Stereotactic Ablative Body Radiotherapy (SABR) For non-small cell lung cancer

What is radiotherapy?

Radiotherapy is the use of radiation to treat a disease, most commonly cancer. Radiotherapy is the use of high energy X-rays and other types of radiation, to treat cancer. Radiotherapy itself is painless and does not make you radioactive. It is perfectly safe for you to be with other people, including children and pregnant women, during the course of your treatment.

Your treatment will be divided evenly into a number of sessions (fractions), usually given every other day, Monday to Friday, with weekends off. Some departments work at weekends, or weekend treatments may be given around bank holidays or in the event of a machine breakdown.

The treatment delivered will be the same each day. The number of sessions you have will vary depending on a number of factors. For this reason, each patient’s treatment is specially tailored to them. Even those with the same type of cancer as you, may receive a different number of treatments.

The treatment will cause damage to the normal cells in the area too, but they can repair themselves much more effectively than the cancer cells. This damage is what causes the side-effects you are likely to experience during the treatment.

Who will I see during my treatment?

The radiotherapy will be delivered by a team of therapeutic radiographers who will see you at each appointment and can answer your questions about radiotherapy, as well as help look after you during your treatment.

You may regularly see other professionals during your treatment, these may include:

• Specialist Therapeutic Radiographers
• Dosimetrists and Medical Physics Experts
• Mould Room Technicians
• Clinical Oncologists
• Oncology Doctors/Registrars
• Clinical Nurse Specialists
• Cancer Support Workers

We recommend that you write down their contact numbers should you need them.

What is Lung Stereotactic Ablative Body Radiotherapy (SABR)?

SABR is a technique which is an effective way of treating lung cancer. It involves giving a high dose of radiotherapy to a small area of the lung. Because such a high dose is given each time a smaller number of treatment sessions are required.

SABR treatment is usually given in 3, 5 or 8 treatments on alternate days (Monday to Friday). The number of treatments you have will depend on the position of your tumour and can often not be determined until after you have attended for your planning appointment.

Radiotherapy is given by therapy radiographers. You will usually see 2 radiographers at each treatment session and they will be happy to answer any questions you may have. You will have your radiotherapy on a treatment machine called a linear accelerator.

Planning your treatment

At your planning appointment you will be asked to sign a consent form for your treatment, if this has not already been completed.

It is a good idea to bring a list of any questions you may have and an up-to-date list of all your medication.

This visit may take up to 1 to 2 hours to complete. As the planning appointments can be quite long, you may wish to bring something to read, eat, and drink.

During this appointment you will need to have a scan taken on a machine called a CT simulator. The team will work on the best position for you at this appointment. This may mean using a wing board, creating a custom bag which supports your back and arms with your arms up or a mask.

Some patients find having their arms up uncomfortable, especially if they have arthritis. If you think that you might have difficulties keeping your arms above your head, please discuss this with your oncologist.

Please take pain relief at least 30 minutes before your scan if you think this will make the experience more comfortable.

Once you are in a suitable position the radiographers will take the required CT scans to accurately plan your radiotherapy treatment. The treatment radiographers will replicate this position at each treatment appointment.

You may be asked to have a special contrast agent commonly referred to as a dye. This involves inserting a small needle into your vein and injecting the dye. It is used to make specific organs, blood vessels and/or tissue types ‘stand out’, to help the doctor in planning your treatment.

You should inform the radiographer if you have any allergies, but they will go over this before they use any dye. The most common side-effects of the dye are; a warm or hot ‘flushed’ sensation during the actual injection, the feeling that you need to urinate, and a ‘metallic’ taste in your mouth. This does not last and no treatment is necessary.

Depending upon your position the radiographer may use a marker to mark your skin. Once the scan has been completed, with your permission, the radiographers may make several small permanent skin marks (tattoos), similar in size to a small freckle, on your skin. This will help position you for each treatment.

The consultant and planning technicians will then produce an individually designed treatment plan.

Radiotherapy treatment

A team of radiographers will see you at each treatment appointment and will ask how you are feeling. The radiographers work together in the treatment room to position you accurately, moving yourself, the treatment couch and machine. You will hear them giving each other instructions and information relating to your treatment.

During treatment, the machine will move around you but it will not actually touch you. It is important for you to stay as still as possible but to breathe normally, unless you are asked to hold your breath or follow a breathing pattern.

Once you are in the correct position the radiographers will leave the room to switch on the machine. The radiographers will be watching you on a closed-circuit TV monitor (CCTV) to ensure your safety during the delivery of the radiation. This allows the radiographers to see that you are keeping still and are not experiencing any distress during your treatment. The CCTV camera is not recording or saving any images.

Each session can take about 30 to 45 minutes. During this time the radiographers may re-enter the room a number of times to adjust your position or move the treatment couch or the machine.

Some treatment machines make a high-pitched noise when delivering X-rays. This is the only way that you will know that the machine is switched on. You will not feel pain, heat or any other sensation.

Some days the radiotherapy department may be very busy and your appointment time may be delayed. You will be kept informed of any delays.

Your appointments for radiotherapy may not all be at the same time of the day and are subject to change. It is possible that during your course of treatment you may miss a day’s treatment due to planned machine maintenance or bank holidays. It is therefore important to speak to a health care professional before booking a holiday immediately following your radiotherapy.

Side-effects of treatment

As your treatment progresses you may experience some side effects. Not everyone will experience all of these effects. Do not worry if you develop any of the following early reactions. They usually begin about halfway through the course of treatment and may last for several weeks after it has finished and then slowly settle down.

Please tell the radiographers how you are feeling particularly if your symptoms worsen, so that you can get the care you need.

Tiredness (fatigue)

Radiotherapy can make you feel more tired than usual, especially if you have to travel a long way for your treatment. You should try to ‘pace’ yourself, listen to what your body is telling you and try to keep active. Your energy levels may take weeks or months to return to normal.

Chest pain

Some patients can experience chest pain after this type of radiotherapy treatment. This is usually mild and relieved with simple pain relief, such as paracetamol. If the pain is more severe, please speak to your radiotherapy treatment team.

Shortness of breath and/or raised temperature

Shortness of breath and a cough are common side effects of SABR treatment. Occasionally, radiotherapy to the lung can produce swelling (inflammation) in the lung tissue. This inflammation or ‘pneumonitis’ can cause symptoms of increase shortness of breath, wheezing, fever and cough. This usually occurs in the first 3 months after the treatment has finished. It can often be mistaken for a chest infection but it is not helped by antibiotics. Pneumonitis is rare, but if you get these symptoms, please contact your Clinical Oncologist, your Lung Cancer Nurse Specialist or other contact numbers you have been given, as we would wish to see you in clinic as soon as possible. If pneumonitis is suspected your Clinical Oncologist will start you on oral steroid tablets to help with your symptoms and reduce the inflammation.

Lung scarring/collapse

Lung SABR will cause scarring of the lung in the area treated. This scarring is permanent and can cause a small portion of the lung to collapse.

The precise planning of your treatment keeps this amount of lung scarring/collapse to a minimum. However, in some patients this scarring and collapse can make you become more short of breath. For patients who were not already receiving oxygen before lung SABR, oxygen may be required for a short period of time. In very rare cases you may need oxygen therapy permanently as a result of the treatment. Very rarely a larger portion of the lung can collapse, and this can be life threatening.

Chest wall pain/rib fractures

Radiotherapy can weaken the ribs and cause pain or fracture. For most patients this does not cause any symptoms and is discovered when you have a scan after the treatment. A small number of patients who have a rib fracture as a result of the lung SABR treatment may have pain that requires pain relief medication for a long period of time.

Second tumour

Radiation, in theory, carries a slight risk of causing a second cancer, but this is extremely rare.

Self-care during radiotherapy

Try to allow time for rest. Everyone reacts differently, and as treatment progresses you will get an idea of the effect it is having on you.

Caring for the skin in the treatment area

• Moisturise frequently; gently smooth it onto your skin until it is absorbed. Do not rub.
• Continue to use the moisturiser you prefer and like – if you do not currently use one, speak with your Radiographer or CNS and they will be able to suggest some options.
• Do not apply moisturiser immediately before treatment.
• If a moisturiser is causing irritation, stop using it and discuss with the Radiographer or your CNS.
• If your skin blisters or peels, stop using moisturiser in that particular area and ask the Radiographer or your CNS for advice.
• Avoid sun exposure to the treatment area – wear a brimmed hat and/or cover up with clothing.

Health and wellbeing

• Keep well hydrated – aim to drink 2 litres (4 pints) of water a day.
• Avoid drinking alcohol.
• Eat a nutritionally well-balanced diet. If you are struggling to eat, a dietitian can advise you on how to add extra nourishment to your food, adapting the texture of your diet and high energy and high protein options. They can also arrange a prescription for nutritional supplements, such as high calorie drinks to help keep your weight up.
• It is important to try to maintain your weight during treatment. This will help to make sure that your mask fits well and should minimise any interruptions to your treatment.
• Keep active if you can – activity helps to improve outcomes and help you cope better with any side-effects.

What can I expect after treatment has finished?

Radiotherapy has a delayed effect in which the side-effects will continue even after your treatment has finished. They tend to reach their peak around 7 to 14 days after your last radiotherapy session, so do not be alarmed if they worsen.

Recovery times vary from person to person, but side-effects should gradually improve over the following 6 to 12 weeks.

In the weeks following your treatment, you will be reviewed by the specialists that have been looking after you. This will vary depending on your diagnosis and treatment regimen, but you will be advised about this by your treatment team.

Everyone is different and may react differently to treatment. If at any point, after you have finished treatment, you are concerned about anything, please contact your radiotherapy team or GP. You will be given the contact details for the radiotherapy department. It is not unusual for people to be anxious and it might be better to seek advice rather than worry.

What support is available?

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 as much as you can, about your treatment, may help to calm your fears and help you to cope better.

The Therapeutic Radiographers, and other healthcare professionals you may meet, will be willing to listen to your worries and support you in any way they can. They may be able to refer you to support services offered in your hospital.

Further information

Further information is readily available online, we would recommend beginning with:

Macmillan Cancer Support

Tel: 0808 808 0000

Website: www.macmillan.org.uk

Cancer Research UK

Website: www.cancerresearchuk.org

Roy Castle Lung Foundation booklet

Website: https://roycastle.org/help-and-support/lung-cancerinformation/

Further support will be available locally, please speak to your oncology team who can advise what local charities are there to help you, and what support groups are available near you.

Your data

All personal images and photographs taken during your radiotherapy will be used in accordance with the local Trust policy on the protection and use of patient information.

To read more about Gloucestershire Hospitals NHS Foundation Trust’s ‘Privacy notice’, please visit:

www.gloshospitals.nhs.uk/privacy-notice/