Series No. 58 - Radiotherapy to Tumours of the Oesophagus

We want to involve you in all the decisions about your care and treatment. If you decide to go ahead with treatment, by law, we must ask for your consent and will ask you to sign a consent form. This confirms that you agree to having the procedure and understand what it involves.  

Staff will explain all the risks, benefits, and possible alternatives before they ask you to sign a consent form. If you are unsure about any aspect of your proposed treatment, please do not hesitate to speak to the team looking after you.

During your time with us we aim to provide the highest standards of care and support you in your decisions regarding your treatment. We will respect your dignity, individuality, and personal preferences. 

Your care will be managed and given by therapeutic radiographers, doctors, and nurses. You will meet both male and female healthcare professionals. If you have any concerns about this, please talk to the radiographers about it. We try to be sensitive to your needs, so please do not hesitate to discuss things with the team caring for you.

If you are of an age where you can get pregnant (12 to 55 years old) and capable of becoming pregnant (you have a womb), you will be asked to confirm that you are not pregnant.  

You must tell the staff immediately if there is any chance of you being pregnant at any time during your treatment. You should not become pregnant for at least four months after radiotherapy.  

If you have any further questions or concerns about this please talk to your clinical oncologist, or specialist nurse involved in your care.

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 x-rays (also called photons), electrons or protons. X-rays and electrons are delivered from a machine called a linear accelerator whilst protons are delivered from a machine called a cyclotron.  

Radiotherapy works by damaging cancer or tumour cells in the part of the body being treated. The radiation stops the cells from dividing and growing. Radiotherapy can also damage nearby normal cells. The normal cells are more likely to recover from the effects of the radiation than the cancer or tumour cells. The clinical team take great care to reduce the radiation dose to a person’s healthy cells. 

Radiotherapy does not hurt, and it will not make you radioactive. You will be completely safe to be around family, friends, and pregnant women. You will feel nothing from the treatment and the machine will not touch you. It is rather like having an ordinary x-ray. The most important thing is for you to lie very still for treatment. 

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

A course of treatment will last one to four weeks. Your treatment schedule will be decided by your doctor and confirmed on your first treatment visit to the radiotherapy or proton beam department.

Some patients will be given drug treatment (chemotherapy) before or during their radiotherapy. The chemotherapy increases the activity of the radiotherapy against cancer cells. Your doctor will tell you which chemotherapy you will be having. 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 use of chemotherapy may increase the likelihood of nausea with your treatment. It may also cause small ulcers in the mouth. The doctors will discuss these issues with you.

The chemotherapy nurses will give you detailed fact sheets about the chemotherapy drugs and their side effects. If you have any concerns or further questions, please do not hesitate to ask for help.

Before beginning Radiotherapy or Proton Beam Therapy, your treatment must be carefully planned. Your first visit will be to the radiotherapy or proton planning pre-treatment department. At this appointment you will have a CT scan, to gain information of the area to be treated. If your clinician has requested, you may also have an MRI scan. The radiographers from MRI will contact you beforehand to ensure you are suitable for the scan.  

Prior to each appointment, you may be asked to follow special instructions such as stomach preparation. You might be asked to avoid eating and drinking for two hours before your appointment. You can have a light meal or snack before this You will be asked to drink approximately 100 ml (1 cups) of water before your scan – you will be told by the radiographer when to do this. If you have a feeding tube in place you may be asked to avoid feeds for 2 hours before and be given the water through this tube just before the scan.

This is important to try to: 

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

Depending on where your tumour is, you may require a plastic mould (also called a mask or immobilisation shell) made of your head and and neck to ensure you are in the correct treatment position. To make the mask, a thermoplastic material is used which is hard when dry and is heated to allow it to soften. This is placed over your head and shoulders and held in position for twelve minutes until it begins to harden.  You will wear the mask each day during your treatment. The mask has two main purposes: 

• To help keep you still during your treatment. 
• To ensure you are in the same position each day for treatment. 

Alternatively, it may be more appropriate that you will be treated with arms above your head. You will have a personalised support made which will enable you to remain still during the scanning and treatment and ensure you maintain the same position each day. 

Sometimes, your treatment may require a process called abdominal compression. Whilst lying down, a belt is placed over the abdomen while you are on the scanning treatment couch, which is slowly inflated to restrict how much your abdomen moves when breathing. This might feel uncomfortable but should not hurt. The belt helps to accurately plan your treatment and will be used for all your radiotherapy treatment appointments. Your doctor will let you know prior to the scanning appointment if abdominal compression is suitable for you.  

In addition, a small lightweight box will be placed on your lower chest or upper abdomen to monitor your breathing. This is to provide as much information as possible to plan your treatment. 

During the CT scan, you will feel the bed move in and out of the scanner. You will pass through the scanner several times. The radiographers will be watching you all the time. When the scan is done, and the radiographers have checked the images they will re-enter the room. The radiographers will then mark several specific points (also called tattoos) on your skin. These are alignment marks to ensure each treatment is accurate. The marks are permanent and are done by placing ink on the skin and then gently scratching the surface of your skin with a fine needle. 

If you also have an MRI scan booked this may be booked for the day after. This is to allow you time to rest and recover from your immobilisation and CT appointments as they can be tiring and sore for your arms.  

The MRI will be carried out with you lying in the same position as for your CT and using the same immobilisation. In MRI you move into the scanner and lie in it for the duration of the scan, it takes approx. 45 minutes. As with all MRI scans, they are noisy, and we will give you ear plugs to protect your hearing.

Some patients have additional CT or MRI scans during treatment. This is to help ensure your treatment plan remains accurate. Your oncologist will talk to you about this during consent and also during treatment if they feel this will be helpful.

For each treatment session you will be lying, on the treatment couch on the special board with your arms raised and supported above your head. The radiographers will ensure you are in the correct treatment position by aligning the tattoo marks on your chest with laser lights. They will then move the treatment machine and couch into position using your personal treatment plan. When final verbal checks have been made, the radiographers will leave the room. To give you the best treatment you will be treated from several different angles. The treatment machine will move around you but will not touch you. You will not feel anything. All we ask is that you keep still. The radiographers will be always watching you on a closed-circuit television. 

Treatment time is dependent on whether you are having radiotherapy with photons or with protons. If you are having photon treatment, then each session takes approximately 15-20 minutes. If you are receiving proton beam therapy the treatment may be a little longer and can last up to 45 minutes. The treatment radiographers will confirm with you how long the treatment is expected to take before they start.

There will be some side effects that will gradually appear during your course of radiotherapy, although these will vary from person to person. The risk and severity of any side effects depends on the dose of radiotherapy given. Your radiotherapy doctor will discuss these fully with you. There are side effects that occur during treatment, some happen soon after treatment, and some can occur months or years after radiotherapy. 

The main side effects that occur during treatment are:

Skin changes

The skin in the area being treated will gradually change colour. Your skin will gradually become pink /red or darker, depending on your skin colour. You may get some dry peeling of the skin in the treatment area, which may become itchy. Some patients may experience peeling of the skin in the armpit or under the crease of the breast which can be sore.  

During treatment we advise that you wash normally using warm water and the soap products you would normally use. Gently pat your 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 skin until it is absorbed. You do not need to wipe the moisturiser off before treatment, but please do not apply moisturiser immediately before treatment.

If your moisturiser starts to irritate your skin or your skin peels and is sore, stop using the moisturiser and let your team know. They will refer you to the radiotherapy review team for appropriate skin care. If you do not currently use a moisturiser then speak with your radiotherapy team and they will be able to suggest some options for you.

Hair Loss

Many patients are worried that radiotherapy will cause hair loss to their head. Please be assured that you will not lose any hair on your head from the radiotherapy. Radiotherapy is a very localised treatment and only affects the area being treated. After treatment you may experience less hair growth in that area. 

Tiredness

Tiredness is a very common side effect of radiotherapy and proton beam therapy. 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 a tumour 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 tell us if you are finding things difficult, as we will be able to offer practical advice and information.

Feeling Sick

Feeling sick is unusual during treatment, although some patients, particularly those who are receiving chemotherapy, may feel sick and sometimes be sick. This can be well controlled with anti-sickness medication. If you are experiencing any symptoms, please tell us.

Difficulty in Swallowing

The lining of the gullet becomes irritated during the treatment. This side effect gradually builds up during treatment. You may feel as if you have a lump in your throat when you swallow. It is advisable not to take hot drinks or eat spicy food. You may need to have foods that are easier to chew or a liquidised diet temporarily. There is a very small risk of damage to the gullet leading to an ulcer or hole which may need surgery. Occasionally, if you cannot swallow at all, a temporary feeding tube will need to be inserted. Sometimes this is a fine tube down the throat (known as a nasogastric or ‘NG’ tube), or sometimes through the skin of the abdomen into the stomach (known as a PEG or a RIG tube). You may have to stay as an inpatient in hospital to have a tube inserted into the stomach. You may have to stay in for a few days until you are able to care for and manage your feeding tube and able to take in enough nutrition. Sometimes, particularly if swallowing is very difficult before treatment, we recommend that a RIG or PEG tube is inserted before treatment starts.

Shortness of Breath

Radiotherapy can make you feel more breathless because of inflammation in the lungs. Please let your doctor or nurse know if this happens. We may prescribe some medication for this. In rare circumstances, this may need urgent assessment and could become life-threatening without any treatment.

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

During treatment you will be assessed on a weekly basis by your clinical nurse specialist or doctor who will monitor your side effects and review your progress.

Late side effects incurred during treatment can develop many months or years after radiotherapy has finished. They are the hardest to accurately predict and, unfortunately, when they do occur, they are usually permanent. Your doctor will discuss the possibility of these late side effects with you, at the time you sign your treatment consent form. Possible late side effects may include: 

Difficulty in Swallowing

If you experience swallowing difficulties months after completing your treatment you may need further investigations as sometimes radiotherapy causes narrowing of the gullet (stricture) due to the development of a scar A minor procedure to stretch the gullet might be needed and this may have to be done on successive occasions. This does not mean that your cancer has come back. On rare occasions, scarring of the gullet can be severe leading to an ulcer which is slow to heal or even a tear (perforation). If this were to happen, surgery may be needed, and you would be counselled about this accordingly. Your treating doctor may also mention the rare occurrence of a hole developing between your gullet and airway (fistula) which may be irreversible and require insertion of a flexible tube (stent). 

Bone Weakness

Rarely, radiotherapy can make some of the ribs more brittle After a severe cough or mild trauma this can result in chest pain and/or a minor rib fracture. 

Spinal Cord Damage

In extremely rare cases, radiotherapy may lead to injury to the spinal cord which can cause permanent difficulties in walking and loss of sensation in the lower body. Every effort is made to carefully plan your treatment to avoid this.

Second Malignancy

Less than 1% of people who have received treatment for one particular tumour may develop another type of tumour in the treated area some years later. The radiotherapy doctors will discuss this risk if it is relevant to you.

This page deals with the physical aspects of your treatment, but your emotional wellbeing and that of your family is just as important. Having treatment can be deeply distressing for some patients. Within the radiotherapy and proton beam therapy departments there will be access and support from the radiotherapy review team, your specialist nurse, the treatment radiographers and the Macmillan information and support team. However, if you feel you require further medical or emotional support you can be referred to a variety of health professionals who can help with any worries or difficulties you may be having.

All the staff are here to make sure your treatment goes as smoothly as possible and to support you through this difficult period. We will try to help you with any questions or problems you may have.

The side effects you are experiencing will continue after treatment has finished. It is common to experience a worsening of the skin reactions for about ten to fourteen days after radiotherapy. You will be reviewed by your radiotherapy consultant four to six weeks after completing your radiotherapy or proton beam therapy. This may be a telephone or face-to-face appointment. Face-to-face appointments will be held in the UCLH Macmillan Cancer Centre.

Some patients will be discharged back to their local referring centres for symptom care and follow-up. Please feel free to contact the radiotherapy or proton beam therapy department if you are worried about your treatment side effects.

Local

Oncology CNS
Telephone: 020 3447 5023
Email: uclh.oesophago-gastriccancercns@nhs.net

Clinical Oncology GI PA
Email: oncology.gi.radiotherapy@nhs.net

UCLH Radiotherapy Department
Telephone: 020 3447 3700 / 020 3447 3701

Out of hours oncology advice number
Mobile: 07947 959020

National

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

Cancer Research UK
Information Line: 0808 800 4040

Carers UK
Adviceline: 0808 808 7777
Email: adviceline@carersuk.org

NHS Choices

UCLH cannot accept responsibility for information provided by external organisations.