What is radiation therapy

Radiation therapy uses high-energy rays or particles (radiation), such as x-rays, gamma rays, electron beams, or protons to kill cancer cells and other problems. Other names for radiation therapy are radiation treatment, radiotherapy, irradiation, or x-ray therapy.

There are different types of radiation. One that you may know about is x-rays. If you’ve ever had an x-ray of your chest or any other body part, you’ve had some radiation. Radiation is used in much higher doses to treat some types of cancer.

Radiation therapy is not like chemotherapy (often called chemo). Radiation treats just the tumor. Chemo uses drugs to treat the whole body. So chemo might be used if a person has cancer in many places. Radiation affects only the part of the body being treated.

More than half of people with cancer get radiation therapy. Sometimes, radiation therapy is the only cancer treatment needed.

How does radiation therapy work

Your body is made up of trillions of normal, healthy cells. Cancer starts when something changes a normal cell into a cancer cell. This cancer cell can then grow and make more cancer cells until a tumor is formed. Tumors can keep growing and cause problems. If the cancer is not treated, it can spread to other parts of the body and form more tumors.

Your cells normally grow and divide to form new cells. But cancer cells grow and divide faster than most normal cells. Radiation works by making small breaks in the DNA inside cells. These breaks keep cancer cells from growing and dividing and cause them to die. Nearby normal cells can also be affected by radiation, but normal cells can repair themselves and most recover and go back to working the way they should. Whereas cancer cells cannot.

Special equipment sends high doses of radiation to the cancer cells or tumor. This keeps the cells from growing and making more cancer cells. Radiation treatment is planned to damage cancer cells, with as little harm as possible to nearby healthy cells.

Some radiation treatments (systemic radiation therapy) use radioactive substances that are given in a vein or by mouth. Even though this type of radiation does travel throughout the body, the radioactive substance mostly collects in the area of the tumor, so there’s little effect on the rest of the body.

Sometimes radiation is the only treatment needed. Other times it’s one part of a patient’s cancer treatment plan.

Your doctor may suggest radiation therapy to treat your cancer. Sometimes radiation can cure cancer. At other times the goal may be to slow the cancer’s growth to help you feel better. Be sure to talk to your doctor about the goal of your treatment.

Who gives radiation therapy treatments?

During your radiation therapy, a team of highly trained medical professionals will care for you. Your team may include these people:

• Radiation oncologist: This doctor is specially trained to treat cancer with radiation. This person oversees your radiation treatment plan.
• Radiation physicist: This is the person who makes sure the radiation equipment is working as it should and that it gives you the exact dose prescribed by your radiation oncologist.
• Dosimetrist: This person is supervised by the radiation physicist and helps the radiation oncologist plan the treatment.
• Radiation therapist or radiation therapy technologist: This person operates the radiation equipment and positions you for each treatment.
• Radiation therapy nurse: This nurse has special training in cancer treatment and can give you information about radiation treatment and managing side effects.

You may also need the services of a dietitian, physical therapist, medical or clinical social worker, dentist or dental oncologist, or other health care providers.

Does radiation therapy cause cancer?

It has long been known that radiation therapy can slightly raise the risk of getting another cancer. It’s one of the possible side effects of treatment that doctors have to think about when they weigh the benefits and risks of each treatment. For the most part, the risk of a second cancer from these treatments is small and is outweighed by the benefit of treating the cancer, but the risk is not zero. This is one of the many reasons each case is different and each person must be part of deciding which kind of treatment is right for them.

If your cancer care team recommends radiation treatment, it’s because they believe that the benefits you’ll get from it will outweigh the possible side effects. Still, this is your decision to make. Knowing as much as you can about the possible benefits and risks can help you be sure that radiation therapy is best for you.

Does radiation therapy affect pregnancy or fertility?

Women: It’s important not to become pregnant while getting radiation – it can harm the growing baby. If there’s a chance you might become pregnant, be sure to talk to your doctor about birth control options.

• If you are or might be pregnant, let your doctor know right away.

Men: Not much is known about radiation’s effect on the children conceived by men while getting radiation therapy. Because of this, doctors often advise men to not get a woman pregnant during and for some weeks after treatment. Talk to your doctor to find out more about this.

What are the goals of radiation therapy?

Most types of radiation therapy don’t reach all parts of the body, which means they’re not helpful in treating cancer that has spread to many places within the body. Still, radiation therapy can be used to treat many types of cancer either alone or in combination with other treatments. Here are some of the reasons radiation therapy may be used:

To cure or shrink early-stage cancer

Some cancers are very sensitive to radiation. Radiation may be used by itself in these cases to make the cancer shrink or completely go away. In some cases, a few cycles of chemotherapy may be given first. For other cancers, radiation may be used before surgery to shrink the tumor (this is called pre-operative therapy or neoadjuvant therapy), or after surgery to help keep the cancer from coming back (called adjuvant therapy).

For certain cancers that can be cured either by radiation or by surgery, radiation may be the preferred treatment. This is because radiation can cause less damage and the organ may be more likely to work the way it should after treatment.

For some types of cancer, radiation and chemotherapy might be used together. Certain chemo drugs (called radiosensitizers) help radiation work better by making cancer cells more sensitive to radiation. The drawback of getting chemo and radiation together is that side effects are often worse.

If you’ll need more than one kind of cancer treatment, your cancer care team will work with you to plan your treatment.

To stop cancer from coming back (recurring) somewhere else

Cancer can spread from where it started to other body parts. Doctors often assume that a few cancer cells might already have spread even when they can’t be seen on imaging scans like CT scans or MRIs. In some cases, the area where the cancer most often spreads to may be treated with radiation to kill any cancer cells before they grow into tumors. For instance, people with certain kinds of lung cancer may get preventive (prophylactic) radiation to the head because their type of lung cancer often spreads to the brain. Sometimes, radiation to prevent future cancer can be given at the same time radiation is given to treat existing cancer, especially if the area the cancer might spread is close to the tumor itself.

To treat symptoms caused by advanced cancer

Sometimes cancer has spread too much to be cured. But some of these tumors can still be treated to make them smaller so that the person can feel better. Radiation might help relieve problems like pain, trouble swallowing or breathing, or bowel blockages that can be caused by advanced cancer. This is often called palliative radiation.

To treat cancer that has returned (recurred)

If a person’s cancer has returned (recurred), radiation might be used to treat the cancer or to treat symptoms caused by advanced cancer. Whether radiation will be used after recurrence depends on many factors. For instance, if the cancer has come back in a part of the body that has already been treated with radiation, it might not be possible to give more radiation in the same place. It depends on the amount of radiation that was used before. In other instances, radiation might be used in the same area of the body or a different area. Some tumors do not respond as well to radiation and for these cancers radiation might not be used to treat recurrence.

What can I do to take care of myself during radiation?

During radiation therapy, you need to take special care of yourself. Your doctor or nurse will give you tips on how to do this. But here are some basic things that you should do:

• Get plenty of rest. You may feel more tired than normal. This can last for 4 to 6 weeks after your treatment ends, and sometimes longer.
• Eat healthy foods. Your doctor, nurse, or dietitian may work with you to make sure you’re eating the right foods to get what your body needs. They may suggest changes to reduce side effects if your stomach or throat is in the area being treated.
• Take care of the skin in the treatment area. Clean the skin each day with warm water and a mild soap that your nurse says is OK to use. Don’t use other products on the treatment area unless your doctor or nurse tells you it’s OK.
• Tell your doctor about all medicines you are taking. If you take any medicines, even aspirin, herbs, or vitamins, let your doctor know before you start radiation.

When should I call the doctor?

After treatment, you may be more aware of your body and any changes in how you feel from day to day. If you have any of the problems listed here, tell your doctor or nurse right away.

• Pain that doesn’t go away or is getting worse
• New lumps, bumps, or swelling
• Nausea, vomiting, diarrhea, not wanting to eat, or trouble swallowing
• Weight loss when you are not trying to lose weight
• Fever or cough that doesn’t go away
• A new rash, new bruises, or bleeding
• Any other signs that your doctor or nurse wants to know about

Types of radiation therapy

Radiation therapy can be given in 3 ways:

1. External radiation (or external beam radiation): uses a machine that directs high-energy rays from outside the body into the tumor. Most people get external radiation therapy over many weeks. It’s done during outpatient visits to a hospital or treatment center.
2. Internal radiation: Internal radiation is also called brachytherapy. A radioactive source is put inside the body into or near the tumor.
3. Systemic radiation: Radioactive drugs given by mouth or put into a vein are used to treat certain types of cancer. These drugs then travel throughout the body.

The type of radiation you might get depends on the kind of cancer you have and where it is. In some cases, more than one type is used.

External beam radiation therapy

External beam radiation therapy or external radiation is like getting an x-ray. External beam radiation therapy (external radiation) is the most common type of radiation therapy used for cancer treatment. A machine is used to aim high-energy rays (or beams) from outside the body into the tumor. (The machine most commonly used is called a linear accelerator or “linac.”)

External beam radiation therapy is painless and only takes a few minutes. But it takes time to get the machines set up, so it may take 15 to 30 minutes to get each treatment. External beam radiation therapy (external radiation) is often given in a walk-in clinic, so you don’t have to be in the hospital.

Radiation technology allows the precise delivery of external beam radiation therapy. Modern machines better focus the radiation and do less damage to normal tissues, so doctors can use higher doses of radiation.

External radiation is usually done during outpatient visits to a hospital or treatment center. Most people get external radiation therapy in multiple sessions over many weeks.

You will lie flat on a treatment table, under the radiation machine. The radiation therapist may put special shields or blocks between the machine and other parts of your body. These protect your other body parts from the radiation. You will be asked to stay still during the treatment, but you don’t have to hold your breath.

Once you’re all set and the machine is ready, the therapist goes into a nearby room to run the machine and watch you. You and the therapist can talk over an intercom. While the machine is working, you’ll hear clicking and whirring. Sometimes you’ll hear something that sounds like a vacuum cleaner. That sound is the machine moving to aim the radiation. The radiation therapist controls this movement and checks to make sure the machine is working the way it should.

If you are worried about anything that happens while the machine is on, talk to the radiation therapist. If you start to feel sick or scared, let the therapist know right away. The machine can be stopped at any time.

Figure 1. External beam radiation therapy

Types of external radiation therapy

Three-dimensional conformal radiation therapy (3D-CRT) delivers radiation beams from different directions designed to match the shape of the tumor. This helps to reduce radiation damage to normal tissues and better kill the cancer by focusing the radiation dose on the tumor.

Image guided radiation therapy is a form of 3D-CRT where imaging scans (like a CT scan) are done before each treatment. This allows the radiation oncologist to adjust the position of the patient or re-focus the radiation as needed to hit the tumor and limit other damage.

Intensity modulated radiation therapy is like 3D-CRT, but it also changes the strength of some of the beams in certain areas. This gets stronger doses to certain parts of the tumor and helps lessen damage to nearby normal body tissues.

Helical-tomotherapy a form of intensity modulated radiation therapy delivers radiation inside a large “donut.” For this treatment, you lie on a table that slowly slides through the donut as the machine spirals around you. It delivers many small beams of radiation at the tumor from different angles around the body. This may allow for even more precisely focused radiation.

Photon beam radiation therapy is another name for what is traditionally known as external beam radiation therapy. It uses photon beams to get to the tumor but also can damage healthy tissue around the tumor. Photons are used in treatments that are given by a machine called a linear accelerator.

Proton beam radiation therapy uses proton beams instead of photons or electrons. Protons are parts of atoms that cause little damage to tissues they pass through but are very good at killing cells at the end of their path. This means that proton beam radiation may be able to deliver more radiation to the tumor while reducing side effects on normal tissues. Protons can only be put out by a special machine called a cyclotron or synchrotron.

Stereotactic radiosurgery isn’t really surgery, but a type of radiation treatment that gives a large dose of radiation to a small tumor area, usually in one session. It’s used for brain tumors and other tumors inside the head. In some cases, a head frame or shell may be used to help keep the patient’s head still. Once the exact location of the tumor is known from brain scans, radiation is sent to the area from many different angles. The radiation is very precisely aimed to affect nearby tissues as little as possible.

Treatment outside the brain is called stereotactic body radiation therapy. Stereotactic body radiation therapy may be used for certain lung, spine, and liver tumors.

In many radiation therapy clinics this technology is called by the name of the vendor that makes the machine.

There are 3 main ways stereotactic radiosurgery can be given:

1. The most common type uses a movable linac that’s controlled by a computer. The machine moves around to target the tumor from many different angles. X-Knife™, CyberKnife®, and Clinac® all work this way.
2. The Gamma Knife® uses about 200 small beams aimed at the tumor from different angles for a short period to deliver a large dose of radiation. It’s usually given in one treatment session. Again, this is a type of radiation therapy – it doesn’t use a knife and there’s no cutting.
3. Another type aims heavy charged particle beams (like proton or helium ion beams) at the tumor from different angles. These particles release most of the radiation’s energy at the end of their paths, at more precise depths. This limits damage to nearby healthy tissues or organs.

Although most patients will be given the full radiation dose in one session with stereotactic radiosurgery, it may be repeated if needed. Sometimes doctors give the radiation in several smaller treatments to deliver the same or slightly higher dose. This may be called fractionated radiosurgery or fractionated stereotactic radiotherapy.

Intraoperative radiation therapy is external radiation given directly to the tumor or tumors during surgery. It may be used if the tumors can’t be removed completely or if there’s a high risk the cancer will come back in the same area. While you are asleep, the surgeon moves normal tissues away from the tumor and protects them with special shields. This lets the doctor give one large dose of radiation to the cancer and limit the effects on nearby tissues. Intraoperative radiation therapy is given in a special operating room that has radiation-shielding walls.

How does your doctor plan your radiation treatment?

Radiation is planned and given by a team of trained health care providers. The radiation oncologist is a doctor who treats cancer with radiation and oversees the care of each patient getting radiation. Working closely with the radiation oncologist, the radiation therapist gives the daily radiation treatment and positions patients for each treatment. Other professionals include the medical physicist and dosimetrist who plan and calculate the doses of radiation.

Before starting radiation therapy, your radiation oncologist will examine you, review your medical history and test results, and pinpoint the exact area to be treated in a process called simulation. You’ll be asked to lie still on a table while the radiation therapist uses imaging scans (like a CT scan or MRI) to define your treatment field (also called the treatment port). These are the exact places on your body where the radiation beams will be aimed.

Radiation beams are aimed very precisely. A special mold, mask, or cast of a body part might be made to make sure you are in the same position for each treatment and to help you stay still during treatment. The radiation therapist might mark the treatment field with freckle-sized dots of semi-permanent ink. The marks will likely fade away over time, but they’re needed until your treatment is finished. Don’t use soap on or scrub these marks. Sometimes the area may be marked with permanent dots like a tattoo. These can later be removed with a laser.

Based on the simulation, other tests, and your cancer type, the radiation oncologist will decide how much radiation is needed, how it will be given, and how many treatments you should have.

How long does external radiation treatment take?

In most cases the total dose of radiation needed to kill a tumor can’t be given all at once. This is because a large dose given one time can cause more damage to nearby normal tissues. This can cause more side effects than giving the same dose over spread out into many treatments.

The total dose of external radiation therapy is usually divided into smaller doses called fractions. Most patients get radiation treatments daily, 5 days a week (Monday through Friday) for 5 to 8 weeks. Weekend rest breaks allow time for normal cells to recover. The total dose of radiation and the number of treatments is based on:

• The size and location of the cancer
• The type of cancer
• The reason for the treatment
• Your general health
• Any other treatments you’re getting

Other radiation schedules might be used in certain cases. For instance, radiation therapy might last only a few weeks (or less) when it’s used to relieve symptoms, because the overall dose of radiation is lower. In some cases, radiation might be given as 2 or more treatments each day. Or it might be given as split-course therapy, which allows for several weeks off in the middle of treatments so the body can recover while the cancer shrinks. Your doctor will talk to you about the best plan in your case.

How long does it take for radiation therapy to work?

For most people, treatments are given 5 days a week for 1 to 10 weeks. The number of treatments you need depends on the size and type of cancer, where the cancer is, how healthy you are, and what other treatments you are getting. Patients often get a break on weekends so their normal cells can recover.

What happens during each treatment visit?

External radiation is a lot like getting a regular x-ray. The treatment itself is painless and takes only a few minutes. But each session can last 15 to 30 minutes because of the time it takes to set up the equipment and put you in the right position.

External radiation therapy is usually given with a linear accelerator (or linac) which delivers a beam (or multiple beams) of radiation. The machine has a wide arm that extends over the treatment table. The radiation comes out of this arm. The machine can move around the table to change the angle of the radiation, if needed, but it won’t touch you.

Depending on the area being treated, you might need to undress, so wear clothes that are easy to take off and put on. You’ll be asked to lie on the treatment table next to the radiation machine.

The radiation therapist might put special heavy shields between the machine and parts of your body that aren’t being treated to help protect normal tissues and organs.

Once you’re in the right position, the radiation therapist will go into a nearby room to operate the machine and watch you on a TV screen. The room is shielded, or protected from the radiation so that the therapist isn’t exposed to it. You can talk with the therapist over an intercom. You’ll be asked to lie still during the treatment, but you won’t have to hold your breath.

The linac will make clicking and whirring noises and might sometimes sound like a vacuum cleaner as it moves to aim the radiation beam from different angles. The radiation therapist controls the movement and checks to be sure it’s working properly. If you’re concerned about anything that happens in the treatment room, ask the therapist to explain. If you feel ill or uncomfortable during the treatment, tell the therapist right away. The machine can be stopped at any time.

Will I be radioactive during or after external radiation treatment?

External radiation therapy affects cells in your body only for a moment. Because there’s no radiation source in your body, you are not radioactive at any time during or after treatment.

Internal Radiation Therapy (Brachytherapy)

Internal radiation therapy is also called brachytherapy, allows a higher dose of radiation in a smaller area than might be possible with external radiation treatment. Internal radiation therapy uses a radiation source that’s usually sealed in a small holder called an implant. Different types of implants may be called pellets, seeds, ribbons, wires, needles, capsules, balloons, or tubes. No matter which type of implant is used, it is placed in your body, very close to or inside the tumor. This way the radiation harms as few normal cells as possible. Getting the implant placed is usually a painless procedure. Depending on your type of cancer and treatment plan, you might get a temporary or a permanent implant.

• During intracavitary radiation, the radioactive source is placed in a body cavity (space) , such as the rectum or uterus.
• With interstitial radiation, the implants are placed in or near the tumor, but not in a body cavity.

How are internal radiation therapy implants put in the body?

Sometimes implants are put in the body with needle-like tubes. This might be done in an operating room, and drugs may be used to make you relax or sleep.

The implant procedure is usually done in a hospital operating room designed to keep the radiation inside the room. You’ll get anesthesia, which may be either general (where drugs are used to put you into a deep sleep so that you don’t feel pain) or local (where part of your body is numbed).

One or more implants is put into the body cavity or tissue with an applicator, usually a metal tube or a plastic tube called a catheter. Imaging tests (an x-ray, ultrasound, MRI, or CT scan) are usually used during the procedure to find the exact place the implant needs to go.

Before being placed, implants are kept in containers that hold the radiation inside so it can’t affect others. The health professionals handling the implants may wear special gear that protects them from exposure once the implants are taken out of the container.

How long do internal radiation therapy implants stay in place?

The length of time an implant is left in place depends on the type of brachytherapy you are getting. Some implants are permanent, while others are taken out after a few minutes or days. The type of implant you get will depend on the kind of cancer, where it is in your body, your general health, and other treatments you have had.

• High-dose rate brachytherapy

High-dose-rate brachytherapy allows a person to be treated for only a few minutes at a time with a powerful radioactive source that’s put in the applicator. The source is removed after several minutes. This may be repeated over the course of a few days to weeks. The radioactive material is not left in your body. The applicator might be left in place between treatments, or it might be put in before each treatment.

• Low-dose-rate brachytherapy

In this approach, the implant gives off lower doses of radiation over a longer period.

Some implants are left in from 1 to a few days and then removed. You’ll probably have to stay in the hospital, sometimes in a special room, during treatment. For larger implants, you might have to stay in bed and lie still to keep it from moving.

Some smaller implants (such as the seeds or pellets) are left in place – they’re never taken out. Over the course of several weeks they stop giving off radiation. The seeds are about the size of rice grains and rarely cause problems. If your implants are to be left in, you may be able to go home the same day they’re put in.

How will I feel during internal radiation therapy implant therapy?

You’re not likely to have a lot of pain or feel sick while implants are being put in. The drugs used while they’re being placed might make you feel drowsy, weak, or sick to your stomach, but these side effects don’t last long. If your implant is held in place by an applicator, you may have some discomfort in that area. Ask for medicine to help you relax or to relieve pain if needed. Be sure to tell your cancer care team if you have burning, sweating, or other symptoms.

What happens after a temporary implant is removed?

In most cases, anesthesia is not needed when the applicator and/or implant is removed. It’s usually done right in your hospital room. The treated area may be sore or tender for some time after treatment, but most people can return to normal activities quickly. Keep in mind that your body is recovering from radiation treatments, and you may need extra sleep or rest breaks over the next few days.

What happens to permanent implants?

The radioactive materials stop giving off radiation over time. It may take weeks or months. Talk to your cancer care team about how long it will take in your case. Once the radiation is gone, the implant(s) are no longer active. They usually stay in place and cause no harm, so there’s no need to take them out.

Will I be radioactive during or after internal radiation treatment?

With internal radiation therapy, your body may give off a small amount of radiation for a short time.

If you have a temporary implant, you’ll be asked to stay in the hospital and might have to limit visitors during treatment. You also may be asked to stay a certain distance away from them. Pregnant women and children might not be allowed to visit you. Once the implant is removed, your body will no longer give off radiation.

Over a few weeks to months, permanent implants will slowly stop giving off radiation. The radiation usually doesn’t travel much farther than the area being treated, so the chances that others could be exposed to radiation is very small. Still, your health care team might ask you to take certain precautions such as staying away from small children and pregnant women, especially right after you get the implants.

Systemic Radiation Therapy

Systemic radiation therapy uses radioactive drugs (called radiopharmaceuticals) to treat certain types of cancer systemically. A radiopharmaceutical is a liquid drug made up of a radioactive substance. It is sometimes bound to a special antibody (called a monoclonal antibody) that attaches to the cancer cells. Examples of radiopharmaceuticals used for systemic radiation include radioactive iodine, strontium, samarium, and radium. These drugs can be given by mouth or put into a vein (IV); they then travel throughout the body. The antibody makes them attach to the cancer cells. They then give off their radiation and kill the cancer cells. You may need to be in the hospital for 1 or 2 days while getting this treatment.

Certain cancers, such as thyroid, bone, and prostate are treated with radiopharmaceuticals (radioactive drugs).

Will I be radioactive during or after systemic radiation treatment?

Because systemic radiation uses an unsealed radioactive substance that goes through your whole body, some radiation will be in your body for a few days until your body has had a chance to get rid of it. You may need to stay in the hospital for 1 or 2 days.

To protect others from radiation, the drugs are kept in special containers that hold the radiation inside, and you’ll be treated in a shielded room that also keeps the radiation inside. The health providers handling the drugs might wear safety gear that protects them from exposure while giving you the radioactive drug.

Patient and family safety

Sometimes safety measures are needed to protect the people around you from the systemic radiation in your body. This is because the radioactive materials can leave your body through saliva, sweat, blood, and urine and that makes these fluids radioactive.

Your cancer care team will tell you what precautions to take until your body no longer contains radiation that might affect others. What you will need to do depends on the substance used.

In most cases, the safety precautions must be followed only the first few days after treatment. Over time, the radiation becomes weaker and your body gets rid of it. Talk to your cancer care team about how long this may take in your case, and if there are special precautions you will need to take.

You might be told to follow these steps for a certain amount of time:

• Flush the toilet twice after each use, and wash your hands well after using the toilet.
• Use separate utensils and towels (laundry may need to be washed separately).
• Drink extra fluids to flush the radioactive material out of your body.
• No kissing or sexual contact (often for at least a week).
• Keep a distance of one arm’s length between yourself and any others who spend more than 2 hours next to you in any 24-hour period. (You may need to sleep alone for a week or so.)
• Limit your contact with infants, children, and women who are pregnant.
• Limit your contact with pets.

Be sure you understand what you need to do to protect the people around you.

Radiation therapy side effects

Some people have no side effects at all, while others do. The most common side effects are:

• Feeling very tired (fatigue)
• Skin changes
• Not wanting to eat (appetite loss)

Other side effects depend on the part of the body being treated. For instance, if you get radiation to your head, you might have hair loss. Or if you get radiation to your chest, you might have a cough or sore throat.

Most side effects go away in time. But there are ways to help you feel better. If you have bad side effects, the doctor may stop your treatments for a while, change the schedule, or change the type of treatment you are getting. Tell your doctor, nurse, or radiation therapist about any side effects you have so they can help you with them.

How long do side effects last?

Radiation side effects often start during the second or third week of treatment depending on the prescribed dose and schedule. Most side effects go away within a few months of ending treatment. Some side effects may continue after treatment ends because it takes time for the healthy cells to recover from radiation. In the meantime, there are ways to reduce the discomfort they may cause. If you have bad side effects, the doctor may stop your treatments for a while, change the schedule, or change the type of treatment you’re getting. Tell your cancer care team about any side affects you notice so they can help you with them.

People often become discouraged about how long their treatment lasts or the side effects they have. If you feel this way, talk to your cancer care team. If needed, they should be able to suggest ways to help you feel better.

Radioprotective drugs for reducing side effects

Doctors look for ways to reduce side effects caused by radiation therapy while still using the doses needed to kill cancer cells. One way to reduce side effects is by using radioprotective drugs. These drugs are given before radiation treatment to protect certain normal tissues in the treatment area. The one most commonly used today is amifostine. This drug may be used in people with head and neck cancer to reduce the mouth problems caused by radiation therapy.

Radioprotective drugs are an active area of research. Not all doctors agree on how these drugs should be used in radiation therapy. These drugs have their own side effects, too, so be sure you understand what to look for.

How do I deal with fatigue?

Fatigue means you feel very tired. It can last for a long time and keep you from doing the things you want and need to do. It’s not like the fatigue a person feels at the end of a long, hard day. That kind gets better after a good night’s sleep. The fatigue caused by cancer and/or cancer treatment is worse and causes more problems. Rest does not always make it go away.

Cancer fatigue is very common. By knowing about fatigue, you can cope with it better. No lab tests or x-rays can show fatigue or tell how bad it is for you. Only you know if you have fatigue and how bad it is.

If you have fatigue, be sure to tell your doctor or nurse. You can say it’s mild, moderate, or severe. Or, you can use a scale from 0 to 10. A 0 means you have no fatigue, and a 10 means you have the worst fatigue ever.

This weak or weary feeling will go away over time after your treatment ends.

Until then there are some things you can do to help reduce your fatigue:

• Do the things that you need to get done when you feel your best.
• Ask for help, and let people help you.
• Put things that you use often within easy reach.
• Set up a daily routine.
• Try to relax to reduce stress. Many people feel better with deep breathing, prayer, talking with others, reading, listening to music, and painting, among other things.
• Balance rest and activity. Don’t spend too much time in bed, which can make you weak. Don’t let rest or daytime naps keep you from sleeping at night. A few short rest breaks are better than one long one.
• Talk to your doctor about how to keep your pain and nausea – if you have these – under control.
• Depression can make you feel more tired. Talk with your doctor about treatment if you think you may be depressed. Feeling sad or worthless, losing interest in life, thinking about death a lot, or thinking of hurting yourself are some signs of depression.
• Get some exercise each day. Talk to your doctor before you start.
• You may be told to eat a special way. If so, try to do it. It’s good to eat a healthy diet that includes protein (meat, milk, eggs, and beans). It’s also good to drink about 8 to 10 glasses of water a day.

Let your doctor or nurse know about your fatigue and talk with them if:

• It doesn’t get better, keeps coming back, or gets worse.
• You are more tired than usual during or after an activity.
• Your fatigue doesn’t get better with rest or sleep.
• You become confused or can’t think.
• You can’t get out of bed for more than 24 hours.
• You can’t do the things you need or want to do.

What can I do about skin changes?

Skin over the part of your body being treated may look red, swollen, blistered, sunburned, or tanned. After a few weeks, your skin may become dry, flaky, itchy, or it may peel. Be sure to let your doctor, nurse, or radiation therapist know about any skin changes. They can suggest ways to ease the discomfort, help keep it from getting worse, and try to prevent infection.

Most skin changes slowly go away after treatment ends. In some cases, though, the treated skin will stay darker and might be more sensitive than it was before. You need to be gentle with your skin. Here are some ways to do this:

• Wear loose clothes made from soft, smooth fabrics.
• Do not rub, scrub, scratch, or use adhesive tape on treated skin. If your skin must be covered or bandaged, use paper tape or other tape for sensitive skin.
• Try to put the tape outside the treatment area, and don’t put the tape in the same place each time.
• Do not put heat or cold (such as a heating pad, heat lamp, or ice pack) on the treated skin. Talk with your doctor first.
• Protect the treated area from the sun. It may be extra sensitive to sunlight. Protect your skin from sunlight even after radiation therapy ends. Wear clothes that cover the skin, or use sunscreen.
• Use only lukewarm water and mild soap. Just let water run over the treated area. Do not rub. Also be careful not to rub away the ink marks needed for your radiation therapy until it’s done.
• Do not use a pre-shave or after-shave lotion or hair-removal products. Use an electric shaver if you must shave the area, but first check with your doctor or nurse.
• Ask your doctor or nurse before using anything on the skin in the treatment area. This includes powders, creams, perfumes, deodorants, body oils, ointments, lotions, or home remedies while you are being treated and for several weeks afterward.

Will I have eating problems?

You may not feel like eating during your treatment. Eating may be more of a problem if you’re getting radiation to your stomach or chest. Even if you don’t feel like eating, you should try to eat foods high in protein and calories.

Doctors have found that patients who eat well can better handle cancer treatment and side effects. There are many recipe books for patients who need help with eating problems. Ask your nurse about these.

If you have trouble swallowing, tell your doctor or nurse. If you have pain when you chew and swallow, you may be told to try a liquid diet. Liquid nutrition drinks come in many flavors. You can buy them at grocery stores and drugstores, or you can make them yourself. They can be mixed with other foods or added to milk shakes.

Here are some tips to help when you don’t feel like eating:

• Eat when you are hungry, even if it’s not mealtime.
• Eat 5 or 6 small meals during the day rather than 2 or 3 large ones.
• Try to eat with family or friends, or turn on the TV or radio.
• If you drink alcohol, ask your doctor if it’s OK during treatment. Ask if alcohol will affect any medicines you are taking.
• Keep healthy snacks close by.
• If others offer to cook for you, let them. Don’t be shy about telling them what you want to eat.
• Add calories to your diet by drinking milk shakes or liquid supplements, adding cream sauce or melted cheese to vegetables, and mixing canned cream soups with milk or half-and-half (half milk and half cream) instead of water.

Will my emotions be affected?

You may feel tired from the radiation therapy, and this can affect your emotions. You also might feel depressed, afraid, angry, alone, or helpless. Talking to others sometimes helps.

One way to meet other people with cancer is to go to a support group. These groups often meet at local cancer treatment centers. Ask your doctor or nurse to find out how you can meet with or talk to others who share your problems and concerns.

Will I have pain?

Radiation therapy isn’t painful, but some of the side effects it causes can be. For instance, if you are getting radiation to the head and neck area, you might have a sore throat, trouble swallowing, or mouth sores. These can hurt.

If you have a tumor that’s causing pain, radiation can shrink the tumor and help relieve that pain.

If you have any pain, talk to your doctor or nurse. Describe your pain and where it is in as much detail as you can. This will help your doctor know how best to help you with your pain.

Pain is not part of cancer treatment. Get help if you have pain.

How radiation therapy can affect different parts of the body

Some side effects of radiation therapy, like fatigue and skin problems, can happen no matter what part of the body is being treated.

But radiation therapy can have other, specific side effects depending on what area is being treated. This information covers some of the most common areas that might be treated with radiation. Talk to your cancer care team about what you can expect.

If you’re getting radiation therapy to the brain

People with brain tumors often get stereotactic radiosurgery (radiation given in one large dose) if the cancer is in only one or a few sites in the brain. Side effects depend on where the radiation is aimed. Some side effects might show up quickly, but others might not show up until 1 to 2 years after treatment. Talk with your radiation oncologist about what to watch for and when to call your doctor.

If the cancer is in many areas, sometimes the whole brain is treated with radiation. The side effects of whole brain radiation therapy may not be noticeable until a few weeks after treatment begins.

Radiation to the brain can cause these short-term side effects:

• Headaches
• Hair loss
• Nausea
• Vomiting
• Extreme tiredness (fatigue)
• Hearing loss
• Skin and scalp changes
• Trouble with memory and speech
• Seizures

Some of these side effects can happen because radiation has caused the brain to swell. Medicines are usually given to prevent brain swelling, but it’s important to let your cancer care team know about headaches or any other symptoms. Treatment can affect each person differently, and you may not have these particular side effects.

Radiation to the brain can also have side effects that show up later – usually from 6 months to many years after treatment ends. These delayed effects can include serious problems such as memory loss, stroke-like symptoms, and poor brain function. You may also have an increased risk of having another tumor in the area, although this is not common.

Talk with your cancer care team about what to expect from your specific treatment plan.

If you’re getting radiation therapy to the head or neck

People who get radiation to the head and neck might have side effects such as:

• Soreness (or even open sores) in the mouth or throat
• Dry mouth
• Trouble swallowing
• Changes in taste
• Nausea
• Earaches
• Tooth decay
• Swelling in the gums, throat, or neck
• Hair loss
• Changes in skin texture
• Jaw stiffness

How to care for your mouth during treatment

If you get radiation therapy to the head or neck, you need to take good care of your teeth, gums, mouth, and throat. Here are some tips that may help you manage mouth problems:

• Avoid spicy and rough foods, such as raw vegetables, dry crackers, and nuts.
• Don’t eat or drink very hot or very cold foods or beverages.
• Don’t smoke, chew tobacco, or drink alcohol – these can make mouth sores worse.
• Stay away from sugary snacks.
• Ask your cancer care team to recommend a good mouthwash. The alcohol in some mouthwashes can dry and irritate mouth tissues.
• Rinse your mouth with warm salt and soda water every 1 to 2 hours as needed. (Use 1 teaspoon of salt and 1 teaspoon of baking soda in 1 quart of water.)
• Sip cool drinks often throughout the day.
• Eat sugar-free candy or chew gum to help keep your mouth moist.
• Moisten food with gravies and sauces to make it easier to eat.
• Ask your cancer care team about medicines to help treat mouth sores and control pain while eating.

If these measures are not enough, ask your cancer care team for advice. Mouth dryness may be a problem even after treatment is over. If so, talk to your team about what you can do.

How to care for your teeth during treatment

Radiation treatment to your head and neck can increase your chances of getting cavities. This is especially true if you have dry mouth as a result of treatment.

Before starting radiation, talk to your cancer care team about whether you should get a complete check-up with your dentist. Ask your dentist to talk with your radiation doctor before you start treatment. If you have one or more problem teeth, your dentist may suggest removing them before you start treatment. Radiation (and dry mouth) might damage them to the point where they’ll need to be removed anyway, and this can be harder to do after treatment starts.

If you wear dentures, they may no longer fit well because of swollen gums. If your dentures cause sores, you may need to stop wearing them until your radiation therapy is done to keep sores from getting infected.

Your dentist may want to see you during your radiation therapy to check your teeth, talk to you about caring for your mouth and teeth, and help you deal with any problems. Most likely, you will be told to:

• Clean your teeth and gums with a very soft brush after meals and at least one other time each day.
• Use fluoride toothpaste that contains no abrasives.
• Rinse your mouth well with cool water or a baking soda solution after you brush. (Use 1 teaspoon of baking soda in 1 quart of water.)
• If you normally floss, ask your dentist or cancer care team if this is OK during treatment. Tell your cancer care team if this causes bleeding or other problems.

If you’re getting radiation therapy to the chest

Radiation treatment to the chest may cause side effects such as:

• Sore throat
• Swallowing problems
• Loss of appetite
• Cough
• Shortness of breath

Radiation can also cause other problems in the heart or lungs.

Heart complications

Getting radiation to the middle portion of the chest can raise your risk of heart disease. This risk increases with higher radiation doses and larger treatment areas in this part of your body. Radiation can also cause hardening of the arteries (which can make you more likely to have a heart attack later on), heart valve damage, or irregular heartbeats.

Radiation pneumonitis

Radiation pneumonitis is inflammation of the lungs that can be caused by radiation treatment to the chest (or less often, the breast). It may occur about 3 to 6 months after getting radiation therapy. It’s more likely if you have other lung diseases, like emphysema (which involves gradual damage of lung tissue). Common symptoms of radiation pneumonitis include:

• Shortness of breath that usually gets worse with exercise
• Chest pain, which is often worse when taking in a deep breath
• Cough
• Pink-tinged sputum
• Low-grade fever
• Weakness

Sometimes there are no symptoms, and radiation pneumonitis is found on a chest x-ray.

Symptoms often go away on their own, but if treatment is needed, it is based on trying to decrease the inflammation. Steroids, like prednisone, are usually used. With treatment, most people recover without any lasting effects. But if it persists, it can lead to pulmonary fibrosis (stiffening or scarring of the lungs). When this happens, the lungs can no longer fully inflate and take in air.

Be sure you understand what to look for, and tell your cancer care team if you notice any of these side effects.

If you’re getting radiation therapy to the abdomen (belly)

If you are getting radiation to your stomach or some part of the abdomen (belly), you may have side effects such as:

• Nausea
• Vomiting
• Belly cramps
• Diarrhea

Ask your cancer care team about what you can expect, and what medicines you should take to help relieve these problems. Check with your cancer care team about any home remedies or over-the-counter drugs you’re thinking about using.

Eating or avoiding certain foods can help with some of these problems, so diet planning is an important part of radiation treatment of the stomach or abdomen. try to pack the highest possible food value into even small meals so you get enough protein, calories, vitamins, and minerals.

These problems should get better when treatment is over.

Managing nausea

Some people feel queasy for a few hours right after radiation therapy. If you have this problem, try not eating for a couple of hours before and after your treatment. You may handle the treatment better on an empty stomach. If the problem doesn’t go away, ask your cancer care team about medicines to help prevent and treat nausea. Be sure to take the medicine as prescribed.

If you notice nausea before your treatment, try eating a bland snack, like toast or crackers, and try to relax as much as possible. See Nausea and Vomiting to get tips to help an upset stomach and learn more about how to manage these side effects.

Managing diarrhea

Many people have diarrhea at some point after starting radiation therapy to the abdomen. Your cancer care team may prescribe medicines or give you special instructions to help with the problem. Diet changes may also be recommended, such as:

• Try a clear liquid diet (water, weak tea, apple juice, peach nectar, clear broth, popsicles, and plain gelatin) as soon as diarrhea starts or when you feel like
• it’s going to start.
• Don’t eat foods that are high in fiber or can cause gas or cramps, such as raw fruits and vegetables, beans, cabbage, whole-grain breads and cereals, sweets, and spicy foods.
• Eat frequent, small meals.
• Do not drink milk or eat milk products if they irritate your bowels.
• When the diarrhea starts to improve, try eating small amounts of low-fiber foods, such as rice, bananas, applesauce, yogurt, mashed potatoes, low-fat cottage cheese, and dry toast.
• Be sure you take in enough potassium (it can be found in bananas, potatoes, beans, peaches, and many other foods). This is an important mineral you may lose through diarrhea.

If you’re having radiation therapy to the pelvis

Radiation therapy to the pelvis (for example, as treatment for bladder, ovarian, or prostate cancer) can cause side effects such as:

• Bladder problems
• Fertility problems
• Changes in your sex life

You might also have some of the same problems people get from radiation to the abdomen, such as nausea, vomiting, or diarrhea.

How radiation to the pelvis can affect the bladder

Radiation to the pelvis can cause problems with urination, including:

• Pain or burning sensations
• Trouble passing urine
• Blood in the urine
• An urge to urinate often

Most of these problems get better over time, but radiation therapy can cause longer-term side effects as well:

• Radiation cystitis. If the radiation damages the lining of the bladder, radiation cystitis can be a long-term problem that causes blood in the urine or pain when passing urine.
• Urinary incontinence. Radiation treatments for certain cancers, such as prostate and bladder cancer, may make you unable to control your urine or have leakage or dribbling. There are different types and degrees of incontinence, but it can be treated. Even if incontinence can’t be corrected completely, it can still be helped. This side effect is most often a problem for men being treated for prostate cancer, but some of the information might also be helpful for women dealing with treatment-related incontinence.
• Fistulas. In rare cases, radiation can cause an opening called a fistula to form between organs in the pelvis, such as between the vagina and the bladder, or between the bladder and the rectum. These can be fixed with surgery.

How fertility might be affected

For women: Talk to your cancer care team about how radiation might affect your fertility – it’s best to do this before starting treatment.

Depending on the radiation dose, women getting radiation therapy in the pelvic area sometimes stop having menstrual periods and have other symptoms of menopause. Report these symptoms to your cancer care and ask them how to relieve these side effects.

For men: Radiation therapy to an area that includes the testicles can reduce both the number of sperm and their ability to function. If you want to father a child in the future and are concerned about reduced fertility, talk to your cancer care team before starting treatment. One option may be to bank your sperm ahead of time.

Not much is known about the possible effects of radiation on the children conceived by men soon after getting radiation therapy. Because of the uncertain risk, doctors often advise men to avoid fathering a child for several weeks after treatment, especially if the radiation is given to or near the genital area.

How sex might be affected

With some types of radiation therapy involving the pelvis and/or sex organs, men and women may notice changes in their ability to enjoy sex or a decrease in their level of desire.

For women: During radiation treatment to the pelvis, some women are told not to have sex. Some women may find sex painful. Treatment can also cause vaginal itching, burning, and dryness. You most likely will be able to have sex within a few weeks after treatment ends, but check with your doctor first. Some types of treatment can have long-term effects, such as scar tissue that could affect the ability of the vagina to stretch during penetration. Again, your cancer care team can offer ways to help if this happens to you. You can also get more information in Sex and Women With Cancer.

For men: Radiation may affect the nerves that allow a man to have erections. If erection problems do occur, they are usually gradual, over the course of many months or years. Talk with your doctor about treatment options if this is a concern for you.

Radiation therapy for breast cancer

Some women with breast cancer will need radiation, often in addition to other treatments. The need for radiation depends on what type of surgery you had, whether your cancer has spread to the lymph nodes or somewhere else in your body, and in some cases, your age. Tumors that are large or involve the skin might also need radiation. You could have just one type of radiation, or a combination of different types.

Radiation therapy is treatment with high-energy rays (such as x-rays) or particles that destroy cancer cells. Two main types of radiation therapy can be used to treat breast cancer:

• External beam radiation: This type of radiation comes from a machine outside the body.
• Internal radiation (brachytherapy): For this treatment, a radioactive source is put inside the body for a short time.

When might radiation therapy be used?

Not all women with breast cancer need radiation therapy, but it may be used in several situations:

• After breast-conserving surgery (BCS), to help lower the chance that the cancer will come back in the breast or nearby lymph nodes.
• After a mastectomy, especially if the cancer was larger than 5 cm (about 2 inches), or if cancer is found in the lymph nodes.
• If breast cancer has spread to other parts of the body, such as the bones or brain.

External beam radiation

This is the most common type of radiation therapy for women with breast cancer. A machine focuses the radiation on the area affected by the cancer.

Which areas need radiation depends on whether you had a mastectomy or breast-conserving surgery (BCS) and whether or not the cancer has reached nearby lymph nodes.

• If you had a mastectomy and no lymph nodes had cancer, radiation is focused on the chest wall, the mastectomy scar, and the places where any drains exited the body after surgery.
• If you had breast-conserving surgery, you will most likely have radiation to the entire breast (called whole breast radiation), and an extra boost of radiation to the area in the breast where the cancer was removed (called the tumor bed) to help prevent it from coming back in that area. The boost is often given after the treatments to the whole breast have ended. It uses the same machine, with lower amounts of radiation, but the beams are aimed at the tumor bed. Most women don’t notice different side effects from boost radiation than from whole breast radiation.
• If breast cancer was found in the lymph nodes under the arm (axillary lymph nodes), this area may be given radiation, as well. In some cases, the area treated might also include the nodes above the collarbone (supraclavicular lymph nodes) and the nodes beneath the breast bone in the center of the chest (internal mammary lymph nodes).

When will I get radiation therapy?

If you will need external radiation therapy after surgery, it is usually not started until your surgery site has healed , which is often a month or longer. If you are getting chemotherapy as well, radiation treatments are usually delayed until chemotherapy is complete.

Preparing for external beam radiation therapy

Before your treatment starts, the radiation team will carefully figure out the correct angles for aiming the radiation beams and the proper dose of radiation. They will make some ink marks or small tattoos on your skin to focus the radiation on the right area. Check with your health care team whether the marks they use will be permanent.

External radiation therapy is much like getting an x-ray, but the radiation is stronger. The procedure itself is painless. Each treatment lasts only a few minutes, but the setup time—getting you into place for treatment—usually takes longer.

Types and schedules of external beam radiation

The traditional schedule for getting whole breast radiation has been 5 days a week (Monday through Friday) for about 5 to 6 weeks. But many doctors are now using accelerated breast irradiation in select patients to give larger doses over a shorter time. There are several different types of accelerated breast irradiation:

• Hypofractionated radiation therapy: In this approach, radiation is given in larger doses using fewer treatments – typically for only 3 weeks. In women treated with breast-conserving surgery (BCS) and without cancer spread to underarm lymph nodes, this schedule has been shown to be just as good at keeping the cancer from coming back in the same breast as giving the radiation over 5 weeks. It might also lead to fewer short-term side effects.
• Intraoperative radiation therapy (IORT): In this approach, a single large dose of radiation is given in the operating room right after BCS (before the breast incision is closed). IORT requires special equipment and is not widely available.
• 3D-conformal radiotherapy: In this technique, the radiation is given with special machines so that it is better aimed at the area where the tumor was removed (tumor bed). This allows more of the healthy breast to be spared. Treatments are given twice a day for 5 days. Because only part of the breast is treated, this is considered to be a form of accelerated partial breast irradiation. (Other forms of accelerated partial breast irradiation are described under Brachytherapy.)

Since more research is needed to know if all of the newer methods will have the same long-term results as standard radiation, not all doctors use them. Women who are interested in these approaches may want to ask their doctor about taking part in clinical trials of accelerated breast irradiation going on now.

Possible side effects of external radiation

The main short-term side effects of external beam radiation therapy to the breast are:

• Swelling in the breast
• Skin changes in the treated area similar to a sunburn (redness, skin peeling, darkening of the skin)
• Fatigue

Your health care team may advise you to avoid exposing the treated skin to the sun because it could make the skin changes worse. Most skin changes get better within a few months. Changes to the breast tissue usually go away in 6 to 12 months, but it can take longer.

External beam radiation therapy can also cause side effects later on:

• Some women may find that radiation therapy causes the breast to become smaller and firmer.
• Radiation may affect your options for breast reconstruction later on. It can also raise the risk of problems if it’s given after reconstruction, especially tissue flap procedures.
• Women who have had breast radiation may have problems breastfeeding later on.
• Radiation to the breast can sometimes damage some of the nerves to the arm. This is called brachial plexopathy and can lead to numbness, pain, and weakness in the shoulder, arm, and hand.
• Radiation to the underarm lymph nodes can cause lymphedema, a type of pain and swelling in the arm or chest.
• In rare cases, radiation therapy may weaken the ribs, which could lead to a fracture.
• In the past, parts of the lungs and heart were more likely to get some radiation, which could lead to long-term damage of these organs in some women.
• Modern radiation therapy equipment allows doctors to better focus the radiation beams, so these problems are rare today.
• A very rare complication of radiation to the breast is the development of another cancer called an angiosarcoma.

Brachytherapy

Brachytherapy, also known as internal radiation, is another way to deliver radiation therapy. Instead of aiming radiation beams from outside the body, a device containing radioactive seeds or pellets is placed into the breast tissue for a short time in the area where the cancer had been removed.

For women who had breast-conserving surgery, brachytherapy can be used along with external beam radiation as a way to add an extra boost of radiation to the tumor site. It may also be used by itself (instead of radiation to the whole breast) as a form of accelerated partial breast irradiation. Tumor size, location, and other factors may limit who can get brachytherapy.

Types of brachytherapy for breast cancer

There are different types of brachytherapy:

• Interstitial brachytherapy: In this approach, several small, hollow tubes called catheters are inserted into the breast around the area where the cancer was removed and are left in place for several days. Radioactive pellets are inserted into the catheters for short periods of time each day and then removed. This method of brachytherapy has been around longer (and has more evidence to support it), but it is not used as much anymore.
• Intracavitary brachytherapy: This is the most common type of brachytherapy for women with breast cancer. A device is put into the space left from breast-conserving surgery and is left in place until treatment is complete. There are several different devices available (including MammoSite, SAVI, Axxent, and Contura), most of which require surgical training for proper placement . They all go into the breast as a small catheter (tube). The end of the device inside the breast is then expanded so that it stays securely in place for the entire treatment. The other end of the catheter sticks out of the breast. For each treatment, one or more sources of radiation (often pellets) are placed down through the tube and into the device for a short time and then removed. Treatments are typically given twice a day for 5 days as an outpatient. After the last treatment, the device is collapsed down again and removed.

Early studies of intracavitary brachytherapy as the only radiation after breast-conserving surgery have had promising results as far as having at least equal cancer control compared with standard whole breast radiation, but may have more complications including poor cosmetic results. Studies of this treatment are being done and more follow-up is needed.

Early studies of intracavitary brachytherapy as the only radiation after breast-conserving surgery have had promising results, but they didn’t directly compare this technique with standard whole breast external beam radiation.

Possible side effects of intracavitary brachytherapy

As with external beam radiation, intracavitary brachytherapy can have side effects, including:

• Redness at the treatment site
• Bruising at the treatment site
• Breast pain
• Infection
• Damage to fatty tissue in the breast
• Weakness and fracture of the ribs in rare cases
• Fluid collecting in the breast (seroma)

Short-term side effects of radiation therapy for breast cancer

If you have radiation to the breast, it can affect your heart or lungs as well causing other side effects.

Radiation to the breast can cause:

• Skin irritation, dryness, and color changes
• Breast soreness
• Breast swelling from fluid build-up (lymphedema)

To avoid irritating the skin around the breast, women should try to go without wearing a bra whenever they can. If this isn’t possible, wear a soft cotton bra without underwires.

If your shoulders feel stiff, ask your cancer care team about exercises to keep your shoulder moving freely.

Breast soreness, color changes, and fluid build-up (lymphedema) will most likely go away a month or 2 after you finish radiation therapy. If fluid build-up continues to be a problem, ask your cancer care team what steps you can take. See Lymphedema for more information.

Long-term changes to the breast

Radiation therapy may cause long-term changes in the breast. Your skin may be slightly darker, and pores may be larger and more noticeable. The skin may be more or less sensitive and feel thicker and firmer than it was before treatment. Sometimes the size of your breast changes – it may become larger because of fluid build-up or smaller because of scar tissue. These side effects may last long after treatment.

After about a year, you shouldn’t have any new changes. If you do see changes in breast size, shape, appearance, or texture after this time, tell your cancer care team about them right away.

Less common side effects in nearby areas

Although it’s rare, radiation to the breast can affect organs in the chest, including the heart and lungs. This is not as common today as it was in the past, because modern radiation therapy equipment allows doctors to better focus the radiation beams on the area with cancer, with less affect to other areas.

Rib fractures: In rare cases, radiation therapy may weaken the ribs, which could lead to a fracture. Be sure you understand what to look for and tell your cancer care team if you notice any of these side effects.

Heart complications: Radiation to the breast can also affect the heart. It can cause hardening of the arteries (which can make you more likely to have a heart attack later on), heart valve damage, or irregular heartbeats.

Lung damage (radiation pneumonitis): Getting radiation to the breast can sometimes cause an inflammation of the lungs, which is called radiation pneumonitis. See “If you’re getting radiation to the chest” below for more details.

Damage to the nerves in the shoulder and arm: Radiation to the breast can sometimes damage some of the nerves to the arm. This is called brachial plexopathy and can lead to numbness, tingling, pain, and weakness in the shoulder, arm, and hand.

Side effects of brachytherapy

If your treatment includes brachytherapy (internal radiation implants), you might notice breast tenderness, tightness, redness, and bruising. You may also have some of the same side effects that happen with external radiation treatment. Let your cancer care team know about any problems you notice.

Radiation therapy for prostate cancer

Radiation may be used for prostate cancer:

• As the first treatment for prostate cancer that is still just in the prostate gland and is low grade. Cure rates for men with these types of prostate cancers are about the same as those for men treated with radical prostatectomy.
• As part of the first treatment (along with hormone therapy) for prostate cancers that have grown outside the prostate gland and into nearby tissues.
• If the prostate cancer is not removed completely or comes back (recurs) in the area of the prostate after surgery.
• If the prostate cancer is advanced, to help keep the cancer under control for as long as possible and to help prevent or relieve symptoms.

The 2 main types of radiation therapy used for prostate cancer are:

• External beam radiation
• Brachytherapy (internal radiation)

Another type of radiation therapy called systemic radiation therapy, in which radiopharmaceutical drug that contain radioactive elements is injected into the body and settle in areas of damaged bones (like those containing cancer spread). These drugs can be used to treat prostate cancer that has spread to many bones. Unlike external beam radiation, these drugs can reach all the affected bones at the same time.

The radiopharmaceuticals that can be used to treat prostate cancer spread to bone include:

• Strontium-89 (Metastron)
• Samarium-153 (Quadramet)
• Radium-223 (Xofigo)

All of these drugs can help relieve pain caused by bone metastases. Radium-223 has also been shown to help men who have prostate cancer spread only to their bones (as opposed to spread to other organs such as the lungs) to live longer. For these men, radium-223 may be an early part of treatment.

The major side effect of these drugs is a decrease in blood cell counts, which could increase risks for infections or bleeding, especially if your counts are already low. Other side effects have also been seen, so ask your doctor what you can expect.

External beam radiation therapy

In external beam radiation therapy, beams of radiation are focused on the prostate gland from a machine outside the body. This type of radiation can be used to try to cure earlier stage cancers, or to help relieve symptoms such as bone pain if the cancer has spread to a specific area of bone.

Before treatments start, your radiation team will take careful measurements to find the correct angles for aiming the radiation beams and the proper dose of radiation. This planning session, called simulation, usually includes getting imaging tests such as CT or MRI scans. You might be fitted with a plastic mold resembling a body cast to keep you in the same position for each treatment so that the radiation can be aimed more accurately.

You will usually be treated 5 days a week in an outpatient center for at least several weeks, depending on why the radiation is being given. Each treatment is much like getting an x-ray. The radiation is stronger than that used for an x-ray, but the procedure is painless. Each treatment lasts only a few minutes, although the setup time — getting you into place for treatment — takes longer.

Newer external beam radiation therapy techniques focus the radiation more precisely on the tumor. This let doctors give higher doses of radiation to the tumor while reducing the radiation exposure to nearby healthy tissues.

Three-dimensional conformal radiation therapy (3D-CRT)

3D-CRT uses special computers to precisely map the location of your prostate. Radiation beams are then shaped and aimed at the prostate from several directions, which makes it less likely to damage normal tissues.

Intensity modulated radiation therapy

Intensity modulated radiation therapy, an advanced form of 3D therapy, is the most common type of external beam radiation therapy for prostate cancer. It uses a computer-driven machine that moves around the patient as it delivers radiation. Along with shaping the beams and aiming them at the prostate from several angles, the intensity (strength) of the beams can be adjusted to limit the doses reaching nearby normal tissues. This lets doctors deliver an even higher dose to the cancer.

Some newer radiation machines have imaging scanners built into them. This advance, known as image guided radiation therapy, lets the doctor take pictures of the prostate and make minor adjustments in aiming just before giving the radiation. This may help deliver the radiation even more precisely, which might result in fewer side effects, although more research is needed to prove this.

Another approach is to place tiny implants into the prostate that send out radio waves to tell the radiation therapy machines where to aim. This lets the machine adjust for movement (like during breathing) and may allow less radiation to go to normal tissues. In theory, this could lower side effects. So far, though, no study has shown side effects to be lower with this approach than with other forms of intensity modulated radiation therapy. The machines that use this are known as Calypso®.

A variation of intensity modulated radiation therapy is called volumetric modulated arc therapy. It uses a machine that delivers radiation quickly as it rotates once around the body. This allows each treatment to be given over just a few minutes. Although this can be more convenient for the patient, it hasn’t yet been shown to be more effective than regular intensity modulated radiation therapy.

Stereotactic body radiation therapy

This technique uses advanced image guided techniques to deliver large doses of radiation to a certain precise area, such as the prostate. Because there are large doses of radiation in each dose, the entire course of treatment is given over just a few days.

Stereotactic body radiation therapy is often known by the names of the machines that deliver the radiation, such as Gamma Knife®, X-Knife®, CyberKnife®, and Clinac®.

The main advantage of stereotactic body radiation therapy over intensity modulated radiation therapy is that the treatment takes less time (days instead of weeks). The side effects, though, are not better. In fact, some research has shown that some side effects might actually be worse with stereotactic body radiation therapy than with intensity modulated radiation therapy.

Proton beam radiation therapy

Proton beam therapy focuses beams of protons instead of x-rays on the cancer. Unlike x-rays, which release energy both before and after they hit their target, protons cause little damage to tissues they pass through and release their energy only after traveling a certain distance. This means that proton beam radiation can, in theory, deliver more radiation to the prostate while doing less damage to nearby normal tissues. Proton beam radiation can be aimed with techniques similar to 3D-CRT and intensity modulated radiation therapy.

Although in theory proton beam therapy might be more effective than using x-rays, so far studies have not shown if this is true. Right now, proton beam therapy is not widely available. The machines needed to make protons are very expensive, and they aren’t available in many centers in the United States. Proton beam radiation might not be covered by all insurance companies at this time.

Possible side effects of external beam radiation therapy

Some of the side effects from external beam radiation therapy are the same as those from surgery, while others are different.

Bowel problems: Radiation can irritate the rectum and cause a condition called radiation proctitis. This can lead to diarrhea, sometimes with blood in the stool, and rectal leakage. Most of these problems go away over time, but in rare cases normal bowel function does not return. To help lessen bowel problems, you may be told to follow a special diet during radiation therapy to help limit bowel movement during treatment. Sometimes a balloon-like device is put in the rectum during each treatment to keep the bowel as still as possible while treatment is given.

Urinary problems: Radiation can irritate the bladder and lead to a condition called radiation cystitis. You might need to urinate more often, have a burning sensation while you urinate, and/or find blood in your urine. Urinary problems usually improve over time, but in some men they never go away.

Some men develop urinary incontinence after treatment, which means they can’t control their urine or have leakage or dribbling. Overall, this side effect occurs less often than after surgery. The risk is low at first, but it goes up each year for several years after treatment.

Rarely, the tube that carries urine from the bladder out of the body (the urethra) may become very narrow or even close off, which is known as a urethral stricture. This might require further treatment to open it up again.

Erection problems, including impotence: After a few years, the impotence rate after radiation is about the same as that after surgery. Problems with erections usually do not occur right after radiation therapy but slowly develop over time. This is different from surgery, where impotence occurs immediately and may get better over time.

As with surgery, the older you are, the more likely it is you will have problems with erections.

There are several options for treating erectile dysfunction:

• Phosphodiesterase-5 (PDE5) inhibitors such as sildenafil (Viagra), vardenafil (Levitra), and tadalafil (Cialis) are pills that can help with erections. These drugs won’t work if both nerves that control erections have been damaged or removed. Common side effects of these drugs are headache, flushing (skin becomes red and feels warm), upset stomach, light sensitivity, and runny or stuffy nose. Rarely, these drugs can cause vision problems, possibly even blindness. Some other drugs such as nitrates, which are drugs used to treat heart disease, can cause problems if you are taking a PDE5 inhibitor, so be sure your doctor knows what medicines you take.
• Alprostadil is a man-made version of prostaglandin E1, a substance naturally made in the body that can produce erections. It can be injected almost painlessly into the base of the penis 5 to 10 minutes before intercourse or placed into the tip of the penis as a suppository. You can even increase the dosage to prolong the erection. You might have side effects, such as pain, dizziness, and prolonged erection, but they are not usually serious.
• Vacuum devices are another option to create an erection. These mechanical pumps are placed over the penis. The air is sucked out of the pump, which draws blood into the penis to produce an erection. The erection is maintained after the pump is removed by a strong rubber band placed at the base of the penis. The band is removed after sex.
• Penile implants might restore your ability to have erections if other methods don’t help. An operation is needed to put them inside the penis. There are several types of penile implants, including those using silicone rods or inflatable devices.

Feeling tired: Radiation therapy can cause fatigue that might not go away until a few weeks or months after treatment stops.

Lymphedema: The lymph nodes normally provide a way for fluid to return to the heart from all areas of the body. If the lymph nodes around the prostate are damaged by radiation, fluid may collect in the legs or genital region over time, causing swelling and pain. Lymphedema can usually be treated with physical therapy, although it may not go away completely.

Brachytherapy (internal radiation therapy)

Brachytherapy (also called seed implantation or interstitial radiation therapy) uses small radioactive pellets, or “seeds,” each about the size of a grain of rice. These pellets are placed directly into your prostate.

• Brachytherapy alone is generally used only in men with early-stage prostate cancer that is relatively slow growing (low-grade).
• Brachytherapy combined with external radiation is sometimes an option for men who have a higher risk of the cancer growing outside the prostate.

The use of brachytherapy is also limited by some other factors. For men who have had a transurethral resection of the prostate (TURP) or for those who already have urinary problems, the risk of urinary side effects may be higher. Brachytherapy might not work as well in men with large prostate glands because it might not be possible to place the seeds into all of the correct locations. One way to get around this may be to get a few months of hormone therapy beforehand to shrink the prostate.

Imaging tests such as transrectal ultrasound, CT scans, or MRI are used to help guide the placement of the radioactive pellets. Special computer programs calculate the exact dose of radiation needed.

There are 2 types of prostate brachytherapy. Both are done in an operating room. You will get either spinal anesthesia (where the lower half of your body is numbed) or general anesthesia (where you are asleep), and you might need to stay in the hospital overnight.

• Permanent (low dose rate) brachytherapy

In this approach, pellets (seeds) of radioactive material (such as iodine-125 or palladium-103) are placed inside thin needles, which are inserted through the skin in the area between the scrotum and anus and into the prostate. The pellets are left in place as the needles are removed and give off low doses of radiation for weeks or months. Radiation from the seeds travels a very short distance, so the seeds can give off a large amount of radiation in a very small area. This limits the amount of damage to nearby healthy tissues.

Usually, around 100 seeds are placed, but this depends on the size of the prostate. Because the seeds are so small, they seldom cause discomfort, and are simply left in place after their radioactive material is used up.

You may also get external beam radiation along with brachytherapy, especially if there is a higher risk that your cancer has spread outside the prostate (for example, if you have a higher Gleason score).

• Temporary (high dose rate) brachytherapy

This technique is done less often. It uses higher doses of radiation that are left in place for a short time. Hollow needles are placed through the skin between the scrotum and anus and into the prostate. Soft nylon tubes (catheters) are placed in these needles. The needles are then removed but the catheters stay in place. Radioactive iridium-192 or cesium-137 is then placed in the catheters, usually for 5 to 15 minutes. Generally, about 3 brief treatments are given over 2 days, and the radioactive substance is removed each time. After the last treatment the catheters are removed. For about a week after treatment, you may have some pain or swelling in the area between your scrotum and rectum, and your urine may be reddish-brown.

These treatments are usually combined with external beam radiation given at a lower dose than if used by itself. The advantage of this approach is that most of the radiation is concentrated in the prostate itself, sparing nearby normal tissues.

Possible risks and side effects of brachytherapy

Radiation precautions: If you get permanent (low dose rate) brachytherapy, the seeds will give off small amounts of radiation for several weeks or months. Even though the radiation doesn’t travel far, your doctor may advise you to stay away from pregnant women and small children during this time. If you plan on traveling, you might want to get a doctor’s note regarding your treatment, as low levels of radiation can sometimes be picked up by detection systems at airports.

There’s also a small risk that some of the seeds might move (migrate). You may be asked to strain your urine for the first week or so to catch any seeds that might come out. You may be asked to take other precautions as well, such as wearing a condom during sex. Be sure to follow any instructions your doctor gives you. There have also been reports of the seeds moving through the bloodstream to other parts of the body, such as the lungs. As far as doctors can tell, this is uncommon and doesn’t seem to cause any ill effects.

These precautions aren’t needed after high dose rate brachytherapy, because the radiation doesn’t stay in the body after treatment.

Bowel problems: Brachytherapy can sometimes irritate the rectum and cause a condition called radiation proctitis. Bowel problems such as rectal pain, burning, and/or diarrhea (sometimes with bleeding) can occur, but serious long-term problems are uncommon.

Urinary problems: Severe urinary incontinence (trouble controlling urine) is not a common side effect. But some men have problems with frequent urination or other symptoms due to irritation of the urethra, the tube that drains urine from the bladder. This tends to be worse in the weeks after treatment and gets better over time. Rarely, the urethra may actually close off (known as a urethral stricture) and need to be opened with a catheter or surgery.

Erection problems: Some studies have found rates of erection problems to be lower after brachytherapy, but other studies have found that the rates were no lower than with external beam radiation or surgery. The younger you are and the better your sexual function before treatment, the more likely you will be to regain function after treatment.

Erection problems can often be helped by treatments such as those listed in the surgery section, including medicines.