SABR for Bone and Nodal Oligometastases

SABR for Bone and Nodal Oligometastases

Introduction

Your oncologist has recommended that you have a course of radiotherapy.

This booklet aims to help you understand more about the proposed radiotherapy treatment for the cancer for your bone and nodal oligometastases. The treatment technique is called stereotactic ablative body radiotherapy (SABR). 

The booklet describes:

• What stereotactic ablative body radiotherapy is
• How your treatment is planned and delivered 
• The side-effects you may experience during and after treatment

What are the alternatives to SABR?

Alternative treatments include surgery, conventional radiotherapy, systemic treatments (chemotherapy, hormone therapy, targeted therapy, immunotherapy etc.) and observation. Your doctor will discuss which (if any) of these treatments may also be suitable for you. Your doctor will also discuss the relative merits of these different approaches for you to consider and decide which is best for you.

Consent to treatment 

Before you start your treatment, your consultant or a member of their team will discuss your treatment options with you. Together you will consider the risks and benefits of the different treatment options available, and decide how to proceed. You will be asked to sign a consent form stating that you understand what SABR involves, that the risks, benefits and possible side effects of SABR have been explained and that you have been given the opportunity to ask any further questions

What is SABR?

Radiotherapy uses X-Rays to treat cancers. SABR is a new radiotherapy technique that allows the targeting of cancers with high accuracy and reduced radiation dose to the surrounding normal areas. This means that a higher dose of radiotherapy treatment can be given in relatively few sessions (typically 3-5 outpatient attendances). 

The potential benefits are:

• To reduce pain or other symptoms
• To prevent further spread of cancer
• To delay the need for chemotherapy or hormone therapy

The number of treatments you have will depend on the position of your tumour/s and can often not be determined until after you have attended for your first planning appointment. 

If you are on any pain medication please ensure that you have taken it prior to your appointments, as well as bringing with you in case of any delays

What is meant by limited spread of cancer and why is this important?
This means that your cancer has spread from its original location (metastasised), but is only visible at three or fewer sites on body scans. Current research suggests that people with this number of metastases may have some benefit from SABR.

Appointment 1 – Planning your treatment 

Radiotherapy needs to be given in the most effective way, causing the fewest possible side effects, so careful planning is required for everybody’s individual treatment plan. 

Radiotherapy machines delivering SABR treatment must to able to accurately determine the position of the tumour being treated. 

In order to do this a radiotherapy CT (Computer Tomography) planning scan is carried out as part of the preparation for radiotherapy. This CT scan is only used to plan your radiotherapy and is not used for making a diagnosis. The scan can be used to give information about the structure and position of individual organs in your body. This information is used to produce an individual radiotherapy treatment plan for you. Some patients may also need an additional MR (Magnetic Resonance) scan. This can provide more detail when planning, particularly spinal treatments. In most cases, you will be positioned lying on your back and this position will be reproduced for your SABR treatment.

For the CT scan the doctor may have requested that you are given a contrast agent commonly known as a dye. This is given intravenously. A needle will be inserted into one of your veins and the contrast injected. The most common side effect of this is a warm sensation as the dye is injected. This does not last and there is no treatment necessary. People can have an allergic reaction to the contrast, but this is rare. Once the scan has been completed the radiographers, with your permission, will make up to 4 small permanent marks on your skin to hep accurately position you for your treatment.

Following your CT scan it will take a few weeks for your consultant and the planning technicians to design and approve your personalised treatment plan.

Appointment 2 – Dry Run 

This is the final check before treatment can begin.  It is carried out on the treatment unit that you will be having your treatment on.

A team of radiographers will set you up in the position that you were in for your CT scan. During this appointment it is important to remain as still as possible and breathe normally.

The radiographers and physicists will carry out some scans and other measurements to ensure that there have been no changes to your tumour position since your planning scan. One of the doctors may also be present for this appointment. 

The radiographers will put some pen marks on your during this appointment – these can be washed off before the next appointment.

Having your SABR treatments

Treatment will usually start within a couple of days of the dry run.

SABR is given over 3-5 treatments, usually on alternate working days and will last about an hour.

A team of radiographers will position you in the same way as you were in for your CT scan and dry run. During the treatment it is important to remain as still as possible and breathe normally.

For the treatment the radiographers will leave the room. They will be watching you on a closed circuit TV monitor (CCTV). The camera is not recording or saving images. There is also a two-way intercom system.

During treatment the machine will move around you but it will not touch you. You will not feel anything during the treatment. This type of treatment will not make you radioactive, so it is safe to mix with other people, including children and pregnant people.

What are the short term side effects of SABR treatment?

Potential side effects will depend on the area of the body being treated. 

Your doctor will discuss the relevant side effects for your particular treatment as the list below covers side effects for all treatment sites. 

In general, current research shows side effects are uncommon but may include the following:

Skin reaction 
The skin in the area being treated may become red, itchy and sore. Moisturisers can be used to relieve dry, itchy or red skin caused by treatment. Please ask your radiographers for further advice on skin care.

Tiredness and fatigue
You may find that you feel tired and lack energy during treatment, it is quite common. If you are able to carry out gentle exercise this can help to ease fatigue. Gentle exercise includes walking, gardening and housework. 

Sore throat 
If you are having SABR treatment to your upper chest or neck may you may experience some discomfort in your throat. 

Eating soft food and pain relief can help to ease this discomfort.

Nausea and vomiting 
If you are having SABR treatment to your abdomen, pelvis, or lower spine you may experience nausea or vomiting. 

This can happen just a few hours after treatment or at any time during the treatment course. The consultant will prescribe anti-sickness medication for you to take before each treatment if necessary. 

Change in bowel habit 
Your bowel habit may change if you are having treatment to your abdomen, pelvis or lower spine. It is helpful to drink plenty of fluids to replace those lost through diarrhoea and to prevent dehydration. Reducing the amount of fibre in your diet may also help to ease the symptoms of diarrhoea. 

Increased pain 
You may experience a temporary (<48 hours) increase of pain in the area treated. Pain is usually mild and can be relieved by taking simple pain relief medication such as paracetamol. 

Inform the radiographers if you experience any of the above side effects or you develop any new symptoms. They will ensure you receive support and any medication that you may need. It is recommended that you maintain all your usual activities if possible. You may prefer to eat more frequent, smaller meals, avoiding rich, spicy and greasy foods.

What are the long term side effects of treatment?

Bone fracture (break) 
If you are having radiotherapy to an area of bone you may experience a higher risk of bone fractures in the area being treated. These fractures can cause pain and discomfort; the commonest example is a rib fracture when a lung metastasis is treated. 

Liver/kidney damage 
If you are having SABR to your abdominal area there may be an increased risk of damage to your liver and kidneys. This can be assessed by taking regular blood tests.

Damage to bowel
Rarely, radiotherapy can cause damage to the bowel which may lead to a blockage or perforation. To repair this, you may require an operation. 

Damage to nerves and spinal cord 
If the treatment is to your spine or close to the spine there is a risk that the radiotherapy may cause some damage to the nerves or the spinal cord in the treatment area. 

Treatment to these areas is carefully planned and monitored to ensure the dose is as low as possible while delivering an effective treatment.

How should I care for myself during and after radiotherapy?

Everyone reacts differently and as treatment progresses you may experience some of the side effects discussed in this leaflet. We offer the following general advice based on current evidence and our experience.

Diet and hydration
We suggest you try to eat a well-balanced, healthy diet and drink plenty of fluids during your course of radiotherapy, as this may help your body to cope with the effects of the treatment. Please ask the radiographers for advice on diet and fluid intake. 

Skin care during radiotherapy 
During your treatment you can continue to wash the area being treated, but:

• Use tepid water. Showering is ideal, but use mild un-perfumed soap.
• Dab yourself dry with a soft towel and avoid rubbing the treatment area.
• If you enjoy swimming you can continue to do so throughout your treatment, but as chlorinated water or your costume may cause skin irritation it is vital to shower thoroughly and immediately afterwards.
• It is important to protect the treated area from exposure to the sun, during and after treatment, by covering the area with soft, loose, comfortable clothing or the use of a sun block.
• Skin dryness is common. You can moisturise the skin in the treatment area using any moisturising cream of your choice.

Smoking 
Stop, if you can, or reduce smoking as it can make any skin reactions worse. We can refer you to a smoking cessation service if required, please ask a member of the team.

If you experience any of these possible side effects your radiographers will be able to give you advice, information, support and medicines that can help. 

If you have completed treatment, please telephone the Macmillan Review Radiographers (contact details on page 8). 

Coping with radiotherapy

Many people, quite naturally, feel emotionally upset and frightened following the diagnosis of cancer. It may be difficult to adjust to what is happening. Finding out about your treatment may help you to understand your fears and help you to cope better.

What can I expect after treatment has finished?

The side effects can get worse for two to three weeks after finishing treatment but will gradually improve over the next six to eight weeks. 

However, tiredness can last for some time following treatment. See the section about

‘tiredness’ for advice on how to deal with this. 

You will meet many other people having radiotherapy during your visits to the department. Their treatment may have been very different from yours, so try not to look for comparisons with them. Please ask the team if you have any questions about your treatment. 

If at any time between your follow up appointments, you are concerned about anything please contact your GP or the hospital so that an earlier appointment can be made if necessary. 

Useful telephone numbers

Radiotherapy Department
01905 761400

Acute Oncology Service 
01905 760158

Macmillan Information and Support Radiographers
01905 761420

If your symptoms or condition worsens, or if you are concerned about anything, please call your GP, 111, or 999.

Patient Experience
We know that being admitted to hospital can be a difficult and unsettling time for you and your loved ones. If you have any questions or concerns, please do speak with a member of staff on the ward or in the relevant department who will do their best to answer your questions and reassure you. 

Feedback
Feedback is really important and useful to us – it can tell us where we are working well and where improvements can be made. There are lots of ways you can share your experience with us including completing our Friends and Family Test – cards are available and can be posted on all wards, departments and clinics at our hospitals. We value your comments and feedback and thank you for taking the time to share this with us.

Patient Advice and Liaison Service (PALS)
If you have any concerns or questions about your care, we advise you to talk with the nurse in charge or the department manager in the first instance as they are best placed to answer any questions or resolve concerns quickly. If the relevant member of staff is unable to help resolve your concern, you can contact the PALS Team. We offer informal help, advice or support about any aspect of hospital services & experiences.

Our PALS team will liaise with the various departments in our hospitals on your behalf, if you feel unable to do so, to resolve your problems and where appropriate refer to outside help.

If you are still unhappy you can contact the Complaints Department, who can investigate your concerns. You can make a complaint orally, electronically or in writing and we can advise and guide you through the complaints procedure.

How to contact PALS:
Telephone Patient Services: 0300 123 1732 or via email at: [email protected]

Opening times:
The PALS telephone lines are open Monday to Friday from 8.30am to 4.00pm. Please be aware that you may need to leave a voicemail message, but we aim to return your call within one working day.

If you are unable to understand this leaflet, please communicate with a member of staff.  

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