Demystifying Radiotherapy

Caption: A radiation therapy technologist prepares a patient for a session at Aga Khan University Hospital

Fear and misconception have caused many patients to either delay or worse still decline radiotherapy- a critical treatment modality in the fight against cancer. By delaying care, patients' may compromise their health and survival outcomes. In this article, I will share frequently asked questions about radiotherapy that should hopefully clear any doubts and dispel myths that may be influencing some patients to delay their care.

In lay man's language what is radiotherapy and how is it administered to patients?

Radiotherapy is the treatment of cancer (and a few non-cancerous conditions) using high energy X-rays. Radiotherapy may be given on its own or, as is often the case, alongside other treatments such as surgery or chemotherapy.

Radiotherapy treatments for most cancers is delivered from outside the body by machines called Linear Accelerators (LINACS) as shown here in the photograph. When receiving the radiotherapy, you do not feel anything and it does not make you radioactive – it is perfectly safe for you to be with other people including children and pregnant women throughout your treatment.

Everyone's' treatment is different and planned individually. It is usually given as a series of out-patient appointments over five days a week and the length of treatment can vary from a single treatment to a course lasting seven weeks or more.

How does it work?

The tissues of our bodies are made up of tiny building blocks called cells. The radiotherapy causes damage to cancer cells in the treated area. Although normal cells are also affected, they can repair themselves and are able to recover and so the damage is mainly temporary. Radiotherapy is a local treatment which means only the area treated is affected.

What types and stages of cancer are treated with radiotherapy?

Radiotherapy can have a benefit at any stage of cancer.

For cancers that are detected early, the aim of treatment is cure, either with radiotherapy alone or in addition to another main treatment. For example, you may have surgery to remove a tumour and may also be given a course of radiotherapy after to kill any cancer cells that may have remained after surgery. Unless treated, these cells may cause a tumour recurrence at a later time. Sometimes. In some cases, radiotherapy is given before surgery to reduce the size of the tumour and make it easier to remove. In other instances, radiotherapy and chemotherapy are used as a combination.

If a cure is not achievable (usually due to delayed diagnosis), it is often possible to limit the growth or spread of the cancer with radiotherapy. Many patients with advanced cancer have benefited from this form of treatment with reduction of symptoms such as pain and bleeding.

There have been complains of people getting burnt while undergoing radiotherapy, what causes it and what has Aga Khan University Hospital (AKUH) done to ensure safety of patients?

Whilst it is true that a skin reaction, termed as radiation dermatitis, is one of the commonest side effect of treatment, technological advances incorporating modern radiation machines with new delivery systems and more powerful computers and software such as those available at AKUH have reduced the incidence and severity of dermatitis. In addition, having specialists adept at managing these and other side effects associated with the individuals treatment is paramount in taking a patient through radiation therapy.

The start, severity and length of the skin reaction will depend on many different things, some are beyond the patients' control such as the patients age, other illnesses such as diabetes, skin folds within the treatment area and previous and continued exposure to the sun. Other factors however, can be controlled by the patient such as having a well-balanced diet, not smoking (and avoiding passive smoking) avoiding skin irritants such as perfumed skin products extremes of heat or cold, swimming as chlorine can irritate skin, friction from tight clothing underwired bras and collars.

There is a perception that once a patient is on radiotherapy their survival rates are low. Could you clarify on the impact radiotherapy in cancer care?

Numerous studies have confirmed the significant role that radiation therapy plays in cancer management.  More often than not poor outcomes are because of the stage of the disease and not the effects of the treatment.

What are some of the side effects for patients undergoing radiotherapy treatment?

Side effects of radiotherapy can either be short or long term and it is important to know that these vary widely depending on the area being treated.

Some general short term side effects include tiredness and sore skin in the treatment area. These will usually improve a few weeks after treatment. Long term side effects take months or even years to develop and can occur in any normal tissues that have been exposed to radiation. Careful treatment planning helps avoid long term side effects. All patients should have a discussion about the expected side effects of their treatment and how they will be managed.

Are there chances of cancer recurring after radiotherapy treatment?

Unfortunately, despite treatments such us radiotherapy, sometimes cancers come back, often as metastatic disease i.e. outside the original (primary) location to another part of the body. Cancers that are diagnosed at a more advanced stage are more likely to recur after treatment than those diagnosed at an early stage

Recurrence is a devastating diagnosis for a patient who was previously successfully treated; it is important to know that recurrence does not mean that the initial treatment was incorrect or unsuccessful. Some cancers are more likely to come back than otherS.

Scientific research has made great strides in understanding how recurrent cancers can be managed and a growing number of treatment options are now available

What lifestyle changes are required after undergoing radiotherapy?

After recovery from the effects of radiation treatment patients are encouraged to return to their normal lives – including regular employment for those who were still working – there is no limitation as to the type of work one can engage in.

In addition, there are ways to improve long-term health that will allow patients to enjoy the years ahead of them. Most of these recommendations are no different to anyone wanting to improve their health – such as regular exercise, eating a balanced diet, maintaining a healthy weight, resting well and reducing stress plus avoiding tobacco, and limiting the amount of alcohol one drinks.

What are some of the other misconceptions about radiotherapy treatment that you have come across?

That the treatment is painful – the actual treatment is painless but sometimes the side effects that develop during treatment can cause discomfort or pain.

That the treatment will cause the patient to become radioactive- this is only true in small number of very specific cases where a radioactive source has been ingested or implanted- all patients receiving this form of radiation will have been guided on the necessary extra precautions such as keeping away from pregnant women or children for the short period that they are radioactive. Otherwise for the vast majority of patients receiving external radiotherapy, the patient is not radioactive.

Radiation therapy will cause cancer to spread – Radiation therapy is carefully considered and recommended where the benefits outweigh the risks and is used to treat and reduce the risk of recurrence. Where cancers recur, it is unlikely that this can be attributed to radiation therapy alone.

What are new developments do we have in the field of radiotherapy and what is the impact on patient care?

Recent notable technological advances include improved target delineation – a critical first step in planning radiation treatments. The extent of the tumour is defined; complimentary images from MRI to PET-CT scans are increasingly incorporated into the treatment planning process allowing for increased safety in delivering the radiation dose whilst minimizing exposure of uninvolved normal tissue to radiation.

Other advances in treatment planning and delivery are devising radiation treatments that closely conform to the tumuor with the delivery of modulated radiation beams known as intensity modulated radiation therapy (IMRT), further refinements have led to improved conformality and reduced treatment times such as with volumetric modulated arc therapy (VMAT), Image Guided Radiotherapy (IGRT) where imaging is used during radiation therapy to improve precision and accuracy of treatment delivery. In recent years, there has been substantial interest in regimens involving a relatively large dose of radiation being delivererd in highly conformal techniques, known as sterotactoc body radiation therapy (SBRT) also called sterotactc ablative radiotherapy (SABR) – these approaches are not appropriate for all clinical scenarios with the size of the lesion requiring treatment and its proximity to critical normal tissues with high sensitivity to radiation being carefully considered.

Some of these forms of advanced radiotherapy are available locally and others like stereotactic body radiotherapy are planned for the near future; where a patient requires treatment other than those locally available, referral mechanisms exist for international treatments.

These and future technological advances ultimately serve to reduce the toxicity of radiotherapy, whilst escalating the doses of radiotherapy which in many cases has led to improvements in disease control.

By Dr Angela K. Waweru, Consultant Radiation Oncologist, Section Head Radiotherapy, Department of Haematology-Oncology, Aga Khan University Hospital, Nairobi

This article was first published in the Business Daily Newspaper