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slide1. Instructions – delete this slide before presenting This 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.<br>
slide2. Radiation therapy Introduction and practical points Developed in collaboration with the Central Coast Cancer Centre<br>
slide3. Contents Introduction to radiation therapy Indications for radiation therapy Side effects Case studies Quiz<br>
slide4. What is radiation therapy? Treatment of cancer with ionising radiation
Local treatment<br>
slide5. How does it work to treat cancer? Stops cells from replicating
Causes damage to cellular DNA
Direct – breaks in DNA strands
Indirect – free radical production
Cancer cells – more susceptible to damage, less able to repair damage
Normal cells – able to repair damage and recover<br>
slide6. Are there different types of radiation therapy? External beam radiation therapy Brachytherapy<br>
slide7. What is involved in having radiation therapy? 1 2 3 4<br>
slide8. How is radiation therapy prescribed? Gray (Gy) 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.<br>
slide9. 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 intent Curative
Palliative
Prophylactic
Emergency Treatment setting Sole treatment
In combination with other modalities<br>
slide10. Curative intent Treatment aim: eradication of disease<br>
slide11. radiation therapy is the sole or primary treatment modality
Systemic anti-cancer therapies may be delivered concurrently as a radiosensitiser
Cancer types Prostate
Cervical
Head and neck
Lung
Anal Colorectal
Oesophageal
Skin
Bladder
Brain Curative - definitive<br>
slide12. Curative - adjuvant radiation therapy is delivered after primary treatments
Aims to:
reduce the risk of the cancer returning locoregionally
improve survival.
Cancer types Breast
Colorectal
Cervical
Endometrial Oesophageal
Head and neck
Melanoma and skin
Lung<br>
slide13. radiation therapy is delivered before surgery
Aim: improving surgical outcomes e.g. shrinking the tumour to improve operability
Cancer types Oesophageal
Rectal
Sarcoma
Lung (Pancoast) Curative - neoadjuvant<br>
slide14. Delivered after primary treatments have failed
Aim: to eradicate residual disease
Cancer types Prostate bed (following removal of prostate) Curative - salvage<br>
slide15. Prophylactic Aim: 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 types
Prophylactic cranial irradiation in lung cancer<br>
slide16. Palliative Aim: control symptoms, improve quality of life Indications
Painful bone metastases
Presence of brain metastases
Skin lesion which is eroding the skin
Oesophageal tumour causing dysphagia
Shortness of breath from lung cancer
Pain, abdominal distension from liver metastases
Haematuria from bladder cancer<br>
slide17. Emergency radiation therapy is used to shrink the tumour with the aim of:
reducing pain
reducing bleeding
alleviating obstruction
reducing compression. For urgent referral to radiation oncology:
moderate to severe cancer pain
spinal cord compression
uncontrolled bleeding due to cancer
superior vena cava obstruction.<br>
slide18. Spine metastases can compress the spinal cord
Swift intervention required
Left untreated can lead to permanent damage and functional loss Spinal cord compression Signs and symptoms:
pain that is increasing
muscle weakness
sensory loss
numbness
paraesthesia
bladder and bowel dysfunction and incontinence
ataxia.<br>
slide19. Some tumours may compress the SVC
May result in:
breathing compromise
cerebral oedema
death. Superior vena cava (SVC) obstruction Signs and symptoms:
oedema (head and neck region)
swelling of the upper extremities
dysphagia cough
hoarseness
dyspnoea
distorted vision
headaches
nausea.<br>
slide20. What treatment related toxicities are possible? Acute Sub-acute - Weeks to months following treatment Late during treatment
usually temporary months following treatment
may be long-term or permanent<br>
slide21. Treatment related toxicities Localised to anatomical site or system being treated
Differ according to treatment site
Examples
Diarrhoea (pelvis)
Nausea and vomiting (abdomen or neurological)
Mucositis (head and neck)
Skin reaction (any site)<br>
slide22. Radiation induced skin reactions (RISR) May present as pain, itching, redness, dryness, peeling, bleeding or ulceration of the skin. Grade 1 Grade 2 Grade 3 Grade 4<br>
slide23. Management of RISR Management differs according to grade experienced
Manage with a step up approach
Unbroken skin – maintain moisture levels
Broken skin – maintain a moist (not wet) healing environment
Manage symptoms
MDT care – grade 4<br>
slide24. What did you remember?
Quiz<br>
slide25. Question 1 Why are radiation therapy doses delivered in fractions?<br>
slide26. Question 2 What patients may benefit from the use of radiation therapy in the management of their disease?<br>
slide27. Question 3 Some indications for radiation therapy are considered an emergency and require an urgent referral.
What are they?<br>
slide28. Question 4 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.<br>
slide29. Question 5 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? Breast Abdomen Head and neck<br>
slide30. Apply what you’ve learnt
Case studies<br>
slide31. Case study 1 Palliative Treatment - Consultation<br>
slide32. You are the ward JMO
A 64yo M was admitted with metastatic prostate cancer
He is now complaining of pain all over the body
Your Registrar reviews the patient and requests a Rad onc consult
How will you make this consult?<br>
slide33. Clarifies the indication/problem
What is the primary cancer/diagnosis?
Where is the cancer?
Where are the problem areas? Reviews the treatment Hx
Is the patient known to any Radiation oncologist?
Has the patient received radiation before? Performs a thorough clinical assessment
ECOG status
Physical examination<br>
slide34. For simulation scan today
Aim to commence RT 1-3 days
20Gy/5# to the L and T spine mets
Request 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<br>
slide35. Case study 2 Rad onc Emergency 1<br>
slide36. 64yo F presents with severe back pain, lower limb weakness and incontinence. Bg breast cancer
The ED JMO is asked to assess the patient
How should the JMO approach this case?<br>
slide37. Physical examination and history
What is the duration of symptoms?
Neurological exam
Vertebral tenderness? Imaging? Spinal Instability Neoplastic Score
Score of 7 – 18 – potentially unstable (consider surgical consult):<br>
slide38. Consider:
glucocorticoids
decompressive surgery
radiation therapy
Decision:
Sim today – plan and treat
EBRT 20Gy/5#<br>
slide39. Case study 3 Rad onc Emergency 2<br>
slide40. 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 obs
Consider head elevation and supplementary oxygen<br>
slide41. The patient is reviewed and sent for CT
CT confirms obstruction of the SVC caused by large mediastinal mass (NSCLC)
Consider:
Symptomatic management – Head elevation, oxygen, morphine for dyspnoea, glucocorticoids
radiation therapy
Chemotherapy, endovascular stenting
Decision
radiation therapy
Sim today – plan and treat
30Gy/10#<br>
slide42. Case study 4 Radiation toxicity<br>
slide43. 65yo M with oropharyngeal ca
Completed 7 weeks of definitive radiation therapy 3 days ago
Admitted for pain and desquamation of skin over neck, painful mouth ulcers and dehydration
The ward resident is asked to review the patient and provide management advice
What may the resident consider in their assessment of this patient?<br>
slide44. What may this patient be experiencing? What grade is being experienced? Complete patient assessment<br>
slide45. Admit pt – monitor weight and oral intake
Commence IV hydration
RISR
Dress neck with non-adherent absorbent dressing
Monitor for signs of infection
Paracetamol prn for pain
Oral mucositis
Regular sodium bicarbonate mouthwashes
Topical anaesthetic
Short active and long acting analgesia titrated to effect<br>
slide46. Debrief Radiation 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.<br>
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.<br>
slide2. Radiation therapy Introduction and practical points Developed in collaboration with the Central Coast Cancer Centre<br>
slide3. Contents Introduction to radiation therapy Indications for radiation therapy Side effects Case studies Quiz<br>
slide4. What is radiation therapy? Treatment of cancer with ionising radiation
Local treatment<br>
slide5. How does it work to treat cancer? Stops cells from replicating
Causes damage to cellular DNA
Direct – breaks in DNA strands
Indirect – free radical production
Cancer cells – more susceptible to damage, less able to repair damage
Normal cells – able to repair damage and recover<br>
slide6. Are there different types of radiation therapy? External beam radiation therapy Brachytherapy<br>
slide7. What is involved in having radiation therapy? 1 2 3 4<br>
slide8. How is radiation therapy prescribed? Gray (Gy) 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.<br>
slide9. 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 intent Curative
Palliative
Prophylactic
Emergency Treatment setting Sole treatment
In combination with other modalities<br>
slide10. Curative intent Treatment aim: eradication of disease<br>
slide11. radiation therapy is the sole or primary treatment modality
Systemic anti-cancer therapies may be delivered concurrently as a radiosensitiser
Cancer types Prostate
Cervical
Head and neck
Lung
Anal Colorectal
Oesophageal
Skin
Bladder
Brain Curative - definitive<br>
slide12. Curative - adjuvant radiation therapy is delivered after primary treatments
Aims to:
reduce the risk of the cancer returning locoregionally
improve survival.
Cancer types Breast
Colorectal
Cervical
Endometrial Oesophageal
Head and neck
Melanoma and skin
Lung<br>
slide13. radiation therapy is delivered before surgery
Aim: improving surgical outcomes e.g. shrinking the tumour to improve operability
Cancer types Oesophageal
Rectal
Sarcoma
Lung (Pancoast) Curative - neoadjuvant<br>
slide14. Delivered after primary treatments have failed
Aim: to eradicate residual disease
Cancer types Prostate bed (following removal of prostate) Curative - salvage<br>
slide15. Prophylactic Aim: 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 types
Prophylactic cranial irradiation in lung cancer<br>
slide16. Palliative Aim: control symptoms, improve quality of life Indications
Painful bone metastases
Presence of brain metastases
Skin lesion which is eroding the skin
Oesophageal tumour causing dysphagia
Shortness of breath from lung cancer
Pain, abdominal distension from liver metastases
Haematuria from bladder cancer<br>
slide17. Emergency radiation therapy is used to shrink the tumour with the aim of:
reducing pain
reducing bleeding
alleviating obstruction
reducing compression. For urgent referral to radiation oncology:
moderate to severe cancer pain
spinal cord compression
uncontrolled bleeding due to cancer
superior vena cava obstruction.<br>
slide18. Spine metastases can compress the spinal cord
Swift intervention required
Left untreated can lead to permanent damage and functional loss Spinal cord compression Signs and symptoms:
pain that is increasing
muscle weakness
sensory loss
numbness
paraesthesia
bladder and bowel dysfunction and incontinence
ataxia.<br>
slide19. Some tumours may compress the SVC
May result in:
breathing compromise
cerebral oedema
death. Superior vena cava (SVC) obstruction Signs and symptoms:
oedema (head and neck region)
swelling of the upper extremities
dysphagia cough
hoarseness
dyspnoea
distorted vision
headaches
nausea.<br>
slide20. What treatment related toxicities are possible? Acute Sub-acute - Weeks to months following treatment Late during treatment
usually temporary months following treatment
may be long-term or permanent<br>
slide21. Treatment related toxicities Localised to anatomical site or system being treated
Differ according to treatment site
Examples
Diarrhoea (pelvis)
Nausea and vomiting (abdomen or neurological)
Mucositis (head and neck)
Skin reaction (any site)<br>
slide22. Radiation induced skin reactions (RISR) May present as pain, itching, redness, dryness, peeling, bleeding or ulceration of the skin. Grade 1 Grade 2 Grade 3 Grade 4<br>
slide23. Management of RISR Management differs according to grade experienced
Manage with a step up approach
Unbroken skin – maintain moisture levels
Broken skin – maintain a moist (not wet) healing environment
Manage symptoms
MDT care – grade 4<br>
slide24. What did you remember?
Quiz<br>
slide25. Question 1 Why are radiation therapy doses delivered in fractions?<br>
slide26. Question 2 What patients may benefit from the use of radiation therapy in the management of their disease?<br>
slide27. Question 3 Some indications for radiation therapy are considered an emergency and require an urgent referral.
What are they?<br>
slide28. Question 4 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.<br>
slide29. Question 5 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? Breast Abdomen Head and neck<br>
slide30. Apply what you’ve learnt
Case studies<br>
slide31. Case study 1 Palliative Treatment - Consultation<br>
slide32. You are the ward JMO
A 64yo M was admitted with metastatic prostate cancer
He is now complaining of pain all over the body
Your Registrar reviews the patient and requests a Rad onc consult
How will you make this consult?<br>
slide33. Clarifies the indication/problem
What is the primary cancer/diagnosis?
Where is the cancer?
Where are the problem areas? Reviews the treatment Hx
Is the patient known to any Radiation oncologist?
Has the patient received radiation before? Performs a thorough clinical assessment
ECOG status
Physical examination<br>
slide34. For simulation scan today
Aim to commence RT 1-3 days
20Gy/5# to the L and T spine mets
Request 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<br>
slide35. Case study 2 Rad onc Emergency 1<br>
slide36. 64yo F presents with severe back pain, lower limb weakness and incontinence. Bg breast cancer
The ED JMO is asked to assess the patient
How should the JMO approach this case?<br>
slide37. Physical examination and history
What is the duration of symptoms?
Neurological exam
Vertebral tenderness? Imaging? Spinal Instability Neoplastic Score
Score of 7 – 18 – potentially unstable (consider surgical consult):<br>
slide38. Consider:
glucocorticoids
decompressive surgery
radiation therapy
Decision:
Sim today – plan and treat
EBRT 20Gy/5#<br>
slide39. Case study 3 Rad onc Emergency 2<br>
slide40. 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 obs
Consider head elevation and supplementary oxygen<br>
slide41. The patient is reviewed and sent for CT
CT confirms obstruction of the SVC caused by large mediastinal mass (NSCLC)
Consider:
Symptomatic management – Head elevation, oxygen, morphine for dyspnoea, glucocorticoids
radiation therapy
Chemotherapy, endovascular stenting
Decision
radiation therapy
Sim today – plan and treat
30Gy/10#<br>
slide42. Case study 4 Radiation toxicity<br>
slide43. 65yo M with oropharyngeal ca
Completed 7 weeks of definitive radiation therapy 3 days ago
Admitted for pain and desquamation of skin over neck, painful mouth ulcers and dehydration
The ward resident is asked to review the patient and provide management advice
What may the resident consider in their assessment of this patient?<br>
slide44. What may this patient be experiencing? What grade is being experienced? Complete patient assessment<br>
slide45. Admit pt – monitor weight and oral intake
Commence IV hydration
RISR
Dress neck with non-adherent absorbent dressing
Monitor for signs of infection
Paracetamol prn for pain
Oral mucositis
Regular sodium bicarbonate mouthwashes
Topical anaesthetic
Short active and long acting analgesia titrated to effect<br>
slide46. Debrief Radiation 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.<br>