omen diagnosed with cervical cancer usually receive some form of radiation therapy to attack the tumor cells in the cervix and to prevent cancer from spreading to other organs. Ideally, a physician wants to use as much radiation as possible to kill the cancer cells, but not affect the healthy surrounding tissue or organs.
A recent report from oncology experts at the UC San Diego School of Medicine indicates that consistently hitting the targeted tumors in the cervix throughout multiple radiation therapy sessions may be more difficult than once believed. It appears that small, normal day-to-day movements of the cervix can add up to big differences in the accuracy and effectiveness of radiation treatments.
The study looked at a series of more than 500 cervical images from 10 patients with cervical cancer during 2007 to 2008. For the study, each patient had two small gold “seeds” implanted into their cervix to serve as easy-to-identify location markers during the radiation therapy and imaging.
The researchers found that the cervix could move anywhere from two to 20 millimeters, depending on the woman, between the first and last therapy sessions. The authors suggest that physicians may need to alter their radiation settings to take these movements into account in order to get the optimal radiation dose to tumors and to avoid healthy tissues.
“The study implies that you have to be very careful from the beginning to the end of treatment,” states Catheryn Yashar, M.D., assistant professor of radiation oncology who lead the study. “Future research will have to solve this problem—how to keep the cervix in our sights and still spare healthy tissue.”
Some groups are investigating the value of combining imaging techniques like PET and CT scans to improve delivery of radiation treatments to cervical cancer patients. A study from Washington University School of Medicine in St. Louis, MO found that taking the two different types of images in a single session helps give physicians a more accurate view of a patient’s cervix and the tumor(s) growing within it.
“Until recently PET/CT simulation involved obtaining a CT scan in one department and a PET in another, often on different days,” said Dr. Sasha Wahab, lead author of the study described in a Bio-Medicine report. "By using a PET and CT taken back to back with the patient in the same position, we reduce the risk of errors due to motion."
"The better we can see the tumor, the better we can treat it. This may lead to more effective treatment with lower side effects," adds Dr. Wahab.
Article Links:UC San Diego Press Release, Feb 2009, “Cervix Moves Significantly More Than Previously Thought During Radiation for Cancer”http://health.ucsd.edu/news/2009/2-10-cervical-movement.htm
BioNews, 2006. “Concurrent PET/CT for Radiation Therapy Planning Shows Promise Over Separate Pet and CT,”http://news.bio-medicine.org/medicine-news-3/Concurrent-PET-CT-for-radiation-therapy-planning-shows-promise-over-separate-PET-and-CT-4990-1/
Related links:Fayed, L., 2008. “Radiation Therapy for Cervical Cancer, About.com article:http://cervicalcancer.about.com/od/treatment/a/radiation.htm
High Dose Rate (HDR) Intracavitary Brachytherapy for Treatment of Gynecologic Cancer
This information will help you get ready for your HDR intracavitary brachytherapy (IN-truh-KA-vih-tayr-ee BRAY-kee-THAYR-uh-pee) for treatment of cervical or endometrial cancer at Memorial Sloan Kettering (MSK).
Read through this resource at least once before your brachytherapy procedure and use it as a reference in the days leading up to your treatment. Bring it with you every time you come to MSK, including for your treatments. You and your healthcare team will refer to it throughout your care.
Back to top About the Female Reproductive SystemYour reproductive system includes your ovaries, fallopian tubes, uterus, cervix, and vagina (see Figure 1).
Your uterus is located in your lower abdomen (belly) between your bladder and rectum (see Figure 2). The lower, narrow end of your uterus is called your cervix. Your cervix connects your uterus to your vagina, which leads to the outside of your body. Your ovaries and fallopian tubes are attached to the upper part of your uterus.
Figure 1. The female reproductive system (front view)
Figure 2. The female reproductive system (side view)
Back to top About HDR Intracavitary BrachytherapyBrachytherapy is a type of radiation therapy. Radiation therapy kills cancer cells by making it hard for them to multiply.
With HDR brachytherapy, a radioactive source is placed inside or close to the tumor(s). This means that the tumor gets a large amount of radiation, while nearby healthy tissue gets less radiation and is less likely to be damaged. Iridium-192 is the radioactive source that will be used during your brachytherapy.
With HDR intracavitary brachytherapy, the radioactive source is placed into a cavity (open space) in your body, such as your uterus.
Most people have both HDR intracavitary brachytherapy and external beam radiation therapy.
What to expectBefore your first HDR intracavitary brachytherapy treatment, your healthcare provider will place an applicator into your uterus through your vagina. The applicator will hold the radioactive source during your treatments. The applicator itself isn’t radioactive, and you won’t be radioactive between treatments.
The applicator has 2 parts:
The procedure to place the applicator will be done in the operating room while you’re asleep. For more information about the applicator placement and your first treatment, read the “During your procedure” section.
The applicator will stay in your uterus between your first and second treatments. You’ll stay in the hospital overnight while the applicator is in place. For more information about what to expect while you’re in the hospital, read the “In your hospital room” section.
Your second treatment will be the day after your first treatment. After your second treatment, the applicator will be removed and you’ll be able to leave the hospital. For more information about your second HDR brachytherapy treatment and applicator removal, read the “Your HDR intracavitary brachytherapy treatments” section.
The same procedure and treatment schedule will be repeated the following week for your third and fourth HDR brachytherapy treatments.
You’ll have a total of 2 applicator placements separated by 1 week. After each applicator placement, you’ll receive 1 HDR brachytherapy treatment right away and 1 HDR brachytherapy treatment on the next day. You’ll have a total of 4 HDR intracavitary brachytherapy treatments.
Your role on your radiation therapy teamYou’ll have a team of healthcare providers working together to provide the right care for you. You’re part of that team, and your role includes:
The information in this section will help you prepare for your procedure.
Read through this section when your procedure is scheduled and refer to it as your procedure date gets closer. It contains important information about what you need to do before your procedure. Write down any questions you have and be sure to ask your healthcare provider.
Getting ready for your procedureYou and your care team will work together to get ready for your procedure.
Help us keep you safe during your procedure by telling us if any of the following statements apply to you, even if you aren’t sure.
The amount of alcohol you drink can affect you during and after your procedure. It’s important to talk with your healthcare providers about how much alcohol you drink. This will help us plan your care.
Here are things you can do before your procedure to keep from having problems:
If you smoke, you can have breathing problems when you have a procedure. Stopping even for a few days before your procedure can help. Your healthcare provider will refer you to our Tobacco Treatment Program if you smoke. You can also reach the program by calling 212-610-0507.
About sleep apneaSleep apnea is a common breathing disorder that causes you to stop breathing for short periods of time while sleeping. The most common type is obstructive sleep apnea (OSA). With OSA, your airway becomes completely blocked during sleep. OSA can cause serious problems during and after your procedure.
Please tell us if you have sleep apnea or if you think you might have it. If you use a breathing device (such as a CPAP device) for sleep apnea, bring it with you the day of your procedure.
Within 30 days of your procedure Presurgical testing (PST)You’ll have a PST appointment before your procedure. The date, time, and location will be printed on the appointment reminder from your healthcare provider’s office. You can eat and take your usual medications the day of your appointment.
It’s helpful to bring the following things to your PST appointment:
During your PST appointment, you’ll meet with a nurse practitioner (NP). They work closely with anesthesiology staff (specialized healthcare providers who will give you anesthesia during your surgery). Your NP will review your medical and surgical history with you. You may have tests, such as an electrocardiogram (EKG) to check your heart rhythm, a chest x-ray, blood tests, and any other tests needed to plan your care. Your NP may also recommend that you see other healthcare providers.
Your NP will talk with you about which medications you should take the morning of your procedure.
Complete a Health Care Proxy formIf you haven’t already completed a Health Care Proxy form, we recommend you complete one now. If you’ve already completed one or have any other advance directives, bring them to your next appointment.
A health care proxy is a legal document that identifies the person who will speak for you if you can’t communicate for yourself. The person you identify is called your health care agent.
Talk with your healthcare provider if you’re interested in completing a health care proxy. You can also read the resources Advance Care Planning and How to Be a Health Care Agent for information about health care proxies, other advance directives, and being a health care agent.
7 days before your procedure Follow your healthcare provider’s instructions for taking aspirinIf you take aspirin or a medication that contains aspirin, you may need to change your dose or stop taking it 7 days before your procedure. Aspirin can cause bleeding.
Follow your healthcare provider’s instructions. Don’t stop taking aspirin unless they tell you to. For more information, read the resource Common Medications Containing Aspirin, Other Nonsteroidal Anti-inflammatory Drugs (NSAIDs), or Vitamin E.
Stop taking vitamin E, multivitamins, herbal remedies, and other dietary supplementsStop taking vitamin E, multivitamins, herbal remedies, and other dietary supplements 7 days before your procedure. These things can cause bleeding. For more information, read the resource Herbal Remedies and Cancer Treatment.
Ask about your diabetes medications, if neededYou’ll need to stop eating and drinking the night before and morning of your procedure. If you take insulin or another medication for diabetes, you may need to change the dose. Ask the healthcare provider who prescribes your diabetes medication what you should do the morning of your procedure.
2 days before your procedure Stop taking nonsteroidal anti-inflammatory drugs (NSAIDs)Stop taking NSAIDs, such as ibuprofen (Advil® and Motrin®) and naproxen (Aleve®), 2 days before your surgery. These medications can cause bleeding. For more information, read the resource Common Medications Containing Aspirin, Other Nonsteroidal Anti-inflammatory Drugs (NSAIDs), or Vitamin E.
1 day before your procedure Note the time of your procedureA clerk from the Admitting Office will call you after 2:00 pm the day before your procedure. If your procedure is scheduled for a Monday, they’ll call you on the Friday before.
The clerk will tell you what time to arrive at the hospital for your procedure. They’ll also tell you where to go. This will be the following location:
Presurgical Center (PSC) on the 6th floorMemorial Hospital1275 York Avenue (between 67th and 68th Streets)New York, NY 10065B elevator to the 6th floor
If you don’t get a call by 7:00 pm, please call 212-639-5014.
If you have any changes in your health or you need to cancel your procedure for any reason, call your radiation oncologist.
The night before your procedure:
Do not eat anything after midnight the night before your procedure. This includes hard candy and gum.
The morning of your procedure Instructions for drinking before your procedure You can drink a total of 12 ounces of water between midnight and 2 hours before your scheduled arrival time. Do not drink anything else.
Do not drink anything starting 2 hours before your scheduled arrival time. This includes water.
Take your medicationsIf your healthcare provider told you to take certain medications the morning of your procedure, take only those medications with a sip of water. Depending on what medications you take, this may be all, some, or none of your usual morning medications.
If you take any medication(s) for diabetes, remember that you might need to take a different dose than usual. Follow your healthcare provider’s instructions.
Things to rememberYou may also want to bring the items below. You’ll be lying in bed most of the time you’re in the hospital. Having ways to pass the time will be helpful.
MSK’s parking garage is located on East 66th Street between York and First Avenues. If you have questions about prices, call 212-639-2338.
To reach the garage, turn onto East 66th Street from York Avenue. The garage is located about a quarter of a block in from York Avenue, on the right-hand (north) side of the street. There’s a tunnel that you can walk through that connects the garage to the hospital.
There are also other garages located on East 69th Street between First and Second Avenues, East 67th Street between York and First Avenues, and East 65th Street between First and Second Avenues.
Once you’re in the hospitalYou’ll be asked to say and spell your name and date of birth many times. This is for your safety. People with the same or a similar name may be having a procedure on the same day.
Get dressed for your procedureWhen it’s time to change for your procedure, you’ll get a hospital gown, robe, and nonskid socks to wear.
Meet with a nurseYou’ll meet with a nurse before your procedure. Tell them the dose of any medications you took after midnight (including prescription and over-the-counter medications, patches, and creams) and the time you took them.
Your nurse may place an intravenous (IV) line in one of your veins, usually in your arm or hand. If your nurse doesn’t place the IV, your anesthesiologist will do it in the operating room.
Meet with an anesthesiologistYou’ll also meet with an anesthesiologist before your procedure. They will:
When it’s time for your procedure, you’ll either walk into the operating room or be taken in on a stretcher. A member of the operating room team will help you onto the operating bed. Compression boots will be placed on your lower legs. These gently inflate and deflate to help blood flow in your legs.
Once you’re comfortable, your anesthesiologist will give you anesthesia through your IV line and you’ll fall asleep. You’ll also get fluids through your IV line during and after your procedure.
After you’re fully asleep, a breathing tube will be placed through your mouth and into your windpipe to help you breathe. A urinary (Foley) catheter will also be placed to drain urine from your bladder.
Applicator placementWhen they’re ready to start the procedure to place the applicator, your healthcare provider will gently dilate your cervix. They’ll place a small tube called a cervical stent into your cervix. Once the cervical stent is in place, the tandem will be placed into the stent. Then, the ring will be placed over the tandem, around your cervix.
The applicator will be held in place by 2 small balloons placed in your vagina and filled with water. The balloons will also push your bladder and rectum away from the applicator. This will help lower the amount of radiation they get during your treatments.
Once the applicator is in place, a magnetic resonance imaging (MRI) scan will be done to make sure it’s in a good position. Your healthcare provider will also use the scan to plan your treatment, including the dose (amount) of radiation that will be used. This will only take a couple of minutes. You’ll still be asleep.
HDR brachytherapy treatmentOnce your treatment plan is ready, you’ll be brought to a separate treatment room. The position of the applicator will be checked again using x-ray images.
For your treatment, the applicator will be connected to a machine that holds the radiation source. The radiation source will travel from the machine into the applicator to deliver the treatment.
Once your treatment is complete, the source will move back into the machine and the applicator will be disconnected from the machine.
After your treatment, you’ll be brought to the Post-Anesthesia Recovery Unit (PACU).
Back to top After Your ProcedureThe information in this section will tell you what to expect after your procedure, both during your hospital stay and after you leave the hospital. It will also tell you what to expect during your HDR brachytherapy treatments. Write down any questions you have and be sure to ask your healthcare provider .
In the Post-Anesthesia Care Unit (PACU)When you wake up after your procedure, you’ll be in the Post Anesthesia Care Unit (PACU).
A nurse will be monitoring your body temperature, pulse, blood pressure, and oxygen levels. You’ll get oxygen through a thin tube that rests below your nose called a nasal cannula. You’ll have compression boots on your lower legs. You’ll also have a Foley catheter in your bladder to monitor the amount of urine you’re making.
You may have some pain after your procedure. Your healthcare providers will ask you about your pain often. You’ll have a pain pump called a patient-controlled analgesia (PCA) device. PCA uses a computerized pump to deliver pain medication into your IV line. For more information, read our resource Patient-Controlled Analgesia (PCA). If your pain isn’t relieved, tell one of your healthcare providers.
There isn’t anything radioactive in your body between your treatments. After your stay in the PACU, you’ll be taken to your hospital room.
In your hospital roomWhile the applicator is in place, you’ll need to lie still on your back in bed. You must stay in bed until the applicator is removed. You’ll be able to raise the head of your bed a little bit, about 20 degrees. You won’t be able to move your hips or legs, but you can wiggle your toes. You’ll have compression boots on your legs to help prevent blood clots and improve blood flow. You’ll be able to move your arms and upper body.
We understand that lying still and flat in bed can be challenging. You’ll be able to read and use your phone and other electronic devices.
If you need help while you’re in your room, use your call bell to let a nurse know. The call bell is by the side of your bed. Your nurse will show you how to use the call bell system.
Your nurse will give you an incentive spirometer and teach you how to use it. They’ll ask you to do deep breathing exercises using your incentive spirometer. This helps your lungs expand, which prevents pneumonia. For more information, read our resource How to Use Your Incentive Spirometer.
You’ll follow a low-residue diet while you’re in the hospital. A low-residue diet has low amounts of fiber, which will help you have fewer bowel movements. You’ll also get medication to keep you from having a bowel movement. You may want to avoid eating foods that cause gas or make you feel bloated. You’ll eat all of your meals in bed.
The Foley catheter will stay in your bladder until your applicator is removed.
Your HDR intracavitary brachytherapy treatmentsFor your HDR brachytherapy treatments, your bed will be moved from your room to the Brachytherapy Suite in the Department of Radiation Oncology. You’ll talk with your healthcare provider before or after your treatment.
In the Brachytherapy Suite, your radiation therapist will check the position of the applicator using x-ray images. Once they know the applicator is in a good position, your radiation therapist will connect the applicator to the machine that holds the radiation source.
Once everything is ready, your radiation therapist will leave the room while you receive your treatment. The room has a video camera, microphone, and speaker so your radiation therapist can see, hear, and talk to you at all times.
During your treatment, the radiation source will move from the machine into the applicator. You won’t feel any pain or discomfort during your treatment. You won’t see or feel the radiation. You may hear a clicking sound from the machine.
Your treatment will take about 10 to 20 minutes.
After your treatment is done, the radiation source will move back into the machine. Your radiation therapist will come into the room and disconnect the applicator from the machine.
Applicator removalRight after your second and fourth treatments (the treatments you’re awake for), your nurse will give you medication to make you relaxed and sleepy. Once you’re relaxed, the applicator and Foley catheter will be removed and you’ll be brought back to your hospital room.
After the applicator is removed, you may feel some cramping in your uterus and pressure in your vaginal area. These feelings usually go away over a couple of hours. Ask your nurse for pain medication if you’re uncomfortable.
You’ll be discharged from the hospital the same day.
At homeAfter your treatments, you aren’t radioactive and don’t need to follow any radiation precautions.
You can go back to moving around and eating normally as soon as you leave the hospital.
You may have cramping for a day after your treatment. You can take an over-the-counter pain reliever such as ibuprofen (Advil® or Motrin ®) or acetaminophen (Tylenol®) as needed. Don’t take aspirin, products that contain aspirin, or vitamin E for at least 1 week after your procedure. Your healthcare provider will tell you when it’s safe to start talking them again.
Follow the guidelines below after you leave the hospital.
You may have side effects after your treatment. Talk to your healthcare provider if you have questions about side effects.
Vaginal scarring and loss of elasticityAfter HDR brachytherapy, your body will start to heal. Your vaginal walls may start to stick together from scar tissue. Your vaginal tissue may also become less elastic. These changes can cause pain and discomfort and make things such as vaginal exams and vaginal intercourse more difficult.
Using a vaginal dilator can help keep scar tissue from forming. It also helps your vaginal tissue stay elastic. Vaginal dilator therapy is a form of physical therapy you can use throughout your life. It’s very important for you to use vaginal dilator therapy after treatment. It will:
Your nurse will give you a vaginal dilator kit and explain how and when to use it. For more information, read our resource How to Use a Vaginal Dilator.
Vaginal bleedingYou may have mild vaginal bleeding (spotting) after going home. If you have heavy vaginal bleeding (bleeding that requires more than 3 pads per day), call your healthcare provider.
Use sanitary pads for vaginal bleeding. Don’t use tampons.
Vaginal drynessYou may have vaginal dryness after your treatment. The dryness may last for the rest of your life. To help, you can use a vaginal moisturizer.
Vaginal moisturizers help to increase moisture in your vagina and improve tissue quality. They can be used up to 3 to 5 times a week. You can use them at any time, not only before or during sexual activity.
Over-the-counter vaginal moisturizers don’t have any hormones. You can buy them online or at your local pharmacy without a prescription. See below for information about types of vaginal moisturizers and how to use them.
Hydrating moisturizersIf you need more help or support, contact the Female Sexual Medicine and Women’s Health Program at 646-888-5076.
Vaginal or anal irritationYour vaginal or anal area may become irritated after your treatment. Avoid rubbing the area, because it can lead to more irritation.
To help with irritation:
Call your healthcare provider if you have:
If you have any questions or concerns, talk with a member of your radiation therapy team. You can reach them Monday through Friday from 9:00 am to 5:00 pm at the numbers listed below.
Radiation oncologist: _____________________Phone number: _________________________
Radiation nurse: ________________________Phone number: _________________________
After 5:00 pm, during the weekend, and on holidays, call 212-639-2000. Ask for the radiation oncologist on call.
If you have any questions or concerns, talk with a member of your radiation therapy team. You can reach them Monday through Friday from 9:00 am to 5:00 pm. After 5:00 pm, during the weekend, and on holidays, call 212-639-2000. Ask for the radiation oncologist on call. Back to top
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