Series No. 39 - Stereotactic ablative body radiotherapy (SABR) for lung cancer

We want to involve you in all the decisions about your care and treatment. If you decide to go ahead with treatment, by law, we must ask for your consent and will ask you to sign a consent form. This confirms that you agree to having the procedure and understand what it involves. Staff will explain all the risks, benefits, and possible alternatives before they ask you to sign a consent form.

If you are unsure about any aspect of your proposed treatment, please do not hesitate to speak to the team looking after you.

During your time with us we aim to provide the highest standards of care and support you in your decisions regarding your treatment. We will respect your dignity, individuality, and personal preferences.

Your care will be managed and given by therapeutic radiographers, doctors, and nurses. You will meet both male and female healthcare professionals during your treatment. If you have any concerns about this, please talk to the radiographers about it. We try to be sensitive to your needs, so please do not hesitate to discuss things with the team caring for you.

If you are of an age where you can get pregnant (12 to 55 years old) and capable of becoming pregnant (you have a womb), you will be asked to confirm that you are not pregnant.

You must tell the staff immediately if there is any chance of you being pregnant at any time during your treatment. You should not become pregnant for at least four months after radiotherapy.

If you can conceive a child (you have testes), you should not conceive a child for at least four months after radiotherapy treatment.

All patients should use reliable contraception throughout this period. If you have any further questions or concerns, please talk to your radiotherapy doctor, specialist nurse or specialist radiographer involved in your care.

1. You will see a clinical oncologist who will explain your diagnosis and discuss treatment options with you. You will also meet the lung specialist radiographer.
2. You will be consented for radiotherapy.
3. Radiotherapy treatment planning appointment - First, you will have a personalised support made for your head and chest area. You will then have a planning CT scan, using intravenous contrast dye if required.
4. First treatment - Your first treatment will be 2-3 weeks from your planning scan. Each treatment will take approximately 30 minutes.
5. Review clinics - You will be reviewed weekly during treatment, either in person or by phone, by the lung specialist radiographer. All review clinics are in the radiotherapy department and are timed with your treatment.
6. Treatment complete - You will have a telephone consultation with the lung specialist radiographer two weeks after radiotherapy has ended. You will be reviewed by your clinical oncologist, as an outpatient, four weeks after your treatment course has completed. This may be a telephone consultation, or if face-to-face, will be held in the UCLH Macmillan Cancer Centre.

Radiotherapy appointments: All take place in the Radiotherapy Department, basement floor, main UCH hospital building.

Radiotherapy is the specialised treatment of cancer (and some other diseases) using high energy radiation beams. These can either be x-rays (also called photons), electrons or protons. X-rays and electrons are delivered from a machine called a linear accelerator whilst protons are delivered from a machine called a cyclotron.

UCLH is one of two NHS proton beam therapy (PBT) centres in the UK, alongside The Christie in Manchester. Proton beam therapy (PBT) is an advanced form of radiotherapy. However, it is not appropriate to treat all tumours with proton beam therapy. The most appropriate treatment for you will be decided by your clinical oncologist and discussed with you.

Radiotherapy works by damaging cancer or tumour cells in the part of the body being treated. The radiation stops the cells from dividing and growing. Radiotherapy can also damage nearby normal cells. The normal cells are more likely to recover from the effects of the radiation than the cancer or tumour cells. The clinical team take great care to reduce the radiation dose to a person’s healthy cells.

Radiotherapy does not hurt, and it will not make you radioactive. You will be completely safe to be around family, friends, and pregnant people. You will feel nothing from the treatment and the machine will not touch you. It is rather like having an ordinary x-ray. The most important thing is for you to lie very still for treatment.

SABR is a precise radiotherapy technique which is a more effective way of treating patients with primary or secondary lung cancers. SABR gives a high dose of radiotherapy to a small portion of the lung.

The possible benefits of SABR are:

• Increased chances of tumour control compared to standard radiotherapy
• Higher doses of radiotherapy per treatment resulting in fewer visits
• Numerous beams being used, sparing the normal tissues from higher doses of radiation, thereby minimising any side effects

Depending on your lung function and general health, you may be offered standard daily radiotherapy, or a short course of palliative radiotherapy to control any symptoms you may be experiencing. Your radiotherapy doctor will be happy to discuss any concerns you may still have.

Your SABR must be carefully planned. Your first appointment will be to the radiotherapy mould room. You will be asked to change into a hospital gown and remove all clothing down to your waist. You will be asked to lie on your back on a couch with your arms above your head. You will have a personalised support made which will help you keep still during treatment and ensure you are in the same position each day.

It is important that you are comfortable and that you are breathing normally. If you are in any discomfort during this process, please tell a member of the team. You will then be taken for a radiotherapy CT planning scan to gain information of the area to be treated whilst you are lying in the treatment position.

When it is time for your scan the radiographers will take you in to the CT scanner room. The radiographers are there to explain the procedure and to answer any questions you may have. The radiographers will ask you to lie on the CT couch.

You will lie on your personalised support. A small lightweight plastic box will be placed on your stomach to monitor your breathing. If you have any problems maintaining a steady breathing pattern, we can offer you breathing coaching to help with this. You will feel the bed move in and out of the scanner. You will pass through the scanner several times. The radiographers will be watching you the entire time.

When the scan is done, and the radiographers have checked the images they will re-enter the room. The radiographers will then mark several specific points (also called tattoos) on your chest. These are alignment marks to ensure each treatment is accurate. The marks are permanent and are done by placing ink on the skin and then gently scratching the surface of your skin with a fine needle. The whole CT process may take up to an hour to complete.

You won’t feel anything during the scan. All we ask is that you lie still and breathe normally. After the scan is completed, you will be free to leave. Before you go, you will be given an appointment card with the date and time for your next visit, which will be your first treatment.

You may have some dye (also called contrast agent) injected into your arm via a temporary cannula. The dye makes the images clearer for planning your treatment. If you need this, the radiographers will explain what is happening before and during the process.

Treatment starts 2-3 weeks after your planning scan. Patients will normally receive their treatment as an outpatient. SABR is usually given in three, five or eight treatment sessions, each lasting about an hour. Each session will be at least a day apart, for example, Monday, Wednesday and Friday, including bank holidays. Your clinical oncologist or lung specialist radiographer will tell you how many treatments you will receive. The treatment radiographers will explain the procedure to you and answer any questions you may have.

Before each treatment, the radiographers will you ask you to change into a hospital gown and remove all clothing down to your waist. They will then escort you in to the treatment room.

For each treatment session will be lying on your personalised support on the treatment couch. The radiographers will ensure you are in the correct treatment position by aligning the tattoos on your chest with laser lights. They will then move the treatment machine and couch into position using your personal treatment plan. Once you are in the correct position, and the final checks completed, the radiographers will leave the room.

The radiographers will take X-rays and CT scans before, and sometimes after, your treatment. These images are to check your treatment remains accurate. When treatment is being delivered, the machine will move around you but will not touch you. You will not feel anything, and you do not have to hold your breath. All we ask is that you keep still and breath normally. The radiographers will be watching you at all times on a closed-circuit television. You will be able to speak to them at any time via a two-way intercom. Each treatment session will take around 20 minutes.

There will be some side effects which will gradually appear during your course of treatment. These effects will vary from patient to patient. There are side effects occurring during treatment, some happening soon after treatment, and some appearing months or years after radiotherapy.

The risk and severity of side effects occurring will depend on the dose of radiotherapy given and the exact area which receives treatment. Your doctor will discuss the risks of treatment with you before you sign a consent form. However, there will still be plenty of opportunity to talk about anything that you feel needs further discussion.

Skin changes

The effects of radiotherapy on the skin are usually mild for this type of treatment. However, towards the end of treatment and for a couple of weeks after, you may notice that your skin in the area being treated may gradually become pink /red or darker, depending on your skin colour.

During treatment we advise that you wash normally using warm water and the soap products you would normally use. Gently pat your skin dry with a soft towel. Radiotherapy skin reactions cannot be prevented, but to minimise any skin irritation we recommend using a moisturiser of your choice. Use the moisturiser frequently and gently smooth it on to your skin until it is absorbed. You do not need to wipe the moisturiser off before treatment, but please do not apply moisturiser immediately before treatment. If your moisturiser starts to irritate your skin stop using the moisturiser and let your team know. They will refer you to the radiotherapy review team for appropriate skin care.

If you do not currently use a moisturiser, then speak with your radiotherapy team and they will be able to suggest some options for you. We recommend that you patch test any new moisturising product you are using on an area of your body that is not the treatment area, to ensure you do not have a reaction.

How can I help myself?

By following this advice, you may keep your skin in good condition and feel more comfortable. This only applies to the skin in the area being treated.

• Wear loose-fitting, natural fibre clothing, such as cotton or silk, next to the skin.  
• Avoid tight or underwired bras as these may rub your skin and make it sore. During treatment you may find cotton crop tops, camisoles or vests are better than bras as they do not rub. • You can continue to use the deodorant you normally use unless it irritates your skin. If your skin becomes too sore, stop using deodorant.
• You may go swimming if your skin has fully healed from surgery and is not peeling from treatment. Always shower immediately afterwards to wash off any chlorine and apply moisturiser. Please stop swimming if it irritates your skin.
• Do not apply any cosmetics, perfumes, or aftershaves to the skin in the treated area.
• Avoid the use of plasters in the area being treated.
• Avoid rubbing or scratching the skin in the treatment area.
• Avoid extremes of temperature such as heating and cooling pads.
• Avoid sun exposure and protect the area from direct sunlight. Continue to protect the area from the sun for at least one year after you have finished treatment. Because your skin will be more sensitive, always use a sunscreen with a high sun protection factor.
• Do not wet shave or use hair removal creams under your arm on the treated side as these can irritate your skin. You may use an electric shaver for removing hair in the treatment area during your radiotherapy unless it is found to irritate the skin.
• To improve your overall health, try to drink 6-8 glasses of water a day and eat a nutritionally well-balanced diet.

Tiredness – 25 in 100 patients

Tiredness is a very common side effect of radiotherapy. You may feel more tired than usual and have less energy, both during and after treatment. Do not worry, this is normal. It is usually a combination of travelling to hospital every day, the side effects of treatment, coping with a diagnosis of a tumour and continuing with normal life. Tiredness usually improves between six months to a year after treatment.

We recommend that you listen to your body. Do as much as you feel you can and rest when you need to. Pick out the things that you enjoy and try to ask others for help with other tasks. Try to get a good night’s sleep where possible. Have enough water to drink to prevent tiredness from dehydration. Gentle exercise has been found to improve fatigue levels in patients and we would recommend walking as a good form of exercise.

Please tell us if you are finding things difficult, as we will be able to offer practical advice and information.

Cough – 14 in 100 patients

You may notice an increase in a dry or productive cough. This is due to the radiotherapy causing inflammation of lung tissue, but this reaction should settle down when your treatment is over. If the cough is persistent, you are unwell, or you have any concerns, inform the radiographers or lung specialist radiographer who can refer you to the doctor.

You may also notice blood in any sputum that you produce. Please inform the lung specialist radiographer if you notice this. The bleeding may be the effects of the radiation and should resolve in a short while.

Chest pain – 11 in 100 patients

You may develop pain or aches in the area being treated due to the radiotherapy causing inflammation of the tissues. This is usually mild and relieved with simple pain killers. If you develop severe pain that is troubling you, please speak to the lung specialist radiographer or radiographers treating you. They can arrange for the doctor to prescribe medication for you.

Breathlessness – 10 in 100 patients

Radiotherapy to the lung may cause inflammation in the lung tissue. Due to this inflammation or “pneumonitis” you may develop symptoms of increased breathlessness, wheezing, fever or cough towards the end of treatment, or after treatment has finished. This should get better on its own within a few weeks. Some patients, however, may require a short course of steroid tablets to settle the inflammation. In severe cases (2 in 100 patients), hospitalisation and supplementary oxygen are required. If you are worried, or if the side effects continue for longer, please contact your radiotherapy doctor, lung specialist radiographer, specialist nurse or GP.

Eating and swallowing

During your radiotherapy treatment, you are advised to maintain a healthy well-balanced diet. If you do not feel like eating, try small regular snacks and supplement these meals with high calorie drinks, which can either be bought from the chemist, given by the dietician or prescribed by your doctor or GP. The radiographers will also give you advice on nutrition or refer you to the dietician.

Feeling sick (nausea)

Please inform the radiographers or lung specialist radiographer if this happens. The doctor can prescribe anti-sickness tablets to help alleviate any symptoms. If you are feeling sick you may not feel like eating, so you can be referred to the dietician who can offer advice.

Hair loss

There may be a temporary loss of chest hair (in male patients) in the treatment area. This is a normal reaction. The hair usually grows back within a few months once the treatment is over. However, sometimes hair loss may be permanent, depending on the dose of radiotherapy given.

It is recommended that you should stop smoking not only during your radiotherapy treatment, but altogether. Continuing to smoke during treatment will worsen any side effects you may experience and may decrease the effectiveness of treatment. Your specialist lung radiographer or lung clinical nurse specialist will be able to offer practical support if you wish to stop smoking.

At your first treatment appointment the radiographers will discuss the treatment with you and explain any possible side effects you may experience. They will see you every day and ask how you are and how you are feeling. During treatment you will be assessed on a weekly basis by the lung specialist radiographer who will monitor your side effects and review your progress.

Late side effects incurred during treatment can appear to develop many months or years after radiotherapy has finished. They are the hardest to accurately predict and, are dependent on which part of the lung is being treated. If late side effects do occur, they are usually permanent. Your doctor or lung specialist radiographer will discuss the possibility of these late side effects with you, at the time you sign your treatment consent form.

Skin changes

Some patients may experience pigmentation of the skin in the treated area. This may vary from light to a darker brown. The skin in the treatment area may feel “leathery” due to a loss of elasticity and suppleness.

Approximately 1% of patients may develop dilation of the tiny blood vessels in the skin, called telangiectasia. Although this is not painful, it can cause red or purple areas on the treated skin, which look like spidery marks. Dilation occurs because the capillaries are compensating for the destruction or narrowing of other blood vessels, due to the radiotherapy.

Lung scarring/collapse

Lung SABR treatment will cause scarring of the lung tissue in the area where the cancer was treated. This scarring is permanent and can cause a small portion of the lung to collapse. The precise planning of your treatment keeps this amount of lung scarring/collapse to a minimum. However, in some patients this scarring and collapse can make you become more breathless than before treatment.

Rib fractures – 3 in 100 patients

For tumours close to the ribs there is a chance that the radiotherapy may weaken the ribs and cause pain or rib fracture. For most patients, this does not cause any symptoms and is discovered when you have a scan after the treatment. This is treated with painkillers whilst the bone heals.

Brachial plexopathy – less than 1 in 100 patients

For tumours close to the top of the lungs, there is a very small risk of the radiotherapy treatment damaging the nerves going to the arm. This would mean that there may be weakness or numbness in part of the arm. The chances of this happening are very small. Great care is taken when planning your treatment to avoid or minimise the doses of radiation to these nerves.

Second malignancy

Less than 1% of people who have received treatment for one tumour may develop another type of tumour in the treated area some years later. The radiotherapy doctors will discuss this risk if it is relevant to you.

This page deals with the physical aspects of your treatment, but your emotional wellbeing and that of your family is just as important. Having treatment can be deeply distressing for some patients. Within the radiotherapy department there will be access and support from the lung specialist radiographer, the radiotherapy review team, the treatment radiographers and the Macmillan information and support team.

However, if you feel you require further medical or emotional support you can be referred to a variety of health professionals who can help with any worries or difficulties you may be having.

The side effects you are experiencing will continue after treatment has finished. It is common to experience a worsening of any side effects reactions for several weeks after SABR after radiotherapy. You will have a telephone consultation with the lung specialist radiographer two weeks after radiotherapy has ended. If you are worried, or have any questions, please call the lung specialist radiographer, or your clinical nurse specialist.

You will be reviewed by your clinical team, as an outpatient, four weeks after your SABR has completed. This may be a telephone consultation, or if face-to-face, will be held in the UCLH Macmillan Cancer Centre.

Your clinical team will discuss your follow up schedule with you, but in general you will be seen every three months for the first year after treatment. Thereafter, if all is well the frequency will decrease to six monthly appointments for up to five years, with regular CT scans.

If you have been referred to us from another hospital your follow up will be performed back with your local team.

My clinical oncologist is:

My lung specialist radiographer is:
They can be contacted on: 020 3447 3714/ 07977 098155

My lung clinical nurse specialist is:
They can be contacted on: 020 3447 2161

Radiotherapy Reception
t: 020 3447 3700/3701

Radiotherapy Review Team (via Radiotherapy Reception)
t: 020 3447 3700/3701

Macmillan Radiotherapy Support Worker
t: 020 3447 3780

Out of hours oncology advice number (available 24 hours)
m: 07947 959020

If you have any concerns that you would like to discuss in confidence, please contact our PALS (Patient Advice and Liaison Service) for information and advice.
t: 020 3447 3042
w: www.uclh.nhs.uk

Roy Castle Lung Cancer Foundation
t: 0333 323 7200
w: www.roycastle.org

British Lung Foundation
t: 0300 222 5800
w: www.blf.org.uk

NHS Smoking Help Line
t: 0300 123 1044
w: www.nhs.uk/smokefree

Maggie’s (Providing cancer information and support in centres across the UK and online)
w: maggies.org

Live Though This (cancer support for LGBTIQ+ community)
w: www.livethroughthis.co.uk

Life After Cancer
w: www.life-aftercancer.co.uk

Macmillan Cancer Support
t: 0808 808 0000
e: cancerline@macmillan.org.uk
w: www.macmillan.org.uk

Cancer Research UK
t: 0808 800 4040
w: www.cancerresearchuk.org

Carers UK
t: 0808 808 7777
e: adviceline@carersuk.org
w: www.carersuk.org

NHS Choices
w: www.nhs.uk

UCLH cannot accept responsibility for information provided by other organisations.