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Radiotherapy is usually given as the main treatment if your cervical cancer is large, or has spread beyond the cervix or to the lymph nodes. Radiotherapy may also be used after surgery if there is a high risk that the cancer may come back. It is often given in combination with chemotherapy, as chemotherapy makes the cervical cells more sensitive to the effects of the radiotherapy, which makes it more effective. This type of treatment may also be called chemoradiotherapy or chemoradiation.
Radiotherapy treats cancer using high-energy rays that destroy the cancer cells while doing as little harm as possible to normal cells. Radiotherapy for cervical cancer can be given either externally or internally (called brachytherapy), and often as a combination of the two.
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External radiotherapy (also known as external beam radiotherapy) is where the high energy rays are directed at the area of your cancer from outside your body.
Planning is a very important part of radiotherapy and makes sure that it is as effective as possible. On your first visit to the radiotherapy department you will be asked to have a CT scan, which will be done with you lying down in the position that your cancer specialist (clinical oncologist) has planned for you to be in during your treatment. You may be asked to fill your bladder before the scan, as this can help to protect your bowel by pushing it out of the way of the radiotherapy rays. The radiographers (the people who give you your treatment) will explain whether you should have a full or empty bladder, as different centres may have different rules on this. This CT scan is then used by your clinical oncologist to individually design your treatment. Marks (like tiny tattoos) will be drawn onto your skin to show the radiographers where to direct the rays. Your clinical oncologist will be able to discuss any concerns you may have.
External radiotherapy is usually given to you as an outpatient and you will need to attend every weekday (Monday to Friday) for treatment, with a rest at the weekend. This treatment will be given in the hospital radiotherapy department. High energy x-rays from a machine are directed at the area of your cancer. The number of treatments you have will depend on the type and size of the cancer, but the whole course of treatment will last a few weeks. Chemotherapy is usually given once a week, each week throughout the duration of your planned treatment. Your consultant or radiographer will discuss the treatment and any possible side effects with you.
When you attend each session of radiotherapy, the radiographer will carefully position you on the couch and make sure that you are comfortable. The couch is very firm, but the radiographer may put rests beneath your knees or put your feet into rests to make it more comfortable and to help you remain still. The treatment usually lasts only a few minutes and you will be alone in the room during this time. You will be able to talk to the radiographers should you need to, as they will be monitoring you closely from the next room.
External radiotherapy is not painful but you do need to lie still when the treatment is being given. The radiation machine may move around you but it doesn’t touch you. The radiotherapy treatment will not make you radioactive and it is perfectly safe for you to be around other people, including children, after your treatment.
Always make sure that you drink plenty of fluids throughout the entire planned timescale for your radiotherapy treatment. How full your bladder is has an effect on your treatment and can affect the dose of radiotherapy received by your bladder and bowels. Like they did during the planning of your treatment, your radiographers will let you know whether you should have a full or empty bladder at the time of treatment.
Brachytherapy gives a controlled dose of radiotherapy using a radioactive ball (source) that is placed directly next to the cervix or at the top of the vagina. If your treatment plan involves brachytherapy it will usually be given after you finish your course of external beam radiotherapy. How the brachytherapy is given depends on whether or not you have had a hysterectomy.
For women who have not had a hysterectomy the brachytherapy delivers a high dose of radiotherapy directly into the cervix and womb. You may have an MRI scan in the last week of your external beam radiotherapy in preparation for the treatment. Under a general anaesthetic (where you are asleep) or a spinal anaesthetic (where you are numb from the waist down), tubes are placed into the vagina and uterus so that they lie directly touching the tumour. A radioactive ball on the end of a wire (source) can then be fed into the tubes and the radiation spreads directly out of the source to the tumour. You will have to have a CT or MRI scan with the tubes in place before the radiation dose is given. This allows the treatment to be individually designed so that the tumour receives a high dose of radiation, while the bladder, bowel and surrounding normal cells get a lower dose to help protect them.
Each hospital will have a slightly different way of delivering this treatment. Your clinical oncologist will explain your individual treatment to you in more detail. Depending on the type of radioactive source your hospital uses, you may have a number of separate sessions of brachytherapy or you may get all of your treatment at once over a 24–48-hour period.
In some centres you will return to the ward after theatre with the tubes in place. The radiation will then be delivered by a machine, called a low dose rate (LDR) or pulsed dose rate (PDR) machine, for up to 24 hours. You will have to remain in bed during this time and will have a catheter in place to drain your bladder. The catheter is generally put in place at the same time as the tubes so it is there when you wake up from the anaesthetic. The radioactive sources can be withdrawn regularly so that nurses can enter the room at regular intervals. The tubes themselves will remain in place and you will not be aware of whether the balls are in place or have been withdrawn. It is not usually painful, but it may be uncomfortable and so painkillers can be given if necessary.
With LDR treatment, it is not possible to have visitors during your treatment and so it can make some women feel very isolated, frightened and depressed at a time when they might want people around them. If you experience these feelings, it is important that you let the staff looking after you know. You might also find it helpful to take plenty of reading material and things to keep you occupied. You only need to be in isolation whilst the tubes are in place. Once they have been removed, the radioactivity disappears and it is perfectly safe to be with other people.
In other radiotherapy departments, high dose rate (HDR) treatment is used. This treatment uses an implant that contains a higher dose of radioactivity, which gives the treatment over a few minutes. These shorter treatments may need to be repeated several times. This can be done in two ways:
Once the treatment is completed, the tubes will be removed by one of the doctors or nurses. This can be a bit uncomfortable. Painkillers will be given before they are removed and sometimes sedation or gas and air may be given to make it easier for you.
For women who have had a hysterectomy (a surgery where the uterus (womb) and cervix are removed, brachytherapy can also be used to give a high dose of radiotherapy directly to the top of the vagina. This treatment is given as an outpatient and does not require any specific preparation from you. In some cases you may have an X-ray or CT scan on the first visit. For your first treatment, the doctor or specialist brachytherapy radiographer will undertake a vaginal examination to decide the correct applicator size. A small plastic tube (sometimes called a Dobbie) or two small tubes (called ovoids) are placed inside the vagina. The radiotherapy treatment is given over a few minutes and then the tube is easily removed and you can go home immediately. This is repeated for a total of two to four visits.
Like for women who have not had a hysterectomy, brachytherapy can also be given with a PDR machine or by HDR treatment. In the case of PDR it would be given on one or two visits, each with an overnight stay. With HDR it would be given on three or four separate visits, with each treatment lasting only five minutes.
Watch Robyn’s story to hear more about her experience with cervical cancer and going through radiotherapy, brachytherapy and chemotherapy.