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Course: Oncology Nursing�Topic: Radiotherapy in Cancer Treatment Part 1

The Nurses International Community

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Module Goals

Learners will be able to:

Recognize the concepts of applied radiation physics and radiation biology.
Describe the factors influencing the selection of radiotherapy for cancer.
Discuss the role of radiotherapy in the treatment and palliation of cancer.
List the methods for delivering radiotherapy.
Describe the radiation safety principles to limit exposure to ionizing radiation for radiotherapy personnel, people affected by cancer and the general public.

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Radiation Physics

EPA, n.d.. Radiation Basics.
USNRC (2020).

Radiation is energy emitted when unstable atoms transform into stable state¹
Two types: Ionizing and Non-ionizing¹
Ionizing radiations cause damages to the cells/DNA when exposed to them^1,2

Alpha particles: Cannot penetrate skin
Beta particles: Can penetrate skin, cause burns
Gamma rays: Penetrates entire body
X-Rays: Less penetrating than Gamma rays, more penetrating than
Neutron particles²: Highest penetration ability compare to above

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Radiation Biology

Radiotherapy uses x-rays, gamma rays, electron beams, or protons, to destroy cancer cells
Radiotherapy destroy cancer cells two ways:

Direct damage to the atoms that make up DNA cause impiaired cellular functioning or cell death
Indirect damage is caused by interaction of ionising radiation with the molecules of the cellular fluid that impair cellular function

Radiotherapy kills cancer cells after:

Weeks of treatment needed before DNA damage
Cancer cells keep dying for weeks/months after radiation therapy ends

EdCaN module: Fundamental of radiotherapy in cancer, Key concepts of radiobiology.
National Cancer Institute (2019).

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Basic Principles of Radiobiology

EdCaN module: Fundamental of radiotherapy in cancer, Key concepts of radiobiology.

Reoxygenation: Reoxygenation of cells, that occur during radiation delivery in multiple fraction, make them more radiosensitive.
Redistribution: Cells synchronized in resistant phases of cell cycle redistribute to more sensitive phase during subsequent doses of radiation.
Repopulation: Cells responding to lethal injury by repopulating or regenerating.
Repair: Following sublethal cellular injury that damage the DNA, cell can be repair by enzymatic processes.

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Radiotherapy in Cancer

Radiotherapy can be used as cure, control, and palliation in terms of:

Organ preservation
Quality of life
Survival outcomes
Effective palliation of symptoms

Used alone or as an effective neoadjuvant and adjuvant treatment with Surgery, Chemotherapy, Hormonal therapy
A significant proportion (approximately 50%) of the population undergoing radiotherapy are treated palliatively to

manage local recurrence
palliation of unresectable tumours

EdCaN module: Fundamental of radiotherapy in cancer, Role of radiotherapy in cancer control.

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Radiotherapy in Cancer

Palliative indications for radiotherapy may include:

Treating pain from bony metastases and pathological fractures
Providing relief from symptoms caused by cerebral metastases
Relieving spinal cord compression
Relieving superior vena cava obstruction
Control of bleeding
Reducing fungating lesions

EdCaN module: Fundamental of radiotherapy in cancer, Role of radiotherapy in cancer control.

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Why is understanding of Radiophysics/Radiobiology important for nurses?

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Main Types of Radiation Therapy

SEER Training Modules,

Types of Radiation Therapy.

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External Beam Radiotherapy (EBRT)

EdCaN module: Fundamental of radiotherapy in cancer, External beam radiotherapy (EBRT).
SEER Training Modules,

Types of Radiation Therapy.

Radiation delivered through linear accelerator from outside the body, directed at the patient’s cancer site^1,2.
Linear accelerator machine generates radiation 1000 times greater than diagnostic X-ray unit¹.
Different levels of radiation used²:

Low-energy radiation does not penetrate deeply.

mainly treat surface tumors like skin cancer.

High-energy radiation treat deeper cancers

Patient’s do not see or feel the actual treatment, it is painless².

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External Beam Radiotherapy (EBRT)

Image scans first analyzed to precisely plan treatment area.
After analysis, radiation beams are designed to conform to the shape of the tumor.
Radiation delivered from many directions to precisely treat tumor while sparing normal tissue.
Some techniques can:

use images while radiation treatment is being delivered.
alter strength of some beams to increase the dose of radiation to certain parts of tumor.

EdCaN module: Fundamental of radiotherapy in cancer, External beam radiotherapy (EBRT)

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Gamma Knife

EdCaN module: Fundamental of radiotherapy in cancer, Gamma knife.
SEER Training Modules,

Types of Radiation Therapy.

Non-invasive alternative to neurosurgery¹.
Uses radioactive sources to predominantly treat brain tumors¹.
Treats both benign and malignant tumors^1,2.
Multiple lesions are also treated simultaneously and accurately¹.
A total of 201 beams of radiation intersect to form a powerful tool focused on a targeted area of abnormal cell².
Highly precisewhich damages unhealthy tissues while sparing adjacent normal healthy tissue^1,2.

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Internal Radiation Therapy (Brachytherapy)

EdCaN module: Fundamental of radiotherapy in cancer, The role of radiotherapy in cancer control.
SEER Training Modules,

Types of Radiation Therapy.

Temporary or permanent placement of a sealed or unsealed radiation as close to tumore as possible^1,2.
Intention of this type of treatment¹:

Preserve of vital organ function.
reduce damage to surrounding tissues.
Improve control of local disease.
Treat areas that may be at high risk.

Radioactive sources (isotopes) are in form of wire, seeds (or molds), or rods².

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Types of Internal Radiation Therapy

Low-dose rate (LDR) implants:

Radiation source stays in place for 1-7 days
Patient likely to be in hospital during this time
Applicator or catheter removed after treatment completion

High-dose rate (HDR) implants:

Source left in place for 10-20 minutes at a time and taken out
Twice a day for 2-5 days, OR once a week for 2-5 weeks
Patient stay in hospital whole time, OR make daily trips

Permanent implants:

Radiation source put in place remain in patient’s body permanently
Radiation gets weaker every day, take safety measure first few days

National Cancer Institute, 2019,

Brachytherapy to Treat Cancer.

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Techniques of Internal Radiation Therapy

SEER Training Modules,

Types of Radiation Therapy

Interstitial brachytherapy:

Implanting radioactive needles/wires in tumor area.
May be put in and out same day, OR removed after several days or left permanently.

Intracavitary brachytherapy

Using metal/plastic applicator the radioactive sources is after-loaded into body cavities to irradiate walls of the cavity/nearby tissues.
Applicator removed after specified dose of radiation is delivered to tumor.

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Techniques of Internal Radiation Therapy

SEER Training Modules,

Types of Radiation Therapy.

EdCaN module: Fundamental of radiotherapy in cancer, The role of radiotherapy in cancer control.

Intraluminal brachytherapy¹:

Specially designed tube or applicator is inserted into the lumen to deliver radiation.

Radiopharmaceuticals²

Unsealed radioactive sources given orally or by intravenous injection
All body fluids are radioactive after administration.

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Factors Influencing Selection of Radiotherapy

Tumor related factors:

The site of the cancer
An histologically-proven cell type
The grade and stage of the tumour
The radiosensitivity of the tumor

Individual factors:

Co-morbidities
Performance status
Lack of suitability for surgical resection or anesthesia

EdCaN module: Fundamental of radiotherapy in cancer, The role of radiotherapy in cancer control.
EPA, n.d.. Radiation Basics.

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Take a moment and think…..

Who Needs Protection From Radiation Sources?

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Radiation Safety Principles

Time:

Less time spent near the radiation source, less radiation absorbed.
Nurse should restrict contact to 30 minutes per eight hour shift.
First responders can use alarming dosimeters.

Distance

Intensity of radiation decreases with increase in the distance from source.
Using remote afterloading technique where possible.
If possible, patient to be encouraged to collect his/her own urine or stool sample.

EdCaN module: Fundamental of radiotherapy in cancer, Principles of radiation safety.
Stanford University,

Environmental Health & Safety.

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Radiation Safety Principles

EdCaN module: Fundamental of radiotherapy in

cancer, Principles of radiation safety.

Shielding:

Type of shielding device used depends on the type of radioactive source emitted
Standard shielding devices include personal protective equipments (PPEs) like-
lead aprons, thyroid shield, and eye shields
Radioactive sources to be transported only by licensed personnel in lead containers
Brachytherapy undertaken in specialized unit with appropriate facilities
Patient generally isolated in a single room

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Radiation Safety Principles

Spill management:

‘Spills’ generally refer to the loss of body fluid (urine/vomit) within 48 hours after ingestion of radioactive substance.

classified as major or minor.
significant amount of fluid loss (emesis/urine) within 24 hours would be defined as major spill.

Appropriate procedures and notifications must be followed in the event of loss or radiation source or a spill.
Spill management must be clearly outlined in the clinical environment as part of radiation safety and hospital policy.

EdCaN module: Fundamental of radiotherapy in

cancer, Principles of radiation safety.

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Radiation Safety Principles

Radioactive waste disposal:

Disposable items such as plates,eating utensils to be used whenever possible
Used bedclothes, towels, bed linen should be placed in a laundry bag and left in patient’s room for monitoring
Urine/stool/emesis may be disposed through toilet by flushing
Radioactive waste collected in double plastic bags and disposed in labeled disposal containers for radioactive wastes
Radioactive waste is handled and disposed by trained personnel wearing necessary PPEs

Stanford University, Environmental Health & Safety.
University of California, n.d., How to Store and Dispose of Radioactive Waste.

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Nurse’s Role in Radiation Safety

Be knowledgeable of the radiation safety protocols of the unit.
Limit contact time with high-dose brachytherapy patient.

Stay only for the time required for the task to be done.
Limit contact time to less than 30 minutes per 8 hour shift.

Wear proper shield/PPE where appropriate while caring for radiotherapy patient.
Follow appropriate protocol to manage ‘Spill’ and disposal of radioactive waste.

EdCaN module: Fundamental of radiotherapy in cancer, Principles of radiation safety.

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Nurse’s Role in Radiation Safety

Provide patient/family education on how to stay safe during high doses brachytherapy:

Patient may need a separate room in the hospital.
Families/visitors not permitted when the radiation is first placed.
Must check with the hospital staff before going to patient room.
Keep visits as short as possible - 30 mins or less each day.
Pregnant women and children below one year old should not visit.
Limit contact with other people as much as possible.

National Cancer Institute, 2019, Brachytherapy to Treat Cancer.

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What should the nurse do first when the patient vomits right after the first high dose radiation therapy ?

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Reference:

Cancer Australia (2018). EdCaN module: Fundamentals of radiotherapy for cancer/Brachytherapy. version 2.2. Retrieved from: https://www.edcan.org.au/edcan-learning-resources/supporting-resources/radiotherapy/treatment-delivery/brachytherapy

Cancer Australia (2018). EdCaN module: Fundamentals of radiotherapy for cancer/External beam radiotherapy (EBRT). version 2.2. Retrieved from: https://www.edcan.org.au/edcan-learning-resources/supporting-resources/radiotherapy/treatment-delivery/external-beam-radiotherapy

Cancer Australia (2018). EdCaN module: Fundamentals of radiotherapy for cancer/Gamma therapy. version 2.2. Retrieved from: https://www.edcan.org.au/edcan-learning-resources/supporting-resources/radiotherapy/treatment-delivery/gamma-knife

Contact info: info@nursesinternational.org

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Reference:

Cancer Australia (2018). EdCaN module: Fundamentals of radiotherapy for cancer/Key concepts of radiobiology. version 2.2. Retrieved from: https://www.edcan.org.au/edcan-learning-resources/supporting-resources/radiotherapy/radiobiology

Cancer Australia (2018). EdCaN module: Fundamentals of radiotherapy for cancer/Principles of radiation safety. version 2.2. Retrieved from: https://www.edcan.org.au/edcan-learning-resources/supporting-resources/radiotherapy/service-delivery/radiation-safety

Cancer Australia (2018). EdCaN module: Fundamentals of radiotherapy for cancer/The role of radiotherapy in cancer control. version 2.2. Retrieved from: https://www.edcan.org.au/edcan-learning-resources/supporting-resources/radiotherapy/role-in-cancer-control

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Reference:

Environmental Health & Safety (n.d.). 11.2 Therapy Patients Treated with Radiopharmaceuticals - Nursing Care Specific Instructions. Stanford University. Accessed from: https://ehs.stanford.edu/manual/radiation-protection-guidance-hospital-staff/therapy-patients-treated-radiopharmaceutical

National Cancer Institute (January, 2019). Brachytherapy to treat cancer. Accessed from: https://www.cancer.gov/about-cancer/treatment/types/radiation-therapy/brachytherapy

National Cancer Institute (January, 2019). Radiation therapy to treat cancer. Accessed from: https://www.cancer.gov/about-cancer/treatment/types/radiation-therapy#HRTWAC

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Reference:

SEER Training Modules, Cancer Treatment: Radiation Therapy/Types of Radiation Therapy. U. S. National Institutes of Health, National Cancer Institute. Accessed on 29 March 2021, from: https://training.seer.cancer.gov/treatment/radiation/types.html

United States Nuclear Regulatory Commission, March 2020, What are the different types of radiation?.Accessed From: https://www.nrc.gov/reading-rm/basic-ref/students/science-101/what-are-different-types-of-radiation.htm l

University of California - Blink, n.d., How to Store and Dispose of Radioactive Waste. Accessed from:https://blink.ucsd.edu/safety/research-lab/hazardous-waste/radioactive.html#Dry-waste

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Reference:

US Environmental Protection Agency (EPA), n.d., Radiation Basics. Accessed from: https://www.epa.gov/radiation/radiation-basics

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