Treatment
Options
Treatment Questions
External
Beam Radiation Therapy Treatments
The goal of radiation
therapy is to get a high enough dose of radiation into the body
to kill the cancer cells while sparing the surrounding healthy
tissue from damage. Several different radiation therapy techniques
have been developed to accomplish this. Depending on the location,
size and type of your tumor or tumors, you may receive one or
a combination of these techniques. Your cancer treatment team
will work with you to determine which treatment and how much radiation
is best for you.
During external beam radiation
therapy, a beam of radiation is directed through the skin to a
tumor and the immediate surrounding area in order to destroy the
main tumor and any nearby cancer cells. To minimize side effects,
the treatments are typically given every day for a number of weeks.
The radiation beam comes
from a machine located outside of your body that does not touch
your skin or the tumor. Receiving external beam radiation is similar
to having an X-ray taken. It is a painless, bloodless procedure.
The most common type of machine used to deliver external beam
radiation therapy is called a linear accelerator, sometimes called
a "linac". It produces a beam of high-energy X-rays
or electrons. Using sophisticated treatment planning software,
your radiation oncology treatment team plans the size and shape
of the beam, as well as how it is directed at your body, to effectively
treat your tumor while sparing the normal tissue surrounding the
cancer cells.
Several special types of
external beam therapy are discussed below. These are used for
particular types of cancer, and your radiation oncologist will
recommend one of these treatments if he or she believes it will
help you.
Three-Dimensional Conformal
Radiation Therapy (3D-CRT)
Tumors usually have an
irregular shape. Three-dimensional conformal radiation therapy
(3D-CRT) uses sophisticated computers and computer assisted tomography
scans (CT or CAT scans) and/or magnetic resonance imaging scans
(MR or MRI scans) to create detailed, three-dimensional representations
of the tumor and surrounding organs. Your radiation oncologist
can then shape the radiation beams exactly to the size and shape
of your tumor. The tools used to shape the radiation beams are
multileaf collimators or blocks. Because the radiation beams are
very precisely directed, nearby normal tissue receives less radiation
exposure.
Intensity Modulated Radiation
Therapy (IMRT)
Intensity modulated radiation
therapy (IMRT) is a specialized form of 3D-CRT that allows radiation
to be more exactly shaped to fit your tumor. With IMRT, the radiation
beam can be broken up into many "beamlets", and the
intensity of each beamlet can be adjusted individually. Using
IMRT, it may be possible to further limit the exact amount of
radiation that is received by normal tissues that are near the
tumor. In some situations, this may also allow a higher dose of
radiation to be delivered to the tumor, increasing the chance
of a cure.
Proton Beam Therapy
Similar to external beam
therapy, proton beam therapy is a form of radiation treatment
that uses protons rather than X-rays to treat certain types of
cancer and other diseases. The physical characteristics of the
proton therapy beam allow doctors to better focus the dose on
the tumor with the potential to reduce the dose to nearby healthy
tissues.
Stereotactic Radiotherapy
Stereotactic radiotherapy
is a technique that allows your radiation oncologist to precisely
focus beams of radiation to destroy certain types of tumors. Since
the beam is so precise, your radiation oncologist may be able
to spare more normal tissue than with conventional external beam
therapy. This additional precision is achieved through rigid immobilization,
such as with a head frame as is used in the treatment of brain
tumors. Although often performed in a single treatment, fractionated
radiotherapy, where patients receive up to five treatments, is
sometimes necessary. Stereotactic radiotherapy may be the only
treatment if a very small area is affected. In addition to treating
tumors, it can also be used to treat malformations in the brain's
blood vessels and certain noncancerous (benign) brain tumors.
Image-Guided Radiation Therapy
(IGRT)
In our facility, radiation
oncologists are using image-guided radiation therapy (IGRT) to
help them better deliver the radiation dose to the cancer. Normal
structures and tumors can move between treatments due to differences
in organ filling or movements while breathing. IGRT is conformal
radiation treatment guided by imaging equipment, such as CT, ultrasound
or stereoscopic X-rays, taken in the treatment room just before
the patient is given the radiation treatment. All patients first
undergo a CT scan as part of the planning process. The digital
information from the CT scan is then transmitted to console in
the treatment room to allow doctors to compare the earlier image
with the images taken just before treatment. During IGRT, doctors
"fuse" these images to see if the treatment needs to
be changed. This allows doctors to better target the cancer while
avoiding nearby healthy tissue. In some cases, doctors will implant
a tiny piece of material called a fiducial marker near or in the
tumor to help them localize the tumor during IGRT.
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Brachytherapy
Treatments
Brachytherapy, also called
internal radiation or seed implants, is the placement of radioactive
sources in or just next to a tumor. The radioactive sources may
be left in place permanently or only temporarily, depending upon
your cancer. To position the sources accurately, special catheters
or applicators are used. Because the radiation sources are placed
so close to the tumor, your doctors can deliver a large dose of
radiation directly to the cancer cells with minimal exposure to
normal tissue.
The radioactive sources
used in brachytherapy, such as thin wires, ribbons, capsules or
seeds, come in small sealed containers. Some sources are placed
permanently and are referred to as implants. These radioactive
sources remain in the body after their radiation has been expended
and the source is no longer radioactive. Other sources are placed
temporarily inside the body, and the radioactive sources are removed
after the prescribed dose of radiation has been delivered.
There are two main types
of brachytherapy: intracavity treatment and interstitial treatment.
With intracavity treatment, the radioactive sources are put into
a space near where the tumor is located, such as the cervix, the
vagina or the windpipe. With interstitial treatment, the radioactive
sources are put directly into the tissues, such as the prostate.
Often these procedures
require anesthesia and brief hospitalization. Patients with permanent
implants may have a few restrictions at first and then can quickly
return to their normal activities. Temporary implants are left
inside of your body for several hours or days. While the sources
are in place, you will stay in a private room. Doctors, nurses
and other medical staff will continue to take care of you, but
they will need to take special precautions to limit their exposure
to radiation.
Devices called high dose
rate remote afterloading machines allow radiation oncologists
to complete brachytherapy quickly, in about 10 to 20 minutes.
Powerful radioactive sources travel through small tubes called
catheters to the tumor for the amount of time prescribed by your
radiation oncologist. You may be able to go home shortly after
the procedure. Depending on the area treated, you may receive
several treatments over a number of days or weeks.
Most patients feel little
discomfort during brachytherapy. If the radioactive source is
held in place with an applicator, you may feel discomfort from
the applicator. There are medications that can help this. If you
feel weak or queasy from the anesthesia, your radiation oncologist
can give you medication to make you feel better.
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Other
Treatment Options
Systemic Radiation Therapy
Using radioactive isotopes
to treat certain cancers is called systemic radiation therapy.
The radioactive isotopes may be swallowed, given intravenously
or injected into the body. For example, radioactive iodine (I-131)
capsules are given to patients to treat some types of thyroid
cancer. Another example is the use of intravenous radioactive
strontium to treat pain due to cancer that has spread to the bone.
Radioimmunotherapy
Recent research has focused
on the use of radioactive monoclonal antibodies, also called radiolabeled
antibodies, to deliver doses of radiation directly to a tumor.
This process is known as radioimmunotherapy. Antibodies are made
by the body in response to the presence of antigens (substances
recognized as foreign by the immune system). Large quantities
of particular types of antibodies, called monoclonal antibodies,
can be made in the laboratory. These monoclonal antibodies can
be attached to radioactive isotopes in a process called radiolabeling.
When injected into the body, the radiolabled antibodies circulate
in the bloodstream until they locate and bind to the surface of
cancer cells. The cancer cells are then destroyed by the radiation
carried in the antibody.
Intraoperative Radiation
Therapy
Radiation therapy given
during surgery is called intraoperative radiation therapy. Intraoperative
radiation therapy is helpful when vital normal organs are dangerously
close to the tumor. During an operation, a surgeon temporarily
moves the normal organs out of the way so radiation can be applied
directly to the tumor. This allows your radiation oncologist to
avoid exposing those organs to radiation. Intraoperative radiation
can be given as external beam therapy or as brachytherapy.
Investigational Radiation
Therapies
Several specialized types
of radiation therapy are available in a limited number of facilities
in the United States. These treatments are currently being studied
to determine their best use. You can discuss with your radiation
oncologist whether these therapies may benefit you.
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Understanding
Clinical Trials
What Are Clinical Trials?
Clinical trials are research
studies involving people.
- They test ways to treat and prevent cancer.
- All of today's standard cancer treatments are a result of
clinical trials completed many years ago.
Who Organizes a Clinical
Trial?
Organizations or individuals
looking for better treatments for cancer or new ways to prevent
or detect cancer may sponsor clinical trials. Individual doctors
at cancer centers or other medical institutions can also conduct
trials.
- The National Cancer Institute sponsors numerous clinical trials
covering a variety of cancers.
- Other sponsors include drug makers, technology companies and
groups like the American Cancer Society.
- Each trial has a person in charge, usually a doctor, who is
called the protocol chair or principal investigator (also called
the PI).
- Before enrolling in a trial, ask whether the trial has been
approved by an Institutional Review Board or IRB. IRBs exist
at most hospitals to help safeguard patient rights.
How Are Clinical Trials
Conducted?
Clinical trials testing
new treatments are carried out in phases.
Phase I — Is the Treatment
Safe?
As the first step
in testing the research, doctors gather information about the
side effects of the treatment and decide on the safe dose. Only
a few patients in a few places take part in a Phase I trial.
Phase II — Does the Treatment
Work?
In this step, doctors
test the treatment to see how well it works. Most of the time,
fewer than 100 patients are involved in Phase II trials.
Phase III — Is the Treatment
Better?
Phase III trials compare
the new treatment against the current standard therapy and randomly
assign patients into one of the two groups. Many people from
all over the country take part in these trials.
Phase IV — Are There Better
Ways to Use the Treatment?
In this final step,
treatments are tested to make sure they are safe and work well
over a long period of time. This phase most often occurs once
the new treatment has been approved for standard use. Anywhere
from several hundred to several thousand people are enrolled
in a Phase IV trial.
Where Are Clinical Trials
Conducted?
Clinical trials are available
through oncologists everywhere — not just in major cities or in
large hospitals.
- Clinical trials take place in teaching hospitals, outpatient
clinics, community hospitals and doctors' offices.
What Are the Types of Clinical
Trials?
Prevention
These trials test new
approaches that doctors believe may reduce your chance of developing
cancer. Most involve healthy people who have not had cancer.
Some studies are conducted with people who have had cancer in
the past to try to find ways to prevent second cancers.
Screening
Since cancer is often
easier to cure when it is found early, screening trials test
methods to better detect cancer, especially in the early stages.
These studies also help find out whether finding cancer before
it causes symptoms will lessen a patient's chances of dying
from the disease.
Diagnostic
Diagnostic trials help
answer whether or not there are new approaches that could be
used to find certain types of cancer and at an earlier stage.
Treatment
The purpose of these
trials is to find out if a new treatment or technique is better
than the standard treatment. This can include new approaches
to radiation therapy, new drugs, vaccines and different combinations
of treatment.
Supportive Care/Quality
of Life
These studies explore
ways to improve the comfort and quality of life of people with
cancer or survivors. These trials also study ways to better
combat the side effects of some treatments.
Genetics Studies
These are generally
done with another clinical trial and focus on how genetic makeup
can affect detection, diagnosis or response to cancer treatment.
Who Can Participate in
a Clinical Trial?
Each clinical trial
calls for certain criteria that a patient must meet to be included
in that trial.
- Your age, gender, medical history, current health, what
type and stage of cancer all factor into eligibility.
It is important to remember
that clinical trials are completely voluntary. Patients can
leave a trial at any time.
What Is Informed Consent?
Informed consent is the
process by which you agree to take part in a clinical trial after
receiving information about the purpose of the study, the treatment
that will be given, the tests that will be taken, and the risks
and benefits of treatment.
- You must sign a written consent form before being enrolled
into a clinical trial. This form says that you understand the
study and agree to take part.
What Are the Benefits?
Although there are risks
with any treatment, there are also many benefits of taking part
in a clinical trial. For example:
- Access to promising new treatments that are not available
outside of the clinical trial setting.
- The treatment being studied may be better than the standard
approach.
- You are followed very closely by a research team that is made
up of doctors and other health professionals.
- You may be the first to benefit from the new method.
- Results from the study may help others in the future.
What Are the Risks?
Before taking part in
a clinical trial, talk to your doctor about some of the risks
involved with your treatment. For example:
- New drugs or treatments may not be any better than the standard
care they are being compared to.
- New treatments may have side effects that are not expected.
- If you are in a randomized trial, you will not be able to
choose if you are getting the new treatment or the standard
approach.
- Health insurance may not cover all your costs.
- You may be required to make more frequent visits to the doctor.
Questions to Ask Your Doctor
Before joining a clinical
trial, you may want to ask your doctor questions about the study
and your treatment.
- What are you trying to learn from the study?
- What do doctors know already about the treatments being studied?
- What treatments and tests will I get during this trial?
- Who will be in charge of my care during the study?
- What are the differences between what I would get on this
treatment and the standard treatment you would recommend?
- What are the benefits and risks?
- How will this affect my daily life?
- How long will the study last?
- What will I be asked to pay?
- How will I know if the study was successful?
How Can I Join a Clinical
Trial?
If you are interested
in joining a clinical trial, talk to your doctor. He or she can
help you find out if a trial is right for you.
- The National Cancer Institute can give you information on
current trials. Call 1-800-4-CANCER or visit www.cancer.gov
to learn more.
Who Pays for a Clinical
Trial?
Before taking part in
a clinical trial, it's important to ask what your costs will be.
- In some cases, the sponsor of the study (such as the government,
drug makers or technology companies) will provide the new treatment
at no cost and pay for any special testing or extra doctor visits.
Some sponsors may pay more than this, such as covering travel
time and mileage expenses. However, other trials may pay very
little of your treatment costs.
- If you have private insurance, check with your provider before
you begin treatment. It may be willing to pay for some or all
of the costs of your treatment, depending on the type of trial.
- Medicare will pay for the routine costs for some government
sponsored clinical trials. Ask your doctor or call your local
Medicare provider to find out what Medicare will pay for your
treatment.
Facts About Clinical Trials
- More than 25,000 cancer patients enroll each year in clinical
trials through the National Cancer Institute. Many more patients
are enrolled in clinical trials sponsored by other groups.
- About 60 percent of the adults enrolled in clinical trials
are women.
- Lung, breast, prostate and colon cancers have the highest
number of clinical trials dedicated to them —
more than 40 percent of the total number of trials.
- Only a small percentage of all cancer patients enroll in clinical
trials. Their participation may benefit them as well as future
cancer patients.
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Managing
Side Effects
Patients often experience
little or no side effects from the radiation therapy and are able
to continue their normal routines. However, some patients do feel
some discomfort from the treatment. Be sure to talk to a member
of your radiation oncology treatment team about any problems you
may have.
Many of the side effects
of radiation therapy are related to the area that is being treated.
For example, a breast cancer patient may notice skin irritation,
like a mild to moderate sunburn, while a patient with cancer in
the mouth may have soreness when swallowing. These side effects
are usually temporary and can be treated by your doctor or other
members of the treatment team.
Side effects usually begin
by the second or third week of treatment, and they may last for
several weeks after the final radiation treatment. In rare instances,
serious side effects develop after radiation therapy is finished.
Your radiation oncologist and radiation oncology nurse are the
best people to advise you about the side effects you may experience.
Talk with them about any side effects you are having. They can
give you information about how to manage them and may prescribe
medicines that can help relieve your symptoms.
The side effect most often
reported by patients receiving radiation is fatigue. The fatigue
patients experience is usually not very severe, and patients can
often continue all or some of their normal daily activities with
a reduced schedule. Many patients continue to work full time during
radiation therapy.
Many patients are concerned
that radiation therapy will cause another cancer. In fact, the
risk of developing a second tumor because of radiation therapy
is very low. For many patients, radiation therapy can cure your
cancer. This benefit far outweighs the very small risk that the
treatment could cause a later cancer. If you smoke, the most important
thing you can do to reduce your risk of a second cancer is quit
smoking.
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How
to Care For Yourself During Treatment
Get plenty of rest.
Many patients experience
fatigue during radiation therapy, so it is important to make sure
you are well rested.
Eat a balanced, nutritious
diet.
A nutritionist, nurse
or physician may work with you to ensure you are receiving the
right calories, vitamins and minerals from the foods you eat and
that you are eating the proper type of foods. With certain types
of treatment, it may be necessary to modify your diet to minimize
side effects. You should not attempt to lose weight during radiation
therapy, since you require more calories due to your cancer and
treatment.
Treat the skin that is exposed
to radiation with extra care.
The skin in the area
receiving treatment may become red and sensitive. Your radiation
oncology nurse will review specific instructions for caring for
your skin with you. Some guidelines include:
- Cleanse the skin daily with warm water and a mild soap recommended
by your nurse.
- Avoid using any lotions, perfumes, deodorants or powders in
the treatment area unless approved by your doctor or nurse.
Try not to use products containing alcohol and perfumes.
- Avoid putting anything hot or cold on the treated skin. This
includes heating pads and ice packs.
- Protect the treated area from the sun by using a sunscreen
with an SPF of at least 15. If possible, avoid exposing the
treated area to the sun altogether.
Seek out emotional support.
There are many emotional
demands that you must cope with during your cancer diagnosis and
treatment. It is common to feel anxious, depressed, afraid or
hopeless. At times, it may help to talk about your feelings with
a close friend, family member, nurse, social worker or psychologist.
To find a support group in your area, ask your radiation oncology
nurse.
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Questions
to Ask Your Doctor
It is important that
you fully understand the potential benefits, side effects and
goals of radiation therapy. Your radiation oncologist and radiation
oncology nurses are available to answer any questions you may
have during treatment. They are the best source of accurate information
about your particular case.
Coping with a diagnosis
of cancer and researching the various treatment options can be
a stressful experience. To assist you in this process, below is
a list of questions you may want to ask your radiation oncologist
if you are considering radiation therapy.
- What type and stage of cancer do I have?
- What is the purpose of radiation treatment for my type of
cancer?
- How will the radiation therapy be administered? Will it be
external beam or brachytherapy? Will the treatments hurt?
- For how many weeks will I receive radiation? How many treatments
will I receive per week?
- What are the chances that radiation therapy will work?
What is the chance that the cancer will spread or come back
if I do not have radiation therapy?
- Will I need chemotherapy, surgery or other treatments? If
so, in what order will I receive these treatments, and how soon
after radiation therapy can I start them?
- How can I expect to feel during treatment and in the weeks
following radiation therapy?
- Can I drive myself to and from the treatment facility?
- Will I be able to continue my normal activities?
- What side effects may occur from the radiation and how are
they managed?
- Will radiation therapy affect my sex life or my ability to
have children?
- Do I need to take any special precautions, like staying out
of the sun or avoiding people with infectious diseases?
- Do I need a special diet during or after my treatment?
- Can I exercise?
- Will side effects change my appearance? If so, will the changes
be permanent or temporary? If temporary, how long will they
last?
- How often do I need to return for checkups?
- How and when will you know if I am cured of cancer?
- What are the chances that the cancer will come back?
- How soon can I go back to my regular activities? Work? Sexual
activity? Aerobic exercise?
- Do you take my insurance?
- How should I prepare for this financially?
- What are some of the support groups I can turn to during treatment?
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