Moist desquamation
ERYTHEMA

Different shades of redness occur from the

release of histamine-like substances from
damaged germinal cells
ERYTHEMA

• Pink to dusky colouration

• May be accompanied by
mild oedema
• Burning itching and mild
discomfort
DRY DESQUAMATION

Dry, flakey, or scaly skin because the

sweat and sebaceous glands have
been impacted by the radiation
therapy
Inflammation results from the invasion
of neutrophils and the migration of
eosinophils,lymphocytes,
macrophages, mast cells and plasma
cells
DRY DESQUAMATION

Pruritus, scaling and hyperpigmentation

occurs
Hyperpigmentation results from increased
melanin production in the basal layer and
flattening of the dermal papillae and thinning
of the epidermis occurs
DRY DESQUAMTION
•Partial loss of epidermal
basal cells
•Dryness, itching, flaking
scaling, peeling
•Pain
•hyperpigmentation
MOIST DESQUAMATION

Results from the eradication of all stem cells

from the basal layer with exposure of the
dermis
Bullae form in the suprbasal and
subepidermal layers shed
A fibrinous layer then covers the denuded
surface and inflammatory infiltrate and
stromal fibrin formation occurs
MOIST DESQUAMATION
•Complete destruction
of basal cell layer
•Blister or vesicle
formation
•Nerve exposure and
pain
•Serous drainage
TREATMENT

• Assessment prior to radiation therapy –

assessment tool RISRAS scale
• Evaluation
– Patient on treatment clinics – evaluation of the
skin minimum of twice a week
– Initiate appropriate intervention
AIMS OF TREATMENT
• Protection
• Comfort
• Reduces irritation
• Reduce friction and trauma
• Ability to treat through without enhancing the
effects of the radiation therapy
• Maintains hydration
• Absorbs exudate
TREATMENT OPTIONS

• Mepilex Lite
• Mepitel One
• Mepitel film
STRATA XRT
POST TREATMENT CARE

• Procare cream
• Appropriate product
• Referral to DN
• Follow up in 4 – 6 weeks with Consultant
• Procare cream protects your skin and encourages healing
after you’ve completed your radiation therapy.Please
start using it AFTER your LAST radiation
treatment.Apply it THICKLY over the whole treatment
area.PLEASE DO NOT wash it off or try to scrub it off in
the shower or when you have a bath. Reapply it twice a
day.Use for 14 days.After 14 days, please wash it off
gently, using plenty of Microshield Wash. (Blue bottle).
Your skin should then look pink, shiny and healthyNB:
Procare cream is very messy so it’s a good idea to
protect your clothes using clean handkerchiefs, old t-
shirts etc under clothes. Procare cream will wash off
your clothing.
REFERENCES
Diggelmann, K.V., Zytkovicz, A.E., Tuaine, J.M., Bennett, N.C., Kelly, L.E., Herst,
P.M.(2010). Mepilex Lite® dressings for the management of radiation-induced
erythema:a systematic inpatient controlled clinical trial. The British Journal of
Radiology; 83:971–978

Ryan,R.I., Haas,M.L., Gosselin,T.K., (2012)Manual for Radiation Oncology Nursing

Practice and Education. Oncology Nursing Society. Fourth Ed.

D’Haese,S et al: (2005) Managemnt of Skin Reactions duraing radiation therapy:

a study of nursing practice. European Journal . Cancer Care

www.Eviq.au.com