What is radiotherapy?

Radiotherapy is the use of high energy x-rays and similar rays (such as electrons) to treat disease. Since the discovery of x-rays over one hundred years ago, radiation has been used more and more in medicine, both to help with diagnosis (by taking pictures with x-rays), and as a treatment (radiotherapy). While radiation obviously has to be used very carefully, doctors and radiographers have a lot of experience in its use in medicine. Many people with cancer will have radiotherapy as part of their treatment. This can be given either as external radiotherapy from outside the body using x-rays or from within the body as internal radiotherapy. Radiotherapy works by destroying the cancer cells in the treated area. Although normal cells can also be damaged by the radiotherapy, they can usually repair themselves.

Radiotherapy treatment can cure some cancers and can also reduce the chance of a cancer coming back after surgery. It may be used to reduce cancer symptoms. Some people find that the side effects are very mild and that they just feel tired during their course of radiotherapy treatment.

Why radiotherapy is given

Curative treatment

Radiotherapy is often given with the aim of destroying a tumour and curing the cancer. When radiotherapy is given in this way it is described as radical radiotherapy. Radiotherapy may be used on its own or may be given before or after surgery or chemotherapy. Chemotherapy is the use of anti-cancer drugs to destroy cancer cells. If radiotherapy and chemotherapy are given at the same time, this treatment is known as chemoradiotherapy. For some types of curative radiotherapy treatment, you may need to go to the hospital each weekday for between two and seven weeks. In this situation, a small dose of radiotherapy is given each time. This is because as well as damaging cancer cells, radiotherapy can also cause damage to healthy cells in the treatment area. If a very high dose of treatment was given all in one go, it could cause too much damage to the healthy cells, so small doses are given to allow them to recover in between.

Palliative treatment

Sometimes, when it is not possible to cure a cancer, radiotherapy may be given to relieve symptoms – for example, to lessen pain. This is called palliative treatment. Lower doses of radiotherapy are given than for curative treatment, usually over a shorter period of time (sometimes just a single treatment).

Total body irradiation

This type of radiotherapy is used much less commonly than the other types of radiotherapy, but may be given to people who are having a stem cell transplant as part of their treatment. A large single dose, or six to eight smaller doses of radiation is given to the whole body to destroy the cells of the bone marrow. Very high doses of chemotherapy are also given. This treatment is followed by giving stem cells by a drip into a vein, to replace the bone marrow that has been destroyed.

Blood and Tumour samples

Many blood samples and bone marrow or tumour biopsies may be taken to help make the right diagnosis. You may be asked for your permission to use some of your samples for research into cancer. If you are taking part in a trial you may also be asked to give other samples which will be frozen and stored for future use, when new research techniques become available. These samples will have your name removed from them so you can’t be identified. The research may be carried out at the hospital where you are treated, or it may take place at another hospital. This type of research takes a long time, so you are unlikely to hear the results. The samples will, however, be used to increase knowledge about the causes of cancer and its treatment. This research will, hopefully, improve the outlook for future patients.

Work and radiotherapy

Sometimes people can carry on working part-time during their treatment, but many people feel very tired and may feel unwell. In this case you may need to make changes to your usual routines. Most employers will be sympathetic if you explain why you need time off work. It is helpful to talk to your employer or personnel officer to explain how much time off you may need and what you will be able to do. It can be hard to predict exactly what you will be able to do, but your employer will appreciate being given some idea of what to expect.

Children and radiotherapy

Radiotherapy can be a frightening experience for both children and their parents, but once everyone understands what is involved this fear can be reduced. The radiotherapy staff are used to treating children and they can offer help and support. Young children, especially if they are aged three or younger, may have their treatment under a mild general anaesthetic. As your child can't eat or drink for at least four hours before his or her treatment, you will probably have a morning appointment. The anaesthetic is usually given in the radiotherapy department by an anaesthetist. You can stay with your child until they are asleep. Although you won't be able to stay in the radiotherapy room during your child's treatment, you can watch through the window or on the TV screen. The nurses will look after the child until they wake up, usually after 20 minutes to an hour. You will then both be able to go home, unless your child is an in-patient, in which case a nurse will take them back to the ward.

Older children may take a while to get used to the size and sound of the machines, but this should get easier once they get to know the staff and the surroundings. If you are finding it difficult to cope with your child's illness, you may find it helpful to contact one of the children's cancer groups. Sharing your experiences with other parents can help you to cope with your own problems and fears.

Where do you have your radiotherapy treatment?

Radiotherapy equipment is very complex and takes up a lot of space, as well as support from specially trained staff, so radiotherapy departments tend to be in the larger regional and teaching hospitals. Often you will have your initial cancer treatment (such as surgery) at your local hospital and will then be referred to your nearest specialist cancer treatment hospital for radiotherapy. Radiotherapy departments have varying types of equipment and are organised according to local needs, so they are run in different ways. While most of the information in this section is fairly general, and will apply to most departments, you may find that there are some differences at the hospital where you are treated.

You can usually have external radiotherapy as an outpatient, but if you are unwell, or having chemotherapy at the same time, you may need to stay in hospital and will be taken to the radiotherapy department each day from the ward. If you are having internal radiotherapy, you may have to stay in hospital for a few days. Staff in the radiotherapy department

Clinical oncologist

Although you will continue to be in the care of your GP during and after your radiotherapy, you will be under the care of a clinical oncologist while you are having the treatment itself. A clinical oncologist is a doctor trained in the use of radiotherapy and chemotherapy. The clinical oncologist will be responsible for prescribing and supervising your course of treatment.

You may see your oncologist before, during, and after your course of radiotherapy treatment, so that the effect of the treatment can be monitored. If you have any problems before or after your treatment, the nurses or radiographers can arrange an extra appointment for you. If you are having chemotherapy as well as radiotherapy, this treatment may be supervised by your clinical oncologist or may be organised by a different doctor, called a medical oncologist. Medical oncologists specialise in chemotherapy treatment.

Medical oncologists and clinical oncologists work as part of a team. The team includes all the other health care staff who look after people having treatment for cancer. This multidisciplinary team (MDT) will have regular meetings to co-ordinate and plan care and treatment.

Radiographers

Radiographers are specially trained in using x-ray equipment. There are two main types of radiographer: therapy radiographers and diagnostic radiographers. Therapy radiographers are the people who operate the machines that give you your radiotherapy treatment. They are highly trained in giving radiotherapy and patient care. Diagnostic radiographers use x-rays and scans to diagnose illness – you may have x-rays or scans from time to time during and after your treatment to check the effect of your radiotherapy treatment.

Therapy radiographers work closely with your specialist and physicist to plan your treatment. Where possible, you will see the same radiographers throughout your course of treatment so you get to know each other quite well. They can give you help and advice about any aspect of your treatment, and you can discuss any of your concerns or anxieties with them. You can ask to be treated by a radiographer of the same sex as yourself, if you prefer. Some radiographers, known as information radiographers, specialise in giving information to patients and their relatives.

Physicist

Working with the clinical oncologist is a physicist – a radiation expert – who will help to plan your treatment, assisting your specialist in decisions about the best way of giving the prescribed amount of radiation. The physicist is also responsible for maintaining the accuracy of the equipment used. Although you may meet the physicist at your initial planning appointment, they usually work behind the scenes.

Mould room technician

If you need to have a mould made of part of your body to keep it still during treatment, this will usually be done by technical staff in the mould room.

Nursing staff

Like hospital wards, the radiotherapy clinic has nursing staff – usually a sister or charge nurse and a team of nurses. They ensure that the clinic is running smoothly and look after any general needs you have, such as dressings and medicines. The nurses in the radiotherapy department can also give information and advice about the treatment and they give practical support. Many cancer centres also have specialist cancer nurses (sometimes called clinical nurse specialists) who will have expert knowledge of your type of cancer. They can be a good source of support and information during your treatment.

Social worker

Social workers can give advice about any non-medical problems that you may have. This includes practical and financial help: for example, some patients can claim travelling expenses and others may be eligible for a grant from a charity. Social workers can also give or organise counselling and emotional support for you and your family. If necessary they will refer you to local support services that can help you at home. You can ask to see a social worker if you think that this would be helpful.

Symptom control team (palliative care team)

Many hospitals have a symptom control team to give additional help and support for people whose symptoms or treatment are causing problems. There may be other staff, such as dietitians or physiotherapists, who can help with any specific questions you may have.

Counsellors

Counsellors are available in some hospitals. If you feel that speaking to a counsellor would be helpful, ask the staff looking after you to arrange an appointment.

Secretaries and clerical staff

The secretaries and clerical staff in the radiotherapy department help to keep the appointment system running smoothly.

General side effects of radiotherapy

While radiotherapy can destroy cancer cells, it can also have an effect on some of the surrounding normal cells. The side effects that may occur are described in the following pages. It is important to remember that no person will have more than a few of them, and for many people they may be mild. Years ago, in the 1950s and 60s, radiotherapy often caused very severe side effects, especially skin burns and scarring. There have been huge improvements in the machines that give the treatment, and severe side effects are now very rare.

As radiotherapy affects people in different ways, it is difficult to predict exactly how you will react to your treatment. Before you start, the staff will discuss with you any likely side effects of the particular treatment you are having. They can also give tips on how to deal with them and how they can be treated. Being aware of side effects in advance can help you to cope with any problems that occur.

Most side effects of radiotherapy disappear gradually once the course of treatment is over. However, for some people, they may continue for a few weeks.

Tiredness

You may feel very tired during your radiotherapy. This can often be made worse by having to travel to your treatment each day. Listen to your body, and if necessary, allow yourself extra time to rest, perhaps by taking a nap in the afternoons. It may help if you spread chores out over the week, sit down to do them, wherever possible, and accept any offers of help. Tiredness can be a problem for some months after your treatment has finished.

Eating and drinking

As always during treatment of any kind, it is important to maintain a healthy diet and drink plenty of fluids. At times you probably won't feel like eating, or you may find that your eating habits change. It may be easier to have small snacks throughout the day rather than large meals. It is not unusual to lose a little weight during radiotherapy, but if you are having any problems with eating it is important to tell the radiotherapy staff. They can arrange for you to talk to the dietitian at the hospital. Our section on eating well also gives useful advice on eating.

Skin care

Some people develop a skin reaction while having external radiotherapy. If this effects you, it will normally happen after 3–4 weeks. People with pale skin may find that the skin in the treatment area becomes red and sore or itchy. People with darker skin may find that their skin becomes darker and can have a blue or black tinge. The amount of the reaction depends on the area being treated and the individual's skin. Some people have no skin problems at all. Your radiographers will be looking for these reactions, but you should also let them know as soon as you notice any soreness or change in skin colour. It’s important not to use any creams or dressings unless they have been prescribed or recommended by your specialist or the radiographer.

Occasionally, if your skin gets very sore, your treatment may have to be delayed for a short time to allow the area to recover. Staff at the radiotherapy department will be able to give you advice on how to look after your skin in the area being treated. Care of the skin will vary according to the part of the body that is being treated and the dose of radiotherapy that the skin is receiving.

You may be advised to use only tepid water and plain soaps, without any perfume, to wash the area; and not to soak too long in the bath. You can dry your skin by patting it gently with a soft towel, but you shouldn’t rub the area as this may make it sore. Perfumed soaps, talcum powder, deodorants and perfumes may also make your skin sore and should not be used. The staff at the hospital may suggest that you gently apply plain moisturisers, such as E45 cream or aqueous cream, to the area. After your treatment, plain soap and plain moisturisers are often recommended. Aloe vera cream can sometimes help the skin to heal. Always check with the radiotherapy staff before applying anything to your skin.

It is very important that any marks put on your skin to show the treatment area are not removed. If the marks do fade or disappear, do not try to replace them yourself but let the radiotherapy staff know. Men who are having radiotherapy to the head and neck may be advised not to shave the area, or to use an electric razor rather than wet-shaving.

These restrictions apply only to the treatment area, and the rest of your skin can be treated normally. Your skin may peel after the redness has faded, but it will gradually heal. Changes in the skin usually settle down two to four weeks after the treatment has finished, but the area may stay slightly darker than the surrounding skin.

Avoiding the sun

Your skin in the treated area is very sensitive and needs protecting from the sun or cold winds. If you are having radiotherapy to the head or neck, try wearing a hat or a silk or cotton scarf when you go outside. For at least the first year after your radiotherapy, it is very important to cover the treated area if you go out in strong sunshine. Wear clothing made of cotton or natural fibres, which have a closer weave and offer more protection against the sun. Even after this time, the area of treated skin will be more delicate than normal, so extra care should be taken. Use a sun-cream (of at least factor 15) and cover the area with a hat or close-weave clothing. It is important to remember that you can burn even through clothing if you are out in hot sun for a long time.

You can swim as soon as any skin reaction has settled down, usually within a month of finishing treatment. However, if you are swimming out of doors, do not stay in the water too long, and remember to use a waterproof sun-cream.

Clothing

Loose-fitting clothes, preferably in natural fibres rather than man-made materials, are more comfortable and less irritating to the skin. If you are having radiotherapy to your neck, avoid tight collars and ties. Shoulder straps and bra straps can also cause irritation if they rub against treated skin. If your breast area is being treated, you may be more comfortable not wearing a bra or wearing a cropped top or vest.

Changes in your blood

Radiotherapy to some parts of the body may affect the bone marrow, which produces the different types of blood cells. If the doctors think this might happen to you, you will have regular blood tests during your treatment to check your blood counts (the number of cells in your blood). If your blood counts are low, you may feel tired and 'run down'. If your blood count becomes very low (which is unlikely), it may be necessary to have a short rest from treatment so that your blood cell levels can return to normal. You may also need to have a blood transfusion. It is very important to let your doctors know if you feel very unwell, or if your temperature goes above 38ºC (100.4ºF), or if you start feeling cold and shaky.

Smoking

Stopping smoking during and after radiotherapy is very worthwhile. Research has shown that it may make the radiotherapy more effective as well as reducing the side effects. It will also improve your general health and reduce your risk of developing other cancers. Stopping smoking or even cutting down at such a stressful time can be very difficult, but do your best. If you want help or advice you can talk to your specialist, GP or a specialist nurse, who will be able to suggest ways of stopping. Organisations such as QUIT also offer advice and valuable support.

Complementary therapies

Complementary therapies can help to improve your quality of life and wellbeing and can sometimes help to reduce the side effects of radiotherapy. Many people find that complementary therapies or practices can help them to feel stronger and more confident in dealing with radiotherapy. These therapies can be used alongside conventional treatments and medicines.

Some complementary therapies, such as meditation or visualisation can be done by the person with cancer themselves and can reduce anxiety. Other therapies such as gentle massage can be carried out by relatives or carers and can help them to support the person with cancer. Physical contact and touch can be among the most powerful forms of support for people who are faced with uncertainty, fear or pain, whether emotional or physical. Touching someone gently can express how much you care about them. Some hospitals offer complementary therapies alongside conventional care. These may include:

aromatherapy

art therapy

colour and sound therapy

massage

reflexology

relaxation, visualisation or guided imagery techniques

acupuncture.

Relaxation

Deep relaxation is a skill which can be learned. It can be used to:

release muscle tension

relieve stress

reduce tiredness and pain

improve sleep and peace of mind

regain control of emotions.

Relaxation is not simply 'taking it easy', but involves making time to reflect on problems or anxieties and, hopefully, develop a positive mental outlook. There are several different relaxation techniques which can be self-taught from books or tapes. You can get these from your local library, bookshop and some chemists. Therapists and groups throughout the country also teach particular relaxation methods.

Research - clinical trials for radiotherapy treatments

Cancer research trials are carried out to try to find new and better treatments for cancer. Trials that are carried out on patients are known as clinical trials.

Clinical trials may be carried out to:

test new treatments, such as new chemotherapy drugs, gene therapy or cancer vaccines look at new combinations of existing treatments, or change the way they are given, to make them more effective or to reduce side effects compare the effectiveness of drugs used to control symptoms find out how cancer treatments work see which treatments are the most cost-effective. Trials are the only reliable way to find out if a different operation, type of chemotherapy, radiotherapy, or other treatment is better than what is already available.

Taking part in a trial

You may be asked to take part in a treatment research trial. There can be many benefits in doing this. Trials help to improve knowledge about cancer and develop new treatments. You will also be carefully monitored during and after the study. Usually, several hospitals around the country take part in these trials. It is important to bear in mind that some treatments that look promising at first are often later found not to be as good as existing treatments, or to have side effects that outweigh the benefits. If you decide not to take part in a trial your decision will be respected and you do not have to give a reason. There will be no change in the way that you are treated by the hospital staff and you will be offered the standard treatment for your situation.

Information courtesy of Cancer Research UK (CRUK)