WHAT TO EXPECT
What Happens Before, During and After Treatment
Once the diagnosis has been made, you will probably talk with your primary care physician along with several cancer specialists, such as a surgeon, a medical oncologist and a radiation oncologist, to discuss your treatment choices. These specialists will work together to help recommend the best treatment for you.
In some cases, your cancer will need to be treated by using more than one type of treatment. For example, if you have breast cancer, you might have surgery to remove the tumor (by a surgeon), then have radiation therapy to destroy any remaining cancer cells in or near your breast (by a radiation oncologist). You also might receive chemotherapy (by a medical oncologist) to destroy cancer cells that have traveled to other parts of the body.
Initial Consultation with Radiation Oncologist
If you are considering radiation therapy, you must first meet with a radiation oncologist to see if radiation therapy is right for you. During your first visit, your doctor will evaluate your need for radiation therapy and its likely results. This includes reviewing your current medical problems, past medical history, past surgical history, family history, medications, allergies and lifestyle. The doctor will also perform a physical exam to assess the extent of your disease and judge your general physical condition.
After reviewing your medical tests, including CT scans, MRI scans and PET scans, and completing a thorough examination, your radiation oncologist will advise you if radiation therapy is a treatment option for your particular situation and disease stage. If it is, the radiation oncologist will discuss with you the potential benefits, risks, and potential side effects of radiation therapy and answer your questions.
(We encourage you to ask all of your questions – however “small”. We know from experience that patients gain a greater peace of mind when they understand the process and can anticipate what comes next. We are very aware that cancer and radiation therapy are often unknowns to patients, and can be very frightening and anxiety-producing. Our goal is to help ease your concerns through letting you know in advance all of the stages of the process, and to answer any and all questions that occur to you, at any point in the process – no matter how seemingly “small”).
At the end of your Initial Consultation, if the decision to undergo external beam radiation therapy has been made, your next appointment will be to return for a Simulation.
During Treatment
Simulation
To be most effective, radiation therapy must be aimed precisely at the same target or targets each and every time treatment is given. During a process called “simulation”, the radiation therapist makes a custom-made immobilization device, and puts marks on the skin to help the treatment planning. Immobilization devices are molds, casts, headrests or other devices that help you remain in the same position during the entire treatment session. The radiation therapist marks your skin with india ink that creates very small permanent tattoos and places plastic catheters on your skin.
CT Verification Image
After the Simulation, a CT scan will be done. This CT scan is different than a diagnostic CT scan, as this CT scan will be done for treatment planning purposes. You will be asked to lie down in the same position as you did during simulation. The plastic and tattooed marks on your skin will help the Radiation Oncologist develop the radiation plan.
Treatment Planning
This next step is vital, however happens out of your sight. Once you have finished with the simulation, the clinic’s medical physicist and dosimistrist (other members of your treatment team) review the information obtained during simulation and your verification CT scan, along with your previous medical tests, to develop a treatment plan. A 3-Dimensional representation of your anatomy will be made allowing for a careful and exacting look at the organs, structures and tissue density of your internal anatomy. Using sophisticated computers, the shape and angles of the radiation beams are optimized using sophisticated mathematical computations. The results of this work by the treatment team is a precise “modeling” of the plan that will be used to deliver radiation to those areas that need to receive treatment, while at the same time avoiding to the best degree possible, tissues and organs that do not. After reviewing all of this information, your doctor will write a prescription that outlines exactly how much radiation you will receive and to what parts of your body.
Confirmation Simulation
This simulation uses all of the treatment planning data and is the beginning of your daily radiation therapy. However your first day is not an actual treatment, but will be where we will run-through the plan to provide confirmation and verification of the precision of the planning which had previously been confirmed on a computer model. This “dry-run” or “dress-rehearsal” will take place with you in the actual treatment room. The radiation therapist will run through each step of an actual treatment, but will take films rather than give the actual treatment – films that are taken for review by the Radiation Oncologist. Any fine-tuning of the planning can then be made prior to treatment commencing, once the final treatment plan has been approved by the physician.
After your confirmation simulation, you will be asked to see up appointments for your treatments, generally every day Monday-Friday. Every attempt will be made to schedule those appointments at times that are convenient for you, and are the least disruptive on your daily routine.
External Beam Radiation Therapy Treatments
When you undergo external beam radiation therapy treatment, each session is painless, just like getting an X-ray. The radiation is directed at your tumor from a machine located away from your body (usually using technology called a linear accelerator). External beam radiation is noninvasive, unlike surgery which is an invasive process. One of the benefits of radiation therapy is that it is usually given as a series of outpatient treatments (meaning you don’t have to stay in the hospital). You may not need to miss work or experience the type of recuperation period that may follow other treatments.
Treatments are usually scheduled five days a week, Monday through Friday, and continue for an average of two to ten weeks. The number of radiation treatments you will need depends on the size, location and type of cancer you have, the intent of the treatment, your general health and other medical treatments you may be receiving.
The radiation therapist will give you your external beam treatment following your radiation oncologist’s instructions. It will take several minutes for you to be positioned for treatment and for the equipment to be set up. If an immobilization device was made during simulation, it will be used during every treatment to make sure that you are in the exact same position every day.
Once you are positioned correctly, the therapist will leave the room and go into the control room next door to closely monitor you on a television screen while giving the radiation. There is a microphone in the treatment room so you can always talk with the therapist if you have any concerns. The machine can be stopped at any time if you are feeling sick or uncomfortable.
Most often, daily "on board imaging" (IGRT) will be done to carefully localize the treatment fields to exactly the precise treatment spot. This is a new, very advanced technology available at our center and only a handful of other radiation oncology centers. Before treatment, a set of CT scans or low energy x-rays will be taken and viewed on a computer screen by the treatment team. The radiation therapist may move the treatment machine and treatment table to target the radiation beam to the exact area of the tumor. The machine might make noises during treatment that sound like clicking, knocking or whirring, but the radiation therapist is in complete control of the machine at all times.
The treatment plan is created and designed to reduce the dose to the normal tissue surrounding the tumor, as much as possible. Still, radiation will affect some healthy cells. Time between daily treatments allows your healthy cells to repair much of the radiation effect, while cancer cells are not as likely to survive the changes.
Sometimes a course of treatment is interrupted for a day or more. This may happen if you develop side effects that require a break in treatment. These missed treatments may be made up by adding treatments at the end. Try to arrive on time and not miss any of your appointments. Time spent in the treatment room may vary depending on the type of radiation, but it generally ranges from 10 to 20 minutes, and most patients can continue with normal daily activities.
Your radiation oncologist monitors your daily treatment and may alter your radiation dose based on these observations. Also, your doctor may order blood tests, X-rays and other tests to see how your body is responding to treatment. If the tumor shrinks significantly, another CT scan and simulation may be required. This allows your radiation oncologist to change the treatment to destroy the rest of the tumor and spare even more normal tissue.
Weekly Status Checks
During radiation therapy, your radiation oncologist will see you regularly to follow your progress, evaluate whether you are having any side effects, recommend treatments for those side effects (such as medication) and address any concerns you may have. As treatment progresses, your doctor may make changes in the schedule or treatment plan depending on your response or reaction to the therapy.
Your radiation therapy team may gather on a regular basis with other healthcare professionals to review your case to ensure your treatment is proceeding as planned. During these sessions, all the members of the team discuss your progress as well as any concerns.
Weekly Beam Films
In addition to daily on-board imaging, correct positions of the treatment beams might be regularly verified with images made using the treatment beam itself. These verification images represent an important quality, but do not evaluate the tumor itself.
After Treatment
Follow-Up Care
After treatment is completed, follow-up appointments will be scheduled so that your radiation oncologist can make sure your recovery is proceeding normally and can continue to monitor your health status. Your radiation oncologist may also order additional diagnostic tests. Reports on your treatment may also be sent to the other doctors helping treat your cancer.
As time goes by, the number of times you need to visit your radiation oncologist will decrease. However, you should know that your radiation oncology team will always be available should you need to speak to someone about your treatment.
