Radical radiotherapy for non-small cell lung cancer (NSCLC)

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 your cancer and reduce the risk of it coming back. Therapy radiographers will look after you during the planning and delivery of your treatment.

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 is tailored to each patient and requires careful planning using a CT scanner. When you attend for your CT 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.

During the CT planning scan

Your chest area will be uncovered during the scan. This enables us to visualise your body outline more accurately on the images. It is important that you remain as still as possible. You will not need to hold your breath.

A small monitoring device will be placed on your chest that is linked to the scanner. This will monitor your breathing throughout the scan so we can see any changes in the tumour position during your breathing cycle. Try to maintain a relaxed, regular breathing pattern and avoid sudden deep intakes of 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.

Contrast injection

It is usually 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.

Skin tattoos

At the end of the scan the radiographers will ask your permission to make some small permanent marks on your skin using ink and a needle. They appear as small blue/black dots and serve as important reference marks for the radiographers to accurately deliver your treatment.

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.

Special consideration for Pancoast tumours

Pancoast tumours arise in the very superior (upper) aspect of the lung. Due to their position, it may be necessary to make an immobilisation shell when you attend for your CT planning scan. You will wear the shell during each treatment to ensure that the radiotherapy is delivered accurately

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. You may then be asked to change into a gown.

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. The lights will be dimmed, and the room laser lights used to align your skin tattoos. 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 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?

A number of factors affect the total number of radiotherapy treatments required including the type of lung cancer that you have. Typically, a total of 20 treatments is delivered once daily, Monday-Friday over 4 weeks. Occasionally treatment is given over 6 weeks. Your oncologist will confirm the most appropriate treatment schedule for you.

How are the 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.

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 early side effects of treatment?

The commonly seen side effects from lung 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.

Smoking while undergoing treatment can cause your side effects to develop earlier and be more severe. We strongly advise you to give up smoking. We can signpost you to smoking cessation services for advice and support.

Tiredness

Tiredness is one of the most common side effects of radiotherapy. 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. Don’t be afraid to ask friends and family for help.

Shortness of breath and cough

Radiotherapy may cause you to feel more breathless and you may develop an irritable cough. These side effects can occur during treatment or a few weeks after treatment has finished. They usually improve without the need for additional medication. Very occasionally a short course of steroids is required.

Chest pain

You may notice mild aches or discomfort in your chest area while on treatment. Regular pain killers may be taken to help manage the discomfort.

Painful swallow

Radiotherapy can irritate the lining of the oesophagus. You may feel as though you have a lump in your throat or notice soreness when you swallow.

• You may need to adopt a softer diet temporarily, making good use of gravies and sauces. Cool drinks and ice cream may help. It is advisable to avoid spicy, scratchy or stodgy foods, very hot drinks, and strong alcoholic drinks.
• Medication may be useful if you develop a painful swallow:
  • Pain medication e.g. paracetamol.
  • Lidocaine and hydrocortisone mouthwash – a liquid that you can swallow to reduce pain and inflammation. This is only available at the Addenbrooke’s pharmacy and is a prescription medication.
  • Gaviscon® (or Peptac®) - A liquid that you swallow to coat and sooth the lining of the oesophagus and reduce the effects of acid reflux.

Reduced 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.

Nausea and vomiting

Nausea (feeling sick) and vomiting (being sick) are less common with lung radiotherapy, but can be controlled with anti-sickness medication if they do arise.

Skin reaction

Radiotherapy will only affect your skin within the treated area. You may notice that the skin here becomes more sensitive, red, warm, itchy, or dry. This may also occur after the treatment has finished. We advise you to:

• Wash daily with a mild soap and warm water and pat dry with a soft towel.
• Apply a gentle unscented moisturiser to the treated area up to twice daily e.g. E45® or Diprobase®
• Deodorant may be used.
• Avoid sun exposure on the treated area as the skin here will be more sensitive.
• You may swim in chlorinated pools, but make sure you rinse your skin well with water afterwards and stop if irritation occurs.
• For male patients – radiotherapy can cause chest hair to fall out. This should regrow after 2-3 months but very occasionally it is permanent. Hair on the head is not affected by radiotherapy to the chest.

Late side effects

Late side effects can occur months to years after the radiotherapy has finished. They are harder to predict and unfortunately if they do occur, they can be permanent. We take great care to minimise dose to the normal tissue surrounding the tumour and to major organs. By doing this we minimise the possibility of late side effects.

Breathlessness

Radiotherapy can cause inflammation (pneumonitis) and scarring (fibrosis) of the lung tissue. This may lead to shortness of breath and cough.

Narrowing of the oesophagus (food pipe)

Radiation to the oesophagus is sometimes unavoidable when treating the lung and can cause the oesophagus to narrow slightly leading to swallowing difficulties. A minor procedure to gently stretch the oesophagus may be used to improve swallowing.

Cardiac effects

Chest radiotherapy can increase your risk of developing heart problems in the future. This is uncommon and may not happen until many years after treatment.

Rib weakness

When a lung tumour is located close to the chest wall, the adjacent rib(s) may become more brittle following radiotherapy. A mild trauma in the future could result in chest pain or minor rib fracture.

Nerve changes

Damage to the nerves that run to your arms is rare, but may result in weakness and altered sensations in your arms or hands. Your consultant will discuss this with you if it is relevant.

Spinal cord damage

This is extremely rare and dose to this region is strictly controlled during the planning process. Damage to the spinal cord can permanently affect mobility, function and sensation depending on the area treated.

Second cancer

Radiation from your scans and treatment may increase the risk of you developing a second cancer many years later. However, this risk is very small.

Follow-up after treatment

Radiotherapy continues to have a beneficial effect on the tumour for some weeks after treatment has finished. The side effects may persist or worsen slightly for 7-10 days before they start to settle down.

You will normally receive an appointment for 6 weeks and/or 3 months in the oncology clinic. This is to see how you are and that the side effects have subsided and 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.

A follow-up CT scan to assess response is usually arranged for 3 months after completion of treatment. This allows time for any radiotherapy related inflammation to resolve.

If you are unsure about what happens next or have questions about any aspect of your treatment please tell a member of your treatment team, either when you visit, or by phoning the department. Some useful telephone numbers are listed on the next page.

Contacts

If anything is worrying you, however small, please do not hesitate to contact us.

Addenbrooke’s 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

Further information and support

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 website (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: Roy Castle website (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 Website (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 website (opens in a new tab)

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

Privacy and dignity

Same sex bays and bathrooms are offered in all wards except critical care and theatre recovery areas where the use of high-tech equipment and/or specialist one to one care is required.