Stereotactic Ablative Body Radiotherapy (SABR) to the pelvic lymph nodes

This information aims to help you and your family and/or carers understand more about radiotherapy to oligometastatic disease within the pelvis, 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 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.

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.

What is stereotactic radiotherapy (SABR)?

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

How is the radiotherapy planned?

All radiotherapy treatment is tailored to the individual patient and requires careful planning. Your first appointment will be a CT planning scan in the radiotherapy department. This appointment can take up to an hour.

At the CT appointment the radiographers will position you for your radiotherapy treatment. This will involve specific positioning devices to ensure that you are comfortable lying in this position for up to 45 minutes. The same position will be used for your radiotherapy treatment. Once the radiographers are happy with your position a CT scan will be undertaken with you breathing normally. Sometimes a contrast dye will be used to 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.

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

An I.D photo might be taken.

How do you prepare for your scan and treatment?

• Avoid foods or drinks that you know will produce gas/give you wind for at least five days before you come for your planning appointment and throughout your radiotherapy treatment. These could include fizzy drinks, alcohol, beans and pulses.
• Aim to drink a minimum of two litres of fluids each day (excluding tea/coffee), spread throughout the day, to ensure healthy hydration.
• Eat your meals as normal and do not skip meals. You do not have to fast before your scan or treatment.
• Try to open your bowels as soon as you feel the urge.
• Taking regular physical exercise will help keep your bowels regular, for example a 30 minute walk each day.
• Continue to take your usual medication.
• Try to open your bowels on the morning of your planning scan appointment and, if possible, daily before each radiotherapy treatment session.

Bowel and/or bladder preparation

For some patients, a more specific bowel or bladder preparation technique is needed. A member of the SABR team will make you aware if this applies for your treatment. An additional information page with this information will be provided.

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). The most appropriate treatment schedule for you will be confirmed by your oncologist.

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. 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. Each treatment session can take up to 45 minutes. 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.

A CT scan is taken on the treatment unit 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. A second scan is taken at the end of each treatment session for verification purposes, though this is not performed on the final treatment.

CCTV cameras allow the radiographers to monitor you throughout. They can also talk to you via an intercom. 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 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.

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 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. A plan will be put into place and a new appointment may be arranged.

What are the side effects of treatment?

Stereotactic treatment volumes are relatively small. For this reason, most patients experience little in the way of side effects, besides general fatigue. However, this does vary between individuals and will depend on the location of the disease being targeted. The possible side effects are listed below. Please tell the radiographers how you are feeling, particularly if your symptoms worsen, so that we can provide the care you require.

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.

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

Bladder symptoms

Irritation of your bladder can lead to a temporary increase in the frequency of urination and a slowing of urinary flow. This is often worse at night. It can also cause burning or stinging when you urinate. Drink plenty of liquid, at least two litres a day, but do not increase your tea, coffee or alcohol intake. We may wish to take a urine sample to rule out a urine infection, if you have moderate or severe bladder problems. Your radiographer or doctor will advise you if they feel it is necessary.

Bowel symptoms

Inflammation of your bowel can cause cramping, increased flatulence (wind), loose bowel motions and increased frequency of opening your bowels. You may also pass a small amount of blood or mucus, or experience some discomfort in your rectum. You may have an urge to open your bowels but without actually passing anything. We may wish to give you extra dietary advice, tablets or steroid suppositories to ease the 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 pelvic lymph nodes 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 dependent on the treatment and location of your disease, but these may include:

• persistent change in bowel habit, which may include cramping or diarrhoea
• bowel obstruction
• frequency or discomfort with urination or bleeding from the bladder
• bleeding or perforation (hole) or fistula (abnormal connection between one organ and another organ) affecting bladder, bowel or rectum
• damage to nerves affecting function of bowels, bladder or legs
• pelvic bone fractures
• lymphoedema within the legs
• men with pelvic cancer may experience problems getting an erection, and women may experience menopausal symptoms

If you notice any blood in your urine or stool in the years after radiotherapy, seek advice and appropriate investigations from your GP.

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 6 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 usual Oncology team 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.