Stereotactic Ablative Body Radiotherapy (SABR) to the Abdomen

Introduction

This information leaflet aims to help you and your family understand more about radiotherapy to treat primary or oligometastatic cancer within the abdomen (liver, pancreas, adrenal glands or abdominal lymph nodes), using a treatment technique called Stereotactic Ablative Radiotherapy (SABR). It explains how the treatment is planned and delivered and provides advice to help you look after yourself during and after the radiotherapy. It covers the commonly seen side effects of treatment, but this doesn’t mean that you will necessarily experience them and you may get a side effect not mentioned here. If you have any questions or concerns about the information given to you, or any other aspect of your treatment, please speak to a member of the team.

What is meant by primary cancer?

Primary cancer is defined as the original site (organ or tissue) of the cancer.

What is meant by oligometastatic cancer?

This means that the cancer has spread from its original location (metastasised), but is only visible in a limited number of sites on the body scans.

What is stereotactic radiotherapy?

Radiotherapy is the use of high energy x-rays (radiation) to treat cancer. It damages tumour cells to stop them from growing or causes them to die. The purpose of radiotherapy is to destroy the cancer cells while causing as little damage as possible to normal cells.

SABR is an effective way of giving focused radiotherapy, increasing the chance of controlling the tumour whilst sparing normal tissues.

It does this by using:

• fewer treatment sessions
• smaller more precise radiation fields
• higher doses of radiation

Radiotherapy itself is painless and does not make you radioactive. It is perfectly safe for you to be with other people, including children and pregnant women during the course of your treatment.

Planning your treatment

Your case will have been discussed at a specialist multidisciplinary team meeting to ensure that radiotherapy is the best treatment option for you. You will be contacted to attend a telephone or face-to-face clinic in the hospital with your oncologist or specialist SABR Radiographer to discuss your proposed treatment. You will be asked to sign a consent form for radiotherapy treatment at this appointment, or during a subsequent visit if other tests or results are needed.

If you require any additional medications to take during radiotherapy this will be explained (for example: tablets to prevent nausea or to protect the stomach/bowel lining). Finally, if we require to give you IV contrast for the planning scan we may need an up to date blood test.

The MRI and CT radiotherapy planning scans

To plan your treatment accurately you will need a radiotherapy planning CT scan and possibly an MRI scan which may be on the same day and will take a minimum of two to three hours. You may wish to bring your regular medication with you and something to read. The radiotherapy planning scan will take place in the radiotherapy department on Level 2 in outpatients.

For the CT scan you may need to fast before the appointment. We will make you aware if this applies to you and if you require any specific instructions.

Please inform us if you are diabetic or under dietician support.

Typically, if you are required to fast you should not eat or drink for two or three hours* before your appointment. Up to 200ml of water may be sipped during this time if required – (this equates to one small cup). We recommend you having a light snack prior to fasting, for example a small sandwich or a couple of biscuits.

*We will provide you with precise information depending on the specific site of your treatment.

For the CT scan you may be required to have oral contrast (dye) to drink and/or an IV contrast injection to help enhance the scan. If this is required, you will be asked to fill in a questionnaire and have a cannula inserted to deliver the dye.

All radiotherapy treatment is tailored to the individual patient and requires careful planning. At the CT appointment the radiographers will position you for your radiotherapy treatment. It is important that you are comfortable lying in the planned position for up to an hour, as the same position will be used for your radiotherapy treatment.

Please tell the CT radiographers if you are uncomfortable as we may not be able to make alterations at treatment.

A specific technique known as “abdominal compression” may be required for scanning and treatment. For this, patients will lie on their back, with arms above their head, in a custom-made support, as shown here in the photograph. This equipment is used to reduce the amount your organs move during breathing. It is not painful to fit, and if suitable it will need to be used every day when you have your treatment.

If you have any pain or difficulty keeping your arms above your head, (due to arthritis for example), please discuss this with your clinical oncologist. Taking painkillers 30 minutes to one hour before the planning appointment and treatment sometimes helps. Painkillers can be prescribed if needed.

Once in the correct position multiple short CT scans may be performed. These help us check that the equipment is in the right place. Once the final position has been decided two longer CT scans will be performed. You will be given breathing instructions by the radiographers that you must follow.

• The first scan will be taken whilst holding your breath.
• The second scan will be taken whilst breathing normally.

After the scan is finished the radiographers will put on some permanent small dots on your skin known as tattoos. These are used to align you in the same position when you come for your radiotherapy treatment.

An I.D photo and positional set-up images might be taken.

The radiotherapy treatment

How are the appointments arranged?

Your SABR treatment is given over three to eight treatment sessions. The sessions will be at least one day apart (for example, Monday, Wednesday and Friday, with a rest at the weekend) and each session will last about forty minutes.

We will accommodate your time preference whenever possible. Please try to be as flexible as possible and give priority to your treatment sessions over other general appointments. During the course of treatment the times may vary each day depending on the number of patients on the unit. Sometimes the Radiotherapy Department can be very busy and your appointment time may be delayed. We will keep you informed of any delays. It is important to make the SABR team aware of any upcoming holiday or other unavailability that could interfere with your proposed treatment schedule.

Having your treatment

If you were required to fast for your CT scan you will be required to follow the same advice as specified to you. You will need to do this for each treatment session.

On your first day of radiotherapy, a member of the team will have a chat with you to discuss the treatment and how to minimise any side effects that it may cause. They will also check that you are happy to go ahead with your treatment. This is an ideal opportunity to ask any questions that you may have (it may be useful to write down any questions as you think of them). Please feel free to bring music on your mobile phone or MP3 player; this can be played through our speakers.

When we call you through to the treatment machine a radiographer may provide you with a cup of water for you to drink just before your treatment starts.

The radiotherapy treatment units are quite large, but they don’t actually touch you.

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.

Scans will be taken on the treatment unit before, after and occasionally during treatments to check your position, and adjustments are made if necessary. The treatment is then delivered. The units make a buzzing sound when giving the radiotherapy, but treatment is completely painless.

There may be pauses during the procedure when the radiographers are reviewing your images or prepping the unit. A Radiographer may also come back into the room part way through your treatment. Please ensure that you remain still and in the treatment position until the radiographers inform you that the procedure has finished.

What do I do if I feel unwell?

It is important that you attend each appointment. If you manage to come for your radiotherapy but feel unwell, let your radiographers know as soon as you arrive. However, if you suddenly feel unwell and are unable to come for treatment, contact your GP and the radiotherapy reception desk who will inform your team. Please do this as soon as possible. A plan will be put into place and a new appointment may be arranged.

What are the side effects of treatment?

This section explains the commonly seen side effects, but this doesn’t mean that you will necessarily get them. It is also possible that you may get a side effect not mentioned here.

Most patients experience some degree of general fatigue and loss of appetite. Fatigue is a common feeling during and after radiotherapy treatment. There is no reason to change your lifestyle during treatment but it can be helpful to try and get enough rest and sleep, especially if you are feeling tired. It is helpful to try to continue with some of your normal daily activities and to try and balance rest and activity. Mild fatigue occurs in 50% of patients. Ensure you drink enough fluids as this can prevent tiredness from dehydration.

Depending on the location of your disease and proximity to the abdominal organs you may experience less common side effects of sickness, indigestion, heartburn and abdominal colic. However, these effects can be prevented with effective medication. You may be asked to take an anti-sickness tablet, and a tablet for abdominal colic, at least 30 minutes prior to radiotherapy. If you are not on any medications to suppress stomach acid production, you may have to take tablets to prevent gastritis during and until at least four weeks after completion of radiotherapy. We will inform you prior to starting treatment if you are required to take the aforementioned medication.

Stereotactic Ablative Radiotherapy is a high precision treatment, the risk of late side effects are lower. Rarely, patients can develop bowel damage (for example, ulceration or bleeding) as late effects.

Psychological effects

This information sheet deals mainly with the physical and practical aspects of your radiotherapy treatment, but the emotional wellbeing of you and your family are just as important. Having treatment can be deeply distressing for some patients. It is not unusual to feel overwhelmed by different thoughts and feelings following a cancer diagnosis. It is important to look after yourself during and after treatment. Advice and support is always available if you are finding it difficult to cope.

There are many resources available for patients and their families and carers to cope with the emotional impact of cancer. Ask one of the treatment team or contact the Macmillan information pod, Maggie’s Centre or the Cambridge Cancer Help Centre for more information.

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 from radiotherapy generally persist or worsen slightly for seven to ten days before gradually subsiding over the next two to four weeks.

Follow up appointment

You will receive an appointment to have a follow up with your SABR oncologist about six weeks after treatment has finished. This may be via telephone or at the hospital. If you have not received a notification of that appointment five weeks after the end of your treatment, please telephone radiotherapy reception and ask to speak to your oncology consultant’s secretary.

Repeat prescriptions

If you need repeat prescriptions of any medication prescribed during your treatment to help with the side effects, these should be available from your GP service.

Ongoing follow-up

After your six week follow-up with the SABR team you will be referred to your original oncology team, with all information being passed onto them as well as your GP.

We do not tend to scan immediately at the end of treatment to see if the radiotherapy has worked. This is because radiotherapy continues to have a beneficial effect on the tumour for some weeks afterwards and the tumour may take time to reduce in size. Radiotherapy also causes inflammation in the surrounding tissue meaning that x-rays and scans at that time are not so helpful.

If you are worried or notice any new symptoms between appointments you must let your CNS or GP know as soon as possible.

Contacts

If you have any worries or questions about any aspect of your treatment, please do not hesitate to contact one of the team.