Patient Information

What to Expect

Radiation Therapy is a multi-step process. Each step involved in the planning and delivery of your treatment are described in detail below.

It is important for you to know that Radiotherapy is a team approach. Multiple professionals are thus involved in your care. Some of these team members you will meet (the Radiation Oncologist, Radiation Nurse, Social Worker etc.) while others will be working behind the scenes (Medical Physicist, Dosimetrist, etc.).

Together, these professionals ensure that you receive the best and safest treatment possible.

Radiation Therapists

Consultation: Your First Visit

Your initial visit to the Radiation Oncology Department is called a Consultation.

The purpose of the Consultation is for you to meet with the Radiation Oncologist to discuss your treatment options. You are welcome to bring along any family member or supportive friend(s) with you to this visit.

Radiation Oncology, Reception

Upon your arrival, you will first check in at our Reception Desk. You will then be escorted into an examination room in the Clinic.

Prior to meeting with the Radiation Oncologist, you will first be greeted by the Radiation Oncology Nurse and together will complete a Medical Intake Form.

Polly Nobiensky, R.N.

What Should You Bring to the Consultation?

List of your current medications
Copy of your current medical records
X-Rays, CT, MRI or PET scan films from your physician or hospital other than UCSD Medical Center
Laboratory Test results
Pathology report and biopsy slides if appropriate
Prior Radiation Therapy treatment and planning records, simulation films and treatment films (if you have been previously treated)

Often your referring physician will have already made arrangements for your records to be available for the Radiation Oncologist to review prior to your visit.

If you are a UCSD patient, your records and test results may be available on the UCSD computer system (if they were performed at UCSD) and it is not necessary to bring additional copies. If your records are complete, it will save you time and possibly an extra visit.

What Happens at the Consultation?

The Radiation Oncologist will review your medical history, radiology studies (CT, MRI scans etc.), laboratory results and, if you have undergone surgery or a biopsy, pathology reports. A physical examination will also be performed.

Physicians reviewing a patient's MRI scan

Although you may have been examined by other doctors prior to your Consultation, the examination by the Radiation Oncologist is a critical part of your visit. Abnormalities may be discovered not noticed before by other doctors.

During this initial visit, your treatment options will be presented. The Radiation Oncologist will also discuss the benefits and potential risks of radiation therapy and fully answer all your questions.

If additional tests are required prior to selecting the appropriate treatment course, these tests will be ordered and scheduled. Finally, in consultation with your other physicians, a decision will be made about whether Radiation Therapy is the best form of treatment for you.

What Questions Should You Ask?

It is often difficult to know what the “right” questions to ask the Radiation Oncologist at the time of the Consultation. Some questions you might wish to consider include:

Why is Radiation Therapy indicated in my case? How long does each treatment take?
What type of radiotherapy will I receive?
How long does the whole course of treatment take?
How soon will my treatment start?
Will there be any limitations during or after treatment?
What side effects may I experience during treatment? How severe will these be?
Should a friend or relative accompany me to each treatment?
Will I be able to drive myself to and from treatment?
What can I do to best take care of myself during treatment?
Will treatments other than radiation be necessary in my case?
How will we know whether the Radiation Therapy is effective once treatment is complete?

What Happens Next?

If you are to undergo Radiation Treatment, you will be scheduled for a planning session, known as a Simulation. A Scheduler will contact you in order to arrange a date and time of the Simulation session. In most cases, your Simulation will take place several days after your Consultation.

Tania Tabor - Scheduler

If another form of treatment other than Radiation Therapy is more appropriate for you, this will be discussed with you and your referring physician.

Your Consultation visit will be one of your longer visits to the Radiation Oncology Clinic. Expect to be in the Department for approximately 1-2 hours.

Informed Consent: Understanding Your Treatment

If you will be undergoing radiation treatment, you will be asked to read and sign a Consent Form.

It is your right to have all your questions fully answered prior to your signing this form. Moreover, if you decide to not undergo treatment or to stop treatment after you have started, signing this form in no way obligates you to continue. If you are under 18, a parent or guardian must sign the form for you.

The example Consent Form provided here is a general Consent Form. You may, however, be asked to sign a Consent Form more specific to your treatment course or disease site, e.g. for patients Breast cancer or Prostate cancer. Consent forms are also available in Spanish.

Tour: See Where You Will be Treated

After your consultation is complete, you may wish to have a tour of the department including the treatment areas. A tour may help you better understand the treatment process.

Treatment Room

A tour may be particularly helpful for pediatric patients and their parents so your child and you can meet the radiation therapy staff who will be performing the daily treatments.

Simulation: First Step in Preparing Your Treatment Plan

Your next visit to the Radiation Oncology Department is called a Simulation.

The purpose of Simulation is to determine how you will be treated. Your simulation is performed on a machine known as a Simulator. This machine looks much like a CT scanner, but is used for Radiation Treatment planning.

PET-CT Simulator

Simulation is a crucial step in your treatment planning process. It allows your Radiation Oncologist to precisely outline the area in your body that needs to be treated. It is also needed for the Medical Physicist and Dosimetrists to accurately calculate your treatment plan.

Most patients undergo one simulation. However, it may be necessary to perform an additional Simulation during your treatment course if changes are made in your treatment.

What Happens on the Day of Simulation?

Upon arrival, check in at our Front Desk and please be seated in the Waiting Room. When the Simulator Therapists are ready for you, you will be asked to accompany them into the Simulator room.

Depending upon the specific part of your body to be treated, you may need to change to a gown. If so, you will be escorted to a private changing room with secure lockers in which you may store your personal belongings. Please remember to bring the locker key with you when you leave the changing area.

Upon entering the Simulator Room, you will be asked to lie down on the Simulator table. Most patients are simulated laying flat on their back (“supine” position). However, it may be better for your treatment for you to be positioned face down (“prone” position). An effort will be made to find a position that you can tolerate.

Care will be taken to properly position your arms and legs. Patients undergoing treatment for breast or lung cancer are often treated with their arms overhead. This ensures that the arms are not within the radiation fields.

Tell your Radiation Oncologist and Simulator Therapist(s) if you have any special physical limitations.

Immobilization: Helping You Keep Still

The next step in the Simulation process is Immobilization.

It is not possible for most people to remain still during treatment without assistance. To reduce potential movements, various assistive devices are used:

Plastic Mesh Masks, for the head and neck region, are made from a hard plastic which becomes flexible in warm water. When wet, they conform to your face. They dry very quickly. You are able to breathe with the mask on without any difficulty.
Foam (Alpha) Cradles, for the chest, abdomen, breast and pelvic areas, are made with a liquid Styrofoam which expands and hardens. As they expand, they conform to the shape of your body. While expanding, the foam gets warm and then as it cools, it hardens.

Baby Cradle

Making these various immobilization devices will take approximately 15 minutes. You will be asked to lie still during this process, but you will experience no discomfort.

Specialized Immobilization Devices: Frameless Stereotactic Radiosurgery

Patients undergoing Frameless Stereotactic Radiosurgery for brain tumors undergo a specialized immobilization process.

In addition to a plastic head mask, a customized “bite block” tray is also made at simulation. This “bite block” is then attached to an array of infrared detector array which is used to monitor your position during treatment.

“Bite Block” in a Patient undergoing Frameless Stereotactic Radiosurgery

"Bite Block” and Attached Infrared Fiducial Array
“Bite Block” and Attached Infrared Fiducial Array

Click here to view a detailed presentation on the planning and treatment of frameless radiosurgery (brain) treatments.

Pediatric Patients

While adults are able to participate in the Simulation, it may be difficult for children, particularly very young children. In such cases, it is common to perform the Simulation under anesthesia. Arrangements will be made in advance if anesthesia is necessary.

Kevin Murphy, MD
Kevin Murphy MD
Chief of the Pediatric Oncology Service with a young patient

Click here for an overview of the Pediatric Cancer program.

Planning CT Scan: Defining the Area to be Treated

Once you are properly positioning and immobilized, you will undergo a planning computed tomography (CT) scan.

Patient undergoing CT simulation

The scan itself is accomplished very quickly, usually within 3 to 5 minutes. After your scan is completed, your Radiation Oncologist reviews the images and sets up the treatment area.

It may be necessary to use intravenous (IV) or oral contrast at the time of your Simulation. Contrast may help visualize certain structures and tissues. If so, the Radiation Nurse may perform a blood test to ensure that it is safe for you to receive contrast.

It is very important to inform the Radiation Oncologist and Simulation Therapist of any allergies that you may have to contrast agents.

Will Any Marks be Made on My Skin?

In some patients, the skin over the area to be treated will be outlined with an ink pen. This aids in setting up your treatment on a daily basis. Please do not wipe these marks off. If the therapist has to mark these areas again it takes more time and may delay the start of your treatment.

You may also require one or more small tattoos (made with ink placed just under the skin) to help define the treatment field. These tattoos are very small, approximately the size of a small freckle.

Patient Being Marked with a Small Tattoo

Simulation for most patients lasts approximately 1 hour. When it is over, the Simulation Therapist will assist you in getting off the table after which you will get dressed, be escorted back to the waiting room and are free to leave.

Brachytherapy

The Simulation Process for patients with gynecologic cancers and other tumors undergoing HDR Brachytherapy is different from the Simulation in patients treated with external beam Radiation Therapy.

Breast Bracytherapy

The Simulation of most brachytherapy patients is preceded by placement of an HDR applicator in the HDR Suite (adjacent to the CT Simulator Room). The HDR applicator is a small hollow apparatus which is designed to hold radioactive sources in their proper position inside you.

In select patients, e.g. women with cervical cancer, the HDR applicator is placed under light anesthesia (“conscious sedation”). In most patients, however, anesthesia is not necessary. In some cases, the applicator is placed in the operating room.

HDR Brachytherapy Machine

Patients undergoing HDR Brachytherapy will then be transported to the HDR Suite for Simulation and Treatment Planning.

Unlike patients undergoing external beam Radiation Therapy (except in emergency cases), Simulation, Treatment Planning and Treatment all occur on the same day.

Treatment Planning: Determining How You Will Be Treated

The next step in the Radiation Therapy process is Treatment Planning.

A very important and complex phase of your overall treatment, treatment planning may require up to a week or more from the time of your Simulation to the completion of your Treatment Planning depending on the complexity of your case.

Treatment Planning involves several key steps. Your CT Simulation data is first sent from the Simulator to Treatment Planning Computers in the Treatment Planning (Dosimetry) Room. Once there, treatment planning professionals known as Dosimetrists work closely with the Radiation Oncologist and Medical Physicist to develop the best plan to treat your tumor.

Rob de los Reyes, Dosimetrist, Generating a Treatment Plan

Contouring: Outline the Target and Normal Tissues

The Radiation Oncologist next outlines (contours) the area to be treated (the “target”) on the planning CT scan. The target typically includes the tumor and nearby areas where tumor cells may have spread. During this step, the Radiation Oncologist works closely with Diagnostic Radiologists, specialists in interpreting CT, MRI and other x-ray scans.

Other special radiology tests may be used to help better define the target. If you underwent a magnetic resonance imaging (MRI) scan prior to the Simulation, that scan may be fused with your planning CT scan. This is often the case in patients with brain tumors.

CT/MRI Fusion in a Patient with a Brain Tumor

Nearby normal tissues are next outlined by the Radiation Oncologist. By doing so, these structures can then be included in the Treatment Planning process and avoided as much as possible.

Example Contours on a Patient with Cervical Cancer
Target (red), rectum (gold), small bowel (pink), bone marrow (light blue)

Once the target and normal tissues have been contoured, the Dosimetrist, Medical Physicist and Radiation Oncologist work closely together to develop the final treatment plan.

During this process, the optimal number and orientation of the radiation beams, are selected to best treat the tumor while sparing as best as possible the normal surrounding tissues. In breast cancer, for example, two angled (oblique) beams are used to ensure irradiation of the breast without excessive dose to the underlying lung.

Example Treatment Plan in a Patient with Breast Cancer

Intensity Modulated Radiation Therapy (IMRT)

In some patients, a specialized Treatment Planning method known as Intensity Modulated Radiation Therapy (IMRT) is used.

Unlike conventional planning techniques, IMRT conforms the dose to the shape of the target tissues in 3-dimensions, thereby improving the sparing of surrounding normal tissues.

IMRT is particularly helpful in head/neck cancer patients in order to reduce dose to the nearby parotid (saliva) glands. In these patients, IMRT has been shown to minimize the risk of long-term dry mouth. Promising results have been reported in many other tumor sites treated with IMRT, notably prostate cancer.

Example IMRT Treatment Plan in a Patient with Right-Sided Tonsil Cancer
Overlaid on the Contours are Isodose Lines which Represent Different Dose Levels. The High Isodose Lines bend in away from both Parotid (Salivary) Glands

Ask your Radiation Oncologist whether IMRT would be appropriate in your case.

What Happens Next?

Once your Treatment Plan is complete, it is carefully checked by the Medical Physicist and reviewed and approved by your Radiation Oncologist.

Great care is not only taken by the entire team to develop an optimal treatment plan which best treats your tumor, but also to ensure that the plan is delivered accurately and safely. Our department has a dedicated quality assurance (QA) program supervised by the Medical Physicists.

Jia-Zhu Wang, PhD
Radiation Physicist

You can expect to be called once your Treatment Planning is complete and you are ready to be scheduled to begin treatment. Many patients begin treatment approximately 1 week after simulation. In patients requiring complex treatment planning, additional time may be necessary.

You will be given an appointment time for your treatment. In general, most patients will be given a 15 minute time slot. However, more complicated treatments and pediatric patients may require 30 minutes or longer.

How Long Will My Treatment Course Take?

In general, you will be treated once a day, Monday through Friday, for 4-6 weeks. Some patients are treated with longer, others with shorter treatment courses.

Currently, there is a trend to treat patients with more abbreviated courses using larger doses per day (hypofractionation).

Ask you Radiation Oncologist whether hypofractionation would be appropriate for you.

Your First Treatment Day

On your first day of treatment, you should check in at the front desk and be seated in the waiting room. A “bar code” sticker will be placed on your UCSD Medical Card which is given to all patients on their first visit to the Moores Cancer Center. You will be able to use this bar code to check in daily for your treatments. This will inform your Therapists of your arrival.

When it is time for your treatment, you will be greeted by the Radiation Therapists who will be administering your therapy and escorted into the Treatment Room.

Treatment Machine: Linear Accelerator

Upon entering the Treatment Room, you will see the Treatment Machine, known as a Linear Accelerator or Linac.

A Linear Accelerator is a sophisticated machine specifically designed to generate high energy X-rays and electrons for the treatment of patients.

At UCSD, you will be treated with the new, state-of-the-art Linear Accelerators capable of delivering sophisticated therapies including intensity modulated radiation therapy (IMRT), image-guided radiation therapy (IGRT) and frameless stereotactic radiosurgery (SRS). Shown below is a Varian Trilogy Linear Accelerator.

Varian Trilogy Machine
Click here for a detailed look at the Trilogy

First Treatment Day: Checking and Double-Checking

After entering the treatment room, you will next be asked to lie down on the Treatment Couch. The Radiation Therapists will assist you if you have any difficulties.

Using any immobilization devices made at Simulation, the Therapists will carefully place you in the proper treatment position and double-check all measurements. Once everything is set, your Radiation Oncologist will verify your setup, prior to treatment delivery.

Kevin Murphy MD
Checking the Setup of a Patient

The entire process requires approximately 30-45 minutes. It is important to lie still during this time, but you may breathe normally. Subsequently treatment days will be shorter.

What Will I Feel? Will I be Alone in the Treatment Room?

You will not see or feel anything. Radiation is invisible.

After your Therapists ensure that you are accurately setup on the treatment table, they will leave the room. However, the Therapists are just outside the room at the treatment console and will be able to speak to you via an intercom as well as see you on a closed-circuit camera. They can also hear you.

Inform the therapists if you are experiencing any difficulties during treatment and they will stop the treatment and immediately enter the room to assist you.

RTT at the Treatment Console

Will I be Treated at the Same Time Everyday?

You will be given an appointment time for your daily treatment. Unless you have problems with this time, this will be the time of your treatment for your entire treatment course.

Tell your Radiation Therapists if your assigned time is no longer convenient and you need to change. We will do everything we can to accommodate your wishes.

Expect that the majority of your daily treatments will be on time. However, on occasion, we may experience treatment delays. If this happens, we will try to accommodate you as best as possible.

We will do our best to notify you if any delays occur. Please make sure that we have a phone number where you can be reached, preferably your cell phone if you carry a cell phone with you.

Our goal is to never cancel an appointment, but to try to accommodate everyone. This may not always be possible and we may have to cancel your treatment appointment. Any missed days will be added to the end of your treatment course to make up for the missed days.

We sincerely apologize for any inconvenience delays and/or appointment cancellations may cause you and your family.

Specialized Treatment Approaches

A number of specialized treatment approaches are used at UCSD in the Radiation Oncology Department including image-guided Radiation Therapy (IGRT), intensity modulated Radiation Therapy (IMRT), respiratory gating, and frameless stereotactic radiosurgery (SRS). These specialized approaches are discussed in detail in the section entitled Treatment Programs and Procedures.

Given the increased complexity of many of these approaches, longer times may be needed to deliver your treatment.

On Treatment Visits (OTV): Seeing the Physician

You will formally meet with your treating Radiation Oncologist once per week. This visit is called an On-Treatment Visit (OTV).

This is a good day to bring family members or supportive friends who may wish to speak with your Radiation Oncologist.

If you are experiencing a problem, you may see your physician on any day. Simply tell your Radiation Therapist and/or Radiation Nurse that you would like to see the physician and this will be arranged.

Each UCSD Radiation Oncologist has a different clinic day on which he or she sees all patients on treatment.

Week Day	Physician
Monday	Yashar, Lawson
Tuesday	Murphy
Wednesday	Mundt, Mell
Thursday	Sandhu
Friday	Einck

At the OTV, you will be first seen by your Radiation Oncology Nurse and/or Nursing Assistant. You will be weighed and your vital signs (heart rate, blood pressure and temperature) will be measured. Your Radiation Nurse will ask you how you are feeling and whether you are tolerating treatment.

The Radiation Oncologist will then see and examine you. If you’re experiencing any side effects, medications may be prescribed to help reduce them.

End-Treatment Visit (ETV): Your Last Day

Your last treatment day is called an End-Treatment Visit (ETV).

At this visit, you will once again meet with the Radiation Nurse and Radiation Oncologist. Tell your Radiation Nurse and Radiation Oncologist how you are feeling. Your physician will prescribe medications as necessary.

At this visit, you will be given an appointment for a Follow-Up visit which is generally 4-6 weeks following the completion of therapy.

Followup Visits: Monitoring How You Are Doing

Follow-up visits are very important for the Radiation Oncologist to monitor your progress as well as address any side effects you may be experiencing.

After your initial follow-up visit, follow-ups are generally scheduled at 3-6 months intervals, depending on your case and how you are doing.

Just as every patient is different, follow-up care varies. Your Radiation Oncologist will prescribe and schedule the follow-up care that you need. Don't hesitate to ask about the tests or treatments that your doctor orders.

See Frequently Asked Questions for additional information

What to Expect

Consultation:

Simulation:

Treatment Planning:

Treatment:

Consultation: Your First Visit

What Should You Bring to the Consultation?

What Happens at the Consultation?

What Questions Should You Ask?

What Happens Next?

Informed Consent: Understanding Your Treatment

Tour: See Where You Will be Treated

Simulation: First Step in Preparing Your Treatment Plan

What Happens on the Day of Simulation?

Immobilization: Helping You Keep Still

Specialized Immobilization Devices: Frameless Stereotactic Radiosurgery

Pediatric Patients

Planning CT Scan: Defining the Area to be Treated

Will Any Marks be Made on My Skin?

Brachytherapy

Treatment Planning: Determining How You Will Be Treated

Contouring: Outline the Target and Normal Tissues

Intensity Modulated Radiation Therapy (IMRT)

What Happens Next?

How Long Will My Treatment Course Take?

Your First Treatment Day

Treatment Machine: Linear Accelerator

First Treatment Day: Checking and Double-Checking

What Will I Feel? Will I be Alone in the Treatment Room?

Will I be Treated at the Same Time Everyday?

Specialized Treatment Approaches

On Treatment Visits (OTV): Seeing the Physician

End-Treatment Visit (ETV): Your Last Day

Followup Visits: Monitoring How You Are Doing

Part of UC San Diego Moores Cancer Center