“Kamal, take a deep breath and hold it,” a voice says, as I lie on a radiotherapy table, with the machine moving to image the cancerous part and place it in the field to receive the rays. To me it seems ironical, as I had always been camera shy! Now I had to let the lens capture me for 33 days. Yes, my treatment protocol had 33 radiations, five days a week, after a lumpectomy in my left breast, followed by eight cycles of chemotherapy. This was in 2013, and when I look back, radiotherapy was the easier, friendlier part of the treatment.
I was amazed by the precision in the calculations made by Dr Mathangi Padmanabhan, Senior consultant and Incharge, Department of Radiation Oncology at BGS Global Hospital, to work out the number of fractions to be administered, the intensity of each, and the markings made on my chest. I followed the dos and don’ts during the treatment, mingled with other patients in the waiting lounge and combined my radiation schedule with official duties.
I met people of all ages, frames, colours and nationalities trooping in and out of the consultation chambers and waiting lounge. I saw myself drawn towards a young boy who would run through the corridor, play with toys, sometimes holding tight to his mother. His spirit was free, footsteps light, fearless of the outcome. I was always next in the queue after him, to receive radiation. Two weeks ahead of my completing radiation he bid farewell to return to his country, only to remain in my thoughts to this day. I missed my little companion who changed me for the better.
My doctors also changed my perspective of looking at my disease by asking me to reach out to a patient in a chemotherapy ward and boost her confidence. It has been six years now and I have befriended unknown people, talking to them to settle their fears and be patient and hopeful through the treatment.
Here is the professional perspective, from Dr Padmanabhan.
What is radiation therapy and how does it work?
Radiotherapy is treatment with ionising radiation, most commonly with high-energy X-rays directed at the site of the tumour. It works by damaging the DNA of the cancer cells. The normal cells have the capacity to repair the damage. But for tumour cells, the damage accumulates and kills them.
Is radiation therapy a cure for cancer or a short-term option for treating cancer?
The role of radiotherapy is generally classified into curative and palliative. Curative/radical is when radiotherapy can cure the disease by itself. This is usually given for areas such as head and neck cancer, anal canal cancer where organ preservation is a priority. It can also play a curative role in cervical, vaginal, vulval, prostate and skin cancers. Radiation therapy is used as an adjuvant/neoadjuvant treatment when it is given before or after a main treatment like surgery or chemotherapy. This modality of treatment is useful for breast cancers, cancers of the gastrointestinal tract like oesophagus, stomach, colorectum, pancreas; brain tumours, and genito-urinary cancers like uterine and penile cancers.
Palliative treatment is offered only to relieve some symptoms like pain, bleeding, obstruction, to improve the quality of life, such as in painful bony metastases and symptomatic brain metastases.
What is external radiation/external beam radiotherapy (EBRT)?
This is the usual form of radiotherapy that is used for the treatment of majority of cancers. A teletherapy machine like Cobalt – 60 or a linear accelerator is used for treatment. The radiation beam is delivered through the head of the machine to penetrate the body of the patient to reach the intended area from different directions. It is usually delivered in many sittings called fractions over 10-15 minutes every day. The entire treatment time may range from 2 -7 weeks, upto 5 days in a week. It is usually given as an OPD treatment unless the patient’s clinical condition warrants it. It is non-invasive and painless.
During my radiation treatment, I received five booster doses. What is a booster dose?
Whenever the lump is removed in a breast cancer patient, the rest of the breast has a risk of having another lump (recurrence) in the same breast, which is higher in the area of removal of the lump. So the entire breast is irradiated to prevent such recurrences and a higher dose (boost) is given to the area where the lump was removed.
What are the significant risks related to radiation therapy?
The risks depend on the region of treatment and the dose received by the adjacent normal tissues. The recent advances in radiotherapy are primarily intended to reduce the dose to normal tissues while delivering full dose to the tumour. For example, the Gating technique avoids a dose to the heart while treating left sided breast cancers, which in turn reduces the risk of heart attacks in the future. The dose to the rectum can be reduced by techniques like IMRT (intensity-modulated radiation therapy) or volumetric modulated arc therapy (VMAT) while treating prostate cancers, which otherwise might result in long term bleeding with stools. Usually, the side effects are temporary and reversible once the treatment is over.
If the patient is treated for brain tumors, we expect temporarily hair loss in the treated area, headache, vomiting that can be controlled by simple medication.
Redness and darkening of the skin in the treated area is also a common temporary side effect related to the skin.
Soreness or ulcers in the tongue or the throat resulting in pain during swallowing is a common temporary side effect during the treatment of head and neck cancers.
When the abdomen or pelvis are treated, we may expect a little increase in the frequency of stools or obvious watery diarrhoea. This also is temporary and manageable.
Is it a myth that radiation turns normal cells into cancer stem cells, while killing cancer cells?
This is not a myth. Of course, radiation is a known carcinogenic factor. When a tissue is exposed to a low dose of radiation that does not kill them, the DNA mutations caused by it can become cancerous, though the incidence is very low. That is why we don’t always advise unnecessary X-ray-based investigation unless the benefits outweigh the risks.
When treating a patient with radiotherapy, we consider the benefit of treating a patient with present cancer to be far more important than the very low (<10%) possibility of developing a cancer 20 years later. Also, during radiotherapy treatment, the tissues are exposed to high doses and high-energy radiation as low dose radiation is usually carcinogenic.
Are there instances when radiation therapy is excluded from being a part of breast cancer treatment?
Yes. Patients who are diagnosed with very early stages and breast limited disease (no nodes), with the entire breast removed by mastectomy, may benefit only minimally from radiotherapy. In such cases, a doctor may advise a person to avoid it.
In recent years, radiation therapy has been used as a standalone treatment for early-stage cancer. Why?
After years of thorough clinical research, in certain cancers like cancer of the vocal cords and anal canal cancers, for instance, the tumours have been found to be extremely sensitive to radiation therapy and can be managed without surgery. Additionally, surgery could be psychologically demoralising in such situations.
What is your message for the readers regarding cancer?
Treating any disease at an early stage will always have better long-term cure rates. Every treatment — surgery/chemotherapy/radiotherapy has its own role and is not interchangeable. Radiotherapy once started should be completed as per the prescribed protocol and timing. It cannot be stopped in between and done after a period of unnecessary breaks — it definitely reduces the efficiency.
This is the last in a three-part series, in which the author, a breast cancer survivor, speaks to oncologists about navigating the cancer care system
