Radiation Therapy for Childhood Cancer

Radiation therapy is a treatment used for many forms of childhood cancer.

This therapy uses beams of radiation, either x-rays or protons, to shrink tumors and kill cancer cells. Radiation works by damaging the DNA inside cancer cells.

The radiation oncologist is the doctor in charge of radiation therapy. The radiation oncologist works with the radiation therapy team to develop a treatment plan for each child’s case.

Sometimes radiation may be the only treatment. Or the treatment plan may combine radiation therapy with other treatments, such as surgery and chemotherapy.

Radiation targets cancer but may damage nearby healthy tissue. This damage can cause side effects. Some side effects can affect the growth and development of children and adolescents. The medical team designs treatments to protect as much healthy tissue as possible.

Receiving radiation therapy

Consultation

The patient and family will meet members of the treatment team. The team will explain the treatment process and can answer your questions. Families are encouraged write down questions before this appointment. You should feel comfortable asking the treatment team if something is not clear. Sometimes it’s helpful to bring a family member or friend along to help take notes. If you think of more questions after the appointment is over, you can reach out to the team.

The doctor may talk to parents about whether patients should have general anesthesia. Doctors may recommend it for young children and other patients who have trouble staying still.

The treatment team will talk to parents about the goal of radiation treatment and side effects. This process is called informed consent. It is where a patient and the family give permission before treatment can start.

Simulation

Simulation is the first step in planning the patient’s radiation treatment. The patient will have a CT scan and sometimes an MRI to show exactly where the tumor is (or was if surgery was performed).

During the simulation, patients will have a customized mask or body mold made that will help them lie in the proper position for treatment.

Contrast for CT or MRI

In most cases, patients will receive a contrast agent for either CT or MRI simulation. The patient’s schedule will contain directions about not eating or drinking before receiving the contrast. It is very important to follow the guidelines exactly. Notify the therapy team of any history of allergies to contrast.

If contrast is used the patient will need an IV. If the patient does not have a port, central line, or other IV device, a nurse will need to start an IV.

Having a CT Scan

The CT scan is an x-ray study that is needed to help calculate the radiation treatment plan. Patients lie in their mask or body mold on a flat table (called a couch) and the table automatically slides (or moves) through the scanner. It that looks like a large ring or donut. This process is how the images are made. It takes about 1 hour.

Having an MRI

When an MRI is used to help with radiation treatment planning patients lie in their mask or body mold and the area to be imaged is placed inside the magnet (inside the round opening in the MRI device). The MRI device makes loud noises, so either ear plugs or headphones are used to protect the ears. The MRI usually takes 30 minutes to an hour.

What You Can Wear

Patients should wear loose, comfortable clothing that does not contain metal such as snaps, buttons, and zippers. The best clothing choices may include T-shirts with sweatpants, pajama bottoms, or other elastic waist pants. The treatment team will often have the patient wear a hospital gown.

During the simulation, several steps will be followed to make sure the radiation is delivered in the precise treatment location each time.

Measuring/marking

• A radiation therapist or nurse may place a small tattoo (freckle size) on the patient’s skin using a very small, sterilized needle. Only the tip of the needle is used. Some pediatric centers may use a permanent marker or paint pen instead.
• This mark helps radiation to be directed safely and precisely to the treatment area.

Treatment planning

After the simulation, the radiation oncologist will work with dosimetrists and radiation physicists to develop a treatment plan.

The team will plan the amount and frequency of radiation and map the radiation beams.

The radiation oncologist will write a prescription that outlines exactly how much radiation is to be given, how often, and where. Not all cancers are treated with the same amount of radiation. The treatment plan depends on many factors, including the type of tumor and the age of the child.

Before the first treatment begins, the radiation therapy team will take x-ray images on the treatment machine of the patient and check that all of the treatment machine settings are correct. These images confirm the area being treated is the precise location the doctor planned. The doctor will approve the images before the first radiation treatment begins.

Discussing the treatment plan

The radiation oncologist will explain the treatment plan to the family before treatment sessions begin. This is an excellent time for families to ask questions. A child life specialist may work with patients to explain the treatment process using child-friendly language and medical play.

The radiation oncologist will explain:

• About how long each radiation treatment session will take.
• The total number of treatments (a common schedule is 5 days a week for anywhere from 1 to 7 weeks.)
• How many “rest” days there will be between the patient’s treatments. This time off gives the radiation time to kill cancer cells and helps healthy cells recover. Typically, the patient won’t have treatments on weekends.
• The radiation oncologist will also talk to patients and families about the importance of the patient remaining still during treatment sessions. Child life specialists can work with patients to create a coping plan.
• If patients aren’t able to stay still, general anesthesia may be used, so an anesthesiologist may also be part of the patient’s treatment team.

Typical radiation therapy appointment

Most patients receive radiation treatment as an outpatient. The scheduler will work with families to make radiation appointments. If the patient is receiving general anesthesia, there will be a separate appointment for this procedure.

Patients and families should always follow the registration procedure of their pediatric center.

The schedule will be similar to the following:

• Before each visit, patients and parents check in at the registration desk. Then they go to the radiation oncology waiting area. Pediatric waiting rooms will usually have a play area.
• When it is time for treatment, someone from the care team, usually the radiation therapist or radiation oncology nurse, will escort the patient and perhaps a parent to the treatment area.
• If general anesthesia is required, a member of the anesthesia team will meet the patient and parent. At some treatment centers, a parent can stay with the patient until it is time for the radiation treatment to begin. Some centers will ask parents to remain in the waiting area.
• In the treatment room, the radiation therapist or nurse will position the patient on the radiation table using the patient’s mask or body mold. The team will make the patient as comfortable as possible, perhaps with a blanket or a special cushion placed under the patient’s legs. (Sometimes positioning takes longer than the actual radiation session.)
• The radiation therapist will go to an adjoining or nearby room to begin the radiation treatment. The patient will be alone in the radiation treatment room. But the therapist can see, hear, and talk to the patient at all times.
• The machine will align to target the radiation to the precise treatment location sometimes by taking an x-ray image of the patient. The patient will see laser beams used for positioning the radiation but will not feel them.
• The patient cannot feel or see the radiation treatment as it is delivered, but the machine will make noise.
• After the treatment session, the care team will help the patient off the bed. If general anesthesia was not used, patients can usually return to normal activities. If anesthesia medicines were given, the patient must recover from its effects before leaving the radiation oncology area. The amount of time for recovery varies with each child. It depends on how the patient responds to anesthesia. It is easier for some than others — how they wake up can impact the rest of their day.

Follow-up visits

The patient will have regular follow-up visits with the radiation oncologist. During follow-up visits, patients will have diagnostic imaging tests, usually CT, PET or MRI scans to monitor how well the cancer is responding to treatment.

Helpful tips

• Arrive on time for radiation therapy appointments, even a few minutes early to allow time for check-in. When patients are late, it can complicate the radiation oncology schedule for other patients. Patients who are late may have to wait until other patients receive their treatment.
• If a mask is used during radiation treatment, the patient’s hairstyle needs to be the same as it was when the mask was made. This may mean getting a haircut before simulation if it is expected that the patient may lose their hair.
• It is best to wear loose, comfortable clothing such as T-shirts with sweatpants, pajama bottoms, or other elastic waist pants.
• Pediatric centers have different policies concerning parents observing therapy sessions. Some will allow one or both parents to observe. Others will ask parents to remain in the waiting area. Siblings will most likely not be allowed to observe sessions and will have to stay in the waiting area under the supervision of an adult. Families should plan accordingly, so an adult is there to watch siblings at all times.

Radiation side effects

Having radiation therapy can cause some physical changes, such as fatigue, nausea and vomiting and having skin reaction. Patients may have some side effects for several weeks after radiation therapy. Sometimes they last several months, but this is rare. Most of them will go away with time.

Other side effects depend on what part of the body is being treated. Patients often have skin changes and hair loss at the site of the radiation treatment. For example, if you receive radiation to your knee, you may have skin changes and hair loss in your knee area.

Other location-specific side effects of radiation include:

Managing radiation side effects

Skin reactions and care

Skin reactions might get worse for 7 to 10 days after the last radiation treatment. It is important to take good care of the skin during this time. Call the radiation clinic if the skin reaction gets worse or more painful, or if your child gets a fever.

Eating and drinking

Patients might be less hungry for a few weeks after radiation treatment ends. It’s important to eat a well-balanced diet. They should also drink at least six, 8-ounce glasses of water a day.

If nausea or vomiting is a side effect, anti-nausea medicine may be prescribed. The doctor might tell you to give it for a longer or shorter time. Make sure you have some nausea medicine at home, in case the nausea comes back. If the medicine does not work, call the care team.

Rest and activities

Patients might have low energy for weeks or even months after therapy ends. Their body is working hard to repair itself, so they need plenty of rest. You might need to change your normal routine so your child can get enough rest.

Patients may return to school and routine activities immediately after radiation therapy if their doctor approves.

Long term effects of radiation

Although rare, a late effect of radiation could be development of a cancer in the area where the patient received radiation treatment. That is one reason why patients have regular follow-up visits after the completion of therapy.

Signs of cancer may include skin changes, changing moles, bone pain, or a thickening or lump that doesn’t go away. The care team will look for signs and changes during physical examinations. Patients (or parent if patient is too young) are encouraged to do self-exams monthly.

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