Radiation therapy

Radiation therapy

• It is one of the oldest methods of cancer

treatment
• It was first used by Emil Grubbe (a medical
student) to treat an ulcerating breast cancer in
1896
• The observation that radiation cause tissue
damage led scientists to explore the use of
radiation to treat tumors
 DEFINITION

• Radiotherapy is the use of high energy ionizing

rays or particles to treat cancer
 USES OF RADIATION THERAPY

• As the only (primary) treatment for cancer

• Before surgery, to shrink a cancerous tumor
(neoadjuvant therapy)
• After surgery, to stop the growth of any remaining
cancer cells (adjuvant therapy)
• In combination with other treatments, such as
chemotherapy, to destroy cancer cells
• In advanced cancer to alleviate symptoms caused
by the cancer
 Effects of radiation

• Radiation – it is the energy that is emitted

from a source and travels though space or
some material
• Delivery of high energy beams, when
absorbed into tissue, produces ionization of
atomic particles
• The energy in ionizing radiation acts on break
the chemical bonds in DNA
• The DNA is damaged, resulting in cell death
 Types of ionizing radiation

• Electromagnetic radiation – x-rays, gamma rays

• Particulate radiation – alpha particles, electrons,
neutrons, protons
• High energy x rays (photons) are generated by an
electric machine called linear accelerator (linac)
• The main GOAL of radiation therapy is to
determine the optimal dose for a tumor with
minimal damage to normal tissues.
 Main principles of radiotherapy

• Given strictly based on indications and

contraindications
• Optimal dose to the tumour cells and
minimal exposure to the surrounding
tissues
• Must be the shortest and most radical
• Hypoxic tumor cells are resistant and
require higher doses of radiation to
achieve cell kill.
• Risk of morbidity increases when doses
increases.
 4 R’s of radiobiology
• Repair- ability of cells to repair between
fractions of therapy
• Repopulation – regrowth of cells between
fractions.
• Redistribution – in the cell cycle occurs in
normal tissues where as not in tumour cells
• Re-oxygenation- of hypoxic cells to make
them more sensitive to radiation
 Units of measuring radiation
• Before 1985, dose of radiation was
measured in “Rad’(radiation absorbed
doses), now the unit is ‘gray’(Gy) or
centigray (cGy).
• 1 Gy= 100 centigray
• 1 centigray= 1 rad
• 1 joule/kg= 1 rad
• Once the total dose to be delivered is determined, that
dose is divided into daily FRACTIONS
• Doses between 180 and 200 cGy/day are considered
STANDARD FRACTIONATION, typically delivered once a
day Monday through Friday for a period of 2 to 8 weeks
Types of fractionation
• High dose of radiation given with fewer fractions –
hypofractionated
• Lower doses of radiation given with higher fractions –
hyperfractions
• Standard doses delivered twice daily over a shortened
treatment time – accelerate fractionation
 Simulation and treatment planning

• Simulation is a process by which the radiation

treatment fields are defined, filmed and marked
out on the skin with the help of a simulator.
• The radiation oncologist specifies dose and volume
of area to be treated
Treatment volumes include
• Gross target volume (GTV) which is the gross
extent of the tumor identified by examination or
imaging
• The clinical target volume – it is the GTV plus
additional margin to encompass any potential
microscopic or subclinical disease
• The planning target volume PTV which is the
GTV/CTV plus additional margin
Treatment planning
TYPES OF RADIATION THERAPY

External-
Internal
beam
radiation
radiation
therapy
therapy
 External-beam radiation therapy
• Also known as teletherapy
• This is the most common type of radiation therapy
which delivers radiation from a machine outside the
body.
• A linear accelerator, or linac, is using for this
• Special computer software adjusts the beam’s size and
shape.
• Fitting supports or plastic mesh masks are used for
radiation therapy to the head, neck, or brain to help
people stay still during treatment.
 Types of external-beam radiation therapy

 Three-dimensional conformal radiation therapy (3D-CRT).

 Intensity modulated radiation therapy (IMRT).
 Proton beam therapy.
 Image-guided radiation therapy (IGRT).
 Stereotactic radiation therapy.
Three-dimensional conformal radiation therapy (3D-CRT).

• It can create Detailed 3-dimensional pictures of

the cancer, typically from CT or MRI scans.
• Main disadvantage is it is not able to spare the
organs at risk
• Dry mouth is common after radiation therapy
for head and neck cancer.
• But 3D-CRT can limit the damage to the salivary
glands that causes dry mouth.
 Intensity modulated radiation therapy
(IMRT).
• It is an advanced mode of high-
precision radiotherapy that uses computer-controlled
linear accelerators to deliver precise radiation doses
to a malignant tumor or specific areas within the
tumor.
• It deliver maximal doses to the target volume while
sparing critical structures (e.g., spinal cord, carotid
arteries, optic chiasm) as much as possible.
 Proton beam therapy
• This treatment uses protons (positively charged
particle) rather than x-rays.
• At high energy, protons can destroy cancer cells.
• Unlike with x-ray beams, the radiation therapy
does not go beyond the tumor hence limits
damage to nearby tissue.
• This therapy is relatively new and requires
special equipment. Therefore, it is not available
at every medical center.
 Image-guided radiation therapy (IGRT).

•This type of therapy allows the doctor to take

images of a patient throughout treatment.
•These images can then be compared to the
images used to plan treatment.
•It allows better targeting of the tumor and helps
reduce damage to healthy tissue.
 Stereotactic radiation therapy

• This treatment delivers a large, precise

radiation therapy dose to a small tumor area.
• The patient must remain very still.
• Head frames or individual body molds help
limit movement.
• This therapy is often given as a single or a few
treatments. Mainly used in brain tumors
 Internal radiation therapy
• Also called as brachytherapy. Radioactive material is placed
into the cancer or surrounding tissue.
• Implants may be permanent or temporary and may require
a hospital stay. It delivers a high dose of radiation to a
localized area. (radioisotope selected based on half life)
• This internal radiation can be implanted by means of
needles, seeds, beads, or catheters into body cavities
(vagina, abdomen, pleura) or interstitial compartments
(breast). It can also administered orally for thyroid cancers
 Types of internal radiation therapy
Permanent implants.
Temporary internal radiation therapy.
Intraoperative radiation therapy (IORT).
Other options : Systemic radiation therapy.
» Radio immunotherapy.
» Radio sensitizers and radio protectors.
» Peptide receptor radionuclide therapy
(PRRT).
 Permanent implants
• These are tiny steel seeds (about the size of a
grain of rice) that contain radioactive material.
• They deliver most of the radiation around the
implant area. But some radiation may exit the
patient’s body. Safety measures are needed to
protect others from radiation exposure.
• Over time, the implants lose radioactivity. And
the inactive seeds remain in the body.
 Temporary internal radiation therapy
This is when radiation therapy is given in one of
these ways:
• Needles
• Tubes, called catheters
• Special applicators
The radiation stays in the body from a few minutes
to a few days. Most people receive radiation
therapy for just a few minutes. Hospital sty only
for those getting lengthy exposure
 Other radiation therapy options
Intraoperative radiation therapy (IORT): This treatment
delivers radiation therapy to the tumor during surgery
using either teletherapy or brachytherapy. This
treatment is useful when vital organs are close to the
tumor.
Systemic radiation therapy: Patients swallow or receive
an injection of radioactive material that targets cancer
cells. The radioactive material leaves the body through
saliva, sweat, and urine. These fluids are radioactive.
Therefore, people in close contact with the patient
should take the safety measures.
Radio immunotherapy: it uses monoclonal antibodies
paired with radioactive materials. This therapy delivers
low doses of radiation directly to the tumor. It does not
affect noncancerous cells. Examples - ibritumomab and
tositumomab.
Radio sensitizers and radio protectors: Researchers are
studying radio sensitizers. They are substances that help
radiation therapy better to destroy tumors. Radio
protectors are substances that protect healthy tissues
near the treatment area. Examples of radio sensitizers
include fluorouracil (5-FU) and cisplatin. Amifostine is a
radio protector.
Peptide receptor radionuclide therapy (PRRT): This type of
radioactive therapy works by attaching to specific proteins
(receptors) that can be found on the surface of certain tumor
cells. After attaching to the receptor, the drug enters the cell,
allowing radiation to damage the tumor cell.

Recently, the FDA approved a treatment called 177Lu-

dotatate (Lutathera) for advanced neuroendocrine tumors of
the gastrointestinal tract.
Sources
• Temporary sealed sources: iridium – 192 and

cesium -137

• Permanent sealed sources: iodine – 125, gold

– 198 and palladium – 103

 CARE OF THE PATIENT RECEIVING EXTERNAL
BEAM RADIATION

• Be aware of the patient’s treatment field and

teach the patient symptom management of
the associated general and site-specific
reactions to the therapy.
• Site-specific reactions may include: diarrhea,
nausea and vomiting, dysuria, dysphagia,
esophagitis, mucositis, xerostomia, hair loss,
and skin reactions.
 Cont..

• Encourage rest periods as needed during the

course
• Provide nutrition counseling to minimize weight
loss. (eg, high protein, high calorie, low residue, or
soft diet).
• Use skin care products (ie, soaps, creams, lotions,
gels) only at the recommendation
Care for a person undergone brachytherapy

• Aware that the patient is emitting radioactivity

• Patients with temporary implants are radioactive
only while the source is in place
• In patients with permanent implants, because the
sources have fairly short half lives and are weak
emitters, the radioactive exposure to the outside
is low. So discharge with minimal precautions
• Pregnant nurses are not to care for implant
patients
• The principles of ALARA (as low as reasonable
achievable) and time, distance and shielding are
vital to health care professional safety when caring
for the person with a source of internal radiation.
• Organize care to limit the time spent in direct
contact with the patient
• Tell the patient for time and distance limitations
before the procedure
• Do not deliver care without wearing a film
badge (dosimeter) indicating cumulative
radiation exposure
• Do not share the film badge
• Do not wear it anywhere but at work
• Return it to the agency protocol
Internal radiation therapy causes the patient
to give off radiation. As a result, visitors should
follow these safety measures:
• Do not visit the patient if you are pregnant or younger
than 18.
• Stay at least 6 feet from the patient’s bed.
• Limit your stay to 30 minutes or less each day.
Permanent implants remain radioactive after
the patient leaves the hospital. Because of
this, the patient should not have close contact
more than 5 minutes with children or
pregnant women for 2 months.
Similarly, people who have had systemic radiation
therapy should use safety precautions. For the first
few days after treatment, take these precautions:
• Wash your hands thoroughly after using the
toilet.
• Use separate utensils and towels.
• Drink plenty of fluids to flush the remaining
radioactive material from the body.
• Avoid sexual contact.
• Minimize contact with infants, children, and
pregnant women.
Cont..
• Check radioactive sources at the beginning
and end of each shift and document the
status of the implant.
• Applicators should have caps, and interstitial
needles and catheters should be counted
and observed for dislodgment.
 Cont..
• If the implant becomes dislodged, the nurse
will retrieve the radioactive source using the
provided long forceps and place it in a source
holder in the room.
• Notify the radiation oncologist immediately.
There is a 24-hour-on-call coverage.
• Children under 18 and pregnant women are
prohibited from visiting.
 NURSING MANAGEMENT
Deficit knowledge regarding treatment as evidenced
by anxiety and asking many questions.
Interventions:
• Assess knowledge from any previous experience with
radiation
• Assess any fears, myths or misconceptions about
radiation therapy
• Explain purpose of radiation therapy
• Teach patient and family what to expect during
therapy
• Explain all site-specific care to client and family
• Provide information about common side effects.
Risk for impaired skin integrity related to radiation
• Interventions:
• Assess patient’s skin in the treatment area for signs of
radiation, Erythema and darkening, dry desquamation & wet
desquamation
• Assess the skin for long term effects of radiation therapy.
• Clean skin over treatment area with mild non- perfumed
soap and tepid water.
• Use soft cloth and avoid rubbing the skin and dry thoroughly
• Apply lubricating creams that do not contain metal, alcohol,
fragrances or additives that irritate skin.
• Teach patient to avoid scratching dry, itchy area
• Teach patient to avoid exposing skin to pressure, sunlight,
rough clothing, shaving and extremes of temperature.
Risk for injury lack of knowledge of radiation principles or
dislodged radiation implant
• Interventions:
• Review the type, isotope used, method of delivery and duration of
treatment.
• Provide patient private room and private bathroom.
• Post signs outside patient’s room. Provide film badges to staff
responsible for direct care
• For patients with encapsulated form of internal radiation, keep
appropriate lead lined containers in patient room.
• Organize care activities to minimize the amount of time at
patient’s bedside
• Provide only essential care to promote patient comfort
• Prepare meal trays outside the room
• Keep bedside tables, call lights and personal care items within easy
reach of patient at all times to reduce return trips to bedside.