What to Expect During Radiotherapy
The following excerpt is taken from Chapter
of Non-Hodgkin's Lymphomas: Making Sense of Diagnosis, Treatment, and
Options by Lorraine Johnston, copyright 1999 by O'Reilly & Associates,
Inc. For book orders/information, call (800) 998-9938. Permission is
granted to print and distribute this excerpt for noncommercial use as
long as the above source is included. The information in this article is
meant to educate and should not be used as an alternative for
professional medical care.
By now you have consulted with several types of oncologists and have decided
that radiation therapy is a good choice for treating your NHL. Perhaps it will
be used alone if you have a single tumor or perhaps one of several sites will be
irradiated to alleviate unpleasant symptoms such as pressure or pain. Radiation
may be used in conjunction with other therapies such as chemotherapy or
We are justifiably afraid of radiation. We know that sunlight can burn us,
that x-ray technicians leave the room and wear lead aprons when they treat us.
We know we should be wary of too many diagnostic x-rays, and that large amounts
of radiation caused tremendous damage at Hiroshima, Nagasaki, and Chernobyl. In
spite of fears about radiation, many NHL patients are pleasantly surprised to
find that radiation therapy is a smooth, quick, silent, painless treatment.
In this article we will acquaint you with a typical radiotherapy experience.
Most radiotherapy used for NHL is external radiotherapy and is administered in
the outpatient setting, so we will walk you through an outpatient treatment,
beginning with your preparation, including treatment simulation, scheduling,
arriving at the treatment office, encountering certain medical personnel and
other patients, advancing through the treatment itself, and finishing with what
you can expect afterward.
Although there are different kinds of radiation, including x-rays and
electron, proton, or neutron beams, for the sake of readability in this article
we will not distinguish among them. We will use only the term radiation.
The information this article provides is not a substitute for your doctor's
knowledge. Always ask your doctor when an aspect of your treatment is unclear,
and report immediately to your doctor any adverse reactions that arise during or
If you would like greater detail on radiation therapy, The Chemotherapy
and Radiation Therapy Survival Guide, by Judith McKay, Nancee Hirano, Myles
Lampenfeld, Making the Radiation Therapy Decision, by David Brenner and
Eric Hall, and Coping with Radiation Therapy: A Ray of Hope, by Daniel
Cukier and Virginia McCullough are books that focus on radiation therapy from
the patient's perspective.
The following sections will walk you through preparation and treatment
simulation, scheduling, receiving therapy, departure, and the days that follow
Your first one or two treatment visits to the radiation oncology treatment
offices will be spent determining precise details of how best to treat you:
positioning you on the treatment bed, marking your skin with small dots of
temporary or permanent ink, and creating shields for sensitive organs. All of
these preparations are called simulation, and may take several hours spread over
one or more visits.
Several medical specialists are involved in this stage of your treatment.
These include your radiation oncologist, the radiation therapy technician who
will administer the treatment, a dosimetrist who calculates the correct dose,
and the radiation physicist who calibrates the machine. Some of these staff
members may work behind the scenes.
For these initial visits, which are lengthy, make yourself as comfortable as
possible by wearing clothing that doesn't bind, that goes on and off easily, and
has no metal zippers. Bring a cassette player if you like, and use the restroom
before the simulation starts.
If parts of your head or neck are being irradiated, a mask or helmet may be
made to protect the areas that are cancer-free and to help you remain still
None of these preparations are painful, although some NHL survivors report
feeling a little claustrophobic if they have a mask or helmet made, or
uncomfortably stiff if they have to hold still for a long time. The substance
used to make masks and helmets takes a few minutes to harden and must harden on
your head in order to provide an exact fit. While you are able to breathe
normally with them in place, during this time you must hold quite still.
Special shields or blocks may be made to shape the radiation beam to match
exactly your tumor's shape. Beams of invisible radiation generated by the
machinery are usually emitted shaped like rectangles, from two to fifteen inches
in any dimension. If these beams were trained against your tumor, nearby healthy
tissue within the two- to fifteen-inch rectangle would be irradiated, too,
suffering damage. To avoid this effect, shields or blocks with cutaways in the
silhouette of your tumor are created using your x-ray films as guides.
The masks and shields made for you are used only by you. You may see the same
kinds of devices belonging to other patients hanging nearby or in other
The machinery used during simulation looks and moves just as the genuine
radiation equipment does, but instead it generates only a plain light beam to
verify positioning, ink markings, and the fit of masks and shields.
After all shields, blocks, masks, or helmets are made and your skin is
marked, the entire simulation will be repeated with all pieces in place--exactly
like a dress rehearsal.
As your treatment progresses and your tumor shrinks, new blocks may be made
to match the new shape of your tumor, and these simulations may be repeated.
Radiation therapy often makes many patients increasingly tired as it
progresses. For this reason, once treatment starts, it would be wise to have a
friend or loved one along, not only for emotional support, but to handle issues
such as saving written instructions for diet and aftercare, understanding and
remembering verbal instructions, communicating insurance information and
handling the co-pay, if any, and assisting with the drive home.
If the area near your stomach is being irradiated, it's best to eat very
lightly beforehand and to arrive with an empty stomach. This will reduce the
chance of nausea.
Ask the medical staff about using cosmetics, antiperspirants, aftershaves,
and lotions before treatment. They may interfere with treatment, or they may
cause your skin to become hypersensitive if they are exposed to radiation.
Ask as well about clothing with metal zippers, removable dentures,
pacemakers, surgical staples, and contact lenses.
Years of research have shown that a large amount of radiation can be
delivered to a tumor safely if it's spread out over several weeks. This is
called fractionating the dose, or simply, fractionation. It spares healthy
tissue from unnecessary damage and gives it time to recover.
Dosage fractionation means that you will have to visit the treatment center
several times a week, or perhaps every day, for two to six weeks, depending on
your treatment plan. It also means that each dose of radiation lasts only two to
four minutes. If your tumor is irradiated from several different angles, each
angle may take two to four minutes after the machine is repositioned. After the
lengthy time spent in simulation, you may feel that ten to thirty minutes of
treatment time is an anticlimax.
Don't be surprised if the schedule on which your radiotherapy is administered
differs from the schedules you hear others discussing, because your radiation
schedule always is tailored to your particular circumstances, based on the size,
number, and location of tumors, your overall health, your body size, and the
subtype of NHL you have.
Depending on what treatment is being used, the timing of your radiation
therapy may be influenced by the quantity of white blood cells remaining in your
blood after your last treatment. Thus, for certain regimens that expose a lot of
bone marrow or the spleen to radiation, your blood may be tested when you
arrive, using a standard measurement known as a complete blood count (CBC). If
your white blood counts are too low, treatment may be delayed a few days or a
For each treatment, you might want to call the treatment center before
leaving home or work. Radiation therapy machines sustain heavy use, and must be
taken offline periodically for recalibration or repair. You can save your
valuable time by calling first to see whether appointments are running on
After a few treatments, you may begin to feel that all of your time is spent
traveling to the office or chatting in the waiting room, because treatment
itself is so brief.
If you are receiving radiation to the head, stomach, or abdomen, make a point
of discussing nausea and diarrhea medications with your doctor before
treatment starts. Although the new antinausea drugs (anti-emetics) are
excellent, ask for suppositories in case oral medications won't stay in your
stomach. If you do develop nausea, subsequent treatments may be preceded by an
injection of one of the new antinausea drugs, such as Zofran.
Ask your doctor if you should avoid possibly dangerous circumstances such as
excessive sunlight or crowds.
Ask about skin care, too. External beam radiation, the most common
radiological means of treating NHL, must pass through your skin to reach tumor
sites, and irritation may result. Newer, higher voltage equipment used today
causes less damage to skin because the damaging rays concentrate in deeper
layers, but some skin reaction still is possible.
The source of radiation will be a machine that either safely contains a
radioactive substance, such as Cobalt 60, or generates its own radiation as
needed. Like a CT scanner or a gamma camera, the radiation machine is designed
to move around you and your bed as you hold still. Many models are almost
silent, but some make a sound like a vacuum cleaner, and of course they may
click and whir as they reposition.
The room in which treatment is given has thick walls and is lead-clad to
prevent the very small amount of radiation that bounces off your shields, known
as scatter, from affecting the medical staff, those in the waiting room, and
random passersby. For the safety of the staff, the treatment room will contain
only you when the machine is engaged. (The small dose of radiation they would
sustain if they stayed with you would probably not harm them, but if they stayed
with all patients, all day, every day, the dose from scatter would indeed
accumulate to dangerous levels.)
The staff can see and hear you at all times, because there are microphones
and cameras connecting you and them. If you feel at all bad, just let them know.
Music and wall art sometimes are available in the treatment room to lower your
boredom and stress levels.
There are four ways to administer radiation therapy: external radiotherapy
(also called external beam radiotherapy), radioimmunotherapy, internal
radiotherapy, and brachytherapy. The latter two, internal radiotherapy and
brachytherapy, are seldom used for NHL, so we will define them briefly and move
Internal radiotherapy is radiation therapy aimed directly and only at your
exposed tumor while your body is open during surgery. Brachytherapy is the
implantation of a source of radiation directly into or very near the tumor.
External radiotherapy, also called external beam radiation, currently is the
most common means of treating NHL tumors, and is administered as described in
the earlier section, "The setting," using the blocks, shields, masks,
or helmets made expressly for you, along with sandbags to hold your arms and
legs still, and blankets to keep you warm.
You should feel no pain, no heat, no sensation at all during treatment,
although some survivors say that they feel a sensation of energizing--not quite
a tingling--in the area of the tumor during treatment. It may indeed be that
some of us can sense a highly active biological entity such as a tumor reacting
to the disruption of its DNA.
Some find the absence of sensation eerie, but most people are grateful that
the treatment is comfortable and brief.
Radioimmunotherapy is a new treatment, still in advanced clinical trials, but
quite promising. It combines the principle of radiation therapy with one of the
newest treatments available, tumor targeting with monoclonal antibodies.
Radioimmunotherapy involves linking one molecule of a radioactive substance,
a radioisotope such as iodine-131 or yttrium-90, to a monoclonal antibody. The
benefit of radioimmunotherapy over existing radiation treatments is that less
healthy tissue is exposed to radiation because the antibody attaches to
cancerous tissue only. Some healthy tissue is affected because the radioactive
substance decays as the antibody travels to the tumor, but it is thought that
this effect is less than that sustained during external beam therapy.
Radioimmunotherapy is administered into a vein like chemotherapy.
The correct dose of radioimmunotherapy must first be determined. To calculate
this dose, a small "tracer" amount of the substance will be injected
first, and visualized using a CT scan or other imaging device. Based on what is
seen, the doctors in charge will determine the total dose you should
You will be kept in a lead-shielded hospital room throughout this treatment,
and your body wastes will be disposed of in accordance with rules for handling
hazardous waste. Face-to-face family visits will be very limited or denied
entirely. The nurses who care for you may wear protective clothing.
If the radioisotope iodine-131 is to be used, your thyroid gland will be
shielded first, unless it has been infiltrated with NHL. The radioactive
isotope, I-131, will destroy the thyroid gland if it is absorbed.
To shield the thyroid, large doses of nonradioactive iodine,
iodine-123, are given to you first. This substance is taken up by the thyroid in
excess compared to other body tissues. After the maximum amount has been
absorbed, the thyroid cannot absorb more iodine for several days. This protects
the thyroid gland from absorbing subsequent doses of I-131.
This method of treatment is not likely to be used for those who have had
previous allergic reactions to iodine in shrimp, other foods, or in other
For external beam radiation, a typical dosage for NHL is 180 to 200
centiGreys (cGy) five times a week. If a higher dosage is required, more
sessions are added, but the dose per exposure is not raised. This moderate dose
per exposure has been determined to be the best amount for killing NHL cells
while allowing healthy cells to recover.
Different subtypes of NHL require different doses of radiation. The varying
doses depend primarily on the different sites involved, whether they are nodal
or extranodal, and the bulkiness of the tumors. Diffuse disease, for instance,
requires more radiation in order to combat growth. Other types of NHL are
unaffected by all but the most extreme doses of radiotherapy, which makes this
treatment useless against them owing to severe or fatal damage to other
After each of your first few treatment sessions, make sure you have received
written instructions regarding any necessary dietary or behavioral changes,
information about possible side effects, prescriptions, and phone numbers for
emergencies, before leaving the doctor's office. Often, side effects of
radiation therapy do not emerge until you've had two or more weeks of treatment.
If you have prepared for these possibilities by asking questions during the
treatment visits when you feel well, side effects may be easier to deal
You are not likely to feel unwell after your treatments, but if you do, do
not leave without telling the medical staff of your problem.