General side effects of radiotherapy

While external radiotherapy can destroy cancer cells, it can also have an effect on some of the surrounding normal cells. The side effects that may occur are described in this section. It is important to remember that no person will have more than a few of them, and for many people they may be very mild.

As radiotherapy affects people in different ways, it is difficult to predict exactly how you will react to your treatment. Before you start your treatment, the staff will discuss with you any likely side effects of the particular treatment you are having. They can also give tips on how to deal with them and how they can be treated. Being aware of side effects in advance can help you to cope with any problems that occur.

Most side effects of radiotherapy disappear gradually once the course of treatment is over. However, the side effects may continue for a few weeks.

Tiredness

You may find that you feel very tired during your radiotherapy. This can often be made worse by having to travel to your treatment each day. Listen to your body, and if necessary, allow yourself extra time to rest, perhaps by taking a nap in the afternoons. It may help if you spread chores out over the week, sit down to do them, wherever possible, and accept any offers of help. Tiredness can be a problem for some months after your treatment has finished. See information on coping with fatigue.

Eating and drinking

As always during treatment of any kind, it is important to maintain a healthy diet and drink plenty of fluids. At times you probably won't feel like eating, or you may find that your eating habits change. It may be easier to have small snacks throughout the day rather than large meals. It is not unusual to lose a little weight during radiotherapy, but if you are having any problems with eating it is important to tell the radiotherapy staff. They can arrange for you to talk to the dietitian at the hospital. The section on diet and cancer also gives useful advice on eating.

Changes in your blood

Radiotherapy to some parts of the body can sometimes affect the bone marrow, which produces the different types of blood cells. If this is thought likely to happen in your case, you will have regular blood tests during your treatment to check your blood counts (the number of cells in your blood). If your blood counts are low, you may feel tired and 'run down'. If your blood count becomes very low (which is unlikely), it may be necessary to have a short rest from treatment so that your blood cell level can return to normal. You may also need to have a blood transfusion.

It is very important to let your doctors know if you feel very unwell, or if your temperature goes above 38oC (100.4oF), or if you start feeling cold and shaky.

Skin care

Some people develop a skin reaction, similar to sunburn, while having external radiotherapy. This normally happens after 3–4 weeks. People with pale skin may find that the skin in the treatment area becomes red and sore or itchy. People with darker skin may find that their skin becomes darker and can have a blue or black tinge. The amount of the reaction depends on the area being treated and the individual person's skin. Some people have no skin problems at all. Your radiographers will be looking for these reactions, but you should also let them know as soon as you notice any soreness or change in skin colour.

Do not use any creams or dressings unless they have been prescribed or recommended by specialist.

Occasionally, if your skin gets very sore, your treatment may have to be delayed for a short time to allow the area to recover.

Staff at your radiotherapy department will be able to give you advice on how to look after the skin in the treatment area. The care of the skin varies according to the part of the body that is being treated and the dose of radiotherapy that the skin is receiving.

You may be asked not to wash the treatment area at all while you are having treatment. Or, you may be advised to use only tepid water to wash the area (and not to soak too long in the bath). You can dry the skin by patting gently with a soft towel or using a hairdryer on the coolest setting. Do not rub the area as this may make it sore.

Soaps, talcs, deodorants and perfumes may also make your skin sore and should not be used. The staff at the hospital may suggest that you gently apply simple moisturisers, such as E45 cream or aqueous cream, to the area. After your treatment, simple soap and simple moisturisers are often recommended. Aloe vera cream or arnica cream can sometimes help the skin to heal. Always check with the radiotherapy staff before applying anything to your skin.

It is very important that any marks put on your skin to mark the treatment area are not removed. If the marks do fade or disappear, do not try to replace them yourself but let the radiotherapy staff know.

Men who are having radiotherapy to the head and neck should use an electric razor, rather than wet-shaving.

These restrictions apply only to the treatment area, and the rest of your skin can be treated normally. Your skin may peel after the redness has faded, but it should heal quickly. Changes in the skin usually settle down two to four weeks after the treatment has finished, but the area may stay slightly darker than the surrounding skin.

Avoiding the sun

Because the treated area is so sensitive it should not be exposed to the sun or cold winds. If you are having radiotherapy to the head or neck, try wearing a silk or cotton scarf when you go outside.

It is very important to cover the treated area if you go out in strong sunshine for at least the first year after your radiotherapy. Wear clothing made of cotton or natural fibres, which have a closer weave and offer more protection against the sun. Even after this time the skin will be more delicate, so extra care should be taken. Use a sun-screen (of at least factor 15) and wear a hat and a long-sleeved shirt. It is important to remember that you can burn even through clothing if you are out in hot sun for a long time.

You can swim as soon as any skin reaction has settled down, usually within a month of finishing treatment. However, if you are swimming out of doors, do not stay in the water too long, and remember to use a waterproof sunblock.

Clothing

Loose-fitting clothes, preferably in natural fibres rather than man-made materials, are more comfortable and less irritating to the skin. If you are having radiotherapy to your neck, avoid tight collars and ties.

Shoulder straps and bra straps can also cause irritation if they are rubbing against treated skin. If your breast area is being treated, you may be more comfortable not wearing a bra or wearing a cropped top or vest.

Smoking

Stopping smoking during and after radiotherapy is very worthwhile. Research has shown that it may make the radiotherapy more effective as well as reducing the side effects. It will also improve your general health and reduce your risk of developing other cancers.

Stopping smoking or even cutting down at such a stressful time can be very difficult, but do your best. If you want help or advice you can talk to your specialist, GP or a specialist nurse, who will be able to suggest ways of stopping. Organisations such as QUIT also offer advice and valuable support.

Complementary therapies

Complementary therapies can help to improve your quality of life and wellbeing and can sometimes help to reduce the side effects of radiotherapy. Many people find that complementary therapies or practices can help them to feel stronger and more confident in dealing with radiotherapy. These therapies can be used alongside conventional treatments and medicines.

Some complementary therapies, such as meditation or visualisation can be done by the person with cancer themselves and can reduce anxiety. Other therapies such as gentle massage can be carried out by relatives or carers and can help them to support the person with cancer.

Physical contact and touch can be among the most powerful forms of support for people who are faced with uncertainty, fear or pain, whether emotional or physical. Touching someone gently can express how much you care about them.

Some hospitals offer complementary therapies alongside conventional care.

These may include:

• aromatherapy
• colour and sound therapy
• massage
• relaxation, visualisation or guided imagery techniques
• acupuncture.
  

Relaxation

Deep relaxation is a skill which can be learned. It can be used to:

• release muscle tension
• relieve stress
• reduce tiredness and pain
• improve sleep and peace of mind
• regain control of emotions.

Relaxation is not simply 'taking it easy', but involves making time to reflect on problems or anxieties and, hopefully, develop a positive mental outlook.

There are several different relaxation techniques which can be self-taught from books or tapes. You can get these from your local library, bookshop and some chemists. Therapists and groups throughout the country also teach particular relaxation methods.

• Side effects of radiotherapy to specific areas of the body
• How radiotherapy might affect your sex life
• How radiotherapy might affect your fertility
• Your emotions and radiotherapy

Radiotherapy Treatment - Where do you have your?

Radiotherapy equipment is very complex and needs a lot of space, as well as support from specially trained staff, so radiotherapy departments tend to be in the larger regional and teaching hospitals. Often you will have your initial cancer treatment (such as surgery) at your local hospital and will then be referred to your nearest specialist cancer treatment hospital for your radiotherapy treatment.

Radiotherapy departments have varying types of equipment and are organised according to local needs, so they are run in different ways. While most of the information in this section is fairly general, and will apply to most departments, you may find that there are some differences at the hospital where you are treated.

You can usually have external radiotherapy as an out-patient, but if you are unwell, or having chemotherapy at the same time, you may need to stay in hospital and will be taken to the radiotherapy department each day from the ward.

If you are having internal radiotherapy, you may have to stay in hospital for a few days.

Staff in the radiotherapy department

Clinical oncologist

Although you will continue to be in the care of your GP during and after your radiotherapy, while you are having the treatment itself you will be under the care of a clinical oncologist. A clinical oncologist is a doctor trained in the use of radiotherapy and chemotherapy. The clinical oncologist will be responsible for prescribing and supervising your course of treatment.

You may see your oncologist before, during, and after your course of radiotherapy treatment, so that the effect of the treatment can be monitored. If you have any problems before or after your treatment, the nurses or radiographers can arrange an extra appointment for you.

If you are having chemotherapy as well as radiotherapy, this treatment may be supervised by your clinical oncologist or may be organised by a different doctor, called a medical oncologist. Medical oncologists specialise in chemotherapy treatment.

Medical oncologists and clinical oncologists work as part of a team. The team includes all the other health care staff who look after people having treatment for cancer. This multidisciplinary team will have regular meetings to co-ordinate and plan the care and treatment of their patients.

Radiographers

Radiographers are specially trained in using x-ray equipment. There are two main types of radiographer: therapy radiographers and diagnostic radiographers.

• Therapy radiographers (also sometimes called radiotherapists) are the people who operate the machines that give you your radiotherapy treatment. They are highly trained in giving radiotherapy and in patient care.

• Diagnostic radiographers use x-rays (including CT scans, mammograms and MRI scans) to diagnose illness – you may have x-rays or scans from time to time during and after your treatment to check the effect of your radiotherapy treatment.

Therapy radiographers work closely with your specialist and physicist to plan your treatment. Where possible, you will see the same radiographers throughout your course of treatment so you get to know each other quite well. They can give you help and advice about any aspect of your treatment, and you can discuss any of your concerns or anxieties with them. You can ask to be treated by a radiographer of the same sex as yourself, if you prefer.

Some radiographers, known as information radiographers, specialise in giving information to patients and their relatives.

Physicist

Working with the clinical oncologist is a physicist – a radiation expert – who will help to plan your treatment, assisting your specialist in decisions about the best way of giving the prescribed amount of radiation. The physicist is also responsible for maintaining the accuracy of the equipment used. Although you may meet the physicist at your initial planning appointment, they usually work behind the scenes.

Mould room technician

If you need to have a mould made of part of your body to keep it still during treatment, this will usually be done by technical staff in the mould room.

Nursing staff

Like hospital wards, the radiotherapy clinic has nursing staff – usually a sister or charge nurse and a team of nurses. They ensure that the clinic is running smoothly and look after any general needs you have, such as dressings and medicines. The nurses in the radiotherapy department can also give information and advice about the treatment and they give practical support.

Other members of the cancer support team

Social worker

Social workers can give advice about any non-medical problems that you may have. This includes practical and financial help: for example, some patients can claim travelling expenses and others may be eligible for a grant from a charity. Social workers can also give or organise counseling and emotional support for you and your family. If necessary they will refer you to local support services that can help you at home. You can ask to see a social worker if you think that this would be helpful.

Symptom control team (palliative care team)

Many hospitals have a symptom control team to give additional help and support for people whose symptoms or treatment are causing problems. There may be other staff, such as dietitians or physiotherapists, who can help with any specific questions you may have.

Counsellors

Counsellors are available in some hospitals. If you feel that speaking to a counsellor would be helpful, ask the staff looking after you to arrange an appointment. You can also contact the Cancer Counselling Trust.

Secretaries and clerical staff

The secretaries and clerical staff in the radiotherapy department help to keep the appointment system running smoothly.

Specialised external radiotherapy techniques

Some newer ways of giving radiotherapy are being assessed to see whether they give better results than standard radiotherapy. Research studies are being carried out to see whether the new techniques can control the cancer better while causing fewer side effects. Some of the techniques are described below.

Conformal radiotherapy

Many specialist hospitals now use a specialised technique known as conformal radiotherapy. Conformal radiotherapy uses the same radiotherapy machine as normal radiotherapy treatment. However, metal blocks are put in the path of the x-ray beam to shape it to match the cancer. This ensures that a higher radiation dose is given to the tumour. Healthy surrounding cells and nearby structures receive a lower dose of radiation, so the possibility of side effects is reduced.

More recently a device called a multi-leaf collimator has been developed and can be used instead of the metal blocks. The multi-leaf collimator consists of a number of metal sheets which are fixed to the radiotherapy machine. Each sheet can be adjusted so that the radiotherapy beams can be shaped to the treatment area without using metal blocks.

Precise positioning of the radiotherapy machine is very important for conformal radiotherapy treatment and a special scanning machine may be used to check the position of your internal organs at the beginning of each treatment.

Intensity-modulated radiotherapy (IMRT)

High-resolution intensity-modulated radiotherapy also uses a multi-leaf collimator. During this treatment the layers of the multi-leaf collimator are moved while the treatment is being given. This method is able to shape the treatment beams even more precisely and allows the dose of radiotherapy to be altered over the whole treatment area.

Research studies have shown that conformal radiotherapy and intensity-modulated radiotherapy may reduce the side effects of radiotherapy treatment. However, it is possible that by shaping the treatment area so precisely, microscopic cancer cells just outside the treatment area may not be destroyed. This means that the risk of the cancer coming back in the future could be higher with these specialised radiotherapy techniques. Research studies currently being carried out should show whether this is the case.

Stereotactic radiotherapy

Stereotactic radiotherapy is used to treat brain tumours.

This technique directs the radiotherapy from many different angles so that the dose going to the tumour is very high and the dose affecting surrounding healthy tissue is very low. Before treatment, several scans are analysed by computers to ensure that the radiotherapy is precisely targeted, and the patient's head is held still in a specially made frame while having the radiotherapy. Several doses are given.

This treatment is available only in some specialist hospitals and is not suitable for all patients with brain tumours. You can discuss with your clinical oncologist whether it may be appropriate in your case.

Stereotactic radio-surgery (gamma knife)

In fact, this type of radiotherapy, again for brain tumours, does not use a knife but very precisely targeted beams of gamma radiotherapy from hundreds of different angles. Only one session of radiotherapy, taking about four to five hours, is needed.

For this treatment you will have a specially made metal frame attached to your head. Then several scans and x-rays are carried out to find the precise area where the treatment is needed. During the radiotherapy, you lie with your head in a large helmet, which has hundreds of holes in it to allow the radiotherapy beams through.

This treatment is available only in specialist hospitals and is not suitable for all patients with brain tumours. You can discuss with your clinical oncologist whether it may be appropriate for you.

External beam radiotherapy

About your treatment

External radiotherapy is normally given as a series of short, daily treatments in the radiotherapy department, using equipment similar to a large x-ray machine.

The treatments are usually given from Monday to Friday, leaving patients to rest at the weekend. Each treatment is called a fraction. Giving the treatment in fractions ensures that less damage is done to normal cells than to cancer cells. The damage to normal cells is mainly temporary, but is the reason why radiotherapy has some side effects.

The number of treatments you have depends on several factors, including:

• your general health
• the type of cancer being treated and where it is in the body
• whether or not you have had, or are going to have, surgery, chemotherapy or hormonal therapy as part of your treatment.

For these reasons, treatment is individually planned for each patient, and even people with the same type of cancer may have different types of radiotherapy treatment.

External radiotherapy does not make you radioactive, and it is perfectly safe for you to be with other people, including children, throughout your treatment.

A course of curative (radical) treatment may be given every weekday for two to seven weeks. Instead of having one treatment a day or having a rest at the weekend, some people will have different treatment plans. They may have more than one treatment a day, or treatment every day for two weeks. Giving radiotherapy in this way is known as continuous hyperfractionated radiotherapy (often called CHART).

Sometimes treatment may be given on only three days each week (for example, on Mondays, Wednesdays and Fridays).

Palliative treatment (for symptom control) may involve only one or two sessions of treatment, or up to five sessions.

The different types of radiotherapy machine work in slightly different ways. Some are better for treating cancers near the surface of the skin, while others work best on cancers deeper in the body.

The type of radiotherapy machine used will be carefully chosen by your specialist and physicist to give you the most appropriate treatment. Some machines are quicker than others and may give treatment in a very short time, such as a few seconds. Usually, radiotherapy treatment (including the time taken to position you) takes 10-15 minutes or less, on any type of machine.

The radiotherapy machine does not normally touch you and the treatment itself is painless, although it may gradually cause some uncomfortable side effects. If you have a specific type of radiotherapy known as electron treatment, a small applicator may be used, which touches a small area of skin.

Radiotherapy affects people in different ways; some find that they can carry on working, taking time off for their treatment, while other people find it too tiring and prefer to stay at home. If you have a family to look after, you may find that you need extra help.

Don't be afraid to ask for help, whether it's from your employer, family or friends, social services, or the staff in the radiotherapy department. As your treatment progresses, you will have a better idea of how it makes you feel, so you can make any necessary changes to your daily life.

The radiotherapy staff will try to give you an appointment for the same time each day. This gives your body a chance to recover from any side effects between treatments and also allows you to get into a daily routine.

Getting to your appointment

If you have to do a lot of travelling each day to get to your appointment you may feel very tired, particularly if you are feeling some side effects from your treatment.

If the treatment makes you feel tired, you could ask a family member or friend to drive you to the hospital, or ask for hospital transport if friends or family cannot easily drive you there.

If you rely on your own or public transport you can usually arrange an appointment which suits both you and the radiographers. Some hospitals provide transport, and if necessary, this can be arranged for you by the radiotherapy staff.

Some local support groups and charities also provide hospital transport. If transport is very difficult, or you live a long way from the hospital, you may need to be admitted to the ward, or a hostel ward in the hospital or nearby. Sometimes it is possible for the hospital to organise local accommodation while you are having radiotherapy.

If you have difficulty meeting the cost of travelling to the radiotherapy clinic each day, you may be able to get a grant towards your travel expenses. People on a low income may be able to claim the costs from the Department of Work and Pensions. Some charities (such as Macmillan Cancer Relief) provide travel grants, and so do some local support groups. You can ask the hospital social worker or one of the nurses in the clinic for information on grants and advice on how to claim.

Giving your consent

Before you have your radiotherapy, your doctor will explain the aims of the treatment to you. They will usually ask you to sign a form saying that you give your permission (consent) for the hospital staff to give you the treatment. No medical treatment can be given without your consent, and before you are asked to sign the form you should have been given full information about:

• the type and extent of the treatment you are advised to have
• the advantages and disadvantages of the treatment
• any possible other treatments that may be available
• any significant risks or side effects of the treatment.

If you do not understand what you have been told, let the staff know straight away so that they can explain again. Some cancer treatments are complex, so it is not unusual for people to need repeated explanations.

It is often a good idea to have a friend or relative with you when the treatment is explained, to help you remember the discussion more fully. You may also find it useful to write down a list of questions before you go to your appointment.

Patients often feel that the hospital staff are too busy to answer their questions, but it is important for you to be aware of how the treatment is likely to affect you. The staff should be willing to make time for you to ask questions.

You can always ask for more time to decide about the treatment if you feel that you can’t make a decision when it is first explained to you.

You are also free to choose not to have the treatment. The staff can explain what may happen if you do not have it. It is essential to tell a doctor, or the nurse in charge, so that they can record your decision in your medical notes. You do not have to give a reason for not wanting to have treatment, but it can be helpful to let the staff know your concerns so that they can give you the best advice.

Planning your treatment

For some conditions, like many skin cancers and for palliative radiotherapy, radiotherapy may be planned and given in a very simple way.

For most curative (radical) treatments, planning is a very important part of radiotherapy and may take a few visits. Careful planning makes sure that the radiotherapy is as effective as possible. It ensures the radiotherapy rays are aimed precisely at the cancer and cause the least possible damage to the surrounding healthy tissues. The treatment is planned by a cancer specialist (clinical oncologist) and a physicist. You may have your first treatment on the same day as your planning session, but often it is necessary to wait a few days while the physicist and specialist prepare the final details of your treatment.

On your first visit to the radiotherapy department, you will be asked to lie under a machine called a simulator, which takes x-rays, or scans, of the area to be treated. The simulator moves in exactly the same way as the treatment machines, but rather than giving treatment it takes x-rays to help the radiographer plan the correct position for your treatment. This procedure takes about 15–45 minutes and may be quite tiring.

Instead of the simulator, sometimes an MRI (magnetic resonance imaging) scan is taken of the area to be treated. This may be done in the hospital scanning department before your planning session appointment. An MRI scan uses powerful magnetic fields to give a detailed picture of part of your body. The scanning department staff will explain the scanning process to you beforehand. Again, the scan is not painful, but you need to lie still for up to 10–30 minutes, which can be uncomfortable.

It is important for you to feel that you are involved in your treatment, so feel free to ask as many questions as you like.

Possible pregancy

Women of childbearing age will be asked whether they could be pregnant, as x-rays given during pregnancy could harm a baby. If you think that you may be pregnant, let the doctors and radiographer know immediately and you will be offered a pregnancy test.

Positioning

During the treatment planning you will be lying on a fairly hard couch that can be uncomfortable. If it is, let the radiographer know: you can be made more comfortable by having foam pads put underneath you. You have to lie very still for a few minutes so that accurate measurements can be taken and your exact position recorded. The radiographer can then make sure that you are lying in the correct position each time you have treatment.

Special procedures

Some special procedures may be necessary to make sure the radiographers get a clear picture. The radiographer will explain these to you. For example, to plan treatment to the pelvic area, a liquid that shows up on x-ray may be passed into your back passage or into your bladder, or a vaginal tampon may be used to show the exact position of the vagina. These procedures may be slightly uncomfortable but are not painful and take only a few minutes. They are used only for planning the treatment, and not during the treatment sessions.

Skin markings

Once the treatment area has been finalised, ink markings are usually made on your skin to pinpoint the exact place where the radiation is to be directed. The staff will explain how to look after these markings. If the marks begin to rub off, tell your radiographer. Do not try to redraw them yourself. Since they can rub off onto clothing, some people choose to wear older clothes next to the skin during their treatment.

Sometimes two, three or more permanent, pinpoint, tattoo marks are also made on the skin. This will only be done with your permission. It is a little uncomfortable while it is being done, but is a good way of making sure that your treatment machines are set up in the right way each time. The tattoo marks are also useful once treatment has finished, as they show where the radiotherapy was given and prevent further radiotherapy being given to that area in the future.

Mould room

As radiotherapy is planned very precisely, to treat exactly the right area, it is important to keep that part of the body as still as possible during treatment. For radiotherapy to some parts of the body, a see-through perspex device called a 'mould' or 'shell' may be made, to prevent movement during treatment. This is often used for treatments to the head and neck area. Any necessary marks can be made on the mould instead of on your skin. Your mould will be made before your treatment is planned.

In the mould room a plaster cast mould is made of the body part. Some people may find this claustrophobic or a little frightening, particularly if the mould is of the face and neck, but it takes only a short time.

After you leave the department, perspex is moulded on to the cast to form a mask. This mask fits snugly to your face and neck, with holes cut for your eyes, nose and mouth. The mould is ready to wear at your first planning or treatment session. Again, this may feel claustrophobic for some people, but try to remember that you will only have it on for a few minutes at a time.

Sometimes a mould of your leg or arm is used to keep the area still during your treatment.

A radiotherapy mask

Having your treatment

Before your first treatment, your radiographers will explain to you what you will see and hear. It is quite normal to feel anxious about having your treatment, but as you get to know the staff and understand what is going on it should become easier.

The sight of large radiotherapy machines can be frightening, especially for children. Don't be afraid to talk about any fears or worries to the staff; they are there to help you, and the more you understand about your treatment the more relaxed you will be.

Radiotherapy itself is painless and each session may take anything from a few seconds to several minutes. Because your positioning is so important, the radiographers may take a little while to get you ready (they may call this setting up). The room may be in semi-darkness while this is happening.

Try to relax as much as possible.

Once you are in the correct position the staff will need to leave you alone in the room, to prevent them from being exposed to any unnecessary radiation. Don't worry if the staff seem to rush out of the room once they have positioned you, this is just to keep your treatment time as short as possible. Radiotherapy units have many patients to treat and the staff need to keep appointments on time.

Some treatment rooms have tape players so that you can listen to music while having your treatment, to help you to relax. During treatment you will be alone for a few minutes but there will be an intercom so that you can talk to the radiographers. They will be watching you carefully from the next room, either through a window or on a closed-circuit television screen. To protect your privacy, no one else will be able to see you. If you have any problems you can raise your hand to attract the radiographers attention and they will come in to help you.

Most radiotherapy machines will be able to rotate around your body to give the treatment from several different directions. At first, this and the sound of the machine, can be unsettling.

Positioning the radiotherapy machine

The radiographers may have to come into the treatment room and change your position slightly in the middle of your treatment. Also, small changes sometimes have to be made to your treatment plan. There may be a number of reasons for this and your specialist will explain these changes to you and keep you up to date with your progress.

Making a radiotherapy mask

This information is about the process of making a radiotherapy mask. Perspex and plastic masks are sometimes used when radiotherapy is given to the brain, or the head and neck area. It may be helpful to read this with our information on brain tumours or head and neck cancer, as well as our information on radiotherapy. You may also want to discuss it with a nurse or doctor involved in your treatment.

Radiotherapy masks

Radiotherapy is the use of x-rays (and other rays) to treat cancer. Radiotherapy has to be aimed very precisely to make sure that exactly the right area of the body is treated each time.

It is important that a person having radiotherapy lies still for a few minutes while the treatment is in progress. However, when radiotherapy is given to treat tumours of the head and neck area or brain tumours, it is even more important to be as still as possible. This is because even a tiny movement could influence the effectiveness of the radiotherapy.

To help with this, a radiotherapy mask (which is sometimes called a mould, a head shell or a cast) is made to be worn during the treatment. The mask is fixed to the radiotherapy treatment table and this ensures that your head and neck are held in exactly the right position for the treatment. Wearing a mask reduces the possibility of any movement whilst the radiotherapy is given. The mask is only worn during the treatment planning procedures and during the treatment itself, ie, for only a few minutes at a time each day. You will not have to wear the mask at any other time.

How the mask is made

The mask is made in the mould room of the radiotherapy department by a mould technician or radiographer. The process of making the mask can vary slightly between hospitals and usually takes around 30 minutes. One technique uses wet plaster bandages and the finished mask is made of perspex. The other technique uses a type of mesh plastic, which is moulded to fit the shape of your face.

Perspex mask

If you are having a perspex mask you may be given a swimming cap or some other covering to wear, to protect your hair from the mould mixture.

Firstly, the mould technician will apply a cool cream or gel onto your face. Then, they will put strips of plaster of paris bandage on top of this. You will still be able to breathe, as holes are left around your nose and mouth.

Plaster of paris is applied to the face to make a mould

Plaster of paris gets warm while it is setting. This is normal and may make the process uncomfortable. Do not worry: it will not burn you. Once the plaster of paris has set (which will take about 5 minutes) the mould is taken off. A perspex mask is then made from this mould.

Mesh plastic mask

This technique uses a special kind of plastic. The plastic is heated in warm water so that it becomes soft and pliable. It is put onto your face so that the plastic gently moulds to fit your face exactly. It feels a little like having a warm flannel put onto your face. You can still breathe easily, as the plastic will not cover your nose or mouth.

Once the mesh has moulded and become hard (which takes a few minutes) the mask is taken off. It is then ready to be used when you have your treatment.

A warm plastic mesh is put onto your face so that the plastic gently moulds to fit your face

Treatment planning

Once the mask is ready, you might need to visit the mould room again so that adjustments can be made to position the mask correctly on the radiotherapy treatment table. You may also have your treatment planned during this visit. Treatment planning ensures that the radiotherapy is aimed very precisely at the cancer. You may be positioned on a machine called a simulator (which helps the radiographer to work out the exact position you need to be in). Sometimes scans or x-rays are necessary to help with planning. The doctor or radiographer may make a few ink marks on the mask; this makes it easier to position you correctly each time you come in for treatment. Radiotherapy planning can take more than one visit.

When you have the radiotherapy you will be lying down on a table below the radiotherapy machine. The mask is placed on your face and fixed to the table so that your head doesn’t move while the radiotherapy is being given. Treatment usually takes only a few minutes and is not painful. The staff will be close by to answer any questions that you may have.

People often worry about how it will feel to wear a mask during treatment, but they usually find that it’s not too uncomfortable. Most people get used to wearing the mask and after a while, they don’t notice it.

Internal radiotherapy

What is internal radiotherapy?

Internal radiotherapy is used mainly to treat cancers in the head and neck area, the cervix, the womb, the prostate gland or the skin.

Treatment is given in one of two ways:

• by putting solid radioactive material (the source) close to or inside the tumour for a limited period of time
• by using a radioactive liquid, which is given either as a drink or as an injection into a vein.

If you have internal radiotherapy, you may have to stay in hospital for a few days and special precautions will be taken while the radioactive material is in place in your body. Once the treatment is over there is no risk of exposing your family or friends to radiation.

The process of putting solid radioactive material close to or inside the tumour is called brachytherapy.

Giving a radioactive liquid, either as a drink, a capsule, or as an injection into a vein is called radioisotope treatment. Your specialist will discuss your particular treatment with you.

Before having your treatment you will be asked to sign a form to say that you give your permission (consent).

Safety measures for internal radiotherapy

To prevent unnecessary radiation exposure to the hospital staff and your friends and relatives, certain safety measures will be taken while you are being treated with the radioactive source, or a liquid radioisotope. Depending on the type of treatment you are having, the restrictions may be needed for a few days – but sometimes it is only for a few minutes.

The staff looking after you will explain the restrictions to you in more detail before you start your treatment. Each hospital has different routines, and it is worth visiting the treatment area beforehand to discuss with the nursing and medical staff what will happen.

You may be admitted to the ward the day before your treatment so that the staff can go over the procedure with you. This is a good time to ask questions and it may help to make a list beforehand so you don't forget something important.

While the radioactive source is in place, or after treatment with a liquid radioisotope:

• You will be nursed in a side room, away from the main ward.
• You may be nursed alone or with someone else having similar treatment.
• Lead screens may be put on either side of your bed to block any radiation given out and protect other people.
• The doctors and staff on the ward will stay in your room only for short periods at a time.
• Children and pregnant women will not be allowed to visit.
• An intsrument called a geiger counter may be used to monitor the level of radiation in the room. The nurses may wear a small radiation counter.
• Visitors will be restricted, and allowed to stay in the room or sit at the end of the bed only for a short time, if at all. They may be able to talk to you from outside the room through an intercom.
• Staff and visitors will be asked to keep away from you, to reduce their exposure to the radiation.

The safety measures and visiting restrictions might make you feel very isolated, frightened and depressed at a time when you might want people around you. If you have these feelings it is important that you let the staff looking after you know. It might also be helpful to take in plenty of reading material and other items to keep you occupied while you are in the single room.

Brachytherapy

If you are having brachytherapy, you only need to stay in isolation while the radioactive source is in place. Once it is removed the radioactivity disappears and it is perfectly safe to be with other people.

Radioisotope

If you are having treatment with a radioisotope (liquid), the radioactivity will disappear gradually and you will need to stay in isolation only until the radiation in your body has broken down. Before you leave hospital, the staff will check that most of the radioactivity in your body has gone, and that your belongings are free from any signs of radioactivity. After you leave hospital you should be able to carry on your life almost as normal, but there may be a few restrictions about contact with people – especially children and pregnant women – for a few more days.

Your feelings

People are different in the way they handle their fears; some want to know everything about their treatment, while others prefer to know as little as possible. If you need any explanations the staff on the ward will be happy to help you. It often helps to bring any fears or worries you have into the open by talking to the staff or to family and friends. You will probably be in the single room only for a short time, perhaps only one or two days, during which you can read your books and magazines, watch TV or listen to the radio.

Brachytherapy

Intracavitary radiotherapy

This type of internal radiotherapy treatment is used for treating cancer of the cervix, womb (uterus) or vagina. A piece of radioactive metal, known as a source, is put close to the area of the cancer. The metal most commonly used is caesium-137. The advantage of treatment with caesium is that it gives a high dose of radiotherapy directly to the tumour, but a low dose to normal tissues.

The caesium is put inside a hollow, plastic tube known as an applicator. Sometimes more than one tube is used. This keeps the caesium in place. The applicator is inserted into the vagina while you are under a general anaesthetic or sedation in the operating room. At the same time, a flexible tube called a urinary catheter may be put into your bladder to drain off urine. This means you will not have to get on and off bedpans, which could dislodge the applicators.

Once the applicator is in place, an x-ray will be taken to check it is in the correct position. Sometimes the radioactive source is put into the applicator while you are in the operating room, but more commonly it will be put in place once you are back on the ward. The applicator is kept in place by a pack (cotton/gauze padding) inside your vagina. This can be uncomfortable and you may need to ask your nurses for regular painkillers.

Once the source is put into the applicators you have to stay in bed, so that the applicator does not move out of position. If you need anything, you can call a member of staff by using the bell by your bed. If the source does move out of position, you need to call the staff on the ward immediately.

Selectron machine

In many hospitals a machine called a Selectron, or similar name, is used to put the radioactive material into the applicators. The machine is attached by tubes to the applicators. When the machine is switched on it passes small radioactive balls into the applicators. If the machine is switched off, the radioactive balls are pulled back inside the machine. The machine is kept switched on throughout treatment, except when someone needs to go into your room. It can then be turned off, to reduce their exposure to the rays. However, safety measures and visiting restrictions are still necessary. The time you spend on the machine varies but it is usually between 12–48 hours.

Microselectron

Sometimes a machine called a Microselectron is used for internal radiotherapy. It gives the radiotherapy more quickly, so the treatments last for only a few minutes and you can go home the same day.

After the treatment

Once the complete radiation dose has been given, the source and the applicators will be removed. This is usually done on the ward. As it can be a little uncomfortable, you will be offered some painkillers beforehand. Sometimes a few breaths of the gas Entonox will help you to relax. Staff on the ward will check that all the applicators and sources have been removed. Your catheter may be removed at the same time.

Your specialist may suggest that you use vaginal douches for a few days after the applicator has been removed to keep the vagina clean. Your nurse will tell you how to use these.

You will probably be able to go home the same day, or the following day. Once the radioactive sources are removed, all traces of radioactivity immediately disappear.

Many women are given both internal and external radiotherapy to ensure the cancer is treated in the most effective way.

Side effects

It is not unusual to have slight bleeding or discharge once the radiotherapy treatment has ended. If it continues or becomes heavy it is important to let your doctor or nurse know.

Radiotherapy to the pelvic area can cause side effects such as tiredness, diarrhoea and a burning sensation when passing urine. These side effects can be mild or more troublesome depending on the strength of the radiotherapy dose and the length of your treatment. Your oncologist will be able to advise you what to expect.

Most of these side effects can be treated with medicines, which your oncologist will provide. Any side effects should gradually disappear once your treatment is over.

It is important that you drink plenty of fluids and maintain a healthy diet during your treatment. If your diarrhoea is not controlled with medicines you can ask to see a dietitian, who can advise you on what to eat to reduce diarrhoea. You may feel sick but this is not common. If you don't feel like eating, you can replace meals with nutritious high-calorie drinks, which are available from most chemists and can be prescribed by your GP. The section on diet and cancer has some helpful tips on eating well when you are feeling ill.

Radiotherapy for cancer of the cervix affects the ovaries, unfortunately, and this brings on the menopause, usually about three months after the treatment starts. This means that your periods will stop and you will have menopausal side effects such as hot flushes, a dry skin and possibly loss of concentration. Some women become less interested in sex and notice that their vagina is dry. Sometimes radiotherapy causes a narrowing of the vagina, which can make sexual intercourse uncomfortable. See our sections on sexuality and fertility.

You can be protected from menopausal side effects by taking HRT (hormone replacement therapy) as tablets or skin patches. These can be started by your gynaecologist during the radiotherapy treatment or shortly after it has ended. They will help choose the correct replacement hormones and dosage.

It is important to get as much rest as you can, especially if you have to travel a long way for treatment each day.

Possible long term side effects

Radiotherapy to the pelvic area can sometimes cause long-term side effects. However, improvements in treatment planning have made these much less likely.

In a small number of people, the bowel or bladder may be permanently affected by the radiotherapy. If this happens the increased bowel motions and diarrhoea may continue, or the person may need to pass urine more often than before. The blood vessels in the bowel and bladder can become more fragile after radiotherapy treatment and this can make blood appear in the urine or bowel movements. This can take many months or even years to occur.

If you notice any bleeding it is important to let your doctor know so that tests can be done and appropriate treatment given.

Our section on pelvic radiotherapy in women has tips on coping with these side effects.

Some people also find that radiotherapy affects the lymph glands in the pelvic area and can cause swelling of the legs. This is known as lymphoedema. It is more likely if you have had surgery as well as radiotherapy.

After caesium brachytherapy there is a slight risk of infection, but this is very rare. If you develop a high temperature or heavy bleeding after your treatment, contact your specialist as soon as possible. You will be prescribed antibiotics to treat the infection.

Caesium or irridium wires

These can be used to treat a number of types of tumours including those in the mouth, lip, cervix and breast. Very thin radioactive needles, wires or tubes are inserted while you are under general anaesthetic in the operating room.

An x-ray may be taken to ensure that the needles are in the correct position. You will be nursed in a separate room, and safety measures will be used until the wires are removed – usually after three to eight days. Sometimes this is done under general anaesthetic.

Wires in the mouth can be uncomfortable, and can make eating and talking difficult. You will need to have a soft or liquid diet while they are in place. Your nurse will show you how to keep your mouth clean, using regular mouthwashes. If eating is a problem you may be fed through a thin tube (a nasogastric tube), passed up your nose and down into your stomach.

The wires are removed once the correct dose of radiation has been given. This may be after two days if the treatment is given as a booster after external treatment, or up to one week if it is the only type of radiotherapy treatment being given.

Once the wires have been removed, the area will feel sore for up to two or three weeks afterwards. Your specialist will prescribe painkillers that you can take regularly until this improves.

Brachytherapy for prostate cancer

Brachytherapy (radioactive seed implants) is sometimes used to treat small tumours of the prostate gland. Brachytherapy is available in some hospitals in the UK. It is carried out under a general anaesthetic, or sometimes a spinal anaesthetic. Small radioactive metal seeds are inserted into the tumour within the prostate gland, and they release small doses of radiation very slowly over a period of time. The seeds are not removed, but stay in the prostate tissue. The radioactivity gradually fades away over approximately a year. The radiation affects only the area a few millimetres around the seeds, so there is no danger of it affecting other people. See the section on prostate cancer that explains this treatment in more detail.

Radioisotopes

These are given as liquids, in capsules that are swallowed or as a drink; or by injection into a vein (as an intravenous injection). The most common type of radioisotope treatment is radioactive iodine. Used to treat tumours of the thyroid gland, it is given as an odourless and colourless drink. The same safety precautions are taken with this type of treatment as for brachytherapy.

Any radioactive iodine that is not absorbed by the thyroid will be passed from the body in sweat and urine. You need to drink plenty of fluids during your treatment as this helps to flush the iodine out of the body. The amount of radiation in your body will be checked regularly and as soon as it falls to a safe level, after about four to seven days, you will be able to go home. You may need to take some special precautions for a short time after going home – and may need to avoid young children and pregnant women for a short time. The hospital staff will explain this to you.

Radioactive iodine does not usually cause side effects, but you may feel very tired for a few weeks after having this treatment.

Radioisotope treatment can also be given if certain types of cancer have spread to the bones (secondary bone cancer). A radioisotope is injected into a vein, and can be given as an out-patient. Before you go home you will be given some simple advice to follow, as your urine and blood will be slightly radioactive for a few days. This type of radiotherapy treatment does not usually cause any side effects, apart from tiredness for a few weeks.

You can read more about radioisotope treatment in the sections on thyroid cancer and secondary bone cancer.

After your radiotherapy treatment has finished

After your radiotherapy treatment has finished you will have regular follow-up appointments. These may be at the radiotherapy department or at your original hospital. The positive effects of radiotherapy may take some time to show. People sometimes expect to be given an x-ray or a scan at the end of their treatment to see if it has worked. However, in many cases the tumour may take some time to shrink, which means that x-rays and scans may not be helpful at this time.

How often you have check-ups will vary depending on your type of cancer, and from one hospital to another; but as time goes by they will become less frequent. Your specialist will keep in contact with your own family doctor so they will know about your progress. Follow-up appointments are a good opportunity to discuss any problems or worries that may have arisen. It may help to make a list beforehand so that you don't forget anything important.

For people whose treatment is over apart from regular check-ups, our section on adjusting to life after cancer gives useful advice on how to keep healthy and adjust to life after cancer.

If you have any problems, or notice any new symptoms in between these times, let your doctor know as soon as possible. You don't have to wait until your next scheduled appointment – just ask for an earlier appointment.

Many people find that they get very anxious for a while before the appointments. This is natural and it may help to get support from family, friends or one of the counselling organisations listed.

Emotional effects

Sometimes the hardest time to cope with is when treatment is finished and you, and everyone else, see this as the time to get back to normal. Recovery time varies, and no one can say for sure how long you should take to get over the side effects, the tiredness and the emotional effects. The end of the visits to hospital for treatment can leave you feeling alone and neglected. Many people find that they feel very low and emotional at this time, when they had expected to be able to put the cancer and the treatment behind them. This may be the time when you need most support. See our list of counselling organisations.

Long-term side effects

All treatments used against cancer (including surgery, chemotherapy and radiotherapy) can result in long-term side effects. Modern treatments are designed to limit the chance of permanent side effects as much as possible. If you are concerned about the risk of developing particular side effects from radiotherapy, it is best to speak to your specialist.

General information on radiotherapy

This section has been written to give you information about radiotherapy. We hope that it will answer some of the questions that you may have about this treatment.

If you have any further questions relating to your treatment, please don't hesitate to ask the doctor, nurse or radiographer looking after you. It is important to talk to someone who is familiar with your treatment, as radiotherapy differs from one person to another. Other people you meet may be having different treatments, even if they have a similar type of cancer.

What is radiotherapy?

Radiotherapy is the use of x-rays and similar rays (such as electrons) to treat disease.

Since the discovery of x-rays over one hundred years ago, radiation has been used more and more in medicine, both to help with diagnosis (by taking pictures with x-rays), and as a treatment (radiotherapy). While radiation obviously has to be used very carefully, doctors and radiographers have a lot of experience in its use in medicine.

Many people with cancer will have radiotherapy as part of their treatment. This can be given either as external radiotherapy from outside the body using x-rays or from within the body as internal radiotherapy.

Radiotherapy works by destroying the cancer cells in the treated area. Although normal cells are also sometimes damaged by the radiotherapy, they can repair themselves.

Radiotherapy treatment can cure some cancers and can reduce the chance of a cancer coming back after surgery. It may be used to reduce cancer symptoms.

Some people find that the side effects are very mild and that they just feel tired during their course of radiotherapy treatment.

Why radiotherapy is given

Curative treatment

Radiotherapy is often given with the aim of destroying a tumour and curing the cancer. When radiotherapy is given in this way it is described as radical radiotherapy.

Radiotherapy may be used on its own or may be given before or after surgery or chemotherapy. Chemotherapy is the use of anti-cancer drugs to destroy cancer cells. If radiotherapy and chemotherapy are given at the same time, this treatment is known as chemoradiotherapy.

For some types of curative radiotherapy treatment, you may need to go to the hospital each weekday for between two and seven weeks. In this situation, a small dose of radiotherapy is given each time. This is because as well as damaging cancer cells, radiotherapy can also cause damage to healthy cells in the treatment area. If a very high dose of treatment was given all in one go, it could cause too much damage to the healthy cells, so small doses are given to allow the healthy cells to recover in between.

Palliative treatment

Sometimes, when it is not possible to cure a cancer, radiotherapy may be given to relieve symptoms - for example, to lessen pain. This is called palliative treatment. Lower doses of external radiotherapy are given than for curative treatment, usually over a shorter period of time (sometimes just a single treatment).

Total body irradiation

This type of radiotherapy is used much less commonly than the other types of radiotherapy, but is often given to patients who are having a bone marrow or stem cell transplant as part of their treatment. A large single dose, or six to eight smaller doses, of radiation is given to the whole body to destroy the cells of the bone marrow. Very high doses of chemotherapy are also given. This treatment is followed by giving new bone marrow given by a drip into a vein, to replace the bone marrow that has been destroyed. This type of radiotherapy is described in the section on stem cell and bone marrow transplants.

Research - clinical trials for radiotherapy treatments

Cancer research trials are carried out to try to find new and better treatments for cancer. Trials that are carried out on patients are known as clinical trials. When you are given radiotherapy it may be as part of a clinical trial and this will be explained to you.

Clinical trials may be carried out to:

• test new treatments, such as new ways of giving radiotherapy, new chemotherapy drugs, gene therapy or cancer vaccines
• look at new combinations of existing treatments, or change the way they are given, in order to make them more effective or to reduce side effects
• compare the effectiveness of drugs used for symptom control
• find out how cancer treatments work
• see which treatments are the most cost-effective.
• Trials are the only reliable way to find out if a different operation, type of chemotherapy, radiotherapy, or other treatment is better than what is already available.

Taking part in a trial

You may be asked to take part in a treatment research trial. There can be many benefits in doing this. Trials help to improve knowledge about cancer and the development of new treatments. You will also be carefully monitored during and after the study. Usually, several hospitals around the country take part in these trials.

The process of clinical trials is described in more detail in a separate section on cancer research trials.

Blood and tumour samples

Many blood samples and bone marrow or tumour biopsies may be taken to find out what is wrong with you. Most of these are needed to make the right diagnosis. You may be asked for your permission to use some of your samples for research into cancer. Some samples may be frozen and stored for future use, when new research techniques become available.

The research may be carried out at the hospital where you are treated, or it may be at another hospital. This type of research takes a long time, so you are unlikely to hear the results. The samples will, however, be used to increase knowledge about the causes of cancer and its treatment. This research will, hopefully, improve the outlook for future patients.

Children and radiotherapy

Radiotherapy can be a frightening experience for both children and their parents, but once everyone understands what is involved this fear can be reduced. The radiotherapy staff are used to treating children and they can offer help and support.

Young children, especially if they are aged three or younger, may have their treatment under a mild general anaesthetic. As your child can't eat or drink for at least four hours before his or her treatment, you will probably have a morning appointment. The anaesthetic is usually given in the radiotherapy department by an anaesthetist. You can stay with your child until they are asleep.

Although you won't be able to stay in the radiotherapy room during your child's treatment, you can watch through the window or on the TV screen. The nurses will look after the child until they wake up, usually after 20 minutes to an hour. You will then both be able to go home, unless your child is an in-patient, in which case a nurse will take them back to the ward.

Older children may take a while to get used to the size and sound of the machines, but this should get easier once they get to know the staff and the surroundings. If you are finding it difficult to cope with your child's illness, you may find it helpful to contact one of the children's cancer groups. Sharing your experiences with other parents can help you to cope with your own problems and fears. Contact Cancerbackup's Cancer Support Service for details of these groups.

Cancerbackup has information on children's cancers which includes more about radiotherapy treatment for children.

Work and radiotherapy

Sometimes people can carry on working part-time during their treatment, but many people feel very tired and may feel unwell. In this case you may need to make changes to your usual routines. Most employers will be sympathetic if you explain why you need time off work. It is helpful to talk to your employer or personnel officer to explain how much time off you may need and what you will be able to do. It can be hard to predict exactly what you will be able to do, but your employer will appreciate being given some idea of what to expect.

For further information, see our sections on work and cancer, which includes details of benefits and financial help.