Radiation Therapy

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 Introduction to Radiation Oncology

 Radiation has been an effective tool for

treating cancer for more than 100 years.
 Radiation oncologists are doctors
trained to use radiation to eradicate
cancer.
 About two-thirds of all cancer patients
will receive radiation therapy as part of
their treatment.

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 Radiotherapy
RADIOTHERAPY is the treatment of neoplastic disease using high
energy ionizing rays (x-rays or gamma rays) to kill cancer cells.

These may be generated by radioactive sources or linear accelerators.

THE HIGHER THE ENERGY OF THE PHOTON, THE DEEPER IT CAN

PENETRATE THE BODY BEFORE LOSING ITS EFFECT.

Radiation deters the proliferation of malignant cells by decreasing the

rate of mitosis or impairing DNA synthesis.

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Sources of Radiation
COLBALT 60
CESIUM 137
IODINE 131
IRIDIUM 192
RADIUM 226
RADON 222
STRONTIUM 90

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Goals of Radiotherapy
Curative
Control:
Adjuvant
Pre/Post Operative
Intraoperative
Palliation

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Radiation therapy may be curative in many types of cancer if
they are localized to one area of the body.

It may also be used as a part of adjuvant therapy, e.g.. after

performing surgery for removing a primary malignant tumor, it
can be used to prevent tumor recurrence ( for example, early
stages of breast cancer). It is common to combine radiation
therapy with surgery, chemotherapy, hormone therapy and
immunotherapy.
It is synergistic with chemotherapy, and has been used before,
during and after chemotherapy in susceptible cancers.
It may also be used as palliative treatment where cure is not
possible and the aim is for local disease control or
symptomatic relief.

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MECHANISM OF ACTION
Ionizing radiation works by damaging the DNA of cancerous
tissue leading to cellular death.

To spare normal tissues, shaped radiation beams are aimed

from several angles of exposure to intersect at the tumor,
providing a much larger absorbed dose there than in the
surrounding healthy tissues.

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Radiation Protection:
Principles
ALARA Principle

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Time

Minimize time spent in close proximity to the patient.

Radiation exposure is directly related to the time spent
within a specific distance of radiation source.
Care giver should not exceed 1/2 to 1 hour exposure
per shift.
◦ Organize care, prior to entering room.
◦ Assemble all equipment, prior to room entry
◦ In room, place supplies/equipment within easy quick access.

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Distance
The amount of radiation decreases with increase in distance.
Doubling the distance from the radiation source, Quarters the
amount of radiation received.
If the exposure at 1 meter from the Radiation Source is X, the
exposure at 2m is ¼ of x, and at 4m, one sixteenth.
Interventions:
Teach patient self-care & rationale for isolation.
Limit patient care by individual caregiver.
Use communication devices outside room to interact
whenever possible.

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Shielding
When used properly, lead shielding can provide added
protection from radiation.

In practice, nurses find lead shielding apron cumbersome to

work with.

Nurses wear a film badge.

NB: Pregnant nurses should not care for radiation patients.

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 Planning Radiation Therapy - Simulation

 Each treatment is
mapped out in detail
using treatment
planning software.
 Radiation therapy must
be aimed at the same
target every time.
Doctors use several
devices to do this:
• Skin markings or tattoos.
• Immobilization devices –
casts, molds, headrests.

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 Methods of Delivering Radiation Therapy

Early 1950s Today

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Types of Radiation
Therapy
External Beam or Teletherapy
•most common type of radiation therapy using machine
(linear accelerator).
• patient is not radioactive.
Internal radiation or Brachytherapy
• implant is placed inside patient temporary/permanent.
• patient is radioactive.

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Teletherapy
Delivering radiation from a source at a distance from the target.

Radiation department administers the dose.

Advantage: skin sparring effect, giving max radiation to tumor not the
skin.

Patient is monitored via TV or intercom

Treatment approx. 10 minutes.

Not painful, though patient may feels heat or tingling.

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EXTERNAL BEAM
RADIATION THERAPY

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 External Radiation Therapy

 Specialized types of external beam radiation therapy

• Three-dimensional conformal radiation therapy (3D-CRT)
 Uses CT or MRI scans to create a
3-D picture of the tumor.
 Beams are precisely directed to avoid radiating normal tissue.

• Intensity modulated radiation therapy (IMRT)

 A specialized form of 3D-CRT.
 Radiation is broken into many “beamlets” and the intensity of each
can be adjusted individually.

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 External Radiation Therapy
• Proton Beam Therapy
 Uses protons rather than X-rays to treat certain
types of cancer.
 Allows doctors to better focus the dose on the
tumor with the potential to reduce the dose to
nearby healthy tissue.
• Neutron Beam Therapy
 A specialized form of radiation therapy that can be
used to treat certain tumors that are very difficult to
kill using conventional radiation therapy.
• Stereotactic Radiotherapy
 Sometimes called stereotactic radiosurgery, this
technique allows the radiation oncologist to
precisely focus beams of radiation to destroy
certain tumors, sometimes in only one treatment.

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Brachytherapy
Delivers a high dose of radiation to a localized area.
The specific radioisotope is chosen on the basis of its half-life

Brachytherapy may be sealed or unsealed:

SEALED:
Interstitial
Intracavitary

UNSEALED:
Systemic (IV, oral)

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Brachytherapy

SEALED UNSEALED
Emits low energy Injected, instilled or
continuously oral.
Systemically
Interstitial & intracavitary
implants
EX. I 131
Ex. Seeds, APPLICATORS

PATIENT AND
PATIENT EMITS EXCRETA are
RADIATION but NONE IN RADIOACTIVE
EXCRETA

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Sealed Brachytherapy:
Intracavitary:
Radioisotopes (cesium or radium) put inside the applicator &
placed in body cavity for a specific amount of time (24-72hours)
When treatment completed, applicator & radioactive material
removed
treats cancer of uterus & cervix.
Interstitial:
needles, beads, seeds, ribbons or catheters are placed directly
into tumor (breast, prostrate)
Radioisotopes: iridium, cesium, gold, radon
Placement can be temporary or permanent
Treats Prostrate, cervical, esophagus cancer etc.

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BRACHYTHERAPY APPLICATORS

Fletcher-Suit applicator

Radioactive seeds implanted in prostate

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Nursing Care of the patient
with Sealed Implant
Provide Private room with bathroom
Radioactive material sign should be placed outside
Wear dosimeter
No pregnant staff
Visitors limited to 30 mins per day
Visitors are restricted and must remain at 6 feet distance
All dressings & linens saved until implant removed
LEAD CONTAINER & LONG HANDLED FORCEPS,LEAD GLOVES KEPT IN ROOM IN EVENT OF
DISLODGEMENT
REMEMBER ALARA
 TIME
 DISTANCE
 SHEILDING

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Nursing Care of patient
with UNSEALED Implant
Presents potential contamination hazard.
All articles in room are considered contaminated.
After discharge, articles are discarded but taken to protected area
‘till detectable radioactivity decays’.
Rubber gloves worn with direct care
No pregnant staff
Articles in room: phone, call light, floors covered with plastic.
Disposable plastic /paper should be used for dietary trays & utensils.
Flush toilet used by patient several times.
Keep linen & gowns kept in separate isolation bags
Patient & excreta
radioactive!
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Loss of Radioactive
Material
Considered an emergency.
Search should initiated by radiation staff.
Removes nothing from the room while patient has
radioactive material in place.
If radioactive material is found, use long handled forceps
& gloves.
Notify Atomic Energy Center.

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RADIATION THERAPY :
INJURY
Phases of Radiation Injury:

Early (acute) Phase: occurs within weeks and resolve 4-6 weeks post
radiation. Usually temporary and affect tissues with rapidly dividing
cells (skin, mucous membranes)

Late Phase: may occur months/years later and usually result from
damage to the micro-circulation. Affect any/all tissues especially:
lymph, thyroid, pituitary, breast, brain, bone, cartilage, pancreas and
bile ducts.

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SIDE EFFECTS OF RADIATION
THERAPY

Factors influencing degree & occurrence of side effects due to

Radiotherapy
Body site irradiated
Dosage
Extent of body area treated
Method of radiation delivery
Age of client
General health of client
Previous surgeries & chemotherapy
Radiosensitivity of tissue/organ treated.

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Symptom Management
in Radiation Oncology
Nausea & vomiting
Diarrhea
Xerostomia
Ocular symptoms ( edema, dryness, photophobia)
Oral mucositis
Alopecia
Hyperthermia
Headache
Cystitis
Esophagitis

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Skin Reactions
Acute: begin about 2 weeks after start of treatment and
resolve over next 3-4 weeks.

Reactions include erythema, dry desquamation, wet

desquamation

Chronic: may occur years later and include atrophy, pigment

changes, fibrosis and telangiectasia.

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Dry desquamation
Begins within 7-10 days of treatment
Erythema that may progress to dry, itchy skin
May be scaling, flaking, peeling
Result of partial loss of the epidermal basal cell layer.
Wet desquamation
Result of complete destruction of the basal cell layer
Blister, vesicles, and serous oozing occur
Pain may occur if nerve endings are exposed
Occurs more often in areas of friction & moisture (skin fold, groins)
Increased risk of infection (may require break in treatment)

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General Skin Care
Wash daily with water or mild scent-free soap
Use hand to wash the area.
Rinse soap well.
Pat skin dry.
Don't use powders, creams unless ordered by Oncologist.
Wear soft clothing over radiation site (cotton).
Avoid belts, straps & tight clothing.
Avoid sun exposure.
Shave with electric razor.
Do not use tape over site.

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Alopecia
May occur within the treatment field.
Extent depends upon area of treatment and dose of XRT.
Often patchy in appearance.
Usually begins 2 weeks after start of XRT.
Usually temporary, but may be permanent.
Regrowth usually begins 3-6months.

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Mucositis
Inflammation of the mucosal lining of the G.I. tract
• If oral cavity - stomatitis
• If esophagus – esophagitis
Common in patients receiving RT to head & neck
Severity depends on dose, size of field, and fractionation schedule of RT
Symptoms include:
Soreness or burning in mouth/ throat
Difficulty swallowing
Sensation of “having lump in throat”
Redness, tenderness, or ulcerations
in the mouth

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 Assessment of
mucositis
History
- Oral symptoms
- Food and fluid intake
- Difficulty swallowing

Physical
- Assess oral cavity for redness, inflammation, ulcers, infection

Investigations
-Take culture Swab of lesions if Candida or herpes suspected

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MUCOSITIS INTERVENTION
Instruct patient/caregiver to:
Gently brush all surfaces of teeth, gums, and tongue with a soft nylon brush.
Brush with a nonirritating dentifrice such as baking soda.
Remove and brush dentures thoroughly during and after meals and as
needed.
Rinse the mouth thoroughly during and after brushing
Avoid alcohol-containing mouthwashes.
Use recommended mouth rinses:
oHydrogen peroxide and saline or water (1:2 or 1:4).
oBaking soda and water (1 tsp in 500 ml).
oSalt (.5 tsp), baking soda (1 tsp), and water (100 ml).
Keep lips moist.
Avoid use of tobacco and alcohol.

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Xerostomia
Dryness in the mouth caused by lack of normal
secretion of saliva
Salivary glands very sensitive to RT
Severity related to dose
May be permanent with higher doses
Lack of moisture to mucosa causes irritation to
the mucosa, fissures may develop on the corners
of the mouth
Xerostomia promotes accumulation of bacteria
and plaque increasing susceptibility to infection,
dental caries, and periodontal disease

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Xerostomia
Interventions
Good oral hygiene
Frequent sips water, sugarless gum, avoid dry foods, liquids
with meals
Avoid alcohol and smoking
Humidifier
Artificial saliva i.e. Moistir ac meals, hs, & prn
Pilocarpine for radiation induced Xerostomia

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Diarrhea
Passage of frequent (more than 3/24hrs), loose, watery stool
Can lead to dehydration, malabsorption, fatigue,
hemorrhoids, and perianal skin breakdown
Caused by irritation/inflammation of the bowel lining
Risk for Diarrhea
Higher in patients undergoing chemo or RT to abdomen or
pelvis
With XRT usually develops 10-15 days into treatment
Lasts 2-3 weeks after treatment

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Assessment of Diarrhea
History - onset, pattern, number of B.M.’s/24 hrs.
Physical – vital signs, assess hydration status
Psychological – anxiety, stress
Investigations – serum electrolytes, creatinine & urea,
stool cultures & stool for c. difficile

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 Interventions
Radiation induced diarrhea usually managed initially with dietary changes
- Small freq. meals
- Drink 8-10 glasses of fluids
- Low fat, low fiber diet
- Avoid gas producing foods
- Avoid caffeinated beverages

Loperamide – if patient has more than 3 watery B.M.’s per day

Protect peri-anal area form skin breakdown
-Keep area clean and dry
-Sitz bathes several times a day can ease discomfort

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Other complications
radiation treatment
Cystitis (usually occurs 1-2 weeks post XRT and subsides 2
weeks after XRT complete

Lhermitte’s syndrome – after spinal cord radiation

Vaginal stenosis – after XRT to pelvis

Radiation pneumonitis – after XRT to lungs

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