SYMPTOMS IN HEMATOLOGICAL CANCERS ANEMIA

1. Anemia:

Anemia, which means reduction in the haemoglobin levels, is one of the common symptoms in blood cancer. Patients who are anemic become pale. They are more tired and may develop breathlessness even on doing day to day activities.

Anemia is due to number of causes and the most common cause in our country is iron deficiency anemia. It is very easy to confirm this type of anemia by simple blood tests and most of the time, there is no need for blood transfusion.

Another common type of anemia in our country is due to increased red blood cell destruction. This is called hemolytic anemia, and the treatment will depend on the cause of destruction. Here also many of them may not need blood transfusion.

Anemias due to other vitamin deficiencies such as B12 and folate are also easy to detect and a blood transfusion is not required.

Anemia due to blood cancer is rare in the population, however it is very important, as missing a diagnosis in the early stages, will end up in loss of bone marrow reserves and lead on to severe infections. Hence early identification becomes very crucial.

So, when someone has anemia, the basic test called complete blood count is mandatory. Also examination of the blood smear by an experienced person is also essential. These two simple tests if done properly, in addition to clinical evaluation of the patient will certainly help in ruling out blood cancers in all patients.

Key points to remember:

  • Iron deficiency is still the commonest cause of anemia, but it is not the only cause of anemia
  • Definite reason for anemia is very easy to find out in most of the patients by simple but dedicated examination.
  • Unnecessary blood transfusions can be avoided if we know the cause with certainty
  • If anemia is due to blood cancer, no time should be lost for proper treatment

Contents (please ignore page numbers)

Introduction

What is radiotherapy?

How does radiotherapy work?

What are the benefits of radiotherapy?

What are the risks of radiotherapy?

Who will plan and give my radiotherapy treatment?

How is radiotherapy given?

External radiotherapy

Internal radiotherapy

What is treatment planning?

What is a shell?

What happens when I go for planning?

How is the radiotherapy machine chosen?

How many treatments will I have?

When do I attend for treatment?

What happens when I come for treatment?

How will I feel during treatment?

Are there any side effects?

Late side effects

What happens after radiotherapy is finished?

Questions you may wish to ask

About my treatment

How treatment might affect my life style

Glossary

Sources of information and support

Notes/Questions

Where can I get help?

Titles available in the Patient Information Series


Introduction

The information in this booklet has been written to help you understand more about radiotherapy treatment. It contains general information about radiotherapy and what you can expect during treatment. The booklet also answers some of the most common questions people ask.

Your doctor will explain why radiotherapy is recommended for you and what your treatment will involve. If you have other questions or want more information, please ask. It can often be difficult to know what questions you might want to ask or to remember them. We have included a list of suggested questions that many people have asked.

What is radiotherapy?

Radiotherapy uses carefully measured doses of radiation to treat cancer. The type of radiotherapy most people have uses beams of high-energy rays, usually x-rays. The radiotherapy machine aims specific amounts of the radiation only to the area of the body that it is pointed at and nowhere else.

How does radiotherapy work?

A high dose of radiation damages cells and stops them from

growing and dividing. Cancer cells, which are abnormal cells, do not recover. Normal cells that are affected usually recover or repair themselves quite quickly. Any side effects, which occur during treatment, are usually temporary.

Radiotherapy

What are the benefits of radiotherapy?

The purpose of radiotherapy is to destroy the cancer cells while

causing as little damage as possible to normal cells. It can be used to treat many kinds of cancer in almost any part of the body.

Curative treatment, which is sometimes called radical treatment, aims to give long-term benefits to people. Sometimes radiotherapy is given on its own or it may be given alongside other treatment. Radiotherapy may be given before surgery to shrink a tumour or after surgery to stop the growth of cancer cells that may remain. It can also be given before, during, or after chemotherapy (anti-cancer drugs) to improve treatment results.

Palliative treatment aims to shrink tumours and reduce pain or relieve other cancer symptoms. While a cure is not likely palliative radiotherapy may also prolong life.

What are the risks of radiotherapy?

Radiotherapy can damage or destroy normal cells as well as destroying cancer cells and cause treatment side effects. Most side effects are temporary and these are discussed on pages 17–19.

Your doctor will not advise you to have any treatment unless the benefits – control of disease and relief from symptoms – are greater than the known risks.

Any side effects, which occur during treatment, are usually temporary.There may be a small risk of long term, or late,

permanent effects from radiotherapy. However, side effects are rarely severe. Your doctor will tell you about your treatment, how it may affect you and any possible late effects. You may be given additional written information. If you have any questions or concerns, please ask. A list of suggested questions that you may want to ask your doctor can be found on pages 20–21.

Radiotherapy


You should not become pregnant before or during radiotherapy because radiotherapy may injure the foetus, especially in the first three months of a pregnancy. Please discuss with your doctor if you think you may be pregnant. Your doctor will also be able to advise you on how long you should wait before becoming pregnant.

Some doctors advise men against fathering a child during radiotherapy and for a few months afterwards. Again, your doctor will be able to discuss this with you.

Who will plan and giv e my

radiotherapy treatment?

Radiotherapy is given in specialist treatment centres. The specialist doctor who is in overall charge of your radiotherapy is called a consultant clinical oncologist or radiotherapist. Most clinical oncologists also prescribe chemotherapy. They supervise a team of doctors including specialist registrars and senior house officers.

The consent form

The doctor will ask you to sign a consent form, which is a written record that you have agreed to the planned radiotherapy. Before you can give your consent, your doctor will discuss with you what the radiotherapy is likely to involve, the benefits and risks, and any available alternative treatments. You may also be given some written information to back up what you’ve been told. It is important that

you understand the information you have been given – ask questions

if you don’t understand or if you want more information. To help

you think about what you want to ask your doctor, you may find the questions on pages 20–21 helpful. Your doctor will write the main benefits and risks associated with the radiotherapy on the consent form before you sign it. You will then be given a copy of this.

Therapy radiographers work in radiotherapy departments and are the main people you will come into contact with when you have


radiotherapy treatment. They work closely with the clinical

oncologist and help plan and give your treatment. They will be able to answer many of your questions. Radiographers are also able to

advise on possible side effects and what you should or shouldn’t do during treatment.

You may also meet nurses in the radiotherapy department, who can advise you on care during your treatment.

How is radiotherapy given?

Radiation therapy can be given in one of two ways: external or internal.

External radiotherapy

External radiotherapy is the most common type of radiotherapy used. It is usually given as a course of several treatments over days or weeks while internal treatment may only happen once or a small number of times.

External radiotherapy is usually given during outpatient visits to a hospital cancer centre. A machine directs the high-energy rays, usually x-rays, at the cancer site and a small area of normal tissue

surrounding it. You will be positioned carefully on a treatment couch and then the machine will be directed exactly at the area to be

treated, often from different angles. Treatment takes several minutes and is painless. Before you start your course of radiotherapy you will usually need to attend the hospital for treatment planning. External radiotherapy doesn’t make you radioactive and you can safely mix with other people, including children, at anytime.

Internal radiotherapy

Internal radiotherapy can be given in several ways either as an outpatient or inpatient. Brachytherapy is treatment, in which solid radioactive sources are placed inside a body cavity or needles are


placed in the tumour. This usually involves staying in hospital for a few days until the radioactive source has been removed.

Another type of internal radiotherapy involves using a liquid source of radiation and is called radionuclide (or radioisotope or unsealed

source therapy). It can either be taken by mouth or given as an injection into a vein. For this type of treatment, you will need to stay

in hospital for a few days until most of the radioactivity has disappeared from your body. If you are going to have internal radiotherapy, your doctor will discuss this with you and give you further information.

Occasionally, with radioactive treatment or with treatment with radioactive ‘seeds’, you will be made radioactive for a few days. You may then have some temporary restrictions on your social life. This

will be carefully explained to you.

The rest of this booklet is about external radiotherapy only.

What is treatment planning?

When you have radiotherapy, your treatment needs to be planned carefully. This is to make sure that the treatment area or treatment field includes all of the cancer and avoids healthy tissues.

Planning usually takes place in a simulator or CT scanner, which are special x-ray machines. This provides an exact “mock-up” of treatment positions. Radiographers operate the equipment and run the planning suite. They will explain what will happen during planning and carry out any preparation you may need. The radiographers and physicists (who are specialists in the subject of radiation) calculate the dose of radiation you will be given. This is usually carried out with the help of computers.

The doctors will use your previous x-rays or scans to help them plan your treatment. Any extra preparation or procedures will be

explained to you.

Radiotherapy


How soon the planning stage of your treatment will begin depends on the reason for your radiotherapy. Your first appointment may be

a few days or weeks after you first saw the clinical oncologist. When radiotherapy is part of a combined treatment plan (with surgery or chemotherapy), you may be given dates for your radiotherapy some time ahead.

You may be given more than one appointment for treatment planning. These sessions may last for between 30 minutes and an hour or more. Ask your doctor or radiographer how long each session will be.

If you are to have radiotherapy to your head or neck you may have an extra step in your planning process – the making of a mould and shell.

What is a shell?

It is important to keep the part of the body being treated, as still as possible during treatment. The head is one of the most difficult parts of the body to keep still, even for a short time, so a support is made for you to wear at each treatment session. This support is called a shell. It is made of Perspex or opaque plastic and keeps you from moving during treatment. Any marks to guide the radiographers can then be drawn on the shell, not on your skin.

You will be given an appointment to attend the mould room. The technicians or radiographers will explain what they are going to do and what you need to do to help them. You will be positioned on a couch. A quick-setting cream will be applied to all or part of your head or neck depending on which area is to be treated. Then a plaster of Paris bandage will be laid over the top of this to make a mould. Your mouth and nose won’t be covered and you will be able to breathe normally. A plastic shell will be made from this mould. A well-fitting shell is difficult to make if you have a beard or moustache, so you may be asked to shave any facial hair before your appointment at the mould room.


What happens when Igo for planning?

When you arrive for planning, the radiographers will explain to you what will happen. Please ask if you don’t understand anything.

You will usually be asked to undress depending on which part of

your body is to be treated. Gowns will be provided and every effort will be made to maintain your dignity and privacy.

You will be positioned on the simulator couch and asked to lie very still. The position will be the same as the one you will lie in for your treatment. If you have recently had surgery, for example to the

breast, it is not always easy to get into the position. You may find it helpful to practise getting into this position before your treatment starts. The simulator will move around and you may hear all sorts of unfamiliar sounds. The lights in the room will be switched off and

on during planning.

The treatment areas will be defined and marked out on your body using one or more small tattoos about the size of a pinhead of coloured, permanent ink. These provide a reference point during radiotherapy. You will be asked to consent to the use of tattoos. As these tattoos are made with dark ink, they may not show so easily

on black skin. If this is a concern for you, ask your radiographer if

there are any alternative options. Sometimes an indelible pen may be used to mark out the field, although this option is not always

available. If this happens, you will be asked not to remove these marks until the end of treatment. Depending on which part of your body is going to be treated, it can be helpful to think about the clothing you wear to this appointment. You may wish to make sure that you wear clothes that cover up any marks.

If you are to have treatment to your head or neck, any marks will be made on your shell (see page 12).

Sometimes changes will be made to the treatment plan, for example the size of the treatment field may be reduced. You may have to

return to the simulator for these changes or they may be made on the treatment machine. A change in the plan is quite usual and doesn’t mean that anything has gone wrong.


It’s natural for you to compare your treatment with other people who have the same condition but remember - your radiotherapy is planned individually for you. Each person’s plan will be different including which radiotherapy machine is used and how many treatments you receive.

How is the radiotherapy machine chosen?

There are several different machines used for giving radiotherapy and they each work in slightly different ways. The machine used will depend on many things, such as which part of your body is to be treated and why treatment is being given.


How many treatments will I have?

You may have a single treatment or a course of treatments, called

fractions, over several weeks. This will depend on why radiotherapy

is recommended for you. Lower doses are given for palliative treatment than for curative treatment and usually over a shorter period of time.

If you want more information about this or your treatment machine, ask your doctor or radiographer.

When do I attend for treatment?

Most patients attend the hospital for treatment daily, Monday to

Friday. However sometimes radiotherapy is given only once or twice a week. Treatment may also be given more than once a day. A course of radiotherapy may last for about six weeks. Ask your doctor or radiographer how long your course of treatment will be.

Most people receive radiotherapy as outpatients, travelling to the department each day. You might like to ask a friend or relative to come with you. The staff will explain where you have to go and will try to arrange an appointment time that suits you. You will usually

be able to book all your appointments at the same time, to allow you to plan ahead. If you are staying in hospital, the radiographers will arrange your treatment times with the ward staff.

It is important that you don’t miss any appointments, particularly if you are having treatment to the head and neck. This is because the radiotherapy doesn’t work as well. If you can’t attend for any reason, please let the radiographers know in advance, if possible.


What happens when I come for treatment?

The radiographers, who carry out your treatment, will explain things to you. If there is anything you don’t understand or you have questions, ask them.

You may be asked to change into a gown before treatment, and then the radiographers will position you on the couch. Using the tattoos or marks which were put on your skin during treatment planning, they will line up the radiotherapy machine. It won’t usually touch you. The preparation may take some time, often longer than

the treatment itself. It will probably take even longer on the first day. When the radiographers are satisfied that you and the treatment machine are both in the correct position, they will leave the room and switch on the radiation beam. You won’t feel anything during the treatment.

The radiographers will watch you using closed-circuit television or through a window. You can speak to them, or vice versa, by an intercom. You should keep very still during the few minutes it takes to give your treatment but you can breathe and swallow normally. The machine may move around you during treatment or the radiographers may come in to change your position or that of the machine. Again, they will explain each step to you.

The radiographers will give you special instructions, for example about care of your treatment area. You must follow these carefully.

How will I feel during treatment?

As your course of treatment progresses, you may find you become more tired than usual. You may need to reduce the hours that you work or cut back on social or sports activities. Make sure you get enough rest and accept offers of help with everyday tasks or jobs around the home. You may also have ‘up’ days and ‘down’ days, which is quite usual. If you are worried about anything, or would just like to talk, your hospital doctor, radiographer or nurse will be happy to listen or advise.

The radiographers will check your progress regularly during your treatment and you may see the doctor or nurse from time to time. If you have questions at any time, do ask.

There are many people in the hospital that may be able to help and support you. Some hospitals have cancer information and support centres. If you would like to find out what services are available or how to contact a particular person, please ask.

Are there any side effects?

Everyone reacts to radiotherapy differently and many people have hardly any side effects. But because radiotherapy affects normal tissues within the treatment field, the side effects will vary depending on which part of your body is being treated and the number of treatments you have.

You will be given additional information about the side effects

relevant to your treatment. Most side effects are temporary and they are rarely severe. They start at varying times during treatment and disappear in the weeks after the end of it.

Your doctor will discuss any possible temporary or permanent side effects with you before the start of your treatment and before you sign your consent form. Extra written information may be available.

Some side-effects may not start until treatment has finished. Tiredness is quite common, particularly towards the end of treatment and this may last for sometime afterwards. Tell your radiographer or doctor if tiredness is a problem. They may be able to offer advice on ways to save your energy and cope with everyday activities. During your course of radiotherapy you may have regular blood tests to check the effects on your general health. If the radiotherapy causes anaemia, it may be necessary for you to have a blood transfusion.

Very few people feel sick during radiotherapy – it depends on which part of the body is being treated. Some people feel sick at the beginning of a course of treatment but find that nausea often disappears within a day or two. Others start to feel sick later on. Do tell the radiographers or your doctor if you suffer from nausea. You can be given drugs to control it and it’s very unlikely that your radiotherapy will need to be suspended. Another booklet in this series, Coping with nausea and vomiting, may be helpful if you do feel sick.

Try to eat well during your treatment and also drink about two litres of fluid (three to four pints) each day. This may not be easy if you are nauseated, tired or spend a lot of time travelling to and from the hospital. The dietitian can help you to plan your meals and can offer lots of hints about what to eat. Any of the team caring for you can contact the dietitian if you would like advice. Another booklet in this series, Eating well when you have cancer, may also be helpful.

Radiotherapy can cause hair loss, but only in the area being treated. Most hair loss is temporary and it starts to grow back within two to three months of finishing treatment.

There is currently no general agreement based on research on caring for skin during radiotherapy. Advice on skin care varies from one hospital to another. The staff at your radiotherapy department will give you advice about how to care for your skin in the treatment area at the beginning of your course of radiotherapy. During treatment the skin may become red and sore and it’s important not to irritate it. Avoid shaving within the treatment area. You may wash the area gently using a mild unperfumed soap, such as baby soap, and pat it dry. Don’t use any deodorants, perfumes or lotions on your skin other than those recommended by the team caring for you. You should protect your skin from extremes of temperature and continue using sunscreen (factor 15 or above) after your treatment has finished. There has been little research into the effects of radiotherapy on different ethnic skin types. However, anecdotal evidence suggests that people with darker skin (for example, Asian or Afro-Caribbean) may develop greater skin reactions during treatment than people with lighter skin.

If you have any discomfort, the radiographers or nurses will advise you on skin care. The doctor may prescribe, or suggest, a cream or lotion for you to use. Swimming may not be advisable if you develop a skin reaction, as the chlorine in the water can cause this. If you do swim during treatment, make sure you rinse the skin well and apply aqueous cream. Discuss this with your doctor, radiographer or nurse.

You may find it more comfortable to wear loose, casual clothing made from natural fibres. If you have ink marks on your skin, you may find they smudge onto your clothes. Stains can be removed from your clothes using a biological washing powder. However, you may wish to wear older or less special clothes during your treatment.

Occasionally people who have radiotherapy to areas over joints or muscles may experience some stiffness. This can occur at any time up to two years after treatment has finished. Regular exercise to these joints and muscles can prevent stiffness. Your doctor may refer you to a physiotherapist. If not, please ask for advice.

Late side effects

Any side effects which may develop in the longer term and which may be permanent depend on the part of your body, which has been treated, the dose of radiotherapy you have received and many other things, such as why you are having radiotherapy. Your doctor will be able to explain these side effects and also the likelihood of them occurring. Do ask your doctor if you have any concerns.


What happens after radiotherapy is finished?

When treatment finishes, many people look forward to life returning to normal. It can seem confusing then, if you find yourself feeling a bit low. This is normal. You will have become used to a new routine of hospital visits during radiotherapy treatment. Ending treatment will also bring about changes that you will need to adjust to. Most side effects only last a few days or weeks but some of the effects of radiotherapy, such as tiredness, may last for a couple of months after the end of your treatment. However, you should gradually start to feel like yourself again, although you must still make sure you get enough rest and eat well. You may find it helpful to read After Treatment, another booklet in this series

You will be given a clinic appointment so that the doctor can check your progress. These appointments will probably become less frequent as time passes. If you are worried about anything at all, you should phone for an earlier appointment.

Your family doctor will be sent a complete report about your treatment.

Q uestions you may wish To ask

It is important that you understand what will happen and why. Many people say they either don’t know what questions to ask or they just can’t remember them. To help you think about what you want to ask your doctor, you may find the following questions helpful.


A bout my tr eatment

  • What are the benefits of the treatment you are advising me to have?
  • What are the risks, if any, of this treatment?
  • What are the success rates for this treatment?
  • What are the risks if I decide to do nothing for the time being?
  • Are there any other treatments I could have?
  • If there is a delay in starting treatment, how will this affect my outcome?
  • What will the treatment be like and how long will it take?
  • Will there be side effects and what can I do about them?
  • How can I expect to feel after the treatment?
  • How will my doctor know if my treatment has worked?
  • Who should I contact if I have questions or concerns, during my treatment or once my treatment has finished?
  • Will I be able to have reconstructive surgery after my radiotherapy (if appropriate)?

How treatment might affect my life

  • Will I still be able to drive?
  • Will it affect my regular activities for example, work?
  • Will it affect my personal/sexual relationships?
  • Will I be able to take part in my favourite sport/exercises?
  • Will I be able to follow my usual diet?
  • Will I need to take any special precautions like staying out of the sun?
  • Will I be able to wash/shower as normal?
  • Glossary

    These are some of the terms you may come across during your radiotherapy treatment.

    Term Definition

    Brachytherapy Treatment, which places solid radioactive material inside a body cavity or needles in the tumour.

    Clinical oncologist A cancer specialist, part of whose responsibility is to treat cancer with radiotherapy.

    CT scan (planning) Uses x-rays and a computer to view organs and areas inside the body for planning radiotherapy treatment Curative treatment Aims to completely get rid of the cancer and give long-term benefits.

    External radiotherapy External radiotherapy is given by a machine, which directs high-energy rays, usually x-rays, to the cancer and a small area of normal tissue surrounding it.

    Fraction Each single days radiotherapy treatment. Internal radiotherapy Treatment using either solid, radioactive material close to or inside the tumour (brachytherapy), or a radioactive liquid, given either by mouth or as an injection into a vein (radionuclide treatment).

    Linac Short for linear accelerator, a type of radiotherapy machine.

    Shell A moulded Perspex or opaque plastic shell to keep you from moving during treatment.

    Palliative treatment Palliative treatment aims to shrink tumours and reduce pain or relieve other cancer symptoms. While a cure is not likely palliative radiotherapy may also prolong life.

    Radionuclide A radioactive liquid / capsules, administered for internal radiotherapy. Sometimes referred to as radioisotope or unsealed source therapy.

    Radiotherapy Treatment using carefully measured doses of radiation.

    Radical treatment Radical treatment aims to cure some patients and gives long-term benefits.

    Simulator A special X-ray machine used for planning / simulating radiotherapy treatment.

    Tattoo Small marks about the size of a pinhead of coloured, permanent ink. These are used to show where the radiation beam is to be directed at each treatment.

    Therapy radiographers Professionally qualified staff who deliver the radiotherapy treatment and are the main people you will come into contact with when you’re having your treatment. Treatment field The area of the body that will be treated. Treatment plan The dose of radiation and number of treatments that make up a course of

    Further reading

    Supportive Care in Radiotherapy (2003)

    Sara Faithful & Mary Wells. Churchill Livingstone. ISBN: 0443064865

    This book is aimed primarily at nurses and therapy radiographers providing clinical and supportive care to patients before, during and after radiotherapy. It includes practical advice on the assessment and clinical management of acute and late side effects, supported by current evidence.

 
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