it is the use of high-energy ionizing rays to destroy a

cancer cell's ability to grow and multiply.

goal
to deliver a precisely measured dose

of irradiation to a defined tumor

volume with minimal damage to
surrounding healthy tissue. This results in
eradication of tumor, high quality of life, prolongation of survival, and
allows for effective palliation or prevention of symptoms of cancer,
with minimal morbidity

General Considerations
Different irradiation doses are required

for tumor control, depending on tumor

type and the number of cells present.
Varying radiation doses can be delivered
to specific portions of the tumor
(periphery versus central portion) or to
the tumor bed in cases in which all gross
tumor has been surgically removed.
Treatment portals must adequately cover
all treatment volumes plus a margin.

Goals of Therapy
Curative: When there is a probability

of long-term survival after adequate

therapy; some adverse effects of therapy, although
undesirable, may be acceptable.

Palliative: When there is no hope of

survival for extended periods,

radiation can be used to palliate
symptoms, primarily pain. Lower doses of
irradiation (75% to 80% of curative dose) can control the
tumor and palliate symptoms without excessive toxicity

Principles of Therapy
Higher doses of irradiation produce

better tumor control.

For every increment of

irradiation dose, a certain fraction of cells will be killed.

A boost is the additional dose

administered through small portals

to residual disease; it is given to
obtain the same probability of
control as for subclinical aggregates

 Radiosensitivity is the degree and

speed of response. This measure of

susceptibility of cells to injury or
death by radiation depends on
cancer diagnosis and its inherent
biologic activity. It is directly related
to reproductive capability of the cell.

Role of oxygen
Oxygen must be present at the time

of radiation's maximal killing effect.

Poor circulation with resultant hypoxia can reduce cellular
radiosensitivity. Giving multiple, daily doses allows
reoxygenation and enhances radiosensitivity. The dose should
allow for repair of normal tissues.

 Cellular response can be modified by

changing the dose rate, manipulating

the process of cell repair, recruiting
cells into replication cycle, and using
hyperthermia (above 104 F [40
C]).

 Radioresistance is the lack of tumor

response to radiation because of

tumor characteristics (slow-growing
tumor, less responsive), tumor cell
proliferation, and circulation.
Radiation is most effective during the
mitotic stage of the cell cycle

Radioresistant tumors
: Many tumors are resistant to

radiation, such as squamous cell,

ovarian, soft tissue sarcoma, and
gliomas. Many other tumors can
become resistant after a period of
time. Normal radioresistant tissues
include mature bone, cartilage, liver,
thyroid, muscle, brain, and spinal
cord

Beam energy and

penetration
: The majority of therapeutic radiation is

administered using the cobalt 60 source or

high-energy photons from linear
accelerators. The radiation beam
decreases in intensity with increasing
depth. The penetration of the radiation
into the body is directly proportional to the
generating energy.
Linear energy transfer (LET) is the rate at
which energy is deposited per unit
distance. High-energy electrons are used
for tumors on or near the skin surface

Types of Radiation
Therapy
Two general types of radiation

techniques are used clinically:

brachytherapy and teletherapy

brachytherapy
, the radiation device is placed within

or close to the target tissue.

Radiation is delivered in a high dose
to a small tissue volume with less
radiation to adjacent normal tissue,
but requires direct tumor access.

Interstitial therapy
utilizes solid radioactive material

such as seed implants. These may be

temporary (removed after several
days) or permanent. The permanent
type remains in place with gradual
decay. Implant procedure is
performed under local or general
anesthesia. Used in breast and
prostate disease

Intracavitary therapy
utilizes radioactive material that is

inserted into a cavity such as the vagina,

as in cancer of the uterine cervix.
Surface radiation is used in choroid
cancer

 Other forms of brachytherapy are

systemic irradiation (parenteral or

I.V.), oral 131I for thyroid cancer, or
intraperitoneal radiation

Teletherapy
is external beam irradiation and uses

a device located at a distance from

the patient. It produces X-rays of
varying energies and is administered
by machines a distance from the
body 31 to 39 inches (80 to 100
cm).

 Teletherapy is given almost exclusively

with supervoltage equipment.

Most common use of radiation is local
therapy

Chemical and Thermal

Modifiers of Radiation
Radiosensitization is the use of

medications to enhance the

sensitivity of the tumor cells.
Radioprotectors increase therapeutic
ratio by promoting repair of normal
tissues.

 Hyperthermia is combined with

radiation. Uses a variety of sources

(ultrasound, microwaves) and produces
a greater effect than radiation alone. It
is usually applied locally or regionally
immediately after radiation.
Intraoperative radiation therapy
involves placement of a targeting cone
directly on the tumor site after surgical
exposure.

 Units for Measuring Radiation

Exposure or Absorption
Gray (Gy) a unit to measure
absorbed dose. One Gy equals 100
rads.
(Radterm used in the past to
measure absorbed dose.)
Joules/kg is also used to measure
absorbed dose; 1 joule/kg = Gy

Roentgen (R)standard unit of exposure

(usually applied to X-ray or gamma

rays).
Radiation dose equivalent (rem) - unit of
measure that relates to biologic effectiveness
(roentgen equivalent in human beings).

The recommendation for maximum

permissible dose (MPD) for radiation

workers is 5 rems for people over
age 18; the maximum dose for
women of reproductive capacity is
1.25 rems per quarter at an even
rate

 Clinical Considerations
Nature and Indications for Use
Used alone or in combination with

surgery or chemotherapy, depending

on the stage of disease and goal of
therapy

Adjuvant radiation
therapy
used when a high risk of local

recurrence or large primary tumor

exists.
Curative radiation therapy - used in
anatomically limited tumors (retina,
optic nerve, certain brain tumors,
skin, oral cavity). Course is usually
longer and the dose higher

 Palliative for treatment of

symptoms.
Provides excellent pain control for bone

metastasis.
Used to relieve obstruction.
Relief of neurologic dysfunction for brain
metastasis.
Given in short, intensive courses

 Radiosurgery (stereotactic) - usually

given in single dose fractions.

Indications for radiosurgery include the

presence of a radiographically distinct

lesion that has the potential to respond
to a single, large dose of radiation

 The largest use has been in the

treatment of arteriovenous
malformations (AVMs) and primary and
metastatic brain tumors.
A frame is attached to the patient's skull
and used to target the treatment beam

Treatment Planning
Evaluation of tumor extent (staging),

including diagnostic studies before

treatment.
Define the goal of therapy (cure or
palliation).

 Select appropriate treatment modalities

(irradiation alone or combined with

surgery, chemotherapy, or both).
All patients undergo simulation and
treatment planning.
Simulation is used to accurately identify

target volumes and sensitive structures. CT

simulation allows for accurate threedimensional (3-D) treatment planning of
target volume and anatomy of critical normal
structures

 Treatment aids (eg, shielding blocks,

molds, masks, immobilization devices,

compensators) are extremely important
in treatment planning and delivery of
optimal dose distribution. Repositioning
and immobilization devices are critical
for accurate treatment.
Lead blocks are made to shape the
beam and protect normal tissues.

 Skin markings are applied to define the

target and portal. These are generally

replaced later by permanent tattoos

 Usual schedule is Monday through

Friday.
Actual therapy lasts minutes. Most
time is spent on positioning

 Determine optimal dose of irradiation

and volume to be treated, according

to anatomic location, histologic type,
stage, potential regional nodal
involvement (and other tumor
characteristics), and normal
structures in the region.

 Complications
Complications depend on the site of

radiation therapy, type of radiation

therapy (brachytherapy or
teletherapy), total radiation dose, daily
fractionated doses, and overall health
of the patient. Adverse effects are
predictable, depending on the normal
organs and tissues involved in the field

 Acute Adverse Effects

Fatigue and malaise
Skin: may develop a reaction as soon

as 2 weeks into the course of

treatment (Skin erythema may range
from mild to severe with possible dryto-wet desquamation. Areas having
folds, such as the axilla, under the
breasts, groin and gluteal fold, are at
an increased risk because of increased
warmth and moisture.)

 GI effects: nausea and vomiting,

diarrhea, and esophagitis

Oral effects: changes in taste,
mucositis, dryness, and xerostomia
(dryness of mouth from lack of normal
secretions)
Pulmonary effects: dyspnea, productive
cough, and radiation pneumonitis
(Usually occurs 1 to 3 months after
radiation to the lung.)

 Renal and bladder effects: cystitis

and urethritis
Cardiovascular: damage to
vasculature of organs, thrombosis
(heart is relatively radioresistant)

 Recall reactions: acute skin and

mucosal reactions when concurrent

or past chemotherapy (doxorubicin
[Adriamycin], dactinomycin
[Actinomycin D])
Bone marrow suppression: more
common with pelvic or large bone
radiation

 Chronic Adverse Effects

After 6 months with variability in time of

expression:
Skin effects: fibrosis, telangiectasia,
permanent darkening of the skin, and
atrophy
GI effects: fibrosis, adhesions, obstruction,
ulceration, and strictures
Oral effects: permanent xerostomia,
permanent taste alterations, and dental
caries

 Pulmonary effects: fibrosis

Renal and bladder effects: radiation

nephritis, fibrosis
Second primary cancer: patients who
have received combined radiation
and chemotherapy with alkylating
agents have a rare risk of developing
acute leukemia

 Nursing Assessment
Assess skin and mucous membranes

for adverse effects of radiation.

Assess GI, respiratory, and renal
function for signs of adverse effects.
Assess patient's understanding of
treatment and emotional status

 Nursing Diagnoses
Risk for Impaired Skin Integrity

related to radiation effects

Ineffective Protection related to
brachytherapy

 Nursing Interventions
Maintaining Optimal Skin Care
Inform the patient that some skin reaction

can be expected, but that it varies from

patient to patient. Examples include dry
erythema, dry desquamation, wet
desquamation, epilation, and tanning.
Do not apply lotions, ointments, or
cosmetics to the site of radiation unless
prescribed

 Discourage vigorous rubbing, friction, or

scratching because this can destroy

skin cells. Apply ointments as instructed
by health professionals.
Avoid wearing tight-fitting clothing over
the treatment field; prevent irritation by
not using rough fabric such as wool and
corduroy.
Take precautions against exposing the
radiation field to sunlight and extremes
in temperature

 Do not apply adhesive or other tape

to the skin.
Avoid shaving the skin in the
treatment field.
Use lukewarm water only and mild
soap when bathing.

 Ensuring Protection from Radiation

To avoid exposure to radiation while

the patient is receiving therapy,

consider the following:
Timeexposure to radiation is directly

proportional to the time spent within a

specific distance to the source

 Distanceamount of radiation

reaching a given area decreases as

resistance increases.
Shieldsheet of absorbing material
placed between the radiation source and
the nurse decreases the amount of
radiation exposure.

 If exposed to penetrating radiation (X-ray or

gamma rays), wear film badges on the front

of the body.
Take appropriate measures associated with
sealed sources of radiation implanted within
a patient (sealed internal radiation).
Follow directives on precaution sheet that is

placed on the charts of all patients receiving

radiotherapy.
Do not remain within 3 feet (1 meter) of the
patient any longer than required to give essential
care

 Know that the casing material

absorbs all alpha radiation and most

beta radiation, but that a hazard
concerning gamma radiation may
exist.
Do not linger longer than necessary
in giving patient care, even though
all precautions are followed

 Be alert for implants that may have

become loosened (those inserted in

cavities that have access to the
exterior); for example, check the
emesis basin following mouth care
for a patient with an oral implant.
Notify the radiation therapist of any
implant that has moved out of
position.

 Use long-handled forceps or tongs

and hold at arm's length when

picking up any dislodged radium
needle, seeds, or tubes. Never pick
up a radioactive source with your
hands.
Do not discard dressings or linens
unless you are sure that no
radioactive source is present

 After the patient is discharged from the

hospital, it is a good policy for the

radiologist to check the room with a
radiograph or survey meter to be
certain that all radioactive materials
have been removed.
Continue radiation precautions when a
patient has a permanent implant, until
the radiologist declares precautions
unnecessary.

 Evaluation: Expected Outcomes

Skin without breakdown or signs of

infection
Radiation precautions maintained