Dr. P Sasikala

No. Radiation therapy is not painful. This is one of the most important things I tell every new patient at SPARSH Hospital, Hennur Road, Bengaluru, because the fear of pain is one of the most common reasons patients approach a radiation oncology consultation with dread, and it is a fear that the treatment itself consistently fails to justify. During each radiation treatment session, the patient lies on the treatment couch, is positioned carefully by the radiotherapy team, and the machine either rotates around them or moves to specific positions to deliver the radiation from the planned angles. The actual radiation delivery is completely invisible and completely silent. The patient feels nothing: no heat, no tingling, no pressure, no discomfort of any kind during the radiation itself. The session from entry to exit typically takes between ten and twenty minutes, most of which is positioning time. Many patients, having anticipated something frightening, find themselves surprised that the experience of each treatment session is simply lying still while the machine moves. The side effects of radiation, which are the source of legitimate concern, are not experienced during the session itself. They develop gradually and cumulatively over the course of treatment, as the normal tissues in the treatment area accumulate radiation dose alongside the tumour. For breast cancer radiation, the main side effect is skin reaction in the treated area and fatigue. For pelvic radiation, the main side effects are bladder and bowel symptoms. These are expected, managed proactively with supportive care guidance, and in the majority of patients they resolve after treatment ends. Most of my patients tell me, at the end of their radiation course, that the treatment was significantly less difficult than they had expected. Knowing what to expect before you start makes the experience of going through it considerably more manageable.

The length of a radiation therapy course and the number of sessions required varies considerably depending on the type of cancer being treated, the stage of the disease, the intent of treatment (curative or palliative), and the specific radiation technique being used. At SPARSH Hospital, Hennur Road, Bengaluru, I design each treatment schedule individually as part of the multidisciplinary plan, but I can give you a general picture of what different cancer types typically involve. For early breast cancer treated with adjuvant radiation after breast-conserving surgery, the modern accelerated protocol that I now use for appropriate patients delivers the entire course in just five treatment sessions, typically given once daily on five consecutive working days. This is a significant change from the older four to six week protocols and reflects the evidence base from large randomised trials showing equivalent outcomes in appropriately selected patients. For cervical cancer treated with curative intent, external beam radiation is delivered over five to six weeks of daily fractions from Monday to Friday, followed by a brachytherapy component consisting of several sessions given over one to two weeks. Radiosurgery using SRS or SBRT, which delivers very high doses to small, precisely defined targets, is completed in one to five sessions over one to two weeks. Palliative radiation for bone metastases causing pain is typically given as a short course of one to ten sessions. Whatever the specific schedule, I explain the full treatment plan including total number of sessions, daily session duration, and the expected timing of side effects at the planning consultation before treatment begins, so that patients can arrange their work and personal commitments around the treatment schedule without uncertainty.

This is one of the questions I am most frequently asked by patients with cervical cancer, and I want to answer it directly because I am aware that brachytherapy, which involves placing a radiation applicator inside the vagina and cervix under short anaesthesia, is an aspect of treatment that some patients find alarming and are sometimes advised they can forgo. They cannot, if the intent of their treatment is cure. The reason brachytherapy cannot be replaced by external beam radiation alone comes down to physics. The dose of radiation needed to kill the central tumour in a cervical cancer is very high, higher than can be delivered to the cervix from outside the body without also delivering an unacceptably high dose to the bladder, which sits immediately in front of the cervix, and the rectum, which sits immediately behind it. The radiation dose from an external beam falls off with distance, but not steeply enough at the short distances involved in pelvic anatomy to protect the bladder and rectum while maintaining a tumoricidal dose at the cervix. An internally placed source, positioned directly at the tumour or within the applicator at the cervix, delivers its dose with a very steep fall-off: the tumour receives a very high dose, while the bladder and rectum, just two or three centimetres away, receive a dose that is a fraction of the tumour dose. This physics cannot be replicated from outside the body. My research in brachytherapy, recognised with the Best Paper Award from the Indian Brachytherapy Society in 2016, reflects my long engagement with the technical and clinical dimensions of brachytherapy delivery. At SPARSH Hospital, Hennur Road, Bengaluru, brachytherapy is performed as a standard part of curative-intent cervical cancer treatment, and I discuss the procedure, the anaesthesia, and what to expect in detail with every patient before the brachytherapy sessions begin.