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Radiation Therapy to the Chest

This information will help prepare you for radiation therapy to your chest, including what to expect before, during, and after your treatment. You will also learn about side effects and how to care for yourself during
your treatment.

You will be getting external beam radiation to treat your cancer. A beam of radiation is directed to the tumor site from a treatment machine. The beam passes through the body and destroys cancer cells in its path.

Simulation

Before you begin your treatment, you will have a treatment planning procedure called a simulation. This is done to make sure that:

  • Your treatment site is mapped out
  • You get the right dose of radiation
  • The dose to nearby tissue is small

During your simulation, you will have x-rays taken and your skin will be marked. These marks identify the area that will be treated.

Your simulation will take 2 to 4 hours.

Preparing for your simulation

If you think you will be uncomfortable while lying still for a long time, bring acetaminophen (Tylenol®) or your usual pain medicine to your simulation. Take it when you arrive for the procedure. If you think you may get anxious during your procedure, speak with your radiation oncologist about medication that can be helpful.

Some patients will need to have a positron emission tomography-computed tomography (PET-CT) scan done during the simulation. If you are having one, your nurse will give you detailed instructions to prepare you for the scan. Some patients are allergic to intravenous (IV; given through a vein) contrast (dye). If you are, your nurse will tell you what to do.

If you are having a PET-CT, do not eat or drink anything except plain water for 6 hours before your appointment time. This includes gum, hard candy, cough drops, and mints. If you have had anything except water, your PET-CT scan may need to be rescheduled.

Day of your simulation

Wear comfortable clothes, and make sure not to wear earrings or necklaces on the day of your procedure.

When you arrive for your simulation, a radiation therapist will greet you. He or she will take a photograph of your face. This picture will be used to identify you throughout your treatment. The therapist will then explain the procedure to you.

If you have not already signed a consent form, your radiation oncologist will review everything with you. You will then be asked to sign the consent form.

If your treatment will be to your esophagus, you may be asked to swallow barium liquid. It makes it easier to see your esophagus on the x-rays that will be taken later.

During your simulation

For your simulation, you will get undressed from the waist down and change into a gown. You may keep your shoes on. The therapists will help you lie down on your back on the simulation table. Although the table will have a sheet on it, it is hard and has no cushion. If you haven't taken pain medication and think you may need it, tell the therapists before your simulation begins. Also, the room is usually cool. If you feel uncomfortable at any time, let the therapists know.

Throughout your simulation, you will feel the table move to different positions. The lights in the room will be turned on and off and you will see red laser lights on each wall. The therapists use these laser lights as a guide when they position you on the table. Do not look directly into the red beam because this may hurt your eyes.

Although the therapists will walk in and out of the room during your simulation, there will always be someone who can see and hear you. You will hear the therapists speaking to each other as they work. They will explain what they are doing, but please do not speak once they begin because it may change your position. You can speak if you are uncomfortable or need assistance.

To help pass the time, music can be played throughout your procedure. If you would like, ask the therapist to play a CD for you. You may bring one of your own from home.

Positioning (mold)

You will probably be lying on your back throughout your simulation. A mold may be made of your upper body to help you stay in the same position each time you receive your treatment. The therapists will pour a warm fluid into a large plastic bag that will be sealed and placed on the table. You will lie on top of the bag, on your back, with your arms raised above your head. The fluid will feel warm at first, but it will cool as it hardens. While it is cooling, the therapists will tape the bag to your skin so that it takes the shape of your upper body and arms. This procedure takes about 15 minutes. During your simulation, and every day of your treatment, you will lie in this mold to help ensure you are in the correct position.

X-ray images

X-ray images will be taken of the area to be treated. You will be lying in the mold when these are done. They may be done with a machine called a simulator or on a CT scan machine. It takes about 45 minutes to get the x-ray images taken.

Sometimes, the CT scans are done in the Department of Radiology. If you are having a CT scan, you may be given contrast through an IV line before your scan. This is done to help us get clear images of the area to be treated. These CT scans are used only to map your treatment plan. They are not used for diagnosis or to find tumors.

During the scan, you will hear the machines as they are turned on and off. Even if the noise seems loud, the therapists will be able to hear you if you need to speak with them. It will take about 45 minutes to have your x-rays taken.

Skin markings (tattoos)

The therapists will draw on your skin with a felt marker. Then, they will make permanent skin markings, called tattoos, with a sterile needle and a drop of ink. The sensation of getting a tattoo feels like a pinprick. The tattoo marks are no bigger than the head of a pin. You will receive 5 to 7 tattoos in the area being treated. The felt markings can be washed off after your simulation. The tattoos are permanent and will not wash off.

After the tattoos are made, the therapists will take several photographs of you in your simulation position. The photographs and tattoo marks will be used to position you correctly on the table each day of your treatment.

After Your Simulation

Treatment planning

At the end of your simulation, we will make an appointment for your set-up procedure. This is the final appointment before your treatment begins. You will also be assigned to a machine for your daily treatment.

During the time between your simulation and your set-up procedure, your radiation oncologist will work with a team to plan your treatment. They will use your simulation x-rays and/or CT scan to plan the angles and shapes of your radiation beams. They will also determine the dose of radiation that your body will receive. The details are carefully planned and checked. This process takes between 5 days and 2 weeks.

Treatment scheduling

At the end of your simulation, a therapist will ask you what time of day you would like to have your treatments. We will try to give you the time you like. However, we need a 2-hour window because the time you prefer may not be open. We will move you to that time slot once it becomes open. Please know that we will do our best to give you the appointment time you want as soon as we can. The appointment for the following week is usually given on Friday. The Radiation Oncology Department is open from 7:00 am to 7:00 pm.

Radiation treatment is given daily, Monday through Friday, for about _____ weeks. Treatment may not be as effective if you skip or miss appointments. However, you may have 1 or 2 scheduled days off for the machines to be maintained. If you need to change your schedule for any reason, please speak with your therapists.

Some patients get chemotherapy and radiation treatment on the same day. It can be given before or after your radiation therapy. The timing does not matter.

Set-up Procedure

Before your first treatment, you will be scheduled for a set-up procedure. This procedure usually takes about1 hour. If pain medication was helpful during your simulation, you may want to take it before this procedure.

When you come for your procedure, you will be shown the dressing room and asked to undress from the waist up. The therapists will bring you to the room where you will receive your treatment each day. They will position you on the table. You will lie exactly as you did the day of your simulation. Beam films (x-rays of each of the radiation beams) will be taken to make sure that your position and the area being treated are correct. The beam films will be repeated throughout your treatment. They are not used to see how your tumor responds to treatment.

You will start your treatment within several days after your set-up procedure.

During Your Treatment

After you check in at the reception desk, have a seat in the waiting room. When they are almost ready for you, the therapists will tell you to change into a gown. When the therapists bring you into the treatment room, they will help you lie into your mold on the table. Once you are positioned correctly, they will leave the room, close the door, and begin your treatment.

You will not see or feel the radiation, but you may hear the machine as it moves around you and is turned on and off. You will be in the treatment room for 10 to 30 minutes, depending on your treatment plan. Most of this time will be spent putting you into the correct position. The actual treatment only takes a few minutes.

Your doctor may recommend certain techniques for your treatment. For example, you may be asked to hold your breath during treatment so that your lungs are not moving, or we may watch the movement of your lungs as you breathe during treatment. If one of these techniques is appropriate for you, your doctor will discuss it with you. You may also get x-rays before your treatment to make sure that the area being treated has not changed with your positioning.

Although you are alone during your treatment, the therapists can see you on a monitor and hear you through an intercom at all times. Breathe normally during your treatment, but do not move. If you are very uncomfortable and need help, speak to the therapists. They can turn off the machine and come in to see you at any time,
if necessary.

Weekly visits during your treatment

Your radiation oncologist and nurse will see you each week to evaluate your response to treatment. This visit will be before or after your treatments each ________________. You should plan on being in the department about 1 extra hour on those days. During these visits, you should ask questions and discuss any concerns you have. If you need to speak with your radiation oncologist or nurse any time in between these weekly visits, ask the support staff or therapists to contact them when you come in for treatment.

Side Effects

Some patients develop side effects from radiation therapy. The type and how severe they are depend on many factors. These include the dose of radiation, the number of treatments, and your overall health. Side effects may be worse if you are also getting chemotherapy. Below are the most common side effects of radiation treatment to the chest. You may have all, some, or none of these.

Cough or shortness of breath

Some people develop a cough or shortness of breath during treatment. Call your doctor or nurse if you develop these symptoms, or if they become worse during your treatment. Call if you develop a fever. Below are suggestions to help you feel more comfortable if you have a cough or shortness of breath.

  • Do not smoke. Smoking will irritate the lining of your airway and cause more coughing. If you would like help to stop smoking, your nurse can refer you to our Tobacco Treatment Program.
  • Use 1 or 2 pillows to elevate your upper body while you sleep.
  • Use a humidifier while you sleep. Be sure to change the water and clean the humidifier as directed by the manufacturer.
  • Fatigue may increase your shortness of breath. Follow the suggestions described in the “Fatigue” section. They can help to minimize your fatigue.
  • Use cough medication as directed.

Pain/difficulty swallowing and heartburn

If your esophagus is in the area being treated, it may become inflamed. This can make it hard or painful to swallow. Some people also get heartburn from radiation to this area. These side effects usually begin the second or third week of treatment. They can last until about 2 weeks after your treatment is done. Below are suggestions to minimize discomfort and ensure that you get adequate nutrition during your treatment.

  • Avoid substances that may irritate your esophagus, such as:
    • Very hot foods and fluids
    • Dry, hard, and coarse foods (e.g., chips, pretzels, crackers)
    • Spices (e.g., pepper, chili, Tabasco®, curry)
    • Acidic or citrus foods and juices (e.g., orange, grapefruit, pineapple, tomato)
    • Substances containing caffeine (e.g., coffee, tea, cola, chocolate)
    • Alcohol
    • Tobacco
  • Take small bites of food and chew well before you swallow.
  • Soft, moist, or puréed foods may be easier to swallow. Sauces and gravies may also be helpful.
  • Cold foods and liquids may be helpful. Some people find that fruit nectars are particularly soothing.
  • If you are having difficulty swallowing pills, ask your doctor or nurse if the medication comes in a liquid form. If not, many pills can be crushed and taken with applesauce. However, check with your doctor, nurse, or pharmacist before crushing any pill. Not all pills can be crushed.
  • If you are having heartburn, do not eat at bedtime. Sit upright for at least 30 minutes after each meal. This will prevent your stomach juices from backing up into your esophagus.
  • You can drink liquid nutritional supplements if you are not eating enough food. There are many products available and they come in a variety of flavors. Speak with your doctor or nurse about how to select the product that will be best for you.
  • Let your doctor or nurse know if you start having any of the symptoms described above. There are medications that can be prescribed to make you more comfortable.
  • You can call or set up an appointment with our dietitian, __________________, if you need help with your diet. The number is (212) 639-7622.

Skin and hair reactions

During radiation therapy, your skin and hair in the area being treated will change. This includes the area on your chest and on your back where the radiation beam leaves your body. This is normal and expected. After 2 or
3 weeks, your skin will become pink or tanned. As treatment goes on, it may become bright red or very dark.
It may also feel dry and itchy and look flaky.

You may also notice a rash, especially in any area where you have had previous sun exposure. Although this may be a side effect of treatment, a rash could be a sign of infection. If you develop a rash at any time during your treatment, tell your doctor or nurse so that you can be evaluated. The skin gradually heals after treatment is completed but it generally takes 3 or 4 weeks.

You may also lose some or all of the hair on your chest. The hair will usually grow back 2 to 4 months after treatment is completed.

Below are guidelines to help you care for your skin during treatment. Follow these guidelines until your skin gets better. These guidelines refer only to the skin in the area being treated.

Keep your skin clean

  • Bathe or shower daily using warm water and a mild unscented soap, such as Dove®, Basis®, or Cetaphil®. Rinse your skin well and pat it dry with a soft towel.
  • When washing, be gentle with your skin in the area being treated. Do not use a washcloth or a scrubbing cloth or brush.
  • The tattoo marks you received before your treatment are permanent and won't wash off. You may get other markings during treatment, such as an outline of your treatment area with a purple felt-tipped marker. Use mineral oil to remove these lines when the therapists tell you they can be washed off.
  • Do not use alcohol or alcohol pads on the skin in the area being treated.

Moisturize your skin often

  • Start using a moisturizer when you begin treatment. This can help to minimize any skin reactions. There are a few over-the-counter moisturizers you can use, such as Aquaphor®, Eucerin®, or pure aloe vera gel. Please note that using aloe vera directly from the plant is more likely to cause an allergic reaction than using pure aloe vera gel. We recommend that you use pure aloe vera gel. There are a number of other products that are also good to use, and your nurse may recommend 1 of these to you. Use only 1 at a time, unless your nurse tells you to use more.
  • Apply the moisturizer 2 times a day. Your nurse will tell you if you need to do it more or less often.
  • Do not wash off the moisturizer before your treatments. Your skin could become irritated.
  • If you are treated in the morning, apply the moisturizer:
    • After your treatment
    • Before you go to bed
  • If you are treated in the afternoon, apply the moisturizer:
    • In the morning, at least 4 hours before your treatment
    • Before you go to bed
  • On the weekends, apply the moisturizer:
    • In the morning
    • Before you go to bed

Avoid irritating the skin in the area being treated

  • Wear loose-fitting cotton clothing and undergarments in the area being treated. Avoid tight clothing that will rub up against your skin.
  • Use only the moisturizers, creams, or lotions your doctor or nurse recommend.
  • Do not use powders on the area being treated.
  • Do not put any tape on your treated skin.
  • If your skin is itchy, do not scratch it. Tell your nurse so he or she can recommend how to relieve the itching.
  • Do not expose your treated skin to extreme heat or cold temperatures. This includes hot tubs, water bottles, heating pads, and ice packs.
  • If you do not have skin problems during your treatment, you can swim in a chlorinated pool. However, be sure to rinse off the chlorine immediately after leaving the pool.
  • Avoid tanning or burning your skin during and after your treatment. If you are going to be in the sun, use a PABA-free sunblock with an SPF of 30 or higher. Also, wear clothing that covers you as much as possible.

Fatigue

Most patients develop fatigue (i.e., sleepiness, weakness, and not being able to concentrate) after 2 or 3 weeks of treatment. This gradually goes away after your treatment is done, but it can last for several months. There are a lot of reasons patients develop fatigue during treatment, including:

  • The effects of radiation on your body
  • Traveling to and from treatment
  • Not having enough restful sleep at night
  • Not eating enough protein and calories
  • Having pain or other symptoms
  • Feeling anxious or depressed

Some patients find that their fatigue is worse at certain times of the day. Below are suggestions to help you manage your fatigue.

  • If you are working and are feeling well, continue to do so. However, working less may help increase
    your energy.
  • Plan on doing your daily activities when you have the most energy.
  • Plan time to rest or take short naps during the day, especially when you feel more tired. You may also find it helpful to go to sleep earlier at night and get up later in the morning.
  • Ask family and friends to help you with shopping, cooking, and cleaning.
  • Some patients have more energy when they exercise. If your doctor approves, try light exercise such
    as walking.
  • Eat foods that are high in protein and calories.
  • Some patients have symptoms such as pain, nausea, diarrhea, difficulty sleeping, or feeling depressed or anxious. These can all increase your fatigue. Ask your doctor or nurse for help with any other symptoms you may have.

Loss of appetite

Some patients find that their appetite decreases during treatment. It is important that you eat well and try not to lose weight during your treatment. If you have a mold to position you for treatment, it may not fit correctly if your weight changes. Also, your body needs enough protein and calories to help you recover from your treatment. We will give you the booklet Eating Well During and After Your Cancer Treatment. It contains many suggestions to help you increase your intake of calories and protein. Try the different foods that are recommended.

Below are suggestions to help you maintain your weight:

  • Choose foods that increase your intake of calories and protein. Protein-rich foods you can eat include:
    • Lean meats
    • Eggs
    • Skinless poultry
    • Low-fat yogurt
    • Fish
    • Lactose-free dairy items
    • Low-fat tofu
  • Try to eat small meals often throughout the day. If you never seem to feel hungry, make a schedule to make sure you eat regularly (for example, every 2 hours).
  • Eat your meals slowly in a relaxing setting. Eat with family or friends whenever possible.
  • Vary the color and texture of your foods to make them more appealing.
  • Bring snacks and drinks with you when you come in for treatment. You can have these while you are waiting or while you are coming to and from the department each day.
  • Drink liquid nutritional supplements if you are not eating enough food. There are many products available, and they come in many flavors. Ask your dietitian which product is best for you.
  • You may take a daily multivitamin if you wish. Do not take more than the recommended daily amount of any vitamin. Do not take any supplements unless your doctor approves them. This includes both nutritional and herbal supplements.

Nausea

Some people experience nausea, with or without vomiting, at some time during treatment. This may occur as early as the first treatment. If you have nausea or vomiting, tell your doctor or nurse. Medication can be prescribed to relieve this. A change in your diet may also be helpful. Below are suggestions to help reduce your nausea and ensure you take in enough foods and liquids:

  • Eat a light meal before your treatment.
  • When feeling nauseous, start by nibbling on dry, starchy foods (toast, crackers, pretzels), and progress to small, frequent meals throughout the day.
  • Some people find drinking ginger tea helpful for managing nausea. You can drink ginger tea if you have no sores in your mouth.
  • Drink only a small amount of liquid with your meals to prevent feeling full or bloated.
  • Sip liquids in between meals throughout the day. Using a straw may help. Try freezing your favorite beverages in ice cube trays and sucking on these during the day.
  • Select foods that will not cause nausea. Foods that are usually well tolerated include:
    • Foods at room temperature or cooler
    • Liquids that are cooled or chilled
    • Dry, starchy foods, such as toast, soda crackers, Melba toast, dry cereal, pretzels, and angel food cake
    • Yogurt, sherbet, and clear liquids (e.g., apple juice, Jell-O®, ginger ale)
    • Cold chicken or turkey, baked or broiled, with the skin removed
    • Soft fruits and vegetables
  • Avoid foods and liquids that may increase nausea. These include:
    • Hot foods with strong odors
    • Spicy, fatty, greasy, and fried foods
    • Very sweet foods
    • Acidic or citrus foods and juices (e.g., orange, grapefruit, pineapple, tomato)
    • Alcohol

Changes to your blood cell counts

Bone marrow is the substance inside bone that makes blood cells. You have 3 kinds of blood cells. White blood cells fight off infection. Platelets help your blood to clot when you injure yourself. Red blood cells carry the oxygen you need for energy.

You may have lowered blood cell counts when large areas of bone marrow are in the area being treated. If you are also getting chemotherapy, it can also impact your blood cell count.

We will monitor you throughout your treatment with a blood test called a complete blood count (CBC). If your counts drop, we may stop your treatment until they return to higher levels. We will discuss precautions with you.

If you develop the following symptoms, notify your doctor or nurse immediately:

  • A temperature of 100.5° F (38° C) or higher
  • Shaking chills
  • Flu-like symptoms
  • Bleeding

You may need to be evaluated to see if you have an infection.

Sexual health

You may be sexually active during your treatment unless your doctor tells you otherwise. However, if you are of childbearing age, you must use contraception so you will not get pregnant during your treatment.

You may have concerns about the effects of cancer on your sexuality. An excellent resource is the booklet Sexuality and Cancer. There are 2 versions available, 1 for men and 1 for women. You can get a copy from the American Cancer Society. Call 1-800-227-2345 and tell them which version you want.

MSKCC has a Sexual Health Program to help patients address the impact of their disease and treatment on sexual health. You can meet with a specialist before, during, or after your treatment.

  • Female Sexual Medicine and Women's Health Program: call (646) 888-5076 for an appointment
  • Male Sexual and Reproductive Medicine Program: call (646) 497-9068 for an appointment

Emotional health

The diagnosis and treatment of cancer can be a very stressful and overwhelming event. You may feel depressed, anxious, confused, afraid, or angry. You may have strong feelings about any permanent changes. These changes can have an impact on your emotional and mental well-being. Help is available for you at any time. If you would like counseling, your nurse can give you a referral to see a social worker, psychiatrist, or counselor.

Also, you may find it comforting to speak with a cancer survivor or caregiver who has been through a similar treatment. Through our Patient-to-Patient Support Program, you have the chance to speak with former patients and caregivers. To learn more about this service, please call (212) 639-5007.

After Your Radiation Treatment

Please be sure to keep your follow-up appointments with your radiation oncologist. He or she will evaluate your response to treatment. You may have blood tests, x-rays, and scans during these visits. Before coming, write down your questions and concerns. Bring this and a list of all your medications. If you are running low on any medication you need, let your doctor know before you run out. You can also call your doctor or nurse at any time after your treatment is completed, or in between follow-up visits, if you have any questions or concerns.

The MSKCC Resources for Life After Cancer (RLAC) Program provides support services after your treatment is finished. To learn more about these services, call (646) 888-4740.