Shenandoah Valley Radiation Oncology Associates

Patients with breast cancer are most often treated by a team of physicians. 

Radiation therapy is recommended after surgery if a patient elects to conserve her affected breast by having only the tumor removed ("lumpectomy" or "partial mastectomy").  Radiation is delivered to the affected breast daily over a period of 5-6 1/2 weeks, beginning at least 4 weeks after surgery.  If chemotherapy is recommended, it is given prior to radiation therapy. 

A subset of early-stage patients may be candidates for a shorter course of radiation therapy, called "accelerated partial breast irradiation".  This is a new technique, and many patients may not be appropriate candidates for this treatment.  Radiation therapy is delivered over a period of one week, twice a day, only to the portion of the breast that was involved with cancer.  We have written a registry protocol to closely track the control of cancer and cosmetic results of patients who are treated with this technique at RMH.

Radiation therapy is sometimes recommended after removing the whole breast ("mastectomy") if there are certain risk factors that may predict recurrence of cancer in the lymph nodes or chest wall.  Radiation is given daily over a period of 6 weeks. 

Early prostate cancer is often treated with either surgery or radiation therapy.  At times, testosterone supression is recommended in addition to radiation therapy in patients with more advanced or more aggressive disease. 

Radiation therapy can be given to the prostate in two major ways:  external beam radiation therapy or brachytherapy.  The recommended treatment depends on multiple factors, such as prostate size, disease stage, and others. 

External beam radiation therapy is given as a daily treatment over a period of 7 1/2 to 8 weeks.  We use a technique called IMRT (intensity modulated radiation therapy), where the higher dose of radiation is concentrated in the prostate, enabling us to spare more normal tissue, such as bladder and rectum, thereby decreasing toxicity of treatment.  Because the prostate location can vary slightly from day to day, it is also important, when IMRT is prescribed, is to image the prostate daily prior to treatment, so that the prostate can be localized before radiation is given.  At both centers, we standardly use a modified CT scan through the prostate prior to each treatment and adjust a patient's position accordingly so that the prostate is within the high dose range for each treatment.  This allows us to treat the prostate with narrow margins and spare additional bladder and bowel.  We may also utilize 3 gold "marker seeds", placed within the prostate before treatment, to aid in localizing the prostate during IMRT treatments.

Example of IMRT radiation dose distribution.

Brachytherapy involves placing radioactive sources into the prostate to deliver radiation therapy "from the inside".  At our institution, brachytherapy is delivered with permanent radioactive seeds that are placed into the prostate while the patient is anesthatized.

Schematic of prostate brachytherapy.

This is an example of a locally advanced, or stage III lung cancer.  Most often, patients in this stage are offered a combined course of radiation and chemotherapy over a period of about 6-7 weeks.  We are able to offer either intensity modulated radiation therapy (IMRT) or 3D-conformal radiation therapy to minimize treatment toxicity.  Consisting of nurses, dieticians, social workers, and counselors, our multidisciplinary team works together to support our patients through treatment.

This is an example of an early, stage I lung cancer.  The standard treatment of this cancer is removal of the affected lobe of the lung.  Chemotherapy may be recommended after surgery if the patient has high risk factors for recurrence of their cancer.  If a patient is unable to undergo surgery due to poor health, an alternative of 6-7 weeks of radiation therapy with or without chemotherapy can be offered.  Although it is considered less effective, it is often easily tolerated due to the small volume of tissue receiving treatment. 

These are examples of early basal cell and squamous cell skin cancers involving the face.  Radiation therapy is equally effective as surgery in curing these cancers, with cure rates in the 90-95% range, depending on the size of the cancer.  This is achieved by delivering a very superficial type of radiation therapy over a period of 3-4 weeks.  Because it does not penetrate deeply, it is well tolerated, but does cause skin redness and possibly peeling in the treated area, which resolves by 4-6 weeks post-treatment. 

We treat a wide range of head and neck malignancies, including cancers of the larynx, pharynx, and oral cavity at both RMH and AMC.  Most patients with locally advanced head and neck cancer are treated with both radiation therapy and chemotherapy, provided they are well enough to withstand this more aggressive treatment.  This combination therapy has been shown to improve both local control and disease free survival in patients with cancer that has spread to lymph nodes.  A multidisciplinary approach, which is very important in treating this often complicated malignancy, is the standard at RMH and AMC.  We also use IMRT and image-guided radiation therapy (IGRT) to reduce radiation dose to normal tissue in our patients when appropriate.

This image is an illustration of possible IMRT beam angles used to treat head and neck cancer.

This can result in sparing of the parotid glands, which are responsible for saliva production, as well as spinal cord, brain, and other structures. 

Colorectal cancer is one of the most commonly diagnosed malignancies in North America.  Treatment of colon cancers located outside the rectum are only rarely treated with radiation therapy.  These cancers are managed with surgery and possibly chemotherapy after surgery. 

Image from health-pictures.com

However, rectal cancer is treated somewhat differently due to its anatomical location, which often makes surgery more challenging.  If the cancer is located near the anal canal, radiation is often given, combined with chemotherapy, to potentially enable the patient to undergo a type of surgery that reconnects the colon to the anal canal, therby avoiding a colostomy bag.  Also, if a cancer penetrates the bowel wall, or involves lymph nodes, radiation and chemotherapy before surgery results in a lower probability of cancer recurrence in the pelvis when compared to surgery alone.  This treatment is usually given over a perior of 5 1/2 to 6 weeks, daily.  Surgery is performed at least 4 weeks after completing this initial radiation therapy.  Depending on findings at the time of surgery, additional chemotherapy may be recommended after the patient recovers from surgery.

Patients with cancers of the uterus or cervix are sometimes recommended to receive radiation therapy to the pelvis after surgery to reduce the risk of relapse of their cancer. 

Also, many patients with cervical cancer are managed with radiation therapy alone or combined with chemotherapy as primary treatment, without surgery.  In fact, radiation plus chemotherapy is considered to be more appropriate treatment than surgery for patients with advanced cervical cancer.  Patients are normally treated with 5-6 weeks of external beam radiation therapy in addition to brachytherapy, which is a proceedure that delivers radiation from the "inside", and can be performed before or after external beam radiation therapy, which treats a larger area in the pelvis.  Brachytherapy is used to concentrate the higher radiation dose to the uterus and cervix.

Images from health-pictures.com

This is an illustration of brachytherapy, a method of delivering internal radiation therapy to the cervix and uterus with radioactive sources.  These sources are placed into the metal tubes to deliver radiation from the "inside" in patients receiving radiation therapy for cervical cancer.  This proceedure, combined with external beam radiation therapy, results in excellent cure rates, particularly in those patients with an earlier stage cervical cancer.

Chemotherapy has become the mainstay of most lymphoma treatments, but radiation alone is sometimes recommended for certain types of low grade lymphoma which is very limited in extent at the time of diagnosis. 

The diagram above describes the staging of lymphoma.  Radiation therapy often follows chemotherapy in early stage I and II lymphomas.  Fortunately, lymphomas are more sensitive to radiation than many other malignancies, and lower radiation doses can be given for excellent control in the region treated.  Daily treatments are usually given for 3-4 1/2 weeks to the regions of the body containing the lymphoma at the time of diagnosis.

Bladder cancer is fairly common, and more often diagnosed at an early stage.  Urologists can often treat bladder cancer successfully by infusing local "chemotherapies" into the bladder, but patients must be monitored closely after treatment, because recurrences are not uncommon. 

If the cancer has invaded the muscle of the bladder, patients require either surgery or chemotherapy and radiation.  Surgery is most often used for patients with bladder cancer in the United States, with chemotherapy and radiation recommended for patients who are not considered good candidates for surgery due to other medical problems.  However, more and more patients are electing to forgoe surgery and spare their bladder by undergoing radiation with chemotherapy.  This alternative management has show much promise in European trials, and has been shown to result in survival rates that are equivalent to surgery, while sparing the bladder at least 2/3 of the time.  Surgery is required for treatment failure. 

Gliomas are the most common adult brain tumors, and unfortunately, most are high grade gliomas, or "glioblastoma multiforme".  They can develop in any region of the brain, but most commonly in the cerebrum. 

Low grade gliomas are managed with surgery or observation if they are in regions of the brain where surgery would cause significant impairment.  Often, low grade tumors do not grow, or if they grow, do so at a slow rate.  If a low grade glioma begins to grow more rapidly, often treatment is recommended (either surgery or radiation with or without chemotherapy).  Repeat biopsy is also recommended, due to the possibility that the tumor has changed, or "dedifferentiated" into a higher grade malignancy.  

High grade gliomas are managed by surgery initially, which may include only a biopsy due to difficult location, partial resection, or total resection of the tumor.  This is followed by radiation and often chemotherapy concurrently daily for 6 weeks.  We are able to use IMRT at both AMC and RMH in the management of brain gliomas to spare uninvolved normal brain structures. 

Surgery is the primary treatment of most soft tissue sarcomas, but radiation therapy often plays an important role in addition to surgery in the management of sarcomas, particularly those that are high grade (more aggressive) or are difficult to resect surgically.  Radiation can be given daily for 5 weeks to reduce the size of the tumor before surgery to reduce the need for amputation and improve overall outcome in terms of disease control.  When surgery is performed first, radiation therapy can be recommended subsequently for high grade tumors or those that have been excised with narrow margins.  Generally, if radiation is given after surgery, it is given over a period of 6-6 1/2 weeks.

When cancer has spread to distant areas, it is usually considered incurable.  However, cancer that has spread to the bone or brain can cause significant pain or other problems for patients.  Short courses of radiation therapy can be used to treat specific areas harboring disease to relieve these symptoms.  Palliative radiation therapy is often given for bone pain from metastatic disease.