Series No.57 - Radiotherapy for cancers of the abdomen

Radiotherapy is a specialised form of treatment for cancer that uses high energy radiation beams. X-rays are most commonly used for radiotherapy to the abdomen and are delivered from a machine called a linear accelerator (linac).

Radiotherapy does not hurt, and it will not make you radioactive. You will be completely safe to be around family, friends, and pregnant women.

Patients will normally receive their treatment on an outpatient basis, attending the radiotherapy department for each session. A course of treatment could last up to 6 weeks.

Appointments are generally on weekdays (Monday to Friday), with weekends off. Your exact treatment schedule will be decided by your doctor and confirmed on your first visit to the radiotherapy department.

Everyone’s treatment is different and is planned individually. During the course of your treatment, you will meet both male and female staff and students.

If you have any concerns about this, please talk to one of the radiographers about it. We will always try to accommodate your needs so please do not hesitate to discuss things with the team caring for you.

The abdomen is the area in between the chest and the pelvis, and includes the digestive organs such as the oesophagus, pancreas, liver, stomach, and gallbladder.

Radiotherapy is a common form of treatment for cancers in the abdomen and can be used in combination with surgery and chemotherapy. Together, you and your doctor will consider the risks and benefits of the different treatment options and decide which treatment(s) are best for you.

Radiotherapy works by damaging cancer cells in the part of the body being treated. The aim of radiation is to stop cancer cells from dividing and growing.

Radiotherapy can also damage normal cells in the area, which are more likely to recover from the effects of the radiation than cancer cells.

Doctors take great care to reduce the radiation dose to a person’s healthy organs when they are having radiotherapy treatment.

You will be seen by an oncologist to discuss your treatment process. They will be able to answer any questions you may have.

If radiotherapy is recommended for your treatment, and once you have received all the required information, the doctor will ask you to sign a consent form agreeing to the radiotherapy procedure.

What will happen if I choose not to have radiotherapy?

During your clinic appointment, the oncologist will discuss all available treatment options with you, however ultimately you must agree to the proposed treatment plan.

You have a right to change your mind at any point and withdraw consent to treatment.

Prior to each appointment, you may be asked to follow special instructions, such as stomach preparation. This is important during your treatment in order to try:

• Improve the accuracy of your treatment.
• Reduce the risk of any long-term side effects.

Depending on your treatment plan, we may ask you to:

• Fast (not eat or drink) for two hours before the appointment. You may eat a small meal or light snack before the two-hour period.
• Be asked to drink approximately 200ml (two cups) of water during the appointment. Please wait until instructed by a radiographer to do this.

We will let you know what preparation, if any, to do before your appointment with us.

It is important that you understand and follow the instructions for planning and treatment preparation given to you.

Before starting radiotherapy, your treatment must be carefully planned. You will need to come to a radiotherapy planning appointment a few weeks before your radiotherapy starts. A radiographer will explain the process to you and complete pre-treatment paperwork.

To plan your treatment, you will have a radiotherapy planning CT (computerised tomography) scan of your abdomen. This scan locates the exact site of the area to be treated in relation to surrounding normal tissues.

Allow up to two hours for this session.

When it is time for your scan the radiographers will take you in to the room. You will be asked to change into a hospital gown and remove all outer clothing, including shoes (socks and underwear can stay on).

The radiographers will place specialised pillows under your head and legs to support them and to ensure you are in the correct position. We may make a specialised full body cushion to support you. We will try to keep you covered up as much as possible during the procedure but will need to be able to see and make pen marks on your skin in the lower chest or abdominal area.

The radiographers will take some measurements recording the position you will be in for treatment. The scan itself will take about five to ten minutes. During the scan you may be given an injection of a special dye (contrast agent) that will help us see your organs and vessels 8 more clearly. The doctor will use these images alongside other scans you will have had to plan your treatment.

The radiographers will then mark three or four specific points (also called tattoos) on your lower chest or abdomen. These are alignment marks to ensure treatment accuracy on a daily basis. They are permanent and are done by placing ink on the skin and then gently scratching the surface of your skin with a fine needle.

You may be asked to hold your breath for around 20 seconds during a certain portion of the scan; we will give you more information at the beginning of your planning session if you require this.

Depending on your treatment plan, you may require the use of a device known as abdominal compression, which is used to limit how much your abdomen moves with breathing. When in position, the belt will be slowly inflated to restrict how much your abdomen moves when breathing.

This may feel uncomfortable but should not be painful at any point. You will have a chance to try using this belt before the scan is done, to get used to how it feels. The belt will be used for the first appointment to plan your treatment, and for all subsequent treatment appointments.

If abdominal compression is an option for your treatment, your doctor would have indicated this during your clinic appointment.

For each radiotherapy appointment, you should allow up to two hours in the department to account for preparation, treatment, and any potential delays. It is important that you understand and follow the instructions for treatment preparation given to you, so please ask a member of staff if you are unsure about any of the information you’ve been given.

Prior to your appointment, you may be asked to drink a specific amount of water, the same as at your planning scan. It is advisable to wait until you are instructed to do this by the radiographers looking after you.

A member of staff will take you to the treatment room, where you’ll be asked to remove outer clothing including shoes (socks and underwear can stay on) to change into a hospital gown. This is so that your position is exactly the same as at your planning scan appointment.

You will be asked to lie on the treatment machine (linac) couch in the same position as at your planning CT scan and take measurements to ensure you are in the correct position.

The radiographers will move the gown to see the tattoo dots on your skin, keeping you covered as much as possible. The room lights will be dimmed, and the radiographers will move you so that you are in the correct position. Once the final checks have been made the radiographers will leave the room. You will hear a loud buzzing noise as they leave.

You will not feel anything from the treatment, but you will need to lie still and breathe normally throughout the procedure. The radiographers will be watching you at all times from outside on a closed-circuit camera. If you need assistance during the procedure, just raise your hand. The linac will move around you but will never touch you.

You may hear a buzzing noise when it switches on but will not feel or see anything.

Each treatment will last between 20-40 minutes and will generally follow the same process from day to day. Once your treatment has finished, the radiographers will come back into the room and help you off the couch.

You will then be free to get dressed and leave the department.

Chemotherapy can increase the activity of radiotherapy against cancer cells. Some patients will be given drug treatment (chemotherapy) during their course of radiotherapy treatment or may have completed their course of chemotherapy before they start radiotherapy.

Other patients may not receive any drug treatment. Your doctor will tell you which chemotherapy regimen you will be having, if it is required for your treatment.

Patients receiving chemotherapy and radiotherapy may experience more severe or additional side effects to those listed here, depending on the drug regimen used. Your doctor will discuss these issues with you. You will be given medicines to control any side-effects if required.

You will be given detailed fact sheets about any chemotherapy drugs you may receive by the doctor or a member of the team.

Although you will not feel anything during treatment, there will be some side effects which will gradually appear during your course of radiotherapy. 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 the radiotherapy. Your doctor will discuss all the risks of treatment fully 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.

The most common side effects that occur during treatment are discussed below. Radiotherapy is associated with different side effects from chemotherapy.

At least 20 out of 100 people will have these side effects:

• Tiredness. This is usually temporary and improves five-six weeks after radiotherapy is completed.
• Rash, redness, itchiness, discomfort in skin.
• Temporary, symptom free changes to your liver blood tests.

Occasional - five to 20 people out of 100 people receiving radiotherapy may experience:

• Feeling sick or being sick.
• Stomach and bowel irritation or bleeding, narrowing of your bowels, or changes in bowel movement following radiotherapy, some of which may be permanent (one in 10) and may require medication and sometimes surgery.
• Pain in chest.
• Rib fracture.
• Damage to your liver may occur within three months of starting radiotherapy. This could affect how well your liver works and can sometimes show as yellow skin and eyes (jaundice). There is an increased risk of side effects to the liver if you have a large tumour or previous history of liver disease.

Fewer than three out of every 100 patients will have these side effects:

• Radiation-induced liver disease (RILD). This would be confirmed by clinical diagnosis of fluid in the abdomen, enlargement of the liver and changes in your liver tests that may occur two weeks to three months following radiation to the liver. RILD can lead to liver failure, but this will be managed with medication.
• Bleeding caused by low number of platelets (blood cells that clot blood).
• Kidney injury.

There is a small increase in the risk of death for patients treated with chemotherapy in combination with radiotherapy.

We will be monitoring you very closely for side effects and we will give you treatment to help prevent or reduce them. In some cases, we may need to temporarily stop your treatment until your side effects improve. If you have severe side effects, we may need to permanently stop your treatment.

Fatigue

Fatigue 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 cancer and continuing with normal life.

We recommend that you listen to your body. Do as much as you feel you can and rest when you need to. However, gentle exercise has been found to improve fatigue levels in patients and we would recommend walking as a good form of exercise.

Please let someone know if you are finding things difficult, as they may be able to offer practical advice.

Nausea and vomiting

During radiotherapy treatment, organs such as your stomach or small bowel may get some of the dose, which may make you feel sick (nausea). Sometimes people may actually get sick (vomiting). These side effects may develop as the treatment goes on and may last for a few weeks after treatment has finished.

You may be given anti-sickness medication by your doctor to help.

Diarrhoea

You may experience changes in your bowel habits, such as loose stools (diarrhoea) and, less commonly, abdominal pain.

Drinking plenty of fluids every day throughout your treatment is important to ensure you remain hydrated and speak to a member of your team if you experience either diarrhoea or abdominal pain.

Appetite

It is important that you try to eat a nourishing, balanced diet throughout your treatment, to help you feel stronger and more able to cope with treatment. It is also important to drink plenty of fluids (two litres a day) during your radiotherapy treatment.

Some people experience a loss of appetite during radiotherapy. This may be due to the illness itself, but also to a number of other factors such as anxiety about treatment, or side effects of radiotherapy and chemotherapy. Heartburn and indigestion may also make you feel less hungry.

If you do experience any significant weight loss or would like to speak to someone about your diet, you can be referred to specialist dietitians.

Skin changes/hair loss

Your skin in the area being treated may become discoloured, dry and more sensitive. Your skin may become pink or slightly darker. It is usual for the skin reaction to begin two to three weeks from the beginning of radiotherapy and usually settle down a few weeks after the radiotherapy is finished. During treatment we recommend that you shower using a non-perfumed soap.

It is not advisable to sit and soak in a hot bath, as this may irritate your skin.

Who can I discuss my side effects with?

At your first appointment the radiographers will discuss the treatment with you and explain any possible side effects that you may experience. They will see you every day and ask how you are and how you are feeling.

You will also be seen weekly - either by your doctor or a member of the team - in a clinic to discuss any side effects that you may be experiencing. It is important to tell your treatment team if you are experiencing any side effects or are having any difficulties.

Late side effects of radiotherapy (after completion of treatment)

Second malignancy

X-rays and gamma rays are types of ionising radiation which may cause cell damage that can, after many years or decades, become cancerous. In view of your clinical condition the risk of this happening to you is very small.

Please talk to your doctor or specialist nurse if you have any concerns about this.

This page deals with the physical aspects of your treatment, but your emotional well-being is just as important. Having treatment can be a distressing time.

Within the radiotherapy department there will be access and support from the radiotherapy care team, the treatment radiographers, the Macmillan radiotherapy support workers and a Macmillan information and support radiographer. However, if you require further medical or emotional support you can be referred to a variety of health professionals specialising in patients’ needs.

All members of staff at UCLH are here to make sure your treatment goes as smoothly as possible, and to support you through this difficult period. We are happy to help you with any questions or problems you may have.

Once your radiotherapy treatment has finished, you will be given a follow-up appointment to see your radiotherapy doctor in four to six weeks’ time. Any side effects experienced during treatment can often begin to improve after around two weeks).

During this time, you should continue to follow the advice given to you during your treatment. Continue to use any prescribed medications for the side effects until they settle down. Please feel free to contact the radiotherapy department, the radiotherapy care team, or your specialist nurse if you are worried about any side effects after treatment.

You could also contact your GP or call the outpatients to request an earlier follow-up appointment.

GI Oncology Secretaries
Direct telephone: 020 3447 9093
Main switchboard: 020 3456 7890

Radiotherapy Review Team
Direct telephone: 020 3447 3705

Macmillan Radiotherapy Support Workers
Main switchboard: 020 3456 7890 bleep 3407/ 3404

Macmillan Information and Support Radiographer
Direct telephone: 020 3447 3711
Main switchboard: 020 3456 7890 bleep 1458

Macmillan Cancer Support Cancer Line
Freephone: 0808 808 0000
Email: cancerline@macmillan.org.uk
Website: www.macmillan.org.uk

Cancer Research UK
Information Line: 0808 800 4040
Website: www.cancerresearchuk.org

Pancreatic Cancer UK
Support Line: 0808 801 0707
Website: www.pancreaticcancer.org.uk

AMMF (Cholangiocarcinoma) Charity
Telephone: 01279 661479
Website: www.ammf.org.uk

British Liver Trust
Telephone: 01425 481320
Website: www.britishlivertrust.org.uk

We hope that you have found this page helpful. If you have any questions or other worries and would like to speak to someone, please ask a member of staff.

Please note: University College London Hospitals NHS Foundation Trust cannot guarantee the quality of the information or advice provided by outside organisations and charities.

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:
Email: PALS@uclh.nhs.uk
Telephone: 020 3447 3042 

• Pancreatic Cancer UK (2019) ‘Radiotherapy for Pancreatic Cancer’ [Online] Available at: www.pancreaticcancer.org.uk/information-and-support/treatments-for-pancreatic-cancer/radiotherapy-for-pancreatic-cancer/
• Cancer Research UK (2018) ‘Side effects of radiotherapy for liver cancer [Online] Available at: www.cancerresearchuk.org/about-cancer/liver-cancer/treatment/radiotherapy/side-effects-radiotherapy
• Cancer Research UK (2019) ‘Radiotherapy for oesophageal cancer’ [Online] Available at: www.cancerresearchuk.org/about-cancer/oesophageal-cancer/treatment/radiotherapy/early-radiotherapy