An oncologist is a doctor who, after 6 years of medical studies, specialises in cancer treatments. This specialisation takes 5 years during which he or she is a junior doctor in a hospital. He /she will, as is the case with all the doctors in our team, become a senior registrar at a University Hospital (Teaching) and a hospital practitioner for a further 2 to 4 years.
There are two categories: radiation oncologists, who prescribe radiotherapy and general treatments, the latter on condition they have obtained the required complementary qualification (Diplôme d’Etude Spécialisé Complémentaire de Cancérologie) and medical oncologists who acquire specific expertise in general treatments.
A therapeutical trial is either a national or international procedure that aims to evaluate the efficacy of a drug in the only situation acceptable, as it has not yet received the AMM (Autorisation de Mise sur le Marché), New Drug Approval.
When you are offered the possibility of participating in a trial, it is already known that the treatment is effective to a point, but it is not known whether its efficacy is inferior, equal or superior to the treatment of reference that you would have been prescribed outside the trial. The aim of the trial therefore is to answer that question.
Your cancerologist can suggest you take part in a therapeutic trial. He/she will explain the modalities and give you an information booklet. You are free to accept or refuse.
A period of reflexion is compulsory before giving your enlightened written consent. If you do consent, you will nevertheless be free at all times to withdraw your consent.
If the case arises, some examinations will have to be carried out to ensure certain necessary criteria (« inclusion criteria ») for participation in a therapeutic trial are met with.
Depending on the nature of the trial, several situations can arise:
The studied treatment in question is administered and evaluated progressively.
Either the studied treatment or the reference treatment that you would have received outside the trial is administered. In this case, in order to avoid any ‘biased’ element, a computerised randomisation is carried out to determine which of the two treatments you will receive. Two situations can then arise;
- an « open » trial : you and your cancerologist know which treatment you have been administered
- a « blind » trial, neither you nor your cancerologist knows which treatment you have received. You will only be told the nature of your treatment long after the completion of the trial.
It is a meeting of the various specialists involved in the treatment of the cancer.
They are the doctors responsible for the diagnosis:
radiologists, nuclear doctors or anatomo-pathologists, and those responsible for the treatment of the cancer :
surgeons, medical oncologists, radiation oncologists.
Other areas of speciality can also be represented although their presence is not required to reach a quorum:
pain specialists, psychiatrists, psychologists, social workers, pharmacists etc.
This multidisciplinary meeting takes place at least twice a month.
Its opinion is consultatory.
Radiotherapy is a treatment that destroys cancerous cells by delivering a large amount of energy to a targeted volume. The energy is transmitted by ionising radiations (accelerated electrons or X-rays).
A distinction is made between internal radiotherapy (also known as curietherapy or brachytherapy) and external radiotherapy.
Different types of rays can be used: high-energy protons (also called X-rays or Gamma rays). Protons have particular characteristics and are used more rarely.
The accelerators produce photon beams by electric current. There is therefore no radioactivity.
You will not be touched by the accelerators during the treatment. The rays are invisible; you will feel no pain.
Before beginning your treatment, you will have met the radiotherapist doctor who will have told you about the possible side effects that can occur either during or after the treatment. Most of these side effects are temporary and controllable with medication.
The beams of high-energy photons deliver their maximum dose to a determined depth depending on their energy and the size of the field; beyond that point, their decrease is exponential.
Beams of electrons are quickly hindered by matter, failing, therefore, to reach the deeper regions of the body. This type of ray treatment is therefore used to treat skin cancer or superficial tumours. Electrons can also be used to deliver a complementary dose to a tumour or to an operatory zone. A typical example is the extra boost given at the end of radiation after breast cancer surgery.
The photons go through the body delivering their energy little by little throughout their trajectory. These deposits of energy cause lesions in the DNA, either directly or as a result of the creation of unstable particles called free radicals. Those cancerous cells whose DNA has been damaged will cease proliferating or die. The dead cells are then destroyed and eliminated by the organism.
In order to destroy the cancer in the radiated zone, a high dose (curative dose) has to be delivered. This high dose is usually spread over several sessions known as fractions. The fractioning is indispensable in order to give the healthy tissue time, in between two sessions, to repair the lesions of their DNA caused by the radiation. Your radiotherapy treatment is constituted by the sum of all the fractions.
Radiotherapy can also be delivered at a lower dose in order to treat a symptom, for instance, pain. If per session the dose is a little higher, the number of sessions will be lower; at times, there will be only one single session. Side effects are less frequent than in curative radiotherapy
When defining your radiation, your radiation oncologist takes into account:
- Your type of cancer
- The localisation of the tumour
- The other treatments you are receiving or have been prescribed
- Your general state of health
You are going to benefit from an individualised treatment.
Curative radiotherapy usually lasts for between 5 and 7 weeks, sometimes longer. Your radiation oncologist will be able to tell you the expected duration of your treatment.
Most patients are treated every day, from Monday to Friday, with a rest at the weekend. The number of sessions can sometimes be reduced to 1 to 3 per week.
Your radiation oncologist chooses the type of radiotherapy and the corresponding machine in order to ensure the very best treatment possible of your cancer, wherever its localisation.
The initial preparatory phase consists of a dosimetric scanner that is carried out on our premises. During this stage, we make a very precise note of your position, sometimes resorting to immobility devices, even discreet tattoo marks, to ensure you are in the exact same position at each session and maintain it throughout the entire treatment. Other images (MRI, TEP scanner, pre-operatory scans) can be combined with the dosimetric scan.
The radiation oncologist carries out the delineation, section by section, of the volumes to be targeted and those organs to be preserved.
He also indicates the desired level of the dose and the constraints to be respected in order to preserve the healthy organs.
(FAQ Team. What is an oncologist, radiation and medical?)
A 3D reconstruction of your anatomy will make it possible to generate a virtual avatar on which the radiotherapy will be modelled. At this stage, one of our 5 medical physicists intervenes, aided by dosimetrists and assistant physicists. This process of optimising the treatment is a keystone of your treatment that can sometimes take several weeks.
Conformational radiotherapy, also called 3D conformational radiotherapy (RC3D) is the most frequent form of external radiotherapy. The shape of the beam of X-rays is adapted to the shape of the tumour. Several beams are used in order to deliver a high dose to the tumour, yet limiting the radiation to nearby healthy tissue.
This technique makes it possible to radiate the tumour even more precisely. The accelerator emits X-rays while moving around the patient, thus multiplying the number of beams used. At the same time, the shape of the beams is modified thanks to a system of lead blades situated at the top of the accelerator (the multi-blade collimator). In all, this technique makes it possible to radiate with great precision the tumour itself or specific zones surrounding it. Thus the dose given to surrounding healthy tissue is reduced thereby limiting the risk of long-term side effects. For example, during the radiation of ENT cancers, the spinal cord is well protected and even the saliva glands can be spared.
This type of complex technique requires rigorous planning, complex computer calculations and numerous verifications, which explains why it takes longer to set up.
The accelerators also contain an on-board system of imagery that makes it possible to carry out radiographs (X-rays) during treatment. These radiographs, carried out daily, check the patient’s position and thereby the reproducibility of the treatment. In the same way, a scan can be done during the session. These scans mean that the position of the tumour can be checked and therefore, the quality of the radiation.
During the course of radiotherapy treatment, the volume of the tumour can decrease. Its shape can change. Weight loss can modify your body shape. Adaptive radiotherapy consists in modifying the treatment plan and the ballistics in order to adapt them to these changes. Your medical team will put together a new treatment plan that may need further control scans and X-rays. Modern radiotherapy techniques provide high precision adaptive radiation. This technique, however, is recent and so far, in little use.
Stereotactic radiotherapy consists of delivering very high doses of radiotherapy in a few sessions to a well-limited tumour. Radiosurgery is the term used when there is only one single session. This type of treatment is made possible thanks to the use of numerous small beams emitted from different angles. Each beam carries a small dose. The sum of the beams makes it possible to deliver a high dose to the target with great precision. Thus a tumour can be radiated with a very high dose yet sparing the surrounding tissue. At the Institut de Cancérologie Hartmann, we use the M6 CyberKnife that makes it possible to offer you this extremely complex technique.
What is extra-cranial stereotactic radiotherapy (stereotactic Body RaqioTherapy – SBRT)?
Stereotactic radiotherapy can be used to treat small, well-limited tumours that are situated deep in the body. Tumours of the liver, pancreas or lung are particularly indicated for this type of treatment. The term used in these cases is extra-cranial stereotactic body radiotherapy or ablative stereotactic radiotherapy (SABR).
External radiotherapy does not make you radioactive. There is no danger therefore for those around you, including children, during the course of your treatment.
Patients react in different ways to radiation:
- Some continue working throughout their treatment
- Others suffer from fatigue and prefer to stay at home
- Some need to be admitted to hospital
Your radiation oncologist and technicians will advise you on the best way to manage your treatment. The entire team is at your complete disposal at all times. Do not hesitate to ask your family, friends and employer for help. As the radiation treatment progresses, you will find it easier to analyse your tolerance to the side effects and thereby improve your day-to-day organisation.
- Why does radiotherapy produce side effects?
Radiation destroys cancerous cells in the radiated zone: this is the aim of the treatment. But the radiation also affects the surrounding healthy cells thereby causing side effects. These vary from patient to patient; it is impossible to predict with precision an individual reaction.
Before the start of your treatment, your radiation oncologist will inform you of all the possible side effects. This prior knowledge will help you prepare for the best management possible of any difficulties. Do not hesitate to ask any question concerning long-term side effects your treatment may cause.
- Side effects
Many patients suffer from fatigue during their radiotherapy treatment, especially if it lasts for several weeks. They feel a lack of energy in their daily life. This is partly due to the efforts demanded of the organism to repair damaged healthy tissue. The fatigue can sometimes last for a few weeks beyond the completion of the treatment.
Do rest if necessary, but do also try to maintain regular physical activity as much as you can. Exercising can often reduce the sensation of fatigue.
In the radiated zone, the skin either reddens or darkens in colour. It can also become drier and more tender to the touch and feel itchy. At times, on completion of a treatment, small sores can appear, similar to burns. The medical and paramedical team is there to advise you on the best preventative measures and treatment available.
For further information: HORG skin index card
Hair loss in the radiated zone
Radiation can cause hair or weight loss but only in the radiated area. The other parts of the body are not affected. Hair will grow again a few weeks after completion of the treatment.
Other side effects
The possible side effects depend primarily on which part of the body is being radiated and the proximity of the organs in that area. Do not hesitate to point out any symptom to the doctors and technicians. Medication can be prescribed to relieve the symptoms and advice will be given you on how to avoid them. Information booklets are also available.
Long-term side effects
Radiotherapy can sometimes be responsible for late side effects that only appear after completion of the treatment.
These depend on the type of cancer, its size, localisation and proximity to certain tissues or important organs. The following can be observed
- modification of the colour of the skin in the radiated zone
- dryness in the mouth
- breathing difficulties
- chronic pain
- bowel movement disruption
- inflammation of the bladder
This list is not exhaustive. It is therefore most important that you ask your radiation oncologist about the risk of long-term side effects and their nature.
In cancerology, the term chemotherapy refers to medication that has an impact on tumour cells preventing them from multiplying by altering the replication process of their genetic material.
Chemotherapy is generally administered intravenously by means of a central catheter (also called « implantable chamber ” or « Porth-à-Cath”, cf corresponding rubric), either in ambulatory outpatient care or conventional hospitalisation, 1 to 4 times a month, at regular intervals.
Before each administration of chemotherapy, required conditions for your security have to be checked. This means assessing your tolerance to the previous administration, your general state of health, your weight and a recent blood test (less than 48h before the date of the administration). The treatment chosen is the one that is most appropriate for you, taking into account the type of your cancer, the original organ affected and the other organs where it may have developed. Several cycles are administered before an assessment can be made of its efficacy.
In this case, the dose is taken once or twice a day, continuously or discontinuously (for example, two weeks out of three). The same precautions are necessary as in the case of intravenous chemotherapy. A few supplementary indispensable precautions:
- your oncologist must be informed of any new medication in order to check it does not interfere untowardly with the medication of your chemotherapy
- NEVER take a higher dose than the one prescribed, even if you forget a dose. Forgetting is not a problem, taking an extra dose is;
this must NEVER happen.
This chemotherapy is administered before local treatment of cancer that is generally localised.
It sometimes facilitates the local treatment (surgery and/or radiotherapy) by diminishing the tumour volume. It can also eradicate cells that are at a distance and could multiply and thereby cause metastases.
Finally, it makes it possible to judge, in situ (on the patient him/herself), the level of sensitivity of the cancerous cells to the medication; this can be most useful for the adaptation of future treatments.
N.B. at times, neoadjuvant treatment can be hormonotherapy or more localised treatments such as embolization or radiotherapy.
This chemotherapy is administered after the local treatment of the cancer that presents no visible metastases.
It aims at reducing the chances of relapse (not only of the organ itself but particularly at a distance).
Chemotherapy aims at stopping the evolution of cancer and, in some cases, curing it. There are times, unfortunately, when its effect is only transitory and other systemic treatments (chemotherapy, targeted treatment or immunotherapy) have to be envisaged, or even, an exclusively symptomatic management of the cancer.
The first targeted therapy was hormonotherapy, even before defining a « target ». These therapies developed at an astonishing rate during the 1990’s. Their aim is to complete the therapeutic arsenal available in the treatment of cancer and are either administered alone or in combination with »conventional » chemotherapy. The treatments are effective thanks to the identification of a target in cancerous cells that are less present or even absent in healthy cells. They »switch off » a receptor at the surface of cancerous cells that commands their multiplication, much in the same way as one would switch off a light.
In some cancers, the target is presumed present in tumour cells; in other cases, the target has to be previously searched for on a tissue sample (« biopsy ») before administering the treatment.
Some targeted therapies are administered intravenously in combination with chemotherapy, at least at the initial phase of the treatment.
Some are administered orally, once or twice a week, continuously or discontinuously (e.g. 4 out of 6 weeks). They are administered alone. As in the case of oral chemotherapy, your oncologist must be informed of any new drug taken. And in the case of forgetting a dose, it must NEVER be replaced.
A type of targeted treatment known as anti-angiogenic aims at stopping the synthesis of new vessels. These new vessels are indispensable for the development of cancerous lesions wider than a millimetre. Even if certain tumour types are more sensitive than others to anti-angiogenic treatments, their essential mechanisms transit via the patient’s reaction and not via the cancerous cells.
They are generally linked to the mechanism of the action of the targeted treatment you are undergoing. For example, if your treatment’s aim is to reduce the development of blood vessels by the tumour cells OR THE » ANTI-ANGIOGENIC » TREATMENT IS ADMINISTERED, ????????
Your cancerologist will ask you to check your blood pressure regularly as it could rise during the treatment and, at times, therefore, require specific treatment.
Immunotherapy, a specific and recent targeted therapy, aims at enabling your immune system to participate more closely in your cancer treatment. Indeed, in many cases, cancerous cells « corrupt » the immune system, preventing it from combating the cancerous cells. Immunotherapy’s aim therefore is to prevent such corruption and enable the immune system to combat the tumour cells.
Immunotherapy can be used in some diseases and situations that are included in the « Autorisation de Mise sur le Marché » (AMM) list or during clinical therapeutic trials.
Some manifestations linked to the reactivation of the immune system can be observed.
Two or more treatments, conventional chemotherapy or targeted therapy can frequently be combined to greater effect.
Combined with radiotherapy
In this case, the aim is to pre-sensitise cancerous cells to the action of the radiotherapy in order to enhance its effect. The associated treatment, chosen by your radiation oncologist, can be administered either orally or intravenously.
- before surgery, chemotherapy known as « neo-adjuvant chemotherapy » : its aim is to reduce the volume of the tumour in order to operate in better conditions.
- after surgery, « adjuvant » chemotherapy : its aim is to reduce the risk of relapse of the disease, that can exist even if the whole tumour has been removed by surgery.
Its aim is to enhance the effects of these two treatments.
Your treatment may be tiring. You may be advised to rest, especially during the 5 to 10 days after a session. You may be proposed a stay in a service dedicated to care and adaptation during your treatment. Physical activity, even moderate, is advised, in order to combat fatigue and improve tolerance to treatment.
There is no medical counter indication to pursuing your professional activity during your treatment, but you are generally advised to plan a break or a reduction of your working hours and, if possible, a time of absence or the possibility of working from home.
There is no particular recommendation concerning your social life during your treatment. It is however preferable to avoid contact with contagious persons (with a cold for example) in order to avoid added fatigue
It is possible to travel during your treatment but you are advised to give thought to how you will tolerate it, i.e., not go away until after the second session. It is also advised to take out specific insurance for repatriation and to travel with your medical file detailing your disease and the treatments already received. Choose ahead the doctor or medical centre on which you could depend in the case of necessity.