Three down, thirty to go. The territory has been mapped, the standing appointments set, radiation treatments have begun. I counted the days down on the calendar. Monday, March 8 should be the last blast. Between now and then, all I have to do is keep marching through the days. No blood counts to worry about and so no delays to change the plan (we hope). Only 8 pages of handouts to read, compared to the 2-inch, 3-ring binder of printed matter they gave me before chemo began. And if I’m clever, I can still sneak across the building into the infusion center for a popsicle.
If I’m going to continue with the idea of omens, I’ll take the first day as a good one. The sky was blue, the sun shone, and it was in the 50s. The appointment took about an hour and a half — longer than subsequent ones will be — because that was the day the doctors’ theoretical plans were put into action for the first time. Most of the session was consumed by the technicians moving equipment, marking territory, and taking measurements before the first zap.
The plan is for a total dose of 5040 units (measured as cGy rather than the old term “rads“), broken up into 28 doses of 180 units, followed by 5 higher doses for a “boost” at the site where the tumor was removed, the most likely site for a recurrence. The goal is the same as for chemo — kill any remaining cancer cells.
The handouts describe the principles and goals of radiation and the side effects, the most prominent one being skin irritation ranging from redness and dryness to itching, peeling and (hopefully not for me) blisters. The doc says these can be treated with applications of aloe vera or other gentle lotions, including emu oil. (I could actually get some emu oil locally. One of the vendors at our farmers’ market sells the stuff.) The skin effects don’t correlate with those from sun exposure, so the fact that I turn the color of a lobster in the sun has no bearing on the effects I may have from radiation.
The other major effect is fatigue, which is cumulative and, as with the skin changes, shows up a few weeks after the treatment begins, dissipating slowly after it ends. I will lose hair, but only in the treated area. And since radiation tends to shrink tissues, my stretching and exercises become more important.
So here’s my new routine (or, if you prefer, the “picnic” or “piece of cake” others have called it) . I drive to the same building, but instead of going to the check-in clerk on the right, I go to the one on the left. Then it’s a short walk round the corner to the dressing area. I strip from the waist up, don one of those flimsy gowns, sequester my clothes in the narrow gray locker, turn the key, and slip the elastic coil that serves as a key ring around my wrist. Then it’s off to the Fish room — the waiting area for patients only, which is dominated by a large, crystal clear aquarium in the center with its blue and purple tangs and a variety of other colorful fish and coral. I don’t have time to check out the magazines scattered on the tables because my technician is right on schedule and moving me back to the inner sanctum — the darkened rooms where the computers are arrayed in a pod in the control room, and then through the massive, thick door (note the purple and yellow danger sign!) into the octagonal, darkened room that houses the linear accelerator (sometimes called the linac), the machine that sends the deadly beam to its assigned target.
Sitting in the middle of the room, the accelerator looks harmless enough. A huge cream-colored tower with a broad arm extending outward and down to support a thick metal disc. Nearby is a flat table, which in my case has been set up with the foam back support the technicians made for me at the assessment appointment, with the arm supports already angled up to keep my arms out of the way. There is a stack of similar blue back supports leaning against the back wall, each one bearing the name of its corresponding patient. To the right are tall shelves, on which sit rigid white mesh “heads” — the supports used to keep patients still while they undergo head or neck radiation. This is not the warm, familiar atmosphere of the infusion center with its beeping pumps and bustling nurses. There is no clutter here, no cushions or lap robes, no baskets of snacks or puzzle tables. This is science fiction.
The linear accelerator has actually been around since the 1930s. There are different types, used for different purposes. At this link, you can see the linear accelerator at Stanford, where the first unit was put to use. Don’t read the article (unless it fascinates you). Just scroll down and look at the historical photos on the right. The one with the child is either amusing or a bit disturbing, depending on your perspective.
To get me ready for the session, the technicians (3, all young women) help me onto the table and into position. I notice the music playing — greatest hits of the 60s and 70s. Not quite as good as the iPod, but there is no place or time for an iPod, or writing or reading for that matter, on this side of the building.
On the first day, the technicians spent a lot of time moving the table around, moving the arm of the accelerator, working from the plan drawn up by the docs to get the positioning just right. They take measurements, calling out numbers to each other, and marking out the field to be treated on my chest, this time with a purple marker (“It‘s washable!” the technician says reassuringly). I was reminded of watching a neurosurgeon in the operating room at the hospital where I worked in Chicago. He too used a purple marker to draw the incision line on the shaved skull of a patient At the time, I was amused. He looked so much like a kid drawing with a huge crayon.
One technician tells me to turn my head slightly to the right so they have a clear line to the supraclavicular nodes, the ones above the collarbone, the first area to be treated. Then they mark out the second area, the left side of the chest, to include the internal mammary lymph nodes arrayed along the sternum, and I feel the cold marker tip move down my sternum and over to the left side. They continue to take measurements and call out positions to the technician in the control booth, positioning the disc of the accelerator directly over me.
In the disc I can see a small window and the reflection of my torso. Over it is superimposed thin green lines of light running the length of my body and some narrow red beams. The field they’ve traced on my chest veers a bit along the sternum, to ensure that the heart is shielded from the radiation. Luckily, my anatomy is such that this is possible. Beyond the short-term effects of skin changes and fatigue, the long-term effects can include heart disease (later on in “young people” like me, Dr. W said) if the patient’s anatomy puts the heart in the range of the beam. And of course, as with the chemotherapy, anything they do with radiation can cause cancer. More hair of the dog.
The technicians leave the room during the actual treatment. Unlike the dentist’s office, there is no lead apron placed anywhere on me. This kind of radiation doesn’t scatter the way other types do. The disc of the accelerator hovers above me to treat the lymph nodes at the collarbone, then rotates over and behind my left shoulder to zap the nodes from behind. On the second round, the disc moves slightly to the right of my chest, angling its beams across my breast to the left. Then it rotates across my torso and down to the left to angle more beams up and across to the right. Later, during the boost phase, the disc will send particles directly down into the scar.
During the session, I feel nothing except my right hand going to sleep, and hear only the robotic movements of the machine, like the hydraulic noises you hear on an airplane when the wing flaps move. During the actual treatment, the machine buzzes loudly, like a very large and unhappy wasp.
As I watched the lines of red light reflected on the wall during the session, I thought of another brain surgery I observed back in Chicago. The patient had an aggressive tumor and the surgeon was experimenting with something called photodynamic therapy, in which light-sensitive radioactive dye was injected into the patient and a laser was then used to activate the material after it had collected in the tumor, with the hope of killing the cells. Those of us in the operating room had to wear goggles to protect our eyes from the laser light. But of course I had to lower those goggles for just a moment. The lines of red light I saw during my session reminded me distinctly of that gorgeous arc of red light I saw reaching into the patient’s brain.
As I left the treatment room after the first session, I thought, “What, no mushroom clouds?”
Last week, Dr. W was doing her week of service in a neighboring town. The radiation oncologists alternate their service between three sites — here in Olympia and in two nearby towns — spending a week in each location. So instead of seeing her, I talked with Dr. H, a tall, thin man with a meticulously groomed beard, gray hair, glasses, and a fashionable suit. When I asked him whether the treatment field included my heart, he pulled up the computer images and traced out the pattern to show that the treatment field skirted just beyond the heart’s edge. He also showed me the piece of lung that could not be avoided, introducing a risk of inflammation in tissue already affected by chemotherapy and changes that will be apparent on any future chest X-rays. Since radiation galvanizes tissue, so to speak, the ribs in the field of treatment will also undergo changes, increasing their risk of fracture, but only in cases of major impact — car accidents and such. I’ll be sure to avoid those.
Here’s an article that includes samples of computer planning images. They’re awful pretty to look at if you don’t think about the implications:
Dr. H also explained the choice of dose and the reason for the boost at the end of the series. Since scar tissue is denser than regular tissue, it takes a higher intensity to get the same effect. He also said that, given my general good health (if you don’t count the cancer!) and energy level, I should do well in treatment. Ah, if only they could give written guarantees. When I joked with him about not seeing the expected mushroom cloud, he replied “Radiation is your friend!” Well, you know, I’ve made a few new friends along this path but radiation is not one I anticipated.
So now I need to make the mental shift — from thinking of going to the oncology center once a week for several hours to every day for about 20 minutes. I can’t put any lotion on the skin within 2 hours of treatment (aloe on twice a day but showered off before the session). No tight clothing (who, me?), perfumes, anything that would irritate the skin. And I see the doc once a week rather than every 2 weeks.
But, no needle pokes in the chest, no steroid crashes, and food once again tastes like it’s supposed to.
If you’re interested in the mechanics of the linear accelerator, you can see an explanation here: http://www.youtube.com/watch?v=lZ9cGVaxOes
And if you want to make one at home, you can find directions here: http://www.kqed.org/quest/television/make-it-at-home-tabletop-linear-accelerator
Remember — no mushroom clouds. And radiation is your friend.