Radiation Oncology Nursing Care Helen Lusby Radiation Oncology Nurse BAROC 2012
Definitions Radiation Therapy: Treatment of cancer using x- ray particles that cause ionisation within the cells. External beam treatment which uses either electrons or protons generated by the Linear Accelerator. Electrons: penetrates approx: 5cms skin/boost to tumour site Photons: Penetrate deeper through tissue. may be used independently or concurrently with electrons
Radiotherapy Radiotherapy is the treatment of cancer using ionizing radiation. The goal of radiation is to destroy or inactivate cancer cells while preserving the integrity of normal tissues within the treatment field.
Radiotherapy Indications It is estimated that as a benchmark, about 60% of patients with cancer will require radiotherapy at some stage during their disease course Usage may be: Radical / Definitive (H+N cancers / Prostate cancer) Palliative Treatment(bone mets, brain mets, painful soft tissue deposits, control of bleeding) Combined/Adjuvant
Radiotherapy 101 To understand the concept of Radiotherapy, we need to understand the cell cycle Cells not dividing Go stage The cell cycle is important b/c cells have varying sensitivity to RRx induced damage depending on what stage of the cycle, they are at. Go, G1, S, G2, M NB chemo agents and cell cycle
Radiosensitivity 1. Cells are most sensitive at or close to mitosis. 2. Resistance is usually greater in the latter part of S phase. 3. If G1 has an appreciable length then a resistant period is evident early in G1 followed by a sensitive period toward the end. 4. G2 is usually sensitive, perhaps as sensitive as M phase
Radiotherapy - ionization Radiotherapy is the treatment of cancer using ionizing radiation Atoms, composed of a nucleus with protons and neutrons POSITIVE charge Orbiting the nucleus are electrons with a NEGATIVE charge These two opposing charges making the atom electrically neutral. Radiation disrupts this stability.
Radiotherapy DIRECT Ionization may cause breakage/damage in one or both chains of the DNA molecule INDIRECT a chain of chemical reactions take place in the water surrounding the cells free radicals are formed which break chemical bonds and trigger chemical changes which leads to biological damage
Radiotherapy - Techniques Conventional RT 3D Conformal RT Combines modern imaging with computerised planning to optimise tumour/organ location Standard dose and standard technique, spine 20:5 Conformal Tailored sheilding to conform to the treatment field to the Planning Target volume. -.
IMRT Intensity Modulated Radiotherapy The intensity of the radiation beam is adjusted throughout the course of treatment. A more conformal dose distribution around irregular targets in enabled with greater sparing of surrounding organs. IGRT Image Guided RT used in combination with other treatments, this allows the use of images taken at time of treatment to be analysed and then machine localized to correct position. Commonly used methods include gold seed fiducial markers with daily portal X-rays.
The concept of Fractionation The reason why courses are protracted and doses fractionated are radiobiological in nature and can be summarized via the 4 R s Radiosensitivity Repair Re-oxygenation
Repair Repair refers to the ability of the cells to recover from sublethal radiation injury Generally occurs within 24 hours and possibly in as few as 6 hours. Normal cells can repair between daily doses of RRx Tumour cells may repair initially but become less capable of repair as treatment is protracted
Re-population Repopulation occurs when irradiated cells are able to complete the cycle and undergo successful mitosis b/w RRx Regeneration of healthy cells continues after repair of sublethal injury allows mitosis to take place, Tumour cells are more likely to die during mitosis as the result of lethal RRx damage Successive daily doses of radiation given at regular intervals help to disrupt the tumour cell cycle causing division delay.
Redistribution Redistribution of the cells in the cell cycle theoretically brings surviving cells into synchrony, with more of them in the sensitive (M) phase of the cell cycle with each successive radiation dose. Healthy cells are less likely to be subject to redistribution
Re-oxygenation Re-oxygenation is the process in which radio-resistant hypoxic tumour cells become radiosensitive aerated cells between doses of a fractionated course of radiation The presence of O2 in the cell at the time of irradiation greatly increases the lethal affect of ionisation
Radiotherapy Treatment regimes Prostate- 78Gy:39# s (Gold seeds) Salvage prostate- 70Gy:35# s Breast 50Gy:25# s with 10Gy electron boost Breast 42.5Gy:16# s (2.66Gy) + Boost Lung 60Gy 66Gy High Dose palliative lung 36Gy:12» 30:10
Treatment Regimes Oesophagus 50.4Gy:28# s Head and Neck 66Gy:33# s Bladder TCC 60Gy:30# s Brain - 50.4Gy:28# s 60Gy:30# s Rectal 54Gy:30# s
Planning of Treatment Visit to BAROC Mould Room Visit to CT scan x-ray department (nondiagnostic ct scan) MRI scan PET scan - Positron Emmission Tomography Planning can take 7-10 days Nursing education
Patient stabilisation
Patient stabilisation
Treatment Radiotherapy is a LOCAL treatment Non painful Non invasive Daily treatment Local treatment = Local reactions Reaction is dependant on dose of radiation
Responsibility: The goal of nursing during radiotherapy is to maximise symptom management; ensure comfort and provide emotional support Education Assessment and Monitoring Support Co-ordinate care within the multidisciplinary team Communication within inpatient team
Radiation Induced Side Effects: WHY? Radiation is not able to discriminate between normal and malignant cells The degree of damage to healthy tissue varies The response of healthy cells depends on: The rate of cell proliferation/total dose/fractionation/concomitant therapies and the patients general health
Acute Side Effects: Area being treated Total dose Dose per fraction General condition of patient Combined chemotherapy & radiotherapy Techniques used Technology used
Side effects Radiation to the gut an organ with a high proliferation rate, produces side effects within hours, while damage to the CNS may take months or years to become apparent. Radiation induced malignancies!!!!
Side Effects S/E s can occur -minutes, hours, days, months and even years after treatment S/E s are dependent on the tissues/organs irradiated and the treatment schedule involved. Whilst certain S/E s are to be expected, there is considerable individual variation in both onset and degree. Some patients effects are hardly noticeable where as in others they may be severe.
Skin Effects Basal cell loss within the epidermis layer usually begins once the radiation dose reaches 20 25 Gy. Maximum depletion of basal cells occurs when patient has received a dose of 50 Gy Skin reactions become visible within the 2 nd or 3 rd wk, reaching a peak at the end or within a week of completion of RRx
Skin effects Grading of skin reaction from Grade 1 4 Skin reaction will tend to peak towards the end of treatment, and frequently worsen after treatment is completed Skin reaction will usually settle within 2 4 weeks following completion of RRX. Upon commencement of RRx, patients will be advised to commence skin care regime using sorbolene which is an emolient and has hydrophilic properties Skin may be hyper pigmented due to stimulation or destruction of melanocytes
Specific side effects SKIN - skin care relevant to all areas basic principles MUCOSITIS/XEROSTOMIA for head and neck or mouth treatment. OESOPHAGITIS/DYSPHAGIA HAIR LOSS. only in treatment field. NAUSEA/VOMITING-dependent on site. DIARRHOEA/DYSURIA-pelvis FATIGUE. variable PATIENT education on commencement of treatment
Potential problems requiring hospitalisation 1. Uncontrolled Nausea /Vomiting 2. Dehydration 3. Pain 4. Loss of symptom control 5 Skin care 6 Adverse event eg: fever, infection (sepsis) seizure, collapse, skin reaction, rash 7. Deterioration of general condition 8. Inability to cope at home 9. Overwhelming fatigue 10. Education, Education, Education
Inpatients: Palliative Nutritional/hydration support Combined modality chemo/radiation Co- morbidities Pain control
Inpatient Nursing Management Responsibility: Baroc NCP s Identify potential reactions Observation
Patient Education: This is SITE and DOSE specific ENCOURAGE a family member/friend to be present INFORMATION about when and why things may happen PROVISION of written and visual diagrams To DISPEL myths and misconceptions Encourages early REPORTING of adverse effects and COMPLIANCE with given advice
Principles of Skin Care Moisturise hydrophilic cream Hydration & Good Nutrition Gentle cleansing Avoid : perfumes/soaps/deodorants/powders with metallic content/friction Moist wound healing
Conclusion Radiotherapy the goal is to control the cancer, spare surrounding normal tissue, preserve organs and reduce acute and long term toxicity. Nursing care is essential through out the radiotherapy process to educate, support and manage any side effects