IS RADIATION ONCOLOGY A POSSIBLE TREATMENT FOR ME?

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FFA treatment must be adapted and personalised for each individual patient and each cancer type.

In many cases, a multidisciplinary approach will be proposed. This is a combination of one or several of the following treatments:

• Radiotherapy
• Surgery
• Chemotherapy
• Hormonal therapy
• Other systemic therapy
• Treatment with ultrasound or microwaves or laser light
• Medication
• ...

These treatments can be directed towards the initial disease (the tumour), and/or to possible metastases of this disease, and/or can be done to calm the side effects of other treatments.

The multidisciplinary discussion

The multidisciplinary approach starts with a multidisciplinary discussion between different physicians. If you are a patient, you can ask your medical specialists when this formal meeting will take place. It is possible for your general physician (GP) to participate. After this meeting, a treatment proposal is made. You can ask to explain to you the content of this proposal, and if you wish you can ask for a copy.

The right to be clearly informed

Even if we like to believe otherwise, medicine is not always hard science: even the best doctors do not have an answer to all questions or a solution for all problems, and more often than not, different approaches are possible for the same disease or patient. Therefore it would be best that during the multidisciplinary discussion multiple specialists are present, including a radiation oncologist.

In most situations, the multidisciplinary team will propose a treatment that goes clearly towards surgery OR radiation OR chemotherapy as main or initial treatment, with a secondary role at a later stage or no role for other treatments. But for some tumours, it is not always possible to come to a consensus, and even after the multidisciplinary meeting different options for treatment may remain. Radiation oncologists strongly believe in patients’ rights to be informed about all options, and therefore suggest that in case of doubt, patients should be personally seen by a radiation oncologist to discuss with the patient which treatment or which order of treatments is desired.

Radiation is not always possible

Some patients have high hopes that a radiation treatment can help them, and while this is often the case, sometimes a radiotherapy treatment is NOT indicated. This should be explained to the patient by a radiation oncologist having access to the detailed files of a patient. Some examples when radiation might not be the best treatment:

• The tumour is located in an area that has already been irradiated before
• The tumour is too large
• The patient is too large or too heavy for the treatment machines or the simulation system
• The tumour is likely to resist irradiation, or rapidly recur locally or regionally
• The tumour might be treatable by radiation, but surgery allows for exploration of surrounding nodal areas
• The tumour is likely to be very sensitive to chemotherapy or targeted therapy
• There are multiple tumours, and it is not possible to treat all of them

In these cases, radiotherapy may not be the first choice, but in the absence of alternatives, a radiotherapy treatment can still be proposed.

Below is a list of possible radiotherapy indications. This is absolutely not a complete list of all possibilities, rather a collection of some examples. Please discuss any questions you might have with a radiation oncologist.

Most prevalent indications for radiotherapy

In addition to the good results obtained by other treatments, modern radiotherapy has also obtained excellent results in a number of tumours that were in the past less often treated by radiotherapy. Some examples:

Prostate cancer

Both for early (limited) as for more advanced prostate cancer, very often a local treatment by precise high dose radiotherapy can obtain very high cure rates. The most technical progress in radiation oncology has been made over the last years in prostate cancer treatment. In some specific cases, it is possible to propose a brachytherapy treatment consisting of one day in the day clinic, without more time-consuming treatments. Not every prostate cancer can be treated with radiotherapy.

Brain metastasis

Both for multiple as for solitary brain metastases, a radiotherapy treatment can be applied. In case the number and size of lesions are limited, a high dose radiotherapy can often be given to avoid having to open the skull to operate the brain. The treatment of the individual lesions is however usually reserved for patients who have been more or less cured of the primary tumour that was responsible for the brain metastases. Not all brain metastases can be treated by radiotherapy.

Skin cancer

To avoid difficult surgery in skin folds or very visible places of the face, external beam or brachytherapy-based radiotherapy can obtain good cure rates. Treatments are also possible elsewhere than on the face. Not all skin cancer can be treated by radiotherapy.

Early stage primary lung cancer

For lung cancer that is limited in size and without invasion of lymph nodes, surgery is a possibility. However, surgery can be more difficult in patients who have a bad lung function or heart problems because they have smoked, or because of a higher age. In this case, high dose local radiotherapy can obtain similar results as surgery. Not all lung cancer can be treated with radiotherapy.

Liver or lung metastases

Liver or lung metastases usually require chemotherapy. But if after treatment of the primary tumour and after chemotherapy, only one or few (smaller) liver/lung metastases remain, it might be indicated to eradicate these lesions by a local treatment such as radiofrequency ablation, surgery or radiotherapy. A short radiotherapy course can avoid the anaesthesia, blood loss and hospital stay often related to surgery, and still effectively remove the metastases. But not all liver/lung metastases can be successfully treated by radiotherapy.

Other treatments with radiation oncology

Adjuvant breast radiotherapy for breast cancer

This is the most common radiotherapy treatment. First breast surgery is performed, including evaluation of the presence of axillary lymph nodes. Then chemotherapy is given if required, and finally, the operated breast is irradiated to strongly reduce the risk of cancer recurrence. After this treatment series, a 'boost' treatment can be added to the area where the tumour was located (by external beam radiotherapy or by brachytherapy). To make the treatment easier, this 'boost' treatment is nowadays sometimes given at the same time as the treatment of the whole breast, making the treatment series shorter (not 33 treatments as in the past, but somewhere between 13 and 25 treatments). New radiotherapy techniques limit the radiation dose to the heart or the lungs.

If the breast was completely removed by the surgery, it might still be necessary to irradiate the 'thoracic wall'.

Pre-operative radiotherapy for rectal cancer

Rectal cancer almost always requires surgery. The results of this surgery can be positively influenced if radiotherapy is added: a longer series after the surgery, or a shorter series before the surgery. In function of the location of the tumour and the hope to preserve the function of the sphincter of the anus, the radiation oncologist will propose the treatment before or after the surgery. For cancer of other intestines, radiotherapy is not always needed.

Radiotherapy for head & neck cancer

Radiotherapy for head and neck cancer can take many forms: with or without surgery, with or without chemotherapy, only on a tumour or also on lymph nodes that are invaded by the tumour, or also on lymph nodes that are not invaded, as a precaution.  In the past,these treatments did have a bad reputation, because dryness of the mouth, irritation of the inside of the mouth, and skin irritation causing serious discomfort. The use of modern radiotherapy techniques has permitted to better spare salivary glands, and to spread the dose more evenly on the skin. Furthermore, medication and laser treatments of irritated mucosa can reduce symptoms. These treatments are still not easy for all patients, but better results are obtained each time due to technical progress and a multidisciplinary approach.

Intraoperative radiotherapy of the breast

In the case of breast cancer, the best-known radiotherapy is the postoperative adjuvant treatment of the whole breast. In case of very favourable tumours, it is sometimes possible to replace this treatment by a 'partial breast irradiation', which means the radiation dose is only given to the area where the tumour was located before the surgery. Because this volume is smaller, a lesser dose is given to the heart, lungs, skin, etc. This partial breast irradiation can be done by brachytherapy, external beam radiotherapy with a classical treatment machine, or also with a dedicated treatment machine in the operating room, immediately after the surgery. This latter method is called 'intraoperative radiotherapy of the breast'. It is an easy treatment for patients, with good results. But these good results in the long run (meaning no recurrence after 7 years) are only obtained if the team of surgeons and radiation oncologists is very strict, only applying this technique to patients with favourable tumours. In all other cases, a more classical approach is often proposed.

Stereotactic body radiotherapy

For well-defined tumours or metastases, in patients with generally a favourable outlook, it might be possible to replace a classical radiotherapy treatment with a stereotactic treatment. The table below shows the differences.

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