RADIATION THERAPY

COURSE CODE ONP420

BY
NR. EKANEM PAULINE CYPRIAN
Table Of Content
• Physics of radiotherapy
• Types of ionizing rays
• Radiation equipment
• Types of therapies
• Effects of radiation on body tissue
• Principles of radiation therapy
• Goal of treatment approach
• External radiotherapy
• Internal radiotherapy
• Effectiveness of radiotherapy
• Radiations safety
• Nurses’ responsibilities
Course description
• The course covers the principles and techniques of management of
patients affected with concerns.
• It highlights the specific roles the oncology nurse plays in the
multidisciplinary team and involvement in the various treatment
modalities.
Objectives Of The Lecture
At the end of the course, the student should be able to:
1. Describe the different treatment modalities for cancers
2. Demonstrate skill in administering drugs through various routes
3. Assist in various treatment plans used in cancer management
4. Apply nursing process in providing holistic care for cancer patients
5. Utilize the knowledge about the growth and developmental stages in
children to manage the commonly occurring pediatric cancers
6. Health educate and counsel patients and family members on treatment
modalities and their side effects as well as their role in the care plan
7. Manage common problems occurring in patients with cancer
Introduction
•Radiation therapy is a cancer treatment that uses high-energy x-
ray or other particles to destroy cancer cells. A doctor who
specializes in giving radiation therapy to treat cancer is called a
radiation oncologist. A radiation therapy regimen, or schedule,
usually consists of a specific number of treatments given over a
set period.
•Radiation therapy can treat many different types of cancer. It can
also be used in combination with other cancer treatments, such as
chemotherapy and/or surgery.
Goals Of Radiation Therapy
•The goals of radiation therapy depend on your type of cancer and if and how far it has
spread. Radiation therapy can be given alone or as a part of a treatment plan that includes
different treatments. Some of the ways radiation therapy is used include:
•As the primary treatment. Often, the goal of radiation therapy is to get rid of all the cancer
and keep it from coming back.
•Before other treatments. Radiation therapy can be given before other treatments, such as
surgery, to shrink a large tumor. This is called "neoadjuvant radiation therapy."
•After other treatments. Radiation therapy can be given after other kinds of treatments to
destroy any remaining cancer cells. This is called "adjuvant radiation therapy."
•To relieve symptoms. Radiation therapy can be used to relieve the signs and symptoms of
cancer. This is called "palliative radiation therapy."
Types Of External-beam Radiation Therapy
•The most common type of radiation therapy is external-beam radiation
therapy. It delivers radiation from a machine outside the body. It can be
used to treat large areas of the body, if needed.
•A machine called a linear accelerator, or linac, creates the radiation beam
for x-ray or photon radiation therapy. Special computer software adjusts
the beam's size and shape. This helps target the tumor while avoiding
healthy tissue nearby.
•The different types of external-beam radiation therapy are:
 Three-dimensional conformal radiation therapy (3D-
CRT). During this type of radiation therapy, detailed 3-dimensional
pictures of the cancer are created from computed tomography
(CT) or magnetic resonance imaging (MRI) scans. The treatment
team uses these images to aim the beam. With this technique, the
treatment team can safely use higher doses of radiation therapy and
reduce damage to healthy tissue. This lowers the risk of side effects.
 Intensity modulated radiation therapy (IMRT). This is a more
complex form of radiation therapy. With IMRT, the intensity of the
radiation is varied. This is different than conventional 3D-CRT, which
uses the same intensity with each beam. IMRT targets the tumor and
avoids healthy tissue better than conventional 3D-CRT.
 Proton beam therapy. This treatment uses protons rather than x-rays. A proton is
a positively charged particle. At high energy, protons can destroy cancer cells. The
protons go to the targeted tumor and deposit a specific dose of radiation therapy.
Unlike x-ray beams, very little radiation dose goes beyond the tumor with proton
therapy. This limits damage to nearby tissue. Proton therapy is a relatively new
treatment that requires special equipment. It is currently only used to treat
certain types of cancer.
 Image-guided radiation therapy (IGRT). IGRT uses imaging during radiation
treatment. Images are taken right before and during treatment and compared to
imaging taken before treatment began. This helps doctors position the radiation
as precisely as possible.
 Stereotactic radiation therapy (SRT). This treatment delivers a large, precise dose
to a small tumor area. The patient must remain very still. A head frame or
individual body molds help limit movement. SRT is often given as a single
treatment or in fewer than 10 treatments. Some people may need more than one
course of SRT.
Internal Radiation Therapy
•Internal radiation therapy is also called brachytherapy. This type of radiation therapy is when
radioactive material is placed into the cancer or surrounding tissue. Implants may be permanent or
temporary. This treatment may require a hospital stay.
The different types of internal radiation therapy include:
 Permanent implants. These are tiny steel seeds that contain radioactive material. The capsules
are about the size of a grain of rice. They deliver most of the radiation therapy around the implant
area. However, some radiation may exit the patient's body. This requires safety measures to
protect others from radiation exposure. Over time, the implants lose radioactivity. The inactive
seeds remain the body.
 Temporary internal radiation therapy. This type of radiation therapy can be given by needle,
through a tube called a catheter, and through special applicators. The radiation stays in the body
for anywhere from a few minutes to a few days. Most people receive internal radiation therapy for
just a few minutes. Sometimes, internal radiation therapy can be given for more time. If so, they
stay in a private room to limit other people's exposure to radiation.
Internal Radiation Therapy Cont…
Brachytherapy treats cancers throughout the body, including the:
• prostate
• cervix
• head and neck skin
• breast
• gallbladder
• uterus
• vagina
• lung
• rectum
• eye
• Brachytherapy requires a treatment team. This team includes a radiation
oncologist, medical physicist, dosimetrist, radiation therapist, nurse and,
sometimes, a surgeon.
• The oncologist evaluates the patient, identifies the treatment and
determines the appropriate therapy and radiation dose. In some cases, a
surgeon will assist by placing treatment devices in the patient. The
medical physicist, dosimetrist and oncologist determine how to deliver
the radiation and how much the patient can tolerate. The physicist and
the dosimetrist then make detailed treatment calculations. The radiation
therapist, a specially trained technologist, may help deliver treatment.
The nurse provides information about the treatment and possible side
effects. The nurse also helps manage care for treatment catheters.
• The type of radioactive material used (iodine, palladium,
cesium or iridium) depends on the type of treatment. In all
types, the radiation source is encapsulated. This means it is
enclosed within a non-radioactive metallic capsule often
referred to as a "seed." This helps prevent the material from
moving to other parts of the patient's body.
• Permanent implants put radioactive seeds directly in the tumor
using a special delivery device. This is usually done with
ultrasound and/or x-ray imaging to ensure accurate placement.
• Temporary implants use needles, catheters or special applicators. After
the device's accurate position is confirmed, the radiation sources are
inserted. This is called "afterloading." The oncologist may insert and
remove the material by hand after placing the delivery device. Or, the
oncologist may use a computer-controlled remote afterloading machine
to insert the material. Medical imaging helps position the material to
treat the tumor in the most effective way. A computer calculates the
source position and the amount of time needed to deliver the desired
radiation dose.
• HDR treatment is usually an outpatient procedure. However, some patients are
admitted to the hospital for one to two days to have several HDR treatments using
the same applicator. HDR treatment delivers a specified dose of radiation to the
tumor in a short burst using a remote afterloading machine. The machine stores a
powerful source of radioactive isotopes (Iridium-192) and protects personnel from
unnecessary radiation exposure. The HDR treatment lasts about 10 to 20 minutes.
The entire procedure (including placement of the delivery device) may take up to
several hours. This may be repeated a couple times in a day before the delivery
device is removed. Patients may receive up to 10 separate HDR treatments over one
or more weeks.
• LDR treatment delivers radiation at a continuous rate over one to two days. It
requires an overnight stay at the hospital. This allows the delivery device to remain
in place throughout the treatment period. PDR treatment delivers radiation similarly
using periodic pulses (usually one per hour). The doctor may insert the material
through the delivery device by hand and remove it later once treatment is complete.
• Once treatment is complete, the doctor removes the delivery device from the
patient.
Other Radiation Therapy Treatment Options
 Intraoperative radiation therapy (IORT). This treatment delivers radiation
therapy to the tumor during surgery using either external-beam or internal-beam
radiation therapy. IORT allows surgeons to move healthy tissue out of the way so
that it does not get damaged during the radiation therapy. 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 urine, saliva, and sweat. These fluids are radioactive, and people in
close contact with the patient should take the safety measures recommended by
the health care team (see below). An example of systemic radiation therapy is
radioactive iodine therapy (RAI; I-131) for thyroid cancer.
 Radioimmunotherapy. This is a type of systemic therapy. Specifically, it
uses monoclonal antibodies, which are proteins that are attracted to very
specific markers on the outside of cancer cells, to deliver radiation directly to the
tumors. Because the treatment uses these special antibodies, there is less effect
on the surrounding normal tissue. An example is ibritumomab (Zevalin), which is
used in the treatment of some lymphomas.
 Radiosensitizers and radioprotectors. Researchers are studying radiosensitizers
and radioprotectors. Radiosensitizers are substances that help radiation therapy
better destroy tumors. Radioprotectors are substances that protect healthy
tissues near the treatment area. Examples of radiosensitizers include fluorouracil
(5-FU, Adrucil) and cisplatin (Platinol). Amifostine (Ethyol) is an example of a
radioprotector.
Types Of Ionizing Radiation
• Energy emitted from a source is generally referred to as radiation.
Examples include heat or light from the sun, microwaves from an oven, X
rays from an X-ray tube and gamma rays from radioactive elements.
Ionizing radiation can remove electrons from the atoms, i.e. it can ionize
atoms
• Ionizing radiation is radiation with enough energy that to remove tightly
bound electrons from the orbit of an atom, causing that atom to
become charged or ionized.
• Here we are concerned with only one type of radiation, ionizing
radiation, which occurs in two forms: waves or particles.
• There are several forms of electromagnetic radiation, which differ only in
frequency and wavelength:
• heat waves
• radio waves
• infrared light
• visible light
• ultraviolet light
• X rays
• gamma rays.
• Longer wavelength, lower frequency waves such as heat and radio have less
energy than shorter wavelength, higher frequency waves like X and gamma
rays. Not all electromagnetic (EM) radiation is ionizing. Only the high
frequency portion of the electromagnetic spectrum, which includes X rays
and gamma rays, is ionizing.
Sources Of Radiation Exposure
• Radiation is permanently present throughout the environment - in the
air, water, food, soil and in all living organisms. In fact, a large proportion
of the average annual radiation dose received by people results from
natural environmental sources.
• Each person is exposed to an average of 2.4 mSv per year of ionizing
radiation from natural sources. In some areas around the world the
natural radiation dose may be 5 to 10-times higher for large number of
people.
Particle form of radiation
• Particulate radiation is a form of ionizing radiation. This consists of atomic or subatomic particles
(electrons, protons, etc.) that carry kinetic energy, or mass in motion. This comes in several
forms, including alpha and beta particles.
• Alpha particles and beta particles are considered directly ionizing because they carry a charge
and can, therefore, interact directly with atomic electrons through coulombic forces (i.e. like
charges repel each other; opposite charges attract each other).
• The neutron is an indirectly ionizing particle because it does not carry an electrical charge.
Ionization is caused by charged particles, which are produced during collisions with atomic
nuclei.
• The third type of ionizing radiation includes gamma and X rays, which are electromagnetic,
indirectly ionizing radiation. These are indirectly ionizing because they are electrically neutral (as
are all electromagnetic radiations) and do not interact with atomic electrons through coulombic
forces.
Types Of Radiation Therapies
• 3D conformal radiation therapy (3DCRT) uses three-dimensional scans
to determine the exact shape and size of the tumor. Radiation beams
are shaped by tiny metal leaves arranged to fit the tumor. This
minimizes the side effects to healthy tissues. Several cancer types have
seen improved outcomes from this including brain cancer, head and
neck cancer, liver cancer, lung cancer and prostate cancer.

• Image guided radiation therapy (IGRT) tracks the tumor or implanted

markers during radiation. This type of radiation treats tumors in areas of
the body that move. This includes cancers of the lungs, liver, pancreas
and prostate gland, as well as tumors located close to critical organs and
tissues.
Types Of Radiation Therapies Cont…
• Intensity modulated radiation therapy (IMRT) delivers multiple
radiation beams directly on the tumor. Our team of experts uses special
planning software to minimize dose to the surrounding normal tissues.
This type of radiation is often used when the tumor is extremely close
to surrounding normal organs.

• Volumetric modulated arc therapy (VMAT) uses multiple radiation

beams of different intensities. As the treatment machine rotates,
radiation is delivered at every angle. This focuses the highest dose of
radiation on the tumor, while reducing radiation to healthy organs.
VMAT can be used to treat several types of solid tumors, including
prostate cancer, liver cancer and pancreatic cancer.
Radiobiology
• Radiobiology (also known as radiation biology, and uncommonly
as actinobiology) is a field of clinical and basic medical sciences that
involves the study of the action of ionizing radiation on living things,
especially health effects of radiation. Ionizing radiation is generally
harmful and potentially lethal to living things but can have health
benefits in radiation therapy for the treatment of cancer
and thyrotoxicosis. Its most common impact is the induction of
cancer with a latent period of years or decades after exposure. High
doses can cause visually dramatic radiation burns, and/or rapid fatality
through acute radiation syndrome. Controlled doses are used
for medical imaging and radiotherapy.
Principles Of Radiation Therapy
• This chapter provides a brief overview of the principles of radiation
therapy. The topics to be discussed include the physical aspects of how
radiation works (ionization, radiation interactions) and how it is delivered
(treatment machines, treatment planning, and brachytherapy). Recent
relevant techniques of radiation oncology, such as conformal and
stereotactic radiation therapy, also will be presented. These topics are not
covered in great technical detail, and no attempt is made to discuss the
radiobiological effects of radiation therapy. It is hoped that a basic
understanding of radiation treatment will benefit those practicing in other
disciplines of cancer management. This chapter does not address principles
of radiobiology, which guide radiation oncologists in determining issues of
treatment time, dose, and fractionation or in combining radiation with
sensitizers, protectors, and chemotherapy or hormones.
How Radiation Works
Ionizing Radiation
• Ionizing radiation is energy sufficiently strong to remove an
orbital electron from an atom. This radiation can have an
electromagnetic form, such as a high-energy photon, or a
particulate form, such as an electron, proton, neutron, or
alpha particle.
Photon-tissue Interactions
• Three interactions describe photon absorption in tissue: the
photoelectric effect, Compton effect, and pair production.
Electron Beams
• With the advent of high-energy linear accelerators, electrons have
become a viable option in treating superficial tumors up to a depth of
about 5 cm. Electron depth dose characteristics are unique in that they
produce a high skin dose but exhibit a falloff after only a few
centimeters.
• Common uses The most common clinical uses of electron beams
include the treatment of skin lesions, such as basal cell carcinomas,
and boosting of areas that have previously received photon irradiation,
such as the postoperative lumpectomy or mastectomy scar in breast
cancer patients, as well as select nodal areas in the head and neck.
Measuring Radiation Absorption
• The dose of radiation absorbed correlates directly with the
energy of the beam. An accurate measurement of absorbed
dose is critical in radiation treatment. The deposition of energy
in tissues results in damage to DNA and diminishes or
eradicates the cell’s ability to replicate indefinitely.
How Radiation Is Delivered
Treatment Machines
• Linear accelerators
• High-energy radiation is delivered to tumors by means of a linear accelerator. A beam
of electrons is generated and accelerated through a waveguide that increases their
energy to the keV to MeV range. These electrons strike a tungsten target and produce
x-rays.
• X-rays generated in the 10–30-keV range are known as grenz rays, whereas the energy
range for superficial units is about 30–125 keV. Orthovoltage units generate x-rays from
125–500 keV.
• Orthovoltage units continue to be used today to treat superficial lesions; in fact, they
were practically the only machines treating skin lesions before the recent emergence
of electron therapy. The maximum dose from any of these low-energy units is found on
the surface of patients; thus, skin becomes the dose-limiting structure when treating
patients at these energies. The depth at which the dose is 50% of the maximum is
about 7 cm. Table 1 lists the physical characteristics of several relevant x-ray energies.
Pretreatment Procedures
• Pretreatment CT Before any treatment planning can begin, a pretreatment CT scan
is often performed. This scan allows the radiation oncologist to identify both the
tumor and surrounding normal structures.
• Simulation The patient is then sent for a simulation. The patient is placed on a
diagnostic x-ray unit that geometrically simulates an actual treatment machine.
With use of the CT information, the patient’s treatment position is simulated by
means of fluoroscopy. A series of orthogonal films are taken, and block templates
that will shield any normal structures are drawn on the films. These films are sent to
the mold room, where technicians construct the blocks to be used for treatment. CT
simulation is a modern alternative to “conventional” simulation and is described
later in this chapter.
• Guides for treatment field placement Small skin marks, or tattoos, are placed on
the patient following proper positioning in simulation. These tattoos will guide the
placement of treatment fields and give the physician a permanent record of past
fields should the patient need additional treatment in the future.
Treatment Planning And Delivery

• Determining optimal dose distribution The medical physicist or

dosimetrist uses the information from CT and simulation to plan the
treatment on a computer. A complete collection of machine data,
including depth dose and beam profile information, is stored in the
computer. The physics staff aids the radiation oncologist in deciding
the number of beams (usually two to four) and angles of entry. The
goal is to maximize the dose to the tumor while minimizing the dose
to surrounding normal structures.
• Establishing the treatment plan The planning computer will calculate
the amount of time each beam should be on during treatment. All
pertinent data, such as beam-on time, beam angles, blocks, and
wedges, are recorded in the patient’s treatment chart and sent to the
treatment machine.
Goal Of Treatment Approach (Curative And Palliative)
• Patients who are treated with radiotherapy (RT) commonly have disease
circumstances with no clear distinction between curative and palliative
goals, especially when factors such as comorbidity, performance status,
organ reserve, and prognosis are taken into account. This chapter
highlights tumor sites where patients with locally advanced disease are
offered radical RT despite the knowledge that the chance of cure is going
to be low, and hence the treatment is often in essence palliative. Equally, it
also highlights circumstances where radical RT may not be feasible due to
either tumor or patient factors, and palliative RT is offered instead. It is also
important to emphasize that while treating those with heavy disease
burden with curative intent, they also require palliative care (PC) treatment
that helps to quell disease symptoms and minimize treatment-related
toxicity.
Planning And Precaution
• The radiotherapy team plans your external beam radiotherapy before
you start treatment. This means working out the dose of radiotherapy
you need and exactly where you need it. Your planning appointment
takes from 15 minutes to 2 hours.
• You usually have a planning CT scan in the radiotherapy department.
• The scan shows the cancer and the area around it. You might have had
other types of scans or x-rays before this appointment to help diagnose
or stage your cancer. Your treatment team might also use these scans
to plan your radiotherapy. The plan they create is just for you.
• To plan the treatment your doctor thinks about:
• your type of cancer
• the position of the cancer in your body
• the size of the cancer
• whether the cancer is close to structures in your body that are
sensitive to radiation
• how far the radiation needs to travel into your body
• your general health and medical history
• Before your planning starts, your nurse or radiographer asks
you to sign a consent form. If you're a woman they check with
you that you’re not pregnant and remind you not to get
pregnant during treatment. This is because radiation can
damage an unborn baby. Very occasionally it can be possible to
have radiotherapy if you’re pregnant. But this depends on
where you’re having treatment to.
Precautions
• Some general guidelines to remember are given below:
• Be sure to get plenty of rest. ...
• Good nutrition is a must. ...
• Avoid wearing tight clothes, such as shape wear or close-fitting collars
over the treatment area. ...
• Do not use any of these personal-care products in the treatment area
without checking first with your doctor: soaps, lotions, deodorants,
medicines, perfumes, cosmetics or talcum powder.
• Do not starch your clothes.
Effectiveness Of Radiotherapy
• Radiotherapy may be used in the early stages of cancer or after it has
started to spread. Radiotherapy is generally considered the most
effective cancer treatment after surgery, but how well it works varies
from person to person. Ask your doctors about the chances of
treatment being successful for you. Radiotherapy can be given in
several ways.
Complications of radiotherapy
• The skeletal effects of radiation are dependent upon many variables, but
the pathologic features are consistent.
• Radiation may cause immediate or delayed cell death,
• Cellular injury with recovery,
• Arrest of cellular division, or abnormal repair with neoplasia.
• Radiation necrosis and radiation-induced neoplasm still occur despite
the use of super voltage therapy.
Complications of radiotherapy are well known and have led to more
judicious use of this therapeutic modality. With few exceptions, benign
bone tumors are no longer treated with irradiation.
Radiations Safety
• Radiation safety measures such as conducting safety inspections help
ensure that critical radiation safety precautions are in place to reduce the
risk of overexposure. There should be visible warning signs,
contamination surveys conducted, and device tests for all radiation-
producing equipment.
• There are three components that figure into the total radiation dose:
time, distance, and shielding.
• Time: The less time you spend exposed to radiation the lower your dose.
When experimenting, make sure you know exactly what you need to get
done with the radiation. If necessary, go through a dry run practicing all your
motions without the radiation. Only use the radiation when you have worked
out all the other potential problems with your experimental procedure.
• Distance: Like most other physical phenomena, radiation decreases with
distance in accordance with the inverse square law. This means that the
further away you are from the source of the radiation, the less radiation
you'll be exposed to. Try to plan your experiments so that you, and anyone
else around, are standing as far away from the radiation source as possible.
• Shielding: As ionizing radiation passes through matter, the intensity of the
radiation is diminished. Thus, to protect yourself from radiation you should
erect a barrier or shield. However, the material you use matters significantly;
some materials reduce the intensity of radiation more than others.
• Every material has a "halving thickness." This is the thickness required to
reduce the radiation intensity by half. So if the halving thickness of a material
is 1 inch, then a 1 inch thick sheet will cut the radiation to 50%. Two inches
will cut the radiation to 25%, 3 inches to 12.5%, and so forth. Traditionally
lead is used for shielding because it has a very low halving thickness (0.4
inches). Before working with radiation, erect the shielding. When working
with radiation, staying behind the shielding can be an effective way of
diminishing your radiation exposure.
• With radiation the answer is usually the less the better. Here are a couple of
facts to keep in mind.
• A single chest X-ray or dental X-ray, both of which are considered to be
medically safe, exposes a patient to 10mrem of radiation. Limiting your
exposure for a single experiment to 10mrem would be similar to getting an X-
ray.
• The international safety standard is 5,000mrem or less per year. Your annual
exposure, both normal and experimental, should fall below the 5,000mrem
level.
Nursing Responsibilities During Radiation Therapy

• Provide education
• Minimize side effects
• Provide a non-stressful environment
• Dental care
• Many patients feel tired due to the radiation therapy which can affect their
emotions.
• Patients might feel depressed, afraid, angry, frustrated, alone or helpless-Peer
support groups may meet at your hospital.
• Emotional and spiritual encouragement also is important to the healing process.
• Side effects can include eating and digestion problems. You may completely lose
interest in food during your treatment.-Even if you are not hungry, it is important to
keep your protein and calorie intake high.
• Doctors have found that patients who eat can better handle their cancers and side
effects.-Eat when you are hungry, even when it is not meal time.-Eat several small meals
during the day rather than 2 or 3 large meals.-Vary your diet and try new recipes.-If you
don’t drink alcohol, ask your doctor if you should avoid alcohol during your treatment.-
Keep healthful snacks close by nibbling when you get the urge.
• Drink milkshakes or prepared liquid supplements between meals.
• Patient receives a low residue diet to prevent frequent bowel movements.
• Radiation therapy may cause anorexia which may lead to inadequate nutrition and
hydration so small frequent feedings or use of nutritional supplements may be required
to maintain adequate nutrition.
• In radiation therapy, fatigue or malaise also contribute to poor nutritional intake thus
planned rest periods may provide relief of fatigue providing increased energy for meal
preparation or consumption.
Summary
•Radiation therapy is a common treatment for cancer. A person
may receive radiation therapy alone or in combination with other
treatments.

•External beam radiation and internal radiation therapy, or

brachytherapy, are the main types of radiation therapy.

•An individual’s cancer type, tumor location, and treatment goals

will help determine the best course of radiation treatment for
them.
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