WHAT IS IT?

DIBH technique is a specialized radiation therapy technique that allows sparing of normal tissue in the treated area. Using an infrared tracking camera and a reflective marker, the system measures the patient’s respiratory pattern and range of motion and displays them as a waveform.

The gating thresholds are set when a tumour is in the desired portion of the respiratory cycle. These thresholds determine when the gating system turns the treatment beam on and off.

WHY AM I HAVING THIS TREATMENT?

The Deep Inspiration Breath-Hold technique facilitates the treatment of lungs, liver or pancreas, and helps minimize the dose to the heart and lung in selected breast treatments.

WHAT CAN I EXPECT DURING MY PLANNING CT SCAN?

During your planning CT scan;

• A Radiation Therapist will place a box with reflective markers on your chest and ask you to inhale and exhale deeply for a few minutes so that the camera tracks the box on your chest and hence your breathing pattern.
• The Radiation Therapist will then ask you to listen and follow the voice prompts given to you throughout the scan via the CT scanner speaker. The voice prompt will ask you to inhale deeply and hold your breath, the CT table will move and the voice prompt will then ask you to breathe normally. The table will move again and the same voice prompt is repeated.
• Once your scans are complete (5 – 10 min), the Radiation Therapist will return to the room to make reference marks/semipermanent tattoos in your treatment area.

WHAT CAN I EXPECT DURING MY TREATMENT SESSIONS?

During your treatment sessions;

• The Radiation Therapists will set you up on the treatment bed using the reference tattoos made at the scanner to align you.
• The box with reflective markers is then placed on your chest in the same position as at your scan.
• The Radiation Therapists will then ask you to listen to their voice prompts over the intercom and will leave the room.
• You will then hear them asking you to inhale deeply and hold your breath and then to breathe normally. These prompts are repeated throughout your treatment as they take images and proceed to treat you until the end of your treatment.

NOTE: The machine is able to switch the treatment on and off according to your breathing pattern, thus, you should hold your breath only for as long as you comfortably can and release when necessary to avoid exhaustion.

TIPS TO HOLD YOUR BREATH FOR LONGER PERIODS

Learn how to take a full, deep breath

• If you want to store more oxygen for your breath-hold, you need to learn how to use the total volume of your lungs. A proper breath begins from the diaphragm. You know you’re breathing correctly if your belly is moving up and down rather than your shoulders. Take a full, deep breath with your mouth, and imagine your lungs filling up, starting from their very bottom. Slowly, you feel your lungs fill near your diaphragm. Next, you feel the air filling your lungs by your sternum. Finally, fill the very top of your lungs near the top of your chest. You’ve successfully taken a full deep breath – the kind you’ll take right before you start holding it. Your deep inhalation should take 20 seconds.

Practice deep breathing

• Inhale and exhale slowly from deep within your diaphragm to get rid of low quality air. Make sure to exhale as much as possible during this process.

If you are a smoker, please inform your Radiation Oncologist

FACTS ABOUT LYMPHOMA

The lymphatic system is a network of tiny vessels extending throughout the body. They are often next to the veins and arteries but are even smaller than them. Scattered along these vessels are lymph nodes. The lymphatic vessels carry a clear fluid called lymph from the extremities and organs back to the blood circulation. The job of the lymphatic system is to fight infection and disease. A tumour of the lymphatic system is called lymphoma. The two main types are Hodgkin’s and non-Hodgkin’s lymphomas.

HODGKIN’S LYMPHOMA

• Hodgkin’s lymphoma (or Hodgkin’s disease) most often begins in the larger, more central lymph nodes of the body-those along the largest blood vessels of the neck, central chest, abdomen along the spine, and armpit and groin areas where the vessels return from the arms and legs. Hodgkin’s is usually treated with chemotherapy and/or radiation therapy, either alone or together.

NON-HODGKIN’S LYMPHOMA (NHL)

• Non-Hodgkin’s Lymphoma is a general term for about 30 different types of lymphoma that differ from Hodgkin’s lymphoma.
• NHL is eight times more common than Hodgkin’s lymphoma.
• All types of NHL are treatable, and many are curable.
• NHL is usually treated with chemotherapy, biologic therapy and/or radiation therapy. In some types of NHL a stem cell transplant may be part of treatment. Depending on your cancer and overall health, you might receive only one of these treatments or several in combination.

STAGING OF LYMPHOMA

The stage of lymphoma is a term used to describe the extent of the disease.

• Stage I: Single lymph node or non-lymph node region is affected.
• Stage II: Two or more lymph nodes or non-lymph node regions are affected on the same side of the diaphragm (the muscle under the lungs).
• Stage III: Lymph node or non-lymph node regions above and below the diaphragm are affected.
• Stage IV: The cancer has spread outside the lymph nodes to organs such as the liver, bones or lungs. Stage IV can also refer to a tumour in another organ and/or tumours in distant lymph nodes.

Talk to your physician to find out exactly which stage you have. Determining the stage and exact type of lymphoma (by microscopic examination of tissue from a biopsy) are essential steps toward planning the best treatment to cure your disease.

TREATMENT OPTIONS FOR LYMPHOMA

Treatment options depend on the type of lymphoma, its stage and your overall health. Treatment may include chemotherapy or radiation therapy, either alone or in combination. It may help to talk to several specialists before deciding on the best course of treatment for you, your disease and your lifestyle.

A radiation oncologist is a doctor who specializes in destroying diseased cells with high-energy X-rays or other types of radiation.

A medical oncologist is a doctor who is an expert at prescribing special drugs (chemotherapy or biologic therapy) to treat disease. Some medical oncologists are also haematologists, meaning they have experience treating blood disorders.

UNDERSTANDING RADIATION THERAPY

Radiation therapy, also called radiotherapy, is the careful use of radiation to kill diseased cells safely and effectively while avoiding nearby healthy tissue.

• Radiation oncologists use radiation therapy to cure disease, to control disease growth or to relieve symptoms.
• Radiation therapy works within diseased cells by damaging their ability to grow. When these cells are destroyed by the radiation, the body naturally eliminates them.
• Healthy tissues can also be affected by radiation, but they are usually able to repair themselves in a way that cancer cells cannot.

EXTERNAL BEAM RADIATION THERAPY

External beam radiation therapy is a series of outpatient treatments to deliver radiation to the diseased cells accurately. Radiation therapy has been proven to be very successful at treating and curing lymphoma.

• Radiation therapists deliver external beam radiation therapy to the lymphoma from a machine called a linear accelerator.
• Each treatment is painless and is similar to getting an X-ray. Treatments last less than 30 minutes each, every day but Saturday and Sunday, for several weeks.
• Involved field radiation is when your doctor delivers radiation only to the parts of your body known to have disease. It is often combined with chemotherapy. Radiation above the diaphragm to the neck, chest and/or underarms is called mantle field radiation. Treatment below the diaphragm to the abdomen, spleen and/or pelvis is called inverted-Y field radiation.
• Your radiation oncologist may deliver radiation to all the lymph nodes in the body to destroy cells that may have spread to other lymph nodes. This is called total nodal irradiation.
• Your radiation oncologist may also deliver radiation to the entire body. This is called total body irradiation. It is often done before chemotherapy and a stem cell or bone marrow transplant to eliminate any remaining diseased cells.

Radiation therapy may be used alone or in combination with chemotherapy or biologic therapy. You will work with your radiation oncologist to agree on a treatment plan that is best for you.

BIOLOGIC THERAPY

Also called immunotherapy, biologic therapy works with your immune system to fight disease. Biologic therapy is like chemotherapy. The difference is that chemotherapy attacks the diseased cells directly, and biologic therapy helps your immune system fight the disease.

• Monoclonal antibodies work by targeting certain molecules in the body and attaching themselves to those molecules. This causes somecells to die and makes others more likely to be destroyed by radiation and chemotherapy.
• Radiolabeled antibodies are monoclonal antibodies with radioactive particles attached. These antibodies are designed to attach themselves directly to the diseased cells and damage them with small amounts of radiation without injuring nearby healthy tissue.

POSSIBLE SIDE EFFECTS

The side effects you might experience will depend on the part of the body being treated, the dose of radiation given and whether you also receive chemotherapy. Before treatment begins, ask your doctor about possible side effects and how best to manage them.

• You may experience mild skin irritation like a sunburn, sore throat, upset stomach, loose bowel movements and/or fatigue. Most side effects will go away after treatment ends.
• Radiation to your head or mouth may cause mouth dryness that can lead to tooth decay. Fluoride treatments may help, so your radiation oncologist will ask you to see your dentist before treatment begins.
• Radiation can cause inflammation in the treated area. For example, treatment to the chest may cause difficulty with swallowing, a cough or feeling short of breath.
• You might lose your hair in the areas treated. Your hair will grow back, but it might not have the same texture or thickness.
• Tell your doctor or radiation therapist if you experience any discomfort or side effects. They may be able to prescribe medication or change your diet to help.

These side effects are temporary and should go away after treatment ends. Because cure rates have improved significantly, there are potential late effects from radiation that vary based upon the area treated and dose you receive. Ask your doctor to discuss any possible longer-term side effects with you before treatment begins.

CARING FOR YOURSELF DURING TREATMENT

Receiving treatments can be difficult both physically and mentally. Take care of yourself by:

• Getting plenty of rest.
• Following doctor’s orders.
• Eating a diet high in protein and calories as directed by your radiation oncology team.
• Treating the skin exposed to radiation with extra care as directed by your radiation oncology team.
• Seeking support from friends, family and cancer support groups.

FACTS ABOUT PROSTATE CANCER

Prostate cancer is the most common cancer in men. Prostate cancer is very manageable and often curable. More than 98 percent of men with prostate cancer will live more than five years after diagnosis.

TREATING PROSTATE CANCER

If you find out you have cancer, you should discuss your treatment options with a radiation oncologist, a cancer doctor who specializes in treating disease with radiation therapy, and a urologist, a surgeon who specializes in the genitourinary system. Prostate cancer treatment options include:

Surgery – An urologist surgically removes the entire prostate.

External beam radiation therapy – a radiation oncologist directs high energy radiation to noninvasively kill the cancer cells.

Brachytherapy – A radiation oncologist surgically implants high energy radiation seeds within the prostate.

Hormone therapy – a doctor prescribes medication to stop the production of hormones that help prostate cancer grow. The prescribing doctor may be an urologist, radiation oncologist or medical oncologist.

Chemotherapy – a medical oncologist prescribes medication to kill cancer cells.

Cryosurgery – doctor, usually an urologist or interventional radiologist, freezes the tumour within the prostate.

Sometimes a combination of treatments is best for your cancer, such as surgery followed by external beam radiation. Some men can safely postpone treatment and watch their cancer closely until treatment is needed. Often called active surveillance, this approach allows men with low-risk prostate cancer to avoid the potential side effects of treatment or to delay them if treatment becomes necessary. Ask your doctors about the risks and benefits of all treatment options compared to active surveillance.

EXTERNAL BEAM RADIATION THERAPY

External beam radiation therapy (also called radiotherapy) involves a series of daily treatments to accurately deliver radiation to the prostate. Recently completed research trials have shown that higher doses of radiation can improve cure rates. With modern techniques, radiation therapy is as effective as surgery to cure prostate cancer.

Before treatment begins, your treatment plan will be designed. A CT scan is done in the position you will be treated, often with a supportive device to keep you comfortably in the same position for treatment. Using information from your pathology, imaging and exam, your doctor and planning radiation therapist will design a treatment plan to treat the prostate gland. Sometimes, this will also include treatment of the seminal vesicles (glands on the back of the prostate) and lymph nodes. Ask your doctor to explain what treatment area is appropriate for you.

With CT scans, three dimensional plans (called 3D-CRT) can be created to fit the shape of the treatment areas. These treatment plans focus radiation beams on the prostate while limiting radiation to healthy tissues around it. As higher radiation doses have been used to improve cure rates, more sophisticated forms of 3D-CRT, intensity modulated radiation therapy (IMRT) and imaging guided radiation therapy (IGRT), have been used. These treatment approaches allow the radiation beams to treat the cancer and lessen the risks of side effects. External beam radiation therapy can be delivered using a variety of conformal techniques such as intensity modulated radiation therapy (IMRT).

With all external beam therapy, treatment is delivered in a series of daily sessions, each about 15 minutes long, Monday through Friday, for several weeks. Each treatment is painless, non-invasive, and similar to a long X-ray: you hear noise but will feel nothing. Each day, you will feel the same when you leave as you did when you came.

The duration of your treatment will depend on your health and the type of radiation plan used. The use of even shorter schedules of external beam radiation therapy is being studied for patients with early stage prostate cancer. Hypofractionated radiation is a form of daily treatment giving higher doses over four to six weeks compared to more standard seven to nine weeks of treatment. Stereotactic body radiation therapy (SBRT) is a technique for treating cancers in five or fewer treatments at substantially higher doses each treatment. Neither hypofractionated nor stereotactic radiation is yet considered a standard treatment option for prostate cancer. It is the subject of ongoing investigations.

PROSTATE BRACHYTHERAPY

Brachytherapy (meaning “close treatment” in Greek) involves treating the cancer by inserting radioactive sources directly into the gland. Minimally invasive, permanent brachytherapy requires anaesthesia and is done as an outpatient surgical procedure. (Outpatient surgery means you can go home the same day as the implant.)

• Permanent seed brachytherapy consists of inserting small metal seeds of radioactive metal “seeds” directly into the prostate gland. Sometimes, it is called a prostate seed implant or low-dose-rate (LDR) brachytherapy. The seeds, typically iodine or palladium, are temporarily radioactive and deliver the radiation to the prostate over several months. After losing their radioactivity, the seeds remain in the prostate. The seeds are then harmless and should not bother you. For the short time that the seeds are giving off radiation, men are asked not to be in close proximity to children or pregnant women because of the very small chance that the radiation may harm the children or foetuses. Ask your radiation oncologist for specific instructions about radiation safety and exposure for pets or family members.
• Temporary high-dose-rate (HDR) brachytherapy delivers radiation to the prostate with a few treatments using a single small radioactive source given through narrow tubes called catheters inserted into the prostate by your radiation oncol-ogist. You will be under anaesthesia and will not feel any pain. The tubes remain in place for only one or two days. Once the treatment is complete, the tubes and the radioactive source are taken out. Because HDR brachytherapy is temporary and there is no radioactivity in your body, you will not need to take special precautions around others after treatment. Often multiple treatments are planned to give an effective dose to treat prostate cancer.

Brachytherapy may treat prostate cancer alone or may be combined with external beam radiation therapy. Ask your doctor whether either approach is a reasonable treatment option for you.

HORMONE THERAPY

Depending on your cancer, you may benefit from adding hormone therapy to radiation. HorPROSmone therapy decreases testosterone production, which plays an important role in prostate cancer progression. It may be used together with radiation therapy or before radiation to shrink the tumour. Hormone therapy may be given by your radiation oncologist, medical oncologist or urologist.

Side effects of hormone therapy may include hot flashes, mild breast tenderness, diarrhoea, nausea and tiredness. The length of time you will receive hormone therapy depends on your cancer. Ask your doctor for more information.

POSSIBLE SIDE EFFECTS OF RADIATION FOR PROSTATE CANCER

External beam radiation therapy is non-invasive, so it is rare for side effects to show up immediately. With brachytherapy, there may be some swelling, soreness and frequent urination just after the procedure. However, these side effects are from the brachytherapy procedure rather than the radiation itself.

Over a period of weeks, radiation therapy may have other side effects develop:

• Urinary frequency, urgency or a weaker stream are reasonably common side effects, sometimes with some mild discomfort. The symptoms tend to be more noticeable with brachytherapy. You doctor can prescribe medication to help relieve these symptoms.
• Changes in bowel habits are also common, usually some urgency or loose bowel movements. In some cases, you may have some diarrhoea, increased gas or some mucus. Less commonly, some men have a flare of haemorrhoids. These side effects are temporary, with long-term symptoms less likely.
• Mild fatigue may develop, starting in the middle of treatment. However, tiredness from radiation should improve within a few weeks after radiation treatment ends.
• Mild skin irritation can occur occasionally with external beam radiation.
• Impotence is a common side effect of any treatment for prostate cancer. The risk depends partly upon the ability to have an erection before treatment. Many men treated with radiation can maintain erectile function. Don’t be shy about talking to your doctor about your sex life. He or she may be able to suggest remedies or prescribe medication.
• Infertility can often occur after radiation. If you wish to consider having children after radiation treatment, ask your doctor about sperm banking before treatment.

Very rare long-term potential side effects include hip injury, oedema (swelling) or a second tumour from the radiation treatment. Some side effects can be controlled with medications and changes to your diet. Ask your doctor or radiation therapist whether you should make any changes in your diet. Tell them if you experience any discomfort so they can help you feel better.

CARING FOR YOURSELF DURING TREATMENT

• Get plenty of rest during treatment, and don’t be afraid to ask for help.
• Follow your doctor’s orders. Ask if you are unsure about anything. There are no stupid questions.
• Tell your doctor about any medications or vitamins you are taking to make sure they are safe to use during radiation therapy.
• Eat a balanced diet.
• Treat the skin exposed to radiation with special care. Avoid hot or cold packs, only use lotions and ointments after checking with your doctor or radiation therapist
• Clean the area with warm water and mild soap (Dove) or Aqueous cream.

Cancer treatment can be difficult. You have many issues to cope with. Your oncology team along with family and friends are available to help.

FACTS ABOUT BLADDER CANCER

The bladder is located in the pelvis. It collects and stores urine and has a muscular wall that allows it to contract and expand. Cancer limited to the lining of the bladder is called non-muscle invasive bladder cancer (NMIBC). This type of cancer is sometimes called superficial bladder cancer. More than 75 percent of bladder cancer is diagnosed as a NMIBC and it has an excellent survival rate. Muscle invasive bladder cancer penetrates the layers of muscles in the bladder and is more likely to spread to other parts of the body but is often still quite curable. Bladder cancer is four times more common in men than in women.

TREATING BLADDER CANCER

Treatment options are based on your type of cancer, age and overall health. Bladder cancer, if caught early, can often be cured. The main treatments are:

• Radiation therapy, where a radiation oncologist uses high-energy X-rays to destroy the tumour.
• Surgery to remove the cancer in the bladder is usually the first step. If a tumour is determined to be invasive, the next step may be removal of part or all of the bladder by a surgical oncologist or urologist.
• Chemotherapy, where a medical oncologist uses drugs to eliminate the cancer.
• Biologic therapy (also called immunotherapy), where doctors use a drug to stimulate your immune system to fight the cancer.

In the past, complete removal of the bladder was the only way to treat bladder cancer. With advances in radiation therapy and chemotherapy, doctors are sometimes able to treat the cancer while preserving the bladder. This organ preserving approach allows many patients to urinate normally rather than requiring surgical reconstruction for urinary function.

RADIATION THERAPY OPTIONS FOR BLADDER CANCER

Radiation therapy, sometimes called radiotherapy, is the careful use of radiation to safely and effectively treat cancer. Radiation therapy works within cancer cells by damaging their ability to multiply. When these cells die, the body naturally eliminates them. Healthy cells are also affected by radiation, but they are able to repair themselves in a way cancer cells cannot.

• External beam radiation therapy is the main type of radiation used to treat bladder cancer, often in combination with chemotherapy. During this treatment, radiation is directed at the tumour from a machine similar to an X-ray machine.
• Internal radiation therapy, or brachytherapy, is occasionally used with external beam radiation therapy. Radioactive material is placed very close to the tumour through small tubes called catheters or with radioactive pellets.

EXTERNAL BEAM RADIATION THERAPY

External beam radiation therapy (also called radiotherapy) involves a series of daily treatments to accurately deliver radiation to the bladder and pelvis. Research trials have shown that radiation and chemotherapy can permit some bladder cancer patients to have organ-preserving treatment that doesn’t require complete removal of the bladder.

Before treatment begins, your treatment plan will be designed. A CT planning scan is done in the position you will be treated, often with a supportive device to keep you comfortably in the same position for treatment. Using information from your pathology, imaging and exam, your doctor will design a treatment plan to treat the bladder and pelvis.

With external beam therapy, treatment is delivered in a series of daily sessions, Monday through Friday, for several weeks. Each treatment is painless, non-invasive and similar to a long X-ray: you hear noise but will feel nothing. Each day, you will feel the same when you leave as you did when you came.

The radiation beam is usually generated by a machine called a linear accelerator, or linac. Doctors use this machine to generate highenergy X-rays to treat your cancer.

Three-dimensional conformal radiotherapy (3-DCRT) combines multiple radiation treatmentfields to deliver precise doses of radiation to thecancer. This improved technique helps keepradiation away from nearby healthy tissue.

Intensity modulated radiation therapy, or IMRT, is a specialized form of 3-D CRT that allows the radiation beams to be further shaped to focuson the tumour. IMRT is still being studied forbladder cancer.

POTENTIAL SIDE EFFECTS

The side effects you might feel will depend on the area being treated, the dose of radiation given and whether you also receive other treatments, such as chemotherapy. Before treatment begins, ask your doctor about specific side effects and how you can best manage them. Side effects may include:

• Bladder irritation with increased need to urinate.
• Bowel irritation with abdominal cramping, rectal pressure and diarrhoea are possible.
• Fatigue where you feel tired much of the time.
• You may experience a mild skin irritation, like a sunburn.
• The radiation will not cause you to lose the hair on your head, but you may lose your pubic hair near where the radiation was aimed. Some people find the hair grows back in a different colour or texture than before.
• Some patients may also see sexual side effects. Women may experience vaginal dryness. Some men may experience difficulty achieving an erection. These are temporary, but tell your doctor or radiation therapist. They may be able to recommend products or medications to help.

Sometimes symptoms don’t appear until treatments are finished. Some people have hardly any symptoms at all. You are unique as will be your reaction to cancer treatments. Talk to your doctor or radiation therapist about any discomfort or side effects you have, however embarrassing. He or she may be able to provide drugs or other treatments to help.

CARING FOR YOURSELF DURING TREATMENT

• Get plenty of rest during treatment. Followyour doctor’s orders.
• Ask if you are unsure about anything or if you have questions about your treatments and side effects.
• Tell your doctor about any medications or vitamins you are taking.
• Eat a balanced diet. If food tastes funny or if you’re having trouble eating, tell your doctor or dietician. They may be able to help you change the way you eat.
• Treat the skin exposed to radiation with special care. Avoid hot or cold packs, and only use lotions and ointments after checking with your doctor. Your radiation oncology team may also recommend special creams.
• When cleaning the area, use only water and a mild soap (Dove) or Aqueous cream. Coping with cancer can be trying. Be sure to ask friends, family, support groups and your radiation oncology team for help. Ask your doctor about what support resources are available to you.

WHAT ARE BONE METASTASES?

Cancer that starts in one part of the body can sometimes spread to other areas of the body. If a tumour spreads to the bone, this new cancer deposit is called a bone metastasis.

• When bone metastases occur, they are sometimes called “bone cancer”. However, in nearly all cases, bone metastases are a result of the spread of the original cancer to the bone. So instead of having both bone cancer and breast cancer, for example, a person usually has breast cancer that has spread to the bone.
• Cancers that may spread to the bone include, but are not limited to, cancers of the breast, kidney, lung, prostate and thyroid. Multiple myeloma, a disease characterized by uncontrolled growth of white blood cells called plasma cells, can also involve the bones.
• Cancer treatments have improved in recent years, allowing many patients to live longer with cancer than ever before. Unfortunately, bone metastases may still occur sometimes months or even years after an original cancer diagnosis. There are many options available for patients with bone metastases to try to provide relief and to suppress local disease.

SYMPTOMS AND SIGNS OF BONE METASTASES

Pain is the most common symptom of bone metastases. Pain from bone metastases may be made worse by movement during normal daytime activities, but sometimes can be worse at night or at rest.

Bone metastases can weaken bones, putting them at risk for breaking (fracture). In some cases, a fracture is the first sign of bone metastases. Bones of the arms and legs as well as those in the spine are the most common ones to break or fracture.

If cancer spreads to the bones that make up the spine, occasionally it may push on the spinal cord causing a spinal cord compression. Signs of this include back pain, numbness or weakness, trouble urinating or having a bowel movement. If any of these symptoms develop, you should call your cancer doctors and seek emergency care right away.

Bone metastases may cause calcium to be released from the bones into the bloodstream. The increased calcium can cause loss of appetite, nausea, thirst, constipation, tiredness or confusion. If you notice these symptoms, you should talk to your doctor right away.

In some cases, you have no noticeable symptoms or signs that the cancer has spread to the bone. Rather, you may come in for a routine follow-up visit and the cancer is found during your exam or on imaging scans.

GENERAL TREATMENT FOR BONE METASTASES

The goal of treatment for bone metastases is to control pain and other symptoms and to improve your quality of life. In some cases, these treatments can also help you live longer with your cancer.

• Your doctor may prescribe medicines called bisphosphonates. These drugs slow the bone loss caused by cancer to reduce the risk of bone fracture and pain.
• Your doctors may also prescribe chemotherapy or endocrine therapy. This is a term that refers to several different medications that kill cancer cells or stops them from growing. These types of treatment can be given when you are first diagnosed with cancer and also if cancer spreads to another part of the body. Talk with your medical oncologist (chemotherapy doctor) about these types of treatments.
• In most cases, treatment for bone metastases will not “cure” your cancer. However, modern treatments allow doctors to control the bone metastases, allowing many patients to improve their quality of life and to live months or years longer.

USING RADIATION THERAPY FOR BONE METASTASES

• Radiation therapy uses high-energy X-rays to kill cancer cells. This type of treatment is given by a radiation oncologist (doctor who specializes in treating cancer with different types of radiation).
• A very common use of radiation therapy is to treat cancer that has spread to the bone. In general, radiation is very effective at reducing symptoms caused by cancer that has spread to a bone.
• Radiation therapy takes time to work. You may experience relief from your symptoms during treatment, but usually the peak effect of radiation is several days to weeks after it has been given.
• Radiation therapy is usually given from outside the body and targeted to be delivered to a specific area where cancer is known to be located and causing symptoms. In selected circumstances, your doctor will place a radioactive substance into your bloodstream. This is called a radiopharmaceutical and it works to attack cancer cells in all bones by floating in the blood stream and being delivered to cancer cells inside the bones.

THE ROLE OF SURGERY OR INTERVENTIONAL PROCEDURES FOR BONE METASTASES

In the case of a tumour that has broken outside of a vertebral body (the individual bones that make up the spine), your doctor may recommend surgery to remove as much of the tumour as possible before beginning radiation. This is typically performed by a surgeon who specializes in surgery for the spine or bone.

• If surgery is performed, radiation typically starts several weeks after surgery to allow your body to heal.
• For tumours that have not broken outside of the vertebral body or that have caused collapse of the vertebral body (sometimes called a compression fracture), your doctor may recommend seeing a specialist (interventional radiologist or spine surgeon) that can insert a type of bone cement to stabilize the bone, which will reduce pain.

WHAT IS RADIATION THERAPY

Radiation Therapy works by damaging the genetic material or other critical components of cancer cells.
This limits their ability to reproduce. Radiation can sometimes stop the blood supply to cancers, which also kills the cancer cells.

• After the radiation treatment ends, your body is still at work getting rid of the cells damaged by radiation. This is why it often takes a few weeks for you to have the full benefit of the treatment.
• Normal cells are also affected by radiation, but they are better able to repair the damage caused by radiation therapy than can most cancer cells.
• Treatments are non-invasive and painless, much like receiving an X-ray. You should be able to go home after treatment.
• In the case of cancer that has spread to the bone, external beam radiation therapy involves a series of outpatient treatments directed to the bone area where the tumour was found.
• Treatments for cancer in a bone are usually given every day, Monday through Friday, for about one to three weeks depending upon what your doctor thinks will be most helpful.
• Sometimes treatments are delivered in large, highly focused doses. When treatment is completed in one day it is called stereotactic radiosurgery (SRS).
  If a few doses are needed it is called stereotactic body radiotherapy (SBRT). In selected situations, retreatment can be considered with specialized radiation techniques.
• Before starting radiation, you will undergo a radiation “planning” session (simulation) where the radiation treatment team creates a way to set your treatments up accurately on a day-to-day basis. Sometimes, devices to keep you in the same position are used to help with accuracy of daily set up. Images of the area affected by cancer will be obtained on this day to help plan the radiation treatment. This is usually a series of X-rays or a CT scan.
• A plan is then developed to allow radiation to be delivered to the tumour area while avoiding as much normal tissue as possible.

POSSIBLE SIDE EFFECTS

• Fatigue is the most common side effect you may notice, often described as an overall “blah” feeling. Feeling tired often starts in the middle of the treatment and may last for weeks after your last radiation session.
• It is normal for you to lose the hair on your body where the radiation beams were aimed. The hair will probably grow back, but it may feel a little different than it did before treatment. However, you will not lose the hair on your head unless your skull is the bone being treated.
• You may also notice some minor skin changes or tingly feeling where the radiation was aimed. This should fade over time.
• Side effects are different for everyone, and depend to some degree on which part of your body is being treated. Your radiation oncologist and radiation therapist will follow you closely during treatment and ask you and your family members about any symptoms. Medications may be prescribed to make you more comfortable.

CARING FOR YOURSELF DURING TREATMENT

• It is important to care for yourself as well as possible during radiation therapy because the normal parts of your body that are near the tumour are also receiving some radiation, although not as much as the cancer. These normal parts of your body need time and support to heal.
• A balanced diet, mild amount of physical activity, and taking time to rest are all important parts of your cancer treatment.
• Make sure to tell your radiation oncologist about any vitamins or dietary supplements that you are currently taking to make sure they are safe to take during radiation therapy.
• During and even after radiation therapy is over, you will need to take special care of your skin. Stay out of the sun, avoid hot or cold packs, and do not use lotions or ointments without checking with your doctor or radiation therapist first.
• You should also be sure to clean the skin over the areas receiving radiation therapy with warm water and mild soap (Dove) or Aqueous cream.

ABOUT BRAIN TUMOURS

The brain is the centre of thought, memory, emotion, speech, sensation and motor function. The spinal cord and special nerves in the head called cranial nerves carry and receive messages between the brain and the rest of the body. There are two general types of brain tumours:

• Primary – a tumour that starts in the brain. Primary brain tumours can be benign (not cancerous) or malignant (cancerous).
  Primary tumours in the brain or spinal cord rarely spread to distant organs.
• Metastatic – a tumour caused by cancer elsewhere in the body that spreads to the brain. Metastatic brain tumours are always cancerous. Brain tumours cause damage because, as they grow, they can interfere with surrounding cells that serve vital roles in our everyday life.

This brochure is designed to address primary brain tumours

TREATING BRAIN TUMOURS

If doctors determine that you have a brain tumour, the treatment options and prognosis are based on the many factors, including tumour type, location and size of the tumour, how aggressive it appears (grade), as well as your age and health. Depending upon these and other factors, surgery, radiation therapy and medical therapy are possible treatment options.

Radiation Therapy

Radiation therapy, sometimes called radiotherapy, is the careful use of high-energy X-rays to safely and effectively treat brain tumours. Radiation works noninvasively within tumour cells by damaging their ability to multiply. When these cells die, the body naturally eliminates them. Healthy cells near the tumour may be affected by radiation, but they are able to repair themselves in a way tumour cells cannot. Radiation therapy can be used after surgery, or in some cases when surgery isn’t safely possible. Ask your radiation oncologist more about whether radiation will be helpful for your treatment.

Surgery

For many brain tumours, surgery is a curative part of treatment. A neurosurgeon will usually perform one surgical biopsy to determine what kind of tumour you have. Often, that is the definitive surgery. Surgery can be done to maximize tumour removal while minimizing nerve injury or effects on your normal functioning. Depending upon what tumour you have, surgery may be the only local treatment needed. However, often radiation is used after surgery to lessen the chances of recurrence or further tumour growth. Ask your surgeon more about the extent of surgery best for you.

Medical Therapy

Sometimes, a medication may be helpful instead of radiation or to make radiation work better. Chemotherapy has the ability to destroy cancer cells by different methods. Depending upon the kind of drug best suited for your kind of brain tumour, chemotherapy may be given as a pill daily or by an intravenous (IV) line on a set schedule. For more details about chemotherapy or newer medications, ask your medical oncologist what may be best for you.

EXTERNAL BEAM RADIATION THERAPY

External beam radiation therapy involves a series of out-patient treatments with a machine called a linear accelerator, or linac. The radiation beam is painless and treatment lasts only a few minutes. Treatments are given daily, Monday to Friday, usually over three to seven weeks.

Before beginning treatment, you will be scheduled for a planning session to map out the area your radiation oncologist wishes to treat. This procedure is called a simulation.
Simulation involves lying on a table, usually with a form-fitting mask to make sure treatment can be delivered the same way each treatment.
A CT scan is performed with that mask, and then your doctor will design individualized treatment, often with information from other CT scans and MRIs you have had. Marks are made on the mask, not your skin, to help the radiation therapist precisely position you for daily treatment.

Different techniques can be used to give radiation for brain tumours.

Three-dimensional conformal radiotherapy (3-D CRT) combines multiple radiation treatment fields to deliver precise doses of radiation to the brain. Tailoring each of the radiation beams to the patient’s tumour allows coverage of the diseased cells while keeping radiation away from nearby organs, such as the eyes.

Intensity modulated radiation therapy (IMRT) is a form of 3-D CRT that further modifies the intensity of the radiation within each of the radiation beams.

Stereotactic radio-therapy can be used in some tumours to be even more precise. At most centres, X-rays (photons) are used for treatment.

POSSIBLE SIDE EFFECTS

• Side effects from radiation can include fatigue, hair loss where you received radiation, scalp irritation and muffled hearing. These will usually resolve a month or so after treatment. However, your hair might not grow back exactly as it was before treatment.
• Radiation may also cause some short-term memory loss and difficulty thinking.
• Side effects are different for each patient.
  Medications may be prescribed to make you as comfortable as possible.
• If at any time during your treatment you feel discomfort, tell your doctor or radiation therapist. They can prescribe medicine to help you feel better.

CARING FOR YOURSELF DURING TREATMENT

• Get plenty of rest during treatment, and don’t be afraid to ask for help.
• Follow your doctor’s orders. Ask if you are unsure about anything. There are no stupid questions.
• Tell your doctor about any medications or vitamins you are taking, to make sure they are safe to use during radiation therapy.
• Eat a balanced diet. If food tastes funny or if you’re having trouble eating, tell your doctor or dietician. They might be able to help you change the way you eat.
• Treat the skin exposed to radiation with special care. Stay out of the sun, avoid hot or cold packs, only use lotions and ointments after checking with your doctor.
• Clean the area with warm water and mild shampoo or baby shampoo.
• Battling cancer is tough. Seek out help from support groups and friends.

FACTS ABOUT BRAIN METASTASIS

Brain metastases are clusters of malignant or cancerous cells that have spread from another part of the body to the brain.

It is common to say a person has “brain cancer” when the cancer has spread to the brain from another part of the body. However, with brain metastases, instead of having both brain cancer and breast cancer, a person has breast cancer that has spread to the brain.

The most common cancers that spread to the brain are lung cancer, breast cancer and melanoma. However, just about any cancer can spread to the brain.

Cancer treatments have become more advanced in recent years, allowing many patients to live longer with the disease than ever before. Unfortunately, brain metastases still occur in many patients sometimes months or even years after their original cancer treatment. There are many treatment options available for patients with brain metastases.

SYMPTOMS AND SIGNS OF BRAIN METASTASES

• Sometimes you have no obvious symptoms or signs that the cancer has spread to the brain. Rather, you may come in for a routine follow-up visit and the cancer is found during exams or on imaging scans.
• Possible common symptoms include headaches, dizziness, nausea, blurred or double vision, memory and/or personality changes, or speech changes.
• Sometimes changes in nerve function may cause numbness or a weakness in part of your body; problems with balance can also occur.
• If you begin to have these symptoms, call your doctor. These symptoms can also indicate other health issues that may need immediate medical attention.

TREATING BRAIN METASTASIS

Treatment for brain metastases can control symptoms and improve quality of life. In some cases these treatments can also help you live longer with your cancer.

Radiation Therapy

Radiation therapy, also called radiotherapy, is effective for treating some brain metastases.
Unlike chemotherapy, radiation therapy’s effectiveness is not limited by the blood brain barrier and can penetrate the brain to kill cancer cells. For brain metastasis, radiation may provide a better quality of life, longer life or both.

Surgery

Sometimes, surgery can help manage symptoms, such as relieving pressure in the brain. Surgery also helps doctors confirm that the tumours in the brain are really brain metastases. Surgery is often considered if you have a single brain metastasis.

Chemotherapy

Literally meaning “drug treatment,” chemotherapy is medication used to kill the cancer cells. Traditionally, chemotherapy has a limited role in treating brain metastases due to the blood-brain barrier, which restricts what can travel from the blood into the brain. This protective barrier prevents many chemotherapy drugs from entering the brain. However, newer drugs may be able to pass through this blood brain barrier to help control the brain metastases.

In most cases, patients with metastases will not be “cured” of their cancer. However, modern treatments including radiation therapy allow doctors to control the brain metastases, enabling many patients with cancer that has spread to live months to years longer with their cancer. The duration of survival time will depend on where the original cancer came from, where else it has spread and how well it responds to treatments rather than on the actual number of brain metastases. Also important is how well controlled the cancer is outside of the brain.

EXTERNAL BEAM RADIATION THERAPY FOR BRAIN METASTASIS

Radiation therapy is the use of various types of radiation to safely and effectively treat cancer and other diseases. The radiation beam usually comes from a machine called a linear accelerator, or linac. The radiation beam is painless and treatment itself lasts only a few minutes. In most cases the beam is made of high-energy X-rays, but sometimes specialized approaches may be used.

Before beginning treatment, you will be scheduled for a planning session to map out the area that your radiation oncologist wishes to treat. This procedure is called a simulation. Simulation involves having a CT scan. Usually, a plastic custom mask is made to keep you in position during treatment.

Often, the whole brain is treated. When the whole brain needs radiation treatments for brain metastases, treatments are usually given daily, Monday through Friday, for two to three weeks.

In some cases, a single high-dose radiation treatment called stereotactic radiosurgery can be used. With stereotactic radio-surgery, doctors only target a small part of the brain with X-rays or less commonly protons, another particle used that is effective and precise. Sometimes combining both stereotactic radiosurgery with whole brain radiation therapy can be helpful. Tailoring each of the radiation beams allows doctors to target more of the cancer cells while sparing nearby organs, such as the eyes and normal brain.

POSSIBLE SIDE EFFECTS

• Fatigue is the most common side effect. Feeling tired often starts in the middle of the treatment and may last several weeks after your last radiation session.
• Radiation therapy to the brain can cause scalp irritation and muffled hearing.
• It is normal for you to lose the hair on your head where the radiation beams were aimed. It will probably grow back, but it may not be exactly as it was before treatment.
• Radiation may cause some short-term memory loss, but any serious nerve injury is rare.
• If you notice a funny whole body skin tingling or rash, contact your doctor right away. For brain tumours, this uncommon symptom may be a sign of an allergic reaction if you are taking anti-seizure medicine.
  Ask your radiation oncologist about what you can expect and what the risks and benefits of each treatment are. Side effects are different for everyone. The radiation oncologist and radiation therapist will follow you closely during treatment and ask you and your family members about any symptoms.
  You may be prescribed a medication called a steroid to lessen or prevent symptoms. This is sometimes given before treatment starts.
  Other medications also may help. Please do not delay in talking to a radiation oncologist or radiation therapist about any side effects or concerns about treatments. They want to help you and your caregivers be as comfortable as possible.

PATIENT CARE DURING TREATMENT

• You should try to get as much rest as possible.
• Coping with cancer may be easier with good support from family and friends. You may want to consider asking your doctor or radiation therapist about support groups in your area that may also help.
• It is important to follow the doctor’s orders and ask a lot of questions. There are no silly questions; often the treatment team has heard similar questions.
• You and your family should ask the doctor if it’s safe for you to drive.
• It is important to tell your doctor about any medications or vitamins you are taking to make sure they are safe to use during radiation therapy.
• Try to eat a balanced diet. The doctor or dietician can help suggest foods if you are having trouble eating or if food tastes funny.
• The area exposed to radiation must be treated with special care. This includes staying out of the sun, avoiding hot and cold packs, cleaning the area with warm water and mild shampoo (such as baby shampoo), and using lotions and ointments only after checking with your doctor or radiation therapist.

FACTS ABOUT BREAST CANCER

Breast cancer can often be cured. About 80 percent of all patients with breast cancer live at least 10 years after their diagnosis.

TREATING BREAST CANCER

Surgery

The main curative treatment for breast cancer is surgery. This is often followed by radiation therapy to decrease the risk of cancer returning in the breast, chest wall and/or lymph nodes. Breast conserving surgery involves surgical removal of the cancerous tissue along with a small rim of surrounding healthy breast tissue to preserve as much of the normal breast as possible. This type of surgery is called a lumpectomy or partial mastectomy and is often followed by radiation therapy. Mastectomy is surgical removal of the entire breast. Sometimes, breast reconstruction can be performed after the mastectomy. While less common, radiation is sometimes recommended after mastectomy as well.

Often, a select number of lymph nodes near the breast are removed to determine if they contain tumour cells. This procedure is called a sentinel node biopsy. If one or more of the selected lymph nodes are involved with tumour, a more complete removal of lymph nodes may be recommended. This procedure is called an auxiliary lymph node dissection. In most cases, an examination of the lymph nodes is performed with the breast surgery of choice.
Both mastectomy and breast conserving therapy (surgery and radiation) can be equally effective approaches in curing breast cancer. Ask your surgeon and radiation oncologist about the risks and benefits of both options.

Radiation Therapy

After surgery, radiation therapy can decrease the chance of cancer returning in the breast and improve survival. Radiation therapy involves delivering focused radiation to the breast/chest wall to treat any cancer cells not detected or removed by surgery. Radiation therapy kills cancer cells by destroying their ability to multiply. Surrounding healthy tissue is also affected by radiation and may have some damage. However, healthy normal cells are better able to heal from radiation injury, compared to cancer cells, because they have maintained the ability to repair radiation induced damage.

Medical Therapy

While surgery and radiation focus directly on treating the breast, medication is often recommended to improve cure rates or prevent a new breast cancer from developing. A medical oncologist will evaluate you and determine what medications may be most helpful in accomplishing those goals.

Chemotherapy has the ability to destroy cancer cells by different methods. Often, two or three different types of drugs may be combined to get the best outcome. The dose and schedule for treatment varies, but chemotherapy is usually delivered every two to three weeks for a few months.

Hormonal therapy can block the effects of oestrogen in the body. The normal female hormone, oestrogen, has been shown in some cases to help your tumour grow. Usually taken as a daily pill, this medication may be started during or after radiation therapy is completed.

Immunotherapy can stimulate your immune system to help target cancer cells. Some cancer cells overexpress the HER2 molecule, which somehow makes these tumours more aggressive. Currently, Herceptin has been used to target these aggressive breast cancers with HER2 molecule overexpression.
For more details about these drugs or newer medications, ask your medical oncologist what may be best for you.

EXTERNAL BEAM RADIATION THERAPY AFTER LUMPECTOMY

After breast conserving surgery (lumpectomy), the usual course of radiation treats only the breast, although you may need to have nearby lymph node areas treated as well. The radiation beam comes from a machine called a linear accelerator or linac. The radiation beam is painless and treatment itself lasts only a few minutes. Treatment is delivered every day, five days a week, Monday through Friday. The full course of treatment is usually delivered over three to seven weeks.
Before beginning treatment, you will be scheduled for a planning session to map out the area your radiation oncologist wishes to treat. This procedure is called a simulation. Simulation involves having a planning CT scan. You will also receive tiny marks on your skin, like a permanent tattoo, to help the radiation therapist precisely position you for daily treatment.
Typically, radiation therapy is done with high energy X-rays, or photons, for the bulk of the treatment. When there is a reason to focus the radiation where the lump was taken out, sometimes a “boost” will be given with electrons to treat with a less penetrating, more focused beam instead of photons. Different techniques can be used to give radiation therapy for breast cancer. Three-dimensional conformal radiotherapy (or 3D-CRT) combines multiple radiation treatment fields to deliver very precise doses of radiation to the breast and chest wall while sparing nearby normal tissue. Intensity modulated radiation therapy (IMRT) is a form of 3D-CRT that further modifies the radiation by varying the intensity of each radiation beam. Doctors are still studying IMRT for the treatment of some types of breast cancer. Talk to your radiation oncologist for more information about the details of your treatment plan.

Recent clinical trials suggest that treatment with whole breast radiation may be shortened by treating with higher daily doses to finish in less time. Ask your doctor for details about the right dose and schedule for your case.

Additional research suggests women aged 70 or older with hormone receptor positive early stage breast cancer benefit from radiation in terms of lowering their risk of getting breast cancer again in the treated breast. This local control benefit, however, has not been shown to affect their long term survival. Because the risks and benefits of radiation differ based not only upon age but other health factors and personal preferences, discuss with your doctor whether radiation is necessary.

EXTERNAL BEAM RADIATION AFTER MASTECTOMY

After a mastectomy, your doctor may suggest radiation therapy for the chest wall and often nearby lymph node areas. Whether or not radiation therapy should be used after removal of your breast depends on several factors. These factors include the number of lymph nodes involved, tumour size, and whether or not cancer cells were found near the edge of the tissue that was removed. Many patients who have a mastectomy can safely skip radiation therapy. Ask your doctor for more information.
For women undergoing reconstruction, postmastectomy radiation may affect your options for reconstruction or the cosmetic outcome. Discuss with your surgeon and radiation oncologist to learn more.

POSSIBLE SIDE EFFECTS

Side effects are usually temporary and usually go away shortly after treatment ends. Below is a list of possible side effects you might notice during your treatment. However, ask your doctor what you can expect from your specific treatment.

• Skin irritation similar to a sunburn, sometimes with a peeling reaction toward the end of treatment.
• Mild to moderate breast swelling.
• Mild tenderness in the breast or chest wall. Thiswill slowly get better over time.
• Mild fatigue that generally gets better a month or two after treatment ends.

Many of these side effects can be controlled with medications. Tell your doctor or radiation therapist if you experience any discomfort so they can help you feel better.

After the short-term side effects of radiation therapy resolve, others may become noticeable months or years later.

• Breast firmness or mild shrinkage.
• Change in skin tone, rarely with fine blood vessels present.
• Scarring of a small part of the lung just under the breast. Generally, no side effects are noticed but rarely may it cause a dry cough or shortness oF breath that is treatable.
• Mild decreased range of motion.
• Hand or arm swelling, called lymphedema, can occur but depends upon the extent of surgery and radiation.
• Heart injury is rare with modern treatment techniques for left-sided breast cancers.
• Rarely, new tumours can be caused by radiation, but in breast cancer the benefits of treatment should outweigh the risks.

Many factors affect your risk for these side effects. Please talk to your radiation oncologist to learn more about how likely these side effects may be for you.

CARING FOR YOURSELF DURING TREATMENT

• Get plenty of rest during treatment, and don’t be afraid to ask for help.
• Follow your doctor’s advice. Ask if you are unsure about anything. There are no stupid questions.
• Tell your doctor about any medications or vitamins you are taking to make sure they are safe to use during radiation therapy. If you’re taking any antioxidants, make sure to tell your doctor.
• Eat a balanced diet and drink plenty of fluids. If food tastes funny or if you’re having trouble eating, tell your doctor, radiation therapist or dietician. They might be able to help you change the way you eat.
• Treat the skin exposed to radiation with special care. Stay out of the sun, avoid hot or cold packs, only use lotions and ointments after checking with your doctor or radiation therapist.
• Clean the area with warm water and mild soap (Dove) or Aqueous cream.

Coping with the stress of a cancer diagnosis can be tough. It may help to seek out help from support groups and friends.

FACTS ABOUT COLON, RECTUM AND ANUS CANCERS

Patients with these types of cancer often benefit from radiation therapy as part of treatment. Some cancers involving the bowel run within families (hereditary colorectal cancers). It is important to discuss your diagnosis with family members so they can decide with their doctors whether they need to be screened for colorectal cancers. This is especially important if you were diagnosed with a colorectal cancer at a young age or if there are several other types of cancers that run in your family.

TREATING COLON, RECTUM AND ANUS CANCERS

Radiation Therapy

Radiation therapy is often used in conjunction with surgery and chemotherapy to treat cancers of the colon, rectum and anus. Treatment involves focused radiation to the bowel and pelvis to treat cancer cells in the area. Surrounding healthy tissue can be affected, but normal cells are often better able to heal from radiation injury, compared to cancer cells, because they have maintained the ability to repair radiation induced damage.

For colon cancer, depending on the location and stage of your cancer, radiation can lower the chance of recurrence.

For some rectal cancers, radiation therapy is given with chemotherapy to make the tumour smaller so it can be removed more easily during surgery. In some cases, radiation can allow an organ-sparing surgery to be possible. It is also common for radiation and chemotherapy to be given before surgery for rectal cancer.

Anal cancer can often be treated with radiation therapy and chemotherapy, as an organ-preserving approach that avoids the need for surgery.

Surgery

Surgery often plays a key role in treatment. For colorectal cancers, it is the main curative treatment. The surgeon will determine how much of the large bowel needs to be removed, but often it involves removal of a section of the colon.
Because the tumour can spread to lymph nodes nearby, often some lymph nodes are removed at the time of surgery. Depending upon the location of the tumour, surgery may or may not allow normal bowel function afterwards.

For anal cancers, surgery is less frequently used at the time of diagnosis because effective organpreserving approaches are available. If bowel function is poor, sometimes surgery is used at first, but often it is reserved as a second chance for cure where organ-preserving treatment does not succeed. Because surgery for the anal canal involves removing the area responsible for how you go to the bathroom, a surgery called a colostomy to re-route bowel movements is usually necessary as well.

Medical Therapy

While surgery and radiation focus directly on treating the bowel or pelvic area, medication is often recommended to improve cure rates. A medical oncologist will evaluate you and determine what medications may be most helpful.

Chemotherapy is a kind of medication that can destroy cancer cells by different methods. Often, two or more drugs may be combined for the best results. The dose and schedule for treatment varies, as some chemotherapy may be every few weeks and in some cases it’s given daily. It also differs depending upon the whether it’s colon or anal cancer. For more details about these drugs, ask your medical oncologist what may be best for you.

EXTERNAL BEAM RADIATION THERAPY

involves a series of daily outpatient treatments that accurately deliver radiation to the area needing therapy. The radiation beam comes from a machine called a linear accelerator.

Before beginning treatment, you will be scheduled for a simulation to map out the area to be treated. This will involve having a planning CT scan. Landmarks placed on your skin (often tiny tattoos) allow the radiation therapists delivering your treatments to precisely position you each day.
To minimize side effects, the treatments are usually over about five or six weeks, five days a week (Monday through Friday). This allows your doctors to get enough radiation into your body to kill the tumour cells while giving healthy cells time to recover each day.
Technical terms that may be mentioned for colorectal and anal cancer treatments include three dimensional conformal radiation therapy (3-D CRT) and intensity modulated radiation therapy (IMRT).
Your radiation oncologist can provide more information about these different techniques.

POSSIBLE SIDE EFFECTS

• Radiation therapy to the abdomen and pelvis may cause more frequent bowel movements, occasionally with diarrhoea, abdominal cramping or rectal discomfort. It may also cause more frequent urination, sometimes with a burning feeling or cause a small amount of blood to appear in the urine or stool. These should resolve after treatment ends. Inform your doctor or radiation therapist if these side effects occur so that you can be given a prescription formedication to manage these side effects.
• Some patients may also feel tired or lose their appetite. This is temporary as well.
• Possible skin irritation problems depend on your tumour and the areas needing treatment. For anal cancer patients, a pronounced but temporary skin irritation is usually the major side effect from the treatment. It is possible that your treatment may need to be put on hold if the skin reaction is severe. Talk with your doctor and radiation therapist about any new symptoms you experience during treatment.
• Side effects that occur are not the same for all patients. Ask your doctor what you might expect from your specific treatment program.

It is likely you will receive chemotherapy in addition to radiation therapy. The side effects from the chemotherapy will depend on the drugs being prescribed and how often you are to receive them. Ask your medical oncologist about chemotherapy side effects you may experience. Side effects often can be controlled with medications or changes in your diet. Tell your doctor or radiation therapist if you experience any of them, so they can work to help you feel better.

CARING FOR YOURSELF DURING TREATMENT

It is important to care for yourself as well as possible during radiation therapy because the normal parts of your body that are near the tumour are also receiving some radiation, although not as much as the cancer. These normal parts of your body need time and support to heal.

• A balanced diet, mild amount of physical activity and taking time to rest are all important parts of your cancer treatment.
• Follow your doctor’s orders and, if you are unsure of anything, ask your radiation therapist or doctor any question you may have about treatment.
• Be sure to tell your radiation oncologist about any vitamins or dietary supplements that you are currently taking to make sure they are safe to take during radiation therapy.
• During and even after radiation therapy is over, you will need to take special care of your skin. Stay out of the sun, avoid hot or cold packs, and do not use lotions or ointments without checking with your doctor or radiation therapist first.
• You should also be sure to clean the skin over the areas receiving radiation therapy with warm water and mild soap (Dove) or Aqueous cream.

Completing treatment and recovery can be challenging. Seek out help from support groups and friends ahead of time. If you have a support network in place before and during treatment, it will be easier to get through side effects since people you can count on will be around to help you. If you need additional support, let your doctor and radiation therapist know.

FACTS ABOUT GYNAECOLOGIC CANCERS

Gynaecologic cancers include malignancies of the female genital tract involving the vulva, vagina, cervix, uterus, fallopian tubes or ovaries. Cancers of the uterus, cervix and ovary are most common.

Widespread screening with the Pap test has allowed doctors to find pre-cancerous changes in the cervix and vagina. This has helped catch some invasive cancers early.

TREATING GYNAECOLOGIC CANCERS

Treatment for gynaecologic cancers depends on several factors, including the type of cancer, its extent (stage), its location and your overall health. It is important to talk with several cancer specialists before deciding on the best treatment for you, your cancer and your lifestyle. Sometimes, your cancer may be treated by using only one type of treatment. In other cases, your cancer may be best cured using a combination of surgery, radiation therapy and chemotherapy.

Radiation Therapy

Radiation therapy, sometimes called radiotherapy, is the careful use of radiation to treat cancer safely and effectively. Radiation oncologists use radiation therapy to try to cure cancer, to control cancer growth or to relieve symptoms, such as pain. Radiation therapy works within cancer cells by damaging their ability to multiply. When these cells die, the body naturally eliminates them. Healthy tissues are also affected by radiation, but they can repair themselves in a way that cancer cells cannot. There are two types of radiation therapy. External beam radiation therapy delivers treatment from a machine outside your body and internal radiation therapy, or brachytherapy, delivers treatment using radioactive sources placed into the vagina, uterus and/or surrounding tissues to kill the cancer cells.

Surgery

Surgery is the main curative treatment for many tumours of the female reproductive system. A gynaecologic oncologist is a doctor who specializes in surgically removing gynaecologic cancers. While radiation therapy is effective enough to eliminate the need for surgery in some diseases, such as many cervical cancers, surgical removal of the tumour is often still an important part of treatment.

For internal gynaecologic cancers, surgery usually involves some kind of removal of the uterus and cervix, called a hysterectomy. Often the surgeon may remove lymph nodes and check for any cancer cells as well. For less common tumours like vulvar cancer, surgery is more likely not inside the pelvis but may still involve sampling lymph nodes.

Surgery and radiation can be combined to help lower the risk of recurrence, but it varies based upon the disease and stage (how much the tumour seems to have spread). In cases where radiation is the main treatment, it is often still important to keep your surgeon involved for follow-up.

Medical Therapy

While surgery and radiation focus directly on treating a particular part of the body, medication is often recommended in gynaecologic cancer to improve cure rates by treating the whole body. A medical oncologist will evaluate you and determine what medications may be most helpful in accomplishing those goals. Sometimes gynaecologic oncologists also prescribe chemotherapy. Talk with your surgeon about whether you need an appointment with a medical oncologist.

Chemotherapy has the ability to destroy cancer cells by different methods. The dose and schedule for treatment varies, but chemotherapy can be done either alone or with radiation therapy. Because the different drugs may be helpful in different situations, ask your medical oncologist what may be best for you.

EXTERNAL RADIATION THERAPY

External beam radiation therapy involves a series of daily outpatient treatments to deliver radiation to the cancer accurately. Treatments are painless and are similar to getting an X-ray. They are usually given in a series of daily sessions, each taking less than half an hour, Monday through Friday, for five to six weeks. Before beginning treatment, you will be scheduled for a planning session to map out the area your radiation oncologist wishes to treat. This procedure is called a simulation. Simulation involves having X-rays and/or a CT scan. You will also receive tiny marks on your skin, like a permanent tattoo, to help the radiation therapist precisely position you for daily treatment. Typically, radiation therapy is done with high energy X-rays, or photons, for the bulk of the treatment.
Different techniques can be used for treatment.

Three-dimensional conformal radiotherapy (3-D CRT) combines multiple radiation treatment fields to deliver precise doses of radiation to the affected area. Tailoring each of the radiation beams to focus on the tumour delivers a high dose of radiation to the tumour and avoids nearby healthy tissue.

Intensity modulated radiation therapy (IMRT) is the most recent advance in the delivery of radiation. Modifying the intensity of the radiation within each of the beams allows more precise adjustment of doses delivered to the tissues within the target area. This technique is currently being studied to determine whether it is better than 3-D CRT.

INTERNAL RADIATION THERAPY

Sometimes radiation is placed inside the body to get the source of the radiation as close to the tumour as possible. This type of radiation is called brachytherapy. In gynaecologic cancers, this is a very important part of treatment, and it is common for this type of radiation to be used. Other names for this type of treatment besides internal radiation therapy or brachytherapy include interstitial implants and intracavitary radiotherapy. Brachytherapy can be done alone or in combination with external radiation therapy.

Usually, the radiation source is placed inside the body for short periods of time and then taken out. Your radiation oncologist will discuss with you whether brachytherapy will be used on its own or together with standard radiation therapy from outside the body to treat your type of cancer.
Low-dose-rate (LDR) brachytherapy is delivered over the course of 48 to 72 hours. You will be admitted to the hospital to receive this treatment. High-dose-rate (HDR) brachytherapy does not usually require you be admitted to the hospital. The entire procedure typically takes a few hours. In some simple cases, treatment can take less than an hour. Depending on your type of cancer, you may need to have several sessions of brachytherapy.

POSSIBLE SIDE EFFECTS

The side effects you may experience will depend on the area being treated and the type of radiation used. Before treatment, ask your doctor to describe what you can expect. Some patients experience minor or no side effects and can continue their normal routines. Side effects following radiation therapy can include symptoms that happen during and/or just after completing radiation therapy (acute effects) and symptoms that develop several months to years after your cancer has been treated (late effects). Short-term side effects for radiation delivered to the pelvic area include feeling tired, skin irritation or redness of the skin, loose bowel movements or more frequent bowel movements, the urge to urinate more often or discomfort when urinating, having a bloating sensation, nausea and decreases in the number of cells in your blood. Long-term side effects that could happen after radiation therapy to the pelvis include changes in your bowel or bladder habits (e.g., going to the bathroom more often), narrowing of the vaginal canal, discomfort with sexual intercourse due to the vagina being drier and less flexible, and the very rare chance of a new cancer forming due to the radiation therapy. If at any time you develop side effects, tell your doctor or radiation therapist. Don’t be embarrassed to talk to your doctor about sexual side effects. Although side effects can sometimes decrease interest in or pleasure with sexual activity, most women are able to resume sexual relations. Ask your doctor how to manage these changes as medications, vaginal dilators and moisturizers may help. Radiation to your pelvic area may affect your ability to have children. Your doctor will have recommendations on fertility preservation options if you are interested.

CARING FOR YOURSELF DURING TREATMENT

• It is important to care for yourself as well as possible during radiation therapy because the normal parts of your body that are near the tumour are also receiving some radiation, although not as much as the cancer. These normal parts of your body need time and support to heal.
• A balanced diet, mild amount of physical activity and taking time to rest are all important parts of your cancer treatment. Follow your doctor’s orders, and if you are unsure of anything, ask your doctor any question you may have about your treatment.
• Be sure to tell your radiation oncologist about any vitamins or dietary supplements that you are currently taking to make sure they are safe to take during radiation therapy.
• During and even after radiation therapy is over, you will need to take special care of your skin. Stay out of the sun, avoid hot or cold packs, and do not use lotions or ointments without checking with your doctor first.
• You should also be sure to clean the skin over the areas receiving radiation therapy with warm water and mild soap (Dove) or Aqueous cream.
• Completing treatment and recovery can be challenging. Seek out help from support groups and friends ahead of time. If you have a support network in place before and during treatment, it will be easier to get through side effects since people you can count on will be around to help you. If you need additional support, let your doctor know.

FACTS ABOUT HEAD AND NECK CANCERS

These tumours can begin anywhere in the head and neck region. Treatment options are based on where a head and neck cancer starts (e.g. tongue vs. throat) because each tumour site responds to treatment type in different ways. The main two forms of treatment that can cure head and neck cancers are either radiation therapy or surgery. Sometimes, chemotherapy and/or targeted systemic therapy will be used together with radiation therapy to improve the chance that the cancer will not come back or spread to other parts of the body.

TREATING HEAD AND NECK CANCER

Treatment for head and neck cancers depends on several factors, including the type of cancer, its size and stage, its location and your overall health. For many head and neck cancers, combining two or three types of treatment may be most effective. Treatment for head and neck cancers requires a multidisciplinary approach, including a surgeon, a radiation oncologist and a medical oncologist. Often, organ preservation with radiation treatment can get rid of a tumour without invasive procedures such as surgery.

Radiation Therapy

Radiation therapy involves delivering focused radiation to treat cancer cells by destroying their ability to multiply. Surrounding healthy tissue is also affected by radiation and may have some damage. However, healthy normal cells are better able to heal from radiation injury, compared to cancer cells, because they have maintained the ability to repair radiationinduced damage.
For head and neck cancer, radiation often allows organ-sparing treatment that can give patients equal cure rates with better swallowing and/or voice function with equal cure rates as compared to surgically removing a tumour. In some cases, radiation will be combined with surgery, chemotherapy or both.

Surgery

Surgery is an important curative approach to treatment. From biopsy to evaluating the nose, mouth and throat with a flexible endoscopic camera, your surgeon can fully assess whether the tumour has spread. If surgery will be part of your treatment, your surgeon can remove the tumour with a rim of normal tissue. Depending upon the tumour location and how advanced it is, the surgeon may also surgically remove lymph nodes in the neck. The lymph nodes, part of the normal immune system, are a common path for spread in some tumours. Ask your doctors the likelihood of the lymph nodes being involved and whether you need surgery or radiation for the lymph nodes in the neck.
In some cases, surgery is combined with radiation. If radiation is the main treatment, some surgery may be helpful afterwards but is determined on a case-by-case basis. If surgery is the main treatment, radiation may be helpful after surgery if more advanced disease is found.

Medical Therapy

While surgery and radiation focus directly on treating the tumour, medication is often recommended to improve cure rates. A medical oncologist will evaluate you and determine what medications may be most helpful in accomplishing those goals. Two of the main categories of systemic therapy (treatment that is injected into a person’s blood system) are:

has the ability to destroy cancer cells by different methods. Often, one to three different types of drugs may be combined to get the best outcome. The dose and schedule for treatment varies, but chemotherapy is usually delivered during radiation therapy. In some cases, chemotherapy may be helpful before radiation treatment. This type of treatment is called neoadjuvant chemotherapy.

Targeted therapy involves focusing anti-cancer treatment on certain molecules, such as the epidermal growth factor receptor (EGFR). It can be used with radiation therapy as well.
Ask your medical oncologist whether these drugs may be helpful for you.

DENTAL CARE

Dental care is an essential part of preparing for treatment. Ask your doctor whether or not you need to see your dentist before starting treatment.
If you have teeth, before you begin head and neck radiation therapy you will need to be examined by a dentist or oral surgeon for a pre-radiation dental evaluation. As your mouth becomes dry following the treatments, you may be at risk for increased cavities.
If the dentist determines that you need any dental proce-dures or if you need bad teeth removed, this must to be done prior to initiating radiation therapy because your jaw bone does not heal as well following radiation therapy. It is important to be aware that this may delay starting radiation treatment for up to two weeks to allow time for healing.

EXTERNAL BEAM RADIATION THERAPY

Radiation therapy treatments are delivered in a series of painless daily sessions. Radiation treatments take only a few minutes, but each session takes about 30 minutes to get checked in, change clothes, get into position and receive the radiation. Treatments are usually scheduled daily, Monday through Friday, for five to seven weeks. In some cases, your radiation oncologist may schedule your radiation treatments to be twice a day, with several hours between treatments.
Before beginning treatment, you will be scheduled for a planning session to map out the area your radiation oncologist wishes to treat. This procedure is called a simulation. Simulation involves having a planning CT scan. To help you keep still during treatment, your radiation therapist may use a plastic mask over your head and shoulders. You can see and breathe through this form-fitting device which is made to comfortably make sure movement during treatment is minimized. In some cases, other devices may help make sure the radiation to normal parts of the mouth are avoided.
Marks will be made on the plastic mask to help the radiation therapist precisely position you for daily treatment.

Three-dimensional conformal radiotherapy (3-D CRT) combines multiple radiation treatment fields to deliver precise doses of radiation to the affected area.

Intensity modulated radiation therapy (IMRT) is a form of 3-D CRT that further modifies the radiation by varying the intensity of each radiation beam. This allows a precise adjustment of radiation doses to the tissue within the target area. Often, IMRT can help lessen the chance of having a dry mouth or other side effects after treatment is complete.

INTERNAL RADIATION THERAPY

Also called brachytherapy, this treatment involves inserting radioactive material into a tumour or surrounding tissue to give a more focused dose of radiation. For head and neck cancers, brachytherapy is often used with external beam radiation therapy, but it may also be used alone or given after surgery. During brachytherapy, your radiation oncologist places thin, hollow, plastic tubes into the tumour and surrounding tissue. These tubes are loaded with tiny radioactive seeds that remain in place for a short time to kill the cancer.
The seeds and the tubes are then removed. With low-dose-rate brachytherapy, the seeds will be left in place for one to three days. For high-dose-rate brachytherapy, a single radioactive seed stops at various positions along the tubes for short times to deliver an equivalent dose and is usually given in a few sessions over two or more days. The exact type of brachytherapy and lengths of time the seeds are in place will depend on your cancer and treatment plan.

POSSIBLE SIDE EFFECTS

• Side effects of radiation therapy are limited to the area that is receiving treatment.
• Side effects can include redness of the skin, sore mouth and throat, dry mouth, thick phlegm, alteration of taste, pain on swallowing, and hair loss on your head, neck and face.
• Fatigue or feeling tired is also very common.
• The way foods taste and the amount of saliva you produce should improve after treatment ends. However, foods might never taste exactly as they did before treatment.
• Side effects are different for each patient. In some cases side effects lessen within several weeks, but with more intensive treatment the time for improvement takes longer.
• Medications may be prescribed to make you as comfortable as possible. Nutritional supplements are important to help prevent weight loss. If at any time during your treatment you feel discomfort, tell your doctor or radiation therapist. They can prescribe medicine to help you feel better.
• If you are malnourished or need more nutritional support, sometimes a feeding tube can be helpful.

CARING FOR YOURSELF DURING TREATMENT

• Get plenty of rest during treatment, and don’t be afraid to ask for help.
• Follow your doctor’s orders. Ask if you are unsure about anything.
• Tell your doctor about any medications or vitamins you are taking, to make sure they are safe to use during radiation therapy.
• Eat a balanced diet. If food tastes funny or if you’re having trouble eating, tell your doctor, radiation therapist or dietician. They might be able to help you change the way you eat.
• Treat the skin exposed to radiation with special care. Stay out of the sun, avoid hot or cold packs, only use lotions and ointments after checking with your doctor or radiation therapist
• Clean the area with warm water and mild soap (Dove) or Aqueous cream.
• Do not shave with a flat blade, rather use an electric razor and do not use any aftershave lotions.
• Good dental care can lessen the risk of mouth infections and tooth decay. Careful brushing of your teeth can help prevent tooth decay, gum disease and jaw infections. Use a fluoride toothpaste without abrasives. Floss gently between your teeth daily using a waxed, nonshredding dental floss. It may help to rinse daily with a salt and baking soda solution. If you have questions about your dental care, ask your dentist and radiation oncologist.

Completing treatment and recovery can be challenging. Seek out help from support groups and friends ahead of time, since you should have support in place before you start getting side effects. If you need additional support, let your doctor and radiation therapist know.