Radiation 101

Thursday, May 17 • 9:45–11 am

Note one action you’ll take after attending this session: ______

Cynthia Briola, RN, OCN, CBCN Key Session Takeaways Staff Nurse 1. Knowing basic principles of radiation contributes toward under- University of Pennsylvania Health System standing of how radiation controls or eradicates cancer. [email protected] 2. The goal of radiation therapy is to achieve maximum tumor death while minimizing damage to normal surrounding tissues, there- fore reducing patients’ side effects and enhancing their quality of life. 3. Radiation oncology is and will remain an instrumental treatment modality in personalized oncology care.

Oncology Nursing Society 43nd Annual Congress Radiation May 17–20, 2018 • Washington, DC 1 ONS 43rd Annual Congress

Radiation: 101 Cynthia J. Briola RN OCN CBCN Radiation Staff Nurse Penn Medicine

Disclosures • Penn Medicine Department of Radiation Oncology Staff Nurse

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Definition of Radiation- noun 1. Physics. a. the process in which energy is emitted as particles or waves, b. the complete process in which energy is emitted by one body, transmitted through an intervening medium or space, and absorbed by another body. c. the energy transferred by these processes. 2. the act or process of radiating. 3. something that is radiated.

http://www.dictionary.com/browse/radiation

What are we talking about? • By definition radiation covers a lot of things, therefore we need to narrow it down • Myths and misconceptions • Media and Social Platforms • Challenge- balance between technology & healthcare • Looking at the past helps us to see the future

Radiation Oncology • Scientific Discipline – Education of personnel – Research & other academic pursuits

• Clinical Discipline – Patient treatment – Patient / family care & support

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Radiation History Through 100+ years

Late 1800 - Roentgen: x-ray 1940-1950 - Becquerel: Uranium - RT delivered by diagnostic -Curies (Marie/Pierre): radium & polonium radiologist - Colbolt & Betatron therapy machines 1900-1920 1950-1970 1st Rad Onc training program - X-rays & radium treatment of malignant & - benign disease - “rad” unit replaces “Roentegen” -1st linear accelerator - Routine use: Megavoltage 1920-1940 equipment & LDR brachy - Orthovoltage x-ray equipment - Clinical Trials -Erythema based treatment parameter - Concurrent chemo & RT - Roentgen dose unit defined - Computers calculating isodoses & - Fractionated scheduling statistical analysis

Hilderley, L. (2007)

Radiation History Through 100+ years 1970-1990 - “Gray” replaces “rad” -Clinical trials: 3-D treatment planning, hyperthermia, intraoperative RT, HDR brachy, sterotatic radiosurgery, 2010-Present radiolabeled antibody therapy, gamma knife . Advances in technology have 1990-2000 impacted radiation therapy treatment - 3D treatment planning in use planning and delivery -Multileaf collimator . Newer positioning techniques -IMRT - Hyperfractionation . On Board Imaging (OBI) - RT primary for specific cancers . Improved Treatment Delivery (prostate) Techniques 2000-2010 . Immune Therapy - Stereotactic body RT - 4D conformal therapy . Pulse Point Dosing - Mammosite - Cyberknife - INTRABEAM Future- Looking Bright - Selective invasive radiotherapy (SIRT)

Hilderley (2007)

Radiation (RT) Therapy- use of high energy electromagnetic waves or particles to treat disease

• Electromagnetic Waves – X-rays • Photons are generated by a linear accelerator – Gamma Rays • Emitted from a radioactive source – Colbolt, Ir, • Particle Beams – Protons – Neutrons – Electrons

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Ionizing Radiation

• Shortest wavelength & greatest energy of the electromagnetic spectrum

• Capable of imparting its energy to the body and causing chemical changes

• Ionizing radiation is emitted by – Radioactive materials – Some devices such as x-ray machines

Radiobiology Principles • Study of events that occur after ionizing radiation is absorbed by a living organism

• The deposit of RT into the cell causes physical, chemical & biochemical changes that result in free radicals which damaged DNA to break into double strands & delayed cell death

• RT exerts damage to tissue by colliding with ionizing particles @ small intervals along the path through tissue

• Both normal & cancer cells are able to recover from RT injury Bio-effects of radiation on tumors & normal tissue are dependent on the 4Ma basic (2012) principles called the 4“R’s”

The 4 “R”s of Radiobiology

Repair Reassortment

• Effect is to increase cell • Effect is to reduce cell survival survival over a fractionated over a fractionated course of course of radiation. radiation. • Repair occurs during interval • Cells move to more between fractions. radiosensitive phase in the cell • Needs 2 hour interval for cycle between fractions. minimal effect. • M and G2 most sensitive phases. • Late S most resistant phase.

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The 4 “R”s of Radiobiology Reoxygenation Repopulation • Effect is to reduce cell • Effect is to increase cell survival over a survival over a fractionated course of fractionated course of radiation. radiation. • Occurs when fraction • Oxygenated cells more interval length greater sensitive. than cell cycle doubling • Pool of hypoxic cells time. diminishes after each • Rate varies with different fraction tissues

Radiosensitivity

• Expression of response of tumor & normal cells to radiation

• Inherent – some cell lines & diseases are more sensitive to RT, while others are more resistant ― Rapidly dividing cells are more radiosensitive

― Non dividing or slowly dividing cells are less radiosensitive or radioresistant

Other Radiosensitive Influences • Radiosensitizers- chemical/pharmacologic agents given with RT to increase damage to sensitive cells (e.g. fluoropyrimidines, taxanes, platinum compounds) • Radioprotectors- chemical agents that minimize normal tissue damage from RT without compromising local tumor control (e.g. ethyol)

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Radiation Dose • Absorbed dose = the amount of energy absorbed per unit mass – Correlates directly to energy of beam – Accurate measurement is critical • Old measurement – Rad: 1rad= 1cGy • New measurement – Gray: 100 cGy = 1Gray (Gy)

Moore‐Higgins (2007)

Fractionation • Total dose of RT is divided into smaller equal fractions • Standard – Single fraction 5 days a week • Hyperfractionation – Smaller doses given more than once a day • Accelerated fractionation – Shorter overall treatment time – Standard doses with increased number of fractions per day • Hypofractionation – Shorter course of treatment using greater than standard 1.8-2.0 Gy per fraction • Concurrent Boost

RADIATION SAFETY

ALARA “As Low As Reasonably Achievable” Alpha

Title 10 CFR, Parts 20 & 35

Beta paper U.S. Nuclear Regulatory Commission Gamma thick concrete/lead

Radiation Safety Officer thin sheet of aluminum

Time – Distance -Shielding

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It is estimated that > 60% of patients with cancer will receive radiation for the management of their cancer at some point (Kelvin 2010) Primary

Palliative Concurrent Anticipatory palliation Indications for Radiation Therapy

Adjuvant Neoadjuvant

Goals of Radiation • Eradicate, control or palliate tumor • Deliver an adequate dose to tumor volume with minimal damage to surrounding healthy tissue • Increase survival with as high a QOL as possible • Achieved at a competitive cost

Multidisciplinary Team

Radiation Oncology • Radiation Oncologist Support Services • APRNs/PAs • Social workers • Radiation Nurses • Nutrition • Medical Oncology • Rehabilitation • Surgical Oncology • Clinical Research Coordinator • Pain Management • Pathologist • • Medical Physicists Patient Service Rep • Radiologist • Administrative staff • Dosimetrists • Transport • Radiation Therapist • Spiritual Care • Engineers

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The Radiation Process for Treatment Radiation Consult • Formulate plan of care • Consent Simulation • Education • Positioning and immobilization • Imaging Treatment Planning • Treatment field design • Dose prescription • Computer calculations Treatment Verification • Quality Assurance Checks • Set up Treatment Delivery • Peer‐Peer • On Treatment Visit (OTV) • Quality Assurance Checks • Education

Radiation Consult

• Meet radiation oncologist and nurse • Review medical, surgical and social history – Previous treatment? Pacemaker? Contraindications? • Complete physical and psychosocial assessment – Baseline symptoms, ID special needs • Reconfirmation of cancer diagnosis – Imaging, pathology, additional imaging & studies – Additional referrals • Discussion of treatment options – Goals of radiation discussed – Based on diagnosis, radiation sensitivity of tumor & Pt’s performance status • Informed Consent • Pt education

Simulation

• Simulation- process of aiming & defining the radiation beams to meet the goals of treatment

• Positioning & Immobilization & Markings – Ensures accurate daily setup – Reduces radiation field placement errors – Consideration for Pt’ comfort & ability to maintain position during treatment

• Imaging – CT Simulator – MRI Simulator – PET/CT Fusion

• Patient Education

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Tools of the Trade

• Positioning devices (cast/mold, mask, biteblock, breastboard) • Skin markings and tattoos • Other equipment that may be used (guide wires, Bolus, Bra, BB’s) • Imaging and localization devices (ultrasound, gold fiducial seeds, beacons)

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Pelvic Alfa Cradle Aquaplast Mask Tools of the Trade the of Tools Vac Loc Body Cast Bite Block

Skin tattoo Guide wires Tools of the Trade the of Tools Bolus Fiducials

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Respiratory Gating

• Synchronized treatments to • Radiation beam turned on/off breathing pattern to synch with Pt’s respiratory • Helps to manage tumor or cycle target motion • Lung, breast, liver, pancreas, – Maximizes dose to tumor kidney – Minimizes dose to surrounding tissue • Respiratory cycle must be modeled prior to radiation delivery • Use of 4-D CT imaging (real time)

Treatment Planning

• Treatment planning done on a computer 3-D system • Fusion & Contouring images • Defining treatment volumes • Dose prescription • Virtual Simulation • Plan approval

Definition of Treatment Volumes Treatment Portal • GTV : Gross tumor volume = All CTV areas of gross disease

• CTV : Clinical tumor volume = GTV + margin: microscopic disease

• PTV : Planning target volume = CTV + margin: variation in internal organ motion

• Treatment portal : Additional margin to account for variation in set-up

MA (2012) PTV

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Treatment Verification

• Physics check – Before, during & after treatment • Set –up – Port film – On Board Imaging (OBI) • Peer to Peer Review (Chart Rounds) – Prior to start of treatment • Daily/Weekly – Imaging of treatment position – Rad Onc approval

Treatment Delivery

• Schedule varies depending on type of treatment modality used – 1 to 40 – Daily M-F, twice daily, every other day • Pt seen at least once a week for On Treatment Visit (OTV) • Ongoing Quality Assurance Checks • End Of Treatment (EOT) discharge instructions • Follow-up

Radiation Delivery Methods • External Beam Radiation (EBRT) Radiation is delivered from an outside source to target

• Conventional • 3D Conformal • Intensity Modulated Radiotherapy (IMRT) • Image Guided Radiation Therapy (IGRT) (4D) • Stereotactic Radiotherapy (SRT) / surgery (SRS) • Total Body Irradiation • Protons

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Radiation Delivery Methods • Internal Radiation Radiation source is placed into or near target

– Brachytherapy • Sealed sources

– Radiopharmaceutical therapy • Unsealed sources

Conventional EBRT

. Two dimensional

. Uses x ray images of treatment area relative to bony landmarks

. Rectangular shaped fields

. Use of blocks and wedges

Three-Dimensional Conformal (3D-CRT)

• 3D digital imaging (CT/MRI)

• Immobilization devices needed

• Beam conformed to shape of tumor /anatomy

• RT delivered from various angles

• Maximizes RT dose to tumor

• Minimizes damage to normal tissue

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Intensity Modulated Radiation Therapy (IMRT)

• Most advanced form 3D-CRT

• Time & resource intensive

• Radiation beam broken into smaller “Beamlets” that vary in intensity and allow beam to change shape during treatment

• Ability to optimize dose homogeneity to the tumor and minimize dose to surrounding normal tissues

• Multi-leaf collimator

• Allows higher doses with fewer side effect

Image Guided Radiation Therapy (IGRT)

• Use of x-rays and scans before and during radiation treatment

. Adjustments can be made with changes in tumor position, size, shape between fractions and within a fraction

. May increase tumor control

. Decrease side effects

. Allows shorter courses of radiation

Cone Beam CT Guidance

• CT image guidance system integrated into linear accelerator • Cone Beam and Simulator CT images are fused daily • Ensures daily reproducibility to accurately treat the target • Allows monitoring throughout treatment process • Should further decrease treatment-related toxicities

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Volumetric Modulated Arc Therapy (VMAT)

• 3D imaging during treatment to delineate tumor • Single or multiple RT beams sweep around patient • Imaging taken during treatment enhances precision and control of beam to target tumor

• Higher RT dose to tumor • Reduced treatment time • H & N, lung, pancreatic, liver and prostate cancer

Total Body Radiation (TBI) • Used in autologous and allogeneic HSCT • Delivers a uniform dose of RT to the entire body • Purpose of TBI is to immunosuppress the patient to avoid rejection of the donor bone marrow transplant • Fractionated doses are better tolerated • Nausea/vomiting can occur during treatment or immediately after treatment

Stereotactic Radiosurgery (SRS) • Noninvasive procedure to ablate intracranial tumors • Delivers multiple beams of RT precisely and accurately to tumor • 1 to 5 fractions • Gamma Knife, Cyberknife or Linac-based

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Stereotactic Radiobody Surgery (SBRT)

• Based on SRS principles • Used to extracranial tumors – Not surgically operable – Located close to vital organs or anatomic structures

Proton Beam RT

• Cyclotron generated • Large particles with positive charge • Energy is deposited within a limited distance and tissue beyond the target volume is spared • Depth charge effect: Allows for conformal dose distributions to be created around irregularly shaped targets

https://www.oncolink.org/healthcare-professionals/oncolink-university/proton-therapy-professional-education/oncolink-proton-education-modules

Sealed Source Internal Radiation • Brachytherapy – Used alone or in combination with other treatment modalities – Ability to deliver a high dose of radiation to tumor with a rapid falloff in dose to adjacent tissues – Permanent vs Temporary – Low Dose Rate (LDR) vs High Dose Rate – Source placement • Interstitial • Intracavity • Transluminal • Surface

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Brachytherapy Use Most common use • Prostate • Gynecological – LDR and HDR used – Cervix – Temporary or permanent placement • HDR Tandem and Ovoid (T & O) • HDR Tandem and Ring ( T & R) • Breast • Vaginal cylinder – HDR mostly used – Vagina – Balloon catheter placed into • HDR vaginal Cylinder lumpectomy surgical cavity – Vulva • Lung • HDR Syed • Skin/soft tissue- Sarcomas

Prostate LDR Brachytherapy • Primary treatment or as boost after EBRT • Anesthesia required • Hollow needle placement with transrectal US guidance • # of radioactive seeds based on volume of prostate • Radiation safety precautions • Patient education

Prostate HDR Brachytherapy

• Primary treatment or as boost after EBRT • Anesthesia required • Hollow needle placement with transrectal US guidance • CT based treatment planning • RT delivered by HDR remote after-loading unit

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Partial Breast Brachytherapy • Guidelines for selection criteria • Radiation to the lumpectomy cavity • Treated twice a day, for 5 days, total 10 Fx’s • Interstitial or Balloon Catheters

Tandem and Ovoids/Ring • Smitt sleeve inserted and sutured into cervix • HDR –outpatient • LDR- inpatient

Vaginal Cylinder

• Endometrial Ca – Single modality or combined with EBRT • Cervical Ca – s/p TAH

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Unsealed Radioactive Sources Radiopharmaceuticals . Drugs that contain radioactive materials (radioisotopes) . Given intravenously, by mouth, or placed in a body cavity . Mostly in the form of alpha and beta particles that target the specific area

Unsealed Radioactive Sources • Radiopharmaceuticals . Treatment of bone pain . Strontium-89 (Metastron), . Samarium 153 (Quadramet), . Radium 223 (Xofigo) . Treatment of thyroid cancer . Iodine 131 . Radio-labeled antibodies (radioimmunotherapy) . Monoclonal antibodies paired with radioactive atoms

Principles of Radiation Induced Side Effects • Direct effect of radiation on normal tissue(s) • Dependent on multiple factors – total dose of RT received, cell sensitivity, fractionation schedule, size of treatment area, patient individuality – AND NOW treatment delivery technique • Type 1. Acute (early): during RT 2. Subacute: few weeks to 6 months after RT 3. Chronic (late): occur 6 months to years after RT

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Principles of Radiation Induced Side Effects • Classification – General – Site-specific • May be more intense and begin sooner when combined with other therapies • Potential impact on quality of life – Physically – Emotionally – Financially

General RT Side Effects • Fatigue • Skin reaction- RADIODERMATITIS • Weight loss • Myelosuppression (dependent on treatment area)

Acute Site-Specific RT Side Effects Confined to the treatment area • Spine- dependent on • Brain region treated . Nausea / Vomiting . Cervical spine . Headaches . Thoracic spine . Seizures . Lumbar spine . Alopecia . Sacral spine . Skin reactions . Mental status changes . Transient exacerbation of • Head/Neck pretreatment symptoms . Difficulty/pain swallowing . Radiation Somnolence . Sore mouth Syndrome (6-12 wks post RT) . Dry mouth . Infection . Taste changes . Voice changes . Skin reactions

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Acute Site-Specific RT Side Effects • Abdomen • Breast . Loss of appetite . Skin reactions . Nausea . Swelling/tenderness . Vomiting . Itching . Diarrhea . Constipation • Pelvis • Chest . Irritable bladder symptoms (↑ . Difficulty/pain swallowing frequency, urgency, nocturia) . Skin reactions . Urinary Tract Infections . Cough/hiccups . Blood in urine . Unable to urinate . Rectal irritation/bleeding . Skin reactions . Sexuality changes

Late RT Side Effects • Dependent on total dose and dose per fraction • Occur months to years after treatment • Generally become progressive and vary in severity • Usually permanent • Risk for second malignancy

Late RT Side Effects by Site • Brain/Spinal Cord • Chest – Necrosis – Stricture of esophagus – Cerebral atrophy – Pulmonary fibrosis – Myelopathy • Abdomen – Decreased hormone production (brain) – Gastric atrophy • H & N – Ulceration – Trismus – Renal function toxicities – Alpoecia • Pelvis – Fibrosis – Enteritis – Dysphaia – Proctitis – Xerostomia – Fistula formation – Osteronecrosis – Small bowel obstruction • Breast – Female – Vascular & fibrotic changes • Vaginal stenosis – Lymphedema • Vaginal dryness – Brachial plexopathy – Male – Cardiac mortality • Erectile dysfunction – Rib fracture

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ONS 43rd Congress Radiation Track Sessions Thursday 5/17/2018 3:30 PM‐ 5:30 PM Room 202 Radiation Emergencies and Other Palliative Considerations‐ Jana Kelly RN MS AOCN

Friday 5/18/2018 Room 202 9:45 AM‐ 11:00 AM Radiation Toxicity and Management ‐ Lorraine Drapek DNP, FNP_BC, AOCNP 2:45 PM‐4:00 PM Understanding HDR Brachytherapy‐ Lorry Lewis RN, OCN / Michelle Levinson RN, BSN

Saturday 5/19/2018 Room 202 9:45 AM ‐ 11:00 AM Role Development in radiation Oncology ‐ Susan Behrend RN, MSN, AOCN 2:45 AM – 4:00 PM Radiation Therapy: What Does the Future Hold? ‐ Annette Quinn MSN, RN, OCN

Recommended Websites • Oncology Nursing Society http://www.ons.org

• National Cancer Institute (NCI) https://www.cancer.gov

• American Society for Therapeutic Radiology and Oncology (ASTRO) http://www.astro.org

• American Brachytherapy Society (ABS) http://www.americanbrachytherapy.org

• Radiation Therapy Oncology Group (RTOG) http://www.rtog.org

Recommended Websites • The Radiosurgery Society http://www.therss.org

• Radiological Society of North America (RSNA) http://www.rsna.org

• Children’s Oncology Group http://www.childrensoncologygroup.org – Survivorship guidelines @ http://www.survivorshipguidelines.org

• Onco Link: Cancer resources for patients and healthcare professionals http://www.oncolink.org

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References

Frankel-Kelvin, J. (2010). Radiation Therapy. In J. Eggert (Ed.), Cancer Basics (p 173-193). Pittsburg: Oncology Nursing Society Haas, M.L., Hogle, W. P., Moore-Higgs, G.J., & Gosselin-Acomb, T. K. (2007) Radiation Therapy: A Guide to Patient Care. St. Louis, MI: Mosby

Iwamoto, R.R., Haas, M., Gosselin-Acomb, T.K. (2012). Manual for Radiation OncologyNursing Practice and Education (4th ed.). Pittsburg, PA: Oncology Nursing Society Ma, C.M. (2012). The Practice of Radiation Oncology. In R.R. Iwamoto, M. Haas, T.K. Gosselin-Acomb (Eds.), Manual for Radiation Oncology Nursing Practice and Education (4th ed., pp. 17-27). Pittsburg: Oncology Nursing Society Moore-Higgins, G.J. (2007). Basic Principles of Radiation Therapy. In Haas, M.L., Hogle, W. P., Moore-Higgs, G.J., & Gosselin-Acomb, T. K. (Eds.), Radiation Therapy: A Guide to Patient Care. St. Louis, MI: Mosby

Oncolink Proton Educational Modules (2018), University of Pennsylvania https://www.oncolink.org/healthcare-professionals/oncolink-university/proton-therapy-professional-education/oncolink- proton-education-modules

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