TREATMENT

RADIOTHERAPY

Overview

What is radiotherapy?

In simple terms, radiotherapy means treatment with ionizing rays; obtained from different sources. External radiation is delivered mainly by linear accelerators (high energy X-rays). Brachytherapy (internal radiation) is obtained from radioactive substances placed inside or against the tumour area. To understand how ionizing rays work, you must understand how cancer cells affect your body.

Understanding radiotherapy

To understand how ionising rays work, you must first understand how cancer cells affect your body.

Cancer starts with one cell that has lost control over its growth. Normal cells divide in a highly controlled manner to form new cells.

Cancer cells also divide and form new cells, but at a more rapid rate. Furthermore, cancer cells do not know when to stop dividing. They keep on dividing and multiplying until they have displaced or damaged the affected body tissue or organ.

Yet these cells still continue their excessive growth and, because cancer cells do not grow within an enclosing capsule, some cells break away and are carried to the next organ by the lymph or the bloodstream, and there they multiply further. This is called metastasis.

The goal of radiation therapy is to damage and eventually destroy the cancer cells, but the rays cannot distinguish between normal and malignant cells.

The success of irradiation lies in the fact that malignant cells are more sensitive to irradiation than normal cells. The goal of irradiation is, therefore, to irradiate until the malignant cells have been killed or sterilised. The surrounding normal tissue is, however, still capable of complete recovery.

Radiation at Alberts Bouwer & Jordaan Incorporated

We have state of the art equipment at our practices in Gauteng and North West, including:

  • Five different accelerators (at our oncology centres in Benoni, Centurion, Klerksdorp, Vereeniging and Wilgers)
  • Varian Clinac 2100c 80 or 120 leaf MLC machines and the Eclips TPS and Varis verification systems. (Wilgers, Benoni)
  • Siemens Primus with 82 leafs MLC and the XIO TPS (used at Klerksdorp, Vereeniging)

Since all our machines have Multi-Leaf Collimators, which make shielding effortless, the time between planning and treatment is reduced dramatically. Treatment can thus begin immediately.

Every unit has a dedicated 3D Treatment Planning System with experienced treatment planning radiographers. This makes the planning to treatment stage hands-on and much more efficient. Interaction with the prescribing oncologist is also face to face. Setup difficulties and problems are easily resolved as the planning radiographers are involved with first treatment setup.

International prescribing and dose determination norms are used for all treatments and radiographers are regularly sent to local and international congresses to keep up to date with new developments. The knowledge of radiation physicists is available at all units.

IMRT or Intensity Modulated Radiation Therapy is also available at all units. This is one of the latest directions in radiotherapy. The dose is administered with dynamic multi leafs, which means the leafs slide open or close throughout the treatment. This makes it possible to get a better dose distribution to the tumour and a lower dose to the surrounding organs at risk.

Brachytherapy, especially for prostate seed implants, is available at all units. Our holistic approach in every department makes the patient’s journey through the treatment process much easier since all the involved entities are close at hand.

1How many radiotherapy treatments are needed?
In certain phases of division, cells are more sensitive than in other, dormant phases. To irradiate as many of the cells as possible in the sensitive phase, the treatments are fractioned; in other words, they are spread over a period of time.

Another reason for fractionation is to give the normal cells, which recover faster than malignant cells, a chance to recuperate. (That is why you do not receive only one treatment). The sensitivity of the various types of tissue and the various organs differs, therefore the number of treatments for different diagnoses will inevitably also differ. The number of treatments prescribed bears no relation to the degree to which the cancer has advanced.

If you are to receive thirty treatments and another person only five, please do not assume that your prognosis is worse than theirs. The dose administered, the number of treatments and the specific diagnosis is very closely linked. It is important to understand that because irradiation is used differently for the different conditions, it is not wise to compare treatments, symptoms or side effects.

Irradiation is only done during the week and may be interrupted for a day when the machine is being serviced, or work is being done on the machine.

During your course of treatments, you will meet other patients, and you will probably compare your treatment and symptoms. It is important to understand that irradiation is used differently for the treatment of different conditions. Your irradiation and side effects may consequently differ considerably from those of another patient.

Accommodation is available for patients who live far away and who have to receive chemotherapy or radiotherapy. However, such accommodation is only available from Monday to Friday at the Wilgers, Unitas, Benoni, Vereeniging and Klerksdorp consulting rooms. Transport to the respective consulting rooms can be arranged.
2How is radiation administered?
Because the radiation passes through normal tissue to reach the affected area, the side effects must be limited. To ensure this, a CT scan is done, which is then transferred to a dedicated Treatment Planning System (TPS). On the TPS, a 3D image of the treatment area is created using the CT slices. The oncologist delineates the area of interest (tumour) on this 3D image. MRI images where soft tissue tumours are better shown can also be used in conjunction with CT images. The 3D image is used to plan the treatment with multiple field combinations with different angles and energies, to ensure that the dose to the normal tissue and sensitive organs is limited while an optimal dose to the tumour is achieved. The combined dose of the fields where they intersect gives the optimal dose required. The different tissue densities, the beam is travelling through, is also taken into account since they have different absorption properties.

To limit the dose to critical organs and normal tissue in the beam path, shielding is used to shape the radiation beam. Modern technology allows for this to be done easily with multi-leaf collimators (MLC) instead of lead shielding blocks which are time-consuming and labour intensive. To achieve optimum treatment planning, highly skilled and experienced planning radiographers, physicists and a specialized TPS is essential.

To ensure that the treatment is being given correctly, recording and verification systems are essential. This will prevent treatment being given unless all parameters are set-up correctly. The system also records treatment data for future reference. Anatomical verification is also required to ensure that the correct treatment position is used. This is done with a portal imager or the use of verification films.
Simulation and marking of the area

The area to be irradiated is determined by means of a localising scan or X-rays and then marked. This is called a simulation.

PLEASE BRING ALONG ANY PREVIOUS X-RAYS OR SCANS that may be of use. Sometimes the treatment area is decreased during the course of the treatments. This is called a booster.

It is very important that the marks that have been made on your body remain there.

Procedure

  • It is very important for you to visit the oncologist once a week during irradiation.
  • Please arrange these appointments with the oncologist's receptionist in good time once you have received the irradiation dates.
  • Please get your irradiation file from the radiotherapists on the day on which you are to visit the oncologist.
  • Please be so kind as to return your file to the radiotherapists after your appointment with the oncologist.
  • When simulation/booster is done, please bring along all your scans and X-rays so that the position of the irradiation area can be determined.
  • To change radiotherapy appointments, please phone the relevant radiotherapy receptionist without delay.

YOU MAY BATH OR SHOWER, but you must make sure that these marks are not washed off. A quick bath or shower is preferable. If you do take a bath, do not soak in the water. Use a gentle soap, for example, Dove soap.

Irradiation is not painful, and patients are not radioactive after irradiation; therefore, you pose no threat to other people.

During irradiation, you will be alone in the treatment room, but you will be monitored on a television screen. There is also an intercom system.

It is extremely important that you keep very still, but you may breathe normally.

Side effects of Irradiation

It is only human to be concerned about the side effects of irradiation, especially as there are so many misconceptions about irradiation.

However, if you understand what may or may not happen, you can avoid unnecessary anxiety and fear.

The aim of the following information is to give you peace of mind.

1Nausea and Vomiting
Only patients who receive irradiation over their abdominal organs sometimes experience nausea and vomiting. If you find that this is a problem, please ask your oncologist for a prescription for medication.

If the symptoms continue in spite of the medication, inform your oncologist immediately so that other medication may be prescribed.

It is extremely important that you take your medication as prescribed to prevent nausea, and not only when you feel nauseous.

It is also important that you continue to eat enough. If you start losing weight or find that you are no longer eating regularly, consult the dietician immediately.
2Bladder
Patients who receive irradiation over the lower abdominal area may suffer from diarrhoea, constipation, a burning sensation when urinating and / or piles.

Please ask for medication immediately if you suffer from any of the above.

It is also important to ask the radiotherapists whether your bladder should be full or empty during irradiation.
3Mouth & Throat problems
Patients receiving irradiation over the throat area will start suffering from a sore throat after about ten treatments. Gargling with a solution of half a teaspoon of bicarbonate of soda mixed with half a teaspoon of salt in a glass of lukewarm water will help. There will also be dryness of the mouth due to the irradiation affecting the salivary glands. This condition may be permanent. You may experience a temporary loss of speech, but speech will be regained in the course of time. You might also find that you develop a double chin after irradiation.

Men who are receiving irradiation over the face must not shave the treatment area, as it would cause skin irritation.

It is important that you drink a lot of fluids.

If you experience problems with your diet due to a sore throat or mouth, please consult the dietician.
4Diarrhoea
If you have three or four loose stools a day, you should drink clear fluids (soup, soft drinks, tea and ± two litres of water per day). Also, consult your general practitioner or oncologist immediately.

You must prevent your body from dehydrating.


Eat a lot of bananas, carrots (cooked) and grated apple (without the skin).

The dietician can compile a special diet for you to help combat the diarrhoea. It may also be advisable to take one or more nutritional supplements. These supplements can be prescribed by the dietician. You may also take medication for the diarrhoea. Please ask the nursing staff to assist you with this.
5Skin reactions
CAUTION: Please do not use any ointment, powder or deodorant spray on the irradiation area. These will make any skin irritations worse. You may use a roll-on deodorant (like Dove). If the skin feels tender, you could use Aqueous water-soluble cream. If necessary, your doctor will prescribe a special cream.

Do not expose the treatment area to direct sunlight. Wear a hat and suitable clothes in the sun. If a skin reaction is to be expected, the oncologist or radiotherapist will tell you. A reddening of the skin will become visible after about fifteen treatments.
6Hair Loss (Alopecia)
Your hair will only fall out if you receive irradiation over the scalp. Irradiation of other parts of the body will not cause hair loss on the head.

The hair will only start falling out after about fifteen treatments, and in most cases will start growing again after about three months.
7White blood cells
White blood cells are the body's protective mechanism against infections.

The white blood cell count of patients receiving irradiation over large areas of bone may decrease; therefore, regular blood counts will be taken if you are such a patient.

When smaller areas of the body are irradiated, the loss of white blood cells is so small that regular blood counts are not necessary.
What to expect during treatment

First Visit: Simulation and Marking of the Treatment area

  • During your first visit, a CT scan could be done for computerised simulation purposes.
  • Your doctor will then use the CT images to reconstruct a 3D model and to plan the radiation treatment. The area to be irradiated is determined by means of a localising scan or X-rays and then marked. This is called a simulation.
  • It is possible that some reference marks will be made on your body and the radiographer will inform you if you need to preserve these or if you can wash them off.
  • Special equipment may be used to immobilise your body in the same position every day.
  • It is very important that the marks that have been made on your body remain there.

PLEASE BRING ALONG ANY PREVIOUS X-RAYS OR SCANS that may be of use. Sometimes the treatment area is decreased during the course of the treatments. This is called a booster.

Irradiation is not painful, and patients are not radioactive after irradiation; therefore, you pose no threat to other people.

During irradiation, you will be alone in the treatment room, but you will be monitored on a television screen. There is also an intercom system.

It is extremely important that you keep very still, but you may breathe normally.

Subsequent visits: Treatment

  • It is very important for you to visit the oncologist once a week during irradiation.
  • Please arrange these appointments with the oncologist's receptionist in good time once you have received the irradiation dates.
  • Please get your irradiation file from the radiotherapists on the day on which you are to visit the oncologist.
  • Please be so kind as to return your file to the radiotherapists after your appointment with the oncologist.
  • When simulation/booster is done, please bring along all your scans and X-rays so that the position of the irradiation area can be determined.
  • To change radiotherapy appointments, please phone the relevant radiotherapy receptionist without delay.
Diet & nutrition during treatment

A good, balanced diet will help you handle some of the side effects better. The dietician can assist you with a diet and vitamin supplements specifically for your type of cancer and treatment.

Subsequent visits: Treatment

  • Try to take in a lot of fluids.
  • In some cases, it will be necessary to take nutritional supplements. These supplements will be prescribed by the dietician.
  • You may feel tired, but you will still be able to perform most of your normal tasks. Try to maintain your normal activities as far as possible.
  • If you get very tired, the dietician can also assist you with supplements or look at your diet. An analysis of your diet to determine which nutrients it lacks is essential.
  • It is very important that the marks that have been made on your body remain there.