During the 20th century, radiation oncology burgeoned from the experimental application of basic X-rays to a specialized high-tech discipline delivering sophisticated cancer treatments. Today, nearly 60% of cancer patients receive radiation therapy (also called radio-therapy) aimed at the specific area where the tumor is located. This article provides a basic overview of radiation therapy, including the various radiation types, side effects, nursing interventions, and patient and family teaching.
Goal of therapy
The goal of radiation therapy is to kill cancer cells using the least amount of radiation possible, with treatments spread over an appropriate period. Unlike the low-dose radiation emitted by standard X-rays, radiation therapy delivers high doses capable of destroying cancer cells, rendering them unable to reproduce and spread. Cell damage occurs immediately; cancer cells die over a period of days, weeks, and months and are eliminated by the body. Usually, healthy cells in the radiation treatment field are able to recover.
Professionals involved in the care of patients receiving radiation therapy include radiation oncologists, cancer nurses specializing in radiation, physicists, radiation therapists, dosimetrists, clinical trial specialists, social workers, dietitians, care coordinators, and spiritual advisors. A radiation oncologist orders radiation therapy. The total radiation dose is fractionated (given in fractions) rather than all at once, giving normal cells a chance to recover. Each dose that’s delivered is termed a fraction. (See Basic radiation terms defined by clicking on the PDF icon above.)
The radiation oncologist and staff involved in planning treatment develop an individualized plan for each patient, including the number of fractions and the amount of radiation administered in each fraction. This approach takes maximum advantage of the difference in radiation tolerance between normal tissues and the patient’s specific cancer type. Typically, radiation therapy is done on an outpatient basis, but occasionally hospital inpatients may receive it. In this case, the radiation oncology staff coordinates the patient’s care and treatment delivery with the inpatient staff.
Patients usually receive daily treatments over several weeks. For some, radiation is the only treatment needed. For others, it’s one treatment in a complex multimodality approach, which might also include adjuvant treatments, such as surgery, chemotherapy, or bone marrow transplant. When a cure isn’t possible, palliative radiation may be given to shrink the tumor, which reduces tumor pressure on surrounding tissues and relieves pain. For example, in patients with brain tumors, palliative radiation typically eases headache, nausea, double
vision, and balance loss.
Typical course of radiation
Radiation usually is given daily for 5 days per week for 5 to 8 weeks. Palliative courses may be much briefer. Weekend breaks in treatment allow normal tissue to repair itself.
The total number of fractions administered depends on:
- tumor size and location
- cancer type
- reason for treatment
- patient’s overall health
- other treatments the patient is receiving.
Once therapy begins, daily treatment lasts about 15 to 30 minutes on average. Generally, radiation doesn’t hurt when administered. The patient doesn’t feel or taste anything and hears nothing except the treatment machine. However, if an area near the optic nerve is radiated, patients may see flashes of light and vivid colors from stimulation of the visual cortex. Rarely, patients report an ozone-like odor, a feeling of warmth, or a buzzing sensation.
External vs. internal radiation
Radiation therapy may be delivered externally or internally. Some patients, such as those with cervical or endometrial cancer, may receive both external and internal radiation. For external-beam radiation, the machine delivers high-energy radiation beams from outside the body to the cancer site.
Internal radiation (also called brachytherapy) involves an implant—a small wire or pellet that’s placed in an applicator and inserted into the body within or near the tumor. Brachytherapy commonly is used to treat prostate and cervical cancer. Radiation from the implant doesn’t travel much further than the localized treatment area and has little effect on normal surrounding tissues. (See Brachytherapy for breast cancer by clicking on the PDF icon above.)
Sometimes internal radiation is used after surgical tumor removal to help ensure any remaining cancer cells are killed. The implant may be permanent or removed after treatment. Radiation from permanent implants poses a miniscule risk of radiation exposure to others. Even so, healthcare providers should consider precautions, such as instructing the patient to stay away from small children and pregnant women, especially during the time it takes for the implant’s radioactivity to decay to safe levels (a period that varies with the type of radioactive material in the implant). Encourage patients to ask providers specific questions about radiation safety.
In another type of internal radiation, a radioactive liquid, tablet, or injection that causes systemic effects is administered; radioactive iodine for thyroid cancer treatment is one example. The patient may be hospitalized for this therapy, with specific radiation safety precautions in place.
Before radiation treatment begins, the radiation oncologist orders a simulation to map out exactly where the radiation needs to be delivered. To help mark the exact radiation spot, a pinhead-sized permanent tattoo may be placed on the patient’s body. After the simulation, the information is presented to the treatment planning team. When the plan is completed, the radiation oncologist reviews all the data and either approves or reevaluates the plan. Multiple checks of the treatment plan help ensure high-quality care and appropriate treatment.
Teaching is a primary responsibility of nursing care for radiation patients. Patients and families must know what to expect, get a chance to ask questions, and have those questions answered to their satisfaction. In some facilities, patients and families can tour the radiation department on designated days to become familiar with the facility and learn about the treatment process. (See Key teaching points for radiation patients by clicking on the PDF icon above.)
Other nursing interventions include the following:
- Monitor and assess the patient’s pain level using a standard 0-to-10 pain scale. Note what pain medications the patient takes and whether these are effective. If the patient is taking prescription analgesics, ask about constipation; as needed, use an effective bowel-care protocol. Know that patients shouldn’t go more than 3 days without a substantial bowel movement.
- If appropriate, refer patients with fatigue for physical therapy, which can ease fatigue and improve stamina.
- Obtain a complete list of the patient’s medications and monitor for drug interactions. Stress the importance of informing all healthcare providers of medication changes.
Radiation can cause skin irritation resembling a sunburn on a cold day. The skin may redden or darken and blisters may develop. Recommend the use of skin-care products that hydrate the entire treatment area, but instruct patients to avoid applying them within 2 hours before treatment because they may exacerbate skin irritation caused by radiation. Hydrogel pads also are effective in reducing heat and improving comfort. If more severe skin irritation occurs, the radiation oncologist may order prescription medication, such as Silvadene Cream. Teach the patient to keep prescription medications out of the treatment field to avoid a radiation bolus (concentrated dose). Advise patients who experience more intense skin irritation they should be seen by a radiation-care nurse more frequently (daily or weekly) after treatment ends to monitor skin healing and the skin regimen.
Know that radiation to the head may cause hair loss and irritate the tops of the ears. Applying mineral oil to the affected areas reduces irritation.
Nutrition and hydration
Weigh patients weekly on the same scale. If appropriate, refer them to a dietitian. Be aware that patients who have difficulty swallowing and maintaining adequate nutrition and hydration may need a percutaneous endoscopic gastrostomy tube.
A dehydrated patient may require I.V. fluids. Teach the patient to report dehydration signs and symptoms, such as weakness, dizziness, and decreased urine output. If the patient reports diarrhea or vomiting, assess for volume depletion and check orthostatic vital signs and weight. Document the color of the patient’s urine. Be aware that patients who complain of dysuria may require a urinalysis to rule out infection.
If your patient has prolonged watery diarrhea, consult the primary healthcare provider about ordering antidiarrheal drugs and perhaps a low-residue diet.
Patients with prolonged nausea and vomiting need antinausea medication to prevent dehydration
Interventions by cancer type or radiation site
Breast radiation: Advise the patient to avoid bras with underwires, nylon, or lace. Instead, recommend a breathable cotton bra or camisole. Tell patients they may use deodorant but should avoid shaving the armpits to avoid skin irritation.
Head or neck: If the patient complains of dry mouth, suggest an oral mouthwash, such as a solution of 1 qt of water, 1 tsp of salt, and 1 tsp of baking soda. Instruct the patient to swish it in the mouth and spit it out, repeating several times a day. Some patients may need a prescription mouthwash. If appropriate, advise patients to see a dentist before radiation treatment starts to check for severely decayed teeth or an oral infection, as these could be a source of infection during treatment.
Brain tumor: Assess the patient for neurologic impairment, such as a change in level of consciousness, speech, vision, balance, or strength. Check for numbness, tingling, and seizures. Recognize that any change from baseline assessment findings requires intervention.
Bone involvement: Assess the patient’s pain level; effectiveness of pain management interventions; and extremity strength, numbness, tingling, and range of motion. Caution patients that a bone tumor impairs bone integrity, setting the stage for fractures.
Pelvic cancer: For younger patients with pelvic cancers (both male and female), provide information about sexuality and possible infertility before radiation treatment begins. As appropriate, teach them about banking sperm or egg-harvesting options.
Radiation side effects
Helping patients and families manage side effects is a key nursing responsibility. Unlike the systemic side effects of chemotherapy, radiation side effects are specific to the treatment site. Make sure your patient receives an explanation of the treatment and its potential side effects. (See Radiation side effects at a glance by clicking on the PDF icon above.) Keep in mind that not all patients experience the same side effects. Every patient is unique and may have comorbidities that can complicate the treatment picture.
A cancer diagnosis affects not just the patient but the entire family. Remember that in their view, there’s no such thing as a “minor” cancer. A cancer diagnosis causes fear, uncertainty, and anxiety; many patients and families feel powerless and even hopeless. They may experience grief over life plans altered or completely eliminated by the disease. They may have financial concerns, too. And once treatment ends, they may wonder if the cancer will return.
Patients need guidance, education, and support from nurses to navigate the healthcare system and the cancer-care continuum. Provide education, encouragement, problem-solving help, and resource assistance to them and their families. Listen empathetically as they express their concerns, and provide support to help them cope with the emotional highs and lows of cancer diagnosis and treatment. As appropriate, work in collaboration with pastoral staff, social services staff, and counselors. Suggest the patient use stress-relieving techniques, such as keeping a journal or meditating. At some cancer treatment facilities, nurses highly trained in the care of radiation patients meet with each patient at least weekly. The patient also meets weekly with the radiation oncologist. Such meetings help patients feel more comfortable with their treatment.
Some cancer treatment programs also offer peer navigators—cancer survivors trained to work with newly diagnosed patients. Navigators mentor the patient and provide ongoing emotional support. They’ve “walked the walk” and can relate to patients on a deeper level.
Reentering life after cancer treatment can be challenging. Families may expect the patient to “get over it” and “get on with life.” To help patients and families manage posttreatment expectations, point them toward local support groups as appropriate. Although support groups aren’t for everyone, many patients benefit from meeting with others who have a similar diagnosis. Inform them about credible cancer websites, such as those of the American Cancer Society, National Institute for Cancer, and Susan G. Komen Foundation. Caution them that some websites offer questionable information that only serves to promote false hope or false claims and generate fear.
More treatment options than ever are available to cancer patients. To promote high-quality care, keep up with changes in this field to expand your radiation knowledge—so you can offer patients the care, support, and education they need during this time of crisis.
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Rebecca Ruppert is a palliative care nurse at Salem Hospital in Salem, Oregon. When she wrote this article, she was a care coordinator at the Salem Cancer Institute in Salem, Oregon. The planners and author of this CNE activity have disclosed no relevant financial relationships with any commercial companies pertaining to this activity.