Transcription:
Common Misconceptions About Radiation Therapy for Cancer

Melanie Cole (Host): Radiation oncology is an important part of the treatment of some types of cancers, and people have many misconceptions about this type of therapy, however meeting with a radiation oncologist to discuss any fears can really answer many of your questions that you may have, and may be able to allay some of those fears. My guest is Dr. Shana Coplowitz, she's the Medical Director of Radiation Oncology at St. Luke's Cornwall Hospital's Littman Cancer Center. Dr. Coplowitz, what is radiation therapy and how does it work to kill cancer cells?

Dr. Shana Coplowitz, MD (Guest): So radiation therapy is basically a localized type of treatment for cancer. Essentially it's very similar to when you go for a diagnostic x-ray, the main difference is that radiation that we use for therapeutic treatment is basically a very high-powered x-ray, and thereby it allows us to be very focal, very precise in terms of our treatment, and we really are able to aim the radiation beam and treat the exact area that we want to treat, and we can also minimize treatment to the areas that we don't want to treat. Essentially the way that it treats cancer is it will cause DNA damage, and that's essentially the way that the cancer cells will wind up being killed.

Melanie: And does it only kill cancer cells, or sometimes the surrounding tissues are affected as well?

Dr. Coplowitz: That's a very good question, and many patients ask that same question, and you are 100% correct. So it will also affect normal healthy tissues in the surrounding area, which is one of the reasons that we try to be very precise when we do our treatment planning. The difference between the way that it will affect the cancer cells versus the way that it will affect a normal healthy tissue is that normal healthy tissue has the ability to heal and repair itself. So even though there will be side effects during treatment because it's affecting the normal healthy tissue, it will repair itself, and so the normal healthy cells will not be killed. That being said, sometimes there can be long-term effects from the radiation because of those effects on the normal healthy tissue.

Melanie: It seems, Dr. Coplowitz, that there are so many types of radiation available today. We've heard about IORT, and external beam, internal beam, SBRT, all of these words and letters, and people don't really know what the differences are, or versus short-term radiation, hypofractionated versus the standard course where people go over six weeks. Just explain a little bit about the theory behind radiation and the different types.

Dr. Coplowitz: Yes, so it's definitely a very exciting time in radiation oncology. We're constantly evolving, and constantly coming out with new technique, but basically for the most part, most radiation is external radiation. So IMRT, SBRT, these are all different types of external radiation treatments. Essentially they're just different techniques.

So IMRT is kind of a more sophisticated technique that allows us to more precisely shape the radiation beam and really treat the area that we want. SBRT is a little bit different. So basically it's essentially a very high-powered, very high-dose radiation that we very focally treat a small area, and typically it's done just over a few treatments. So it's a little bit different than IMRT, although sometimes we can use IMRT technique to treat with SBRT.

IORT is intra-operative radiation, so that's actually a little bit different. So that is not external radiation per se, that's actually given at the time of surgery, and it's delivered in the operating room. There's also brachytherapy which is basically either seed implantation, so in prostates we actually can implant radioactive seeds in the prostate. We also sometimes use brachytherapy for gynecologic cancers where we will insert different devices and do the treatments that way.

So there's kind of all different types of techniques of doing the radiation, but probably most people who come for radiation are getting kind of a standard external beam type of radiation.

Melanie: So then how do you plan for an individual patient? And where does radiation therapy fit into the cancer treatment schedule for surgery, if it's breast cancer for example, or even prostate cancer if you're doing a prostatectomy, or breast cancer having a mastectomy or a lumpectomy? Where then does radiation come in, and how do you work with the patient to determine timing and course?

Dr. Coplowitz: So really we follow the NCCN guidelines for when we determine how to sequence radiation, how to give radiation, so it really varies on the type of cancer that the patient has, and it's pretty standard and really there's just convention as to how we do it. So for example, for breast cancer, typically the radiation is kind of the last thing. So the patient will have chemotherapy and surgery, and then will have the radiation as the last thing. For prostate cancer, sometimes we're treating prostates definitively with radiation where the patient is not having surgery. If the patient does require radiation in conjunction with surgery, then typically it's given after surgery. And really for most types of cancers, these are kind of done by convention, standardly. And in terms of how we figure out the dose of radiation to give, so typically we're doing that based on evidence.

So for each disease site that we're treating, there have been many large clinical trials that look to see what is the appropriate dose of radiation. And different types of cancers are more responsive to radiation, some cancers are more sensitive to radiation, some cancers are less sensitive, some cancers we know require higher doses of radiation. So for example, for prostate cancer, oftentimes patients are coming for nine weeks of treatment, which seems like quite a lot of radiation, but there have been many good studies that have looked at this and have shown that because of the way that prostate cancer grows, it's a very slow-growing type of cancer, we actually require higher doses of radiation to treat it appropriately. And so that's why we're typically treating patients for nine weeks.

That being said, there have been lots of studies now looking to see whether we can shorten that, and so sometimes we'll use a bit of a higher dose of radiation with each treatment, and thereby we can shorten the treatments sometimes down to about five and a half weeks of treatment. So kind of different, different evidence-based medicine really to determine the appropriate numbers and treatments for each type of cancer.

Melanie: There are many misconceptions, and people are really concerned about the radiation and radiation therapy. So one of the myths; does radiation therapy make a patient radioactive?

Dr. Coplowitz: Yes, that is definitely a big one. I get asked that a lot, and so the easy answer is no. So anytime a patient received external radiation, when they're in the room - when they're in the treatment room - the machine will be turned on, and at that point the radiation is on, it's being delivered to the appropriate body part. As soon as the radiation is turned off from the machine, that's it. There's no radiation, the patient is not radioactive. They can be around children, they can be around pregnant women, it's not a problem.

The only time patients are radioactive is if they get a seed implantation. So for example in prostate cancer, if they get a prostate seed implant, then they will be radioactive. Also sometimes we actually will give oral iodine for patients who either have thyroid cancer, or even for patients who have overactive thyroids who don't have cancer, and in those cases they are also radioactive typically for about two or three days.

Melanie: Another myth is that radiation treatments can be painful and cause burning of the skin. People have been talking about that, and oh you hear about somebody on the Internet had a terrible reaction. Tell us about that myth.

Dr. Coplowitz: Yes, so I think there kind of have been a lot of horror stories, and some of that I think is probably related to the way that we used to do radiation years ago when we really did not have sophisticated planning techniques. Nowadays we have much more sophisticated planning techniques and we really pay close attention to the skin dose. And so other than skin cancer, when you really want to treat the skin, we're really trying to avoid giving high doses to the skin.

That being said, different body parts do sometimes have more skin reactions than others. So for example when we treat breast cancer, patients do typically develop some type of skin reaction. It's often difficult to predict which patients will have a worse reaction than others, but sometimes it does happen that people will have peeling, what we call desquamation of the skin. And you know, we do monitor our patients at least on a weekly basis if not more often to make sure that they're not having those reactions. And if they do, we have lots of things that we can do to treat it, lots of creams that we give, and different things that we can make it improve and heal. And you're right though, it can sometimes be uncomfortable, and we do try to control pain as well if that happens.

Melanie: Speak about the radiation oncology process from consult to follow-up. Does the patient work with the radiation oncologist? Because certain other fields like pathology, you never meet your doctor, but radiation oncology is different. So speak about that process.

Dr. Coplowitz: So in radiation oncology it's really nice because our patients come on a daily basis usually for anywhere from five to up to nine weeks of treatment, and so we really get to know the patients quite well because we're seeing them very often. So when they come for consultation, that's usually the first visit, that's when I meet them and we'll sit down, I'll kind of take a detailed history, get all the information regarding their cancer, regarding any treatments they may have had so far. Also very important to find out if they have any history of prior radiation, if they have any history of connective tissue disorders, all that stuff is important. And then we'll sit down and I'll kind of explain the entire process of the radiation, explain how many treatments they're going to be getting, and then the next time they come will be for the planning session, we call it the stimulation, and essentially what that is, is a CAT scan and we use the images from that CAT scan to plan out their radiation treatment. So they come for that stimulation, we do the scan, we set them up in the treatment position, and then we will give them a little tiny permanent tattoo mark that we use to set them up for their treatment every day.

After that procedure, they will go home and we will work on their plan which can take anywhere from a day for a really simple plan, up to a week for a really complicated plan. And then they will actually come back and do their treatments. And like I said, they're coming every day, and I'm typically seeing them at least once a week while they're undergoing treatment, and if they're having concerns or issues, I will see them more frequently. And then once they're done with the treatment I follow them up. Specifically I would like to see my patients back a month after they're done with their treatment, and then I try to follow them up fairly regularly afterwards to make sure that they're not developing any long-term or any late side effects from the radiation.

Melanie: Are there any special dietary needs or work requirements during radiotherapy? Is it very fatiguing, Doctor? Does it kind of limit some of the quality of life, or not really?

Dr. Coplowitz: So fatigue can definitely be an issue during radiation. That's actually one of the only systemic side effects of radiation. So most of the other side effects depend upon the area that we're treating, but fatigue definitely can be there regardless of the area that we're treating. So that can certainly be an issue, but otherwise in terms of dietary restriction, it really depends on the area that we're treating. So for example breast cancer treatment really are not going to have any type of weight issues or need any diet modifications during treatment, so that's usually not a problem. However when we treat, for example, head and neck cancer patients, they tend to have a lot of difficulties with swallowing, they tend to lose a lot of weight during treatment, and so we really do work with them to try and make sure that they're maintaining their weight, and we actually have nutritionists here on staff that will meet with them on a regular basis, and we pay very close attention to that. And unfortunately sometimes people do wind up needing to have feeding tubes placed during those types of treatment as well.

Melanie: Wrap it up for us, Dr. Coplowitz with your best advice and information. When you get all these questions from people about the misconceptions, myths, and fears about radiation therapy, what do you tell them every day and what would you like the take home message to be about the Littman Cancer Center and the radiation therapy that you work with every single day?

Dr. Coplowitz: I think the major thing is that people don't really know about radiation. It's not really something that they have much experience with, and so they tend to be very scared of it, and I think the take home message really needs to be that we are trying to make this process as easy and as pleasant as possible, and if they do have concerns, if they do have issues they should bring it up as soon as it comes up because we will try to work with them. But really for the most part, we are here for them and I do want to make the radiation process as easy and as painless as possible.

Melanie: Thank you so much for being with us today and sharing your expertise with this really important topic. This is Doc Talk presented by St. Luke's Cornwall Hospital. For more information, please visit www.StLukesCornwallHospital.org. That's www.StLukesCornwallHospital.org. I'm Melanie Cole, thanks so much for tuning in.