Radiotherapy for children

Cancerous cells are more sensitive to radiation than normal cells within the same area. The DNA in the cancer cells is damaged by the radiation, which means that they cannot grow and divide and so are destroyed. The normal cells are usually able to recover from the effects of the radiation and function properly.

Radiotherapy aims to deliver a highly-targeted dose of radiation to as many cancerous cells as possible, whilst causing as little harm as possible to nearby healthy cells. Radiotherapy treatment does not hurt.

Standard radiotherapy uses high-energy x-rays (called photons). The photons (x-rays) are aimed at the cancer in the body. They travel through normal cells to reach the cancer and pass through the body beyond the cancer cells.

Proton beam therapy uses small particles (called protons) instead of x-rays. The protons are made into a beam which is targeted at the cancer. The beam is set to stop when it reaches the cancer and release a large amount of energy.

Radiotherapy can be given from outside or inside the body.  

• External radiotherapy is given from outside the body – this is the most common way radiotherapy is given.
• Internal radiotherapy is given from inside the body. The doctor may place a tube containing a radioactive substance in the area of the cancer. Or they may give you a drink or capsule of radioactive iodine. Sometimes these specialised types of radiotherapy, including brachytherapy and molecular radiotherapy, are the best way of giving treatment.

This information is about external beam radiotherapy for children. Please talk to your child's doctor if you want to find out more about other types of radiotherapy. 

Radiotherapy is only given to children and young adults in specialist treatment centres, as not every hospital which gives radiotherapy to adults has the skilled staff needed for young people. It may be necessary to travel further away for radiotherapy treatment. 

Treatment is different for everyone and will be planned individually. Your child's radiotherapy doctor will decide the amount (dose) needed, over how many days. How long the treatment lasts will depend on your child's particular cancer. 

Each treatment is called a fraction. The treatment is given in separate daily fractions to reduce the damage to normal cells and hopefully cause fewer side effects.

The treatments are usually given from Monday–Friday with a rest at the weekend. The treatment is usually given as a series of short daily sessions over a few weeks. 

The treatment itself is painless but it can take a while to get used to the size and sounds of the machines. Your child has to lie completely still for a few minutes while the treatment is being given. That is why some younger children are given a general anaesthetic.

The treatment is planned by a consultant clinical oncologist (specialist radiotherapy doctor). Radiotherapy care will be carried out by a team of specialists including therapeutic radiographers, specialist paediatric radiographers or nurses and physicists or planning radiographers.

Your child's oncology or haematology consultant will continue to be involved with decisions about treatment and support care throughout the radiotherapy part of treatment. The multi-disciplinary team (MDT) who are already involved in your child's care, such as physiotherapists and occupational therapists, will continue to support with treatment related side-effects or any other issues that may arise. Radiotherapy care will be carried out by a team of specialists including some or all of the below:

Consultant clinical oncologists - doctors specialising in radiotherapy. They are responsible for prescribing and supervising radiotherapy treatment. You will meet your child's clinical oncologist when you come for an appointment to find out about radiotherapy. They will go through your child's medical history before explaining about the different types of radiotherapy and what the treatment options are. Once treatment begins, they will see you and your child regularly to discuss how it is going and answer any questions you may have.

Therapeutic radiographers - trained in all aspects of radiotherapy and patient care. You will meet them when you come for the pre-treatment (also called radiotherapy planning) appointment and at every visit. They can provide support, advice and information. They also liaise with other healthcare professionals such as doctors, specialist nurses, play specialists, dieticians, physiotherapists and clinical psychologists.

Specialist paediatric radiographers/nurses - many radiotherapy departments will have specialist paediatric radiographers or nurses who are skilled in treating children and young people and have access to a wide range of support.

Radiotherapy students or trainee assistant practitioners - students or trainees work alongside the radiographers and are under supervision at all times.

Physicists, planning technicians or planning radiographers - physicists or planning radiographers work with the clinical oncologist to draw up a personalised treatment plan.

Radiotherapy has to be planned carefully and this may take a few visits. 

Planning scans

On your child’s first visit to the radiotherapy department, they will have a planning scan which usually happens on a CT scanner. The images from the scan are used alongside other scans previously done to plan the best position for the radiotherapy machine. Sometimes MRI scans are used for planning.

For the radiographers to get the correct images, it is very important for your child to lie very still. The radiographers will help your child to get into the position needed, depending on the area of the body to be treated. They may use cushions or shaped supports to help. Clothing over the area to be treated will need to be removed.

Moulds and masks

Depending on the area of the body being treated, sometimes a mould or mask is made to keep the part of the body still each time the treatment is given. Radiographers may also use foam blocks or special 'vac-bags' that are formed around the body and moulded to shape.

Masks and moulds are usually made from a material which is heated to make it very soft and then placed over the appropriate area of the body. This feels like a warm flannel and takes about 5-10 minutes to cool down and become hard again. Some departments will use a plaster cast to take an impression of the relevant part of the body and then make a clear plastic mask or mould from that.

A vac-bag is a bag full of polystyrene balls (like a large bean bag) that is wrapped around the relevant part of the body and then the air is sucked out so that it moulds to the exact shape.

Masks, moulds or vac-bags help to keep the body in the correct position while the radiotherapy treatment takes place. They help to ensure that the same position is used every time.

The doctors or a specialist nurse will explain more about this if your child needs a mould or mask. 

Skin markings

Once the radiographers are happy with positioning, they will draw some marks on the skin or mask and then stick some special markers over the top that will show up on the CT scan. During the scan, the couch will move in and out of the scanner for a few minutes. The
scanner doesn’t touch the body at all and cannot be felt although it will make noises as it is working.

After the scan, the radiographers will remove the special markers and, if the markers were on the skin, they will ask permission to make some permanent dots (like tiny tattoos) on your child's skin so that they don’t wash off before or during treatment. The marks are important for the radiographers to make sure the scan position matches to the radiotherapy machine position each time treatment takes place.

Preparing for treatment sessions

To help your child prepare, a hospital play specialist or specialist radiographers may spend some time with them explaining what is going to happen. This may take some visits. You may also be given games and exercises to play with your child before the treatment starts, to help them overcome their fears and get used to the idea.

During the treatment sessions, your child will be left alone in the room, but they will be able to talk to the radiographer who will be watching from the next room. Your child will be able to listen to music or stories while the treatment takes place. It may be helpful to talk to your child in advance and plan what they might like to do or listen to during treatment sessions.

After the radiotherapy planning appointment, your child's clinical oncologist will work with the planning team to produce a personalised treatment plan. This may take several days or weeks depending on the complexity of the treatment and the area of the body that is being treated.

Before treatment begins, the radiographer will be able to give you a good idea of how long each treatment will take. They are usually quite short.

Consent

Before radiotherapy can begin, consent must be given. Parents or carers will need to give consent for children.

It is important to understand all the information about the radiotherapy treatment and have the opportunity to ask questions before a consent form is signed.

The form is a written record that you have agreed to the radiotherapy and give permission to carry on with planning and treatment.

Remember, radiotherapy treatment is an ongoing process so don’t be afraid to ask questions at any time. There is no such thing as a silly question!

At the start of each radiotherapy session, the radiographer will position your child carefully on the couch and make sure they’re comfortable. The radiographers will check the position and help with any masks, moulds and vac-bags. The couch can also be moved to help make sure all marks made at the planning appointment match the treatment machine.

When the radiographers are happy that the position is correct, they will leave the treatment room while the treatment is being delivered. They will watch all the time on their monitors.

The machine comes close but does not touch the body and the treatment does not hurt. There is nothing to see or feel when the machine is switched on, but there will be noises from the machine and a warning sound.

Radiotherapy is not painful, but your child has to lie completely still for a few minutes while the treatment is being given. Occasionally, they may need to have a general anaesthetic so the treatment can be given. If your child is given a general anaesthetic, they will not be able to eat to drink beforehand so they will usually have a morning appointment.

Radiotherapy will not make your child radioactive and it is safe for them to be with other people after the treatment.

Watch our children's guide to radiotherapy. It tells the story of Will and Sophie who have radiotherapy, and helps young children know what to expect.

Radiotherapy can cause some side effects. Every child will not have the same side effects and some people will have more than others.

Side effects will depend on the area of the body being treated. There are general side effects of radiotherapy
as well as side effects which may occur in the part of the body being treated. Your treatment team will
provide information and advice specific to your child's treatment plan. The radiography team will monitor side effects every day.

Some side effects may not occur for a few weeks after starting radiotherapy treatment. Side effects may increase throughout treatment and may continue for a while after radiotherapy finishes. Always tell your radiotherapy team about any side effects or if existing side effects get worse. They will be able to offer advice and medications to help prevent or reduce these.

General side effects may include:

• tiredness
• skin irritation
• increased sensitivity to the sun
• poor appetite
• nausea (feeling sick) and vomiting (being sick)
• headaches
• problems with balance and coordination

Tiredness

Tiredness is different for each person and does not happen straight away. After a couple of weeks of treatment, your child may feel more tired than usual, especially if there is a lot of travelling needed each day or other treatment is continuing. Tiredness may increase throughout treatment and continue for a while afterwards.

It is important to follow your child's lead and allow extra time to rest. This can mean going to bed earlier or having naps during the day. Some gentle exercise, such as short walks, can also help as this will help increase energy levels.

Tiredness can continue for a few weeks or months. Your child's energy levels may take a few months to return to normal once the treatment is finished. If it does not get better, talk to your medical team. 

Eating difficulties

You may find that your child loses their appetite. Radiotherapy may cause side effects that make eating
difficult. Depending on the area of the body being treated, it can become difficult or painful to swallow. Some children feel sick (nausea) or may be sick (vomit). 

It may help for them to eat small snacks and meals frequently throughout the day, rather than large meals. Your medical team can give you advice about nutrition and provide anti-sickness medicines to help with feeling and being sick.

Effects on the skin

Some children develop a skin reaction during their treatment. This is dependent on the skin sensitivity, the
area being treated, and the amount of treatment the skin receives. 

Some people don’t experience any skin problems at all and others find that their skin is affected in a similar way to sunburn. Skin can become dry, sore and itchy. Depending on skin colour, it can become redder or darker.

Skin reactions don’t generally happen straight away, but gradually build up over a period of time and can continue for a couple of weeks after the radiotherapy has finished. The radiographers will give you specific advice about how to care for skin while on treatment. 

It can help to:

• wear loose cotton clothing
• wash skin gently with mild soap and water, and pat dry
• use unperfumed moisturiser
• protect skin from strong sunlight during and after treatment — always use factor 50 sun cream and wear a hat

Effects on the bone marrow

Radiotherapy to some parts of the body can sometimes affect the bone marrow, which produces the different types of blood cells. Normally, blood tests will be done before radiotherapy starts and possibly once or twice a week during treatment to check their blood cell levels. If these become low, they may feel very tired and lethargic. Let your child’s doctor know if you notice these symptoms. Some children may need to have a blood transfusion.

Long-term side effects

Some side effects from radiotherapy can be long-term or may happen many years after treatment has finished.
This is called late effects of radiotherapy. 

These side effects will depend on the area of the body being treated, the dose of radiation given, and the age when it was given. Your clinical oncologist will discuss these late effects with you, and provide detailed information at the first introductory appointment, before consent for the treatment is given. Monitoring for late effects
continues after treatment.

Proton therapy uses protons rather than x-rays to treat a tumour. But it is given in a very similar way to standard radiotherapy. 

If your child's doctor has recommended that they have proton beam therapy (PBT), treatment will either be at The Christie Hospital in Manchester, or at University College London Hospital.  

For further information visit:

UCLH, London

The Christie, Manchester

Your child's doctor will give you more information if they think proton therapy might be helpful.