Radiation Therapy

Yes, everyone I've spoken with has a similar experience with chemo. I found that I could not concentrate and therefore reading was useless. Too bad, I love to read and learn - its exciting to learn by reading. Eating was not so hot either, my tasting ability was gone along with my appetite. So I ended up watching the clock tick, went for long slow walks. I improved physically as my body acclimated to the chemo. Then, I became much more active - reading, watching tv, walking, talking on the phone, checking out the internet, writing letters, and more. Getting by is definitely what you do. I did not try to attend everything with my girls. We would talk about what do you want Mom to be at and what can you go to with a friend. I took a lot of naps. We planned the meals for the week and ate really simple to prepare meals. Raw carrots and apples were a staple. Buy the cut up fruit or have a neighbor come wash and cut up your fruits and veggies for you. My husband did a lot of the cooking. To build strength, try to do a little bit more. At first I could not even walk around the block. So I would just go to the end of the driveway. I was in physical therapy for my arm and shoulder. The chemo messes with all your muscles. Try to move all your different muscle groups, even if you are lying down. Point and flex your toes 10 times, Raise and lower your arms 10 times, flex and relax your gluts, then your stomach. If you are watching TV, do a few reps of something during the ads. Drink a lot of water!

Give yourself lots of extra time. It took tons of energy to shower and get dressed. So I would get ready and then rest on the couch near the kitchen for 20 minutes. I could answer questions from everyone but not be tempted to do stuff for them. I did the same thing after school. I would be on the couch in the room that my girls play in. They would bring me a drink and I could help with homework or sign papers or talk. But I did not get up if I could avoid it. If someone else can do what you need done, then ask someone to do it. Only do what is important to you and will help you get better.

I would start a task and not be able to finish it. This gets really frustrating. And my husband would get frustrated at the mess I made that he had to clean up or finish. I had to acknowledge how weak I was and learn to ask for help and let go of things that do not really matter. Your priorities will change and your standards of what is acceptable. Decide what is important to you and let the rest go. You will get stronger but it is a very gradual process.

I see. I did not realize it was an individual plan related to autonomy. Very helpful. Patients who need radiation after reconstruction are at a risk of complications with regard to their reconstruction. A woman may have her reconstruction done at the time of surgery (immediate reconstruction) or at some point in the future (delayed reconstruction). Each carries with it different possible complications. Patients need to discuss all options with their surgeons – patient’s cancer and their anatomy play an important role in the determination of which type of reconstruction is appropriate. Regardless, it is essential that proper radiation planning take place and good dialogue between the treating radiation oncologist and the plastic surgeon.

"Internal" radiation or brachytherapy involves use of a variety of radioactive isotopes which are placed inside or near the tumor/cancer. By doing so, radiation does not have to go through the normal tissue between an external source and the target of radiation. Depending on whether the radioactive isotope is placed permanently or used temporarily, brachytherapy is categorized into two categories of permanent and temporary.

The most common form of permanent brachytherapy is prostate seed implant. In this form of treatment either Palladium (Pd-103) or Iodine (I-125) seeds are implanted inside the prostate. These seeds would irradiate the prostate gland and the cancer inside it as long as they are radioactive but eventually become inert.

Depending on the strength and therefore speed of delivery of radiation, temporary brachytherapy is categorized into Low Dose Rate and High Dose Rate brachytherapy. The most common example of temporary brachytherapy is the use of either Low Dose Rate (LDR) or High Dose Rate (HDR) forms of brachytherapy for the treatment of gynecological cancers specifically cervical and endometrial cancer. Through special catheters either cesium-137 (LDR) or iridium-192 (HDR) would be inserted nearby the tumor. During the period of time when the catheters remain in area, the prescribed dose of radiation would be delivered to the target. This would take about 48 hours in LDR but only a few minutes in HDR treatment.

HDR brachytherapy is also used in the treatment of breast cancer. This form of radiation for breast cancer is called Accelerated Partial Breast Irradiation or APBI. After a lumpectomy a special applicator such as Mammosite or Contura balloon catheter or a Savi applicator is placed inside the lumpectomy cavity. Using HDR technology an iridium-192 radioactive source is inserted into any of these catheters to deliver radiation to the wall of the lumpectomy cavity.

Intraluminal brachytherapy is also used for the treatment of endobronchial tumors, esophageal cancer and cancers of biliary tract. Other forms of temporary brachytherapy include radioactive eye plaque in treatment of choroidal melanoma and Strontium-90 applicators for treatment of pterygium. "Internal" radiation or brachytherapy involves use of a variety of radioactive isotopes which are placed inside or near the tumor/cancer. By doing so, radiation does not have to go through the normal tissue between an external source and the target of radiation. Depending on whether the radioactive isotope is placed permanently or used temporarily, brachytherapy is categorized into two categories of permanent and temporary.

The most common form of permanent brachytherapy is prostate seed implant. In this form of treatment either Palladium (Pd-103) or Iodine (I-125) seeds are implanted inside the prostate. These seeds would irradiate the prostate gland and the cancer inside it as long as they are radioactive but eventually become inert.

Depending on the strength and therefore speed of delivery of radiation, temporary brachytherapy is categorized into Low Dose Rate and High Dose Rate brachytherapy. The most common example of temporary brachytherapy is the use of either Low Dose Rate (LDR) or High Dose Rate (HDR) forms of brachytherapy for the treatment of gynecological cancers specifically cervical and endometrial cancer. Through special catheters either cesium-137 (LDR) or iridium-192 (HDR) would be inserted nearby the tumor. During the period of time when the catheters remain in area, the prescribed dose of radiation would be delivered to the target. This would take about 48 hours in LDR but only a few minutes in HDR treatment.

HDR brachytherapy is also used in the treatment of breast cancer. This form of radiation for breast cancer is called Accelerated Partial Breast Irradiation or APBI. After a lumpectomy a special applicator such as Mammosite or Contura balloon catheter or a Savi applicator is placed inside the lumpectomy cavity. Using HDR technology an iridium-192 radioactive source is inserted into any of these catheters to deliver radiation to the wall of the lumpectomy cavity.

Intraluminal brachytherapy is also used for the treatment of endobronchial tumors, esophageal cancer and cancers of biliary tract. Other forms of temporary brachytherapy include radioactive eye plaque in treatment of choroidal melanoma and Strontium-90 applicators for treatment of pterygium.

A patient may not be eligible to receive radiation treatment either because radiation therapy is not indicated for treatment of that particular cancer or stage of the disease or because, even though indicated, it would not be safe to receive radiation.

Contraindications to radiation therapy are often categorized as relative or absolute contraindications. Generally speaking autoimmune/connective tissue diseases increase the risk of acute and chronic side effects of radiation therapy. These patients may be at risk of severe skin reaction, severe scarring and even soft tissue necrosis. Depending on the type and level of activity of this form of diseases, radiation can be relatively or absolutely contraindicated. For example Scleroderma and active lupus are considered absolute contraindications to radiation therapy but an inactive, or limited Lupus such as Discoid Lupus and Rheumatoid Arthritis are considered relative contraindications to radiation therapy.

In recent years and with the invention of sophisticated radiation technology such as CyberKnife and Steroeotactic Radiosurgery, a traditional contraindication to radiation therapy due to previous radiation to the same target area, has been challenged. Without this precise form of targeting the tumor, a relatively significant dose of radiation was given to adjacent normal tissues. Each critical organ in our bodies has a certain tolerance to radiation. That is the dose an organ can safely receive without permanent and irreversible damage. Traditionally we could not reirraidate the same target area because we would have exceeded the safe dose an adjacent organ could tolerate. With this new technology, we can deliver additional doses of radiation to the same target without exceeding the safe dose to the adjacent organs. Despite this technology, at some point, we may reach a point when no additional radiation can be safely delivered and that would make a patient ineligible for additional radiation.

Patients' ineligibility for receiving radiation is a very compelling reason for a multidisciplinary approach to the treatment of cancer. As an example would it not be a shame to subject a patient ineligible for radiation therapy to a lumpectomy when radiation is a critical part of breast conservation therapy? That would sadly would subject the patient to a second operation, a mastectomy, because lumpectomy without radiation would not adequately address the risk of a recurrence in that breast. To avoid similar scenarios, consult all the members of a treatment team before initiating any form of treatment and undergoing any form of procedure. Be proactive! A patient may not be eligible to receive radiation treatment either because radiation therapy is not indicated for treatment of that particular cancer or stage of the disease or because, even though indicated, it would not be safe to receive radiation.

Contraindications to radiation therapy are often categorized as relative or absolute contraindications. Generally speaking autoimmune/connective tissue diseases increase the risk of acute and chronic side effects of radiation therapy. These patients may be at risk of severe skin reaction, severe scarring and even soft tissue necrosis. Depending on the type and level of activity of this form of diseases, radiation can be relatively or absolutely contraindicated. For example Scleroderma and active lupus are considered absolute contraindications to radiation therapy but an inactive, or limited Lupus such as Discoid Lupus and Rheumatoid Arthritis are considered relative contraindications to radiation therapy.

In recent years and with the invention of sophisticated radiation technology such as CyberKnife and Steroeotactic Radiosurgery, a traditional contraindication to radiation therapy due to previous radiation to the same target area, has been challenged. Without this precise form of targeting the tumor, a relatively significant dose of radiation was given to adjacent normal tissues. Each critical organ in our bodies has a certain tolerance to radiation. That is the dose an organ can safely receive without permanent and irreversible damage. Traditionally we could not reirraidate the same target area because we would have exceeded the safe dose an adjacent organ could tolerate. With this new technology, we can deliver additional doses of radiation to the same target without exceeding the safe dose to the adjacent organs. Despite this technology, at some point, we may reach a point when no additional radiation can be safely delivered and that would make a patient ineligible for additional radiation.

Patients' ineligibility for receiving radiation is a very compelling reason for a multidisciplinary approach to the treatment of cancer. As an example would it not be a shame to subject a patient ineligible for radiation therapy to a lumpectomy when radiation is a critical part of breast conservation therapy? That would sadly would subject the patient to a second operation, a mastectomy, because lumpectomy without radiation would not adequately address the risk of a recurrence in that breast. To avoid similar scenarios, consult all the members of a treatment team before initiating any form of treatment and undergoing any form of procedure. Be proactive!

The three common treatment modalities in treatment of breast cancer can be given in different sequences. The most common sequence is to start with surgery, continue with chemotherapy if indicated and finish with radiation therapy. But in some cases chemotherapy is delivered before surgery and is followed by radiation therapy. There is one exception to this general rule of radiation therapy being the last modality in the sequence of treatments and that is when Accelerated Partial Breast Irradiation (APBI) using brachytherapy balloons such as Mammosite, Contura or Savi applicator is the form of radiation utilized. In APBI, radiation is delivered immediately after surgery and chemotherapy, if recommended, would follow radiation.

Therefore a "delay" in beginning of radiation treatment can be a planned or an unplanned one. For example we often recommend 4-6 weeks between surgery and beginning of radiation in order to make sure that all the surgical incisions are completely healed. One of the potential side effects of radiation is delay in healing of wounds and that is the reason behind that planned delay. We also recommend about 2-4 weeks of gap between last chemotherapy administered and beginning of radiation therapy. This form of planned delay in beginning of radiation is due to the fact that some chemotherapy agents are radiosensitizers and may potentially increase the risk of side effects from radiation therapy.

The unplanned or undesired delays in beginning of radiation therapy may be due to an unhealed surgical incision or persistent seroma or a hematoma in the lumpectomy cavity or in soft tissue pouches after a mastectomy. Radiation therapy is based on very accurate measurements and calculations of the volumes of tissue irradiated and the doses delivered. If the calculations and radiation plan is based on a certain size of breast and certain size of lumpectomy cavity and this volume is changed due to an enlarging seroma or hematoma, our calculations and therefore radiation doses would be off. Therefore we would await resolution of a seroma or a hemtoma either by giving it some time to absorb or by aspirating it before planning the radiation treatment.

With increase in the use of tumor genetic assay tests such as Oncotype DX, often there is a delay in determining whether a patient requires chemotherapy or not. In this scenario, the radiation oncologist would need to await the test result before starting patient's radiation because if the Oncotype DX result indicates benefit from chemotherapy, this treatment should be delivered before beginning of radiation therapy. The three common treatment modalities in treatment of breast cancer can be given in different sequences. The most common sequence is to start with surgery, continue with chemotherapy if indicated and finish with radiation therapy. But in some cases chemotherapy is delivered before surgery and is followed by radiation therapy. There is one exception to this general rule of radiation therapy being the last modality in the sequence of treatments and that is when Accelerated Partial Breast Irradiation (APBI) using brachytherapy balloons such as Mammosite, Contura or Savi applicator is the form of radiation utilized. In APBI, radiation is delivered immediately after surgery and chemotherapy, if recommended, would follow radiation.

Therefore a "delay" in beginning of radiation treatment can be a planned or an unplanned one. For example we often recommend 4-6 weeks between surgery and beginning of radiation in order to make sure that all the surgical incisions are completely healed. One of the potential side effects of radiation is delay in healing of wounds and that is the reason behind that planned delay. We also recommend about 2-4 weeks of gap between last chemotherapy administered and beginning of radiation therapy. This form of planned delay in beginning of radiation is due to the fact that some chemotherapy agents are radiosensitizers and may potentially increase the risk of side effects from radiation therapy.

The unplanned or undesired delays in beginning of radiation therapy may be due to an unhealed surgical incision or persistent seroma or a hematoma in the lumpectomy cavity or in soft tissue pouches after a mastectomy. Radiation therapy is based on very accurate measurements and calculations of the volumes of tissue irradiated and the doses delivered. If the calculations and radiation plan is based on a certain size of breast and certain size of lumpectomy cavity and this volume is changed due to an enlarging seroma or hematoma, our calculations and therefore radiation doses would be off. Therefore we would await resolution of a seroma or a hemtoma either by giving it some time to absorb or by aspirating it before planning the radiation treatment.

With increase in the use of tumor genetic assay tests such as Oncotype DX, often there is a delay in determining whether a patient requires chemotherapy or not. In this scenario, the radiation oncologist would need to await the test result before starting patient's radiation because if the Oncotype DX result indicates benefit from chemotherapy, this treatment should be delivered before beginning of radiation therapy.

The best way to deal with fatigue from radiation therapy is creating a balance between getting enough rest and staying active enough. To succumb to the fatigue and give up physical activity would create a vicious cycle resulting in less energy and more fatigue. Yet you don't want to push yourself too much. It is all right to go to bed earlier, get up a little bit later or even take a nap during the day if one feels that tired but it is important to schedule a routine daily activity such as walking and stick with it throughout the course of radiation therapy. The other very important factor is to stay hydrated. Dehydration would negatively impact one's level of energy and may even interfere with their sleep pattern. This is particularly important during the warmer seasons and during the routine daily activity. Extremes of temperature should be avoided. A minimum of 8 cups of fluid per day will prevent dehydration. (That is 64 ounces, 2 quarts, or 1 half-gallon). Beverages containing caffeine do NOT count neither do alcoholic ones. Maintaining good nutrition can help you feel better and have more overall energy. Sticking to a regular schedules such as going to bed at a certain time and eating at regular hours would also be very helpful in creating that fine balance between resting and staying active. The best way to deal with fatigue from radiation therapy is creating a balance between getting enough rest and staying active enough. To succumb to the fatigue and give up physical activity would create a vicious cycle resulting in less energy and more fatigue. Yet you don't want to push yourself too much. It is all right to go to bed earlier, get up a little bit later or even take a nap during the day if one feels that tired but it is important to schedule a routine daily activity such as walking and stick with it throughout the course of radiation therapy. The other very important factor is to stay hydrated. Dehydration would negatively impact one's level of energy and may even interfere with their sleep pattern. This is particularly important during the warmer seasons and during the routine daily activity. Extremes of temperature should be avoided. A minimum of 8 cups of fluid per day will prevent dehydration. (That is 64 ounces, 2 quarts, or 1 half-gallon). Beverages containing caffeine do NOT count neither do alcoholic ones. Maintaining good nutrition can help you feel better and have more overall energy. Sticking to a regular schedules such as going to bed at a certain time and eating at regular hours would also be very helpful in creating that fine balance between resting and staying active.

Radiation therapy is a very technical treatment and takes a great deal
of work by the radiation oncologist, the dosimetrist and the radiation
physicist to create a radiation plan which would deliver the required
dose of radiation to the cancer while minimizing radiation dose to the
surrounding normal and critical organs. To create such a fine balance,
sophisticated technology and treatment planning software are utilized.

Traditional radiation therapy used plain X-ray films to map the target
area and radiation fields. This was a two-dimensional technique and
the exact dose of radiation to critical organs was not determined
carefully. Three-dimensional conformal radiation therapy uses CT scans
to carefully define each and every critical organ at risk of receiving
radiation as well as the tumor itself.

Over the past decade or so a more sophisticated form of
three-dimensional conformal radiation therapy called IMRT (Intensity
Modulated Radiation Therapy) has evolved. This technique utilizes
reverse planning. That is instead of learning how much of radiation
the critical organs would receive should we deliver a certain dose of
radiation to a tumor, we can set limits on how much of radiation these
organs can tolerate in advance.

Nowadays we also have the capability of fusing MRI and PET images with
our CT scan images to enhance the quality of our contours and mapping
of the target areas. By doing so we can be more precise in focusing
radiation on the areas requiring radiation.

So in general before starting radiation treatments a planning session
or simulation is required. During this session immobilization devices
are used prior to obtaining CAT scan of the area which requires
radiation. Once the images are obtained, a radiation oncologist would
define i.e. contour the target area as well as adjacent critical
organs. Radiation oncologist would set limits on how much of radiation
these organs can safely receive and also prescribes the required dose
of radiation to the tumor.

Using sophisticated treatment planning software, the dosimetrist would
generate one or more plan for the radiation treatment. Radiation
oncologist would review the plans and chooses the plan which has
optimized the dose of radiation to the target and adjacent organs.
Once the optimal plan is chosen, the physicist would review the plan
for quality assurance and subsequently approved by radiation
oncologist.

Prior to delivering the very first fraction of radiation, patient
would undergo another simulation consisting of obtaining films on the
radiation table (AKA Port Films). Radiation oncologist would review
these films to make sure that everything is aligned with what has been
planned. Once the radiation oncologist approves these films, the
actual treatments can begin.

Patients are anxious to begin radiation immediately but as you can
appreciate, a considerable amount of time and work is spent in
preparation for radiation. Our moto as radiation oncolgoists: safety
first! Radiation therapy is a very technical treatment and takes a great deal
of work by the radiation oncologist, the dosimetrist and the radiation
physicist to create a radiation plan which would deliver the required
dose of radiation to the cancer while minimizing radiation dose to the
surrounding normal and critical organs. To create such a fine balance,
sophisticated technology and treatment planning software are utilized.

Traditional radiation therapy used plain X-ray films to map the target
area and radiation fields. This was a two-dimensional technique and
the exact dose of radiation to critical organs was not determined
carefully. Three-dimensional conformal radiation therapy uses CT scans
to carefully define each and every critical organ at risk of receiving
radiation as well as the tumor itself.

Over the past decade or so a more sophisticated form of
three-dimensional conformal radiation therapy called IMRT (Intensity
Modulated Radiation Therapy) has evolved. This technique utilizes
reverse planning. That is instead of learning how much of radiation
the critical organs would receive should we deliver a certain dose of
radiation to a tumor, we can set limits on how much of radiation these
organs can tolerate in advance.

Nowadays we also have the capability of fusing MRI and PET images with
our CT scan images to enhance the quality of our contours and mapping
of the target areas. By doing so we can be more precise in focusing
radiation on the areas requiring radiation.

So in general before starting radiation treatments a planning session
or simulation is required. During this session immobilization devices
are used prior to obtaining CAT scan of the area which requires
radiation. Once the images are obtained, a radiation oncologist would
define i.e. contour the target area as well as adjacent critical
organs. Radiation oncologist would set limits on how much of radiation
these organs can safely receive and also prescribes the required dose
of radiation to the tumor.

Using sophisticated treatment planning software, the dosimetrist would
generate one or more plan for the radiation treatment. Radiation
oncologist would review the plans and chooses the plan which has
optimized the dose of radiation to the target and adjacent organs.
Once the optimal plan is chosen, the physicist would review the plan
for quality assurance and subsequently approved by radiation
oncologist.

Prior to delivering the very first fraction of radiation, patient
would undergo another simulation consisting of obtaining films on the
radiation table (AKA Port Films). Radiation oncologist would review
these films to make sure that everything is aligned with what has been
planned. Once the radiation oncologist approves these films, the
actual treatments can begin.

Patients are anxious to begin radiation immediately but as you can
appreciate, a considerable amount of time and work is spent in
preparation for radiation. Our moto as radiation oncolgoists: safety
first!

Palliative treatment are usually given either to palliate pain, remove compression of tumor on a vital organ such as spinal cord, preventing fracture if the cancer has spread to a weigh-bearing bone, or in the case of brain metastasis to relieve the life-threatening pressure inside the brain. Palliative treatments are often given in short courses of 2-3 weeks not only because the radiation dose per individual treatments (aka fractions) is usually higher but also because the total dose of radiation is lower. Palliative radiation is often used stage IV. That is when the cancer has spread to other organs and even though it might be treatable, it is not curable.

Definitive treatment is given when, based on the stage of the cancer, statistically there is a chance for its cure (i.e. stage I-III). Depending on the type of cancer, definitive radiation can take up to 9 weeks not only because the radiation dose per individual treatments (aka fractions) is usually lower but also because the total dose of radiation is higher. Definitive treatments are given to the primary site of cancer (i.e. original site where the cancer started). Palliative treatment are usually given either to palliate pain, remove compression of tumor on a vital organ such as spinal cord, preventing fracture if the cancer has spread to a weigh-bearing bone, or in the case of brain metastasis to relieve the life-threatening pressure inside the brain. Palliative treatments are often given in short courses of 2-3 weeks not only because the radiation dose per individual treatments (aka fractions) is usually higher but also because the total dose of radiation is lower. Palliative radiation is often used stage IV. That is when the cancer has spread to other organs and even though it might be treatable, it is not curable.

Definitive treatment is given when, based on the stage of the cancer, statistically there is a chance for its cure (i.e. stage I-III). Depending on the type of cancer, definitive radiation can take up to 9 weeks not only because the radiation dose per individual treatments (aka fractions) is usually lower but also because the total dose of radiation is higher. Definitive treatments are given to the primary site of cancer (i.e. original site where the cancer started).

Even though the new radiation technology has given us the capability to spare patients from significant skin burns, depending on the type of cancer and its location, sometimes either the skin itself is the target of radiation or it is impossible to spare it completely. Skin burn from radiation in many ways is similar to a sunburn. There are a number of products that radiation oncologists may recommend to alleviate the discomfort from the skin burn. These include but are not limited to Aquaphor ointment, Miaderm Lotion, Aloe Vera gel, Calendu, RadX Radiation Therapy cream, Radia-Guard lotion and many other products. If the skin has blistered or the shiny and moist part of skin is exposed Silvadene cream and/or a variety of gel wound dressings may be recommended. In worst case scenarios, your radiation oncologist may decide to advise a break in the course of treatment but this has to be weighed carefully against the negative impact of breaks during radiation on the final outcome of treatment. Avoiding sun exposure and products containing alcohol is advisable. Cleaning the area with mild and fragrance-free soap and water to prevent infection is essential. If the affected area is in perineal area, sitz baths with water and Hydrogen Peroxide would be helpful. Women should avoid wearing wired bras if the treatment area includes the chest. Please do not use any product without consulting your radiation oncologist first. Even though the new radiation technology has given us the capability to spare patients from significant skin burns, depending on the type of cancer and its location, sometimes either the skin itself is the target of radiation or it is impossible to spare it completely. Skin burn from radiation in many ways is similar to a sunburn. There are a number of products that radiation oncologists may recommend to alleviate the discomfort from the skin burn. These include but are not limited to Aquaphor ointment, Miaderm Lotion, Aloe Vera gel, Calendu, RadX Radiation Therapy cream, Radia-Guard lotion and many other products. If the skin has blistered or the shiny and moist part of skin is exposed Silvadene cream and/or a variety of gel wound dressings may be recommended. In worst case scenarios, your radiation oncologist may decide to advise a break in the course of treatment but this has to be weighed carefully against the negative impact of breaks during radiation on the final outcome of treatment. Avoiding sun exposure and products containing alcohol is advisable. Cleaning the area with mild and fragrance-free soap and water to prevent infection is essential. If the affected area is in perineal area, sitz baths with water and Hydrogen Peroxide would be helpful. Women should avoid wearing wired bras if the treatment area includes the chest. Please do not use any product without consulting your radiation oncologist first.

Traditionally the indications for post-mastectomy radiation have been as following:
- A tumor 5cm (2 inches) or larger
- 4 or more lymph nodes involved by cancer
- Inflammatory Breast Cancer
- when the surgical margins of the mastectomy specimen are grossly or closely involved with cancer

About a decade ago, studies from Denmark and Canada revealed benefit of post-mastectomy radiation for women with 1-3 involved lymph nodes. Even though initially in the US we were slow to accepting these data, independent studies in US have convinced most of radiation oncologists in the US to recommend post-mastectomy radiation not only to post-menopausal but also premenopausal women with less than 4 lymph nodes involved.

Even though the above-mentioned factors continue to be indications for radiation after mastectomy a few challenges have been introduced to these seemingly straightforward indications in the past decade. This is mainly due to sentinel lymph node biopsy replacing most of complete axillary lymph node dissections, introductions of PET imaging and also increase in use of neoadjuvant chemotherapy.

The challenge sentinel lymph node biopsy has introduced is that often the number of lymph nodes removed are less than 4. The question of whether additional nodes need to be removed if one or more of these sentinel lymph nodes are involved, has been subject of debate amongst surgical, radiation and medical oncology experts for years. The recent publication of the results of the American College of Surgeons Oncology Group trial (Z0011) put this issue to rest because it showed that completion axillary dissection in these patients did not add local control or survival benefit. But it also left radiation oncologists in a dilemma regarding the necessity for irradiating the lymph nodes for patients with positive SLNs who do not undergo ALND is uncertain. So this issue is often addressed by assessing the individual's risk of having residual disease in the axilla.

When chemotherapy is administered prior to mastectomy, it can potentially completely destroy the cancer cells. That is an ideal outcome but would not eliminate the need for mastectomy. In such a scenario, the challenge for the radiation oncologist is whether postmastectomy radiation is necessary or not. If a sentinel node biopsy is performed prior to the administration of chemotherapy, the status of the lymph nodes prior to chemotherapy may provide helpful information regarding this dilemma, otherwise the radiation oncologist does not have such a basis for making the recommendation. The jury is still out on this issue and individualized recommendations must be based on taking other factors predictive of risk of local recurrence.

PET scans might suggest involvement of internal mammary nodes. Because of the risk of false-positivity and the fact that these nodes are not normally sampled or dissected, the decision regarding treating these potential positive lymph nodes by irradiating them becomes another subject of discussion at tumor boards.

So as you can appreciate, practice of radiation oncology, like many other fields in medicine is moving away from one size fits all towards individualized medicine. Traditionally the indications for post-mastectomy radiation have been as following:
- A tumor 5cm (2 inches) or larger
- 4 or more lymph nodes involved by cancer
- Inflammatory Breast Cancer
- when the surgical margins of the mastectomy specimen are grossly or closely involved with cancer

About a decade ago, studies from Denmark and Canada revealed benefit of post-mastectomy radiation for women with 1-3 involved lymph nodes. Even though initially in the US we were slow to accepting these data, independent studies in US have convinced most of radiation oncologists in the US to recommend post-mastectomy radiation not only to post-menopausal but also premenopausal women with less than 4 lymph nodes involved.

Even though the above-mentioned factors continue to be indications for radiation after mastectomy a few challenges have been introduced to these seemingly straightforward indications in the past decade. This is mainly due to sentinel lymph node biopsy replacing most of complete axillary lymph node dissections, introductions of PET imaging and also increase in use of neoadjuvant chemotherapy.

The challenge sentinel lymph node biopsy has introduced is that often the number of lymph nodes removed are less than 4. The question of whether additional nodes need to be removed if one or more of these sentinel lymph nodes are involved, has been subject of debate amongst surgical, radiation and medical oncology experts for years. The recent publication of the results of the American College of Surgeons Oncology Group trial (Z0011) put this issue to rest because it showed that completion axillary dissection in these patients did not add local control or survival benefit. But it also left radiation oncologists in a dilemma regarding the necessity for irradiating the lymph nodes for patients with positive SLNs who do not undergo ALND is uncertain. So this issue is often addressed by assessing the individual's risk of having residual disease in the axilla.

When chemotherapy is administered prior to mastectomy, it can potentially completely destroy the cancer cells. That is an ideal outcome but would not eliminate the need for mastectomy. In such a scenario, the challenge for the radiation oncologist is whether postmastectomy radiation is necessary or not. If a sentinel node biopsy is performed prior to the administration of chemotherapy, the status of the lymph nodes prior to chemotherapy may provide helpful information regarding this dilemma, otherwise the radiation oncologist does not have such a basis for making the recommendation. The jury is still out on this issue and individualized recommendations must be based on taking other factors predictive of risk of local recurrence.

PET scans might suggest involvement of internal mammary nodes. Because of the risk of false-positivity and the fact that these nodes are not normally sampled or dissected, the decision regarding treating these potential positive lymph nodes by irradiating them becomes another subject of discussion at tumor boards.

So as you can appreciate, practice of radiation oncology, like many other fields in medicine is moving away from one size fits all towards individualized medicine.

The duration of radiation treatments are also determined by the type and stage of the courses. Before prescribing any dose of radiation, a radiation oncologist has to first determine what the intention of the treatment would be. Treatment intent is either palliative or definitive.

Palliative treatment are usually given either to palliate pain, remove compression of tumor on a vital organ such as spinal cord, preventing fracture if the cancer has spread to a weigh-bearing bone, or in the case of brain metastasis to relieve the life-threatening pressure inside the brain. Palliative treatments are often given in short courses of 2-3 weeks not only because the radiation dose per individual treatments (aka fractions) is usually higher but also because the total dose of radiation is lower. Palliative radiation is often used stage IV. That is when the cancer has spread to other organs and even though it might be treatable, it is not curable.

Definitive treatment is given when, based on the stage of the cancer, statistically there is a chance for its cure (i.e. stage I-III). Depending on the type of cancer, definitive radiation can take up to 9 weeks not only because the radiation dose per individual treatments (aka fractions) is usually lower but also because the total dose of radiation is higher. Definitive treatments are given to the primary site of cancer (i.e. original site where the cancer started).

Radiation is normally given five days a week Monday through Friday. In some instances twice a day radiation may be recommended. In this case the two treatments are at least six hours apart. How long each individual treatment would take depends on many factors including the dose per fraction, the number of fields used to treat a target, the technology used and the energy and form of radiation.

Brachytherapy (aka "internal radiation") is usually given in much fewer number of treatments. For example prostate seed implant requires one procedure to place the seeds in the prostate. In treatment of gynecological cancers depending on whether Low Dose Radiation (LDR) or High Dose Rate (HDR) radiation is used anywhere between 2 to 6 treatments often one to two weeks apart is given. In a similar manner systemic radiation, in the form of an injection or oral intake, would require much fewer number of treatments. For example treatment of thyroid cancer using I-131 often requires only one treatment. The duration of radiation treatments are also determined by the type and stage of the courses. Before prescribing any dose of radiation, a radiation oncologist has to first determine what the intention of the treatment would be. Treatment intent is either palliative or definitive.

Palliative treatment are usually given either to palliate pain, remove compression of tumor on a vital organ such as spinal cord, preventing fracture if the cancer has spread to a weigh-bearing bone, or in the case of brain metastasis to relieve the life-threatening pressure inside the brain. Palliative treatments are often given in short courses of 2-3 weeks not only because the radiation dose per individual treatments (aka fractions) is usually higher but also because the total dose of radiation is lower. Palliative radiation is often used stage IV. That is when the cancer has spread to other organs and even though it might be treatable, it is not curable.

Definitive treatment is given when, based on the stage of the cancer, statistically there is a chance for its cure (i.e. stage I-III). Depending on the type of cancer, definitive radiation can take up to 9 weeks not only because the radiation dose per individual treatments (aka fractions) is usually lower but also because the total dose of radiation is higher. Definitive treatments are given to the primary site of cancer (i.e. original site where the cancer started).

Radiation is normally given five days a week Monday through Friday. In some instances twice a day radiation may be recommended. In this case the two treatments are at least six hours apart. How long each individual treatment would take depends on many factors including the dose per fraction, the number of fields used to treat a target, the technology used and the energy and form of radiation.

Brachytherapy (aka "internal radiation") is usually given in much fewer number of treatments. For example prostate seed implant requires one procedure to place the seeds in the prostate. In treatment of gynecological cancers depending on whether Low Dose Radiation (LDR) or High Dose Rate (HDR) radiation is used anywhere between 2 to 6 treatments often one to two weeks apart is given. In a similar manner systemic radiation, in the form of an injection or oral intake, would require much fewer number of treatments. For example treatment of thyroid cancer using I-131 often requires only one treatment.

What form of radiation a radiation oncologist would recommend depends on many factors but mainly the type of cancer, the stage of cancer and its location. What equips a radiation oncologist is not only four years of specialty training including radiation physics and biology but the evidence supporting these forms of treatments based on decades of research in the field. For each type of cancer there is a standard of care basically dictating what the appropriate radiation should consist of. For example for cervical cancer a combination of external radiation and brachytherapy is used. For prostate cancer one can use either external radiation or seed implant of a combination of both. What form of radiation a radiation oncologist would recommend depends on many factors but mainly the type of cancer, the stage of cancer and its location. What equips a radiation oncologist is not only four years of specialty training including radiation physics and biology but the evidence supporting these forms of treatments based on decades of research in the field. For each type of cancer there is a standard of care basically dictating what the appropriate radiation should consist of. For example for cervical cancer a combination of external radiation and brachytherapy is used. For prostate cancer one can use either external radiation or seed implant of a combination of both.

In general, no. However, there may be reasons to avoid certain foods depending upon where the radiation is being directed. Your radiation oncology physician or nurse would be the best source of information for your particular situation. Although anti-oxidants interfere with radiation, there is no evidence that the anti-oxidants found in whole foods (not dehydrated, concentrated versions of what was once a whole food) are harmful during treatment. In general, no. However, there may be reasons to avoid certain foods depending upon where the radiation is being directed. Your radiation oncology physician or nurse would be the best source of information for your particular situation. Although anti-oxidants interfere with radiation, there is no evidence that the anti-oxidants found in whole foods (not dehydrated, concentrated versions of what was once a whole food) are harmful during treatment.

The main difference between chemotherapy and radiation therapy is the fact that chemotherapy is a systemic treatment and radiation is a local treatment. In this sense radiation is similar to surgery and would only address the area which is receiving radiation. With chemotherapy, once it is injected into your blood stream, it goes everywhere in your system. That is like a double-edge sword though because often it affects organs which do not necessarily need to receive chemotherapy such as your hair, your nails, your bone marrow, or kidney etc. But the fact that it addresses your entire system has the advantage of killing any cancer cell that potentially has cut loose through your system. More and more research is done on creating mechanisms towards targeted therapy that is to direct chemotherapy towards the cancer cells only and avoid side effects of chemotherapy by sparing the normal tissues. The main difference between chemotherapy and radiation therapy is the fact that chemotherapy is a systemic treatment and radiation is a local treatment. In this sense radiation is similar to surgery and would only address the area which is receiving radiation. With chemotherapy, once it is injected into your blood stream, it goes everywhere in your system. That is like a double-edge sword though because often it affects organs which do not necessarily need to receive chemotherapy such as your hair, your nails, your bone marrow, or kidney etc. But the fact that it addresses your entire system has the advantage of killing any cancer cell that potentially has cut loose through your system. More and more research is done on creating mechanisms towards targeted therapy that is to direct chemotherapy towards the cancer cells only and avoid side effects of chemotherapy by sparing the normal tissues.

Throughout the past two decades, the role of radiation therapy in treatment of ovarian cancer has been consistently diminishing. This is due to two major factors. The first factor is the increasing knowledge that most of ovarian cancers, especially the ones which are not localized and require more than surgical intervention i.e. adjuvant treatment, are considered either systemic disease or at least putting the entire abdominal cavity at risk of recurrence. The second factor is the advances made in chemotherapy, not only by having better supportive care so that the patients can tolerate chemotherapy better but also in the number new chemotherapy agents.

When radiation therapy was routinely used for ovarian cancer, it was given in the form of whole abdominal radiation. That is the radiation was covering all and every tissue below diaphragm down to the pelvis. These large radiation fields were very difficult to tolerate. Large does could not be delivered to these large fields and patients had to endure many side effects particularly nausea, vomiting, and diarrhea. Later on injection of Phosphorus-32, a radioactive isotope of phosphorus into the abdominal cavity replaced the external radiation to the whole abdomen. Nowadays even that has been mostly replaced by injection of chemotherapy agents into the abdominal cavity.

Currently surgery and chemotherapy are the mainstays of treatment of ovarian cancer and as opposed to many other cancers, repeating surgery either in the form of debulking the disease or for second look, takes place before considering radiation therapy. That has limited the role of radiation therapy in treatment of ovarian cancer to treating the metastatic areas. That is if the cancer spreads to the bone, brain or other organs, radiation may be used to address those areas in a palliative manner. Also if disease becomes resistant to second and third line chemotherapy agents, and surgery is not an option either, radiation can be used to locally treat the residual or progressive disease at the primary site. Throughout the past two decades, the role of radiation therapy in treatment of ovarian cancer has been consistently diminishing. This is due to two major factors. The first factor is the increasing knowledge that most of ovarian cancers, especially the ones which are not localized and require more than surgical intervention i.e. adjuvant treatment, are considered either systemic disease or at least putting the entire abdominal cavity at risk of recurrence. The second factor is the advances made in chemotherapy, not only by having better supportive care so that the patients can tolerate chemotherapy better but also in the number new chemotherapy agents.

When radiation therapy was routinely used for ovarian cancer, it was given in the form of whole abdominal radiation. That is the radiation was covering all and every tissue below diaphragm down to the pelvis. These large radiation fields were very difficult to tolerate. Large does could not be delivered to these large fields and patients had to endure many side effects particularly nausea, vomiting, and diarrhea. Later on injection of Phosphorus-32, a radioactive isotope of phosphorus into the abdominal cavity replaced the external radiation to the whole abdomen. Nowadays even that has been mostly replaced by injection of chemotherapy agents into the abdominal cavity.

Currently surgery and chemotherapy are the mainstays of treatment of ovarian cancer and as opposed to many other cancers, repeating surgery either in the form of debulking the disease or for second look, takes place before considering radiation therapy. That has limited the role of radiation therapy in treatment of ovarian cancer to treating the metastatic areas. That is if the cancer spreads to the bone, brain or other organs, radiation may be used to address those areas in a palliative manner. Also if disease becomes resistant to second and third line chemotherapy agents, and surgery is not an option either, radiation can be used to locally treat the residual or progressive disease at the primary site.

Discussing with my colleagues, the answer was always the same. “Never assume”, there are certain protocols that you must always maintain regarding the administration of chemotherapy or radiation.

1. Ask the patient his first and last name, birthday and make sure that it is correct on all orders.
2. Know the patient’s allergies and medical history
3. Inform the patient the side effects of the medications that they will be receiving or radiation.
4. Check the order for time, date, clear meaning of what is written, is the order appropriate to that patient and who wrote the order.
5. Check the BSA and the calculations to the order that is written.
6. Know the correct name of the chemotherapy agent that you will be administering to the patient.
7. Know what proper route, dose and quantity that you will be administering to the patient.
8. Know the side effects of the medications.
9. Check the Intra venous site to see good access, blood returned and patency.
10. Instruct the patient to what they are supposed to feel while the patient is receiving chemotherapy or radiation.
11. If you have any questions regarding what you are administering always ask before you administer. Never assume. Discussing with my colleagues, the answer was always the same. “Never assume”, there are certain protocols that you must always maintain regarding the administration of chemotherapy or radiation.

1. Ask the patient his first and last name, birthday and make sure that it is correct on all orders.
2. Know the patient’s allergies and medical history
3. Inform the patient the side effects of the medications that they will be receiving or radiation.
4. Check the order for time, date, clear meaning of what is written, is the order appropriate to that patient and who wrote the order.
5. Check the BSA and the calculations to the order that is written.
6. Know the correct name of the chemotherapy agent that you will be administering to the patient.
7. Know what proper route, dose and quantity that you will be administering to the patient.
8. Know the side effects of the medications.
9. Check the Intra venous site to see good access, blood returned and patency.
10. Instruct the patient to what they are supposed to feel while the patient is receiving chemotherapy or radiation.
11. If you have any questions regarding what you are administering always ask before you administer. Never assume.

Balloon radiotherapy for breast cancer, also known as intracavitary brachytherapy, can deliver a focused dose of radiation to part of the breast. The standard since the 1980s has been whole breast radiation therapy given over a period of a few weeks. With the balloon placed by the surgeon, radiation can be delivered twice a day for ten treatments to make treatment more focused and convenient.

This is one form of accelerated partial breast irradiation, or APBI. This technique is investigational but promising enough that it's reasonable to consider as an alternative to whole breast radiation therapy. Depending upon how conservative you are regarding medical evidence, it may be best done only on a clinical trial or there are guidelines for treatment off protocol in selected circumstances, which I have answered on TalkAboutHealth before: http://bit.ly/mZ2Fdg

I offer this treatment to selected women but tend to favor standard whole breast radiation. There's a fair amount of hype about APBI but it's still not proven to be equally effective. I'm not sure if this is the NY Times article you meant, but I'll discuss this: http://nyti.ms/wVW62K

Recent data presented at the San Antonio Breast Cancer Symposium showed that women receiving APBI were "about twice as likely to have a mastectomy in the following five years" after treatment compared to women receiving whole breast radiation. Sounds terrible, right? I call foul on the NY Times:

1. The failure rate almost doubled; 4% vs. 2.2%. Had the NY Times presented it based upon success rate, 96% vs 97.8%, it's not news.

2. It's a retrospective, broad stroke study. There can be all sorts of bias and no ability to account for quality control in how the treatment was done for APBI.

3. Presentations at academic meetings are interesting, but it's not finalized, peer-reviewed research until it's published.

I'm conservative regarding use of APBI. Don't believe the positive hype, but I don't put too much stock in the NY Times article. I hope that answers your question!


Balloon radiotherapy for breast cancer, also known as intracavitary brachytherapy, can deliver a focused dose of radiation to part of the breast. The standard since the 1980s has been whole breast radiation therapy given over a period of a few weeks. With the balloon placed by the surgeon, radiation can be delivered twice a day for ten treatments to make treatment more focused and convenient.

This is one form of accelerated partial breast irradiation, or APBI. This technique is investigational but promising enough that it's reasonable to consider as an alternative to whole breast radiation therapy. Depending upon how conservative you are regarding medical evidence, it may be best done only on a clinical trial or there are guidelines for treatment off protocol in selected circumstances, which I have answered on TalkAboutHealth before: http://bit.ly/mZ2Fdg

I offer this treatment to selected women but tend to favor standard whole breast radiation. There's a fair amount of hype about APBI but it's still not proven to be equally effective. I'm not sure if this is the NY Times article you meant, but I'll discuss this: http://nyti.ms/wVW62K

Recent data presented at the San Antonio Breast Cancer Symposium showed that women receiving APBI were "about twice as likely to have a mastectomy in the following five years" after treatment compared to women receiving whole breast radiation. Sounds terrible, right? I call foul on the NY Times:

1. The failure rate almost doubled; 4% vs. 2.2%. Had the NY Times presented it based upon success rate, 96% vs 97.8%, it's not news.

2. It's a retrospective, broad stroke study. There can be all sorts of bias and no ability to account for quality control in how the treatment was done for APBI.

3. Presentations at academic meetings are interesting, but it's not finalized, peer-reviewed research until it's published.

I'm conservative regarding use of APBI. Don't believe the positive hype, but I don't put too much stock in the NY Times article. I hope that answers your question!

Good question, complex answer. I'll do my best.

In early stage cervical cancer, surgery is often possible but sometimes an organ-preserving approach is preferable and radiation can be used alone. In more advanced disease, surgery isn't possible but cure still is, so radiation is combined often with chemotherapy.

In these cases, radiation can be given partly with external x-rays, but to focus the dose some internal radiation treatment is also given. Usually, this is intracavitary brachytherapy (meaning close treatment in a cavity) by placing radioactive sources into the vagina, cervix and uterus.

Historically, radium was used. In the past 20 years, most of the brachytherapy has been with Cesium-137. Treatment required going to the operating room to place the applicator that would hold the radioactive sources, then determining how much Cesium to place internally for a period of 2-3 days while hospitalized. This is often referred to as LDR (low dose rate) brachytherapy because it's delivered slowly over time.

More recently there has been a move toward pulsed doses of HDR (high dose rate) brachytherapy with an Ir-192 source. This seems to be an equally effective approach with more radiation safety than LDR, but there are supporters for both approaches. The treatments are short but often more internal treatments are needed with HDR. Good question, complex answer. I'll do my best.

In early stage cervical cancer, surgery is often possible but sometimes an organ-preserving approach is preferable and radiation can be used alone. In more advanced disease, surgery isn't possible but cure still is, so radiation is combined often with chemotherapy.

In these cases, radiation can be given partly with external x-rays, but to focus the dose some internal radiation treatment is also given. Usually, this is intracavitary brachytherapy (meaning close treatment in a cavity) by placing radioactive sources into the vagina, cervix and uterus.

Historically, radium was used. In the past 20 years, most of the brachytherapy has been with Cesium-137. Treatment required going to the operating room to place the applicator that would hold the radioactive sources, then determining how much Cesium to place internally for a period of 2-3 days while hospitalized. This is often referred to as LDR (low dose rate) brachytherapy because it's delivered slowly over time.

More recently there has been a move toward pulsed doses of HDR (high dose rate) brachytherapy with an Ir-192 source. This seems to be an equally effective approach with more radiation safety than LDR, but there are supporters for both approaches. The treatments are short but often more internal treatments are needed with HDR.

Treatment options are dependent on a variety of factors including the stage, a patient's other medical conditions, and a patient's understanding of these options. For example, there are now certain conditions/situations where by stereotactic body radiation therapy (SBRT) may be an alternative to surgery. Our physicians always take their time in going through all modalities and side effects with our patients so that they can make the most educated decision for themselves, and be comfortable with the treatment they decided on. Treatment options are dependent on a variety of factors including the stage, a patient's other medical conditions, and a patient's understanding of these options. For example, there are now certain conditions/situations where by stereotactic body radiation therapy (SBRT) may be an alternative to surgery. Our physicians always take their time in going through all modalities and side effects with our patients so that they can make the most educated decision for themselves, and be comfortable with the treatment they decided on.