Cervical Cancer: Radiation

If you're getting ready to start radiation therapy for cervical cancer, you likely have a lot of questions. You may be feeling overwhelmed. That's completely normal. But learning more about your radiation treatment may help you to mentally prepare for what to expect next.

Radiation therapy is one method used to treat cervical cancer. It's also called radiotherapy. In this treatment, beams of high-energy X-rays are targeted at cancer cells to break them down. Your doctor may give you radiation on its own or along with other kinds of treatments.

Many people with cervical cancer who get radiation therapy also get chemotherapy (chemo). Chemo uses strong medicine to kill cancer cells. When chemo is given with radiation it is given at a lower dose. This has been shown to help radiation therapy work better.

Radiation is a local therapy. That means it only targets cancer cells in the area being treated instead of your whole body.

Your doctor may suggest radiation therapy for you if:

• Your cancer is small and found only in your cervix. You may have radiation instead of surgery.
• You have a large tumor that's just in your pelvis.
• You want to avoid surgery or can't have surgery because of other health problems.
• You have a large tumor that could shrink from the radiation and then be removed with surgery.
• You need treatment after surgery to make sure that all the cancer cells are gone.
• You have cervical cancer that has spread past your cervix to nearby tissues, blood vessels, or lymph nodes.

A radiation oncologist will be your go-to doctor during your radiation treatment. These are specially trained doctors who treat cancer with radiation therapy. They'll help direct your treatment plan according to your needs. Your oncologist might talk with you about:

• The goal of radiation therapy.
• The type (or types) of radiation you'll need.
• How much radiation you need.
• How long and how often you need treatment.
• The expected side effects of radiation therapy and how they are managed.

You and your doctor will likely talk about your health history and lifestyle before you start radiation. This helps them create the best treatment plan for your needs. Some things your doctor may want to discuss include:

• Imaging tests. Your doctor might start by doing imaging tests to decide which type of treatment will be most helpful. These tests take pictures of the inside of your body to find the cancer. Imaging tests may include X-rays, CT scans, or MRIs. You may have the same tests done after treatment to see how well it worked.
• Impact on fertility. Radiation can impact your ability to get pregnant. It's important to talk with your doctor about whether you want to get pregnant in the future, because it will affect your treatment plan. Many find this is a sensitive subject. It can be a hard topic to discuss. You may find it helpful to bring a family member or friend to appointments. They can take notes, help ask questions, or just be there to comfort you. Try to make a list of questions ahead of time and bring it to your visit.
• What to expect. Your oncologist will tell you what will happen during radiation and how you might feel during and after treatment. Remember that your health care team is there to help you through everything you're facing. Bring up any concerns you have before getting radiation.

There are two main types of radiation for cervical cancer. Your treatment may either include one or both of these:

• External beam radiation therapy (EBRT). In this therapy, a machine directs beams of high-energy X-rays at the tumor from outside your body. There are specialized types of EBRT your radiation oncologist may discuss with you called intensity-modulated radiation therapy (IMRT) and stereotactic body radiation therapy (SBRT).
• Internal radiation (brachytherapy). Your doctor puts a device to deliver the radiation source into your vagina, cervix, or uterus. This helps the radiation get close to any cancer on your cervix. There are two types of brachytherapy: low-dose rate (LDR) and high-dose rate (HDR). The schedule and setting will depend on the kind of treatment you need.

You've likely had an X-ray or know someone who has had one. EBRT is done in a similar way. The machine doesn't touch you during the treatment. The process is quick and painless. But the radiation dose is much stronger than a routine X-ray. It comes from a large machine that directs a beam of high-energy X-rays where the cancer cells are. It's important that you stay very still while the machine sends this radiation to your tumor.

EBRT is typically given for a few minutes once a day, 5 days a week, for 4 to 6 weeks. Your doctor will leave the room while the machine is working. During this time, they can still see, hear, and talk to you. The machine only runs for a few minutes. The whole process lasts less than an hour.

Your health care team knows how important it is to aim EBRT right at your cancer cells. Here are some ways they help make sure that happens on the day of radiation:

• Imaging tests will be done before you start treatment to locate the tumor.
• Small marks (or tattoos) may be put on your skin to clearly mark the treatment area.
• Your doctor will carefully put you into a position that will help the radiation beams stay on target. Special molds might be made to make sure you stay in the same position for each treatment. This helps the beams reach the tumor instead of directing them at healthy parts of your body.
• You may see lights from the machine line up with the marks on your skin. This also helps your doctor aim the radiation exactly where it needs to go.

Brachytherapy targets cervical cancer with a radiation source that's inside your body for minutes or hours at a time. It uses a type of radiation that only travels a short distance. The radioactive material is put in a device that fits in your vagina, cervix, or uterus. The radiation from it mostly affects the cervix and the inside of the vagina. Brachytherapy also causes less damage to nearby organs, like your bladder and rectum. It is often used with EBRT starting toward the end or after EBRT is completed.

There are two types of brachytherapy:

• Low-dose rate (LDR) brachytherapy. Your doctor will put a device that contains a radioactive substance inside your body near your cervix. The device will stay there for a few days. You'll rest in bed in the hospital during this type of therapy.
• High-dose rate (HDR) brachytherapy. Your doctor will put a radioactive device inside your body for a short amount of time. Then they'll take it out before you go home. You'll usually go home the same day you get the treatment. But once in a while the implanted device will stay in place overnight and require a short hospital stay. You may need a few treatments. These might be done once a week.

Radiation therapy works well at targeting cancer cells. Unfortunately, it also affects healthy cells. This can cause you to have side effects. The type and amount of side effects that you have depend on how much radiation you get and how it's given. When chemo is given with radiation, the side effects may be worse (such as nausea and lower blood counts). Common side effects include:

• Diarrhea or loose bowel movement
• Tiredness
• Loss of appetite
• Nausea and vomiting
• Skin changes where the radiation beams enter your body
• Vaginal irritation, bleeding, and discharge
• Pelvic area soreness
• Temporary or permanent loss of pubic hair
• Vaginal dryness and scarring (This can make your vagina shorter, narrower, and less able to stretch. This can cause pain during sex and pelvic exams. It can be a long-term problem. But there are things you can do to help keep it from happening.)
• Rectal bleeding, narrowing, and scarring, which may need treatment
• Menstrual changes or early menopause
• Damage to the ovaries that causes early menopause (This can lead to bone weakening.)
• Reduced fertility or infertility, making it hard to get pregnant
• Bladder irritation, bleeding, and problems urinating
• Weak hip bones and higher risk of breaks (This can be a long-term side effect.)
• Low blood counts that cause low levels of red blood cells (anemia) and white blood cells (leukopenia)
• Swelling of one or both legs (lymphedema)

When you know what to watch for and talk openly with your doctor, you can help play an active role in treating or even preventing side effects.

Most side effects of radiation will go away or get better within a few weeks or months after your therapy ends. Keep in mind that many symptoms can be treated. So be sure to talk with your health care team about any problems you have. Also ask about long-term side effects that may appear months or even years after treatment. There may be things you can do to help prevent them from happening. Here are a few long-term side effects you may have.

Pain during sex. After treatment, you may start to feel pain during sex. The pain could be from dryness or scar tissue in your vagina. Scar tissue can make your vagina narrower (vaginal stenosis) or shorter.

All these things can make having sex painful. Talk with your radiation oncologist about things that could help. One way is to use a vaginal dilator. This is a device you can put in your vagina a few times a week that prevents it from becoming more narrow or shorter. It's best to start about 2 to 4 weeks after your radiation treatment ends. You may need to use the vaginal dilator long-term.

Lymphedema. You might notice swelling in your leg(s) if lymph nodes in your pelvis are treated with radiation. This side effect is called lymphedema. It is caused by fluid drainage problems in the legs. It is important to receive treatment before it gets worse. Talk with your doctor about your risk for lymphedema. Ask what steps you can take to treat, prevent, and manage lymphedema.

It's vital that you keep your health care team updated about how you're feeling throughout the radiation process for your cervical cancer. Talk with your doctors about any side effects you should look for and when you should reach out to them. And make sure you know what number to call with any questions. Find out ahead of time if there is a different number for you to call on evenings, holidays, and weekends.

Try to keep a diary of your side effects. You can write down any changes you go through, whether they affect you physically, mentally, or emotionally. Be sure to share any concerns with your health care team.

Remember, you're not alone. Your health care team is here to guide you through your radiation therapy and beyond.