Stereotactic Ablative Body Radiotherapy (SABR) to the bones

Introduction

This information aims to help you and your family and/or carers understand more about radiotherapy to oligometastatic cancer within the bone, using a treatment technique called Stereotactic Ablative Radiotherapy (SABR). It explains how the treatment is planned and delivered and contains advice to help you look after yourself during and after the radiotherapy. It covers the commonly experienced side effects of treatment, but this doesn’t mean that you will necessarily get them. It is also possible that you may experience a side effect not mentioned here. If you have any questions or concerns about the information given to you, or any aspect of your treatment, please speak to a member of the team.

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 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 these will be explained (for example, tablets to prevent nausea or additional analgesia).

The MRI and 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 have intravenous contrast (dye) injected 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 will depend on what part of your body is being treated. At the CT appointment the radiographers will position you for your radiotherapy treatment. It is important that you are comfortable lying in this position for up to an hour, as the same position will be used for your radiotherapy treatment. After the scan is finished the radiographers may put 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.

Specific equipment may be required for scanning and treatment. This could include a custom made “bean bag” to support your body (shown here in the photograph).

Some patients may be asked to lie with their arms over their head, holding on to a bar. 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. These can be prescribed if needed.

For treatment in the upper chest, neck and head, a mask may be needed. You will be made aware if this is required and how you should prepare for it. A mask is individually moulded to your shape and is made from a thermoplastic material. The mask will cover your head, face and shoulders. You can see and breathe through the mask. If a mask is required, marks will be drawn on the mask rather than needing any permanent skin marks.

If we are treating a rib we may need to account for normal movement with breathing by doing a longer CT scan (four-dimensional CT). We will provide further information if this is relevant to you.

The radiotherapy treatment

How many treatments will I have?

Your SABR treatment is given over three or five treatment sessions. The sessions will be at least one day apart (for example, Monday, Wednesday and Friday, with a rest at the weekend). If you are having more than one body area treated, they may all be treated within the same session or they may be treated separately. Therefore, you will have more treatment appointments and may have to attend every weekday for up to two weeks.

Having your treatment

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.

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 it 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.

How are the appointments arranged?

We will accommodate your time preferences 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. Some days the radiotherapy department may 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 dates when you are not able to attend that could interfere with the proposed treatment schedule.

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?

You may experience some side-effects during or following your radiotherapy. Some side effects such as fatigue can last for some time after treatment. Please tell the radiographers how you are feeling, particularly if your symptoms worsen, so that we can provide the care you require. You should make sure that your family and/or carers are aware of any possible side effects of your treatment.

Early side effects of treatment

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. Do not be afraid to ask friends and family for help. Having enough to drink can prevent tiredness due to dehydration.

Skin reaction

Radiotherapy will only affect your skin within the treated area. You may notice that the skin here becomes more sensitive, slightly red, warm, itchy or dry. This may appear in the weeks following treatment.

We advise you to:

• wash daily with a mild soap and warm water and pat dry with a soft towel
• apply a gentle moisturiser to the treated area up to twice daily e.g. E45® or Diprobase®
• avoid sun exposure on the treated area as the skin here will be more sensitive

Bone pain

Patients receiving SABR for a problem in the bone may experience pain in the bit of bone being treated after the course of treatment has finished. It may be necessary to take painkillers such as paracetamol to ease this pain before it settles down.

If the site of treatment is near the bladder or bowel you may experience the following early side effects:

Abdominal pain

You may experience some abdominal discomfort and colicky pains (a sharp, localised pain that can arise abruptly and tends to come and go in spasm-like waves) or you may feel bloated. Please make your oncologist aware of this if you experience severe discomfort.

Nausea or vomiting

Nausea (feeling sick) and vomiting (being sick) from radiotherapy may occur at any time during the treatment course. Medication to be taken before or after treatment may be provided.

Longer term side effects

Your doctor will discuss any long-term side effects of SABR to the bone that are relevant to you and the risk of these happening when you consent for treatment. Serious long-term side effects are rare and are very dependent on the treatment and location of your disease, but these may include:

• bone pain and/or fracture
• damage to stomach or bowel - such as ulceration, bleeding or perforation
• lung inflammation
• damage to nerves such as the brachial plexus or lumbo-sacral plexus causing pain or weakness/numbness of a limb.

If you experience any of these side effects, or have any concerns following treatment, please contact your CNS team.

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.