GYN Brachytherapy

Paula Berner, BS, CMD

U.T. M.D. Anderson Cancer Center
 Disclaimer
• I receive no support/income from any
companies whose products are discussed
and/or illustrated in this presentation.
 Course Objectives
• After this lecture, the participants should be able to
– Define Brachytherapy
– Have a basic understanding of brachytherapy GYN
implants
– Describe the applicators used in GYN brachytherapy
– Have an understanding of how these applicators are
placed
– Have a basic knowledge of radiation safety for the GYN
brachytherapy patient and nurse.
 Teletherapy

• Tele – is a prefix meaning

“at a distance”.
• Teletherapy is a general
term applied to treatment in
which the source of the
radiation is at a distance
from the body.
 Brachytherapy
• Brachy is from the Greek
word for “short”.
• Brachytherapy can be
roughly translated as short
distance therapy.
 Brachytherapy
• “…is a method of treatment in which sealed radioactive
sources are used to deliver radiation at a short distance by
interstitial, intracavitary, or surface application.”
• “With this mode of therapy, a high radiation dose can be
delivered locally to the tumor with rapid dose fall-off in the
surrounding tissue.”

• From “The Physics of Radiation Therapy 3rd Edition”, Faiz M. Khan, 2003
Brachytherapy Dose Distribution
Brachytherapy External Beam -Teletherapy
6300 cGy
3150 cGy
945 cGy
 Why Do Brachytherapy?

MDACC (1980 - 1994) EBRT + ICRT for Cervix Cancer

FIGO Staging # Patients Pelvic Control % 5 – yr Survival
– IB1 524 98 86
– IB2 482 81 67
– IIA 149 84 67
– IIB 211 81 54
– III 328 70 47
 GYN Intracavitary
Brachytherapy
– The source carriers, – Most often used to treat
applicators, are inserted cancers of the uterine
into the body through an cervix, uterine body, and
existing body cavity. vagina.
– The radioactive material – Examples
is then inserted into the • Tandem & ovoids
applicators by manual or • Vaginal dome cylinders
remote afterloading • Tandem & ring
techniques. • Tandem & cylinders
 Tandem & Ovoids
AP Lateral
• Used in the treatment
of
– Cervix cancer
– Pre-operative
endometrial cancer
– Inoperable endometrial
cancer
– Vaginal cancer
 Vaginal Dome Cylinders
AP Lateral

• Used to treat
– Post-operative
endometrial cancer
– Vaginal cancer
 Tandem & Ring
AP Lateral

• Used in the treatment

of
– Cervix cancer
– Pre-operative
endometrial cancer
– Inoperable endometrial
cancer
– Vaginal cancer
 Tandem & Cylinders
Lateral
AP

• Used to treat
– Cervix cancer – narrow
vagina
– Vaginal cancer
 Interstitial Brachytherapy
• Interstitial brachytherapy is the implantation
of radioactive sources within and around a
tumor.
– Allows for a continuous deliverance of high dose
of radiation within a short time.
– The dose is delivered to a well circumscribed
area without excessive irradiation to the
surrounding structures.
 Interstitial Implants
• Interstitial implants can
be
– Permanent
• Seed implants
– 125I , 198Au, 103Pd, 131Cs
– Temporary
• Seed ribbons or wire
– 192Ir
GYN Interstitial Brachytherapy
– The source carriers are – For GYN most often
inserted directly into the used to treat the uterine
body tissue. cervix, vagina, vulva,
– The radioactive material and both sub urethral
is then inserted in to the and pelvic side wall
applicator by either masses.
manual or remote – Examples
afterloading technique. • Needles
• Templates (Syed)
 Dome Cylinder & Needles
AP Lateral
 Inverse Square Law
• States that the dose of radiation at a given point from the
radioactive source is inversely proportional to the square of
the distance from the center of the radioactive source.
• Therefore, a large dose of radiation can be delivered to the
tumor and immediately surrounding tissues with a rapid
dose falloff that is proportional to the square of the distance
from the radioactive source.
 Inverse Square
Activity in Dome Only
Point Dose@ Dose @ 5mm
surface from surface
A
A 1368 cGy 770 cGy B

B 1434 cGy 807 cGy C

C 1442 cGy 811 cGy D

D 989 cGy 556 cGy

 Inverse Square
Activity in Dome Only Activity in Dome & Needles
 Dome + Needles
Recurrent Endometrial CA
 Dose @ 5mm from Dome Surface
Activity in Dome & Needles
Point Dome surface Dose from Total surface Dose @ 5mm
dose/dome needles to dose to dome from surface
sources only dome surface dome + dome +
needles needles
A 1368 cGy 500 cGy 1868 cGy 1052 cGy
(dome only) (770 cGy)

B 1434 cGy 816 cGy 2250 cGy 1266 cGy

(dome only) (807 cGy)

C 1442 cGy 1876 cGy 3318 cGy 5194 cGy

(dome only) (811 cGy)

D 989 cGy 1955 cGy 2944 cGy 4899 cGy

(dome only) (556 cGy)
Dome Cylinder & Interstitial
t

Needles for Vaginal Cancer

Radioactive source in dome cylinder Radioactive source in dome cylinder
137Cs tube & in needles x 11
137Cs tube + 192Ir wire
 Syed Template

AP 3500 cGy
3000 cGy
2500 cGy
 GYN Brachytherapy
• Optimal placement of applicators in the
tumor.
• Optimal geometry of radioactive source(s).
• Deliver adequate dose to most distant point
of disease.
• Respect for critical structures and normal
tissue tolerances.
Applicators Used in GYN
Brachytherapy
HDR/PDR Applicators for
Intracavitary Treatment
Fletcher-Williamson
Tandem & Ovoid Set
HDR/PDR Fletcher-Williamson
Tandem & Ovoids
HDR/PDR Tandems
HDR/PDR Tandems
3 Curvatures
HDR/PDR Flange
HDR/PDR Tandem & Flange
 HDR/PDR
Fletcher-Williamson Shielded Ovoid
Stems
Tube is 4 mm in diameter
 HDR/PDR
Fletcher-Williamson Shielded Ovoids
with Small Caps
 HDR/PDR
Fletcher-Williamson Shielded Ovoids
with Small Caps

Ovoid Stems without Caps are 29 cm in length

 HDR/PDR
Fletcher-Williamson Tandem &
Small Ovoids
Lateral View AP View
 HDR/PDR
Caps for Fletcher-Williamson Ovoids
 HDR/PDR
Fletcher-Williamson Small & Medium
Ovoid Cap

2.8 cm
2.8 cm

2.0 cm 2.5 cm
 HDR/PDR
Fletcher-Williamson Ovoid Large Cap

2.8 cm
3.0 cm cm
 HDR/PDR
Fletcher-Williamson Ovoid Caps

Medium Cap Small Cap

 HDP/PDR
Fletcher-Williamson Ovoid Caps
Large Caps
Medium Caps
 HDR/PDR
Fletcher-Williamson Shielded &
Non-Shielded Ovoid Stems

Non-shielded Shielded Stem

Stem Shielded with
Small Cap

Non-shielded with
Mini Cap
 HDP/PDR
Fletcher-Williamson Ovoid Caps
Mini Caps
Small Caps
 HDR/PDR
Fletcher-Williamson Mini Ovoid Cap

1.6 cm 3.0 cm
 HDR/PDR
Fletcher-Williamson Non-Shielded
Ovoid Stems with Mini Caps

Flat Medial Outer Surface

 HDR/PDR
Fletcher-Williamson Tandem with
Mini Ovoids
 HDR/PDR
Fletcher-Williamson Tandems
with Flanges & Ovoids
Tandem Tandem

Flange

Flange

Mini
Ovoids Shielded
Ovoids
 HDR/PDR Tandem & Ring
• Ring applicator can be
Tandem
used instead of mini
ovoids.
• Ring is unshielded.
• Produces same pear-
shaped dose Ring cap
distribution as tandem
& ovoids do.
HDR/PDR Tandem & Ring
HDR/PDR Tandems from
45° Tandem&Ring set
6.0 cm 4.0 cm 2.0 cm
HDR/PDR 45° Rings
Small & Large
 HDR/PDR
45° Large Ring Applicator
HDR/PDR Large Ring with Cap
HDR/PDR Small & Large Rings
HDR/PDR Tandem &Ring
Small /Large
HDR/PDR 45° Tandem & Ring
2.0 cm Tandem &
Large Ring 4.0 cm
Tandem &
Small Ring
HDR/PDR 45° Tandem & Ring

4.0 cm Tandem

2.0 cm Tandem
HDR/PDR Vaginal Domes &
Cylinders
 HDR/PDR Vaginal Domes
• Applicators are used to treat the
vaginal apex/cuff on patients that
do not have a uterus.
• Patient may receive one or
multiple fractions with this
applicator.
• Patient usually does not require
sedation when this applicator is
used.
• Can be used alone or with
cylinders behind the dome.
 HDR/PDR Vaginal Domes

2.0 cm 2.5 cm 3.0 cm 3.5 cm 4.0 cm

HDR/PDR Transfer Tube
HDR/PDR Flange
HDR/PDR Vaginal Dome with
Cylinders x 2
HDR/PDR Vaginal Cylinders

2.0 cm 2.5 cm 3.0 cm 3.5 cm 4.0 cm

HDR/PDR Tandem & Cylinders
Lateral
AP
HDR/PDR Tandem &Cylinders x 2

Used with tandem when vagina is to narrow for ovoids or vaginal extension
of disease is present.
 HDR/PDR Miami Applicator
• Applicator is 3.0 cm in
diameter.
• Can be inserted into
sleeves that increase
diameter to 3.5 & 4.0
cms.
HDR/PDR Miami Applicator
HDR/PDR Miami Applicator
Needle View
 HDR/PDR Tandems
for Miami Applicator
HDR/PDR Miami Applicator with
Tandem
 Eifel Fixation Device

3.0 cm 3.5 cm
LDR Manually Afterloaded
Applicators
Manually Afterloaded
Tandem & Ovoids
Manual Tandems
Manual Tandems
#1 #2 #3 #4
6 mm
diameter
Manual Flange Set
 Manual Tandem with Flanges

• The flange stops the

forward advancement of
the tandem in the uterus.
• The flange is set on the
tandem at the distance
obtained from the sound.
• The sound is the distance
from the cervix to the
fundus of the uterus.
Manual Tandem with Flanges

Total length is 27.0 cm

Fletcher-Suit-Delclos Small Ovoid

2.7 cm

2.0 cm
Fletcher-Suit-Delclos Small Ovoid
Fletcher-Suit-Delclos Manual Small
Ovoids
Caps for Fletcher-Suit-Delclos Small
Ovoids
Medium Cap Large Cap
Medium Cap Large Cap

2.8 cm 2.8 cm
2.5 cm 3.0 cm
Large Caps on Fletcher-Suit-Delclos
Small Ovoids with Caps
Large Caps
Large
Cap

Medium
Cap
Tandem & Fletcher-Suit-Delclos
Small Ovoids
Small Ovoids Small Ovoids with
no Caps Large Caps
Fletcher-Suit-Delclos Manual
Unshielded Mini Ovoids

2.7 cm 1.6 cm
Fletcher-Suit-Delclos Manual Mini
Ovoid (unshielded) & Small Ovoid
Fletcher-Suit-Delclos Ovoids

Medium Mini Large

 Tandems with
Fletcher-Suit-Delclos & Ovoids
Small Ovoids with
Small Ovoids Large Caps
Mini Ovoids
Tandem & Fletcher-Suit-Delclos
Mini Ovoids
LDR Manual Domes
LDR Manual Domes
LDR Manual Dome & Cylinders
 Vaginal Cylinders

2.5 cm 2.0 cm 2.5 cm 3.0 cm 3.5 cm 4.0 cm 4.5 cm

Circle Flange set
LDR Manual T&C
 LDR Manual Eifel Dome
with Needles

Lateral View
 LDR Manual Eifel Dome
with Needles

AP View
Eifel Dome & Fixation Device
Interstitial Applicators
 Syed Template

AP
HDR Syed Template & Needles
HDR Interstitial Needles
HDR Plastic Interstitial Needles
HDR Rigid Interstitial Needles
LDR Interstitial Rigid Needles

6.3 cm

5.3 cm

4.3 cm

3.3 cm
Dose Rate

What is it?
 Dose Rate

• Dose Rate • Low

– 0.4 to 2.0 Gy/hr
– The amount of ionizing
• Medium
radiation delivered per
– 2.0 to 12.0 Gy/hr
unit of time
• High
– Important in the – >0.2 Gy/min
radiobiology of cell kill • Pulsed
vs cell survival – Simulates LDR with a higher
activity source exposed for a
fraction of each hour
 Afterloading

How does the radiation get into the

applicators?
 Manual Afterloading

• Manual
– Radioactive sources,
usually 137Cs tubes, are
inserted into applicators
by hand
– Exposure
• Patient 2.0 cm
• Staff
• Family
 Manually Loaded Tandem with
Tube Sources
• The tube sources are
placed into a straw in the
arrangement (source
activities & spacers) as
specified in the
prescription.
• This straw is then inserted
into the tandem.
 Manual Afterloading
Ovoids
Tube source is loaded in a bucket Tube source is attached to a
spring
 Remote Afterloading

• With remotely controlled afterloading devices the direct

handling of radioactive sources for patient treatment has
been eliminated.
• The sources can be “instantly” loaded and unloaded,
making it possible to provide patient care with sources
retracted into a shielded internal safe.
• Remote afterloaders are available for either pulsed-dose
rate (PDR), or high-dose rate (HDR) treatment.
 Remote Afterloading

• PDR/HDR
– 192Ir stepping source
– Radioactive material is
inserted into the
applicators by
mechanical means.
– Exposure
• Patient HDR/PDR source
Remote Afterloading

• High Dose Rate/Pulse

Dose Rate (HDR/LDR)
– A single high activity source
is welded to the end of a
flexible cable
– Source is precisely
positioned in the applicators
by programmed dwell
weights and dwell times
– Source is stored in safe in
machine when not in use
 Remote Afterloading

• Treatment using remote afterloaders must be done in rooms

with shielding appropriate for the source(s) being used.
• There are state and federal guidelines for the storage and
quality assurance of these treatment units.
Q.A. & Radiation Safety
Radioactivity
Types of Radioactive Decay
Important in Brachytherapy
 Types of Radioactive Decay
Important in Brachytherapy
• α Decay
– Alpha disintegration occurs
mainly in heavy nuclei (A > 82).
An alpha particle consisting of 2
protons and 2 neutrons is
ejected. Alpha particles can be
shielded by a sheet of paper or
by the human skin. Alpha
particles can be inhaled,
ingested, or enter the body
through broken skin. Alpha
particles can be very harmful.
• β Decay
– Disintegrations by the
ejection of a positron or
electron from the nucleus.
Beta particles cannot be
stopped by a sheet of paper,
but some can be stopped by
the human skin. Some beta
particles need a thicker shield
such as wood to stop them.
Beta particles can also cause
damage to your body.
 Types of Radioactive Decay
Important in Brachytherapy
• γ-decay
– Gamma rays are photons and have no charge or mass.
Gamma rays are the most penetrating of the three types
of radiation that are important in brachytherapy. Gamma
rays usually accompany beta particles, and some alpha
particles. Gamma rays will penetrate paper, skin, wood,
and other substances. The thickness of concrete needed
to stop a gamma ray is dependent upon the energy of the
gamma ray. Gamma rays can cause damage to internal
organs.
 Principles of Radiation Safety
• Time
– limit
• Distance
– remember inverse square
• Shielding
– use it, but don’t let it become obstructive!
• Common Sense
 ALARA
• “As Low As Reasonably Achievable”
– This means making every reasonable effort to maintain
exposures to ionizing radiation as far below the dose
limits as practical, taking into account social and
economic factors.
– ALARA is part of the NCRP recommendations on
exposure limits of radiation workers.
 Occupational Exposures - Annual
(NCRP values)
Organ Limit Limit
(mSv/year) (rem/year)
Whole Body 50 5
Lens of the Eye 150 15
Extremities 500 50
Skin 500 50
Individual 500 50
Organs
 Occupational & Public
Dose Limits
• Radiation workers are limited
to an annual effective dose
equivalent of 50 mSv (5 rem)
per year.
– Nurses, radiation safety
personal, physicians,
physicists, and therapists.
• General public is not to
exceed one tenth of this
value – 5 mSv (0.5 rem) – for
infrequent exposure and 1
mSv (0.1 rem) for continuous
or frequent exposure.
– Patient visitors.

*Note – these limits do not include exposure from medical procedures or natural
background radiation.
 Dose Limits for Pregnant Women
• The pregnant women who is a
radiation worker can be
considered an occupationally
exposed individual, but the fetus
cannot.
• The total dose limit to an
embryo-fetus is 5 mSv (0.5
rem), with the added
recommendation that exposure
to the fetus should not exceed
0.5 mSv (0.05 rem) in any one
month.
• Some institutions have
developed a policy of not
assigning pregnant nurses,
etc. to care for the
radioactive patient.
• Such measures come under
the ALARA principle, with
the fetus being the exposed
person.
 Regulation of Radioactive
Material
– The state you work in maybe
what is know as an
“agreement state”.
• This means that the state
has established its’ own
program for the safe use of
radioactive materials.
– The state you work in maybe
what is know as an “non-
agreement state”.
• This means that the use of
radioactive materials is
controlled by a license
issued by the NRC.
• Adheres to the safety
requirements in the Code of
Federal Registration.
 Regulation of Radioactive
Material
• If your institution uses radioactive material
– Radiation Safety Committee
– Radiation Safety Office
• Look under Environmental Health & Safety
– Radiation Safety Officer
– Radiation Safety Manual
• May be on-line
 Personnel Monitoring

• Must be used in
controlled areas for
occupationally exposed
individuals.
• Cumulative radiation
monitoring is performed
using film, TLD or track-
etch devices.
• Badges are mostly used
to monitor whole body
exposure, and should
be worn on the chest or
abdomen.
 Personnel Monitoring

• Special badges may also be

used to measure exposure
to specific parts of the body,
hands, if higher exposures
are expected during
particular procedures, such
as source preparation for
patients and insertion of
sources into the patients.
 Storage of Radioactive
Sources

• Federal and state laws

require that “when not in
use, sealed sources and
applicators containing sealed
sources shall be kept in a
protective enclosure of such
material and wall thickness
as may be necessary to
assure compliance with the
provisions of” these laws.
Quality Assurance

HDR/PDR
Remote Afterloader
HDR/PDR Pretreatment
Quality Assurance
 HDR/PDR Treatment Console

• Screen on treatment
console allows you to track
for each channel
programmed
– Dummy cable test run before
each channel is treated
– The location of the 192Ir
stepping source (dwell
position)
– Time in/remaining in each
programmed dwell position
HDR/PDR Treatment Console
 Remote Afterloader
Quality Control
• Survey meter is in working
order
• Survey treatment unit to
check for source presence
• Place “pig” next to
treatment unit for
emergencies
 Remote Afterloader
Quality Control

• Source calibration
• Source positioning
• Applicator tests
 Remote Afterloader
Quality Control
• Interlock checks
• Audiovisual device checks
• Area radiation monitor
• Door lights
• Indicator lights & audible
alarms
 Remote Afterloader
Quality Control
• Treatment console area
• Accuracy of printouts
• Printer paper supply
• Manuals
 Remote Afterloader
Quality Control
• Warning signs
• Emergency power
• Timer accuracy
• Room and treatment unit
surveys
 Equipment Malfunctions
Remote Afterloaders
• Remote afterloading treatment units have built in
safety checks
• Problems are detected internally, audible alarm
sounds, unit will try to withdraw sources from
applicators to machine safe
• Treatment unit cannot be restarted unless unit is
reset and/or turned off and restarted.
 Equipment Malfunctions
Remote Afterloaders
• Before assessing situation
– Survey patient
– Survey room
– Survey afterloader
• After assessment has been made
– Implement corrective actions
– Notify physics/staff physician if needed
• Restart treatment
– Continued equipment malfunction may result in termination of
treatment
• Always survey patient & room
HDR/PDR Treatment Console
Emergency Stop
 Equipment Malfunctions
HDR

Source cable can be manually withdrawn (both HDR/PDR)

Quality Assurance

Manual Afterloading
 Preparation of Radioactive
Sources

• Before you place radioactive sources into a

patient you must verify the isotope and the
activity of the source.
• This can be accomplished by
– visual inspection of the isotope
– assay of the isotope
– film verification of distribution of activity.
 Manual Afterloading Q.A.

• Source Loading
– At least 2 individuals observe loading/preparation of
radioactive material
– Patient room is surveyed to check for any “stray”
radioactive material after implant is loaded
– A lead “pig” is placed in patient’s room in event that
sources need to be removed before designated removal
time
 Brachytherapy
Patient & Caregiver
Safe Environment
 Radiation Protection
for Caregivers
• When caring for GYN
brachytherapy patients
with continuous radiation
– Use lead shields on rollers
placed by the patient’s bed
when in a when in a room
with a brachytherapy
patient.
• Nursing/support staff
should receive annual
radiation safety training.
 Personnel Monitoring

• When caring for the

brachytherapy GYN patient
remember
– Always wear your personnel
monitoring badge
– Time
– Distance
– Shielding
– Common Sense
 Creating a Safe Environment for
the GYN Brachytherapy Patient
• Patient chart
– Documented
– Tagged as a radioactive patient
• Patient room
– Radiation sign hung on door
• Patient
– Banded as a radioactive patient (manual LDR)
 Reporting Changes in
Implant/Applicator Condition

• Changes in implant/applicator integrity

– At MD Anderson
• Nursing staff is to √ integrity/position of
implant/applicators every 4 hours
• Medical staff to √ 2 x daily
– Document in patient chart
• Count number of needles/catheters
• √ position of applicators against skin marks
 Reporting Changes in
Implant/Applicator Condition

• Changes in implant/applicator integrity

– At MD Anderson
• Nursing staff is to contact resident/staff if change in
integrity is seen
• √ by resident
• Resident informs staff
• Applicator position can be checked by film
• If necessary √ for radioactive material outside of
applicators
• Document action(s) taken
 Patient Safety
Interruption of Treatment
• Implants can be stopped when necessary
– For the medical safety of the patient
– Specific request of patient
– Patient removes implant
– Change in prescription
The Radioactive Sealed Source
During a Cardiac Arrest
• Check your institutions
policies
• At my institution
• Inside M. D. Anderson
• Institutional Policies Home
• Volume VI
• Book E Nursing
• Chapter 26 General
• Policy VI.E.26.02
• Applies to the code blue team
members.
• Sealed radioactive sources
should not be removed in the
event of a life-treating situation.
• Code blue team provides
medical interventions during the
life-threatening event.
• Following code blue activities,
the team remains in the nursing
unit until team is cleared by
radiation safety officer.
 Radioactive Patient Survey
• The following information should be recorded
after radioactive has been inserted and/or
removed from a patient
– Patient name and number
– Isotope and amount (mCi)
– Date of survey
– Results of survey
– Serial number of survey instrument
– Name of individual who performed survey
Remote Afterloaders & Area Surveys
Special Attention

• If an HDR remote
afterloading machine has
been used for a patient’s
treatment the patient must
be surveyed before being
released.
• Patients have died and
others have been exposed to
high activity radioactive
material because this simple
rule was not followed.
ALWAYS SURVEY PATIENT & ROOM AFTER COMPLETION OF TREATMENT
WHETHER LDR/PDR/HDR
 Acknowledgements
• Physicians • Physicists
• Patricia Eifel, MD • John Horton, PhD
• Anuja Jhingran, MD • Ann Lawyer, MS
• Luis Delclos, MD • Firas Mourtada, PhD
• Barry Berner, PhD
 Medical Nutrition
Therapy in the Patient
Receiving Pelvic
Radiation Therapy
Melissa Hamilton, RD, LD
Clinical Dietitian
The University of Texas MD Anderson Cancer Center
 Objectives
• Demonstrate a clear understanding of
nutrition and its role for the patient receiving
pelvic radiation therapy
• Describe Medical Nutrition Therapy (MNT) of
the cancer patient receiving radiation
therapy, and in special circumstances
• I have nothing to disclose.
 Nutrition and Cancer Care
• Medical Nutrition Therapy (MNT) – The
development and provision of a nutritional
treatment/therapy based on a detailed
assessment; used to treat/prevent disease or
illness or complications of a disease
 Nutrition and Cancer Care
• Oncology dietetics professionals should address:
– What is the most effective MNT for patients experiencing
side effects of cancer therapy
– What is the evidence to support the use of
Complementary and Alternative Medicine (CAM),
specifically dietary supplements (such as antioxidants)
– What nutrition intervention is most appropriate
– What are the expected nutrition outcomes
 Nutrition Needs of the Patient
Receiving Pelvic Radiation
Therapy
• Nutrition needs are site specific and
dependant upon dose, duration and if
radiation therapy is administered in
combination with another form of treatment
• Areas affected are in the abdominal cavity,
therefore potential for nutrition problems is
significant
 Nutrition Needs of the Patient
Receiving Pelvic Radiation
Therapy
• Nutrition impact symptoms:
– Acute – nausea/vomiting, loss of appetite,
diarrhea, cramping, bloating, gas, acute colitis or
enteritis, lactose intolerance, and fatigue
– Late effects – Diarrhea, malabsorption and
maldigestion, chronic colitis or enteritis, intestinal
stricture, ulceration, obstruction, perforation, and
fistula
 The Nutrition Assessment
• The purpose of the nutrition assessment is to determine the
need for intervention, set parameters, develop a plan, and
evaluate effectiveness
• Screening
– Changes in weight
– Food intake
– Side effects
– Medications and dietary supplements
– Activity
– Laboratory data
– Medical History
– Social Implications
 The Nutrition Assessment
• Nutrition intervention
– Address possible problems and side effects
– Provide energy and protein requirements
– Discuss specific goals
• Documentation and implementing the Nutrition Care
Process
– Contributing data
– Nutrition diagnosis(es)
Altered GI function related to side effects of pelvic radiation therapy as
evidenced by BM > 3 times per day
– Measurable outcomes
Adherence to nutrition related recommendations: low fiber diet
 The Nutrition Assessment
• Estimating Needs
– Calories
• Harris Benedict Equation
– Men: REE = 66 + 13.7W + 5H – 6.8A
– Women: REE = 655 + 9.6W + 1.7H - 4.7A
– REE = resting energy expenditure (kcal/day)
– W = weight (kg); H = height (cm); A = age (yr)
• Mifflin-St Jeor
• Ireton Jones (hospitalized patients)
 The Nutrition Assessment
• Estimating Needs
– Protein
• Account for changes in protein metabolism
• Inadequate energy and protein intake may contribute
to loss of lean body tissue
– 0.8-1.0 gram/kg for maintenance
– 1.0-1.2 gram/kg for non-stressed cancer patient
– 1.0-1.2 gram/kg for hypermetabolic
– 1.5-2.0 gram/kg for severe stress
 The Nutrition Assessment
• Estimating Needs
– Fluid
• From the ADA Manual of Clinical Dietetics (for
maintenance needs)
– 16-30 years, active: 40 mL/kg
– 31-55 years: 35 mL/kg
– 56-75 years: 30 mL/kg
– 76 years or older: 25 mL/kg
• 1 mL fluid per 1 kcal
• BSA x 1500 mL
 How Radiation Affects the
Gastrointestinal Tract
• Radiation therapy effects rapidly proliferating
epithelial cells, such as those lining the large and
small intestine
• Causing crypt cell wall necrosis, villous atrophy,
cystic crypt dilation resulting in intestinal barrier
breakdown
• Nutrition impact symptoms present as nausea,
vomiting, abdominal cramping, tenesmus, and
watery diarrhea
• Digestive and absorptive functions of the
gastrointestinal tract become compromised
 How Radiation Affects the
Gastrointestinal Tract
• Concern for malabsorption of fat, lactose, bile salts,
and Vitamin B12
• Nutrition impact symptoms usually appear in the
third week of radiation therapy and begin to resolve
2 - 3 weeks after the completion of therapy
 Bowel Management and
Nutrition
• Low fiber diet (low residue) – Approximately 15
grams or less per day
• Patients may also need to avoid or limit milk
products (lactose intolerance), spicy or fatty foods,
foods that have a laxative effect, concentrated
sweets, and caffeine
• Stress the importance of fluid
• Monitor electrolytes
• Possible probiotic benefit?
 Bowel Management and
Nutrition
• Sample Menu:
– Breakfast
• ½ cup orange juice
• 1 cup corn flakes w/ 4 ounces of milk
• 1 scrambled egg
• 1 slice white toast w/ 1 tsp margarine and 1 Tbs jam
• 6 ounces of coffee w/ 2 tsp sugar
– AM snack
• 8 ounces of plain yogurt
– Lunch
• Roast turkey sandwich made with 2 slices of white bread and 2 tsp mayo
• ½ cup egg custard
• 12 seedless grapes
• Iced tea with 1 tsp sugar
 Bowel Management and
Nutrition
• Sample Menu, continued:
– PM snack
• ½ cup canned fruit cocktail
• 2 graham crackers
– Dinner
• 3 ounces of baked fish
• ½ cup pasta
• ½ cup asparagus tips
• 1 cup lettuce
• 1 Tbs salad dressing
• 1 slice white bread with 2 tsp of margarine
– Evening snack
• 1 ounce of cheese
• 6 soda crackers
• 8 ounces of skim milk
 Special Circumstances
• Chemotherapy
• Obesity
• Diabetes
• The use of Complementary and Alternative
Medicine (CAM)
 Chemotherapy
• Patients receiving combination therapy often
experience more serious side effects
• Timeliness of nutrition intervention can
prevent or improve nutrition impact
symptoms
• Monitor weight, nutrition related labs, intake
and tolerance to food
 Obesity
• Avoid overfeeding … Predictive equations may
over-estimate needs
• For BMI 30-50, acutely ill:
– Use the Harris-Benedict equation using average weight
(kg) x injury factor. Do not use activity factor. Average
weight is equal to Ideal Body Weight + 50% excess body
weight
– 21 kcal/kg
– Ireton Jones equation for obesity
– Mifflon-St. Jeor formula
 Diabetes
• Approximately 8-18% of cancer patients have
diabetes
• Cancer patients with diabetes have a poorer
prognosis compared to those without, higher
infection rates, shorter remission periods, shorter
median survival times, and higher mortality rates
• Patients receiving cancer therapy are at a high risk
for developing severe hyperglycemia
 Diabetes
• Consider diet modification and close monitoring of
blood glucose levels
• The patient’s health care team may provide a new
target range for blood glucose
• Special consideration may also need to be given if
patients:
– Need to stay fasting for testing and procedures
– Sick and unable to eat
 The Use of Complementary
and Alternative Medicine
• CAM includes a variety(CAM)
of medical, health, and lifestyle
practices
• Used in conjunction with or in lieu of conventional therapy
• Concern for potential interactions
• Estimated that more than 60% of patients use CAM
• Many patients do not report the use of CAM to their
healthcare provider
• Dietary supplementation may be the most common form of
CAM used among cancer patients
 The Use of Complementary and
Alternative Medicine (CAM)
• Evaluating CAM therapies
– Is there scientific evidence to support safety and
effectiveness?
– Does the diet eliminate foods or nutrients?
– Have singular unfounded claims been made?
– Is the cost of the product excessive?
– Does the product appear to be harmless?
 Summary
• MNT plays a very important role in managing nutrition
impact symptoms, preventing or treating deficiencies, and
preventing weight loss
• Patients should be screened throughout the course of
radiation therapy
• Complete a thorough nutrition assessment to determine the
need for intervention, set parameters, develop a plan, and
evaluate effectiveness
• Consider the patient’s needs in special circumstances
 References
• Kogut, V.J., Luthringer, S.L.: Nutritional Issues in Cancer Care.
Pittsburg, PA: Oncology Nursing Society, 2005, pp 79-102.
• Oncology Nutrition Practice Group: The Clinical Guide to Oncology
Nutrition, Second Edition. Chicago, Illinois: American Dietetic
Association, 2006.
• National Cancer Institute. (2007). Gastrointestinal Complications
(PDQ®) Health Professional Version. Accessed 6/6/2007 from
www.cancer.gov
• Francois, A., et al. (2005) Bowel Injury associated with pelvic
radiotherapy. In Radiation Physics and Chemistry 72, 399-407.
• Psarakis, H.M. (2006). Clinical Challenges in Caring for Patients with
Diabetes and Cancer. In Diabetes Spectrum 19, 157-162.