Radiation Oncology Nursing

Radiation Oncology Nursing

Learning Objectives Explain radiation safety for the work place
Identify the different types of radiation Distinguish how radiation works as a treatment modality Explain common side effects of radiation treatment Differentiate between IR procedures Explain skin care management options when receiving radiation Discuss patient preparation for radiation therapy Describe oncologic emergencies related to radiation therapy

Table of Contents Chapter 1: Radiation Safety
Chapter 2: Fundamentals of Radiation and Radiation Procedures Chapter 3: Radiation Oncology Procedures Chapter 4: Interventional Radiation Procedures Chapter 5: Skin Care - Management Chapter 6: Side Effect Management Chapter 7: Radiation Emergencies This is the corrected Table of Contents

Chapter 1: The History Radiation Therapy And Safety Guidelines

Wilhelm Roentgen ( ) While performing experiments on electricity, Roentgen noted that an energy “ray” was produced which passed through most objects, including his own body. He also noted that these rays, which he named “x-rays”, could be used to produce images of bones. The field of Radiation Therapy (currently referred to as Radiation Oncology) was born not long after the discovery of x-rays in 1895 by the German physicist Wilhelm Roentgen. (USSanDiego School of Medicine Department of Radiation Medicine and Applied Sciences: The History of Radiation Oncology)

One of the first known x-ray images ever produced was of his wife Bertha’s left hand. He also noted that these rays could be used to produce images of bones. In fact, one of the first known x-ray images ever produced was of his wife Bertha’s left hand. In 1901 Roentgen received the first Nobel Prize awarded in physics November 8th, 1895

Chicago 1896 Emil Grubbe World’s first Radiation Oncologist
Grubbe, a medical student, began experimenting with Crookes tubes and coils. These sealed glass tube from which nearly all the air had been removed produced cathode rays. The bare flesh of his hands, face and neck exposed to the tubes began blistering and peeling. After noting peeling of his hands exposed to x-rays, a medical student in Chicago named Emil Grubbe convinced one of his professors to allow him to irradiate a cancer patient, a woman named Rose Lee, suffering from locally advanced breast cancer. By doing so, Grubbe became the World’s first Radiation Oncologist. He convince one of his professors to allow him to irradiate a breast cancer patient, Rose Lee.

Marie Sklodowska Curie , the world's first studies were conducted under her direction into the treatment of cancer, using radioactive isotopes. Curie died in 1934 at a sanatorium France, due to aplastic anemia brought on by exposure to radiation – including carrying test tubes of radium in her pockets during research Curie died in 1934 at a sanatorium in France due to aplastic anemia brought on by exposure to radiation – including carrying test tubes of radium in her pockets during research

Roentgen Therapy 1915 At first, Radiotherapy was delivered primarily in a limited number of treatments. A Professor at the Radium Institute in Paris name Claude Regaud, however, recognized that treatment may be better tolerated and more effective if delivered more slowly with modest doses per day over several weeks. Ray apparatus used for treatment of epithelioma of the face, 1915

One of the big limitation of the early radiation therapy machines was their inability to produce high energy, deeply penetrating beams. It was thus difficult to treat deep-seated tumors without excessive skin reactions. This approach, known as fractionation, is one of the most important underlying principles in Radiation Therapy. To this day, fractionation lies at the heart of many treatment programs currently used in Radiation Oncology.

One young cancer patient in 1956
, was the first to undergo X-ray treatment from a medical linear accelerator that Kaplan developed with campus physicists. The treatment saved the child's sight and he lived the rest of his life with his vision intact. A 2-year-old boy suffering from a tumor in his eye

At first, Radiotherapy was given in large doses.
A Professor at the Radium Institute in Paris name Claude Regaud recognized that treatment was more effective and not as damaging to the skin the doses of radiation were smaller and given over several weeks instead of large doses.

Alpha Radiation Alpha radiation is a heavy, very short-range particle and an ejected helium nucleus. Characteristics of alpha radiation: Most are not able to penetrate human skin Internal exposure harmful to humans Geiger-Mueller (GM) probe Not an external hazard Not currently used in any diagnostic radiopharmaceuticals Examples of some alpha emitters: Radium Radon Uranium Thorium Characteristics- Most alpha radiation is not able to penetrate human skin. Alpha-emitting materials can be harmful to humans if the materials are inhaled, swallowed, or absorbed through open wounds. A variety of instruments have been designed to measure alpha radiation. Special training in the use of these instruments is essential for making accurate measurements. A thin-window Geiger-Mueller (GM) probe can detect the presence of alpha radiation. Instruments cannot detect alpha radiation through even a thin layer of water, dust, paper, or other material, because alpha radiation is not penetrating. Alpha radiation travels only a short distance (a few inches) in air, but is not an external hazard. Alpha radiation is not able to penetrate clothing. Alpha radiation is not currently used in any diagnostic radiopharmaceuticals.

Beta Radiation Beta radiation is a light, short-range particle and an ejected electron. Characteristics of beta radiation: Moderately penetrating May be harmful if deposited internally Most beta emitters can be detected with a survey instrument Clothing provides some protection against beta radiation Examples of some pure beta emitters: Yittrium-90 Strontium-90 Carbon-14 Sulfur-35 Beta radiation may travel several feet in the air and is moderately penetrating. Beta radiation can penetrate human skin to the "germinal layer," where new skin cells are produced. If high levels of beta-emitting contaminants are allowed to remain on the skin for a prolonged period of time, they may cause skin injury. Beta-emitting contaminants may be harmful if deposited internally. Most beta emitters can be detected with a survey instrument and a thin-window GM probe (e.g., "pancake" type). Some beta emitters, however, produce very low-energy, poorly penetrating radiation that may be difficult or impossible to detect. Examples of these difficult-to-detect beta emitters are hydrogen-3 (tritium), carbon-14, and sulfur-35. Clothing provides some protection against beta radiation.

Gamma Radiation Gamma radiation and X-Rays are highly penetrating electromagnetic radiation. Characteristics of Gamma Radiation: Are able to travel many feet Constitute mainly an external hazard to humans. Are electromagnetic radiation like visible light, radiowaves, and ultraviolet light. Dense materials are needed for shielding from gamma radiation Is easily detected by survey meters Examples of some gamma emitters: Iodine-131 Cesium-137 Cobalt-60 Radium-226 Technetium-99m Characteristics- Gamma radiation or X-Rays are able to travel many feet and readily penetrate most materials and are sometimes called "penetrating" radiation. X rays are like gamma rays. X-rays, too, are penetrating radiation. Sealed radioactive sources and machines that emit gamma radiation and X-Rays respectively constitute mainly an external hazard to humans. Gamma radiation and X-Rays are electromagnetic radiation like visible light, radio waves, and ultraviolet light. These electromagnetic radiations differ only in the amount of energy they have. Gamma rays and X-Rays are the most energetic of these. Dense materials are needed for shielding from gamma radiation. Clothing provides little shielding from penetrating radiation, but will prevent contamination of the skin by gamma-emitting radioactive materials. Gamma radiation is easily detected by survey meters with a sodium iodide detector probe. Gamma radiation and/or characteristic X-Rays frequently accompany the emission of alpha and beta radiation during radioactive decay.

Radiation Therapy Basics
Radiation Therapy is the use of high energy x-rays or particles to treat disease Everyone working around Radiation Therapy treatments need to be aware of radiation safety principles

Radiation Safety The Goal of Radiation Safety precautions are to keep radiation safety exposure of health care workers and the public below a certain threshold to prevent radiation- induced health effects Health Effects of large radiation exposure include increase cancer risk, damage to eyes, immune system, skin and GI tract *Resource Oncology Nursing Society Radiation Therapy Course, 2006 Picture:

Measuring Radiation Exposure
Radiation exposure is measured in rem or millirems (mrem) 1000 mrem = 1 rem Person flying from New York to Tokyo receives 20 mrem. Potentially life threatening health effects can occur with exposures of 100 rems (100,000 mrems) Manual for Radiation Oncology Nursing Practice and Education 3rd edition, pg29

Background Radiation Background radiation refers to low-level radiation occurring naturally as a result of radioactivity present in the air, soil, and buildings and other structures Examples: television, microwaves, high altitude, soil The National Council on Radiation Protection (NCRP) states an average American receives 360 mrem of radiation annually from background radiation Encarta World English Dictionary

Monitoring Devices Monitoring devices are used to measure radiation exposure of health care workers Occupational Safety and Health Administration (OSHA) has set specific guidelines on the amount of radiation exposure that is acceptable for health care workers Monitoring devices are reviewed monthly or quarterly OSHA Radiation Regulations Example: Film Badge: Guidelines for film badge (MRONP and E, 4th edition pg 27): Only worn at work, not to be exchanged/shared, not left on a lab coat not being worn, in general best placement is on front between waist and collar.

Occupational Exposure
The NCRP has set annual occupational radiation exposure limit to mrem annually Typical year at SRMC: occupational exposure mrem/yr These examples are given to illustrate that the use of radiation safety principles in the health care setting keeps radiation exposure to health care workers well within acceptable safe limits.

Pregnant Employees Fetus is the most radiosensitive tissue (especially during first trimester) Annual safe exposure for fetus is 500 mrem Stakeholders who are pregnant or attempting to get pregnant, must inform manager and Radiation Safety Officer (RSO) Monitoring device will be placed on abdomen RSO will counsel stakeholder about additional safety precautions Pregnant stakeholders in the health care setting, need to declare their pregnancy as soon as possible so that they can receive additional monitoring and training about ways to minimize radiation exposure to fetus. a pregnant woman assumes all responsibility for the exposure of the fetus until the pregnancy is “declared”. Once it is declared, the supervisor and RSO are responsible for ensuring that radiation exposure to the fetus does not exceed 500 mrem Manual for Rad Onc Nsg Practice and Education 4th edition, pg 42

International Radioactive Sign
Should be placed on the door of a room once a radiation source is present. It should not be removed until the source is no longer present or exposure risk no longer exists International radioactive signs will be placed on doors where potential radiation exposure exists. Also, in radiation therapy units there may be additional signage that can be turned off and on as a warning when the radiation source is active. Signs should remain in place until room is surveyed to determine exposure risk no longer present RONP & E , 4th edition pg 39

ALARA Principle As Low Reasonably Achievable
A guideline used to minimize radiation exposure to workers by keeping the radiation exposure As Low Reasonably Achievable Radiation exposure cannot be avoided, everyone is being exposed to radiation on a daily basis. The goal is to keep the additional exposure related to health care treatments as low as possible and within safe limits. Picture designed with ICMC

Three Methods of Radiation Protection
TIME DISTANCE SHEILDING The amount of exposure is directly related to the amount of time spent near the radioactive source The amount of radiation exposure is inversely related to the distance from the source The amount of radiation exposure received can be decreased by placing a shield between the source and the person

Time Minimize time near the source by:
Providing the maximum amount of direct nursing care before the source is placed or administered Using time efficiently when in contact with the patient and organize care Rotating nursing staff caring for patient Checking frequently on patient via phone or intercom MRONP&E , 4th edition, pg 37

Distance Increase distance from the radioactive source by:
Standing as far away from the sealed radioactive source as possible When possible, assist patient with needed tasks from a distance (e.g. preparing food tray) Reinforce teaching of self care when possible MRONP&E , 4th edition, pg 37

Shielding Decrease radiation exposure by shielding:
Keeping shielding between the source and person exposed Building shields into the walls and floors of designated treatment rooms Selecting the correct material for shielding based on the source of radiation High energy gamma rays: Lead shielding Beta rays: Plastic shielding MRONP&E , 4th edition, pg 37

Potential Exposure Exposure risk can be determined by asking the following questions: Where is the radiation source located? (internal or external) Is the source sealed or unsealed? What is the energy of the radiation source? (e.g. beta, gamma, xray, proton) What is the half life of the radiation source? (half life is length of time for the radioactive substance to lose half of its radioactivity) To ensure appropriate radiation precautions are taken, ask yourself the following questions The next few slides will cover this in greater detail

Potential Exposure: Sealed Source External Beam Radiation Therapy
Personnel are not allowed in the room during External Beam Radiation Therapy Source represents little risk of exposure

Potential Exposure: Internal Beam Radiation Therapy (Unsealed Source)
Radiation exposure can occur from exposure to the patient’s body fluids Follow specific radiations precautions determined by the Radiation Safety Officer Reinforce education on radiation precautions to patient

Activity – Key Takeaways
Which radiation is highly penetrating? Beta Gamma Alpha

Which radiation can be blocked by a sheet of paper? Beta Gamma Alpha

What does the acronym ALARA mean? As Little As Required Anyway As Long As Really Allowed As Low As Reasonably Achievable

When should a pregnant employee expect radiation protection assistance from management?

What are three methods of radiation protection? Time, Distance, Shielding ALARA Rock, Paper, Scissors

Chapter 2: Fundamentals of Radiation Therapy and Radiation Procedures
Knowledge tester – Ask the participants what they know about radiation therapy and the different types of therapy. Depending on their answers, will know how long to spend on the following definitions of radiation therapy.

Radiation Therapy How does radiation serve as a treatment for cancer?
May be used alone or in combination with surgery and/or chemotherapy About half of all cancer patients receive radiation during their course of treatment May be curative or palliative About half of all cancer patients receive radiation therapy during their course of treatment. It may be given independently or in combination with surgery ( to reduce tumor size prior to debulking or removal, or after to treat residual cells) and/or chemotherapy. Radiation therapy may be considered curative (death of tumor or residual cells) or palliative (to shrink tumors pressing on nerves or blood vessels, etc.).

Sealed vs Unsealed Source
The SOURCE, not the patient is radioactive Radiation precautions followed wherever the source is located The source is encapsulated Examples: rods, ribbons or seeds that are surgically implanted or in special applicators placed in body cavities Unsealed Liquids, capsules or colloids ingested, injected or instilled into the body Patient and his body fluids (blood, urine, feces, saliva, sweat) are radioactive for a specified amount of time Example of sealed: brachytherapy. We follow radiation precautions around patient only for the time that the source is in the patient. Once source is removed, patient is not radioactive. Example of unsealed: I 131 MRONP&E , 4th edition, pg 35-36

Radiation Therapy The type of radiation therapy prescribed by a radiation oncologist depends on many factors, including: Type of cancer Size of the cancer Location of cancer in the body Proximity of cancer to normal tissues that are sensitive to radiation How far into the body the radiation needs to travel The patient’s general health and medical history Other factors, such as the patient’s age, co-morbidities and whether the patient will have other types of cancer treatment will help determine the type of radiation prescribed. (Photo from WRMC 2011)

How do you dose radiation?
Determined by the amount of radiation absorbed by 1 kg of human tissue Different amounts required for different types of tissue/tumors. Measured and dosed in units called Grays (Gy) Divided doses Hyper-fractioned Hypo-fractioned Given in fractions Radiation doses for cancer treatment are measured in a unit called a gray (Gy) or centigray (cGy), which is a measure of the amount of radiation energy absorbed by 1 kg of human tissue. Different doses of radiation are needed to kill different types of cancer cells. Most types of external-beam radiation therapy are given in once-daily fractions. There are two main reasons for once-daily treatment: -To minimize the damage to normal tissue. -To increase the likelihood that cancer cells are exposed to radiation at the points in their individual cell cycles when they are most vulnerable to DNA damage Hyperfractionation—smaller doses of radiation given more than once a day. Hypofractionation—larger doses given once a day or less often to reduce the number of treatments.

Fundamentals of Radiation
Very important to track previous treatments and doses! Dose limited Simulation Head masks, body molds, skin markings Physician, dosimetrists, computers Pre-planned Radiation effects both normal and cancer cells within the site of treatment Non-specific Dose limits applies to individual body parts, which may allow for additional radiation at a later date. During simulation and daily treatments, it is necessary to ensure that the patient will be in exactly the same position every day relative to the machine delivering the treatment or doing the imaging. Body molds, head masks, or other devices may be constructed for an individual patient to make it easier for a patient to stay still. Temporary skin marks and even tattoos are used to help with precise patient positioning. Radiation oncologist’s (including physicists and dosemitrists – specially trained members of the radiation team that calculate the specific doses needed by the individual patient based on body mass, tumor types. Etc.) use sophisticated computers to design the details of the exact radiation plan that will be used. After approving the plan, the radiation oncologist authorizes the start of treatment. On the first day of treatment, and usually at least weekly after that, many checks are made to ensure that the treatments are being delivered exactly the way they were planned.

Radiation as a treatment modality
Causes Cell Death Rapid Dividing Cells are more Sensitive Oxygen Enhances Radiation Effects The ionizing effects of prescribed radiation cause both cell death and damage to the cell membrane (externally), causing alterations in the DNA of the cancer cell (internally), so the cells are not able to reproduce. The cells that are not eradicated, may, at the very least, be damaged. The damaged cells may repair themselves, but the rate is slowed because cancer cells do not have the organized and effective means of repair that healthy cells do. This slowing also contributes to the effectiveness of the treatment. Some cells are more sensitive than others. Cancer cells re-oxygenate to support mitotic activity and oxygen enhances Radiation Therapy. So, the more vascular (or better oxygenated) and rapidly dividing the cells are, the more sensitive to the ionizing radiation they will be. A hematocrit of 30% or better is preferred to maximize treatment effects. There are also many radio-sensitizing chemotherapy drugs that may be used to increase sensitivity to radiation.

Benefits of Radiation Therapy
Destruction and shrinkage of tumors Pain Relief Does not allow cancer cells to regenerate Destruction and shrinkage of tumors, along with significant pain relief. Radiation has powerful effects on tumors when treating them which do not allow cancer cells to regenerate. Any normal healthy tissue will regenerate, however cancer cells cannot after radiation therapy. Side effect can occur, however with new technology the radiation beam is more precise, thus side effects are much less than in the past years.

The Journey of a typical patient receiving radiation
With how Cancer Treatment Centers is changing, along with our new Outpatient Care Clinics, patients may end up being referred straight to Radiation, Urology, or Surgery as primary visit. The Intake/Medical Oncologist as the primary team still happens in some cases, but has been slowly changing. Intake Physician Completes history and physical Orders all needed lab, scans, et A consult order is written for patient to see a Medical Oncologist: Medical Oncologist All diagnostics reviewed Cancer diagnosis and staging Order for radiation oncology consult if appropriate With how Cancer Treatment Centers is changing, along with our new Outpatient Care Clinics, patients may end up being referred straight to Radiation, Urology, or Surgery as primary visit. The Intake/Medical Oncologist as the primary team still happens in some cases, but has been slowly changing.

Radiation Oncologist All scans and diagnostics are reviewed
Radiation Oncologist decides if radiation is appropriate for specific cancer If radiation can be part of patient’s treatment a plan is sent to insurance for precertification Once approved a CT Simulation is ordered Timing of CT simulation is dependent on cancer type and complexity of planning. A max of 5-6 days is required for simulation, but can often be much quicker. All will be dependent on physician, dosimetry, and Physic’s teams safety checks, and planning.

CT Simulation CT Scanner
The images from the CT scan will be used to create the radiation plan along with other diagnostic scans that can be fused into the treatment field. CT Scanner

Patient Positioning Depending on the area being radiated, small tattoo markings, masks or frames are individually created to assure the patient is in the same position with each radiation treatment. We also use VacLoc bags, similar to how bean bags feel. The bag is molded around the area we want to immobilize (Ex: Lower legs, pelvis, upper arms), and is then hooked up to a vaccum that removes air in the bag and becomes a hard cast of the immobilized area. The patient is then able to move into their mold daily, and aligned using their tattoos for a starting position. Size of tattoo markings Molding

Post Mapping/Simulation
The Radiation Oncologist, Physicist and Dosimetrist contour the treatment field with the dose volume for tumor and surrounding area Every area of the body has a radiation dose limit and tolerance

Education the Patient CT planning
Protection/ blocking of critical structures Port films and imaging during treatment Simulation procedure Contrast administration IV/ catheter/ marker placement Tattoos Immobilization devices In order to create a customized, precise plan for treatment, CT scan planning, also called simulation, is necessary. Assess if the patient is claustrophobic in scanning machinery and intervene as appropriate. The patient may need a sedative prescription, may have the medication at home but needs reminding to take it prior to the CT scan, or may need behavioral intervention such as relaxation and imagery or hypnosis. Explain to the patient the following details regarding the CT planning process. The goal of the computerized planning utilizing a CT scan are to target the tumor site but limit radiation exposure to critical organs and normal tissues. Port films and imaging will be performed with each radiation treatment, compared to the planning images in order to verify accuracy and replication of the intended treatment site identified by the CT plan. During the simulation the patient they will probably wear a gown. IV and/or oral contrast or an intracavitary marker may be required during the scan for improved structure visualization. Pen markings on the skin together with permanent pinpoint tattoos may be applied to aid in exact body positioning with each treatment. A plastic mask may be created as an immobilization device for treatment to head and neck sites. A body immobilization device may be constructed to recreate exact positioning for every treatment. A photo is taken for identification purposes and attached to the chart. Picture:

Education Daily radiation routine length of daily treatment
number of treatments prescribed boost weekly assessment with Radiation Oncologist and RN monitoring of laboratory results Inform the patient the expected length they will spend in the treatment room each day and in the department. Tell the patient how many treatments are prescribed and explain “boost,” treatment to a smaller field, tumor site or tumor bed only, if prescribed by the radiation oncologist. Explain weekly checks which is a weekly assigned time with the radiation oncologist and radiation nurse to assess treatment tolerance, side effects, manage symptoms, and the patient is given the opportunity to ask questions or discuss progress. Lab draws may be ordered based on the site of treatment. If bone marrow depression is a concern, a weekly CBC may be prescribed. If nutrition or dehydration is an issue, a chemistry panel may be ordered. The frequency and type of lab orders are individual to the patient and treatment site. Picture:

Patient Education Materials
Provide patient with written information for review Document the education the patient record

CT Simulation Question:
Goals of the CT Simulation process include determining the position of treatment and planning the type and size of any needed _______________ devices. a. Absorbent b. Potentiation c. Immobilization d. Skin protectant ONS Educator Resource Center

Radiation is a palliative treatment method only.
True False Answer is False

Factors that decide the type of radiation needed include:. A
Factors that decide the type of radiation needed include: A. Type of cancer B. Size of cancer C. Cancer’s location in the body D. How close the cancer is to normal tissues that are sensitive to radiation. A & B C & D B & C All of the above Answer-4. All of the above

Radiation therapy can be delivered by… (Click all that apply)
External Beam Prescription Generic Systemic Internal Answer-1. External Beam 4. Sytemic and 5. Internal

Chemotherapy + Radiation
What is (are) the benefit(s) to adding chemotherapy to radiation therapy and giving it at the same time? a. Synergism b. Different mechanisms of action c. Similar toxicity profiles d. Both a and b ONS Educator Resource Center d. Both a and b

Chapter 3: Radiation Oncology Procedures

Radiation can be delivered by
External Beam Internal Radiation Systemic Radiation Radiation may come from a machine outside the body (External Beam Radiation), may be placed inside the body (Internal Radiation), or may use unsealed radioactive materials that go throughout the body (Systemic Radiation).

External Beam Radiation Therapy

What is External Beam Radiation?
Is delivered in the form of photon beams (either x-rays or gamma rays) and electron beam energy. A “beam” of radiation that is directed from outside the body. The beam focuses on the cancerous internal organ and/or tissue The procedure lasts a few minutes at a time, usually for five days a week. A typical regimen can range from one day to nearly ten weeks External beam radiation may be used in conjunction with surgery or chemotherapy A photon is the basic unit of light and other forms of electromagnetic radiation. It can be thought of as a bundle of energy. The amount of energy in a photon can vary. For example, the photons in gamma rays have the highest energy, followed by the photons in X-rays. Electron beam energy is small negatively charged particles delivered at a superficial depth by linear accelerators. External beam radiation is a when a beam of radiation is directed from outside the body. The beam focuses on the cancerous internal organ and/or tissue. A high energy x-ray machine called a linear accelerator directs radiation to a tumor. The procedure lasts a few minutes, usually for 5 days a week. A typical regimen can range from 1 day to nearly ten weeksneardfdnear External beam radiation may be used in conjunction with surgery or chemotherapy.

Types of External-Beam Radiation
3-Dimensional Conformal Radiation Therapy (3D- CRT) Intensity Modulated Radiation Therapy (IMRT) Image-Guided Radiation Therapy (IGRT) Tomotherapy 3-dimensional conformal radiation therapy (3D-CRT). 3D-CRT uses very sophisticated computer software and advanced treatment machines to deliver radiation to very precisely shaped target areas. Intensity Modulated Radiation Therapy (IMRT): IMRT uses hundreds of tiny radiation beam-shaping devices, called collimators, to deliver a single dose of radiation. The collimators can be stationary or can move during treatment, allowing the intensity of the radiation beams to change during treatment sessions. This kind of dose allows different areas of a tumor or nearby tissues to receive different doses of radiation. The goal of IMRT is to increase the radiation dose to the tumor areas and reduce radiation exposure to specific sensitive areas of surrounding normal tissue. However, with IMRT, a larger volume of normal tissue is exposed to radiation. Whether IMRT leads to improved control of tumor growth and better survival compared with 3D-CRT is not yet known. Image-guided radiation therapy (IGRT): In IGRT, repeated imaging scans (CT, MRI, or PET) are performed during treatment. These imaging scans are processed by computers to identify changes in a tumor’s size and location and to allow the position of the patient or the planned radiation dose to be adjusted during treatment as needed. Therefore, there can be an overall decrease in the total amount of XRT given in relation to a decrease in tumor size. Tomotherapy is a type of image-guided IMRT and IGRT. A tomotherapy machine is a hybrid between a CT imaging scanner and an external-beam radiation therapy machine. Tomotherapy machines can capture CT images of the patient’s tumor immediately before treatment sessions to allow for very precise tumor targeting and sparing of surrounding normal tissue.

Types of External-Beam Radiation
Stereotactic Radiosurgery (SRS)/ Stereotactic Body Radiation Therapy (SBRT) (IORT) Intraoperative Radiation Therapy Proton Therapy Stereotactic Radiosurgery (SRS) is a term that encompasses SBRT. SRS is used when treating tumors in the brain and spinal cord. The mask shown is designed to immobilize the head for SRS of the brain. SRS is delivered in a single dose. GammaKnife® is a type of SRS. Stereotactic body radiation therapy: Stereotactic body radiation therapy (SBRT) delivers radiation therapy in fewer sessions using smaller radiation fields and higher doses than 3D-CRT in most cases. By definition, SBRT treats tumors that lie outside the brain and spinal cord. SBRT may be given in one to 5 fractions. SBRT is used frequently in the lungs, liver, and prostate. SBRT can be used in certain retreatment areas including head and neck. *Many doctors refer to SBRT systems by their brand names, such as the CyberKnife®. IORT: Intraoperative radiation therapy is applying therapeutic levels of radiation to a target area, such as a cancer tumor, while the area is exposed during surgery. In other words IORT delivers electrons directly to the exposed surgical site during the operation. Proton therapy: External-beam radiation therapy can be delivered by proton beams. Protons are a type of charged particle. Proton beams differ from photon beams mainly in the way they deposit energy in living tissue. Whereas photons deposit energy in small packets all along their path through tissue, protons deposit much of their energy at the end of their path (called the Bragg peak) and deposit less energy along the way. In theory, use of protons should reduce the exposure of normal tissue to radiation, possibly allowing the delivery of higher doses of radiation to a tumor. Proton therapy has not yet been compared with standard external-beam radiation therapy in clinical trials.

Cyber Knife Tomotherapy

make the patient radioactive!
External Beam Radiation Therapy does not make the patient radioactive! 5. Stereotactic Radiosurgery (SRS) is a term that encompasses SBRT. SRS is used when treating tumors in the brain and spinal cord. The mask shown is designed to immobilize the head for SRS of the brain. SRS is delivered in a single dose. GammaKnife® is a type of SRS. Stereotactic body radiation therapy: Stereotactic body radiation therapy (SBRT) delivers radiation therapy in fewer sessions using smaller radiation fields and higher doses than 3D-CRT in most cases. By definition, SBRT treats tumors that lie outside the brain and spinal cord. SBRT may be given in one to 5 fractions. SBRT is used frequently in the lungs, liver, and prostate. SBRT can be used in certain retreatment areas including head and neck. *Many doctors refer to SBRT systems by their brand names, such as the CyberKnife®. SRS and SBRT use multiple beams to sculpt around the tumor for greater precision, have a size limit, use a higher dose with fewer treatments, and usually have fewer side effects than other forms of external beam radiation. 6. Proton therapy: External-beam radiation therapy can be delivered by proton beams. Protons are a type of charged particle. Proton beams differ from photon beams mainly in the way they deposit energy in living tissue. Whereas photons deposit energy in small packets all along their path through tissue, protons deposit much of their energy at the end of their path (called the Bragg peak) and deposit less energy along the way. In theory, use of protons should reduce the exposure of normal tissue to radiation, possibly allowing the delivery of higher doses of radiation to a tumor. Proton therapy has not yet been compared with standard external-beam radiation therapy in clinical trials. 7. IORT: Intraoperative radiation therapy is applying therapeutic levels of radiation to a target area, such as a cancer tumor, while the area is exposed during surgery. In other words IORT delivers electrons directly to the exposed surgical site during the operation. EXTERNAL BEAM RADIATION DOES NOT MAKE THE PATIENT RADIOACTIVE!!!!!

Internal Radiation May be called Brachytherapy
Takes the radiation directly to the tumor Interstitial Radiation Therapy Intracavitary or Intraluminal Radiation What is Internal Radiation? The word Brachytherapy is derived from the greek word βράХυς brachys, meaning “short-distance” and refers to the fact that the radioactive source is placed internally, a very short distance from the tumor or the area being treated. There are two types of Internal Radiation: Interstitial radiation therapy uses a source in or near the tumor site and is used to treat head and neck, prostate, cervix, ovary, breast, perianal and pelvic region tumors Intracavitary or Intraluminal uses a source inserted into the body cavity and is used to treat uterine cancers. Studies are being performed to include breast, bronchial, gallbladder, oral, rectal, tracheal, uterine, and vaginal tumors.

High Dose Brachytherapy (Brachy mean “short”)
Placement of radioactive source into body cavity, tissue, or body surface May be used alone or combined with external beam therapy. Benefits Cervical, vulva, vaginal, or endometrial Breast Prostate Bronchogenic Choroidal Melanoma Lung Retinoblastoma Esophageal Sarcoma Head/neck Brain Used to Treat Treatments may be Low Dose Rate or High Dose Rate Brachytherapy may be able to deliver higher doses of radiation to some cancers than external-beam radiation therapy, while causing less damage to normal tissue. Doses are delivered directly to the tumor or bed, sparing the surrounding tissue. May be completed in shorter time span (days instead of weeks) May be used on inoperable or recurrent tumors

LDR (Low Dose Radiation) Intracavitary or Interstitial Brachytherapy
Seeds or ribbons placed directly into tissue or body cavity Risk of exposure is greater because patient is radioactive for a period of time Example: comparing different types of prostate brachytherapy. 1. radioactive seeds are permanently placed into the prostate tissue (interstitial) Radiation precautions will differ based on which approach is used. Intracavitary or Interstitial Brachtherapy: seeds or ribbons placed directly into tissue or body cavity. Risk of exposure is greater than remote afterloading brachytherapy MRONP&E, pg , 30

HDR (High Dose Radiation) Brachytherapy
Remote Afterloading Brachytherapy Source is housed in a shielded unit No exposure risk to staff when inserted remotely Newer approach: Remote afterloading brachytherapy where radioactive source is temporarily placed into the tissue via plastic catheters. Risk of exposure is less with the afterloader approach. MRONP&E, pg , 30

Prostate Brachytherapy
Surgical Procedure- for percutaneous catheter placement Radiation Treatment- series of two-four exposures after sim Requires overnight inpatient stay for serial dosing Bed rest/ urinary catheter/ pain medication or epidural (PCA) Prostate brachytherapy requires a surgical procedure to place multiple introducers/catheters, performed by the radiation oncologist and a urologist then does a cystoscopy to ensure the brachycatheters did not enter the urinary bladder. The radiation source actually enters in and out through the catheters with each treatment lasting several minutes. The pt will receive 2-4 treatments with at least 6 hours between treatments (usually about 36 hours total).

Total Nodal Irradiation Radiation treatment to all major lymph nodes including spleen and thymus
Mantel Field involves: Supradiaphragmic lymph nodes, bilateral cervical, supraclavicular, infraclavicular, axillary, and mediastinal and hilar. Inverted Y Field involves: Para-aortic field (with spleen) and pelvic (iliac & inguinal) Picture from: familyalbum0.tripod.com

Side Effects of Total Nodal Irradiation
Fatigue, skin reaction (greater in axilla and inguinal area) Myelosuppression Xerostomia N/V Occipital alopecia Esophagitis Stomatoxicity-mucositis (with transplant) Lung toxicity causing pneumonitis or pulmonary hemorrhage Acute Side Effects Sepsis Herpes zoster (shingles) Radiation Pneumonitis Cardiotoxicity (pericarditis) Gonadal dysfunction (female: menopause or alteration in menstrual cycle) (male: sterility) Thyroid dysfunction Lhermitte’s sign Second malignancies Late Side Effects Acute side effects may include: Fatigue, skin reaction (greater in axilla and inguinal area) myelosuppression Xerostomia (dry mouth due to lack of saliva) N/V occipital alopecia esophagitis stomatoxicity-mucositis (with transplant) lung toxicity causing pneumonitis or pulmonary hemorrhage Late side effects may include: Sepsis herpes zoster (shingles) radiation Pneumonitis cardiotoxicity (pericarditis) gonadal dysfunction (female: menopause or alteration in menstrual cycle) (male: sterility) thyroid dysfunction Lhermitte’s sign (an electrical sensation running down the back and into the limbs, especially when the head is bent forward) second malignancies.

Total Skin Irradiation (TSI)
TSI is a special radiotherapeutic technique that aims to irradiate the patient’s whole skin while sparing all other organs. Treats Cutaneous T cell Lymphoma (CTCL) Used to Treat Electron Beam Therapy Positioning Duration How Treats Cutaneous T Cell Lymphoma (CTCL) alone or combined with chemotherapy, biotherapy, or photochemotherapy Mycosis Fungoides (MF) most common form Sezary Syndrome (later stage of MF) Patients are usually treated with multiple large electron beams by rotating them in a large electron field. There are six fields for treatment requiring the patient to maintain a standing position for minutes to complete. The positions usually require a straight anterior approach with right and left posterior oblique positions, alternated with straight posterior approach with right and left anterior oblique positions. Positioning Goals: Prevent skin folds by extending extremities and using positioning grips and bars. Hands and feet are shielded and treated separately if indicated Eye shielding should be utilized at all times Duration of treatment 6-8 weeks treatment for body dosing at Gy and hands and feet dosing at Gy.

Side Effects of Total Skin Irradiation
Acute Side Effects: Edema of the hands and ankles Pruritus Blistering Erythema Inability to sweat Dry and moist desquamation Gynecomastia Superficial atrophy with wrinkling Telangiectasia Xerosis Uneven pigmentation of skin Pain Reversible alopecia Nail loss Acute Side Effects: Pruritus, erythema, dry & moist desquamation, superficial atrophy with wrinkling, telangiectasia (small dilated blood vessels near the surface of the skin or mucous membranes), xerosis (abnormal dryness of the skin or mucous membranes), uneven pigmentation of skin, pain, reversible alopecia, nail loss, edema hands and ankles, blistering, inability to sweat, gynecomastia

Side Effects of Total Skin Irradiation
Late Side Effects: Superficial atrophy with wrinkling Telangiectasis Xerosis Uneven pigmentation Rare permanent alopecia Mottled skin Skin fragility Subcutaneous fibrosis Late Side Effects: Superficial atrophy with wrinkling, telangiectasis, xerosis, uneven skin pigmentation, rare permanent alopecia, mottled skin, skin fragility, subcutaneous fibrosis

Intraoperative Radiation Therapy (IORT)
IORT used to treat gynecologic, genitourinary, soft tissue sarcoma, and breast treatments Also has some use in head/neck and brain IORT is a single fraction high dose radiation treatment to exposed tumor or tumor bed during surgery. It may be used in combined modality treatment, before or after external beam radiation therapy May occur in OR with portable units or in Rad/Onc requiring temporary wound closure/dressing, portable anesthesia followed by a transfer of the pt to treatment table requiring that staff rescrub and re-open the room.

Side Effects of Intra-Operative Radiation Therapy
Ureteral or bile duct stenosis/fibrosis (pelvic) Surgical GI Hydronephrosis Sexuality concerns Limb edema Toxicity Cystitis Peripheral nerve injury Neuropathy Edema Surgical related responses: pain, wound, risk of sepsis, fistula, abscess, hemorrhage, or obstruction GI: bowel constipation/diarrhea anorexia Sexuality concerns Greater risk of toxicity in bone or soft tissue sarcomas Peripheral nerve injury if in radiation site Neuropathy Edema Ureteral or bile duct stenosis/fibrosis (pelvic) Hydronephrosis Limb edema Cystitis

Stereotactic Radiosurgery (SRS)/ Stereotactic Radiotherapy (SBRT)
Delivered through: Proton Gamma Knife LINAC CyberKnife Multiple high dose beams of radiation to small specific area This treatment is usually used for inoperable tumors or postoperatively, to treat any remaining abnormal tissue. This treatment method is limited to tumors <4 cm. SRS or SRT occludes tumor vascular structures or inhibits tumor growth at a cellular level. Though primarily used for brain tumors, SRS/SRT may also be used on the spinal cord or the eye and is being used or studied for liver, lung and prostate cancer.

Hyperthermia What is it? How it works Heating of tissue
Treatment in which body tissue is exposed to high temperatures to damage and kill cancer cells. Heating of tissue Used to decrease tumor size Sensitizer for some radiation and chemotherapies What is it? Variable duration and temperature How it works Tissues (usually skin) are heated to various temperatures depending on tumor type: Mild hyperthermia- equal to a natural high fever (may stimulate natural immunological attack against the tumor, but may also induce thermotolerance) Moderate hyperthermia- cells heated to 40°-42°C (damages cells directly as well as increasing sensitivity). This usually lasts about an hour up to twice/week. May be daily prior to radiation therapy. It is optimal to administer hyperthermia within 2-4 hours of external beam radiation treatment. Intense hyperthermia- cells heated above 50°C (122°F)- (used directly on the tumor for ablation). Usually performed once. Mechanism of action: Because of the disorganized and compact vascular structure that most cancer cells have, they have difficulty dissipating heat. Intense heating causes denaturation and coagulation of cellular proteins, killing cells within the tumor. Prolonged moderate heating cause more subtle changes. Mild heat treatment combined with other stresses cause cell death by apoptosis. Biochemical changes within the cell can cause slowed cell division and increased sensitivity to radiation. May be used alone or in combination with external beam radiation or brachytherapy for breast cancer, sarcoma, and prostate cancer to actually shrink the size of the tumor.

Types of Hyperthermia Tx
Focused ultrasound Infrared sauna Microwave heating Induction heating Magnetic hyperthermia Infusion of warmed liquids Direct application Heat Sources Local hyperthermia Regional hyperthermia Whole-body hyperthermia Types of Hyperthermia Tx Several methods for heat delivery exist, including: Focused ultrasound Infrared sauna Microwave heating- Microwaves and ultrasound pass through de-ionized water-filled pillows of treatment area. Last about minutes about 1-3 times a week Induction heating Magnetic hyperthermia Infusion of warmed liquids Direct application- which may be as simple as sitting in a hot room or wrapping a patient in hot blankets. Hyperthermia Therapy is broken down by types or regions. Local hyperthermia heats a very small area; usually the tumor itself. Depending on the location of the tumor, heat may be applied to a body surface (superficial hyperthermia), inside normal body cavities, or deep into tissues by using needles or probes (interstitial hyperthermia). Regional hyperthermia heats a larger portion of the body (such as an organ or limb). The same techniques as local hyperthermia may be used or it may rely on blood perfusion. In this case the patient’s blood may be removed, heated and returned with or without concurrent chemotherapy. In some cases the chemotherapy itself is heated and infused into a cavity (such as peritoneal). Whole-body hyperthermia heats the entire body and is used to treat metastatic cancer.

Side Effects of Hyperthermia
Skin redness Skin breakdown with possible skin peeling Pain Fatigue Dehydration Bleeding/infections N/V Acute Side Effects Fat necrosis Thermal injury (3rd degree burn) Late Side Effects Acute side Effects: All hyperthermia therapies have the potential for blisters and burns and may result in pain, fatigue and dehydration. Moderate or Intense hyperthermia may cause swelling, blood clots and bleeding. Whole-body hyperthermia usually results in diarrhea, nausea, vomiting and other symptoms of sunstroke. It may also cause cardiovascular problems. Late Side Effects: Fat necrosis may develop after therapy is complete and thermal injuries may appear throughout treatment, or after, and heal slowly.

Accelerated Partial Breast Irradiation
An approach that treats only the lumpectomy bed plus a 1-2cm margin, rather than the whole breast. Multi-catheter interstitial brachytherapy Balloon catheter brachytherapy 3D-CRT IORT APBI Accuboost APBI Techniques Age 45 years or greater Invasive ductal carcinoma or ductal carcinoma in situ Tumor size ≤ 3cm Negative surgical margins Sentinel lymph node negative Strict Qualifying Protocol APBI is a suggested therapy when discussing Breast Conservation Therapy (BCT) and only applies to patients diagnosed in the early stages of breast cancer. This therapy treats the lumpectomy bed plus a 1-2cm margin (area to most likely see recurrence) versus irradiating the entire breast. Because the tumor bed itself is being irradiated, the therapy takes less time and the duration of treatment is much shorter. This is felt to increase compliance and success, while maintaining more of the natural breast. Though the theory for treatment is the same, there are several routes of administration. Intra-operative radiation (IORT) may occur at the time of surgery or catheters (multiple or Mammo-site brachy catheter) may be inserted with the tip lying under the tumor bed. Catheters may also be placed after the surgery. 3-D-conformal radiation therapy (3-D-CRT) is performed postoperatively after the resection margins have been evaluated and has the advantage of being non-invasive. It is also more readily available at multiple locations. Differing bodies have set specific qualifying criteria. The American Society of Breast Surgeons have the following criteria recommendations: Age 45 years or greater Invasive ductal carcinoma or ductal carcinoma in situ Total tumor size (invasive and DCIS) less than or equal to 3cm in size Negative microscopic surgical margins of excision Sentinel lymph node negative

Side Effects of Accelerated Partial Breast Irradiation
Pain at site Skin reaction Wound drainage Cellulitis Hematoma Bleeding Sinus tract Early Effects Skin changes Abnormal mammograms from seromas Calcifications Fat necrosis Late Effects Early side effects may include: Pain at the site Skin reaction Wound drainage Cellulitis Hematoma Bleeding Sinus tract development Later effects may include: Skin changes Abnormal mammograms from seromas Calcifications Fat necrosis

AccuBoost

Treat the breast, spare the heart...
AccuBoost directs the radiation parallel to the chest wall The exposure to the organs below the chest wall is substantially reduced Traditional electron boost treatment directs the radiation directly at the chest wall. Deep Inspiration Breath Hold (DIBH) This is a computer system that we used to move the heart out of the way during external beam radiation therapy.

Are you radioactive after External Beam Radiation Therapy?
Yes No Answer-B. No

The purpose of radiation therapy is to damage the cells’ DNA and cause cell death.
True False What is the purpose of radiation therapy and what enhances radiation therapy? Answer: Radiation Therapy is designed to damage DNA and cause cell death. Cancer cells are rapidly dividing cells and in general are more sensitive to RT. Cancer cells reoxygenate to support mitotic activity and oxygen enhances RT. A hematocrit of 30% or better is preferred to maximize treatment effects.

Does a low hemoglobin decrease the effectiveness of radiation therapy?
Yes No What is the purpose of radiation therapy and what enhances radiation therapy? Answer: Radiation Therapy is designed to damage DNA and cause cell death. Cancer cells are rapidly dividing cells and in general are more sensitive to RT. Cancer cells reoxygenate to support mitotic activity and oxygen enhances RT. A hematocrit of 30% or better is preferred to maximize treatment effects.

Chapter 4: Interventional Radiation Procedures

Therapies Preformed by Interventional Radiology
Photodynamic Therapy (PDT) SirSphere® Therapy TheraSphere® Therapy I-131 Thyroid Ablation Zevalin® Therapy Quadramet® Therapy Xofigo® Therapy Clip art (2012) Microsoft Corporation

Photodynamic Therapy (PDT)
Treatment that uses a photosensitizing agent and a particular type of light to produce a form of oxygen that kills nearby cells. Combination Therapy 3-5 day treatment process Used to treat esophageal, non-small cell lung cancer Photodynamic Therapy is a combination therapy that uses a photosensitizing agent (Photofrin®) and a particular type of light to produce a form of oxygen that kills nearby cells. Wavelengths determine how far the light can travel into the body. Each photosensitizer is activated by a specific light wavelength, so physicians can choose specific photosensitizers to treat different areas or depths of a body. Usually the patient is injected with Photofrin® which is absorbed by cells all over the body. Because cancer cells retain the drug longer than normal cells, this allows a window of opportunity for the drug to be activated, affecting cancer cells with minimal affect on healthy tissue. After 24 to 72 hours the tumor is exposed to light. This light can be laser (via fiberoptics for internal tumors) or light-emitting diodes (surface tumors). Bronchoscopy or endoscopy may be performed a few days later for removal of necrotic tissue.

Side Effects of Photodynamic
Acute Side Effects Local hemorrhage Photosensitivity Infection Mild skin erythema to severe burns Dyspnea Chest pain N/V Dysphasia Constipation Fever Localized swelling/inflammation Local pain/discomfort Mucositis Pharyngitis Acute side Effects include: Photosensitivity lasting at least 30 days (patients should avoid sunlight for at least 6 weeks), mild skin erythema to severe burns, N/V, constipation, fever, localized swelling/inflammation, local pain/discomfort, mucositis, pharyngitis, local hemorrhage, infection (pneumonia or bronchitis), dyspnea, chest pain, dysphasia

What is SirSphere® SirSphere® microspheres are tiny polymer beads loaded with yttrium- 90. Injection into the artery supplying blood to the tumors trapping the radiated spheres in the tumor's vascular bed, delivering the beta radiation. TheraSphere® is a low toxicity, targeted liver cancer therapy that consists of millions of tiny glass beads containing radioactive yttrium-90. The glass radioactive beads are delivered directly to the liver tumors usually via a femoral artery sheath under flouroscopy. The radiation destroys the tumor cells from within the tumor, with minimal impact to the surrounding healthy liver tissue. The radioactive microspheres will continue to emit radiation over the course of several weeks after TheraSphere® treatment and radiation levels will decrease to insignificant levels. Reference including photo: TheraSphere A Patient’s Guide (no date) Retrieved from:

What is TheraSphere® ? TheraSphere® microspheres are tiny glass beads loaded with yttrium- 90. Injection into the artery supplying blood to the tumors trapping spheres in the tumor's vascular bed, delivering the beta radiation. TheraSphere® microspheres are considered a regional treatment. TheraSphere® is a low toxicity, targeted liver cancer therapy that consists of millions of tiny glass beads containing radioactive yttrium-90. The glass radioactive beads are delivered directly to the liver tumors usually via a femoral artery sheath under flouroscopy. The radiation destroys the tumor cells from within the tumor, with minimal impact to the surrounding healthy liver tissue. The radioactive microspheres will continue to emit radiation over the course of several weeks after TheraSphere® treatment and radiation levels will decrease to insignificant levels. Reference including photo: TheraSphere A Patient’s Guide (no date) Retrieved from:

SirSphere® / TheraSphere® Treatment Summary
Pre-planning Angiogram Start Treatment within two (2) weeks after pre-planning angiogram Week 2 Follow-up phone call two (2) weeks after treatment Week 4 Repeat CT/MRI, PET scan if needed, lab tests and office visit with physician one (1) month after treatment. Week 6 Pre-planning Angiogram or Mapping This is the first step to prepare the pt for treatment (this is not the radiation treatment). The angiogram helps determine if the pt is a candidate for TheraSphere. Mapping includes: Pain medication and a sedative are given to help pt relax. A catheter is guided through femoral artery and into the hepatic artery of liver. 3 important steps are then performed: 1. Mapping the arteries of liver to identify any blood vessels that may be feeding tumor. 2. Possible insertion of coils into small blood vessels going to stomach or intestines. This prevents any radioactive microspheres from traveling to stomach and causing an ulcer. Not every patient needs this portion of the procedure. 3. Finally, some diagnostic imaging spheres are injected into liver. These diagnostic imaging spheres consist of harmless proteins (that are similar in size and shape to the TheraSphere Yttrium-90 microspheres) and will provide the treating physician information regarding blood flow within the liver. By using these diagnostic imaging spheres, the doctor is able to ensure that TheraSphere will stay in the liver and won’t travel to other organs that could cause serious side effects. Shunting of 90 Y microspheres to the lungs or deposition of the microspheres into the gut is of primary concern. The angiogram takes up to 2 hours. Then the pt is transferred to Nuclear Medicine for a scan to see the location of the diagnostic imaging spheres. This scan takes approximately 30 to 90 minutes. Patients are usually discharged 2 to 6 hours post procedure. Week 2 Typically, the treatment day will be 1–2 weeks following the planning angiogram. The procedure normally takes up to 2 hours and includes a repeat angiogram. The patient may be discharged after recovery or admitted to the hospital for pain management. Reference TheraSphere A Patient’s Guide (no date) Retrieved from:

Contraindications to SirSphere® / TheraSphere®
Ascites or clinical liver failure Markedly abnormal liver function tests (LFTs) Greater than 20% lung shunting Abnormal vascular anatomy Disseminated extra-hepatic malignant disease Capecitabine within the two previous months, or who will be treated with capecitabine at any time following treatment Portal vein thrombosis. Contraindicated for TheraSphere and SirSphere: • Patients with Tc-99m macroaggregated albumin (MAA) hepatic arterial perfusion scintigraphy showing shunting to the gastrointestinal tract that may not be corrected by angiographic techniques. • Patients with shunting of blood to the lungs that could result in delivery of greater than 30 Gy to the lungs. Radiation pneumonitis has been seen in patients receiving doses to the lungs greater than 30 Gy in a single treatment. • Patients that have severe liver dysfunction or pulmonary insufficiency. • Patients that present with complete occlusion of the main portal vein.

Side Effects SirSphere® / TheraSphere®
Typical side effects are mild to moderate and may include: Abdominal/stomach pain Nausea Vomiting Fever or fatigue Lung damage Irritation of the gastrointestinal tract Pain at site of tumor Abdominal/stomach pain Nausea Vomiting Fever or fatigue generally resolve within 48 hours. Lung damage, which could include swelling, scarring or shortness of breath Irritation of the gastrointestinal tract, which could result in chronic pain, nausea, vomiting, ulcers, bleeding or pancreatitis (swelling of the pancreas) As possible with every treatment, rare, serious side effects may occur.

Nursing Considerations for SirSphere®
Pain Management Arterial site monitoring Flat for 2-6 hours Assess site for bleeding or hematoma formation Assess pulses Maintain pressure dressing for 24 hours Monitor for tumor lysis syndrome Patients may have considerable pain due to embolization of the vessels feeding the tumor. Pain management may be required. Due to the arterial access, routine arterial precautions apply: Pt must remain flat for 2 hours (if closure device used) or 6 hours (no closure device). The access site should be monitored for leaking or hematoma formation with standard recovery vital signs. Pulses should be assessed with all vital signs and patient should be assessed for a retroperitoneal bleed. The pressure dressing to the femoral site should remain in place for 24 hours. The patient should be monitored for tumor lyses syndrome.

What is Systemic Radiation?
Systemic radiation therapy uses radioactive drugs called radiopharmaceuticals May be taken by mouth or injected into the body Radiation source travels throughout the body What is Systemic Radiation? Systemic radiation uses radioactive materials such as iodine 131, samarium and strontium The materials may be taken by mouth or injected into the body. The radiation source travels throughout the body. Systemic radiation therapy is sometimes used to treat cancers of the thyroid and adult non-Hodgkin’s lymphoma. Researchers are investigating agents to treat other types of cancer.

What is I-131 Thyroid Ablation?
Given to patients with thyroid cancer post thyroidectomy. The purpose of Iodine-131 for thyroid ablation is to destroy all remaining functioning thyroid tissue. Thyroid Cartilage Thyroid Gland Sodium Iodide-131 is a radiopharmaceutical and is given to patients with thyroid cancer who have had a total thyroidectomy (surgery). They stop all thyroid medications for several weeks, then complete an iodine body scan that shows any remaining activity in the residual thyroid tissue and/or in metastatic lesions. The purpose of Iodine-131 for thyroid ablation is to destroy all functioning thyroid tissue, eliminating possible sources. It has been shown that the use of thyroid hormones after surgery decreases the recurrence rate of cancer — a rate that is further decreased when radioiodine is used post surgically. Photo: Drugs.com (2012). Thyroid Ablation (Aftercare Instructions). Retrieved from:

I-131 Thyroid Ablation Treatment Summary
Surgical thyroidectomy (Not all thyroid cancer patients have surgery prior to receiving I-131) Start 2 weeks post thyroidectomy the patient should be admitted as an inpatient in order to receive a therapeutic dose of I-131. Week 2 Typically patients are discharged to outpatient status 3-5 days post I-131 dosing. These patients must register below specific levels in order to obtain this status. Week 3 Patients should return to the Imaging department for a follow up scan post the I-131 Thyroid Ablation to detect any ectopic residual thyroid tissue. Week 6 Once the incision has healed the patient may be scheduled for the I-131 procedure. (Occasionally patients will have the procedure months to years after the thyroidectomy.) The patient’s room is lead-lined and must be prepped before the patient arrives. . Once the patient swallows the capsules, physical contact is limited. The patient is encouraged to eat and push fluids to facilitate excretion/elimination of the radiation through the urine and feces. They may shower more than once/day to help ‘drop their counts’ quicker. The patient’s radiation level is assessed daily with a Geiger counter by Nuclear Medicine and the patient must remain isolated until numbers drop to what the facility deems an acceptable level. This usually takes 3-5 days. Once the levels are low enough to allow the patient to leave isolation, they can be discharged. The room usually remains sealed an additional 1-2 days, until Nuclear Medicine declares the room to be safe for cleaning. The room is stripped and everything disposed of per policy. Housekeeping then provides a “terminal” cleaning (ceiling to floor).

I-131 Thyroid Ablation Nursing Considerations
Lead-lined Room for therapy Minimal patient contact after dosing No labwork until patient cleared PPE required to enter the room Maintain 3 foot perimeter for patient contact Exposure > 5 minutes requires a lead apron Surfaces are covered to minimize patient contact. All items taken into the room should be disposable and left for disposal after patient discharge. Patient belongings should be limited also because of radiation contamination. Visitors may speak over the phone, but bedside contact is discouraged. The patient is assessed and all labs drawn prior to dosing. No IV access is required for this hospitalization Anyone entering the room should wear personal protective equipment (gown, shoe cover, hair cover and dosimeter) to minimize contamination. Staff should attempt to remain greater than 3 feet from patient whenever possible, and use disposable medical equipment (b/p cuff, stethoscope, thermometer). Any one staying in the room for more than 5 minutes should also wear a lead apron with thyroid shield under their gown.

I-131 Thyroid Ablation Contraindications
I-131 therapy is contraindicated: In pregnant women because of the potential for ablation of the fetal thyroid gland. I-131 therapy is contraindicated in women who are breast feeding. I-131 therapy is contraindicated: In pregnant women because of the potential for ablation of the fetal thyroid gland (which begins to accumulate radioiodine at 8-10 weeks gestational age). Accordingly, it must be documented that a female patient is not pregnant (or does not have child-bearing potential) before administration of I- 131, by establishing that the patient is premenarchal or post menopausal; has had tubal ligation or hysterectomy; or has had a negative serum (or urine) pregnancy test (qualitative beta-HCG) performed within the previous day to therapy dosing. I-131 therapy is contraindicated in women who are breast feeding because a large fraction of the administered activity will be secreted in breast milk, which when ingested will cause radiation exposure to the infant’s thyroid gland (potentially resulting in thyroid ablation or radiation- induced thyroid carcinoma).

I-131 Thyroid Ablation Side Effects
Loss of appetite Change in taste Nausea Swelling of Saliva Glands Headache Depression Management of side effects require a team effort and close communication with the health care professionals. Oral care reduces risk of infection, scheduling antinausea and laxatives, and massage of jaw stimulates salivary glands. It is important to make sure the patient has contact information and knows when to report side effects such as: Vision changes Fatigue Fever/Chills Oral infections (thrush) Increased nausea or vomiting HR more than 100 beats per minute Reference Drugs.com (2012). Thyroid Ablation (Aftercare Instructions). Retrieved from:

Questions Why do we worry about the calcium level postoperatively?
How long should the patient plan to be in the hospital? What should the patient bring to the hospital? What medications will she be required to take after discharge? Possible accidental parathyroid removal. Hospital stay is usually 3-5 days. Bring as little as possible. Avoid electronic equipment or games. Bring snacks and drinks that will encourage them to consume. Avoid sex for 1 month and pregnancy for 6 months. Take all medications as prescribed. Maintain good oral hygiene. Thyroid hormone replacement will be life-long.

Radioimmunotherapy Cancer treatment that combines two types of therapies — radiation therapy and immune therapy—using monoclonal antibodies. Targets B Cells The monoclonal antibodies engage the body's own immune system to selectively target and bind to the cancer cells. Radiation is then emitted in a cross-fire pattern intended to kill the targeted cell, as well as the surrounding cancer cells. This targeted radiation has the additional benefit of attacking cancer cells over a period of time, prolonging and maximizing its effect. Targeting limits the toxic effects on normal tissues, although the production of blood cells by the bone marrow is decreased for a period of time. Patients who receive radioimmunotherapy also benefit from a treatment regimen that is significantly shorter than many other Non-Hodgkin's Lymphoma treatment options. The ability to selectively destroy the cancerous cells—combined with its short treatment regimen—is what makes radioimmunotherapy a Non-Hodgkin's Lymphoma treatment option every patient should explore with their oncologist. Radiopharmaceuticals require specific patient instructions for limiting exposure to family/persons living with the patient after treatment.

What is Zevalin® Therapy?
This medicine allows radiation to target specific kinds of white blood cells. It is used to treat non-Hodgkin's lymphoma. Zevalin® is a radiotherapeutic antibody injection with three separate components: Two treatments of rituximab, followed by One treatment of Yttrium-90 Targets B Cells ZEVALIN® (ibritumomab tiuxetan) radiotherapeutic antibody administered as part of the ZEVALIN therapeutic regimen indicated for the treatment of patients with: Relapsed or refractory, low-grade or follicular B-cell non-Hodgkin's lymphoma (NHL) previously untreated Follicular NHL who achieve a partial or complete response to first-line chemotherapy

Zevalin® Treatment Summary
First dose of Rituximab Nuclear Med- IN-111 Zevalin® administered 4 hours after Rituximab Day 1 Second dose of Rituximab Nuclear Med- Y-90 Zevalin® administered by radiologist 4 hours after Rituximab Day 7-9 Strict adherence lab protocols due to potential severe nadir Week 2-4 Administration of premedications and a drug called rituximab (e.g. Rituxan®). 4 hours later IN-111 Zevalin® will be administered in the Nuclear Medicine department Administration of premedications and Rituximab (e.g. Rituxan®) 4 hours later the patient should arrive in the Nuclear Medicine department for administration of Y-90 Zevalin® by the authorized user (physician trained and licensed to prescribe and administer radionuclides. Patients should strictly follow the instructions of routine blood work following the administration of Y-90 Zevalin® 2-4 weeks due to a severe nadir period.

Zevalin® Contraindications
Hemorrhage Pregnancy Breastfeeding Severe Infection Decreased Function of Bone Marrow Severely Decreased Activity of the Bone Marrow Anemia Blood Clotting Disorder Decreased Platelets Decreased Neutrophils Screen pt and ask if pt has the following: A severe infusion reaction to rituximab in the past. Is taking any medications that increases risk of bleeding such as aspirin or warfarin. Has, or have recently had, an infection. Has recently received a vaccination or is scheduled to be vaccinated. It is recommended that pts do not receive a live vaccine for 12 months after receiving the ZEVALIN therapeutic regimen. Pregnant or planning to become pregnant. The ZEVALIN therapeutic regimen may cause harm to an unborn child. Instruct in the use of effective birth control during treatment and for at least 12 months after treatment. Breastfeeding. It is not known if the different parts of the ZEVALIN therapeutic regimen pass into human breast milk. A decision should be made to discontinue breastfeeding or not to treat with the ZEVALIN therapeutic regimen. Reference: Spectrum Pharmaceuticals. (2012). Zevalin. Retrieved from:

Zevalin® Side Effects Serious Infusion Reactions
Prolonged and Severe Cytopenias Severe Cutaneous and Mucocutaneous Reactions Leukemia and Myelodysplastic Syndrome Fatigue Abdominal pain Nausea Nasopharyngitis Asthenia Diarrhea Cough A multidisciplinary team is needed to prevent and/or support patients through the side effects.

What is Quadramet® ? Quadramet® is a radiopharmaceutical (injection)used to treat bone pain related to metastasis. Quadramet® is currently approved by the United States Food and Drug Administration (FDA) to relieve pain in patients who have confirmed osteoblastic* metastatic bone lesions. If patients have confirmed osteoblastic lesions, they may benefit from treatment with Quadramet®. Quadramet® is a radiopharmaceutical that is used to treat bone pain that often results when cancer has spread to the bone. Quadramet® is currently approved by the United States Food and Drug Administration (FDA) to relieve pain in patients who have confirmed osteoblastic* metastatic bone lesions that are evident on a Nuclear Medicine bone scan. To explain, when cancer spreads (metastasizes) to the bone, it is often characterized as osteolytic (the breakdown of bone), osteoblastic (the formation of bone), or mixed (a mixture of osteolytic and osteoblastic components).

Quadramet® Treatment Summary
Patient should have blood drawn 1 week prior to the administration. Week 1 The Nuclear Medicine department administers therapeutic SM-153 Quadramet® 3-4 hours post injection a Whole Body Bone Scan is preformed. Week 2 Patients should have blood work drawn every week 1-2 weeks post injection of therapeutic Quadramet® Week 3-6 Repeat Whole Body Bone Scan in 3-6 months. Week 12-24 Week 1: Patient should have blood drawn 1 week prior to the administration of Quadramet® to ensure white blood cells (WBC) and platelet levels are within acceptable range. Patient should also have a recent Nuclear Medicine Whole Body Bone Scan to show active metastasis throughout the skeletal system. Week 2 Patient should arrive in the Nuclear Medicine department for the administration of therapeutic SM-153 Quadramet®. The patient can expect to be in the department for approximately minutes. Week 3-6 Patients should have blood work drawn every week 1-2 weeks post injection of therapeutic Quadramet®. Sever cytopenia is common and should be monitored after receiving this therapy. Week 12-24 Patients should return to the Nuclear Medicine department 3-6 months after receiving therapeutic Quadramet® for a Whole Body Bone Scan. These results should be compared to the previous results by a radiologist Additional Quadramet® Therapies are common in the oncology field.

Quadramet® Contraindications
Concurrently with chemotherapy or external- beam radiation therapy. Patients with compromised of bone marrow Patients who have known hypersensitivity to EDTMP or similar phosphonate compounds. Pregnant or nursing women. Quadramet® should not be given at the same time as chemotherapy or external- beam radiation therapy. Quadramet® should not be given to patients whose bone marrow supply has been affected, either from disease or other therapy. Quadramet® should not be used in patients who have known hypersensitivity to EDTMP or similar phosphonate compounds. Quadramet® can be harmful to fetuses and infants and should not be used by pregnant or nursing women. If Quadramet® is administered to a nursing mother, formula feeding should be substi- tuted for breast feeding.

Quadramet® Side Effects
Bone marrow toxicity (which causes a decrease in the number of blood cells) Transient increase in bone pain within 72 hours The most common side effect with Quadramet® is bone marrow toxicity, which causes a decrease in the number of blood cells. Bone marrow toxicity may increase your risk of infections by reducing the number of white cells, which guard against infection; or bleeding by reducing the number of platelets A transient increase in bone pain shortly after injection. This is usually mild and self-limiting and occurs within 72 hours of injection Patients who respond to QUADRAMET® might begin to notice the onset of pain relief one week after QUADRAMET®. Maximal pain relief generally occurs at 3-4 weeks after injection of QUADRAMET®.

What is Xofigo® Therapy?
Xofigo® is a radioactive therapeutic agent used in the treatment of bone mets in certain prostate cancer. 6 monthly treatments of Radium 223 Dichloride Utilizes Alpha radiation Xofigo®, Radium 223 dichloride is indicated for the treatment of patients with castration, resistant prostate cancer, symptomatic bone metastes and no known visceral mets. 1 injection monthly for 6 months Injection dose base on body weight

Xofigo® Treatment Summary
Week 1 Labs drawn week prior to injection: Hemoglobin, ANC, platelets. Week 2 Injection takes place the following week Week 5-end Patient returns in 3 weeks for lab and process repeats for a total of 6 injections Lab work and patient weight obtained Lab work within acceptable limits IV access obtained for the therapy injection Xofigo®, radium 223 dichloride, administers over 1-3 minutes.

Xofigo® Contraindications
Known visceral mets Non-symptomatic bone mets Lab values outside of acceptable limits The use of Xofigo with concomitant use of chemotherapy has not been established and is NOT recommended.

Xofigo® Side Effects Bone marrow suppression Nausea Vomiting Diarrhea
Peripheral Edema Lab work, monitoring and nursing assessment of the patient is performed routinely at 3 week intervals.

What types of radiation would cause body fluids to be an exposure source?

Chapter 5: Skin Care - Management

Assessment National Cancer Institute’s CTCAE scale or RTOG used for documentation. It can reflect changes over time, responses to interventions and wound healing. (grading 1-5) Assess the patient’s verbalization of: pain, pruritus, burning Document serous drainage (type, color, amount, odor) and topical fungal or other infections. Major side effects to the skin while receiving RT are erythema, dry desquamation, moist desquamation, and ulceration. The goal is to keep the skin intact by minimizing scratching and rubbing and keep the skin moist. If moist desquamation develops, the goal is to support epithelial recovery and avoid super infections. These occurrences can be dose limiting. Radiation doses as low as 2 Gy may result in injury and doses of 18 Gy can result in weeping and sloughing of skin. (Giordano, Radiology Nurses 2010) Skin injuries can be apparent less than 24 hr after exposure, whereas other injuries appear many years (up to 3 years) later. The type of radiation and the dose to skin determines the extent of skin reaction. Not all treatments will involve skin in the plan, however breast and head and neck are of greatest risk.

Radiation injuries to the skin
Erythema Hair loss Hyperpigmentation Chronic scaly skin Blistering, weeping and sloughing Injuries A single dose of 2 Gy may result in erythema. With the early presence of erythema indicates a low exposure to radiation but that erythema would increase in severity as the dose of radiation increased. For greater than 6 Gy, the early erythema would increase in severity over a period of 10 days. The pt would exhibit symptoms of pain, itching and burning that will peak at day 14 and then begin to fade over a 4 wk period. (Koenig 2001). Higher than 2 Gy is hair loss. It can occur with a single dose and usually resolves in 3 months.. In excess of 7 Gy, can damage the hair follicle permanently. Damage to the sebaceous glands can cause skin changes, Hyperpigmentgation caused by damaged melanocytes. If doses exceeds 10 Gy, it can last for forever. Doses greater than 14 Gy may have chronic scaly skin, and doses greater than 18 Gy can have blistering, weeping and sloughing of skin. These can occur 4 weeks after initial exposure to rx. 6 weeks after exposure, healing can begin, but if the irradiated area is large, or has become infected or been exposed to subsequent radiation, the area may become ulcerated and unable to heal. At 16 weeks, the skin may become necrotic and require skin grafting to promote healing. Changes have been reported up to 4 years after exposure. Hyperthyroidism pt have quicker and sometimes more severe skin reactions. Fair skin pts compared with dark skin also have this. Areas like the groin or axilla, prone to moisture and friction have a higher sensitivity to radiation. Anterior neck, antecubital spaces and popliteal spaces are radiosensitive. Least sensitive are the scalp, palms of hands and soles of feet. (Mettler et al 2002

Interventions Devices used to reduce skin fold exposure
Surgical wounds should be healed before initiating RT Hydrophilic agents (absorb water) and bathe using soap and water Silicone Dressing A study done (MacBride, Cancer Nursing, 2008) looked at using Mepilex Lite. The challenge is to find a drsg that is protective, comfortable and atraumatic to delicate irradiated skin. Pts found the drsg minimized pain during dresg changes and was easily lifted without loss of adherent properties. The new drsg had a soothing and cooling effect on the skin. Had no negative effect on wound healing. Concluded worthy of further research Picture from:

Interventions The effectiveness of hydrocolloid and hydrogel dressings for moist desquamation has not been established (Barney et al., 2011) Historically, use of topical agents (lotions, deodorants) prior to RT has been discouraged due to potential build up. 1-5% of skin dose increased when products were used. Keep the skin moist and supple with moisturizing lotions, use sun block. Aquaphor Glaxal Base Cream which is over the counter, prophylactic BID, but not within 4 hours of treatment Regenicare (MPM) Do not use Sesame seed oil on the skin (pt can swallow it) some Naturopathic physicians prescribed this Dermagram B – needs to be cleaned off of skin before treatment Oramagic with benzocaine – good for head and neck patients Silvadene can be used, but has sulfa in it which could be a problem for patients with allergy to it Aloe Vera can be used, but some have alcohol in it which can be harmful Rebalance LED light therapy – increases collagen

Review of Literature on Interventions
Trolamine - Biafine Aloe vera Calendula Cream Hyaluronic acid cream Corticosteroids Sulcrafate Barrier Films Wheatgrass Extract Biafine – oil-in-water emulsion. Reported to have non-steriodal anti-inflammatory properties, heal wounds by recruiting macrophages to the wound bed and promoting granulation tissue. Studies do not show sign. differences. Aloe vera – may provide a protective skin effect with increasing cumulative doses. Can have anti-inflammatory and anti-bacterial properties, but is not a moisturizer. Calendula cream ––has shown to be effective with radiodermatitis. pt have been happy with the pain relief, application of the cream was difficult. Hyaluronic acid cream – HA a polymer that has been show to stimulate fibroblasts and fibrin development thereby accelerating the granulation phase of healing. HA destroys the oxygen free radicals associated with impairing wound healing. Only one human study has been conducted. Recent study showed difference between hyaluronic acid and simple emollient. Corticosteroids – have been prescribed for both the prevention and management of RT, due to the anti-inflammatory effect. They effect vasoconstriction, reduced capillary permeability and the inhibition of leukocyte migration. Possible effect on grade IV skin reaction, no difference in pain reduction or pruritus. Sulcrafate – stimulate cell growth in rats and an anti-inflammatory effect on gastrointestinal mucosa. Studies show no difference in erythema Barrier films – used to reduce trauma and retain moisture in the maintenance of intact skin, thereby reducing radiation injury. Cavilon No-Sting barrier film (3M) showed reduction in frequency and duration of moist desquamation and pruritis in No sting group. Wheatgrass Extract – (Currie & Wheat, 2006 Journal of Australian Traditional-Medicine Society) has been of interest in the healing properties with particular interest in the effects of chlorophyll. Decreases the anti-inflammatory response, takes the heat and pain away. Demonstrated to be effective for the treatment of open wounds in 98% of animals.

DOMBORO SOLUTION SOAKS
Soothing Can be used with compresses or soaks Three times daily

LED Light for Skin LED Light has been used to help reduce some of the skin reaction side effects Used primarily for head, neck and breast Is used in cosmetic salons to improve skin and reduce wrinkles Helps by bringing collagen up to the surface Used twice weekly Takes about two minutes each time

Patient Education Gently wash the skin with tepid water using a soft washcloth, no scrubbing and nondeodorant soap. Studies show Dove is a non irritating soap but wound care nurses state that Dove is harsh to irradiated skin related to pH. Pat dry. Wear loose fitting natural-fiber clothing Avoid perfumed skin products and powders Avoid scratching the skin. Steroid cream if folliculitis is present. Use an electric razor instead of wet shaving Electronic Razor Picture:

Patient Education Protect skin from wind, sun, and extreme temperatures. Sunblock with sun protection factor (SPF) 30 with UVA/UVB protection is recommended for irradiated skin. Skin that has received prior irradiation is more sensitive to the sun Avoid hot and cold material directly on treated skin. Avoid swimming pool, hot tubs, or lakes as it could worsen reactions

Patient Education Do not use adhesive tape or bandage within treatment fields Use gentle detergents to wash clothing, avoid starching clothes Teach the pt/family when to expect skin reactions as well as duration and resolution time and to report signs of infection. ONS 4th edition Manual for Radiation Oncology Nursing Practice and Education - resource

QUESTION What percentage of patients receiving radiation therapy will experience some degree of skin reaction? a. 40% b. 60% c. 75% d. 95% d. 95%

QUESTION What are the three grades of radiation therapy skin reactions? a. Erythema, dry desquamation, and moist desquamation b. Redness, excoriation, and bleeding c. Radiosensitivity, radiation recall, and radiodermatitis d. Stomatitis, mucositis, and radiodermatitis . Erythema, dry desquamation, and moist desquamation

QUESTION What are the three grades of radiation therapy skin reactions? a. Erythema, dry desquamation, and moist desquamation b. Redness, excoriation, and bleeding c. Radiosensitivity, radiation recall, and radiodermatitis d. Stomatitis, mucositis, and radiodermatitis a. Erythema, dry desquamation, and moist desquamation

Chapter 6: Symptom Management
Nursing patient care in the radiation oncology field is a relatively new arena for the nursing profession. Advances in responsibilities and subspecialties within radiation oncology have changed over the past 20 years. Nurses are actively involved with assessment, education, symptom management, and psychological support of the patient and family during and post the radiation therapy experience. The nurse-patient interaction begins with the initial consultation and continues through the treatment phase into the post treatment follow up/survivorship continuum.

Side Effects of Radiation
Skin reactions GI disturbances Myelosuppression Cystitis Pericarditis and Pneumonitis Acute Side Effects Bone Fractures Vaginal stenosis Costochondritis Late Side Effects Side effects associated with radiation are numerous! Each side effect entails specific diagnostic criteria and treatment plans. Some of the most common radiation-related side effects include: Skin reactions GI disturbances such as nausea, vomiting, esophogitis, heartburn and diarrhea. Myelosuppression-pay particular attention to the WBC’s and platelets Cystitis, pathologic fractures of the bones, pericarditis and pnuemonitis. Radiation pneumonitis is the topic for today. This too, may or may not be deemed an oncologic emergency, but it is important to remember that the potential for an emergency is present. Costochondritis: Costochondritis occurs when the costal cartilage that joins the ribs to the sternum becomes inflamed. Any one of the seven junctions of costal cartilage and rib can be affected, although the second to fifth costochondrial junctions are most commonly affected. In 90% of cases, more than one joint is involved. Pain related to costochondritis can be minor to severe, manifesting in the upper sternal area or the lower rib cage. Because this area has so many nerves, the pain can radiate to the arms, back, or shoulders, mimicking cardiac-related chest pain. Wisniewski, Amy RN, BSN Taking a closer look at costochondritis November Volume 36 - Issue 11

Patient Surveillance Through:
Weekly Assessment Reinforce Education Symptom Management Site Specific Survivorship/follow up The components of radiation oncology nursing practice consist of assessment, education, site specific symptom management, and survivorship and follow up. Picture:

Side Effects of External Beam Radiation
Acute Late Effects Site Specific Psycho/ Social

Brain and CNS Alopecia in the field of radiation
Hair regrowth once treatment stopped Hair care Gentle shampoos Wig & head coverings Treatment to the brain and central nervous system. Alopecia The hair follicles are acutely susceptible to radiation effects due to their rapid growth. Hair loss may occur after 5Gy, usually is temporary at 30Gy, and may become permanent alopecia after 45Gy. Hair loss does not occur until two to three weeks after radiation treatments have started. The patient may not begin losing hair until after treatments have ended if the patient received a short course of whole brain irradiation. Regrowth may take three to six months after radiation has been completed. A mild shampoo such as baby shampoo is safe for hair and scalp during the weeks of radiation treatments and months following. Trauma to hair such as hot curling irons, blow drying, hot curlers, even frequent brushing may cause the hair to fall out sooner rather than later. Prepare the patient for hair changes if regrowth is expected. The hair may be a different color or consistency. Patients should refrain from chemical applications, permanents, and dyes for several months as the new hair regrowth is fragile. Education on wigs or head coverings is necessary. Patients should shop for a wig while they still have hair in order to more closely match the color, style, and texture. Resources for wig locations and salons should be available. Discuss insurance reimbursement with the patient as a prescription for a hair prosthesis is often necessary for reimbursement. Some patients prefer other options, so supply resources for alternative head coverings such as turbans, scarves, or hats, recommending comfortable, breathable fabrics. Picture from ICMC Marketing

Brain and CNS Steroid management for: Edema Inflammation Nausea
Educate and monitor: side effects of steroid use Tapering dose Steroids are often prescribed to prevent or treat edema which may be worsened by radiation therapy to the brain. Dexamethasone or methylprednisolone are the usual steroids prescribed as they reduce capillary permeability rapidly. The nurse needs to educate the patient and family on a taper schedule as steroids are not to be stopped abruptly. A calendar with the appropriate daily dosing and highlighted changes to the dosing schedule is a recommended educational tool. Steroids have multiple side effects. Discuss with your patients the risk of steroid-induced elevated blood glucose. Monitor blood glucose in diabetic patients. Gastric irritation may be prevented if patients take the steroid tablet with meals and may need to add an antacid, histamine H2 antagonist, or proton pump inhibitor. Restlessness, mood swings, and insomnia may be exhibited while taking the steroids. Patients may report weakness of the legs, especially when walking stairs or rising from chairs. Steroid myopathy manifested in the thigh muscles and upper arm muscles resolve after the steroids have been tapered and discontinued.

Brain and CNS Assessment for Cerebral edema Signs and symptoms
Nausea and vomiting Changes in mental status Headaches Changes in speech patterns Seizures Hemiparesis Treatment Medications Assessment for cerebral edema is essential while the patient is taking the steroid, while the patient is tapering the steroid, and after the patient has stopped taking the steroid. Remind the patient and family to observe and report signs such as nausea or vomiting, changes in mental status, and headaches particularly when the headache is unrelieved by the typical headache medications used by the patient such as acetaminophen or ibuprofen.

Brain and CNS Spinal Cord Compression Changes in bowel and bladder
Changes in sensory perception Metastasis to the spine may result in the oncologic emergency spinal cord compression. The radiation oncology nurse needs to be vigilant for patient statements regarding changes in bowel or bladder function, often noted as incontinence. These may be the first signs of cord compression. Sensory perception changes may be described by patients as numbness, paresthesias, loss of temperature sensation, proprioception, and vibratory sense. Motor weakness may occur simultaneously. The combination of radiation therapy and corticosteroids are quite effective in treating spinal cord compression. These concurrent therapies are initiated quickly after the diagnosis of compression as permanent neurologic damage is a possibility.

Brain and CNS Cognitive impairment Driving Decision making
Safety issues Cognitive training programs After completing radiation, cognitive impairment may be present. Whole brain radiation has been associated with increased risk of cognitive impairments which may include slowed information processing speed, alterations in speech –varying forms of aphasia, impaired memory and attention and dysfunction of motor coordination Doses as low as 189cGy have resulted in neuro cognitive deficits in pediatric patients. Patients and family education includes monitoring for signs of cognitive changes over time and contacting the care team if changes are observed. Referral to neuropsychologist as needed for motor stimulants or cognitive training programs Assisting in making the home environment safe Assisting with driving until it is determined that it is safe for the patient to drive independently Late effects of radiation to the brain and CNS that occur from 6 months or years after radiation are usually irreversible. The possible etiology is white matter damage from vascular injury, demyelination and necrosis. Picture:

Brain and CNS Physical impairment Physical therapy
Occupational therapy Ear concerns Outer ear sun protection Cerumen impactions Medications In addition to cognitive impairment, there may be some physical impairment that lingers after radiation has been completed. Outpatient physical and occupational therapy can help to decrease the changes that have occurred related to the tumor or the radiation. Occasionally, after radiation to the whole brain, there may be issues with the outer ear. The entire ear is usually in the treatment field, and the outer ear should be protected from the sun after treatment. This protection can be achieved with sunblock or with a large brimmed hat. Auditory changes: Assess the ear canal for infection, desquamation, and for cerumen impaction and remove blockage if appropriate and institute routine management of cerumen. Treat the infection as needed, and consider hearing testing as needed Picture:

Head and Neck Possible Side Effects:
Stomatitis, Mucositis Esophagitis Pain management referral to Pain Clinic Xerostomia Taste changes Dental impairment Thrush Trismus Nutritional problems Skin reactions Stomatitis Stomatitis is the inflammation and potential ulceration of the oral cavity. Since rapidly proliferating tissues are at risk for radiation damage, the oral mucosa demonstrates the damage sometimes after one week of treatment. Stomatitis leads to alteration in nutrition, dehydration, increased pain, and strongly effects quality of life. Regular oral assessments are required during the treatment course. Utilizing a grading tool is recommended. Topical anesthetics may provide temporary relief especially prior to meals. Due to the numbing effect with these agents, care must be taken with chewing so as not to injure the tongue. Swallowing small food portions is important as the gag reflex is less sensitive if the numbing agent is swallowed. Oral rinses include a bland oral rinse of 8 ounces water with one teaspoon salt and one teaspoon baking soda. Other commercial oral interventions are available to coat ulcers, lubricate and soothe inflamed mucosa. Recommendations for patients to manage stomatitis include brush several times daily using a soft toothbrush, floss daily if not contraindicated due to decreased blood counts, perform bland oral rinses four times daily, avoid irritants such as tobacco products, alcohol, spicy, acidic, rough-textured, and hot foods. Pureed foods, cold, soft, moist foods seem to be tolerated best. Maintaining hydration is essential. The lips may become dry, peel, and develop ulcerations. Recommend moisturizers for the lips. Food and liquid irritants should be avoided as previously mentioned. A consultation with a dietitian is recommended.

Stomatitis, Mucositis and Esophagitis Symptom Management
Antifungal agents Medications to thin secretions Cold Laser Auricular Therapy / Accupuncture Speech Pathology GI / Metabolic Support Stomatitis Stomatitis is the inflammation and potential ulceration of the oral cavity. Since rapidly proliferating tissues are at risk for radiation damage, the oral mucosa demonstrates the damage sometimes after one week of treatment. Stomatitis leads to alteration in nutrition, dehydration, increased pain, and strongly effects quality of life. Regular oral assessments are required during the treatment course. Utilizing a grading tool is recommended. Topical anesthetics may provide temporary relief especially prior to meals. Due to the numbing effect with these agents, care must be taken with chewing so as not to injure the tongue. Swallowing small food portions is important as the gag reflex is less sensitive if the numbing agent is swallowed. Oral rinses include a bland oral rinse of 8 ounces water with one teaspoon salt and one teaspoon baking soda. Other commercial oral interventions are available to coat ulcers, lubricate and soothe inflamed mucosa. Recommendations for patients to manage stomatitis include brush several times daily using a soft toothbrush, floss daily if not contraindicated due to decreased blood counts, perform bland oral rinses four times daily, avoid irritants such as tobacco products, alcohol, spicy, acidic, rough-textured, and hot foods. Pureed foods, cold, soft, moist foods seem to be tolerated best. Maintaining hydration is essential. The lips may become dry, peel, and develop ulcerations. Recommend moisturizers for the lips. Food and liquid irritants should be avoided as previously mentioned. A consultation with a dietitian is recommended.

Xerostomia, Taste changes Symptom Management
Amifostine Avoid tobacco and alcohol Medications (Salagen) OTC moisturizers, Biotene mouthwash & toothpaste, Prevention mouth rinse, Avoid dry foods (breads, chips, dry meat, etc,) Water or oral sprays continuous Lip balms Acupuncture / Cold Laser / Auricular therapy Lemon drops, sugar free gum Xerostomia, dry mouth related to reduced salivary gland function, is a difficult radiation side effect. Patients report significant effect upon quality of life as xerostomia interferes with eating, speaking, and general comfort. Saliva’s many functions include lubrication, digestion of starches, adds minerals to teeth, improves the ability to taste, and regulates acidity of the mouth. The salivary glands are sensitive to radiation therefore xerostomia may occur after only one week of therapy. Sparing the salivary glands reduces the risk and severity of xerostomia. Tobacco and alcohol should be avoided as these products may intensify mouth dryness. Pilocarpine, a cholinergic drug, may be prescribed to enhance salivation. It has shown clinical effectiveness but needs to be taken for weeks before the patient may notice improvement. Educate the patient that there may be a delay with increased saliva production therefore pilocarpine should not be stopped too soon. The patient may experience increased generalized perspiration as a side effect of pilocarpine. Caphasol, a topical calcium phosphate rinse, may shorten the duration and severity of xerostomia. A variety of commercial oral moisturizers are also available. Commercial mouthwash use is discouraged during the course of radiation and after completion of treatments due to the drying effect of the alcohol content. Saline rinses are encouraged several times daily. A moisturizing mouth wash, Biotene, is often used by head and neck cancer patients. Moist, soft foods and foods with sauces are better tolerated. Dry- textured and sticky foods are not well tolerated. Although there is no supportive evidence, patients have reported trying home remedies such as olive oil or butter applied to the oral mucosa to keep a degree of moisture prior to eating or at bedtime. To dissolve thick saliva, patients have tried drinking papaya juice or rinsing and expectorating a meat tenderizer with water solution. Sugarfree candy, usually sour or lemon, may stimulate saliva production. In order to avoid cavity development, sugarfree candy is recommended. Articulation with a chronic dry mouth may lead to difficult communication. Sipping water frequently is helpful to patients. Often patients carry bottled water with them whenever away from home as they may need to moisturize their mouth while conversing with others. Thick saliva also interferes with quality of life during and after radiation treatments. Rinses help clear the mouth of the thick, ropey saliva. Carbonated water, sparkling water rinses help break up the thick saliva. Moisturizing lip care may be necessary. Patients find that having a humidifier at the bedside at night helps keep the mouth moist. Chronic xerostomia may respond to acupuncture as supported by several studies.

Dental impairment Symptom Management
Dental concerns Pre radiation dental assessments Extractions as needed Dental trays/ mouth guards Fluoride treatments Brushing and flossing Soft tooth brush Alcohol free mouth rinses Before radiation treatments start, a patient needs a dental evaluation. Prophylactic dental interventions such as extractions need to be completed and the sites healed prior to the first treatment. Communication between the dentist and the radiation oncologist and radiation nurse will clarify the risks of radiation side effects if poor dental hygiene is an issue. The patient needs to be aware of the priority of the dental evaluation. Dental trays may be constructed by the dentist and nightly fluoride treatments using the trays will be prescribed by the dentist if the patient has remaining teeth. The side effect of xerostomia, reduced saliva production, places the patient at risk for cavities. Oral infections after radiation therapy need to be avoided as they may ultimately cause bone destruction. Fluoride treatments strengthen the enamel against cavity development. Mouth guards may be worn during radiation treatments to cover metal fillings. The radiation beam may cause “scatter” when striking the fillings causing irritation to adjacent mucosa. This occurrence is reduced by covering the fillings with a mouth guard. Daily oral hygiene as addressed in the stomatitis section should be followed.

Thrush Symptom Management
Antifungal agents Nystatin rinse, oral lozenges, tablets, Naturopathic agents – probiotics, yogurt Avoiding oral steroids Thrush, an opportunistic fungal infection, commonly occurs when patients receive radiation therapy to the head and neck region. Regular oral assessment is necessary. When oral white patches are detected which cannot be easily removed, medications are prescribed. These may consist of anti-fungal tablets, slowly dissolving lozenges or troches, or a liquid antibiotic rinse. Naturpathic physicians recommend probiotics, immune supportive botanicals, and nutrients. The WBC needs to be monitored for a neutropenic state, which will alter the recommendation of probiotics. Yogurt containing active bacteria is an option to aid in the treatment of thrush. Each patient and situation is considered individually for the use of immune system supportive supplements.

Nutrition Concerns Symptom Management
High protein shakes Marinol Speech Therapy Swallow evalation Parenteral hydration Metabolic Support Feeding tube TPN Dependent upon location of tumor, location of radiation field, past surgical effect upon chewing and swallowing, nutrition is greatly impacted. Soft, bland, moist, and cool temperature foods are usually better tolerated. A nutritional evaluation with a dietitian is recommended prior to treatments, followed by regular assessments throughout the course of radiation therapy. Taste changes occur when radiation is directed at the oral cavity. Taste changes will be intensified if chemotherapy is added to the therapy plan. Patients may detect changes after two to three days of treatments. Taste changes may persist for two years. Recommend to patients to focus on eating foods they can tolerate and enjoy. Avoiding food smells may be necessary, therefore using an exhaust fan while cooking, cooking foods outside, heating precooked foods, or eating cool foods reduces exposure to food smells. Eating with plastic flatware rather than metal flatware reduces the metallic taste patients often experience. Meat may taste different, therefore patients often substitute with other proteins such as poultry, peanut butter, fish, beans, eggs, and dairy products. A salt and baking soda water rinse before eating may neutralize taste. Monitoring weight loss with once to twice weekly weightchecks is recommended. The dietitian will participate in the weight surveillance. Do not overwhelm the patient with frequent weight directed conversations as this may be counterproductive. The patient may become more stressed by weight loss and pressure to maintain weight. Anorexia is another factor contributing to weight loss. Small, frequent meals, protein nutritional supplements between meals, or homemade smoothies with fruits, powdered milk, higher fat-content dairy products can help stabilize weight in patients with little desire to eat. Potential for dehydration should be monitored. The patient may need to keep a fluid diary and food diary. Fluid maintenance may be achieved orally, via feeding tube, or IV hydration may be routinely required. Options other than oral intake are available, especially if aspiration or inability to swallow are current problems. A feeding tube is frequently placed prior to the start of radiation therapy, when the procedure is better tolerated and the patient is more receptive to the teaching and care of the feeding tube. Total parenteral nutrition, TPN, may be an option when a feeding tube is not possible. A consultation to the speech pathology department is recommended for the head and neck cancer patient. A swallowing evaluation and possible swallowing exercises may be initiated by the speech therapist.

Trismus Symptom Management
Physical and Occupational Therapy Speech Therapy ENT evaluation Possible surgical intervention Pain management Radiation to the oral cavity increases the risk for compromised dental health. Radiation induced damage to the salivary glands reduces the ability of the saliva to remineralize teeth, compromises the cleaning and buffering ability of the oral cavity and increases colonization of bacteria. This added with changes in the dental collagen, add to compromised dental integrity. Frequent dental assessments need to continue after radiation has been completed. Daily fluoride applications will continue for the remainder of the patient’s life. If dental extractions are needed, oral surgeons familiar with late effects of radiation need to be part of the dental team. The patient may need hyperbaric oxygenation prior to extractions to prevent osteoradionecrosis . Osteoradionecrosis is a severe delayed injury caused by failure of bone healing. The incidence of osteoradionecrosis has decreased when radiation is delivered with IMRT. Lymphedema occurs under the chin frequently after radiation to the head and neck. This is usually a permanent condition but not one that interferes with quality of life. Referral to PT early in treatment and following completion of treatment will help with management of neck lymphedema. Trismus or limited opening of the jaw, can occur because of tumor invasion into the masticatory muscles or temporo mandibulary joint (TMJ)or be a result if these muscles or the TMJ is in the treatment field. Limited jaw opening interferes with oral hygiene, speech , nutritional intake, and oral cavity examination. The risk of Trismus increases over time, and patients that are resistant to mouth stretching exercises have greater incidence of trismus. Treatment includes physical and speech therapy, mouth exercises and the use of stacked tongue blades to stretch the mouth. Consultation with RD is beneficial to insure proper nutritional intake.

Breast Skin care Prophylactic skin care Deodorant/ shaving of axilla
Skin folds and axilla Exit area when treating supraclavicular lymph nodes Treatment of dry and moist desquamation Pain management Bra Recommendations Skin Care When radiation treatments involve a breast field, skin is a common concern regarding side effects. The skin may manifest changes such as dryness, pruritus, erythema, hyperpigmentation (darkening or tanning), dry peeling, dry desquamation, or wet or moist peeling, moist desquamation. Skin folds tend to develop more reaction. Therefore advising the patient of increased reaction in the inframammary fold under the breast, a skin fold anterior to the axilla, and the skin over the supraclavicular field, if this site is being irradiated, are expected areas of irritation. Spotty pink to red folliculitis may be observed. Breast tenderness and swelling are common experiences. For patients receiving treatment to the supraclavicular field, remind patients to apply lotion to the back skin behind the treated supraclavicular field, as exit dose will also cause skin reaction to the back skin directly behind the supraclavicular lymph nodes. A moisturizing, non-greasy skin product is usually initiated with the first treatment, applied twice daily, not four hours prior to the radiation treatment. Avoidance of powders, alcohol-based lotions, perfumes, and metal salt antiperspirants within the treatment field are recommended. Using a mild pH soap is permissible and regular hygiene is advised. Patients may request aloe vera gel application for pruritus. Although evidence does not support aloe vera gel reduces radiodermatitis, patients have reported a soothing sensation when applied. Steroid creams may be ordered for pruritus and patients have reported reduced itching sensations, although no evidence concludes skin improvement with steroid cream applications. Remind the patient not to shave in the ipsalateral axilla region of treatment. Avoiding folliculitis and infection of the axilla during treatments are important. The hair within the axilla field will fall out midway through the treatment course.

Breast Lymphedema Measurement Treatment Physical therapy
Manual lymph drainage Compression sleeves Precaution instructions Blood pressure & blood draws Hand and arm care Weight lifting limitations Lymphedema is the accumulation of lymphatic fluid in interstitial spaces causing swelling of an extremity. The disruption of lymph nodes and lymph vessels from surgery and/or radiation therapy can place a patient at risk for arm lymphedema. This complication may develop during the course of treatment, or may develop years later. Assessment for lymphedema is performed upon initial consultation. Measurements of the ipsalateral arm of the breast surgery are to be performed at the wrist, below the antecubital area and above the antecubital area. Educate the patient on lymphedema prevention which includes: no blood pressure or blood draws from the arm on the side of the breast surgery assess the arm for signs of infection and seek medical attention if infection develops maintain skin integrity using moisturizing lotion, using low pH lotion reduces bacterial growth apply insect repellent to prevent insect bites and related infections do not cut cuticles, push cuticles back, avoid cuts and skin breaks if a skin break occurs, clean with soap and water, apply antibacterial cream and a sterile dressing use an electric razor to shave the axilla on the treated site wear protective gloves when gardening or using chemicals wear an oven mitt when working on the stove or placing the arm in oven prevent sunburn to the arm avoid tight clothing or jewelry wear compression sleeve during air travel as cabin pressure changes may induce edema avoid carrying packages, purse, suitcase, brief case on the arm on the side of the breast surgery or treatment drink plenty of water daily and maintain a healthy weight check with the radiation oncologist and surgeon regarding weight lifting restrictions Picture:

Late effects of Breast Radiation
Pneumonitis Telangiectasia Skin Discoloration Capsular Contracture Costochondritis Late effects from radiation to the skin is a result from injury to the dermis. Pigment changes can manifest as either hyperpigmentation or hypopigmentation. Talengeictasis as described earlier in this presentation. Patients should be taught to avoid exposure to sun including tanning beds and booths, and the use of sunscreen with SPR 30 or greater. Up to 60% of patients treated for breast cancer will develop lymphedema. Patients have developed lymphedema as late a 30 years after completion of treatment. The advent of breast conservation treatment and sentinel lymph node biopsy has decreased the incidence of lymphedema. Patient and family education includes: use of compression sleeve, daily assessment of the involved arm for symptoms of warmth, erythema, pain and increased swelling. Maintaining clean supple skin Avoiding cuts Prevention of insect bites by using insect repellant Avoiding blood draws on the affected arm Wearing protective gloves when gardening or cleaning Prevention of sunburn by using sunscreen SPF 30 or greater Wear compression garment with air travel Radiation pneumonitis can occur between 6 weeks and 6 months after completion of radiation therapy and tends to be related to the volume of the lung in the treatment field. Risk is greater for those with chest wall radiation than those who receive whole breast radiation Telangiectasia

Thoracic Esophagitis Cough Dyspnea Chest and back skin care
Pain management Pneumonitis Radiation fibrosis Esophageal injury Treatment to the thoracic region effects mainly lungs. Other targeted treatment site may include the mediastinum, ribs, and esophagus. Esophagitis occurs when the esophagus is within the field of treatment. Refer to the previous esophagitis section for the related assessment and interventions. A productive or nonproductive cough may occur during radiation therapy to the lung due to bronchial mucosal irritation, edema, or hypervascularity. Continued smoking further irritates the bronchus and tissues, therefore smoking cessation is advised. Monitor respiratory status, oximetry, development of fever, and changes in the character of the cough. Prescriptive medications such as antitussives with an opioid, expectorants, or bronchodilators may be appropriate. Oxygen therapy may be initiated. A chest x-ray will rule out other causes of symptoms. Dyspnea is an anxiety-provoking symptom. Again smoking cessation is recommended to assist in alleviating dyspnea. Assess respiratory status, breathing pattern, vital signs, oximetry, skin color, nail bed color, and patient’s anxiety level. Oxygen therapy may be initiated. Prescriptive medications include bronchodilators for airway dilation, corticosteroids for inflammation reduction and decreased lung irritation, and anxiolytics for anxiety control and management. A chest x-ray will most likely be ordered. Normal activities may be altered such as using a wheelchair rather than walking long distances and resting after short bouts of exertion. Methods of energy conservation should be addressed. Alternative breathing techniques such as pursed-lip breathing can be taught to the patient. Dyspnea becomes more challenging as it encompasses physical discomfort and an anxiety component. Skin care when treating the chest also includes assessing the back area. Assess the back as an exit site for the radiation beams. Erythema, tanning, and dry skin may be noted anteriorly and posteriorly. Follow the general skin care recommendations previously discussed regarding hygiene, soap, and cream when skin changes occur. Manage pain as previously discussed with analgesics and opioids as indicated. Post pneumonectomy patients may experience a severe neuropathic pain for an extended period of time. This type of pain may require alternatives to opiods such as lidocaine patches, tricyclic antidepressants, or anticonvulsants. A pain team consultation is recommended for this often severe pain.

GI/Abdomen Anorexia Dehydration Nausea/ vomiting Diarrhea
Diet restricting foods Pharmacologic Management Patient Education Primary radiation to abdominal structures may be used for treatment of some malignancies of the GI tract such as distal esophageal or GE junction, gastric tumors, pancreatic and biliary tract tumors, hepatic tumors or obstructive tumors in the colon. Incidental radiation to the stomach or small bowel may also occur during the treatment for lower thoracic cancers or pelvic malignancies. The side effects of radiation exposure may be acute or chronic and are dependent on the dose of radiation given to the area. In some situations, using IMRT can reduce the toxicities to the GI by more effectively limiting the dose to these structures. Symptoms of anorexia are associated with: Can occur as a manifestation of the cancer or increased by the treatment. Radiation produces alterations in the GI function and related denudement or atrophy of the small bowel villi and flattening of the large bowel epithelial surface. -Anorexia, Dehydration and Nausea/ Vomiting: early satiety Approximately 50-70% of all patients will experience anorexia, nausea and vomiting during the treatment. Weight loss is highest among patients with pancreatic and gastric cancers. Patients with poor nutritional status have been associated with reduced response to treatment, decreased quality of life, and poor survival nausea and vomiting taste and smell alterations Interventions to treat anorexia include: Weight assessment on initial consultation and each subsequent assessment in Radiation Oncology. Use the same scale. Appetite stimulants such as Megestrol acetate, corticosteroids such as dexamethasone improve treatment related nausea and vomiting. Nutritional assessment- At CTCA, the PEC teams incorporate Registered Dieticians (RD) who perform a subjective Global Assessment. The RD’s are triggered to intervene for weight loss greater than 3 lbs/ 6.6 Kg per week. * eating small amount of food prior to Radiation therapy *Antiemetics: Administration of antiemetics prior to radiation therapy is effective in prevention of nausea and vomiting. Prevention of Nausea and Vomiting is the goal during treatment. * Naturopathic interventions as determined by the ND * Reduce food aromas associated with certain foods. Cold foods generally have less aroma than warm foods * Eating small frequent meals during the day * Application of seabands® on accupressure point bilateral wrists Diarrhea is defined as “ an abnormal increase in stool liquidity and stool frequency (≥to 4 to 6 stools per day over baseline), with or without noctural bowel movements, and may be accompanied by abdominal cramping.” Eastern Cooperative Oncology Group, 2007 Radiation affects the rapidly dividing cells of the small and large bowel. The Crypt cells responsible for cellular replacement are effected and resulting in denudment and atrophy of villi in the small bowel and flattening of the surface of the epithelial surface of the large bowel. Pathophysiology of diarrhea: Diarrhea occurs as a result of hypermobility of the bowels, loss of absorptive surface and decreased absorption of nutrients and bile salts, decreased or absent lactase resulting in lactose intolerance. Decreased lactase production in the small bowel causes accumulation of lactose. Loss of epithelial absorption function results in loss of water, electrolytes, protein , and blood. Incidence increases with higher dose fraction, larger treatment volume, concomitant chemotherapy, prior abdominal or pelvic Symptoms usually develop during treatment or shortly thereafter, and resolve within two to six weeks of completing therapy. surgery, and history of colitis, ileitis or IBS. Symptoms usually begin to occur at Gy. Management of Diarrhea includes: Dietary modifications include low residue foods such as baked, broiled or steamed meats, fish or poultry refined grains, Include potassium rich roods canned fruits and applesauce, bananas, and fruit nectars cooked vegetables Avoid : high fiber foods lactose products (Milk products) fried and fatty foods, strong spices and herbs tobacco Alcohol Caffeine fluids should contain some salt, sugar, such as broths, gelatin deserts and sports drinks Drink at least 2,000-3,000ml of fluids/ day Pharmacologic Management The goals are to inhibit intestinal motility, reduction of intestinal secretions and promotion of absorption. Loperamide hydrochloride: usually 4 mg with first diarrhea of day, followed by 2 mg after each unformed stool to maximum of mg 1-2 tablets every 4 hours not to exceed 8 tablets in 24 hours. Diphenoxylate/atropine: has a similar effect to Loperamide hydrochloride, but is associated with more CNS side effects. Dose is usually Per day. This agent should be avoided in patients with suspected bowel obstructions. Narcotics: May be used as needed for relief of abdominal pain Tincture of opium: Used alternating with loperamide. On initial consultation and CT simulation, it is imperative that the patient and family are educated about the potential side effects of radiation Patient Education: To the abdomen, including but not limited to: record the consistency and frequency of bowel movements and teach when to seek medical attention: Teach dietary modifications as above Teach signs and symptoms of dehydration: excessive thirst, fever, dizziness, extreme fatigue, light-headed-ness, and palpitations. rectal spasms, excessive abdominal cramping, watery or bloody stools, diarrhea not controlled by treatment Instruct on skin care –sitz baths and cleansing after diarrhea Teach proper administration of antidiarrheal medications

GI/Abdomen Cause Mechanical obstruction Decreased peristalsis
Treatment Avoid eating two hours before radiation Keep hydrated Activity assists GI function Medication (anti: nausea, diarrhea, constipation) Metabolic Support for dietary concerns Constipation is defined as a decrease in the passage of formed stool characterized by stools that are hard and difficult to pass. Patients have fewer than two to three stools per week and / or may strain to have a bowel movement. Constipation can be accompanied by abdominal pain, nausea, and vomiting, abdominal distention, loss of appetite, headache, and dry, hard formed stools Radiation to the abdomen and pelvis generally causes smaller, frequent bowel movements. Causes of constipation can be caused by: mechanical obstruction from the tumor within the colon, or may be external compression from lymphedema, or extrinsic tumors of the pelvic or abdominal cavity. Decreased peristalsis from medications Treatment for constipation relies on determining the cause, and treating this symptom. However simple measures can assist in preventing and treating constipation such as: Diet : Fresh fruits and vegetables as tolerated by the patient Fluids: Increasing total fluid intake to ounces ( ml) per day activity: activity increases the tone of the bowel and promotes peristalsis Medications: Stool softeners and laxatives as prescribed Fiber: adding natural fiber from foods is usually the best option, however, there are some additives available commercially such as Miralax®, Benefiber®, Metamucil® and others as determined by the RD or physician.

Low Fiber GI Abdomen Diarrhea
Low fiber diet for 2 weeks post radiation until diarrhea resolved Medications Low Fiber Side effects of radiation to abdomen are usually resolved within 6 weeks of completion of radiation . During the healing phase, anti-diarrheal medication, and low fiber diet should be continued until diarrhea is resolved. If symptoms persists, consultation for Gastroenterology consultation and a Registered Dietician may be beneficial.

Bladder Dysuria Hematuria/ clots Frequency Urgency Nocturia
Irritative Bladder symptoms is a group of symptoms that includes dysuria, frequency, hesitancy, nocturia and urgency. These symptoms may occur as acute or early symptoms and can be seen during treatment and up to 12 months after treatment is completed. Because of the nature of bladder cancer, it is not easy to determine if the symptom is from the tumor or from the treatment. Early or acute symptoms are a result of injury or inflammation of the epithelial layer of the bladder mucosa caused by the ionizing radiation. The degree of injury varies because of the amount of bladder that is treated, field setup, total dose and previous surgeries to the area. Side effects usually are decreased when normal tissue is spared. Assessment of patients undergoing pelvic radiation includes voiding pattern related to : frequency or urination Urgency Nocturia Dysuria Time of day the symptoms get worse

Bladder Treatments UA / C & S for assessment and diagnosis Fluids
Medications Analgesics Antibiotics Anesthetics The treatment of Irritative Bladder symptoms includes: Instructing the patient to keep a diary to record voiding patterns and symptoms Encouraging fluid intake to 2-3 liters/ day- unless contraindicated for cardiac or other medical conditions. The increased fluid will keep the urine dilute and less irritating to the bladder mucosa and also helps to flush and wash out clots that can cause obstruction of the urine flow. Encourage avoiding caffeine and spicy foods and drinks as these can also irritate the bladder mucosa. Obtain urine for culture and sensitivity Administer medications as prescribed to relieve symptoms. The most common are: Phenazopyridine hydrochloride ( Pyridium®) has analgesic and anesthetic effects on the urinary tract that can be beneficial for many irritative symptoms. Warn the patient this will turn the urine orange. Dose is usually 200 mg 3 times a day after meals. Antibiotics are determined by the culture and sensitivity results. Instruct your patients to increase fluid intake, and prepare him that the urine may be discolored by these agents. Antispasmodics such as oxybutynin ( Ditopan ®, Ditropan XLl®) produce a direct antispasmotic and antimuscarinic effects on the urinary tract smooth muscles, increasing bladder capacity and providing local anesthesia and mild analgesia.

Male Pelvis/ Prostate/Rectal
Constipation Diarrhea Urinary symptoms Erectile dysfunction Rectal Tenesmus Proctitis Hemorrhoids Rectal bleeding When radiation therapy is delivered to the male pelvis, the symptoms are directly reflective of the amount of radiation each organ receives. As described earlier, constipation, diarrhea and irritative bladder symptoms may occur during treatment to the pelvis. If a patient is having radiation to the prostate, the urinary symptoms may be more severe than if he is receiving radiation to the iliac crest. Urinary dysfunction side effects include frequency, urgency, hesitancy, retention, dysuria, nocturia and cystitis. The use of IMRT, and 3D conformal radiation can reduce these effects. Moderate to severe urinary symptoms can occur in up to 1/3 of patients treated with external beam radiation therapy. Males with obstructive symptoms ( increased frequency, urgency, weak urinary stream) may be caused by an enlarged prostate, and should be assessed before initiation of radiation therapy and frequently during treatment. Androgen Deprivation Therapy ( ADT) had been found to decrease prostate volume by 30-50%. The reduction in the prostate volume decreases the amount of bladder tissue irradiated and has been shown to reduce the severity or urinary and rectal toxicities. The amount of fluid in the bladder, and the stool or gas in the rectum will affect the positioning of the prostate during treatment, so decreasing the variables in this matter is very important Treating the male patient with his bladder full will cause the bladder to move out of the radiation field and thereby, reducing the amount of radiation that the bladder receives. This should be done according the Radiation Oncologists prescription for radiation, and the patient needs to be instructed to empty his bowel and bladder one hour prior to radiation and then drink 200 ml of fluid to then refill his bladder.

Male Pelvis Treatments
Topical wipes Medication Topical Suppositories Sitz bath Interventions include: Dietary assessment including fiber intake, lactose tolerance. Assessment of medications in use, including over the counter meds Referral to Nutrition (RD) Increase fluid intake 2,000-3,000 ml/ day Topical treatments; Topical wipes without alcohol to assist in rectal cleansing Medications to decrease rectal inflammation both topical and rectal Suppositories with or without hydrocortisone Enemas with hydrocortisone to decrease inflammation Sitz baths- clean warm water baths without soaps, bubbles or crystals added. Baths should be minutes 2-3 times a day.

Female Pelvis Diarrhea Urinary Skin Changes Sexual concerns
Loss of libido Vaginal dryness Vaginal stenosis Pelvic radiation is used to treat gynecologic cancers ( cervical, endometrial, ovarian, vaginal and vulvar) along with bladder, colon and rectal cancers. When treating these organs, the large and small bowel, bladder and skin are often affected. Diarrhea occurs when the small bowel is incidentally irradiated during radiation treatment to the pelvis. Radiation induced small bowel mucositis can be expressed as cramping and diarrhea starting one – two weeks after the start of radiation. Weight loss can be a secondary consequence to the diarrhea. Concurrent chemotherapy increases the potential for acute bowel toxicity Management of diarrhea is the same for males and females as outlined in slide 117. Acute cystitis usually becomes symptomatic after days of treatment and presents as: dysuria, increased frequency, urgency, hesitation, and increased nocturia These symptoms usually resolve within one month of completion of treatment. Picture: Skin changes hyperpigmentation usually occurs after 2-4 weeks of treatment with approximate cumulative dose reaching 20 Gy. The patient may experience dryness, flaking or itching of the skin in the treatment area, usually the genital area. This occurs as a result of the decreased ability of the basal layer to replace surface layers, shedding of the epidermus, and decreased functioning of the sweat glands. At doses of Gy, extracapillary cell damage occurs with increased capillary blood flow, hyperemia and edema. If severe, moist desquamation can occur. As can be imagined, this desquamation of the skin in the genital area can be quite uncomfortable for the patient. Teaching good skin care at the onset of treatment, along with signs and symptoms of skin breakdown to report to the Radiation Nurse and Radiation Oncologist go a long way in reducing stress and the ability to intervene early with skin breakdown. Teach the patient to assess her skin, especially in the skin folds of the treatment area on a daily basis, and explain that a visual inspection on a weekly manner by the Radiation RN and Radiation Oncologist will occur to document and treat any desquamation. Altered sexual function is the most compromised quality of life issue after treatment of gynecologic cancers affecting % of patients. Depletion of estrogens and androgens will cause younger women to experience what their older counterparts have already been through, including hot flashes, mood swings, vaginal thinning, decreased vaginal lubrication. As a result, dyspareunia often follows, which may influence a decrease in sexual arousal, and intercourse will no longer be pleasurable. Up to 88% of women treated with pelvic irradiation develop vaginal stenosis and this most often occurs within the first year after treatment. Keeping sexually active during pelvic radiation is not contraindicated and as long as there is no bleeding or pain, intercourse and orgasm can be achieved. Radiation can cause vaginal dryness and vaginal stenosis. Use of vaginal dilators and lubricants can improve these symptoms. Vaginal dilators are available for those women who are not sexually active . These should be used 3 times a week because it will be necessary to have continued cancer surveillance vaginal exams. Teach women to use water based vaginal lubrication or silicone based products only not oil based products.

Survivorship Department and Radiation Follow Up
4-8 weeks post treatment Imaging and tumor markers Nursing assessment/ teaching Long term side effect management Interval follow up as dictated by site of body treated After Radiation therapy is completed, the patient will return for routine follow up care. CTCA has a Survivorship Department that assist this crucial point in the follow up/ after care process. Radiation follow up is usually ordered for 4-8 weeks post treatment. This allows for coordination with the medical oncologist for patient convenience, and satisfaction. The Radiation Oncologist will order tests to determine the effectiveness of the treatment delivered. At the time of discharge or completion of radiation therapy the Radiation Nurse will spend time with the patient reviewing his discharge instructions, management of acute and long term radiation side effects and follow up testing as needed. The length of interval follow up is determined by the body site irradiated and concurrent therapies as ordered by the Medical Oncology team.

Survivorship Screening guidelines and Cancer Prevention Prevention
Surveillance Interventions Coordination Cancer survivorship has been an essential part of cancer care since 1986. The components of survivorship care include four major areas Prevention and detection Surveillance Interventions for symptoms associated with cancer and its treatment Coordination of care and information among oncologist, primary care physicians, patients and consultants. According to the Radiological Society of North America 50-60% of patients receive radiation as part of the cancer treatment. The numbers of survivors is expected to be 20 million by 2020.

Long term effects post radiation and recommendations
Fatigue May extend up to 6 weeks after treatment. Skin care Flare of skin reaction after treatment Usually 1-2 weeks Continue radiation skin care Sun protection The effects of radiation continue after the radiation therapy has been completed. Fatigue The general rule of thumb is the further away from radiation , the less fatigue is experienced, however, this is must be monitored at each follow up visit. ONS uses the fatigue scale of =no fatigue, 2= mild fatigue, 3= moderate fatigue, 4=extreme fatigue, 5= worst fatigue. Nurses can assess fatigue and assist to identify the treatable causes such as: anemia depression pain sleep disturbances Exercise has the strongest evidence to support its benefits in managing cancer related fatigue during and after treatment Skin care: The acute skin reactions are self limiting and will resolve within 2 weeks of completion of radiation therapy. The patient is educated to continue skin care used during radiation therapy for an additional 2 weeks as needed. The skin in the radiation site will be more sensitive to the sun than skin not exposed to radiation, therefore, sun block should be applied when out in the sun. The major late side effects of radiation on the skin include: Telangiectasias (small dilated blood vessels near the surface of the skin), fibrosis, and necrosis can occur after receiving radiation because of the physiologic changes in the wound healing process. The goal is to improve skin texture and elasticity. Interventions to accomplish this are using moisturizing lotions to keep the skin moist and supple, and the use of sunblock. Picture:

Additional Late Toxicities of Radiation Therapy
Fibrosis Infertility Decreased sexuality Secondary Cancers Pneumonitis Some additional late toxicities may include: Fibrosis- replacement of normal tissue with scar tissue leading to restricted air flow and movement. Infertility- prior to starting treatment men and women may be offered the opportunity to preserve eggs and sperm for use at a later date and becoming pregnant during treatment is not recommended. Secondary Cancers- often develop in area of the body directly exposed to radiation therapy. Secondary Cancers area very late complication that usually occurs years later. Ex.- lymphoma patients- have greater risk of developing breast or lung cancers later in life. Pneumonitis occurs when irritation to the alveoli cause the lungs to become inflamed. Picture taken from:

QUESTIONS If severe enough, mucositis can result in temporary interruptions in treatment and may result in the need to reduce treatment doses. a. True b. False a. True

QUESTIONS A patient receiving radiation therapy to the brain initially experiences worsening of his or her pretreatment symptoms, primarily sensorimotor control issues. What pharmacologic intervention is most helpful in this situation until symptoms improve? a. Opioid pain medications b. Corticosteroids c. Antidepressants d. Anticonvulsants b. Corticosteroids

Chapter 7: Radiation Emergencies

Story of a Dislodged Source
Nov 16, 1992 Elderly lady living in a care facility was to receive 3 brachytherapy treatments using HDR (High Dose Rate) for anal cancer Patient was transported from care facility to the hospital where 5 catheters were placed The HDR source connected to a wire attached to the afterloader successfully went into four of the five catheters Nuclear Regulatory Commission / Nureg-1480

(Dislodged Source Story)
Several unsuccessful attempts were made to insert the source into the fifth catheter The treatment was then terminated An area radiation monitor was observed to be in an alarm condition at various times during the attempts to place the source into the fifth catheter Three techs and the attending physician were aware of the alarm but did not conduct a radiation survey with the portable Geiger counter

Dislodged Source A statement was made that there had been previous false alarms reported for that room The only action taken was to check the control console of the HDR afterloader The console indicator showed it was “SAFE” Everyone believed the source to be fully retracted safely back in the afterloader They assumed that the radiation monitor was malfunctioning

(Dislodged Source) The physician and the technologists were unaware that the Iridium- 192 source was broken off inside catheter number FOUR that was still inside the patient The patient stayed 50 more minutes in the treatment room before being transferred back to the care facility All four catheters remained in the patient with catheter four containing the source MRONP&E pg 42

(Dislodged Source) On day four the catheter with the source fell out of the patient Personnel placed the catheter with source in a red biohazard bag and it was taken to the dirty utility room then added to the facilities medical waste MRONP&E pg 42

(Dislodged Source) The source went to another city in Pennsylvania where it was loaded onto a trailer. It sat on the trailer two more days then was taken to a Ohio Now it has been 11 days since the initial dislodgement and is going to its third city The Ohio waste management facility had monitors in place that detected radiation in the medical waste that came from PA Ohio returned it the same day back to PA where it sat for the whole weekend Nov 30 the BFI staff were able to identify the name found on the red bag belonging to the care facility

Dislodged Source From Nov 16 to Nov 30—15 days
The people exposed to Ir-192 included: Everyone caring for the patient at the hospital Anyone passing the patient during transport other patients, visitors and staff Transporters Care Facility Staff Patient’s family and visitors Waste management people Numerous to name

Dealing with a Dislodged Source
Immediately notify Radiation Safety Officer Have a lead storage container and long handled forceps available Never pick up a dislodged source unless you have had special training MRONP&E pg 42

What to do for a radioactive patient having a life threatening emergency
Begin CPR immediately Notify Radiation Safety Officer Staff performing CPR should wear gloves, gown and shoe covers All equipment used for CPR should be surveyed for radiation contamination All personnel involved in CPR will be cleared to leave the area by radiation personnel Life Threatening emergency in patient who is radioactive. Make certain that the priority is the patient. Exposure is likely to be minimal (30 minutes of cpr = 100 mem). MRONP&E pg 42

Agencies That Oversee Radiation Safety
US Nuclear Regulatory Agency National Council for Radiation Protection Food & Drug Administration (FDA) Occupational Safety & Health Administration (OSHA) State Radiation Protection Agencies Institutional Radiation Safety Committees and Radiation Safety Officer MRONP&E , 4th edition, pg 31-32

Resources for Patient Education
National Cancer Institute Publications CANCER

References Bruner, D.W., Haas, M.L., & Gosselin-Acomb, T.K.(2006). Manual for radiation oncology nursing practice and education (3rd ed.). Pittsburgh, PA: Oncology Nursing Society. Evolution of cancer treatments: Radiation American Cancer Society (2014)

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