1. Radiotherapy and More… Linda Bedford, Macmillan Lead AHP, Peninsula Cancer Network Sally Donaghey, Macmillan AHP Lead, Anglia Cancer Network

2. Radiotherapy Radiotherapy is designed to direct a lethal dose of radiation directly to cancer cells in tumours, while minimizing exposure to the healthy cells that surround them Radiation beam passes through all the cells in its path Linacs direct the beam to the tumour in short bursts from many different angles –healthy cells actually receive less radiation –cancerous target at the centre receives a significantly larger dose.

3. Physics Atomic structure

4. More Physics X-Ray production: –When atoms are struck by high energy electrons –Deceleration leads to “braking energy” – bremmstrahling xrays –Interaction with orbiting electrons causing movement within orbit and/or ejection, leads to “characteristic xrays” www.ucl.ac.uk

5. Radiotherapy – what happens? Radiotherapy Direct damage - Ionisation Indirect damage – Free radicals DNA damage (replication, function) Cell death (therapeutic and side effects) Cell modification (Potentially harmful)

6. A Linear Accelerator

7. A Bunker

8. Patient Immobilisation Devices

9. Portal Imaging

10. MLC’s Multileaf collimators

11. IMRT – Intensity Modulated Radiotherapy

12. IGRT – Image Guided Radiotherapy

13. Gating Patient respiration during radiotherapy can cause significant motion of the tumour

14. Simple 2 Field Technique

15. 27 segment Forward planned IMRT

16. Dose shaped around critical organ at risk

17. Sterotactic Radiosurgery

18. TBI Total Body Irradiation

19. Brachytherapy For the women And for the men

20. Cyber Knife

21. The Future Proton therapy Works by aiming energetic particles (in this case, protons accelerated with a particle accelerator) onto the target tumour.

22. Effects on Tissues Effects are indiscriminate –Normal –Malignant cells Tissue tolerance – dose limitation Therapeutic window –Radiosensitivity –Sensitive tissue –Bigger window –Lower effective dose –Fewer side effects www.dkfz.de

23. Dose and Fractionation Radiation doses are measured in the unit Gray (Gy), just like flour is measured in kg Doses delivered in “fractions” Safe delivery of higher total dose Smaller areas can be treated to higher doses Exploitation of cell cycle Dose (generally) proportionate to damage Low dose potential for sub lethal damage Cell repair Serial and parallel organs Biologically effective doses Examples of dose: –70Gy in 35 # - 2 Gy per fraction. –8Gy single #

24. Side Effects Acute side effects: Rapid cell division/high mitotic activity Sudden, short-term effects Commence during/end of treatment (2-3 weeks) Repair 4-12 weeks post tx Genetics Chronic side effects: Develop months/years after treatment Longer term or permanent changes Expression of damage not evident immediately –Eg nervous tissue – v slow mitotic division so damage presents with later effects.

25. Carcinogenesis RT causes cancer Hiroshima and Chernobyl Generally within organ/site previously irradiated Latent period of 5-30 years depending on studies Risk factor of younger age at initial tx HD leukaemia and breast Ca Brain tumours PCI/CNS tx Leukaemia Ankylosing spondylitis Teratogenicity –Radiation during pregnancy –To be avoided unless clinically indicated –Highest risk in first trimester –Patient choice regarding tx

26. Radiosensitive Tissues Highly Sensitive: –Skin –Lining of GI tract –Oro-pharynx –Haemopoietic tissues – bone marrow –Reproductive cells Intermediate Sensitivity: –Liver –Kidney –Lung –Nervous tissue –Eye Low Sensitivity –Bone –Muscle –Connective tissue

27. Skin Skin –Inevitable –Skin folds –Moist areas –Thin skin areas Effects: –Erythema –Dry desquamation –Moist desquamation –Hair loss –Pigmentation –Fibrosis –Telangiectasia

28. Skin Management Conflicting evidence (please see October 2011 report from Scor) –Advice –Loose cotton clothing –Don’t scrub –Unperfumed soaps –Aqueous cream –No wet shaving –Chlorine –Hydrocortisone –Hydrogel –Hydrocolloid –Silicone dressings

29. Oro-Pharynx Oro-pharynx –Epithelial turnover and thinness of skin in area –Can interrupt tx –Exacerbate surgical/functional difficulties Effects: –Mucositis –Dysgeusia –Xerostomia –Dysphagia –Pain –Oedema –Mucosal fibrosis and atrophy –Dental caries –Osteradionecrosis – 60 Gy TD5/5 –Susceptibility to ulceration www.caphasol.ca

30. Oro-Pharynx Management AdviceSupportDietetics –Liquidise food –Small portions frequently –Sips of water –Supplements –Dispersible analgesia/anaesthesia before eating –Avoid spicy/sharp/v hot/v cold food Speech therapy Physiotherapy Oral hygiene Loose clothing

31. Gastro-intestinal Gastrointestinal –Rectum can be OAR for other pelvic treatments –Consider whole length of tract Effects –Diarrhoea –Proctitis –Rectal bleeding –Nausea –Vomiting –Enteritis/granulation leading to stricture and obstruction –Permanent change in bowel habit –Faecal incontinence –Fistulae medrevise/.co.uk

32. Gastro-intestinal Management Conformal RT/IMRT improving side effect profile AdviceAnti-emeticsAnti-diarrhoealsCreamsCorticosteroids Dietary advice ClothingHydration

33. Breast SkinFibrosisShinkage Hardening of tissue Lymphoedema Rib fractures – 1% Lung fibrosis/pneumonitis – maximum lung volume Cardiac toxicity – particularly 60+. Max heart volume www.wales.gov.uk

34. Fatigue Common, under- estimated in effect and debilitating High incidence Ltd management options – NICE guidance = info and exercise advice Patterns of fatigue –Cumulative - ?increase with dose/tx –Persistence post tx 4- 12 wks+ Management: Its normal Energy conservation Fluids and diet Delegate! Rest when needed Gentle exercise may help to increase energy levels Organise and plan ahead

35. Thank you Any Questions?