One of the most devasting diagnoses that a patient ever receives is the news that he or she is suffering from cancer. Cancer is the terrifying beast of nightmares to every patient. And once the initial diagnosis is made, the news that the treatment of choice for this disease is Radiation Therapy and/or Radiation Therapy conjoined with chemotherapy can conjure up even more terrifying images for the patient. Every patient has heard the scary stories from a friend or a relative of "burnt" skin, baldness, nausea and diarrhea. To some patients, the cure sounds worse than the disease.

It is necessary to dispel some of the myths that surround Radiation Therapy and to deal with the reality in a rational informed manner. In the following paragraphs we will follow a patient through a hypothetical scenario in order to allay some of those fears and hopefully, give a more accurate picture to those patients who are contemplating their choices in the battle against cancer. I have been a Radiation Therapist for over 15 years, both as a Staff Therapist and as a Clinical Instructor and I will try to gie you a clearer picture of everything that will go into giving you the best treatment possible.

Day One

Mr. Jones has been given his diagnosis of prostate cancer by his urologist and has been given a referral for an initial evauluation by a Radiation Oncologist. After being given information about several means of treating his cancer -- surgery, radioactive implants and radiation therapy, or radiation therapy alone -- he has decided to go through an extended course of radiation therapy alone. At his appointment, he is examined by the Radiation Oncologist, which is the term given the physician whose field of practice is in Radiation Therapy. All aspects of the use of radiaiton therapy in his treatment are discussed with Mr. Jones. He also meets the Radiation Oncology nurse who can answer questions about his overall care during his treatments and can usually spend more time with the patient in order to triage or determine what services in the department the patient needs.

Mr. Jones is given an appointment to come in for simulation. Simulation is the first step in his treatment and is the method by which all parameters are set up and used for each and every one of his treatments. Many patients think that the simulation is an actual treatment and may count this in when they are keeping track of their treatment days, but it isn't. All that is done on this day is the taking of films and measurements and the marking of the patient's body either by tattoos or in a special ink so that on the first day of treatment, the correct area that the Radiation Oncologist determines for Mr. Jones' treatment is treated.

The date for simulation may be the same day as the initial consultation, the next day or depending on scheduling, may not be for several days. If the situation warrants an immediate simulation and treatment, the physician will expedite the simulation date. In the meantime, the Radiation Oncologist may order additional tests to be done, such as CT Scan or an MRI, in order to get as much information gathered on the extent of Mr. Jones' cancer. The Radiation Oncologist may also order blood tests to have a base line to which to compare future blood tests. Commonly, blood tests called CBC's or complete blood counts, are ordered during the treatment period in case of infection or a reduction in white blood cells or platelets which are necessary to prevent bleeding. Sometimes, depending on whether the area being treated encompasses marrow producing areas of the body, such as the sternum or breast bone or parts of the pelvis, radiation may affect blood cell and platelet production, especially if chemotherapy is being given. In most cases, blood counts are simply a precaution and seldom a cause for worry.

The Simulation

On the day of the simulation, Mr. Jones is met by a Radiation Therapist who will be doing the simulation with the Radiation Oncologist. The Radiation Therapist is specially trained and liscensed to operate radiation equipment and to have a full understanding of the treatment of cancer.He or she works as a close partner with the physician and is the person that Mr. Jones will see on a daily basis. The Radiation Therapist who is working on the Simulator that day will explain carefully what is going to take place as the simulation is being done. The Radiation Therapist will also make sure that an informed consent is signed by the patient, Mr. Jones, if it was not done on the day of the initial consultation. This is to ensure that Mr. Jones is aware of any potential side effects from the treatment and gives his permission to continue with the radiation therapy.

During the simulation, Mr. Jones will be placed on a treatment bed or table in the exact position in which he will be treated on the actual treatment machine. Though the simulator looks like a treatment machine, it is basically an x-ray machine that has the ability to replicate what the treatment machine will do. For instance, this may include different machine angles, so Mr. Jones will see the head of the machine rotate to different angles around his body. Most commonly, the patient either lies on his back or sometimes, on his stomach.The position of the patient is dependent upon the physician's choice.

Built into the simulator is a device called a fluoroscope. This gives the Radiation Oncologist the ability to actually see in real time the physical structure of the patient's body. Sometimes in order to better visualize some organs of the body, a contrast agent will either be injected into a catheter, which is inserted into the body, or swallowed. This contrast agent has a special quality that allows it to be seen clearly on an x-ray and helps to define what is called soft tissue. Soft tissue can be your esophagus, or your bladdr or your stomach, as opposed to boney structures like your pelvis or your ribcage. The Radiation Oncologist will set up the area that he wants treated and then the Radiation Therapist will take an x-ray of the area as a record and to be used for treatment planning. The physcian may also mark off areas that do not need to be included and will be shielded by custom made lead blocks to protect the tissues underneath them from the treatment x-rays.

After the films have been taken and approved by the Radiation Oncologist, the Radiation Therapist will either apply tattoos which are permanent marks as small as the period on the end of this sentence and can be found by the Therapist on the treatment machine, or will use a special ink or pen to draw what look like target marks on Mr. Jones' body. It is important that Mr. Jones not scrub these marks off as these will be used on a daily basis for his treatment. Measurements will be taken so that the dosimetrist and the physic's department will be able to plan a specific treament just for Mr. Jones' body. The simulation actually prepares everything for Mr. Jones' treatment in advance so that on the first day of the treatment, everything is ready and in place and as accurate as possible.

Mr. Jones is given his appointment time by the Radiation Therapist.The Therapist tries as hard as possible to cooperate with Mr. Jones and make the appointment as convenient as possible for Mr. Jones and his family. This is especially important as Mr.Jones will be coming for treatment every day, Monday through Friday, with Saturday and Sunday off, for approximately 6 to 7 weeks of treatment.

The Radiation Therapist at the simulation will try to answer as many non-medical questions about the treatment for Mr. Jones as possible, but for many patients it is difficult to absorb much of the information at this time.Suffice it to say that the Radiation Therapist and the nurse are there for Mr. Jones on a daily basis to re-inforce any information that Mr. Jones may need. If it is determined that Mr. Jones should be seen by the Radiation Oncologist, the nurse will see to it. The nurse is also a source of information regarding medications and patient care. Most departments have a standard schedule for the the physicians to see the patient at least once a week for a routine visit to check how the patient is tolerating his treatment and whether or not Mr. Jones is having any problems that need attending to with medication.

The First Day of Treatment

On the first day of treatment there are many things that need to be considered. Mr. Jones enters the reception area and notifies the desk that he is here for his first treatment. If the department where Mr. Jones is being treated has more than one treatment machine, he may wonder why others are being taken ahead of him. The staff is aware that he is here and are preparing for his first treatment. The blocks are made and verified for their accuracy. The treatment has been planned out by the Dosimetrist and Physic's staff. Each patient is seen as an individual and the measurements that were taken at the simulation are entered into special computers that draw up a plan specifically for Mr. Jones and his body. All the calculations have been entered into the treatment machine. Everything is ready for Mr. Jones.

While Mr. Jones is waiting in the waiting room, he may hear other patients talking about their treatments. Some of the discussions may make him nervous, especially since some patients may appear to be quite ill. What Mr. Jones needs to understand is that different patients may be having different parts of their bodies treated. They may be getting chemotherapy, and of course, may be much more ill than he is. He may see people that have lost the hair on their heads and may wonder if that will happen to him. If Mr. Jones has a concern about any part of his treatment, the best people to ask are the therapists, the nurse, and of course, the Radiation Oncologist. They will know the specifics of his illness, and can help to alleviate his anxiety. However, on many occasions patients have found support from being surrounded by others who are going through similar experiences. Since Mr. Jones is not having his head treated, or chemotherapy, he will not loose the hair on his head!

After Mr. Jones' name is called, he is escorted to the treatment room by the Radiation Therapist, who may or may not be the same therapist that simulated him. As he is being walked back to the treatment area, Mr. Jones will have some of the steps of his first day of treatment explained to him. Usually, on the first day, verification films are taken of each field that is being treated. These are shown to the Radiation Oncologist before the treatment is given, so that his OK to continue can be given. Films are generally taken at least once a week to assure the accuracy of treatment and to check that nothing has changed in the treatment area. This is done so that adjustments to the therapy can be made. Other adjustments may be made during the course of treatment by the Radiation Oncologist, again to ensure that the treatment is as accurate as possible. Mr. Jones should be assured that these adjustments are usually in increments of 1-2 millimeters, a very tiny move.

After the films are taken and approved, the first treatment is given. The Radiation Therapist will place Mr. Jones' body to match the marks that were put in during simulation. These lasers are like the cross hairs of a sighting scope. The word that is used is "triangulation" or the use of three points, one on the anterior part of the body, (the pelvis, in Mr. Jones' case) and one on each side of Mr. Jones' pelvis. Again, everything is done for accuracy. Once these points are lined up and the blocks put in a tray above Mr. Jones, the Therapist will tell Mr. JOnes that he or she is leaving the room. The Radiation Therapist will assure Mr. Jones that he is being observed by television monitors and can be heard over an intercom system at all times during his treatment. The usual time span for each treatment field or port is approximately 30 seconds with the new higher energy machines, the Linear Accelerators, that are being used in Radiation Oncology.

Mr. Jones will not feel anything. He may hear the click and hum of the machine coming on and then the Radiation Therapist is in the room again to set up the next part of the treatment. Mr. Jones may actually wonder if anything happened at all, but he should be assured that this is a normal feeling. When his treatment for the day is finished, Mr. Jones will be helped off the treatment table and his appointment for the next day is verified with him. This will be the normal routine for most of the course of treatment.

The Radiation Therapist will tell Mr. Jones that if he has any questions, no matter how trivial they may seem, he should not be shy about asking them. If the Radiation Therapist cannot answer Mr. Jones, there is usually a support staff of nurses, social workers, and nutritionists available for him. And of course, for anything medically related to Mr. Jones, there is his Radiation Oncologist.

What is a Cone-down and why do I need another simulation?

In many cases it is not necessary to treat the entire field throughout the entire course of treatment. The initial treatment field usually encompasses the tumor or tumor bed if there has been surgical removal before radiation therapy plus an adequate margin that may include any lymphatics that serve the area around the tumor, in order to prevent any stray cancer cells from moving from the tumor into other areas of the patient and metastisizing. Cancer metastisizes or spreads by direct growth into surrounding tissues or by utilizing the network of vessals making up the lymphatic system or veins and capillaries of the blood system. By treating a slightly larger area than the tumor, the Radiation Oncologist hopes to prevent any further local spread or distant spread of the cancer. In most cases it is not necessary to give as high a dose to the surrounding tissues as it is to the actual tumor. Therefore, at some point in Mr. Jones' treatment he may be required to have a second simulation to plan his "cone-down" or "boost" to the actual tumor.

The cone-down is simply a term for a smaller treatment area and is usually given at the end of the treatment for a limited number of times. This does not necessarily mean that something has changed in the initial diagnosis. This is standard operating proceedure for most treatment plans.

The Last Day

Eventually, Mr. Jones' treatments come to an end. There is a dose that is considered adequate for the treatment of Mr. Jones' cancer which has been arrived at through much research and experience with prostate cancer and beyond which may lie the developement of side effects. During his treatment, Mr. Jones developed some diarrhea which was controlled with medication given to him by either the nurse or the Radiation Oncologist and by following a diet plan given to him by either the Radiation Therapist or a nutritionist that helped him learn which foods may make the diarrhea worse and how to avoid them. He also had a problem at one point with urination and again was given medication to help him and given pointers about various things to help. During his treatment he was cautioned about skin care to his pelvis and anal area and was able to avoid too many problems due to irritated skin. All in all the seven weeks of treatment went smoothly and reasonably comfortably primarily due to the support of the staff in the Radiation Oncology department. Mr. Jones felt that he was treated with respect and that his questions were answered to his satisfaction. He actually felt like he was leaving his best friends and would really miss coming in to see the staff.

Mr. Jones, after seeing the Radiation Oncologist for his final visit, is then given a follow up appointment for a month after his treatment ends. A month's break is given in order for the tissues to heal from any irritation from the radiation. Once the irritation dies down, the Radiation Oncologist is better able to evaluate the results of his treatment. Follow up appointments are then arranged with Mr. Jones for 3 months, 6 months and then finally one year. Of course, if any problems arise related to the Radiation Therapy, Mr. Jones is advised to come in to be seen. Mr. Jones is also followed by his urologist. Other patients would be followed up by their private physicians and if further treatments are needed, they would then be referred to the Radiation Oncologist.

I hope that this will give the cancer patient a better idea of what to expect from Radiation Therapy. Though Mr. Jones is a fictional patient, much of the above information is common ground for the treatment of cancer by Radiation Therapy. Each patient, of course, will be slightly different and their treatments will vary accordingly. Radiation Therapy is a highly beneficial method of treatment for many types of cancer and the success rate is getting higher and higher every year with the advent of new medications and treatment protocols. Remember, the staff of the Radiation Oncology department is working as a team to ensure that you, the patient, is getting the best and most accurate treatment that can be given.