Instructions – delete this slide before presenting - PowerPoint Presentation

1. Instructions – delete this slide before presentingThis presentation can be used either as a complete in-service or as a practical follow-up session following staff completing the ‘Understanding radiation oncology’ rapid learning.If using as a complete in-service start from slide 2.If using as a follow-up session, start from slide 24.Read through all slides and notes and adapt contents as necessary to ensure contents are consistent with local policies, procedures and models of care.All case studies contained within this presentation are fictional.All patient management information contained in this presentation is an examples only and is not designed to be used as a management guideline in clinical practice.Refer to your local policies and procedures regarding the management of oncological emergencies and radiation toxicities.

2. Radiation therapyIntroduction and practical pointsDeveloped in collaboration with the Central Coast Cancer Centre

3. ContentsIntroduction to radiation therapyIndications for radiation therapySide effectsCase studiesQuiz12345

4. What is radiation therapy?Treatment of cancer with ionising radiationLocal treatment

5. How does it work to treat cancer?Stops cells from replicatingCauses damage to cellular DNADirect – breaks in DNA strandsIndirect – free radical productionCancer cells – more susceptible to damage, less able to repair damageNormal cells – able to repair damage and recover

6. Are there different types of radiation therapy?External beam radiation therapyBrachytherapy

7. What is involved in having radiation therapy?Initial consultSimulationPlanningTreatment1234

8. How is radiation therapy prescribed?Gray (Gy)Fractions(#)Radiation therapy doses are prescribed in a unit called a Gray (Gy). This is a measure of the radiation dose absorbed by the body.Prescribed doses are broken up and delivered over a number of treatments or fractions (#). Breaking the dose into fractions allows time for the body’s normal cells to recover. Treatment siteTotal  doseDose /#Fractions (#)#/day#/fortnightRight lung60Gy2Gy /#30 1 9 

9. Who can benefit from radiation therapy?Approximately 50% of all people diagnosed with cancer can benefit from radiation therapy in the management of their disease.Treatment intentCurativePalliativeProphylacticEmergencyTreatment settingSole treatmentIn combination with other modalities

10. Curative intentTreatment aim: eradication of diseaseCurativeDefinitiveAdjuvantNeoadjuvantSalvage

11. radiation therapy is the sole or primary treatment modalitySystemic anti-cancer therapies may be delivered concurrently as a radiosensitiserCancer typesProstateCervicalHead and neckLungAnalColorectalOesophagealSkinBladderBrainCurative - definitive

12. Curative - adjuvant radiation therapy is delivered after primary treatmentsAims to:reduce the risk of the cancer returning locoregionallyimprove survival.Cancer typesBreastColorectalCervicalEndometrialOesophagealHead and neckMelanoma and skinLung

13. radiation therapy is delivered before surgeryAim: improving surgical outcomes e.g. shrinking the tumour to improve operabilityCancer typesOesophagealRectalSarcomaLung (Pancoast)Curative - neoadjuvant

14. Delivered after primary treatments have failedAim: to eradicate residual diseaseCancer typesProstate bed (following removal of prostate)Curative - salvage

15. ProphylacticAim: to eradicate subclinical disease in order to prevent or delay the clinical spread of disease. May provide benefit in those cancers where the pattern of disease failure is well recognised.Cancer typesProphylactic cranial irradiation in lung cancer

16. PalliativeAim: control symptoms, improve quality of lifeIndicationsPainful bone metastasesPresence of brain metastases Skin lesion which is eroding the skinOesophageal tumour causing dysphagiaShortness of breath from lung cancerPain, abdominal distension from liver metastasesHaematuria from bladder cancer 

17. EmergencyAimIndicationsradiation therapy is used to shrink the tumour with the aim of:reducing painreducing bleedingalleviating obstructionreducing compression.For urgent referral to radiation oncology:moderate to severe cancer painspinal cord compressionuncontrolled bleeding due to cancersuperior vena cava obstruction.

18. Spine metastases can compress the spinal cordSwift intervention requiredLeft untreated can lead to permanent damage and functional loss Spinal cord compressionSigns and symptoms:pain that is increasing muscle weaknesssensory lossnumbnessparaesthesiabladder and bowel dysfunction and incontinenceataxia.

19. Some tumours may compress the SVCMay result in:breathing compromisecerebral oedemadeath.Superior vena cava (SVC) obstructionSigns and symptoms:oedema (head and neck region)swelling of the upper extremitiesdysphagia coughhoarsenessdyspnoea distorted visionheadachesnausea.

20. What treatment related toxicities are possible?AcuteSub-acute - Weeks to months following treatmentLateduring treatmentusually temporarymonths following treatmentmay be long-term or permanent

21. Treatment related toxicitiesLocalised to anatomical site or system being treatedDiffer according to treatment siteExamplesDiarrhoea (pelvis)Nausea and vomiting (abdomen or neurological)Mucositis (head and neck)Skin reaction (any site)

22. Radiation induced skin reactions (RISR)May present as pain, itching, redness, dryness, peeling, bleeding or ulceration of the skin.Grade 1Grade 2Grade 3Grade 4

23. Management of RISRManagement differs according to grade experiencedManage with a step up approachUnbroken skin – maintain moisture levelsBroken skin – maintain a moist (not wet) healing environmentManage symptomsMDT care – grade 4

24. What did you remember?Quiz

25. Question 1The total dose is broken up and delivered in fractions to allow time for the body’s normal cells to recover between doses.Why are radiation therapy doses delivered in fractions?

26. Question 2Radiation therapy can be used in the management of almost all cancers as a curative treatment, to palliate symptoms or as a prophylactic treatment.Radiation therapy can be used as a sole treatment or in combination with other treatment modalities. What patients may benefit from the use of radiation therapy in the management of their disease?

27. Question 3Moderate to severe cancer painSpinal cord compressionUncontrolled bleeding due to cancerSuperior vena cava obstructionAirway/bronchial obstructionSome indications for radiation therapy are considered an emergency and require an urgent referral. What are they?

28. Question 4Acutestart presenting after the first week or two or treatmentbegin to resolve a few weeks after completing treatment e.g. radiation induced skin reaction. Subacutestart presenting weeks or months after treatment has been completede.g. radiation induced pneumonitis following radiation to the chestLatestart to present months after treatment. may be long term or permanente.g. cataracts following irradiation to the head and neck or brain region.What are the types of radiation therapy side effects?What is the pattern of onset for each of these?BONUS points if you give an example of each.

29. Question 5RISRbreast oedemarib pain.RISRnausea and vomitingdiarrhoeaanorexiagastritisenteritis.RISRdysphagiaodynophagiaxerostomiadysgeusiamucositistinnitus.Most side effects from radiation therapy are ‘site specific’ or localised to the anatomical site or system being treated. What acute side effects may be experienced by patients receiving radiation therapy to the following sites?BreastAbdomenHead and neck

30. Apply what you’ve learntCase studies

31. Case study 1Palliative Treatment - Consultation

32. You are the ward JMO A 64yo M was admitted with metastatic prostate cancerHe is now complaining of pain all over the body Your Registrar reviews the patient and requests a Rad onc consultHow will you make this consult?

33. Clarifies the indication/problemWhat is the primary cancer/diagnosis? Where is the cancer? Where are the problem areas?Reviews the treatment HxIs the patient known to any Radiation oncologist? Has the patient received radiation before?Performs a thorough clinical assessmentECOG statusPhysical examinationProstateMetastatic. Results of recent bone/PET scans show sclerotic lesions at T8 and L5Pain in lower and upper back, legs and right ribsYes - previously at another hospitalPrevious salvage RT following RP1Pain likely referred from spine mets, ribs not tender to palpationWhat might the rad onc registrar plan/suggest?

34. For simulation scan today Aim to commence RT 1-3 days20Gy/5# to the L and T spine metsRequest previous treatment details – check overlap with L spine What members of the MDT may you need to involve/consider?Palliative care review for pain management

35. Case study 2Rad onc Emergency 1

36. 64yo F presents with severe back pain, lower limb weakness and incontinence. Bg breast cancerThe ED JMO is asked to assess the patientHow should the JMO approach this case?

37. Physical examination and historyWhat is the duration of symptoms? Neurological exam Vertebral tenderness?Imaging?Spinal Instability Neoplastic Score Score of 7 – 18 – potentially unstable (consider surgical consult):2 days (>few days complete recovery less likely)Motor strength of lower extremities decreased, sensory function reducedYes, tenderness in lumbar spineUrgent Whole spine MRI ordered immediatelyDemonstrates compression at L3patients scores 6What might the JMO consider in their management plan?

38. Consider:glucocorticoidsdecompressive surgeryradiation therapyDecision:Sim today – plan and treatEBRT 20Gy/5#

39. Case study 3Rad onc Emergency 2

40. You are a nurse working on an inpatient ward.You are performing obs for a patient with a known lung cancer.You note that the patient is experiencing mild SOB, some difficulty swallowing and mild facial oedema What may this patient be experiencing?Potential SVC obstruction What action should the nurse take?Request immediate medical review, complete obsConsider head elevation and supplementary oxygen

41. The patient is reviewed and sent for CTCT confirms obstruction of the SVC caused by large mediastinal mass (NSCLC)Consider:Symptomatic management – Head elevation, oxygen, morphine for dyspnoea, glucocorticoidsradiation therapyChemotherapy, endovascular stentingDecisionradiation therapySim today – plan and treat30Gy/10#

42. Case study 4Radiation toxicity

43. 65yo M with oropharyngeal caCompleted 7 weeks of definitive radiation therapy 3 days agoAdmitted for pain and desquamation of skin over neck, painful mouth ulcers and dehydrationThe ward resident is asked to review the patient and provide management adviceWhat may the resident consider in their assessment of this patient?

44. What may this patient be experiencing?What grade is being experienced?Complete patient assessmentAcute toxicities of radiation therapy – RISR, oral mucositis, dysphagia, xerostomia, anorexiaRISRAS tool, mucositis assessment scale, CTCAE grading toolRISR – grade 3 – moist desquamation and bleeding induced by minor trauma/abrasionOral mucositis – grade 3 – severe pain interfering with oral intakeReduced oral intake, recent weight loss of 5kg, dehydration, reduced urinary outputWhat might the resident consider in their management plan?

45. Admit pt – monitor weight and oral intakeCommence IV hydrationRISRDress neck with non-adherent absorbent dressingMonitor for signs of infectionParacetamol prn for painOral mucositisRegular sodium bicarbonate mouthwashesTopical anaestheticShort active and long acting analgesia titrated to effect

46. DebriefRadiation therapy can be used in the management of almost all cancers as a curative treatment, to palliate symptoms or as a prophylactic treatment.Some indications for radiation therapy are considered an emergency and require an urgent referral.Side effects from radiation therapy may present as acute, sub acute or late.Radiation therapy is a local treatment and only affects the area of body being treated. Side effects will be localised.