Radiotherapy for cervical cancer
Radiotherapy treats cancer by using high-energy x-rays, which destroy the cancer cells while doing as little harm as possible to normal cells.
Radiotherapy for cancer of the cervix can be external or internal, and is often given as a combination of the two. Treatment with radiotherapy may last for 5-8 weeks. Your cancer specialist (clinical oncologist), who plans your treatment, will discuss your treatment in detail with you.
Radiotherapy may be given to treat early-stage cervical cancer. It’s also usually given for larger tumours contained in the cervix, or if the cancer has spread beyond the cervix and is not curable with surgery alone. Radiotherapy may also be used after surgery if there is a high risk that the cancer may come back. It’s often given in combination with chemotherapy (called chemoradiation).
Radiotherapy treatment for cervical cancer will affect the ovaries. For younger women who are still having their monthly periods, radiotherapy will stop the ovaries producing eggs and the hormones oestrogen and progesterone. This will make you infertile, so that it’s no longer possible to have a child. It will also bring on an early menopause, usually about three months after the treatment starts. Your healthcare team will discuss this with you before your treatment starts. They will also be able to give you information about treatments to help you cope with menopausal symptoms, and options for preserving your fertility if you’d like to have a child.
Some women may be offered an operation before radiotherapy to reposition their ovaries higher in the abdomen, out of the radiotherapy site. The aim of this surgery is to prevent an early menopause, as the ovaries won’t be affected by the radiotherapy treatment. It’s known as ovarian transposition and is usually carried out at the same time as initial surgery if it’s thought that radiotherapy will be needed afterwards. It may also be possible to have an ovarian transposition using laparoscopic (keyhole) surgery.
For some women, ovarian transposition isn’t successful and an early menopause still happens.
External radiotherapy is normally given as an outpatient, as a series of short daily treatments in the hospital radiotherapy department. High-energy x-rays are directed from a machine (called a linear accelerator) at the area of the cancer.
Planning your treatment
Planning is a very important part of your treatment and may take a few visits. It makes sure that your treatment is as effective as possible.
On your first visit to the radiotherapy department you’ll have a CT scan, which will take images of the area to be treated. These images are used to plan the precise area of treatment.
Once the treatment area has been decided, some small tattoo markings are made on your skin. These help the radiographer (the person who gives you your treatment) ensure that you’re in the correct position for your treatment. The marks are permanent, but they are the size of a pinpoint and you’ll only have them if you give your permission. It’s a little uncomfortable while the tattoo is being done, but it’s a good way of making sure that treatment is directed accurately.
Having your treatment
The treatments are usually given from Monday-Friday, with a rest at the weekend. Occasionally if you’ve missed a treatment due to illness or a bank holiday, you may be asked to have two treatments on the same day (6-8 hours apart).
The number of treatments will depend on the type and size of the cancer, but the whole course of external radiotherapy will usually last 5-6 weeks. Your doctor or radiographer will discuss the treatment and possible side effects with you.
Before each session of radiotherapy, the radiographer will position you carefully on the couch and make sure that you are comfortable. During your treatment you will be left alone in the room, but you’ll be able to talk to the radiographer who will be able to see you from the next room. The treatment itself will only last a few minutes.
Positioning the radiotherapy machine
External radiotherapy isn’t painful, but you do have to lie still for a few minutes during treatment. The treatment will not make you radioactive and it’s perfectly safe for you to be with other people, including children, afterwards.
Internal radiotherapy (also called brachytherapy) gives radiation directly to the cervix and the area close by. It’s usually given following external radiotherapy. The treatment may be given as an inpatient or outpatient.
To give brachytherapy, a piece of radioactive material called a source is put close to the cancer or, if you’ve had surgery, the area where the cancer was before it was removed. The source is placed inside specially designed hollow tubes called applicators. A brachytherapy machine is used to place the source into the applicators and to deliver the radiotherapy.
If you’ve not had a hysterectomy, you will have intrauterine brachytherapy. A doctor inserts the applicators into the vagina and passes them up through the cervix into the womb. Sometimes additional applicators are placed alongside the cervix. The applicators are inserted in an operating room while you’re sedated or under a general anaesthetic. Occasionally a spinal anaesthetic may be used - your doctor will be able to tell you more about this. To prevent the applicators moving, a pack of cotton/gauze padding is placed inside the vagina. Occasionally a piece of gauze is also placed inside the back passage (rectum), and you may have a catheter put into your bladder to drain off urine.
While the applicators remain in place during treatment they can be uncomfortable, so you will usually need painkillers to ease any discomfort.
If you have had a hysterectomy, a single larger hollow tube applicator is placed in the vagina. With intravaginal brachytherapy you won’t need an anaesthetic or sedation to insert the applicator and padding isn’t necessary.
You’ll have an MRI scan, CT scan or x-rays to check the position of the applicators. Once it’s confirmed that the applicators are in the correct position, they are connected to the brachytherapy machine. The machine is then used to place the source into the applicators and deliver the radiotherapy treatment.
Brachytherapy may be given in several short bursts or in one long slow treatment, depending on the systems used. There are several different systems in use, and they’re described over the next few pages.
High-dose rate treatment
This is the most common way of giving brachytherapy to the cervix in the UK. With high-dose rate treatment, a machine containing a radioactive source of iridium or cobalt is used to give a high dose of radioactivity over a few minutes. High-dose rate treatment may be given as an inpatient or outpatient.
How high-dose rate treatments are given varies from hospital to hospital. Your radiotherapy team will be able to tell you exactly how your treatment will be given.
Usually the treatment takes about 10-15 minutes and is repeated several times, a few days apart. For example, you may have treatment four times over several days while you’re an inpatient. The applicators are usually removed between treatments, but in a few hospitals they’re left in place between treatments and then removed after the final treatment. Alternatively the treatment may be given as an outpatient or day case on three or four occasions over several days or a week. If you have your treatment as an outpatient, the applicators are removed before you go home. A plastic tube may be left in your cervix to help your radiotherapy team position the applicators for your next treatment.
You may have a tube (catheter) put into the bladder to drain urine during high-dose rate treatment.
Low-dose rate treatment
Low-dose rate treatment is usually given over 12-24 hours as an inpatient, but sometimes it may be given over a few days. One type of brachytherapy machine that’s used to give low-dose rate treatment is known as a Selectron. A Selectron places a radioactive source of small balls of caesium into the applicator tubes to deliver the treatment.
The applicators are usually left in place until the treatment has finished. You will be asked to stay in bed to make sure that the applicators stay in the right position. You will also have a urinary catheter. It can be uncomfortable while the applicators remain in place, so you’ll usually be given regular strong painkillers until the treatment has finished and the applicators have been removed.
They put everything near me like food, water. I had a book. There was a TV in the room and I could move my head and my arms.
You’ll be cared for in a single room. This is to prevent other people being exposed to radioactivity while the machine is delivering the treatment. However, the radioactive source can be withdrawn from the applicators back into the brachytherapy machine if a nurse or doctor needs to come into the room. This keeps the dose of radioactivity to the nurses and doctors as low as possible. Visitors are usually restricted and children aren’t encouraged to visit while you’re having your treatment.
The safety measures and visiting restrictions might make you feel isolated, worried and depressed at a time when you might want people around you. If you have these feelings, it’s important to tell someone so that you can get some support. It might also help to take in plenty of things to read, an MP3 player and other things to keep you occupied while you’re in isolation. You only need to be in isolation while the applicators are in place. Once they’re removed the radioactivity disappears and it’s perfectly safe to be with other people.
The applicators will be removed by one of the doctors or nurses and this may be a bit uncomfortable. You’ll be given painkillers beforehand. To make it easier for you, sometimes you might be sedated or given gas (nitrous oxide) and air, known as Entonox®.
Pulsed-dose rate brachytherapy
In this treatment the applicators stay in place for the same length of time as low-dose rate treatment, but the radiation dose is given in pulses rather than as a continuous low dose.