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Patient Handbook


Introduction to the Center

General Information
Our Philosophy

What is Radiation Therapy?

Radiation Therapy: Technology and Techniques
Linear Accelerator
Simulator
Contour
Computerized Treatment Planning
Treatment Planning CT scan
Customized Blocks
Port Films
Some Facts About Radiation Therapy

Safety

Equipment
Treatments

Your Radiation Therapy: From your first visit through the last day of treatment

Your Initial Consult
Simulation
What to Expect for Your Simulation
Photographs
Care of Skin Marks
Your First Treatment
What to Expect for Your First Treatment
On-treatment Clinic Visits
Care of Skin and Mouth during Treatment
Keeping Appointments
Last Day of Treatment and Follow-up
Patient Questionnaire
Insurance Counseling and Billing Information
How to reach a Physician
Useful Numbers


Introduction to the Center

Welcome to the Chesapeake Potomac Regional Cancer Center. Your physician has referred you here for consultation and possible treatment. This booklet provides you with information about our center and about radiation therapy. We encourage you to read it carefully and keep it for future reference.


General Information:

Radiation Oncology, also known as radiotherapy, radiation therapy, and therapeutic radiology, is that branch of medicine that specializes in the use of high energy x-rays to treat patients with malignant diseases.

Radiology, also called diagnostic imaging, is that branch of medicine which uses images of the body to monitor health and identify disease. These include chest x-rays, mammograms, CT scans, MRI scans, nuclear medicine scans and ultrasounds.


Our Philosophy

The daily operation of our center is designed to be efficient and attentive to the individual needs of our patients. We employ a well trained, certified technical staff dedicated to offering oncology care in a compassionate and professional manner. A dedicated administrative staff works with the technical staff to ensure that our services function smoothly, and that information is promptly and accurately exchanged between your referring physician, your insurance carrier, and our staff.

We hope that by learning more about radiation oncology and our center, you will be confident that you are being treated by dedicated and caring professionals, and that you become a partner in your health care.


What is Radiation Therapy?

High energy x-rays have a long history in the treatment of cancer, dating back to the turn of the century when x-rays were discovered. X-rays cause damage to malignant cells so that the cell cannot divide and grow. X-rays can also alter normal tissue around the cancer, sometimes causing side effects.


Technology and Techniques

In the past, radiation therapy clinics used low energy x-ray machines, also known as “orthovoltage machines”, and machines with radioactive sources such as cobalt. Although these machines could and did treat cancers, they were limited by the relatively low energy beams they produced. In recent years, many cancer centers have replaced those machines with high energy (megavoltage) linear accelerators. Linear accelerators generate radiation by electrical/ physical means, and do not contain cobalt or any other radioactive elements.


Linear Accelerator

Linear accelerators produce x-rays by generating electrons from a metal coil, accelerating them down a long tube where they interact with a target which produces x-rays. These x-rays are then focused directly at the patient for treatment. If the target is removed, the electrons themselves are used for treatment. Electrons are used to treat tumors close to the body surface, as in the skin or breast. Linear accelerators have improved our ability to treat both small and large tumors, as well as tumors deep in the body.

Linear Accelerators can generate photons and electrons at different energies, from any angle of rotation, in a stationary position, in continuous motion, or in multiple sequential stationary treatments. This flexibility is useful in designing treatments for the more than 250 known types of malignancy.


Simulators

Radiation treatment is planned on a simulator or a CT or both. The simulator is designed much like the linear accelerator. Instead of delivering treatments, the simulator takes x-ray films. With these films, the doctors and therapists locate the tumor, and co-ordinate this with diagnostic films to plan the “field” to be treated. After the treatment field is determined, the corresponding area of skin will be marked with special ink. The “simulation x-ray film” documents the simulation.


Contour

A precise agreement between the light field and x-ray field is a feature of both the linear accelerator and the simulator. The therapists align the skin marks established at simulation with the lights from the accelerator, ensuring consistent and accurate daily treatment.

During simulation, we sometimes use a mechanical device to make a record of the external contour (shape) of your body from several different levels. This device consists of a row of small, nylon-tipped rods which touch your skin, but are not painful. This takes about five minutes.


Computerized 3D Treatment Planning

Information from the CT simulation film and body contour is entered into the treatment planning computer. It displays the body contour, and how the x-ray beams will enter the body and deposit x-ray dose to the tumor and adjacent areas. When multiple beams are used to treat the same area, the computer calculates how these beams interact. With computer modeling, we can display the effect of choosing different beam energies, beam directions, beam weighting and the effect of putting shielding blocks in the field.

Options for treatment plans are reviewed by the radiation oncologist and the physicist, and the best one is chosen for each patient. The treatment plan is placed in each patient’s medical record.


Treatment Planning CT Scan

Many patients also need a treatment planning CT scan, during which the patient is positioned in the same position as during simulation. This allows the external and internal anatomy to be imaged precisely as it will be during treatment.

The information from this scan is entered into the computer, adding the patient’s position, internal anatomy, and body contour to the beam information on the screen.


Customized Blocks

The linear accelerator produces x-ray beams which are square or rectangular. Patients often need treatment fields which are circular or irregularly shaped. We shape these fields with “customized blocks”. These blocks are positioned between the linear accelerator and the patient, through which x-rays penetrate very poorly. This significantly reduces the x-ray dose to those parts of the body lying in the shadow cast by the blocks on the body. One block may be needed for each beam direction used in treatment.

The radiation oncologist designs a block by outlining the size and shape of the block or blocks needed onto the simulation film. The therapists cut holes of that shape and size into large styrofoam blocks, into which is poured a molten metal alloy, which hardens into the desired shape. The finished blocks are mounted onto a plastic tray in the precise position drawn on the simulator film. The block tray is slipped into a grooved slot in the head of the treatment machine, and is left in place during the treatment. Customized block trays are reserved for each patient for the duration of their treatment, and are stored in the treatment room.


Port Films

The day that you start treatment and once every week thereafter, the linear accelerator will take an x-ray picture of you, called a ‘port film’. As one part of our quality assurance program, we carefully match each port film to the original simulation film, to insure that the treatment field corresponds precisely to what was planned on the simulator or CT.

‘Port films’ are taken weekly only to document that we are accurately treating the correct area of your body. They do not reveal anything about how your cancer is responding to treatment.


Some facts About Radiation Therapy

  • Radiation treatments do not hurt; you will feel no sensation while the machine is on.
  • X-rays enter one side of the body and exit through the opposite side. None remain inside you. You are not radioactive and you can go near anyone, including pregnant women and babies.
  • X-rays can affect normal tissues as they act to kill cancer cells. How radiation affects normal tissues varies greatly. Each patient is counseled by their Radiation Oncologist before, during, and after radiation treatment regarding the potential side effects of radiotherapy, and how to manage those side effects.

Safety


Equipment

Safety is one of the most important features of our center. We comply with all state and federal regulations for the installation, maintenance, and servicing of our equipment.

We perform numerous safety procedures daily, weekly, monthly and yearly to ensure that every piece of equipment works properly and safely.


Treatments

Daily, numerous checks and double checks are performed to insure that each treatment is given as planned.

Once a week, the staff meets to review and discuss each patient and their treatment course. “Port films” are compared to simulation films, cumulative doses are reviewed, and the following week’s treatment, including any necessary change, for each patient is planned.


Radiation Therapy-from your first visit through the end of treatment.


Your Initial Consult

At your first visit, you will meet our receptionists, who will ask you to fill out paperwork, including your personal history and insurance information. This usually takes about 15 minutes.

We will ask you or a family member to sign an authorization to release information about your medical history and treatment. This information may be shared with referring physicians, hospitals, insurance companies or other similar organizations, but will not be released to others without your permission. We will communicate closely with your referring physician by mail and phone throughout your treatment and follow-up.

At your first visit you will be interviewed and examined by a radiation oncologist. You will be asked about your medical history, and be given a complete physical exam. You should bring all reports from referring doctors, especially x-rays, CT scans, MRI scans, nuclear medicine scans, operative notes, and pathology reports. (You should bring the films themselves, not just the reports.) With very few exceptions, patients cannot be treated without a formal written pathology report in the radiation chart.

You should report all medicines you take regularly or occasionally (for cancer or anything else) by name and dose, including any allergies you have had in the past to any medicines.

After the history and physical, the radiation oncologist will discuss with you the reasons to use (or not to use) radiation at this time. An overall plan will be outlined, including potential benefits, side effects, and possible complications of treatment. Any questions you may have will be discussed in detail. Family members are welcome and encouraged to participate in this discussion.

Do not worry if you forget to ask all relevant questions at the initial consultation. The physicians will be available to answer your questions during your visits to the department.

After the initial consultation, the radiation oncologist will confer with your referring physician, and if agreed, an appointment will be made to plan treatment.

Before you begin treatment, you or a family member will be asked to read and sign an informed consent form. We cannot administer treatment without your signed consent. You may withdraw from therapy at any time even though the consent form has been signed.

At your first visit you may also meet other members of the staff, including the nurse. The nurse will explain clinic procedure, provides individual instructions or advice, and will take a photograph of your face for your chart. If the nurse is not available, another member of the staff will fulfill this function. A clinic representative will also help you arrange transportation to and from your treatment if needed.


Simulation

If radiation therapy is the appropriate treatment for you, you will meet one of our therapists, who will schedule you for a return appointment for simulation and, if necessary, a treatment planning CT scan.

At simulation, which is usually your second visit, you will meet our therapists, as well as our dosimetrist, who works in the physics area and performs the computerized treatment planning.


What to Expect for Your Simulation

Simulation takes from 1/2 to 2 hours, and usually less than one hour. Most patients do not receive a treatment on the day of simulation.

You will be positioned on the simulator table with appropriate supports to enable you to lie still comfortably; these supports will also be used in the same way during treatment. Except for quiet breathing, you should not move once you have been positioned for simulation.

Like treatment, simulation is not painful or difficult, except that it may be awkward to lie on a flat surface for an hour or more. For this reason, we always try to work as quickly as possible.


Photographs

When the simulation is complete, we usually take pictures of your position and skin marks, which are used to help reproduce your position every day. These pictures are part of your confidential medical record and are never used to identify you in any way.

Carefully safeguard the felt-tip pen skin marks which the therapists apply during simulation, as it is important that treatment is delivered exactly as planned.


Care of Skin Marks

Do not wash the marks off or alter them in any way. They may need to be refreshed daily by the therapists.

If the marks do disappear between treatments, it may be necessary to repeat all or part of the simulation process before we can begin treatments again. If this happens, you should inform us as soon as possible.

In most patients, we may ask to mark the treatment area with an ink-like fluid making a permanent freckle-sized mark (tattoo) on the skin. The advantages of permanent marks over felt-tip pen marks are:

  • You cannot accidentally wash them off. If additional treatments are needed later, the previously treated area is easily identified.
  • The tattoo will not rub off onto your clothes.
  • With tattoos you will not need to maintain the marks.

Your First Treatment

The first treatment usually takes about 30-45 minutes, somewhat longer than the usual 10-15 minutes, due to additional accuracy and safety procedures. We try to arrange your daily treatment to fit your schedule, which will be discussed with the therapists, who are responsible for the treatment machine schedule.

Treatments are usually given once daily, Monday through Friday. On the average, patients can expect a 10 - 15 minute visit each day. Actual treatments usually take 4 minutes or less, but 15 minute appointments are scheduled to allow for set-up, clothing changes, and “port films”. Treatment courses can be as short as one day or as long as 8 weeks, the average treatment course lasting from two to six weeks.


What to Expect for Your First Treatment

For treatment set-up, the therapists will position you on the table, program the machine to your prescribed dose, go to the control console outside the treatment room, close the door, recheck the machine settings, and initiate the treatment. If more than one machine position is required, the therapists will reenter the room each time to reset the machine and recheck your position. Treatment takes 4 minutes or less, but you may be in the room longer while the staff positions you and performs safety checks.

You must not move during treatment, except for quiet breathing, so that treatment can be delivered precisely. A TV camera, which is linked to a monitor outside the room, will monitor you from the wall. The camera enables the therapists to watch you, to be sure that you are safe and that you do not move. An intercom allows for two-way conversation between you and the therapist. When the treatment is over, the therapists will help you sit up and get off the table. Do not try to get up off the table yourself; we do not want you to fall.


On-Treatment Clinic Visits

Once every week you will be seen by the radiation oncologist and/or the nurse. We pay special attention to the treatment area and discuss how you are feeling. You may ask any questions you have about treatment, side effects, and medications at this time. Medications, if needed, will be prescribed or renewed. This clinic examination can be done before or after your daily treatment and usually lasts only a few minutes.

Once a week we may draw blood to check relevant blood counts. If the tests are drawn in another physician’s office, we will get copies of those reports.

Your weight will also be checked weekly, to make sure you are maintaining adequate nutrition. The weekly clinic visit is a good time to talk with the nurse about any questions you have. Staff can provide you with booklets and handouts that address any needs or questions you may have about taking care of yourself during radiation therapy.


Care of Skin and Mouth During Treatment

  • Don’t put anything on your skin (or in your mouth if it is included in the treatment field) This pertains to only the skin in the treatment area, not all skin.
  • Do not shave with a razor in the treatment area
  • Do not apply heat (heating pad, hot water bottle or heat lamp) to the treated area.
  • Do not expose the treatment area to direct sunlight or extreme cold.
  • We will provide you with a list of products which are mild and safe to use.

Keeping Appointments

We do our best to keep our appointments on time for all our patients. Please try to be prompt for your treatment. Occasionally, very ill patients or emergencies make us deviate from our schedule.

If you know that you cannot keep an appointment or that you will be late, please let us know the day before if possible, as a courtesy to other patients and our staff. Our office hours, phone number, and instructions on how to reach us during off hours are listed in this booklet.


Last Day of Treatment and Follow-up

On or near the last day of treatment you will be seen by the radiation oncologist. Your treatment, your medications and follow-up plans will be reviewed. Following your last treatment, a summary of your treatment will be sent to your referring doctor.

Most patients need to be seen in our clinic for follow-up 30 days after the completion of treatment. Most patients will be seen for regular follow-up thereafter, which is shared between the medical oncologist, surgeon, and radiation oncologist. You will make your first follow-up appointment on your last day of treatment. You can call for an earlier appointment if unusual problems or symptoms develop before that time.


Insurance and Billing Information

As you know, many insurance plans do not cover the full cost of radiation therapy; you may be responsible for a portion of your bill. One of our administrative staff will contact your insurance company for information regarding your benefits, and provide you with the approximate reimbursement rate. She can also give you a rough estimate of the cost of your therapy. If you have these, or any other questions, please feel free to inquire at the billing office or the front desk. Please note that should you receive a bill from our group, the statement will be from Associates in Radiation Medicine, the name of our Physicians Group.


Patient Questionnaire

We value your opinion about how we are doing. On your last day of treatment we will ask you to fill out our Patient Questionnaire and give it to our receptionist. We appreciate your taking the time to do this.
Monday - Friday, 8:30 am to 5 pm:


How to Reach a Physician

Clinic Hours and Useful Phone Numbers

Please call if you have a medical problem related to treatment, a question about your treatment, or need to change your next appointment. If a problem cannot be handled over the phone you may be asked to come in for an examination in the clinic.

After Hours - Weekends
We have a Radiation Oncologist on call 24 hours a day. If your physician is not on duty, the physician covering our patients will be able to help you.

The phone number after hours is the same as our regular phone number. We have your call forwarded to our answering service. They will contact the physician on call, who carries a beeper. You will be called back as soon as possible. Do not hesitate to call if you need help at any time.

Charlotte Hall - 301-884-2508
Waldorf - 301-705-5802


Useful Numbers

For information on resources and support for cancer patients, contact:

The American Cancer Society
(30I) 933 9353
(Montgomery County)
11323 Amherst Ave., Silver Spring, MD 20902
(301) 261-6000
(Prince George County)

Cancer Information Service:

1-800-4-CANCER
A service provided by the Nation Cancer Institute, which will answer specific questions, as well as mail free publications on a variety of related subjects.


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