Prophylactic Cranial Irradiation (PCI)

Introduction

Your oncology team has recommended a course of radiotherapy to treat your cancer. Although there may be side effects, it is felt that the advantages for you outweigh the disadvantages. If you decide to go ahead, you will be asked to sign a consent form. However, you are free to change your mind at any time. If you have any questions or would like more advice, please ask a member of your oncology team.

What is radiotherapy?

Radiotherapy uses carefully measured doses of strong x-rays to treat cancer and other conditions. It works by damaging the DNA in tumour cells causing them to die or stop growing while allowing your normal cells to recover. The aim of the radiotherapy is to eradicate any cancer cells within the treated area. Therapy radiographers will look after you during the planning and delivery of your treatment.

Why am I having my brain treated?

PCI may be offered to patients with small cell lung cancer when there is no visible sign of tumours in the brain. Small cell lung cancer cells may spread to the brain in a proportion of patients. Although not visible on scans, these cells if present have the potential to develop into secondary tumours in the brain. Prophylactic cranial irradiation treats the whole brain and is given to reduce the risk of secondary brain cancer developing.

Before radiotherapy starts

Pacemakers – If you have a pacemaker, please tell your doctor or radiographer as soon as possible. We will arrange a pacemaker check before and after your treatment.

Pregnancy – It is very important that you are not and do not become pregnant while undergoing radiotherapy planning or treatment. If you think that you may be pregnant at any point, please inform your treatment team immediately.

How is the radiotherapy planned?

Radiotherapy treatment is tailored to the individual patient and requires careful planning using a CT scanner. We will make an immobilisation mask for you to wear each time you have treatment. This helps you to stay still and the reference marks we draw on the mask will be used to deliver your treatment accurately.

When you attend for your CT planning scan, please book in at the radiotherapy reception. The radiographers will ask you to confirm your name, address and date of birth and re-confirm your consent to go ahead with the proposed treatment. We may take an identification photograph, which serves as an additional check when you attend for treatment.

You may eat and drink normally and take your regular medications on the day of your scan and throughout your treatment.

We will make you comfortable on the CT couch. The mask is made by warming a plastic sheet in a water bath until it becomes soft and flexible. It is then placed over your head and secured to the couch. You will be able to breathe easily through the holes in the mask. It takes 5-10 minutes for the mask to cool and become rigid.

The radiographers will then perform a CT scan of your head while you are in the mask. It is important that you remain as still as possible. You will not need to hold your breath. The radiographers will leave the room to switch the machine on but will be watching you through a glass window and on monitors. They can also speak to you via an intercom.

If you need help, raise your arm. The machine can be switched off and the radiographers can return to the room to assist you. The bed will move in and out of the scanner a few times and you will hear the machine buzzing. You will not feel anything and the machine will not touch you.

When the scan is complete, we will remove the mask and store it until you are due to have your radiotherapy treatment. You will not need skin tattoos. All reference marks will be drawn on the mask.

Contrast injection

Occasionally it is necessary to give you a contrast injection during the scan. A liquid dye is injected into a vein in your arm. This helps to provide a clearer picture of your internal anatomy and blood vessels.

When will my radiotherapy treatment start?

In your absence, the oncologist, radiographers and physicists will produce a personalised plan using your CT scan. Radiotherapy usually starts within 1-2 weeks of your planning scan.

What will happen on my first day of treatment?

When you arrive for your first treatment, please book in at the radiotherapy reception. A radiographer will speak with you to discuss the treatment and how best to minimise any side effects that it may cause. They will again confirm your consent to go ahead with treatment. Please feel free to ask any questions.

Radiotherapy treatment is given by a machine called a linear accelerator (or linac). The machine is quite large and will move around you. It comes close to you but it will not touch you. The procedure will take 15-20 minutes.

The radiographers will help you to lie in the same position you were in for the planning CT. They will then place your mask over your head and secure it to the couch. The lights will be dimmed and the room laser lights used to move the couch into the correct position. Try to relax and breathe normally.

Once you are correctly positioned on the treatment couch, the radiographers will leave the room to switch the machine on. You will be alone in the room during treatment but the radiographers will be watching you on monitors. They can also speak to you via an intercom. If you need help, raise your arm. The machine can be switched off and the radiographers can return to the room to assist you.

CT or x-ray images are taken initially to ensure that the treatment will be delivered accurately. There may be a short delay while these images are being assessed. The machine will make a buzzing sound when taking images and delivering treatment but it is completely painless and will only last a few minutes.

After treatment, do not move or attempt to get off the table without assistance as it will be quite high. The radiographers will tell you when the procedure has finished, remove your mask and help you down off the table. You will not be radioactive after radiotherapy and will be safe to mix with other people including children and pregnant women.

How many treatments will I have?

Prophylactic cranial irradiation is typically given in 10 treatments over 2 weeks. Treatments are delivered once daily Monday-Friday.

How are treatment appointments arranged?

We will accommodate your time preference wherever possible. Please try to be as flexible as you can and give priority to your treatment sessions over other general appointments. The time may vary each day depending on the number of patients on the unit.

If you are scheduled to have a number of treatments, you will be reviewed by a doctor or advanced practice radiographer in the radiotherapy review clinic weekly. This may be a telephone consultation. At this appointment we will enquire about your side effects and ensure that they are being optimally managed. If you have questions or concerns about any aspect of your treatment or side effects please ask one of the treatment radiographers at any time.

What are the side effects of treatment?

The commonly seen side effects from brain radiotherapy are listed below, but the severity may vary between individuals. Side effects cannot be prevented but they can be managed. They will continue, and possibly worsen for 7-10 days after treatment has finished before they gradually start to improve. Fatigue however may persist for longer.

Smoking while undergoing treatment is not recommended. We can signpost you to smoking cessation services for advice and support.

Tiredness

Tiredness is a common side effect of radiotherapy. Radiotherapy to the brain can be particularly tiring and this may persist for a number of weeks after treatment has finished. Listen to your body. You may need to rest and relax more than usual, particularly if you are travelling long distances to the hospital. However, it is good to maintain a level of activity such as gentle walking if you feel able.

Sickness and headache

Some people develop these symptoms as a result of the radiotherapy, which can cause slight temporary swelling of the brain tissue. Your doctor may prescribe some steroid medication to prevent or manage this. If you do experience nausea or headache please let your treatment know.

Loss of appetite

You may feel less like eating when you have radiotherapy. Try to eat high calorie small meals and snacks regularly throughout the day. Drink plenty of fluids to stay well hydrated. Nutritional supplements and fortified drinks may be useful for patients struggling to eat sufficient calories.

Hair loss

You will lose your hair with the radiotherapy. This usually starts after 10-14 days. Arrangements can be made for you to see a wig supplier. Most hair loss is temporary, and will begin to regrow 2-3 months after finishing treatment. Re-growth may not be as thick as it was before, and your hair may not be the same colour or texture. Occasionally hair loss is permanent.

Skin reaction

Radiotherapy will only affect your skin within the treated area. You may notice that your scalp, skin behind the ears and forehead become more sensitive, slightly red, warm, itchy or dry. This may occur after the treatment has finished. We advise you to:

• Use a mild shampoo and warm water when washing your hair. Pat dry with a soft towel.
• Avoid excessive heat when styling. Use the cooler setting on your hairdryer.
• Dyes, strong styling products and perms are best avoided during radiotherapy.
• Swimming in chlorinated pools is permitted, but rinse your hair/scalp well with water afterwards and stop if irritation occurs.
• Avoid excessive sun exposure on the treated area where possible, and for about one year after treatment. Wear a hat when out in the sun.
• After the hair has fallen out you can apply a gentle moisturiser to the scalp 2-3 times a day e.g. E45® or Diprobase® to ease redness or irritation.

Memory loss

It is recognised that whole brain radiotherapy may cause cognitive impairment (disturbances in memory and ability to think clearly) in some people. These effects may be temporary and gradually subside in the weeks following treatment. However they can persist long term or develop many months after treatment has finished.

What happens after treatment has finished?

Side effects from the radiotherapy tend to persist for 7-10 days after completion and then gradually settle over the next couple of weeks. It can take a few months for your energy levels to return. Hair should start to regrow after 2-3 months.

You will normally receive an appointment for 6 weeks and/or 3 months in the oncology clinic. It may be a telephone consultation. If you have any problems, or notice new symptoms in the interim, please contact one of the team for advice. You don’t have to wait for your next scheduled appointment.

Important information for drivers

If we are treating your brain with prophylactic radiotherapy there will have been no evidence of cancer in your brain on your last scan. Therefore you are able to continue driving.

Contacts

Addenbrooke’s Hospital
Main Switchboard
01223 245 151

Radiotherapy Reception
01223 216 634

Rachel Kirby
Macmillan Advanced Practice Radiographer
Lung/Oesophageal Cancer
01223 596 199

Lung Cancer Clinical Nurse Specialists
01223 217 541

Addenbrooke’s emergency 24 hour helpline for oncology patients (AOS service)
01223 274 224

The Macmillan Pod at Addenbrooke’s offers support, advice and information for anyone affected by cancer. It is located in Oncology, level 2.

They offer assistance with blue badge and Macmillan grant applications, and help with referrals and signposting to benefits advice. The service will also help find local support groups and self-management courses.

Drop by Monday to Friday to pick up information or to speak with an information specialist.

Tel: 01223 274 801

Website: macmillan (opens in a new tab)

The Roy Castle Lung Cancer Foundation offers support and information to patients and families affected by lung cancer. They provide a forum for patients, information booklets, and fund awareness campaigns and research projects.

Telephone: 0333 323 7200

Website: Roycastle (opens in a new tab)

The British Lung Foundation provides a helpline staffed by nurses and benefit advisors, support groups, a web community to share experiences, and information publications.

Telephone: 03000 030 555

Website: British Lung Foundation (opens in a new tab)

Maggie’s is located in the grounds of Addenbrooke’s hospital and provides free practical, emotional and social support for people with cancer and their family and friends. Their support programme includes clinical psychology, nutrition, benefits advice, exercise, and complementary treatments.

Cancer support specialists are on hand Monday to Friday, 9am-5pm. No appointment required.

Phone: 01223 249 220

Website: Maggies centres (opens in a new tab)

Address: 21 Milton House, Puddicombe Way, Cambridge, CB2 0AD