1. PATIENT CENTRED CARE DURING RADIOTHERAPY
Hello, I have been asked to talk to you about patient centered care during radiotherapy treatment.
My name is Janice Fletcher and I am the Macmillan Clinical nurse specialist within Ninewells for Radiotherapy and Oncology.
We know that people with cancer have special needs and my role is to acknowledge these needs to provide and promote continuity of care and maintain or improve quality of life.
This is achieved through provision of information, physical, psychological and practical support to patients at ANY stage of their illness.
It is also my role to address the holistic needs of both the patient and their families and provide a link between the different members of the MDTeam as well as the community
Janice Fletcher
Macmillan Clinical Nurse Specialist
(Radiotherapy & Oncology)

2. By Direct Hit, By Indirect Hit, which damages the RNA or DNA directly
‘Radiation Therapy is the use of high energy ionizing rays or particles to treat cancer’
The Cells are damaged
By Direct Hit,
which damages the RNA or DNA directly
By Indirect Hit,
where Ionization causes molecular changes and thus cause damage to the DNA
I would like to quickly recap on Radiotherapy and its principles. I am aware that Una has covered this so I will not spend long on this. As stated Radiation therapy is the use of high energy ioni\ing rays or particles to treat cancer.
The cells are damaged by direct hit causing breakage in one or both of DNA strands, mismatching or loss of a nitrogenous base. Indirect hit causes a chemical reaction. The ionization of water results in significant toxic changes that ultimately affect the cells function and survival. Both these reactions to radiotherapy help render the cell unable to replicate. Since malignant cells, by their very nature, replicate much quicker than normal cells the intention is to achieve greater cell kill.
Already we can see a pattern of effect that starts helping us to understand why radiation side effects occur. If chemical reaction continue via indirect hit then it makes sense that surrounding normal cells will be affected.
Thus we have more of a local effect from radiotherapy rather than the more systemic one experienced by chemotherapy
‘Free Radicals’ – what are they?
Why we need them?
White Cells produce oxygen free radicals and the process to do so is essential to killing microbes.
Drugs to stop ‘free radicals’ -

3. So, What Does This Mean For The Patient?
Side Effects
Skin Reaction, Irritation of surrounding tissues to treatment area, Fatigue
Anxiety/Fear
Unknown, stories, fear of radiation, intimate
Life Disruption
Daily visits, travelling long distances, cost
So lets link that with the patients experience. It is all very well being able to explain the workings of Radiotherapy but how will this effect the patient.
There are the direct effects, actual side effects from the treatment, which can range from mildly irritating to severely debilitating depending on the individual. I would like to explore certasin side effect that the patients will commonly experience in more detail; in a moment. However it is important to look at other issues which may be difficult for the patient.
Anxiety & fear of radiation can be a real issue, especially in our aging population who will remember early experiments or stories of Radiation We must be aware of these issues, it may be an ‘easy’ thing in our minds but not in everyone's. Careful explanation and support in language that can be understood is very important.
Life disruption is also not to be under estimated as a source of concern. Ninewells covers from Dunblane to Laurancekirk, a huge geographical area. It can put a strain on family life with daily disruption, financially travelling daily 70 mile round trip plus car parking can be very expensive.. We need to be aware of these issues when holistically caring for the patients undergoing radiotherapy or when providing information for these patients.

4. Symptom management Skin and wound care 80 - 90% patients = erythema
10-15% patients = moist desquamation
(Wells et al)
Different for each individual
Influenced by other factors
Here we will discuss some of the symptoms that patients may experience while undergoing radiotherapy. However, as we discussed earlier, they will only experience particular side effects such as nausea or diarrhea if that area is being treated.
Let it to say that the breakdown of skin will occur within the treatment site. Modern radiotherapy machines are now able to spare the skin from the maximum dose of radiotherapy therefore reducing the severity of the skin reaction. However some times we need to treat close to the skin surface (H&N) or on the skin surface (skin tumours/wounds) and these will have much worse skin reactions due to the higher dose received.
‘radiation burns’ have a bad connotations for patients, it is a more negative comment than positive and for a lot of patients makes them think of accidents or mistakes. As professionals we should be using the proper terms when describing skin reactions, erythema or moist desquamation and talking to patients of their skin reaction rather than their burns!
These skin reactions will differ with each individual and preparations that contain alcohol (perfumed soap) and metals (some talc and cream) will exacerbate the effect. Caring for the skin, keeping it moisturized can help to reduce the skin reaction.

8. Symptom Management Oral Care Breathing Changes Swallowing Changes
Bowel care
Oral care is very important if a patient is receiving head and neck irradiation. As the cells of the oral cavity have a high turnover rate they are very sensitive to radiation. Mucositis, thrush infections, taste alterations and pain can all be very distressing side effects. Good oral hygiene, pain control and prompt attention to any deterioration or infection present can provide excellent symptom control for the patient
Breathing changes, ? When would you get this
Moist chest due to radiation irritation, cough increase, breathlessness increase, can be significant. Nebulizers, limits on activities, Oxygen therapy – only if o2 stats low, do not wish to start o2 dependance
Swallowing changes, ?what and when
Any treatment that includes the oesophagus or larynx. Pain on swallowing, difficulty swallowing solids, easily irritated by acid reflux
Sucralfate suspension to coat raw area, analgesic to reduce pain, bland soft food to reduce trauma
Diarrhea is a very debilitating and distressing side effect to pelvic irradiation. Radiation causes cell depletion, flattening of the villi and hypermobility in the small intestine. This causes decreased absorption of nutrients, lactose intolerance and increased transit time. If the colon is also involved then superficial erosions, ulceration and inflammation also occurs causing decreased absorption of water. So as you can see, not only do we get additional water but also increased movement. The preventative measures are that of Lower fibre to cease irritation, lower fat to prolong transit time.
Fybogel
With these side effect it is easy to see why nutritional support and dietary advice is so important, both in helping to lessen the side effects and to prevent weight loss

9. Symptom Management Continued
Nutritional support and dietary advice
Psychosexual care
Fatigue management
Prevention and self care strategies
Weight loss, preventable in most cases, early identification of dietary issues and intervention. Societies view of nutrition can cause family difficulties and conflict.
Sexuality is often overlooked by health professionals. It is especially important in an outpatient setting where patients have little point of contact and are embarrassed to ask. Pelvic irradiation can produce reduce lubrication produced, narrow passages, such as vaginal area and cause less flexibility within the tissues. All these can have an effect on sexual function, sometimes as a permanent effect. For men, pelvic irradiation can induce impotence or difficulties with erection.
Professionally would you give someone a drug or treatment that will make them sick and not tell them? Why is it different for these side effects?
Alongside this can be the worry of passing on the cancer. Sensitive enquiry can help initiate the conversation allowing any concerns to be raised.
Fatigue is a major issue in cancer patients. It is the overwhelming sense of exhaustion and decreased capacity for physical and mental work regardless of sleep or rest. This can multifaceted problem with psychological, spiritual and physical elements. Acknowledgement of this helps patients to feel less alone and ‘different’, supportive measures can help with household duties. Fatigue will last after treatment, at times for months. Current recommendations by studies (Dr windsor) is to combine rest with activity. Discuss.
By informing the patient adequately and addressing the different aspects of their care through radiotherapy the health professional can help hand some of the control back to the patient. Diet that they can monitor, fatigue management suggestions and acknowledgement that they are not alone in this feeling can help a patient share their own care. Reducing loss of control and feelings that their life is not their own.
It is always important to be aware that the side effects will continue after radiotherapy treatment finishes. Cell destruction can continue for up to days post treatment end. This has importance in management of continuing or late effects.

10. Supportive care issues in radiotherapy
Information
Assessment of toxicity's
Symptom management
Emotional support
Rehabilitation
Therefore to recap. The supportive issues in patient care receiving radiotherapy are;
Providing information, about treatment, truths and myths, about side effects to prepare patients for possible concerns. To provide information on how they can help themselves.
Assessment of toxicity's, in order to combat any distressing side effects prior to there severity upsetting the patient. To be proactive in the maintenance of side effects rather than reactive. Better for the patient.
Emotional support as they go through different stages of cancer and its treatment.
Looking to the future, being aware of the continuation of side effects and to continue their management even after the end of treatment. Liaison with primary care and patient knowledge are very important.

11. What happens after treatment?
Radiation reactions peak at end of treatment when daily contact is lost
Post treatment follow up only provides a snapshot view
Day to day experience largely unknown
94% patients were still experiencing at least one symptom days after completion of therapy (Rose et al 1996)
After treatment is finished our work should not stop. It is known that radiation effects continue as discussed and, but can also just be at their peak on discharge from daily contact.
Where do we go from her though? The patients experience is unknown at present as stated. We know that symptoms continue but how is it best to support the patient.

12. Rehabilitation End of treatment assessment
Self medication / self care strategies
Telephone follow up
Drop in clinics
Liaison and education
Some of these strategies may be of use. Currently through the nurse led review clinic patients are given an end of treatment assessment and if they are experiencing any effects or difficulties then the primary care team are contacted. This is not always satisfactory for all concerned.
All aspects of health care are stretched and the additional workload for community cane sometimes be difficult to manage.
Communication from the hospital is slow and at times has limited information.
Some ways of combating this are those of
telephone contact, maintaining the continuity of care after treatment.
Drop-in clinics can provide access for patients with concerns, yet this would be difficult for all the surrounding areas to be involved due to travelling.
Liaison and education with our colleagues in the primary care team, allowing the transfer of information easily.