These FAQs have been answered by women who have had radiation treatments for a gynecologic cancer. For more information, please visit our Web Resources section "Treatments and Tests" and Our Stories by survivors treated with internal and external radiation therapy.
How is radiation used to treat gynecological cancers? What are the different types, and when are each used?
Georgia P., Massachusetts, USA: For endometrial cancer with spread to the lymph nodes, I was required to have five weeks of external pelvic radiation, and then a twenty-four hour internal "implant". The lymph node containing the cancer cells had been removed, but there was always the possibility that another node still within me might contain more minute cells, and the radiation is used to kill those (possible) cells. The pelvic area was marked (using a simulator of the linear accelerator, and x-rays) and tattooed. A special shield was made to protect the small bowel from the rays, and I was radiated from all four sides to avoid concentrated rays to the skin. The actual radiation was painless and took about a minute or two, done daily, five days per week, for five weeks.
Two weeks later I was admitted to the hospital for the internal. This was a plastic "tampon" filled with radioactive material, inserted into the vagina, and kept in place while I was immobile, and in isolation, for twenty-four hours. Except for the severe discomfort of the large plastic tampon, there were no physical side effects to speak of for this procedure. Emotionally it was the most difficult part of my entire treatment.
There are many methods of internal radiation used. The California Endocurietherapy Cancer Center has excellent explanations of the various types of radiation for gynecologic cancer. http://www.cetmc.com/gyn.html
Katie, California, USA: Since my Stage 1B cervical carcinoma had spread to my lymph nodes, I underwent a course of external pelvic radiation as well as two internal (intracavitary) treatments. The external treatments occurred approximately six weeks following BSO (bilateral salpingo-oophorectomy, surgical removal of both fallopian tubes and ovaries) and lymphadenectomy. I did not have an hysterectomy; my uterus and cervix had been left in place to facilitate the brachytherapy (internal radiation) which was to follow. The course of my external treatments was virtually identical to that described by Georgia. The internal treatments were quite different, however.
Two weeks after external radiation was completed, I underwent the first of the two brachytherapy (internal) treatments. Under epidural anaesthesia, a rod called a tandem was inserted through my cervix into the uterus, and two ovoid objects were placed near my cervix on the vaginal side. Gauze packing was then inserted to keep the equipment in place and my labia were sewn together. I was then moved from the operating room down to radiation oncology to be x-rayed to determine if things were placed correctly. Once that was ascertained, I was moved to a hospital room while the dosimetrist calculated treatment time. A couple of hours later, the radiation oncologist loaded the tandem and ovoids with radioactive cesium and positioned chest-high lead shields around my bed to protect anyone who entered the room. My dose was calculated at around twenty-four hours, during which time I remained in isolation, on my back in the hospital bed. I was only able to raise my head fifteen degrees...more than that and I could feel the tandem like a sharp pole extending from my uterus to approximately six inches outside of my vagina. During this time I was catheterized and given lomotil to stop my bowels. After the prescribed dosage time, the radiation oncologist removed the cesium, the packing, the stitches, and the tandem and ovoids. Finally, a technician ran a geiger counter over me, the bed, and the surrounding area to make sure the room was safe for others to enter. I was then moved to a regular room for the night and went home the next day.
I had spent a total of two and a half days in the hospital and was able to resume my normal activities as soon as I got home. Two weeks later I returned for a second treatment, identical to the first. While this treatment sounds terrible, I really was never in any pain, just uncomfortable.
Karen, Alberta, Canada: I had HDR (high dose rate) brachytherapy (internal radiation) in 1995. I'd had a hysterectomy for stage 1A cervical cancer in 1990, and then abnormal cells had begun to develop in my vagina. The official diagnosis was "VAIN lll/can not rule out invasive cancer". VAIN is Vaginal Intraepithelial Neoplasia; as I had had similar cervical problems (CIN) which had rapidly developed into cervical cancer, and as my doctors were unable to rule out invasive vaginal cancer, and because the abnormalities were "multi-focal" (many areas), it was felt that it should be treated aggressively with radiation rather than just monitored. Brachytherapy was chosen over external treatments to maximize the radiation dosage to the vagina, while minimizing it to other organs - bladder, bowels etc.
I had five treatments, all in one week, and other than the first one, which took a little longer to get everything adjusted, each treatment was over in just a few minutes. I laid on an examining table with my legs in stirrups. First a hollow cylinder was inserted in my vagina, using lots of lubricant. This wasn't any more uncomfortable than a regular pelvic exam. A small machine was wheeled over - in it, inside a lead chamber, was the radioactive source - some type of iridium, if I recall correctly. The machine was connected to the cylinder inside me, and also to special attachments on the examining table (to keep everything stable). Everyone left the room - the controls to operate the machine were behind a lead wall. I was monitored by videocamera, and told to lie really still during the treatment. The machine hummed and whirred for a few minutes as the source moved its way down the cylinder, according to the dosage calculated by the dosimetrist, and then was returned into the machine. They checked me over with a geiger counter to be sure that the source had returned to the machine, and then took out the cylinder. It was quick, easy, and painless.
Georgia P., Massachusetts, USA: If this is your first visit, it will probably be a consultation, rather than simulation, but be prepared for both. I suggest you call the department the day before your appointment to ask exactly what this first visit will entail.
A simulation is a "trial run", or simulated treatment, during which set-up and tattoos are done to prepare for the actual treatments. If they plan to simulate at this first appointment/consult, they usually ask you to drink something to help them locate the intestines and small bowel in x-ray views. Tattoos (small dots) are used as targets to define the radiation field.
Here are some questions to ask during your consultation when they discuss your treatment plan with you:
What is the exact stage of my cancer, and why do you recommend this radiation?
Will my treatments be external, internal, or both?
How many treatments will I have?
How will the treatments be done? Assuming I have both external and internal, what type of internal radiation is used, and when?
During external radiation treatments, do you use shields to protect the small bowel, and other organs? Will the beam be directed at all four sides (front, back, and laterals) to help diminish side effects?
Are the treatments painful?
Do you recommend use of a vaginal dilator, and, if so, how and when I should use it?
How will treatment affect my sexuality, both in the long and short term?
If, for modesty reasons, I am uncomfortable having male technicians, is it possible to have only female technicians attend me during my treatments?
Do you prescribe medications to help me with any emotional issues?
Will I get advice on my diet and supplemental nutrition from a registered nutritionist?
Will I get advice on caring for the radiated area from an oncology nurse?
If I am pre-menopausal, and have not had my ovaries removed during surgery, what impact will the radiation have?AND - last, but not least -
14. What are the expected side effects, and how do I deal with them?
Cathy B., Ontario, Canada: Despite being told of the possible side effects of my radiation treatment, I found I wasn't truly prepared. In retrospect, I think much of it was 'glossed' over. I was told I would experience issues with my bowels. I did and still do, one and one-half years later. I first experienced 'loose' bowels about four weeks into treatment. Up until a few months ago, mornings meant staying close to home because the urge to void is fast and furious!
For months after radiation I had lower back and leg aches. No one could truly offer an explanation for it, but I sense that much of what I felt was nerve and tissue damage. Bending or squatting down was especially painful.
Being fast-forwarded through menopause has a huge impact for many of us, especially if we are not in the traditional 'age range' for it. Sterility is another. These are two very big, life-affecting losses. I sought out emotional support for these issues especially and found it helpful.
I was surprised to find out one morning that I had temporarily lost my pubic hair. It made looking in the mirror a strange experience! Also, those tiny little tattoo dots are a permanent reminder of my battle with cancer. I think of mine like medals.
I also had three days of internal radiation, that contributed to what is called 'stenosis' or vaginal scarring. It makes sex painful and examinations difficult if the use of a dilator or regular sexual relations are not practised. For me, this is one of the biggest side effects and the one that left me feeling that parts of my body were not mine anymore. There are lubricants and creams to help with vaginal dryness and sexual function (Astroglide*tm, for one).
Many of these side effects disappear, or subside as time goes on...so will the emotional 'fog' you're in while undergoing radiation. I found my tummy was upset in the beginning, but I believe now that had more to do with stress. Similarly, about eight months after treatment, I had rectal bleeding and feeling of 'blockage' that turned out to be chronic inflammation due to radiation (determined by a sigmoidoscopy).
Katie, California, USA: During the last two weeks of my external radiation treatments, I experienced diarrhea, loss of appetite, and fatigue. My pubic hair fell out and I had occasional vaginal itchiness, but no skin problems...it darkened, but did not burn. With the exception of the bouts of diarrhea that I still get from time to time, the other problems resolved themselves soon after treatment was completed. Longer term, I have developed a problem with stress incontinence (urinary leakage when sneezing, coughing etc). My radiation oncologist told me the radiation has damaged the sphincter and has suggested Kegels. I hope it will not become worse!
Georgia P., Massachusetts, USA: I followed instructions, and had very little problem with the pelvic radiation for endometrial cancer. I did not use soaps, creams, or lotions on the radiated area. I used pure cornstarch to dry it after showering. Pure cotton panties (one size larger than usual) also helped keep the skin from "sweating". A low residue diet was recommended after the first two weeks, which helped with the intestinal discomfort. Lomotil was also prescribed.
One side effect is the drying and scarring of vaginal tissue, leading to adhesions if the vagina is not dilated regularly. This can be accomplished either by using a dilator furnished by the radiation oncology nurse, or frequent sexual intercourse (I found this worked well for me, and was much more pleasant). If regular sexual relations are not continued after radiation, the dilator must be used to prevent adhesions. The liberal use of Astroglide® lubricant also helps. The intestinal/diarrheal problems resolved in time, and several years later I find things close to normal "most" of the time.
Karen, Alberta, Canada: Like Cathy, I feel that the side-effects were definitely minimized, almost to the point of lying. I can understand that they don't wish to scare you with all sorts of rare complications, but I would rather have been "given the straight goods", so to speak, on the more likely ones. I was told that the internal radiation treatments would probably cause some temporary and mild bladder and bowel problems. I asked about premature menopause, and was assured that it "almost never" happened. Stenosis (scarring) and fibrosis (loss of flexibility of the tissues) of the vagina were also mentioned.
I started experiencing minor bladder irritation immediately after the first radiation treatment, and also had mild diarrhea. Five years after the treatments, I still have "funny" bowels - when I have to go, I usually have to go *NOW*, sometimes several times a day, and "normal" seems to be everything from loose to constipated. I didn't realize this was after-effects from radiation until I found other women on the internet who'd also had radiation and were having the same symptoms.
I felt tired and "draggy" for a couple of months after my treatments - and took it as my body's message to take good care of myself during my recuperation.
I also underwent menopause, at age thirty-four. Symptoms of menopause, especially hot flashes, inability to concentrate, and moodiness, increased in intensity for several months until I finally realized what was going on. I have been on estrogen replacement therapy since then.
The radiation also caused some scarring in my vagina, which made sexual intercourse uncomfortable at times.
Katie, California, USA: Everybody's different; some work through it, others don't. Since I was already off work recovering from surgery, I didn't go back to work. And, to be honest, I don't think I could have worked through it because I was too tired, and had too much diarrhea.
If you think you can do it, schedule your daily appointment for after work, then afterwards, you can just go home and go to bed. Or you could try it for the first couple of weeks while you are still strong, then take time off work later if you need to.
Teresa A., Pennsylvania, USA: It wasn't bad working while I was having the radiation. I was tired, but going to work felt normal when nothing else did. I think it helped me to keep my routine. If you like your job, it will probably help you also to keep your routine if you are physically able to. All the people I work with were very supportive through everything.