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Oncology Nursing 101 Debra L. Winkeljohn, RN, MSN, AOCN®, CNS—Associate Editor

Basics of Radiation Treatment

Jayne Camporeale, MS, RN, OCN®, APN-C

Cancer is the second-leading cause of or particles to a specific area to treat the dose to the treatment area and sparing
death in the United States, exceeded only disease (Watkins-Bruner, Haas, & Gosse- healthy tissues as much as possible
by heart disease (American Cancer Soci- lin-Acomb, 2005). The treatment area is (Bourland, 2000). Treatment-planning
ety, 2008). Approximately 1.43 million determined by visible tumor, microscopic techniques can more precisely define ra-
non-skin cancer cases will be diagnosed in tumor, and positional boundaries. The diation delivery to an irregularly shaped
2008 (ACS) and three out of four patients boundaries create gross tumor, clinical tumor. Conformal treatment with a
with cancer are likely to receive radiation tumor, and planning target volumes (see computer-controlled multileaf collima-
during the course of the illness (Belka & Table 1). Other patient-related positional tor helps reduce radiation exposure to
Camphausen, 2006). Understanding the uncertainties that should be accounted at-risk organs (see Figure 3). Additional
basics of radiation and treatment goals for include organ motion, digestion, excre- shielding or lead blocks may be used
are essential to provide the best possible tion, weight, and ability to remain still. to minimize exposure of normal tissue
patient care. near the treatment area (Bourland).
Radiation can be very effective for What Is the Linear The desired treatment depth deter-
curative purposes, localized control, and
palliation of pain and symptoms. It also
Accelerator? mines the type and amount of energy
used. For example, many skin cancers
can be used in the neoadjuvant setting to The linear accelerator is the most com- are treated with electrons because they
shrink a tumor before surgery. monly used treatment machine. Located travel a finite distances before stopping.
a distance from the tumor site, the linear Photons, on the other hand, have wave-

What Is Radiation? accelerator produces the radiation the

patient will receive through high-energy
length, frequency, and energy ranges
over an unlimited order of magnitude
Radiation is any type of radiant energy x-rays and electrons (see Figure 2). (Bourland, 2000) and, therefore, are
that can impart energy to the medium Through microwave technology, elec- used on deeper cancers such as lung
through which it passes (Zeman, 2000). trons either accelerate to a high-energy tumors.
Radiation kills cancer cells by perma- state and exit as an electron beam or are The linear accelerator’s radiation
nently damaging the cell DNA or by cre- directed into a target to produce x-rays. beam is projected through a section
ating free radicals that damage cell DNA X-rays collide inside the linear accelera- known as the gantry, which can rotate
(Zeman). Accurate and precise delivery tor and scatter and bump into a heavy 360º around the patient. The patient is
of radiation to the tumor can minimize metal target in the machine, where a positioned on a moveable table called
damage to surrounding healthy tissue. portion are collected and shaped into the couch, which can move in vertical,
a beam equal in size to the area of the longitudinal, lateral, or arc motions

Radiation Delivery targeted tumor (Watkins-Bruner et al.,

2005).
(Bourland, 2000). This setup allows the
radiation to be delivered to the tumor
Methods Treatment design and planning takes from any angle (Radiologic Society of
place within the physics and dosimetry North America, Inc., 2007).
Radiation can be delivered using mul-
rooms where beams are customized for The linear accelerator is controlled
tiple techniques, but, in general, three
each patient. Three-dimensional confor- by a radiation therapist (see Figure 4)
are used for cancer treatment (see Figure
mal and intensity-modulated radiation who is responsible for ensuring that the
1). This article will focus on teletherapy
therapies have advanced cancer treat- dose is delivered to the correct area as
or external beam radiation therapy.
ment by providing a more heterogeneous prescribed. The therapist uses visual and

Teletherapy or External Beam

Radiation Therapy
External beam radiation therapy, the Jayne Camporeale, MS, RN, OCN®, APN-C, is an adult nurse practitioner in the Department of
most common radiation delivery method, Radiation Oncology at the Cancer Institute of New Jersey in New Brunswick.
involves delivery of high-energy x-rays Digital Object Identifier: 10.1188/08.CJON.193-195

Clinical Journal of Oncology Nursing • Volume 12, Number 2 • Oncology Nursing 101 193
audio monitoring devices from inside
a lead-shielded room throughout treat-
Table 1. Radiation Treatment Planning
ment. Multiple quality assurance checks Treatment Boundary Treatment volume included area
and balances are in place to ensure that
only the targeted area is treated. Visible tumor Gross tumor Gross malignant growth and abnormally
enlarged lymph nodes

Dosage Microscopic tumor Clinical tumor Tissue volume that contains the gross
tumor and the subclinical microscopic
The radiation dose that is delivered
malignant disease
to the patient usually is provided in a
five day per week pattern called frac- Positional Planning target Clinical tumor volume with margin for
tionation, meaning that the dosage ac- geometric uncertainty, variation in setup,
cumulates to the prescribed treatment and an anatomic motion during treat-
ment
level over the course of the week. The
fractional amount delivered each day Note. Based on information from Halperin et al., 2004; Watkins-Bruner et al., 2005.
is related to the amount of energy ab-
sorbed per unit mass. The amount of
energy absorbed previously was known
as a radiation absorbed dose, but is tinue to function and undergo several clinical examinations, magnetic reso-
now known as Gray or centigray. One divisions before final mitotic death (Hal- nance imaging, computed tomography
gray equals 100 centigray; 1 centigray perin et al., 2004). Fractionation assaults scans, surgical reports, positron emis-
equals 100 radiation-absorbed doses the tumor cells by not allowing them to sion tomography scans, etc. (Zeman,
(Watkins-Bruner et al., 2005). Fraction- repair between treatments. 2000). Once the isocenter is placed and
ation helps spare acute reactions in the the information is obtained, freckle-
tissues, allows for a higher cell kill, and Simulation sized tattoos or fiducial markers are
avoids damage to normal tissues which Patients must undergo a computed placed on the patient. The tattoos are
might not be repaired if the dose was tomography simulation to prepare for lined up with laser beams in the treat-
delivered all at once (Halperin, Schmidt- radiation. The simulation has diagnos- ment room and assist with the daily
Ullrich, Perez, & Brady, 2004). tic radiographic and fluoroscopic ca- treatment setup. Tattoo information
The total delivered dose is determined pabilities and can mimic the functions and any needed immobilizers will be
by tissue tolerance in the treatment and motions of the linear accelerator. recorded on a prescription in the treat-
area. Tissue tolerance is defined as the The patient is placed on the simulator ment record. The patient should be pho-
therapeutic irradiation dose believed table in the anticipated treatment posi- tographed in the anticipated treatment
to minimize the risks of complications tion. The computed tomography scan position so accurate replication occurs
or permanent damage (Haas & Kuehn, simulates the radiation properties of the during each treatment.
2001). Normal tissue tolerance depends treatment beam, allowing the anatomy to
on the ability of the dividing cells to be viewed from the direction of the radia-
produce enough mature cells to ensure tion beam. Field shaping is done through
organ function. a computerized virtual simulation work-
Radiation-induced lethality does not station (Purdy, 2004). IV contrast may
occur instantaneously because cells con- be administered during the simulation
to improve visualization. Immobilizers,
including face masks, head holders, foam
Brachytherapy: short or slow radiation molds, cushions, pillows, bite blocks, and
therapy placed into or near tissue or body vacuum bags that are shaped to the cor-
cavities or on the skin at or near the tumor responding body part, also may be used
Radiopharmaceuticals (unsealed sources): during the simulation to maintain patient
liquid radioactive sources that are ingested, position. Communication with the pa- Note. The linear accelerator’s gantry rotates
injected, or instilled with characteristics that tient during the simulation is imperative around the patient during treatment. The
determine treatment locations to determine comfort in the position couch rotates around the circle on the floor
he or she will be required to maintain and moves up and down. The multileaf col-
Teletherapy: radiation projection generated
throughout treatment. limator is located near the tip of the gantry.
by electricity and provided via external beam
Once the radiation oncologist views Any needed shielding blocks would be
machines
placed at the tip of the gantry.
the planning scan, an isocenter will be
Figure 1. Definitions placed on the computed tomography
Figure 2. Linear Accelerator
of Radiation Delivery Systems scan. The isocenter is the center of
treatment through which all rotational Note. Photo courtesy of Robert Wood
Note. Based on information from Halperin et Johnson University Hospital Department of
axes must intersect (Bourland, 2000).
al., 2004; Watkins-Bruner et al., 2005. Radiation Oncology. Used with permission.
The isocenter location is determined by

194 April 2008 • Volume 12, Number 2 • Clinical Journal of Oncology Nursing
Positioning Dosimetrist: responsible for calculating
Bourland, J.D. (2000). Radiation oncology
physics. In L.L. Gunderson & J.E. Tep-
Actual treatment setup will take place doses to the treatment area and the shape
of the planned radiation beams per (Eds.), Clinical radiation oncology
after planning is complete, possibly oc- (pp. 64–118). Philadelphia: Churchill
curring the same day as the simulation. Physicist: ensures treatment machines deliver Livingstone.
Setup is a practice run that offers the the correct amount of radiation to the patient Haas, M.L., & Kuehn, E.F. (2001). Tele-
healthcare team an opportunity to make theray: External radiation therapy. In
Radiation oncologist: a physician who
adjustments based on simulation infor- specializes in radiation as the main modality D. Watkins-Bruner, G. Moore-Higgs, &
mation. Portal imaging, an x-ray which for cancer treatment M. Haas (Eds.), Outcomes in radiation
compares simulation films to the an- therapy (pp. 55–66). Sudbur y, M A:
ticipated treatment films, validates the Radiation therapist: a technician with Jones and Bartlett.
advanced training in radiology who en-
data (Kudchadker, Chang, Bryan, Maor, Halperin, E.C., Schmidt-Ullrich, R.K.,
sures correct dose, location, and treatment
& Famiglietti, 2004). Obtaining a portal Perez, C.A., & Brady, L.W. (2004). The
schedule
image at the beginning of treatment discipline of radiation oncology. In C.A.
Perez, L.W. Brady, E.C. Halperin, & R.K.
and weekly thereafter is common. The Figure 4. Radiation Treatment
radiation oncologist will verify that the Schmidt-Ullrich (Eds.), Principles and
Team Members practice of radiation oncology (4th
two images match each other within a
prescribed parameter (often millimeters) Note. Based on information from National ed., pp. 1–95). Philadelphia: Lippincott
Cancer Institute, 2008. Williams and Wilkins.
and, once the films are approved, treat-
ment begins. Kudchadker, R.J., Chang, E.L., Bryan, F.,
Maor, M.H., & Famiglietti, B.S. (2004).
The patient is informed that he or she
An evaluation of radiation exposure
should not feel the treatment and that
from portal films taken during defini-
the experience is comparable to having Conclusion tive course of pediatric radiotherapy.
an x-ray. Noises that patients hear will be
Patients receiving radiation experi- International Journal of Radiation
from the movement of the linear accel-
ence many stresses during treatment. Oncolog y, Biolog y, Physics, 59 (4),
erator. The therapist is able to view the 1229–1235.
patient during treatment, and the patient Radiation may be the first step in cancer
National Cancer Institute. (2008). Diction-
is taught to raise a hand if assistance is treatment and, by providing a guiding
ary of medical terms. Retrieved Febru-
required. As the patient becomes more hand and being available for the many
ary 28, 2008, from http://www.cancer
acclimated to treatment, the daily setup questions that arise, oncology nurses
.gov/dictionary
and treatment may only take minutes. can assist patients through the journey.
Purdy, J.A. (2004). Principles of radio-
Side effects may not occur until one to Understanding the radiation therapy
logic physics, dosimetry and treatment
two weeks into treatment and are likely process will help oncology nurses react planning. In C.A. Perez, L.W. Brady,
to last two to three weeks after the treat- to their patients’ experiences and bet- E.C. Halperin, & R.K. Schmidt-Ullrich
ment ends. Patients should be informed ter enable them to answer questions, (Eds.), Principles and practice of radia-
of possible side effects, such as fatigue, assist during treatments, and accurately tion oncology (4th ed., pp. 180–218),
skin redness, and hair loss in the treat- diagnose and treat the side effects that Philadelphia: Lippincott Williams and
ment area prior to treatment. patients may be experiencing. Wilkins.
Radiologic Society of North America, Inc.
Author Contact: Jayne Camporeale, MS, RN, (2007). Radiology info–linear accelera-
OCN®, APN-C, can be reached at camporjm@ tor. Retrieved March 3, 2008, from http://
umdnj.edu, with copy to editor at CJONEditor@ www.radiologyinfo.org/eninfo.cfm
ons.org. Watkins-Bruner, D., Haas, M.L., & Gosselin-
Acomb, T.K. (Eds.). (2005). Manual for
References radiation oncology nursing practice
and education (3rd ed.). Pittsburgh, PA:
American Cancer Society. (2008). Cancer Oncology Nursing Society.
facts and figures 2008. Atlanta, GA: Zeman, E.M. (2000). Biologic basis of
Author. radiation oncology. In L.L. Gunderson
Belka, C., & Camphausen, K.A. (2006). & J.E. Tepper (Eds.), Clinical radia-
Why “radiation oncology.” Radiation tion oncology (pp. 1–41). Philadelphia:
Oncology, 1(1), 1. Churchill Livingstone.
Note. The multileaf collimator’s open or
closed position during treatment is predeter-
mined in the planning phase.

Figure 3. Multileaf Collimator Do you know who ONS’s newest leaders are?
Note. Photo courtesy of Robert Wood Visit the Membership area of www.ons.org to find out
Johnson University Hospital Department of this year’s ONS election results.
Radiation Oncology. Used with permission.

Clinical Journal of Oncology Nursing • Volume 12, Number 2 • Oncology Nursing 101 195