Short course radiotherapy for cancer of the oesophagus (gullet)

Introduction

Your oncology team have 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 control the cancer and ease the symptoms that it is causing. Therapy radiographers will look after you during the planning and delivery of your radiotherapy.

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 can 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. 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

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.

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 the tip of 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 upper oesophagael tumours

It may be necessary to make an immobilisation mask if your tumour is in the upper oesophagus or neck. The mask is made just prior to your scan by warming a plastic sheet in a water bath until it becomes soft and flexible. It is then placed over your head and shoulders 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. Reference marks will be drawn on the mask and it will be removed when the scan is complete. You will wear the mask 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 (or the marks on your mask if you have one). 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?

5-10 treatments are usually given Monday-Friday over 1-2 weeks. Occasionally we give a single treatment. Your doctor 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. In these appointments we will enquire about your side effects and ensure that they are being optimally managed.

What are the early side effects of treatment?

The commonly seen side effects are listed below, but the severity may vary between individuals. Side effects cannot be prevented but they can be managed. They may worsen for 7-10 days after treatment has finished before they gradually start to improve.

Smoking

Tobacco smoking can cause your radiotherapy 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.

Difficult and painful swallow

Radiotherapy causes the lining of the oesophagus to become inflamed and sore. This happens gradually as you progress through the treatments. Most people will experience a difficult and painful swallow, and this may worsen before it improves. You may have some chest discomfort, especially when you swallow. It can feel like heartburn or back pain. Please tell us if you are having discomfort and we will prescribe medicines to help.

It is important to maintain a good nutritional intake during your treatment. 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. Eat small meals and snacks regularly, even if you are not hungry. Oncology dieticians will support and advise you throughout your treatment.

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.

Nausea and vomiting

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

Shortness of breath and cough

Radiotherapy to the thoracic area can cause irritation in the lungs. You may notice mild breathlessness or an irritable cough. These side effects can occur during treatment or a few weeks after treatment has finished and usually resolve spontaneously.

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 twice daily
• 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.
• 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 many months 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. 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

Radiation to the oesophagus can cause scarring (fibrosis). The oesophagus may narrow and become less flexible, leading to more swallowing difficulties. Gentle stretching of the oesophagus during endoscopy is sometimes performed to improve swallowing.

Second cancer

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

After treatment ends

Radiotherapy can continue to have a beneficial effect on the tumour for some weeks after the completion of treatment. The side effects will persist and possibly worsen for 7-10 days before they start to settle down. A difficult and painful swallow can take up to 6 weeks to settle. Your energy will gradually improve but this may take 6 weeks to 3 months.

Follow-up after treatment

You will normally receive an appointment for 6 weeks in the oncology clinic. This may be a telephone consultation. We will assess how you are and that the side effects are subsiding. 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.

Further information and support

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.