Paediatric Series No 18 - Radiotherapy to the neck, chest, abdomen and pelvis

Radiotherapy appointments:

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

Proton Beam Therapy appointments:

All take place in the Proton Beam Therapy Department, floors B3 and B4, Grafton Way Building.

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

University College Hospital Trust 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 paediatric/TYA tumours with proton beam therapy. The most appropriate treatment for your child will be decided by their clinical oncologist and discussed with you.

Radiotherapy does not hurt, and it will not make your child radioactive. They are completely safe to be around siblings, friends, family, and pregnant women. Your child will feel nothing from the treatment and the machine will not touch them. The most important thing is for your child to lie very still for treatment. Lying still can be very difficult for some children and we have health play specialists who will support your child throughout their treatment. However, some children, particularly very young children, will require a general anaesthetic for their treatment.

Treatment is given daily Monday to Friday, including Bank Holidays.

A course of treatment can last up to 6 weeks. Your child’s treatment schedule will be decided by their clinical oncologist and confirmed on your first visit to the radiotherapy or proton beam therapy department.

Before beginning radiotherapy or proton beam therapy, your child’s treatment must be carefully planned. Their first visit will be to the radiotherapy or proton planning pre-treatment department. There will be plenty of opportunity to explore what radiotherapy involves for your family. You will meet the team members who will spend time getting to know your child’s needs and how best to support them, and the family, through treatment.

We have a series of short films and photo books that help to explain the different aspects of radiotherapy. This allows children and young people the opportunity to ask questions and to gain an understanding of what radiotherapy is all about. The radiotherapy paediatric team, which includes a specialist paediatric radiographer, a paediatric clinical nurse specialist and radiotherapy health play specialists, will go through step by step what to expect with treatment specific to your child.

Whenever possible, and especially with younger children, we plan separate visits to the mould room, CT scanner and treatment machine in advance of the actual treatment. This is a hands-on experience and questions are encouraged. This ensures your child is comfortable and familiar with what is going to happen.

For more information on preparing your child for radiotherapy treatment you may contact the health play specialists directly on 020 3447 3792.

Radiotherapy for children is an individualised treatment, and any side effects will vary depending on which area of the neck, chest, abdomen, and pelvis is being treated, the type of radiotherapy chosen for your child and the radiotherapy dose given. Your child’s clinical oncologist and specialist radiographer will discuss with you how the radiotherapy will affect your child in more detail. However, there will still be plenty of opportunity to talk about anything that you feel needs further discussion.

There are side effects that start during treatment. They gradually get worse during treatment and for a couple of weeks afterwards and then get better after several weeks. Late effects can develop months or years after treatment has ended.

We give radiotherapy treatment in addition to surgery and/or chemotherapy. Patients receiving chemotherapy in addition to radiotherapy may experience more severe or additional side effects to those listed here, depending on the drug regimen used.

The main side effects that occur during radiotherapy treatment are:

Skin changes

The skin in the area being treated will gradually change colour. Your child’s skin will gradually become pink /red or darker, depending on their skin colour. Your child may get some dry peeling of the skin in the treatment area, which may become itchy. Some children may experience peeling of the skin, which can be sore. If your child’s skin peels and is sore, they will be referred to the radiotherapy review team for appropriate skin care.

During treatment we advise that your child wash normally using warm water and the soap products they would normally use. Gently pat the 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 child’s skin until it is absorbed. You do not need to wipe the moisturiser off before treatment, but please do not apply moisturiser immediately before their treatment. If your child’s skin becomes irritated or peels, stop using the moisturiser. They will be referred to the radiotherapy review team for appropriate skin care.

If your child does not use a moisturiser, speak to the radiographers and they will be able to suggest a few options.

Avoid exposing the skin in the treatment area to strong sunlight or extreme temperature changes during treatment. After radiotherapy, the skin in the treatment area is always going to be more sensitive to the sun, so it needs to be protected with clothing, and we recommend that you always use a high protection sun cream, Factor 50 or more, on your child’s skin in strong sunlight.

Sore throat

Your child may experience a mild discomfort when swallowing food as the radiotherapy irritates the gullet (oesophagus). In most cases, children are still able to eat and drink normally, but some may require oral medication to ease any discomfort.

Effects on the voice

If your child is having radiotherapy to the neck, his/her voice may become sore and occasionally hoarse. Some children may require oral medication to ease any discomfort. When the treatment has finished it may be a few weeks before his/her voice starts to recover.

Eating and drinking

It is important that your child tries to eat a well-balanced diet and drink plenty of fluids during treatment. If your child has a sore throat due to treatment, they may lose their appetite or find swallowing food painful. They may require oral medication to assist with swallowing. Your child will be weighed weekly by the team and if there is any significant weight loss your child will be referred to the dietitian for helpful advice about nutrition.

It is important that your child drinks plenty of fluids, between one to two litres a day. This can include water, squash, or hot drinks. This will vary depending upon their individual needs. You will be advised accordingly by the team members.

Feeling sick

Occasionally, some children may feel sick and vomit because of the radiotherapy treatment. This can be well controlled with anti-sickness medication which will be prescribed if your child experiences such symptoms.

Hair Loss

There may be a loss of hair at the back of the neck if this is in the treatment area. Once treatment is over the hair will start to regrow in three to six months.

Cough

Occasionally, some children may experience a dry irritating cough. This is a short- term reaction to the radiotherapy and can be eased with a cough syrup.

Tiredness

Tiredness is a very common side effect of treatment. Your child may feel more tired and have less energy than usual, both during and after treatment. Do not worry, this is normal. The tiredness is usually at its worst near the end of treatment and for several weeks afterwards. Allow your child to do as much as they feel they can and rest when they need to. However, gentle exercise has been found to improve energy levels in patients. Some children do not have a problem with tiredness and should be encouraged to lead a normal life as much as possible. Please tell us if your child is struggling with tiredness. They can be referred to physiotherapy and occupational therapy for practical tips and advice.

Diarrhoea

About two weeks into treatment your child may experience diarrhoea. This is due to the radiation irritating the bowel. Your child may also experience wind pains and/or cramping sensations. If the diarrhoea persists or becomes severe your child may be prescribed regular anti-diarrhoeal medication. It is important that your child maintains a good fluid intake if this is a problem (between one to two litres a day). This can include water, squash, or hot drinks.

Effects on the bladder

During pelvic radiotherapy it is possible that your child may experience a burning sensation on passing urine and an increase in the need to pass urine. This is due to the radiotherapy irritating the bladder and is called “radiation cystitis”. If your child experiences such symptoms, please inform a member of staff. Your child will be sent for a urine test to check that it is radiation cystitis and not an infection. It may help if your child increases their fluid intake.

Blood and bone marrow system

Treating the neck and chest, abdomen and pelvis may affect the bone marrow. Bone marrow makes blood cells and is found in the centre of bones such as the spinal bones. The white blood cells (which fight infection) and platelets (which are important for blood clotting) might be affected. Your child’s blood count will be monitored regularly during radiotherapy. If your child requires a blood transfusion, this will be arranged with the paediatric/teenage oncology teams.

Late side effects incurred during treatment can appear to develop months or years after radiotherapy has finished. They are the hardest to accurately predict and, unfortunately, when they do occur, they are usually permanent.

Skin changes

Radiotherapy may turn soft, supple skin in the treatment area firm and less supple. It is more likely to happen if your child has previously undergone surgery or chemotherapy. Good skin care, the use of water-based moisturisers and sun avoidance can minimise these side effects.

Decreased thyroid function

If your child has had radiotherapy to the neck this can affect the thyroid gland. It may become underactive, overactive (very rarely), or tend to form lumps many years after treatment has finished. Your child will be monitored through regular blood tests and if a dysfunction is detected, it can easily be treated.

Lung function

It is possible for lung function to be affected by the radiotherapy treatment. This can take two forms: six to twelve weeks after radiotherapy your child may experience some shortness of breath and dry cough. This may be due to radiation pneumonitis, which may be treated with a short course of steroids and usually resolves completely. This occurs in a small proportion of children only. In some children symptoms may never occur.

There may be some long-term effect on your child’s breathing. This is very unusual, but if it occurs it tends to be noticeable on moderate to severe exercise only. After treatment your child will have regular lung function checks in a dedicated follow-up service. It is very important that any child who has received this treatment never smokes, especially if he/she has received chemotherapy as well.

Heart

The heart is also in the treatment field when the chest is treated. Radiation to the heart can eventually cause later problems with function and/or rhythm disturbance, particularly if radiotherapy is given with chemotherapy. This will be monitored closely in a late effects clinic.

Some treated females have an increased risk of heart failure in later life, particularly under the stressful conditions of pregnancy and labour. Pre-pregnancy checks are essential, and, in the case of pregnancy, it is important that a full medical history is known by the obstetrician and that obstetric care is hospital-based.

Breast development

Radiotherapy to the chest may cause a reduction in breast development in female patients. Both breasts will be underdeveloped, but this should occur symmetrically. Lactation (milk production in pregnancy) can also be reduced by radiotherapy which may prevent breast feeding. Any lumps in the breast should be reported to a doctor as they can be worrying.

Growth

Radiotherapy can affect the growth of bones and soft tissues in the treated area. In younger children this will mean that the treated area will be smaller, thinner, or less muscular than the untreated areas. The radiation may affect the growth of the vertebrae (the bones of the spine), collar bones, ribs, and the pelvic bones if they are included in the treatment field. There might be some underdevelopment of these bones, with some loss of height and a small chest and waist. The loss of height is unlikely to be more than two inches and will probably be less, but this will depend on your child’s age at treatment. The radiotherapy doctors will discuss this with you and your child.

Bowel problems

Any potential bowel problems depend on the dose of radiotherapy given. The symptoms may vary from mild diarrhoea to bleeding. However, sometimes after surgery and radiotherapy the tissue surrounding the bowel can stick together (adhesions), and this can sometimes require further surgery to correct. This is a rare problem, but please do speak to the doctors if you are worried.

Bladder

The bladder may shrink in size and be slightly smaller after radiotherapy. This may mean your child passes urine more often. Rarely, some bleeding may occur in the urine. This is not usually serious, but if it occurs it is important to let your child’s doctor, specialist nurse or GP know. They may wish to arrange further tests.

Female fertility

It is likely that radiotherapy to the pelvis may mean treating both ovaries and the uterus (womb). This will almost invariably cause pubertal arrest and infertility, in which case hormone replacement therapy will be necessary in the future. Some young girls may apparently recover ovarian function and retain a small window of fertility as adults. The doctors will discuss this with you and your child.

Male fertility

It is often possible to avoid treating the testes, but sometimes it cannot be avoided. The doctors will be able to tell you if the dose to the testes is likely to cause infertility or affect the production of the male sex hormone testosterone. Your child will be referred to an endocrinologist to discuss the implications on growth and sexual maturation.

Low bone density (osteopaenia)

Low bone density can occur for several reasons. These can include immobilisation, poor nutrition, low calcium, steroid therapy as well as radiotherapy to the skeleton. Weight bearing exercise, eating a healthy diet and timely hormone replacement therapy can all prevent osteopaenia occurring. Your child will be screened for osteopaenia in the endocrine clinic as he/she grows up.

Splenic dysfunction

If your child has received radiotherapy or proton beam therapy to the upper abdomen or lower chest there is the possibility that their spleen may have been irradiated. The spleen helps the body fight against bacterial infections. The spleen is very radiosensitive, and radiotherapy can have an impact on splenic function in the future. The higher the dose received, the higher the risk of splenic dysfunction.

Patients with a dysfunctional spleen are at an increased risk of severe, life- threatening infections such as pneumonia, septicaemia (blood poisoning) and meningitis.

If your child is at risk of splenic dysfunction their consultant will discuss this with you and what this will mean for your child and the family. Your child may need to take lifelong antibiotics, may require prophylactic vaccinations, may have to carry a card to alert health professionals to the risk of infection and be educated as to the potential risks of overseas travel and the risk of infection.

For up-to-date patient information on splenic dysfunction and a health alert card please visit the following links:

• https://assets.publishing.service.gov.uk
• assets.publishing.service.gov.uksplenectomy-record-card.pdf

Second malignancy

Very rarely, children 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 with you if it is relevant to your child.

Other factors such as smoking and excess sun exposure may also lead to an increased cancer risk in later life. It is therefore very important that any child who has received this treatment never smokes and always takes precautions against excess sun exposure.

This information deals with the physical aspects of your child’s treatment, but their emotional wellbeing and that of the family is just as important. Having treatment can be deeply distressing for your child and family.

Within the radiotherapy department there will be access and support from the paediatric clinical nurse specialist, the specialist paediatric radiographer, health play specialists, treatment radiographers and the radiotherapy review team. However, if your child requires further medical or emotional support, they can be referred to a variety of health professionals specialising in children’s and young people’s needs.

Once your child has finished radiotherapy treatment you will be given a follow-up appointment to see the radiotherapy doctors in two to three weeks’ time. This will either be at Great Ormond Street Hospital, University College Hospital, or your child’s local referring hospital.

Any side effects your child is experiencing will continue for some weeks after treatment has finished. The side effects may become worse before they start to improve. This can be very worrying for families. We expect the side effects to worsen, but please be assured they will gradually settle. Please continue to follow the skin care advice you have been given by the radiotherapy team until your child’s skin returns to normal.

If you are worried about your child’s skin or any other side effects after their radiotherapy treatment, please call the paediatric clinical nurse specialist or paediatric specialist radiographer for advice. Please see the contact numbers at the back of this information.

My child’s keyworker is:

Paediatric/TYA Clinical Nurse Specialist telephone: 07929 079599

Paediatric/TYA Specialist Therapeutic Radiographer telephone: 07817 941313