Overview.   Cancer is a frightening diagnosis. The good new for cancer patients is that modern medical treatment offers more hope for cancer patients than ever before. Over half of all cancer patients can be cured. There are three major medical specialty areas that treat cancer:

1. Surgery. Surgeons in many medical specialty areas treat cancer surgically. The cancer and possibly some surrounding normal tissues are removed.
2. Medical Oncology. Medical Oncologists (Oncology means "study of cancer") specialize in treating cancer with chemotherapy. Chemotherapy may be given by mouth or intravenously. They often coordinate with other physicians to evaluate the extent of cancer prior to treatment. Medical Oncologists may coordinate the overall medical management of patients during treatment and follow up after treatment.
3. Radiation Oncology. Radiation Oncologists, also known as Radiation Therapists, use high energy x-rays in the treatment of human disease, especially cancer.

Only surgery, chemotherapy, radiation therapy, or any combination of the three treatment modalities (including all three) may best manage different cancers. The decision to use a particular cancer treatment modality(s) depends on many factors including the site of cancer in the body, cancer type (what it looks like under the microscope), cancer extent, symptoms the cancer is causing, the patient's health and other factors.

For the majority of newly diagnosed cancer patients, medical literature clearly guides the optimal cancer treatment approach. Cancer physicians in different specialties often spend considerable time discussing among themselves the optimal treatment approach prior to beginning treatment. If the patient's physicians believe radiation therapy might be important in treatment, a consultation is arranged with the Radiation Oncology physician.

Consultation. At the time of consultation, the Radiation Oncology physician will obtain a medical history and do a physical examination. It may be helpful to prepare for the consultation by bringing any x-rays and medical records the Radiation Oncologist may need. It is also helpful to bring any medicines you are taking, or a list of your medications. Don't hesitate to ask questions! Many patients find it useful to prepare a list of questions prior to the consultation to help assure they are all answered. It is a good idea to bring another person to the consultation to help understand what the physician communicates. Please remember to bring all insurance cards and any necessary referral forms. If you have questions about insurance or referrals, contact your primary care physician or insurance company as soon as possible. You may ask the person accompanying you to leave or stay during the physical examination. The physician may communicate a great deal of information in a short period of time. Don't hesitate to call the physician after the consultation to clarify any of your questions, or repeat what was said to you at the time of the consultation. It is important for you to be comfortable with the health care team treating you. If you encounter health care team members that you are not reasonably comfortable with, please discuss your concerns with a physician you are comfortable with. If radiation therapy will be used, a detailed discussion will take place regarding your treatment. If your physician tells you anything different than the general overview of radiation therapy you read here, accept your physician's explanation as more accurately reflecting what your treatment will involve. Most patients are quite relieved that radiation therapy will be easier for them than they might have guessed. There is generally no nausea or vomiting with radiation therapy unless the stomach or very large portions of the bowel is treated. Radiation therapy does not cause hair loss unless the hair is directly treated. After the consultation, the Radiation Oncologist may order additional tests, await results of other pending tests or consultations, or obtain addition records and reports. After all necessary information has been obtained and the Radiation Oncologist has communicated with other appropriate physicians (multidisciplinary care is increasingly important for optimal cancer care), a decision may be made to treat with radiation therapy. The possible alternatives for your treatment will be discussed. The Radiation Oncologist will send a complete report of their evaluation and any treatments to the referring physician and any other physicians you request. You will be asked to sign a consent form prior to treatment. Please read and understand the consent form prior to signing! The next step is simulation.

Simulation. Simulation is a treatment planning step and not an actual radiation therapy treatment. The simulation procedure is generally done by Therapists (specially trained technologists) under the supervision of the Radiation Oncologist. This procedure is usually performed in a room with a special fluoroscopic x-ray device that simulates or "mimics" the treatment machine. A special simulation x-ray ("simulation film") is taken of the area of the body to be treated. Alignment is critical during this process and is facilitated by lasers mounted on the wall and ceiling. Special individually constructed immobilization devices may be used to help achieve this alignment. You will likely see these red lines of light. These low energy lasers are for alignment purposes only and you will not feel burning or anything else from the laser light. Ink lines are usually drawn on the skin to identify the area to be treated. Tattoos (tiny permanent skin markings the size of a freckle) may be placed at the time of simulation or early in the course of treatment. If you have concerns about these tattoos, please discuss them with the Radiation Oncologist prior to simulation. If there will need to be any special contrast agents given (orally or intravenously) or any other procedures performed at the time of simulation, the Radiation Oncologist will discuss these with you. During simulation, your body contours may be taken to allow special computerized treatment planning. Treatment is often given with the radiation beams directed from several different directions to optimize treatment. The simulation procedure often takes 30 minutes to well over an hour of lying flat on a rather hard table. You will be required to lay still during this procedure. If this will be difficult for you, discuss your concerns in advance with the Radiation Oncologist. If you are taking pain medication, plan to take it about a half-hour prior to you simulation time to help stay comfortable. Sometimes several simulation sessions will be needed to optimize treatment, and are often done prior to planned "boost" or "reduced field" treatments as part of the overall treatment plan. Photographs are usually taken during simulation or early during treatment.

Treatment planning. Several steps occur after simulation and prior to treatment. You will not need to be present during these procedures. The simulation x-ray may be used to design special lead alloy blocks. This is necessary because the radiation beam that comes directly from the linear accelerator is only square or rectangular in shape. Many treatment areas require a portion of this square or rectangular beam to be blocked to help spare normal tissues from the effect of radiation. These lead alloy blocks are placed on a plastic tray and will be attached below the head of the linear accelerator prior to each treatment. These blocks are designed to maximize the radiation dose to the cancer site while minimizing harmful effects to normal tissue. The dose of radiation that can be delivered to a cancer depends on the radiation sensitivity of the cancer and the radiation sensitivity of the surrounding normal tissue. You may need to return after simulation and prior to treatment to verify the placement of these blocks and accuracy of the treatment plan. Special calculations are performed to help assure the proper radiation dose will be delivered. Computerized treatment planning may facilitate these calculations. Computers have become extremely sophisticated in planning radiation therapy delivery. Some computers are even capable of extremely complex three-dimensional representation of the treatment area and surrounding normal tissues. If such computerized planning is necessary, you may be asked to have a special CT scan (a special type of x-ray device with a donut shaped opening). Specialized radiation oncology team members (Medical Physicists and Dosimetrists) assist in this process. It may take several days for treatment planning to be completed after simulation and prior to treatment. After all treatment planning is complete, radiation therapy treatments are ready to begin.

How radiation therapy is given. Radiation therapy is the treatment with high-energy radiation of cancer (though occasionally non-cancerous conditions are treated). The following comments will refer to by far the most common form of radiation therapy delivery: external beam radiation treatment. A brief overview of other specialized forms of radiation delivery (brachytherapy) will be given later. The radiation used for treatment is generally produced in a machine called a linear accelerator. The linear accelerator is so named because it accelerates electrons using microwaves to near the speed of light. The accelerated electrons then strike a tungsten target in the head of the accelerator. The de-acceleration of electrons results in high energy therapeutic x-rays. Cobalt-60 machines were used in the past to deliver radiation therapy. Cobalt-60 machines are largely disappearing, as they are generally inferior as a treatment device to modern linear accelerators. It is unusual but not rare for the linear accelerator to not be operational for one or several days, and treatments during this time cancelled. There should be not change in the originally planned number of treatments unless the number of treatments missed is substantial.

Radiation therapy treatment overview. At the time of consultation, you will be informed of your medical condition that is being treated, and whether radiation therapy is given with the hope of curing the condition, relieving symptoms it may be causing, or both. Radiation therapy can be used to treat almost any type of cancer anywhere in the body. About 50-60% of all cancer patients receives radiation therapy at some time during their illness. About half of these patients are treated with the hope of curing the cancer, and the other half are treated for "palliation", meaning to relieve symptoms the cancer is causing. Radiation therapy given for palliation is usually effective. Radiation therapy is generally given once a day, Monday through Friday, five days a week. Occasionally treatment is given twice a day or less frequently than daily. Treatment is usually given at the same time each day. Every effort will be made to schedule treatment times that are most convenient for the patient, but unfortunately this is not always possible. It is important not to miss too many treatments after the course of radiation therapy has begun. The number of treatments to be given depends on multiple factors, and varies from 5-10 to 40 or more. This means treatment is given over a time period of 1-2 weeks to 8 weeks or more. Treatment given with the intent to cure the cancer often requires a larger number of treatments. It is necessary to give many treatments in this fashion to allow normal cells to heal between treatments, resulting in a higher cancer control probability with fewer complications. Extending treatments beyond the number recommended would reduce the chance of the cancer being controlled. The first time or two you are seen in the radiation oncology department you may need to be there for an hour or more. After daily treatments have been established, patients are usually in and out of the department in about 30 minutes. Waiting time for treatments will be kept to a minimum, though unfortunately there may be unforeseen delays. The patient's understanding during these delays is appreciated. Thus, patients are usually quite reassured that while a large number of treatments may be necessary, they can generally be given as an outpatient and involve relatively little time each day. It is important to try to come to each treatment on time every day. If a scheduled treatment must be missed, please give as much advance notice as possible to the Therapists (specially trained technicians treating the patient under the Radiation Oncologist's prescription and supervision) or front office personnel. It is not unusual for patients to feel anxious on the first treatment day. If you would like information about support groups or others trained in emotional support and counseling, please ask your health care team. Please share any of your concerns with the health care team. At the time of treatment, the patient usually puts on a special gown in a private dressing room. The Therapists then bring the patient into the treatment room. The patient then lies on the treatment table. The Therapists spend several minutes are aligning the head of the accelerator with the skin markings to help assure precise treatment. The Therapists leave the room prior to each treatment. While they are out of the room, the Therapists continuously monitor the treatment via a video camera and audio connection with the treatment room. The patient may talk to the Therapists at any time via the audio system while alone in the treatment room. The treatment machine does not touch the patient, but they will hear the machine running during actual treatment. The radiation is actually delivered in just several minutes. As with diagnostic x-rays, the patient will not feel the radiation as it is being delivered. Even severely claustrophobic patients generally find they have no problem with their treatments. The patient may breathe normally during treatment but must lay still. Special x-rays ("port films") are taken in the treatment room periodically. These port films help assure the treatments are being delivered to the exact same area as was planned. Usually port films are performed very early in treatment, then at least weekly. It is not unusual for small adjustments in the alignment of the accelerator with the skin markings to require more frequent port films. The Radiation Oncologist generally does not see the patient daily. Visits with the Radiation Oncologist, and possibly other members of the health care team, usually are scheduled for once a week. Of course patients may see the Radiation Oncologist more frequently if they have questions or symptoms requiring more frequent visits. At the time of these visits, patients are encouraged to ask any questions or discuss any symptoms they may have. Many radiation oncology departments have nurses who help the physicians evaluate the patient and help educate the patient and family about cancer and radiation therapy. Routine blood tests may be periodically obtained. Although it is very unlikely to be necessary, you should know what arrangements there are to contact a Radiation Oncologist outside regular business hours. Most radiation oncology departments have physician on-call arrangements.

How radiation therapy works. Normal cells in the body divide and replace themselves in an orderly process. This process keeps the body healthy and in repair. Sometimes the cells lose their ability to limit and control their growth. They divide rapidly without control resulting in cancer. These cancer cells have the ability to invade local normal tissues or spread to distant parts of the body via lymphatics or the bloodstream. Radiation therapy works by damaging the DNA in the cancer cell. DNA is the part of the cell vital for its reproduction. After the cancer cell DNA has been damaged, if the cancer cell attempts to reproduce and grow it is unable to do so and dies. The body's natural mechanisms removes dead cancer cells, and the cancer shrinks. The ability of radiation to treat cancer has been known since the late 1800's. Radiation therapy is an effective treatment modality, and virtually all cancer treated will shrink. It often takes many weeks for a cancer that can be seen or felt to noticeably shrink, as it takes this period of time for the bodies natural mechanisms to remove dead cancer cells. For other patients, radiation therapy is given to an area where only microscopic amounts of cancer may be present. In this case, there is generally no physical exam finding, x-ray or laboratory test effective in documenting the cancer cell killing. Fortunately, radiation therapy is most effective in controlling very small or microscopic amounts of cancer. Normal cell's DNA is also damaged by the radiation. Normal cells are generally much better at using the bodies natural healing mechanisms to repair the DNA damage. Radiation may affect normal tissues enough to cause radiation side effects, which will be discussed later.

Restrictions during treatment. Patients generally can drive themselves to their treatments. If you have doubts about your ability to drive, find an alternate source of transportation or discuss your concerns with your health care team. Patients usually can take all their medicines and do any and all of their daily activities, including continuing employment, while receiving radiation therapy with no restrictions. The one notable exception to this is the need to avoid washing off any ink marks placed on the skin to facilitate treatment (discussed above). It is very important for both men and women to practice birth control during and awhile after treatment. If any patient believes they might be pregnant, the Radiation Oncologist must be informed prior to treatment and prior to obtaining any diagnostic x-rays. If there are any other restrictions or exceptions to the above, your health care team will inform you. Patients (and their clothes, etc.) are not radioactive at any time during external beam radiation therapy, and do not pose a radiation hazard to anyone at any time. Neither the effects of radiation therapy nor cancer can be transmitted by the patient to others.

Side effects of radiation therapy- overview. Most patients are quite pleased to find they have no side effects, or they are much milder than they anticipated. The majority of patients have no side effects, or only mild side effects easily controlled medically. The side effects of radiation therapy result from radiation effects only in the area being treated. Radiation therapy will not cause side effects in areas outside of the area being treated. There is significant individual variability in the side effects that may result. It is usually policy in radiation oncology departments to see patients at least once a week while they are under treatment. This brief visit with the health care team serves as an opportunity to ask questions and discuss side effects, if any, which may be occurring. Blood tests are often obtained at regular intervals to be sure no blood count abnormalities develop (usually very unlikely). The following is a discussion of side effects that may occur during treatment. There are also long term side effects of radiation therapy that may occur months to years after treatment. If these long-term side effects are severe enough, they may be considered a complication of treatment. Such complications of radiation therapy are very uncommon and can occur only in the area directly irradiated. The type of complication and probability of it occurring is very dependent on the site treated, cancer extent and type of cancer. Because complications are so uncommon and treatment technique specific, a detailed discussion will not be provided here. Your Radiation Oncologist will explain the risk of complications of radiation therapy with you prior to your treatment. It is important that you not be so concerned about an exceedingly unlikely radiation complication that you refuse recommended radiation treatment which is important to your health.

Radiation therapy side effects- specific sites. The majority of patients do not feel tired during radiation therapy, though a few do. If tiredness occurs, it usually occurs early in the course of treatment. Tiredness can be a result of the body using energy to repair radiation effects in normal cells to keep them healthy. There is no specific treatment for tiredness, though many patients find it helpful to take a nap after the radiation treatment and avoid unnecessarily tiring activities. For further information, see the patient information section of this web regarding Fatigue.  The following are an overview of radiation side effects occurring at specific treatment sites. Virtually no patient will have all these side effects. Remember that most patients receiving radiation therapy tolerate treatment well. The following side effects usually resolve in a few days to several weeks following completion of radiation therapy.

    Skin. The skin is necessarily irradiated in the treatment of virtually all sites. The great majority of patients have no significant skin reactions. Skin effects are more likely if treatment is given to areas of skin fold or if the radiation is delivered with tangential beam technique (such as is necessary in treating breast cancer). After 2 1/2 to 3 1/2 weeks the skin may turn pink, then darker red. If the reaction progresses, the reaction may progress to look like a sunburn. The skin reaction may become uncomfortable or itch. Although unusual, occasionally the reaction may progress to damage the full thickness of skin with blistering. Mild to moderate itch or discomfort in the intact skin is often treated with 1% hydrocortisone cream (available over the counter) with usually excellent control of symptoms. See the patient information section in this web regarding Skin Reactions.

    Mouth and throat. Radiation effects in the mouth and throat often begin 2-3 weeks into treatment. These effects include mouth discomfort, variably altered taste of food (often with decreased taste acuity), and discomfort swallowing. Hoarseness may occur if the vocal cords are in the treated area. Several months after treatment a permanent dry mouth may result if most of the salivary glands are treated to a high enough radiation dose. A dry mouth increases the risk of dental problems developing months to years after radiation therapy is complete. If a dry mouth is likely to result, your Radiation Oncologist may have you see a dentist or oral surgeon prior to radiation therapy for any necessary dental surgery and to recommend a course of special fluoride treatment to reduce the risk of future dental complications.

    Breast. Radiation effects from radiation therapy to the breast usually include some degree of skin redness that is usually mild and does not cause symptoms. See the previous discussion on Skin side effects for more details, and also see the patient information section in this web regarding Skin Reactions. Usually there are no other significant side effects of radiation therapy to this site. The skin reactions usually resolve in a few weeks and long term adverse cosmetic results attributable to radiation therapy are unusual.

    Chest. Lung and esophagus (the tube you swallow through) cancers are the most common cancers involving radiation therapy to the chest. After 2-3 weeks, radiation effects in the esophagus may result in a lumpy feeling with swallowing. This reaction may progress to discomfort with swallowing. If this happens, special dietary instructions may be given. There are several helpful medications available if discomfort swallowing occurs.

    Abdomen (see below for pelvis). Radiation effects in the abdomen may include diarrhea (from radiation effects on the small bowel) which may begin 2-3 weeks into treatment. Diarrhea is usually easily controlled with the medications Imodium (available over the counter), Lomotil (available by prescription) and dietary adjustments (see patient information section of this web regarding Low Residue Diet). If a significant portion of the stomach is treated, nausea and possibly vomiting may result. There are very effective medications to help control nausea.

After treatment care. Any side effects of treatment that may have occurred usually go away in a few days to several weeks. You should call your physician if you have concerns regarding side effects after treatment or if any side effects seem unexpectedly severe or worsen. After radiation therapy treatments are complete, you will probably be given an appointment for a follow up visit. Follows up visits are often coordinated with other physicians involved in your care.

Brachytherapy. Brachytherapy is a specialized cancer treatment technique involving the placement of radioactive sources in or near the cancer. These radioactive sources may be placed a short time or left in place permanently. There are a variety of brachytherapy treatment techniques, and your physician will explain the details of your treatment.

    High dose rate brachytherapy.  One common brachytherapy technique involves high dose rate brachytherapy (HDR). This is a special device usually allowing treatment as an outpatient.

    Low dose rate brachytherapy.  Low dose rate brachytherapy is often used for gynecological cancers and involves the placement of radioactive sources over a period of many hours to several days. This procedure requires hospitalization. During hospitalization, the patient will need to stay in a private room and remain at bedrest to avoid dislodgment of the radioactive sources. Visitors will be restricted with regard to how close they may get to the patient and how long they may stay in the room with the patient. Pregnant women and children below the age of 18 are not allowed to visit. Prostate cancer may be treated with permanent implantation of radioactive seeds. This involves a minor brief surgical procedure. If you will be treated with brachytherapy, your physician will provide a more detailed discussion of how your treatment will be given. Brachytherapy is often given in combination with external beam radiation therapy.

Patient resources. There are many resources available for patients with cancer. This web has many links and helpful information. The American Cancer Society (1-800-4-CANCER) has many offices with resources, sometimes including assistance with transportation, for cancer patients. The National Cancer Institute has many brochures regarding a variety of cancers and their treatment. Most radiation oncology treatment centers have these or can get them for you at your request.