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02.23 Radiation Cancer Treatment

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Overview

  1.  What is radiation therapy?
    1. Treatment with radiation to destroy cancer cells 
    2. Given to 60% of all patients with cancer 
    3. Review: Electrical charge of atoms → neutral with balance of protons (+), electrons (-), and neutrons (neutral) 

Nursing Points

General

  1. Radiation treatment destroys cancer cells by delivering high-energy particles, beams, or waves 
    1.  These disrupt the balance of protons and electrons and cause atoms to be unbalanced → free radical formation   breaks down DNA stand   keeps cancer cells from growing and dividing 
      1. Cancer and healthy cells are susceptible but healthy cells are better at repairing damage 
    2. In high doses causes cell apoptosis in endothelial lining of blood vessels   microvascular dysfunction  cell death 
      1.   Rapidly dividing cells are more susceptible (radio-sensitive) 
  2.  Amount to destroy cancer cells without destroying healthy cells ordered in Gy (Gray) or Centigray 
    1. Fractionation: Total dose divided into daily treatments over a period of time to allow for healthy cell recovery between treatments
      1.  Hypofractionation: Larger doses given over a short time
      2. Hyperfractionation: Doses further divided, can be delivered multiple times/day 

Assessment

  1. Side effects of treatment
    1. Acute- occur about two weeks after initiation of treatment and typically resolve in less than 6 months 
      1.   General
        1. Fatigue- Energy conservation technique
        2. Skin irritation- teach skincare → mild moisturizing products, avoid sun exposure, mild soaps, loose clothing 
      2.  Site-specific- depending on tissues surrounding treatment areas
        1. Brain- Hair loss- can be permanent, cognitive changes 
        2. Head and Neck- Dry mouth, mouth sores, difficulty swallowing
        3.  Chest- Cough, heavy, swollen breasts 
        4. Abdomen- Nausea and vomiting, diarrhea, GERD
    2.  Late- >6 months after treatment
      1.  Can be permanent damage from fibrosis, necrosis, or atrophy
        1. Organ damage
        2. Connective tissue damage
        3. Radiation-induced tumor- rare but can occur 

Therapeutic Management

  1. Goals of radiation therapy
    1. Cure- alone or with a combination of chemo and surgery 
    2. Control- stop the spread of disease
    3. Prophylaxis- to prevent the anticipated microscopic spread 
    4.   Palliation- Control pain, bleeding, improve quality of life 
  2.  Types of radiation therapy
    1.  External Beam Radiation Therapy (EBRT)- uses a machine to deliver a beam that passes through the body
      1.  Patient evaluated to determine eligibility → simulation completed to determine the position of patient and apply permanent tattoo markings for guides  treatment planned by physicist and radiation oncologist  treatment by a radiation therapist 
      2. Patients must be in same position each time for treatment
      3.  Patients might hear the machine and will see machine moving but will not feel the treatment 
      4.   Patients are not radioactive after treatment 
      5. Special types of EBRT
        1.   Image-guided radiotherapy (IGRT)- uses imaging to visualize area with each treatment 
        2.  Intensity-modulated radiation therapy- More targeted treatment adjusts size and intensity of beams 
        3. TBI- total body irradiation for hematologic malignancies prior to a stem cell transplant
        4.  Stereotactic radiosurgery- delivered directly to brain tumors using special head ring
        5. Stereotactic body radiotherapy- high dose to small area guided by internal or external markers and body frame to immobilize patients 
        6. Intraoperative radiotherapy- single high dose delivered to the exposed tumor in OR 
    2.   Internal Radiation Therapy
      1.  Delivers radioactive isotopes that release energy to destroy atoms as they decay  
      2.  Brachytherapy
        1.  Sealed sources of radioactive isotopes placed in or close to the tumor 
        2.   Low dose radiation- delivers radiation over days/ weeks
          1. Radioactive precautions during treatment
          2. ALARA- As low as reasonably achievable exposure to others
          3. Dosimeter to monitor exposure
        3. High dose radiation- delivers dose when activated for 10-20 min
          1. Precautions only during the short treatment 
      3.  Radioisotope or radiopharmaceutical therapy 
        1. Ingested, injected, or instilled into body cavity
        2.   Directed toward the target area
          1.   Bound to monoclonal antibodies ® to be delivered directly to tumors
          2. Bound to Iodine to be delivered to thyroid (Iodine- 131)
          3. Precautions to avoid exposure to others
            1.  Time, Distance, and Hygiene to reduce exposure 

Nursing Concepts

  1. Cellular Regulation
    1. Radiation causes disruption of cell cycle mitosis, apoptosis 
  2. Patient Education
    1. Specific side effects
    2. Safety of radiation therapy 
  3. Tissue/ Skin Integrity
    1. Local skin irritation common with certain radiation treatments

Patient Education

  1. Safety of radiation therapy
    1. Explain what to expect before, during and after treatment
    2. Reducing exposure to others 
  2.  Site-specific education about anticipated side effects
    1. This is very important for people getting short duration of treatment because side effects might appear weeks after treatment 
    2. Available resources
      1. Support groups for cancer patients and families
      2. Education material specific to their treatment

Reference Links

Video Transcript

All right. Hi guys, today, we’re going to be talking about radiation cancer treatment, which is just so fascinating what we can do. And so it’s treatment with high energy, it’s high energy going to low energy to result in cancer cell death. It’s common. 60% of patients going through cancer treatment receive radiation therapy and patients are terrified that they’re going to, you know, turn green or radioactive forever, but it is safe for patients. It’s a treatment we’ve been doing for a long time. So I just want to talk to you a little bit about how this works, and this is going back to chemistry to remember how an atom works. Sorry. That’s not the best circle, but remember inside an atom, we have the positively charged protons, the neutral neutrons, and then the negatively charged electrons. And they kind of orbit around each other and they keep this neutral charge right now. 

Radiation therapy is going to target protons, usually into this cell that disrupts this whole atom and this results in free radicals being released. And that can result in disruption of the DNA, which means cell death, because it can no longer replicate or it can also cause apoptosis, which as we know is cell death. So that’s how radiation works. It works on cancer cells and also on healthy tissues, unfortunately. So our goal is to destroy the cancer cells as much as possible and not destroy the healthy cells, right? So the total amount of radiation, a patient needs is ordered in a Grey You’ll hear grey. That’s what it’s ordered as, and then this total dose is going to be divided. That’s called fractioning it out based off of what we think a patient can tolerate. So it can be broken up into less treatments, but higher dose. 

If someone can tolerate that or more treatments, lower dose. And that would be if it’s required to allow more time for these healthy cells to recover because the healthy cells can repair this DNA better than the cancer cells. So sometimes we need to do more treatments at the lower dose to allow the repair. So the goals of treatment ofcourse, are to destroy cancer cells, keep healthy cells healthy. It might be with the intent to cure. So you completely get rid of the cancer, to control it, or to stop spread, to prevent a microscopic spread of the disease that we can’t even see yet. Like after someone’s treated with surgery, they might get radiation to prevent growth, or it might be a palliative care to reduce pain, reduce bleeding, some way to improve quality of life, even though we’re not looking at a cure.

Radiation therapy in general can be divided into two categories: internal and external radiation.

First, we’re going to talk about internal radiation therapy, and this is also depositing a negative or positive charge, usually a proton into an atom, but instead of directly targeting it kind of like the picture I drew, it’s actually a radioactive substance that’s contained in some sort of a seed or a pill. And it’s deposited somehow into the body. And as it decays, that’s how it releases its charge, It’s radioactive charge. So brachytherapy is one way it can be high dose brachytherapy or low dose brachytherapy. Now in high dose, it’s only a 10 to 20-minute treatment in low dose. It is done over days. So this is an example of low dose. In this case, there was between 80 and a hundred seeds, radioactive seeds that were deposited. You can see them there and they’re going to decay over time. As they decay, they’re going to release the radioactive isotope and that’s going to destroy the cancer and they are needing radiation precautions during this time. 

So they’re releasing radiation. So this is when we need to do ALARA: as low as a reasonably achievable exposure to radiation. So nurses will wear a dosimeter and that monitors the amount of exposure that they have. Radioisotope therapy is another type of radiation therapy. And this is when a radioactive isotope is actually ingested or injected. An example is iodine-131. You might have heard of that. That’s for thyroid cancer. So this radioactive isotope is attached to iodine that goes straight to the thyroid, and then it delivers this radiation to it. Or there’s also monoclonal antibodies. That’s a good example that will be targeted towards a tumor. And then their radiation will work directly on that tumor and people are doing this radiation or radioisotope therapy. We also need to prevent exposure to staff and family members. So to do that, we need to reduce the time that we’re around people. But we need to increase the distance from people while they’re undergoing this treatment. And then we need to educate about hygiene to prevent exposure.

Now, external radiation, there’s a lot of different types of external radiation therapy. We’re just going to talk about it kind of in general terms. So external radiation passes through the body, and this is a diagram of what a treatment room might look like. So the patient is going to lie right on the bed. There we go. My person is kind of funny there. It’s important that they are in the exact same position every single time that they get treated for radiation. And they have little tattoos on them actually, and that directs their radiation to directly where that radiation needs to go. So these markings on the skin tell their radiologists this is exactly where we’re treating this cancer. They are not radioactive after receiving treatment. So that’s important. They do not need to do radiation precautions. We talked about that detailed planning. So the patient gets a tattoo. A whole diagram is made to determine what sort of treatment they’re going to receive. And it takes time. That’s an important thing. I talked to several radiation-oncology nurses, and that’s the big thing that they say is sometimes patients expect this to happen overnight, like going for an X-Ray, but it takes days to make a proper plan even weeks to make a good plan for a patient to receive radiation. 

And I had mentioned there are several different types of radiation. So I just want to mention some of them, um, image guidance. So sometimes we use an MRI or a CT scan directly, um, before every single treatment to make sure that we’re, um, treating the exact correct spot or there are certain things that can guide the radiation to a direct spot that might be a special head ring. If we’re delivering it to the brain, there can be things that are actually injected to guide the radiation. And then there’s also total body irradiation. And that’s what I see most often when I treat patients who are getting STEM cell transplants because that’s part of their transplant protocol before they receive the new cells. Everything gets wiped out by total body irradiation and then also there is radiation that’s given in the OR to an exposed organ, they’ll get one treatment of radiation. So those are some types of external radiation.

Okay. Let’s talk about an assessment of what we’ll see with these patients receiving radiation treatment. So we might see some general or site-specific. These both occur early they’re called acute reactions and they usually occur after two weeks of getting treatment. General things we’ll see is fatigue, general fatigue from cells being destroyed. Another general side effect we often see is skin irritation in the area that’s being treated. And these radiation burns can be pretty severe. The radiation oncologist is going to order exactly what they want to treat the skin irritation with. But it’s important to know that usually there’s really not a whole lot that we can do. We just kind of have to let these cells recover. Site-specific is going to be depending on what site is treated. So for treating the brain, we might see things like hair loss directly around that, and that can actually be permanent. Or we might even see cognitive changes depending on the area of the brain that’s being treated in head and neck cancer. We might see impaired swallowing. That’s a big one. Sometimes people even get feeding tubes, dry mouth, mouth sores, that sort of thing. And for doing chest radiation, we might see a cough, or swollen breasts is another thing. And then if the radiation is going to the abdomen and that’s when we see nausea, vomiting, diarrhea, GERD, that sort of thing. Now late permanent changes. This is what we really don’t want to see more than six months later, we’re still seeing things. And this can be from necrosis, basically, tissue death that was not able to recover. So it can impair organ function. That would be a big one or a late permanent change that we never want to see, but we can see sometimes is the secondary tumor forming. This is very rare and it seems more often in children actually.
So patient education about radiation safety: we talked about as low as reasonably achievable, right? Time, distance, hygiene, site-specific side effects. It’s important to know what type of radiation your patient is getting and where they’re getting it, then we can talk to them about side effects and available resources. Your radiation oncology nurses are very great resources and they can direct you towards different resources to give your patients. American Cancer Society is one source that has great information.
Now, nursing concepts that we talked about cellular regulation at the anatomic level, right? The way that we disrupt the negative and positive charge. Patient education is really specific to the site that’s being treated and then tissue and skin integrity. That’s a huge one. With those radiation burns. We need to teach our patients just to keep it clean and dry and just wait for it to heal basically. 

So some key points with radiation therapy, there is internal and external radiation. There are very different side effects which are going to depend on which one you’re getting.  Also, radiation safety. We need to talk to our patients about how to avoid exposure to other people and nurses to avoid exposure, right? And then we need to know our goals of treatment. Are we treating for palliative? Are we treating for cure? It’s important to know that. And then the most important one is we want to destroy cancer cells, but keep healthy cells healthy, allow healthy cells to recover. Right. All right guys, that’s all I have about radiation today. I hope you learned a lot. We love you. Go out and be your best self today and as always happy nursing.

 

 

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