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Cancer Treatment

Part 1: Caring for Your Loved Ones

Volume 8, Number 4 - June, 2004

Editors: Carol A. Rice, Ph.D., RN, Professor and Extension Health Specialist, and Janet M. Pollard, MPH, Extension Associate-Health

Download PDF version of this Newsletter [262K]

Inside HealthHints....

• Cancer Treatment
• Types of Treatment
• Surgery
• Supporting the Person Undergoing Surgery
• Chemotherapy
• Side Effects of Chemotherapy
• Supporting the Person Undergoing Chemotherapy
• Helping Others to Help You and Them: Asking Family and Friends for Help
• Radiation Therapy
• Side Effects of Radiation Therapy
• Supporting the Person Undergoing Radiation Therapy
• Immunotherapy
• Reading About Cancer and Answering Questions
• References

Cancer Treatment: Caring for Your Loved Ones

Cancer (KAN-ser) is a group of over 100 diseases where cells that are not normal grow and divide rapidly, crowding out and destroying normal cells the body needs (National Cancer Institute, 2004b).

Cancer...This word seems ever more prevalent in most of our lives. Few, if any, of us reading this are untouched by cancer in someway, either having cancer, knowing someone who is recently diagnosed with cancer or already undergoing cancer treatment, or someone who is in cancer remission.

The purpose of this issue of HealthHints is not to explain different types of cancer or discuss treatment decisions, rather our goal is to give an overview of what happens during and after four of the most common types of cancer treatment, and how family, friends, and other caregivers can help support the individual undergoing these and other cancer treatments.

Types of Treatment: Four Common Categories of Treatment

An individual may undergo one type of treatment or a combination of several different treatments, depending on the type of cancer diagnosed. Treatment will usually follow a protocol (i.e., a plan for treating cancer), however, treatment decisions also depend on factors, such as:

• how old the patient is,
• whether the cancer has spread to other places in the body, and
• what the doctor and patient think is best.

There may be more than one way to treat any given cancer, so people with the same type of cancer may receive different treatment(s). Each person is different and reacts differently to treatment. So, even if two people are receiving the same type of treatment for the same type of cancer, the treatment may not work the same for both of them (National Cancer Institute, 2004b).

There are four main types of treatment for cancer:

1. surgery
2. chemotherapy
3. radiation therapy
4. immunotherapy (also called biological therapy, biotherapy, or biological response modifier therapy) (National Cancer Institute, 2002, National Cancer Institute, 2004b).

Though we will not go into every detailed type of surgery, immunotherapy, etc., it is important to understand some basic occurrences in each type of treatment (e.g., how it is administered, where it is administered, common side effects, etc.) so that we can better understand how to support those undergoing these procedures.

Surgery: What is Involved in Surgery

Surgery is an operation (National Cancer Institute, 2004b). It is the oldest form of treatment for cancer and offers the greatest chance for cure for many types of cancer, especially those that have not yet spread to other parts of the body. Most people who have cancer will, at some point, have some type of surgery (American Cancer Society, 2002).

Surgery is often done for one of the following eight reasons:

1. Prevention -- a procedure used to prevent cancer formation, such as the removal of non-cancerous body tissue that is likely to become cancerous (e.g., a precancerous condition like polyps in the colon).
2. Diagnosis -- a surgery (known as a biopsy) used to take a sample of tissue to identify specific cancer. (Cancer diagnoses can often only be confirmed by looking at the cells under a microscope.) Biopsies are typically done by inserting a needle attached to a syringe to withdraw a small amount of tissue from a tumor, however, occasionally biopsy procedures require the physician to cut through the skin to remove an entire tumor. Other procedures used in diagnosis may include endoscopy or laparoscopy, in which flexible tubes are inserted into the body through a natural opening or incision to allow viewing of the inside of the body. Occasionally, open surgical exploration will be needed, which requires larger incisions, opening of an area for viewing, and general anesthesia.
3. Staging -- a procedure, such as laparoscopy (placing a long, flexible tube through an incision to view the inside of the body), done to determine the extent and amount of disease present.
4. Cure (potentially) -- curative surgery is a primary treatment for cancer where a tumor is removed when it is thought to be confined to one area. Curative surgery is often used with chemotherapy and radiation therapy, which can be given before, after, or during (intraoperative radiation therapy) surgery.
5. Debulking -- Debulking procedures are the removal of part of a tumor, where removal of the whole tumor would present too much damage to an organ or surrounding area. The patient is then treated with radiation therapy or chemotherapy in hopes of destroying the rest of the tumor (commonly used in advanced cancer of the ovary).
6. Pain and disability reduction -- palliative surgery, as it is known, is used to treat complications of advanced disease and is not intended to cure cancer. An example would be surgery to alleviate obstruction of the intestines by abdominal cancer growths.
7. Treatment support -- some surgeries are done to support other types of treatment, such as inserting a catheter for vascular access (a port/tube placed into a vein) to help deliver chemotherapy and reduce the number of needle sticks needed.
8. Restoration/Reconstruction -- these surgeries are used to restore a person's appearance or the function of an organ or body part after primary surgery (e.g., breast reconstruction after mastectomy; prosthetic materials after surgery for oral cavity cancers) (American Cancer Society, 2002).

Some special surgical techniques are now being used to treat cancer and it's complications. Some of the more common procedures are described below, while others are still being explored for safety and effectiveness.

Laser Surgery

A laser is a highly focused and powerful beam of light energy, which can be used in medicine for very precise surgical work such as repairing a damaged retina in the eye. It can also be used to cut through tissue (instead of using a scalpel) or to vaporize cancers of the cervix, larynx (voice box), liver, rectum, or skin.

Some surgeries can be less complicated with laser light. For example, with fiber optics the light can be directed to parts of the body without having to make a large incision.

Laser surgery is also called photoablation or photocoagulation. This type of surgery is often used to relieve symptoms, such as when large tumors press on the windpipe or esophagus, causing problems with breathing or eating.

For more information on laser surgery techniques, see "Lasers in Cancer Treatment" (http://cis.nci.nih.gov/fact/7_8.htm).

Cryosurgery

Cryosurgery involves the use of a liquid nitrogen spray or a very cold probe to freeze and kill abnormal cells. This technique is sometimes used to treat precancerous conditions such as those affecting the cervix. Cryosurgery is also being studied as a treatment for some cancers such as those of the prostate.

For more information on cryosurgery, see "Cryosurgery in Cancer Treatment: Questions and Answers" (http://cis.nci.nih.gov/fact/7_34.htm).

Electrosurgery

High-frequency electrical current can be used to destroy cells. It is used for some cancers of the skin and mouth.

Mohs Surgery

Mohs surgery, also called microscopically controlled surgery, is a technique to remove cancerous tissue by shaving off one layer at a time. After each layer is removed, a specially trained dermatologist (skin doctor) or pathologist looks at the tissue layer under a microscope. When all the cells look normal under the microscope, the surgeon stops removing layers of tissue.

This technique is used when the extent of the cancer is not known or when as much healthy tissue as possible needs to be preserved (as in cancers around the eye). It is performed under local anesthesia by a specially trained surgeon.

Chemosurgery is an older name for this surgery and refers to certain chemicals applied to the tissue before it is removed. The procedure does not involve use of cancer chemotherapy drugs (American Cancer Society, 2002).

Supporting the Person Undergoing Surgery: Preparation, Procedure, Recovery

There are probably as many different surgical techniques as there are diseases to treat, and each case is different. Still, some aspects of the surgical process are common to most operations, including preoperative testing and preparation, the surgery itself (often including some type of anesthesia), and a recovery period (American Cancer Society, 2002).

Surgery Preparation

To be prepared for surgery, it is recommended that the patient prepare to have the best chance for a good outcome by knowing what to expect (as much as possible) and being comfortable with the decision made. Although people differ as to how involved they want to be in the decision-making process, knowing as much as possible about what lies ahead can, at the very least, help reduce the level of stress.

As a close friend or family member, it may be helpful to discuss the procedure and recovery with your loved one...being sensitive to fears and concerns. Help list out the pros and cons of the process so that your loved one can make an informed decision about what is best for him/her. If there are any doubts about the surgery, talk about them with the doctor. Encourage getting a second opinion from another doctor or surgeon if there are questions as to whether or not a suggested operation is the best choice. A doctor should not mind this request, and the original doctor can often provide test results to take to the second doctor to avoid duplicate testing. Some insurance companies actually require a second opinion; so, be sure to check with your insurance company before proceeding with a surgery (American Cancer Society, 2002).

Once the decision is made for surgery, the patient usually undergoes common tests, such as x-rays, and urine and blood tests. In addition to these preparations, the patient is required to sign a consent form giving written permission for the doctor to perform surgery. The informed consent form is typically signed after the doctor has explained the following items:

• patient's condition and why surgery is an option
• goal of the surgery
• how the surgery is done
• how the surgery may benefit the patient
• what the patient's risks are
• what to expect in terms of side effects
• what other options are available to the patient.

Signing the informed consent means that the patient has received this information and is willing to have the surgery. The patient should make sure he/she understands all of the information presented and has all of his/her questions answered by the doctor in a way that he/she understands. This is a time when it can be helpful to have a family member or friend go over all of the information with you (American Cancer Society, 2002).

Surgery Procedure

Though each surgical procedure is different, they often have anesthesia in common. The patient may receive:

• local anesthesia -- (used for minor surgeries, like biopsies near the surface of the skin) which deadens the nerves in the area where surgery is being performed;
• regional anesthesia -- also called a "nerve block" affecting a larger area of the body, while still allowing the patient to stay awake; or
• general anesthesia -- which puts the patient to sleep (American Cancer Society, 2002).

Knowing what type of anesthesia your loved one is having can help you to know what to expect in terms of alertness after the surgical procedure. People who have local anesthesia may be able to go home right away, depending on health prior to the procedure and the extensiveness of the operation. People receiving regional or general anesthesia will be taken to a recovery room following surgery. After general anesthesia, a person may not feel fully awake until the following day, and may have a sore throat for a time, since an endotrachael tube is placed in the throat to continue the medication (anesthesia) and allow the medical team to monitor the patient's vital signs (i.e., heart rate, breathing rate, blood pressure). A person may also have a catheter (tube leading from the bladder, which allows urine to exit the body).

Surgery Recovery

When people undergo surgery, they will often need to stay in the hospital until they are strong enough to come home. Patients will often be encouraged to get up and walk, which speeds recovery by getting the digestive tract moving and preventing blood clots from forming in the legs. Note: The digestive tract (stomach and intestines) is one of the last parts of the body to recover from the effects of anesthesia, and needs to be working properly before the patient will be allowed to eat solid food. The patient may also be asked to do deep breathing exercises to help inflate the lungs and reduce the risk of acquiring pneumonia. Patients should also be encouraged to let their medical team know if they are experiencing a lot of pain, which can usually be controlled with medication (American Cancer Society, 2002) (see HealthHints Vol. 8 No. 5, Cancer Treatment Part II: Diet, Pain Management, and Support Services for more information).

When the patient comes home, he/she may still be weak from surgery. There are often things the individual should not do, such as lifting heavy objects or climbing stairs, allowing the body more time to heal first (National Cancer Institute, 2004b). Some assistance will often be required at home. This is an area where family and friends can help, or the medical team can arrange for home assistance with regular nurse visits.

Some aspects of recovery may be more long term. Wounds heal at different rates. People who have undergone a mastectomy (breast removal, limb amputation, or ostomy (opening in the abdomen connected to the end of the intestine) will have permanent changes to the body and may require learning new ways of doing things.

Having an understanding beforehand of what the results of the surgery will be is important in helping the patient adjust to changes after the procedure. Be sure all questions are answered up front -- be as specific as you need to and be sure the health care team gives specific answers in response to your questions (American Cancer Society, 2002).

Chemotherapy: What Happens During Chemotherapy

Chemotherapy is the treatment of cancer with drugs that destroy cancer cells. These drugs go into the blood stream and are carried to cancer cells anywhere in the body (National Cancer Institute, 2004b).

Chemotherapy can be administered in four ways:

1. intravenously or IV (a needle inserted into a vein) -- this is the most common way chemotherapy is given
2. into a muscle (a shot);
3. by mouth (liquid or pills) (National Cancer Institute, When someone in your family..., 2004); or
4. on top of the skin/topically (a medicated cream or lotion applied to a cancerous area on the skin) (American Cancer Society, 2004e).

For more detailed information on how drugs in chemotherapy regimens are given, see the following resources:

• "What Are the Different Ways to Take Chemotherapy"
  (http://www.cancer.org/docroot/ETO/content/ETO_1_4X_
  What_Are_The_Different_Ways_To_Take_Chemotherapy.asp), and
• "How Will the Chemotherapy Treatment be Given to Me?"
  (http://www.cancer.org/docroot/ETO/content/ETO_1_7X_How_Will_
  The_Chemotherapy_Treatment_Be_Given_To_Me.asp).

Many different drugs are used in chemotherapy. Doctors decide which drug or groups of drugs to use based on the type of cancer the person has (National Cancer Institute, 2004b). For more specific information on types of chemotherapy drugs see "What are the Different Type of Chemotherapy Drugs?" (http://www.cancer.org/docroot/ETO/content/ETO_1_4X_
What_Are_The_Different_Types_Of_Chemotherapy_Drugs.asp).

Chemotherapy is usually given many times for several months or over the course of a year or more (National Cancer Institute, When someone in your family..., 2004). How often chemotherapy drugs are taken depends on the kind of cancer, drugs used, goals of treatment, and how the body responds. Treatments may be given daily, weekly, or monthly. Treatments are usually given in "on-off cycles" with rest periods for the body to regain strength and build healthy new cells (American Cancer Society, 2004d).

Chemotherapy treatments may be given in the hospital, doctor's office, clinic, workplace, or home. Both convenience and how the drugs are administered must be considered when deciding the treatment location. The patient's general state of health and potential side effects must also be considered. When a patient begins chemotherapy treatments, a hospital stay may be required so that the doctor can observe the medicine's effects and make any necessary changes (American Cancer Society, 2004n).

Though chemotherapy is sometimes the only treatment given, more often it is used in addition to surgery, radiation therapy, or immunotherapy. The purpose of chemotherapy may be to:

• shrink a tumor before surgery or radiation;
• help destroy cancer cells that may remain after surgery or radiation;
• make radiation and immunotherapy work better;
• help destroy cancer if it recurs or has spread to other parts of the body from the original tumor (National Cancer Institute, 1999a).

Side Effects of Chemotherapy: Know What to Expect

Normal cells grow and die in a controlled way. When cancer occurs, cells in the body that are not normal keep dividing and forming more cells without control. Anti-cancer drugs destroy cancer cells by stopping them from growing or multiplying. Chemotherapy works mainly on cancer cells, however, healthy cells can also be harmed, especially those that divide quickly. Harm to healthy cells is what causes side effects. Almost all people taking chemotherapy will have side effects. Most side effects don't last long and will gradually go away after treatment is stopped. The cells usually repair themselves after chemotherapy. The doctor can discuss which side effects are most likely in each particular treatment.

When chemotherapy acts on normal cells in the stomach and the rest of the digestive tract, from the mouth on down, it can cause nausea and vomiting. Sometimes people lose their appetite. If they have sores on the tongue, gums, or inside the cheeks, it is hard to eat, especially if the food is too hot, cold, or spicy. People often lose some weight because of these side effects (see HealthHints Vol. 8 No. 5, Cancer Treatment Part II: Diet, Pain Management, and Support Services for more information).

Nausea and vomiting usually stop within 1 or 2 days after the drug is taken. Mouth sores, another potential side effect, may last longer and may not even start until 1 or 2 weeks after taking certain drugs. Many people with mouth sores use special mouth rinses to ease the pain. Burning, numbness, tingling, or shooting pain in the finger and toes may also result due to nerve damage that can be caused by chemotherapy. Headaches, muscle aches, and stomach pains may also result. These side effects should be reported to your doctor. Pain can often be controlled with medication or may require changes in treatment (see HealthHints Vol. 8 No. 5, Cancer Treatment Part II: Diet, Pain Management, and Support Services for more information).

Temporary hair loss is another common side effect of chemotherapy. Sometimes the hair falls out all at once, and other times it slowly thins out. There's no way to know whether all the hair will come out or if some parts of the body will lose more hair than others. Even if hair is lost, it usually grows back after treatment has stopped. Some people wear a wig, cap, or scarf until their hair grows back.

The bone marrow, the innermost part of the bone, makes new blood cells. If chemotherapy affects the bone marrow, it cannot produce as many blood cells as usual. For a while, the person may have fewer red blood cells, white blood cells, or platelets, which are different kinds of cells in the blood.

• Red blood cells carry needed oxygen to the tissues. When red blood cells are low and the body tissue does not receive enough oxygen, this condition is called anemia. The person may be fatigued (feeling very tired and weak), pale, cranky, dizzy, feel faint, have shortness of breath, or feel as if their heart is pounding or beating very fast.
• White blood cells fight infection. When they are low, the person is more likely to get sick and may need to stay out of crowded places or away from people who have something they could catch -- like a cold,
  the flu, or chicken pox. Because of this, family and friends may need to stay away from them if they are sick. Persons undergoing chemotherapy should report any signs of infection to their doctor immediately -- day or night. Controlling infection fast is crucial in avoiding further complications.
• Platelets help stop bleeding. People who don't have enough platelets may bruise or bleed easily. They may have to stay away from rough play with children, etc. If they get a nosebleed while their platelets are low, don't panic. They may bleed a little more than someone else would, but it will stop.

You may notice changes in how the person who is getting chemotherapy acts sometimes. Everyone has ups and downs, but these may be more extreme in people taking some kinds of chemotherapy. Chemotherapy can effect the central nervous system (brain) causing tiredness, confusion, nervousness/anxiety and depression.

Persons undergoing chemotherapy may feel very hungry, or not hungry at all. They may also experience diarrhea or constipation, affecting what food should be consumed (see HealthHints Vol. 8 No. 5, Cancer Treatment Part II: Diet, Pain Management, and Support Services for more information).

It is especially important, as well, for chemotherapy patient to discuss sexual side effects prior to treatment. Doctors can answer questions about sexual side effects, however, it may help for the patient and his/her partner to talk with a nurse, counselor, social worker, clergy, or friend if this is more comfortable.

The side effects people have depend on the drugs they take. They may have some or none of the side effects mentioned here, or they may have others.

Side effects of chemotherapy are not pleasant, but they are usually temporary. The drugs do not destroy all of the normal cells. Once chemotherapy is over, the hair usually grows back, and the bone marrow produces the normal amount of new blood cells. People with cancer begin to feel and act like themselves again.

(This section adapted from National Cancer Institute, 1999a; National Cancer Institute, 2004b).

Supporting the Person Undergoing Chemotherapy: How You Can Help

The following are some ways that you might support the person undergoing chemotherapy:

• Drive the person to and from treatment.
• Care for children during treatment.
• Help with children and household tasks at home the day of and the day after treatment.
• If you are an employer, be accepting and encouraging of temporary work at home, flexible scheduling to allow for naps due to fatigue or other symptoms, or a part-time schedule.
• Allow person plenty of time and space to get rest.
• When providing meals, inquire about needs as related to any side effects.
• If the person has pain, help by allowing them to explain it to you, so that you can explain it to their care provider if needed (e.g., if the person is too tired or in too much pain at the time of the conversation). To help, ask these questions:
  • Where do you feel the pain?
  • Is it sharp, dull, throbbing, steady, other?
  • How strong is the pain?
  • How long does the pain last?
  • What eases the pain?
  • What makes the pain worse?
  • What medicines are you taking for pain?
  • How much relief are you getting from your medications?
  • How much pain are you feeling on a scale of 0 to 10 (0 being no pain, 10 being as bad as it can be).
• If you are a hair stylist, offer to give a short haircut to make the hair look thicker and fuller. This will also make hair loss easier to manage if it occurs. Offer scarves, turbans, caps, wigs, or hair pieces if appropriate, being sensitive to the person's feelings/ desires/needs about their hair loss -- going without a head covering is perfectly fine and sometimes the most comfortable choice. Encourage head coverings for sun damage protection.
• Help the person avoid infection in the following ways:
  • Do not visit the person if you or someone in your immediate family is sick.
  • Do not take the person undergoing chemotherapy treatment among crowds or crowded places like malls, shopping areas, stores, or movies.
  • If a child has recently received live vaccines (which are live viruses, such as the chicken pox and oral polio vaccines), do not allow the child around the person receiving chemotherapy treatment, since they may be contagious to the person with a low blood cell count.
  • Help the person avoid contact with animal litter boxes and waste, bird cages, and fish tanks.
  • Have the person avoid standing water, such as bird baths, flower vases, or humidifiers.
  • Encourage the person's use of gloves when gardening, and cleaning up after others, especially children.
  • Encourage use of electric shavers, instead of razors to prevent breaks or cuts in skin.
  • Do not serve raw meats, fish, seafood, or eggs -- raw foods can contain bacteria that can cause infection.
  • Encourage the person to report any signs of infection right away -- even in the middle of the night. If the person has fever DO NOT give aspirin without consulting the doctor or care provider.
• Encourage movement when recommended by the care provider. Exercise with the person for encouragement when exercise is recommended. Understand that the person may be limited in their physical abilities for awhile during and after treatment. Encourage plenty of fluid intake, which also helps with symptoms of constipation and diarrhea. Have the person report any muscle weakness, pain, burning, tingling, etc. to their doctor.
• If the person's muscle strength or balance are affected by treatment, help the person avoid falls by adapting the home -- use bath mats, hand rails, rubber pads under loose rugs to prevent slips (or remove the rugs altogether), move awkwardly placed furniture. Encourage use of rubber-soled shoes.
• If you are the person's partner, talk openly about your feelings and allow your partner to do the same. Seek support through counselors, social workers, doctors, nurses, and friends (National Cancer Institute, 1999a).

Radiation Therapy: What Happens During Radiation Therapy

Many years ago doctors learned how to use energy to "see" inside the body and find disease through the use of x-rays. Now, radiation is used to treat cancer and other illnesses (National Cancer Institute, 1999b). To understand how radiation therapy works to treat cancer, it is helpful to understand what radiation is. "Radiation is energy that is carried by waves or a stream of particles that can alter the genetic code of a cell. This genetic code controls how a cell grows and divides in the body (American Cancer Society, 2004b)."

"Radiation therapy is an important part of many cancer patients' treatment plan (American Society of Radiation Technologists, 2000b)." During radiation treatments, carefully targeted and measured doses of radiation are administered to specific sites of the body. "The radiation produces highly energized ions that gradually shrink and destroy cancer cells (American Society of Radiation Technologists, your radiation therapy..., 2000)." Though radiation therapy attacks reproducing cancer cells, like chemotherapy, it can also affect reproducing cells of normal tissue. The damage to normal cells is what causes side effects. Each time radiation therapy is given it involves a balance between destroying cancer cells and sparing healthy cells (American Cancer Society, 2004b).

The treatment of a cancerous area, while saving as much healthy tissue as possible requires careful planning. The radiation treatment team must make an individualized plan for each cancer patient. Using imaging techniques, such as x-rays and computed tomography (CT), the team maps out a plan for where best to administer radiation and how to protect other sites of the body. This usually involves marking the site for radiation with ink and providing or developing special devices such as mesh masks or immobilization devices to protect healthy areas of the body and help to keep the patient still during radiation, respectively (American Society of Radiation Technologists, 2000a).

Like surgery, radiation treatment is a local treatment -- it affects the cancer cells only in a specific area of the body. Radiation therapy is often used as an adjunct therapy (i.e., a treatment added to the primary method of treatment):

• before surgery to shrink a tumor for easier removal
• before or during chemotherapy treatment to make the tumor smaller and improve the effectiveness of the anticancer drugs (chemotherapy)
• after chemotherapy to kill any cancer cells that might return
• to shrink tumors and reduce pressure, pain, and other symptoms of cancer when a cure is not possible (this is called palliative care or palliation) -- in an effort to provide better quality of life (National Cancer Institute, 1999b).

Radiation therapy is administered in three primary ways:

• External beam radiation -- This is the most widely used type of radiation therapy, where radiation is focused from a source outside the body onto the area affected by cancer.
• Internal radiation therapy -- The advantage to this type of radiation is the ability to deliver a high dose of radiation (more than the normal tissues could tolerate) to a small area. The disadvantage is that this method cannot effectively treat widespread cancer. Internal radiation therapy can be done by implanting the radiation source in the affected tissue in small pellets, wires, tubes, or containers (i.e., interstitial radiation) or by implanting a container of radioactive material in a body cavity (e.g., the vagina) a short distance away from the affected area (i.e., intracavitary radiation).
• Radiopharmaceuticals -- When given in small doses, these unsealed sources of radiation given intravenously, orally, or through a body cavity can help diagnose or treat cancer. Radiopharmaceuticals are sometimes used in combination with other treatment options (American Cancer Society, 2004c).

If your loved one is given external beam radiation, he/she is not radioactive and does not need to take special precautions to protect others from radiation (American Cancer Society, Safety for the patient and family, 2004).

If your loved one is given radiopharmaceuticals, however, radioactive substances will be eliminated from the body within a few weeks. During that time the patient will need to take special precautions as guided by your doctor, including:

• good handwashing after using the toilet
• flushing the toilet several times after each use
• using separate utensils and towels (laundry may need to be washed separately)
• drinking plenty of fluids to help flush remaining radioactive iodine (or other radiopharmaceuticals) from the body
• avoiding prolonged contact with infants, children, and pregnant women (American Cancer Society, 2004g).

If internal radiation therapy is given, only while the implant is in place will the patient need to take precautions to avoid exposing others to radiation. With this type of radiation, body fluid (urine, sweat, blood, and feces) are not considered radioactive and require no special handling. If you need to stay in the hospital while receiving the implant, however, you will most likely be given a private room and visitors will be limited. Pregnant women and children under age 18 are typically not admitted to visit patients with implants. Visitors should sit at least 6 feet from the bed and should limit their time each day to 10 to 30 minutes. If the implant is permanent, it will lose energy each day. You will need to stay away from other people for a few days. Daily close contact (less than 6 feet) and lengthy (more than 5 minutes) contact with pregnant women or children should be avoided for 2 months after the implant (American Cancer Society, 2004g). Talk with your doctor and follow his/her instructions carefully.

Side Effects of Radiation Therapy: Know What to Expect

Since radiation is a local treatment, most side effects of radiation therapy are related to the area that is being treated. Many patients have no side effects from radiation therapy (National Cancer Institute, 1999b). When side effects occur, the early effects are often seen a few days or weeks after treatments have started, and may continue for several weeks after treatments are completed. Some of the major side effects may include the following:

Fatigue

Fatigue is a general effect of radiation, but the exact cause is unknown. The tumor may cause the immune system to make substances that cause fatigue. Anemia (low red blood cell count), poor nutrition, pain, medications such as steroids or chemotherapy, depression, and stress may also cause fatigue. There is no single treatment for fatigue, but if possible, the treatment tries to address the cause of the fatigue. For example, if the fatigue is in part caused by anemia, some patients will benefit from blood transfusions or from medications to stimulate the production of red blood cells. Talk with the doctor about treatments for severe anemia. Light or moderate exercise with frequent rest breaks may be included in a program to reduce fatigue.

Skin

Modern radiation therapy may cause less damage to the skin than in earlier types of therapy because most of the radiation dose is delivered below the surface of the skin; however, skin changes may still occur. During the first 2 weeks of treatment, a faint and short-lasting redness may occur. Dryness and peeling of the skin may occur in 3 to 4 weeks. The skin over the treatment area may become darker. This is because of the effect radiation has on the cells in the skin that produce pigment. The skin may become dry and itchy. Moisturizing the skin with aloe vera, lanolin, or vitamin E may help -- always consult your doctor before use of any such product. After a month of treatment, some people receiving radiation may experience some extreme peeling and weeping (moist) areas. If this occurs, the patient should consult his/her doctor. Later effects of radiation may include thinning of the skin. The skin may feel hard, especially if surgery has also been done in the same area. Some people may experience difficulty with wounds healing in the area that was treated.

Mouth

Mucositis (inflammation of the lining of the mouth) is a temporary side effect that may happen when radiation is given to the head and neck area. It usually improves within a few weeks after treatments are completed. Dryness and a loss of taste result from radiation damage to salivary glands and taste buds. These side effects may disappear after treatments but in worse cases may be permanent. Keeping the mouth clean is important to reduce the chance of infection. If your mouth becomes tender, medication may be given to numb the mouth or help the pain. Radiation to the head and neck area can also increase chances of getting cavities. Mouth care designed to prevent problems will be an important part of treatment.

Hair

Loss of hair can occur with radiation therapy, but only in the area being treated. For example, if the abdomen is being treated, you will not lose hair from the head, rather only from the abdominal area. If radiation to the head is needed, however, then hair loss from the scalp is possible (American Cancer Society, 2004l).

Brain

Radiation therapy to large areas of the brain can sometimes result in significant changes in brain function such as memory loss, diminished sexual desire, or poor tolerance for cold weather. Usually these symptoms are minor compared to those caused by a brain tumor, but they can be bothersome. Sometimes a large area of dead cells, radiation necrosis, forms at the site of the radiation. This occurs months to years after radiation is given. Patients with radiation necrosis generally do better than patients whose brain tumors come back. Nevertheless, a small number of patients with radiation necrosis do poorly or even die.

Lung

When radiation treatments include the chest area, the lungs can be affected. One early change is a decrease in surfactant, the substance that helps keep the air passages open. This keeps the lungs from fully expanding and shortness of breath or cough may be experienced. These symptoms are sometimes treated with steroids to decrease inflammation. The late effect of radiation on the lungs is fibrosis (stiffening or scarring), which reduces the ability of the lungs to inflate and take in air. If a large area of the lungs is irradiated, these changes can cause shortness of breath and less tolerance for physical exercise.

Gastrointestinal Tract

Radiation to the abdomen may result in swelling and inflammation to the esophagus or intestines, causing nausea, vomiting, or diarrhea. Antacids, sometimes combined with xylocaine, (a numbing medication) may be helpful in relieving pain from inflammation of the esophagus. Nausea and vomiting can be treated with medications and if severe, some patients may need intravenous fluids to avoid or treat dehydration. Diarrhea can be treated with medications and by avoiding spicy, fried or high fiber foods (see HealthHints Vol. 8 No. 5, Cancer Treatment Part II: Diet, Pain Management, and Support Services for more information).

Reproductive Organs

Radiation to the testicles can cause permanent loss of sperm production, but unless the cancer is in the testes, they can usually be protected from radiation by using a "clam shell" type of shield. In women receiving radiation to the abdomen, it is more difficult to protect the ovaries from radiation. Usually both ovaries are not included in the treatment field so that permanent loss of fertility may not occur. If both ovaries are irradiated, permanent loss of fertility and ovarian function may occur.

Sexual Impact of Radiation Therapy in Women

Radiation to the pelvic area can cause the vagina to be tender and inflamed during and for a few weeks after treatment. Scarring of the area occurs as it heals and can interfere with the ability of the vagina to stretch. The lining of the vagina also gets thinner and may cause light bleeding after intercourse. A few women get ulcers, or sore spots, in their vaginas. It may take many months after the end of radiation therapy for these areas to heal.

Sexual Impact of Radiation Therapy in Men

Radiation therapy to the pelvis can cause problems with erections by damaging the arteries that carry blood to the penis. The higher the dose of radiation and the wider the section of the pelvis irradiated, the greater the chance that an erection problem will develop. Experts estimate that a quarter to a third of men who receive radiation notice a change for the worse. Men who have high blood pressure or who have been heavy smokers seem to have a higher risk for these erection problems. This is because their arteries may already be mildly damaged.

Second Cancers

The connection between radiation and cancer was recognized many years ago from the study of the survivors of the atomic bomb in Japan, the occupational exposure of workers, and patients treated with radiation therapy. Some cases of leukemia are related to radiation exposure and usually develop within a few years of exposure, peaking at 5 to 9 years, then slowly declining. Developing other types of cancer after radiation exposure has been shown to take much longer to occur. Most do not occur until 10 years after radiation exposure and some are diagnosed even 15 or more years later.

Radiation therapy techniques have steadily improved over several decades. Treatments now target the cancers more precisely, and more is known about selecting radiation doses. These advances are expected to reduce the number of secondary cancers resulting from radiation therapy. The risk of second cancers is generally low and must be weighed against the usually dramatic benefits gained with radiation treatments.

(This section adapted from American Cancer Society's Side Effects of Radiation Therapy, 2004h.)

Supporting the Person Undergoing Radiation Therapy: How You Can Help

The most common side effects of radiation therapy are:

• fatigue (feeling tired)
• skin changes
• loss of appetite.

Other side effects are usually related to treatment specific areas (as noted in the previous section) (American Cancer Society, 2004j).

Coping with fatigue can be helped by learning and understanding it before it occurs. Having a family member who participates in the education about cancer as provided by the patient's medical team and other personal avenues can be helpful. This family member can then help talk with the patient's health care team about the patient's fatigue when needed.

Family and friends might also support the patient by helping them to:

• list activities according to importance when they have the most energy
• delegate or offer help when you can
• place things the person with cancer needs within easy reach to save energy
• help the loved one to establish a daily routine
• guide the person in methods for reducing stress (e.g., deep breathing, meditation, prayer, listening to music, painting or other pleasurable, relaxing activities
• Help the person balance rest and activities -- avoiding excessive bedrest, while scheduling activities with plenty of time for rest
• offer a balanced diet that includes proteins (meat, milk, eggs, legumes, etc.) and drinking plenty of fluids (see HealthHints Vol. 8 No. 5, Cancer Treatment Part II: Diet, Pain Management, and Support Services for more information)
• Talk with the doctor about fatigue when needed (American Cancer Society, 2004a).

When providing gifts:

• Skin care products may be appropriate, but consider giving non-perfumed aloe vera, lanolin, or vitamin E products (lotions or creams). Lip salves can also be nice for those experiencing dry or sore mouths. The patient, however, should be sure to check with his/her doctor before using any of these types of products. No skin care products should be used during treatment without approval from the medical team.
• Other ideas would be to provide loose clothing, without starches that won't rub the skin.
• Sun protective wear are also helpful items to avoid damage from the sun, which can cause further irritation and problems.
• Another suggestion would be items that help the person rest and relax, such as a favorite book, magazine, or video/DVD. (American Cancer Society, what can I do about skin..., 2004, National Cancer Institute, eating hints..., 2004).

Family members and friends can also help with loss of appetite issues by:

• encouraging the person to eat when hungry and realize that several small meals during the day, rather than 2 to 3 large ones can be helpful and more tolerable.
• If the person enjoys company while eating -- provide a healthful meal (see HealthHints Vol. 8 No. 5, Cancer Treatment Part II: Diet, Pain Management, and Support Services for more information) and stay to eat -- be sensitive to the person's needs for rest and personal space.
• Consider making snack foods or providing a basket of snack food that the person can have at hand when the urge to eat comes.
• If the person lives alone, arrange for Meals on Wheels or other groups to provide meals.
• Encourage the person to accept offers when others want to provide meals or other help, remember allowing others to help can help them to deal with your illness as much as it can help you.

As with chemotherapy, support can also be given by:

• driving the person to the treatment facility
• caring for children during treatment
• allowing time for plenty of rest
• being a flexible employer
• encouraging activity when appropriate and participating with the person
• understanding when activity is limited for the person
• being a communicative and listening partner
• helping to seek support from counselors, doctors, nurses, social workers, clergy, friends, and family when needed.

Immunotherapy: What is Involved in Immunotherapy

Immunotherapy, also called biological therapy, biotherapy, or biological response modifier therapy, is treatment that uses certain parts of the immune system to fight disease, including cancer (American Cancer Society, 2004m). The body's natural defense system is known as the immune system (National Cancer Institute, 2004b). The immune system is a collection of organs, specialized cells, and substances that help protect the body from disease (American Cancer Society, 2004f).

"To understand how your immune system works, think of your body as a country, and the immune system as that country's defense forces. Think of viruses, bacteria, and parasites as a hostile, foreign army, because they are not normally found in your body. When they enter your body, they want to use your body's resources to serve their own purposes, and they don't mind hurting you in the process (American Cancer Society, 2004f)."

"Anything that causes the immune system to react (producing an immune response) is called an antigen, from the Greek words anti, meaning against, and genein, meaning to produce. Microorganisms such as viruses, bacteria, and parasites contain substances that are not normally present in the body. These foreign substances cause the immune system to react to them (American Cancer Society, 2004f)."

"Obviously, some people with functioning immune systems still develop cancer. Sometimes the immune system doesn't recognize cancer cells as foreign because the cancer cells' antigens are not different enough from those of normal cells to cause an immune reaction. Or the immune system may recognize cancer cells, but the response may not be strong enough to destroy the cancer. Cancer cells themselves may also give off substances that keep the immune system from doing its job (American Cancer Society, 2004i)."

"Generally, the immune system is much better at recognizing germs than cancer cells. Germs are truly 'foreign' to the body, and their cells differ quite a bit from normal human cells. In contrast, the differences between normal cells and cancer cells may be less clear cut. Continuing the military analogy, cancer cells are less like soldiers of an invading army and more like traitors within the ranks of the human cell population (American Cancer Society, 2004f)."

"Because of this, researchers have designed different types of immunotherapies to help the immune system recognize cancer cells and to strengthen the response so that it will destroy the cancer.

Active immunotherapies stimulate the body's own immune system to fight the disease. Passive immunotherapies do not rely on the body to attack the disease; instead, they use immune system components (such as antibodies) created outside of the body (American Cancer Society, 2004i)."

Immunotherapy uses substances (usually by injection) to try to improve the ability of immune cells to fight infection and disease, including cancer. Some other terms you may hear in reference to immunotherapy are interleukin, interferon, growth factors, or colony-stimulating factors (National Cancer Institute, 2002)."

Three common categories of immunotherapies include:

• Cancer vaccines (active, specific immunotherapies) -- Like other vaccines that use weakened or killed viruses, bacteria, or other germs given to a healthy person to prevent infectious diseases, such as measles, cancer vaccines contains cancer cells, parts of cells, or pure antigen that hope to increase the immune response against cancer cells that are already present in the body. Cancer vaccines are considered active immunotherapies because substances injected into the body are meant to trigger the immune system to respond. They are specific because they don't bring about a generalized immune response ((American Cancer Society, 2004i).
• Monoclonal antibody (MOAB) therapy (passive immunotherapies) -- Researchers are evaluating the effectiveness of certain antibodies made in the laboratory called monoclonal antibodies (MOABs). These antibodies are produced by a single type of cell and are specific for a particular antigen. Researchers are examining ways to create MOABs specific to the antigens found on the surface of the cancer cell being treated. MOABs may be used in cancer treatment in a number of ways:
  • MOABs that react with specific types of cancer may enhance a patient's immune response to the cancer.
  • MOABs can be programmed to act against cell growth factors, thus interfering with the growth of cancer cells.
  • MOABs may be linked to anticancer drugs, radioisotopes (radioactive substances), or other toxins. When the antibodies latch onto cancer cells, they deliver these poisons directly to the tumor, helping to destroy it.
  • MOABs may help destroy cancer cells in bone marrow that has been removed from a patient in preparation for a bone marrow transplant (adapted from National Cancer Institute, 2002).
• Nonspecific immunotherapies and adjuncts -- There are many other types of immunotherapies being used in conjunction with primary courses of treatment or currently under research; however, these are too numerous to mention here. For more information on immunotherapies, see:
  • Biological Therapies: Using the Immune System to Treat Cancer (NCI)
    (http://cis.nci.nih.gov/fact/7_2.htm)
  • Immunotherapy for Specific Cancers (ACS)
    (http://www.cancer.org/docroot/ETO/content/
    ETO_1_4X_Immunotherapy_for_Specific_Cancers.asp)
  • Types of Immunotherapy (ACS)
    (http://www.cancer.org/docroot/ETO/content/
    ETO_1_4X_Types_of_Immunotherapy.asp)

Like other forms of cancer treatment, immunotherapies can cause a number of side effects. Some side effects are specific to the type of immunotherapy being given, but may include: nausea, vomiting, fever, chills, rash, loss of appetite, fatigue, feeling weak, blood pressure changes, bone pain, and muscle aches. The doctor can answer questions about side effects for each type of immunotherapy (National Cancer Institute, 2002; National Cancer Institute, 2004b).

As a friend or family member, the best support you can give is understanding that these side effects may occur and helping out when they do as you would anyone who is feeling bad. If the individual wants company -- stay; do quiet activities together, such as reading, watching TV, or playing games (National Cancer Institute, 2004b). If rest is needed, allow the person peace and quiet.

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References

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• American Cancer Society (2004b). How does radiation work to treat cancer? [on-line].
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  ETO_1_4X_How_does_radiation_work_to_treat_cancer.asp.
• American Cancer Society (2004c). How is radiation given [on-line].
  Available: http:// www.cancer.org/docroot/ETO/content/
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• American Cancer Society (2004d). How often will I receive chemotherapy treatment? How long will it last? [on-line].
  Available: http:/ /www.cancer.org/docroot/ETO/content/ ETO_1_7X_How_Often_Will_I_Receive_Chemotherapy_
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  The_Chemotherapy_Treatment_Be_Given_To_Me.asp.
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  Available: http://www.cancer.org/docroot/ETO/content/
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  family.asp.
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  Available: http:// www.cancer.org/docroot/ETO/content/
  ETO_1_4X_Side_Effects_of_Radiation_Therapy.asp.
• American Cancer Society (2002). Surgery on-line].
  Available: http://www.cancer.org/ docroot/
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  Available: http:// www.cancer.org/docroot/
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Last updated: 6 January, 2008

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