Cervical brachytherapy questions

[Brachytherapyquestions]

I have a couple of questions for those who've experienced cervical brachytherapy.

I should make something clear before anyone shares their experiences. I'm not having the procedure myself. I'm a student nurse who's had an oncology placement and, at the end, the ward had some women who were having brachytherapy for cervical cancer. It raised quite a few questions for me but the nurses were unable to answer as they had a different specialism and the women were with us because of bed availability. Additionally, placement is finished so I can't try to reach the brachytherapy nurses and the uni staff have other backgrounds.

If you're willing to answer share your experience to increase my understanding I'd be grateful.

I'm curious how long the course of treatment was and how long individual treatments lasted? The two women I assisted had to lie flat on hard beds - effectively trolleys - for several hours and had to remain still to prevent injury from the rods. We all attended to the women as best we could but one woman in particular found it painful to lie flat and still for so long. We carefully carried out a log roll to rub her back. Additionally, there appeared an element of fear lest something went wrong. Has anyone else experienced cervical brachytherapy in the same way?

I have looked for literature on the subject, but patient experience literature is scant. Most papers and books focus on efficacy and the scientific aspects of the treatment rather than on the person aspect.

Women having brachy for cervix cancer will usually have 4 doses of it (we call them fractions), and though the treatment itself only takes a few minutes the part where an MRI scan is taken so that the physics team can work out exactly the right pattern of places for the radioactive source to stop and for how long to give the exact radiation pattern needed for the size, shape and location of the tumour takes some time.
What you describe as rods are applicators, and make sure the radiation can go where it is needed, and spaced away from the parts that need to be protected.
Theres a very good free book about womens experiences of gynaecological brachytherapy from University of Nottingham.
I'd be happy to answer any questions, brachy is my specialist area

I should have said that before the brachytherapy they will have had external beam radiotherapy 25 times (which covers a larger area, so any cancer cells that have spread to lymph nodes are caught) at the same time as chemotherapy

@CMOTDibbler thank you! So are fractions delivered weekly or can it vary when it comes to brachy? I am confused why the women had the applicators in for hours. They had had the applicators inserted in a nearby hospital then were transported to us and stayed with us for hours before they returned to the original hospital for applicator removal. That part has confused me for a while because I can't imagine any type of radiotherapy that would go on for hours but I am a student and so my education is both ongoing and general rather than in-depth and specialist.

The actual radiotherapy doesn't go on for hours, they would have gone down to your radiotherapy department for the actual treatment which only lasts a few minutes, but its all the treatment planning that takes a long time along with the MRI that takes time. With external beam radiotherapy, this treatment planning is done without the patient waiting, but as the applicators change the shape/position of things inside (and its a very, very precise treatment, so millimetres matter) in brachytherapy it is done for each fraction.
As the applicators have to be inserted in theatre, unfortunately in some places patients have to be transported with them in if the theatres and radiotherapy department aren't in the same place or building - and sometimes if the MRI scanner is in a different place. Its not very common, but I know a few UK hospitals where it happens. Usually applicators would be removed in the RT department.
The brachy will either be given twice a week, or in some places the applicators are put in once, and the four treatments are given over two days. It all depends on logistics at that particular place.

If you'd like to learn more, this YouTube video is very good (WARNING for others, it is graphic)

Brachy seems brutal, but it is the biggest factor in a woman surviving locally advanced cervical cancer, and modern changes to it have doubled survival, so its super crucial.

So what I could have come across was women who were either awaiting the actual radiotherapy process but all the preparation was in place. Or, perhaps more likely, these were women who were going to have 4 # over 2 days and so applicators were left in place?

Is it usual for the patients to be lying flat and not really doing anything else? My placement was a breast ca facility and the nurses all appeared quite...fearful, I suppose...that something might go wrong. They were very concerned that a patient might move and that an applicator would cause internal damage.

I did ask questions but they said it really wasn't their area of expertise and that we just take the women as needed and keep them still.

What really struck me beyond the physical discomfort was the psychological discomfort and the boredom. Staring at the ceiling for hours with nothing to do but perhaps worry or ruminate and chew things over. Is what I saw the usual experience do you think?

I'm sorry for so many questions but it's an experience that has really stuck with me. I wonder if the process can be improved. I understand it is highly effective, I'm just thinking of the experiences of the two women that I saw.

Thanks for answering my earlier questions btw, the video was interesting! Seeing the width of the devices used I wish I'd been able to see the patients' medicine charts and note any analgesia. However, the ward was changing to an electronic system and staff were literally being trained whilst doing rounds so students were asked to busy themselves with other duties.

The patients do need to stay flat, but normally they'd be able to watch things on their phone or whatever - maybe the transfers at your centre make it harder to keep patients possessions with them. But patients do express that all the waiting around is very hard and leaves them with a lot of time to think.
Analgesia is another thing that varies a lot. Some patients will have a PCA, others a spinal for the duration, and others IV paracetamol or using Penthrox for breakthrough pain. The applicators are almost always (in the UK) inserted under GA. Once the applicators are in place the majority of discomfort is uterine cramping and bowel cramping rather from the applicator so buscopan really helps.

This is all super interesting. I actually qualify soon and had been thinking about some type of oncology. I ended my oncology placement on a really good note with the team.

As I say, the cervical brachy patients really stuck out for me because their experience seemed so harsh. It's possibly something that can be improved locally, even if it's just through my own actions should I end up in that environment. I also have a dissertation this year and might focus it on patients' experiences of cervical brachy. It's not real research, it's a literature review and research proposal but I'd like to do something that I'm interested in and that stems from practice.

Thank you for answering my many questions!

Patient experience relates to recovery and consequence's of managing scarring and pain as well the impact of radiotherapy sessions on the pelvic bones.Women who survive cervical cancer due to the improvement in treatment don’t usually talk about managing their health after treatment is successfully concluded .

Evening,

I'm a year out from CC. Brachy, was quite a positive experience for me. I had the rods put in under epidural and sedation and pretty much slept through the whole day. The radiation itself was only about 10 mins. Had three sessions over the course of a week.

Throughout my radiation treatment I was appointed a radiotherapist, therapist who I met with frequently to talk things through with. She was there through all the Brachy appointments which helped a great deal.

Had mine at the BRI in Bristol where the MRI machines were in a completely separate building to the Radiology department, accessed by tunnels which made it interesting. Was completely dignified though.

Happy to answer any questions

@JlL2013 i'll come back to you soon, have an exam this week so i need to prioritise that :)

I had three brachytherapy treatments for my cervical cancer. There was a week between each treatment. I also carried on daily radiotherapy sessions on the days I wasn't having brachytherapy treatment.
I would go into hospital on a Tuesday evening and be sedated and given an epidural early on the Wednesday morning . They also put a catheter in and inserted the rods during the sedation.
I would then be taken back to the ward and have to lay flat, because of the epidural this wasn't a problem. After 5/6 hours I would be taken to have the brachytherapy treatment.
During the first two sessions I felt absolutely nothing. I went back to the ward afterwards and was discharged a few hours later. Afterwards pain wise it felt exactly as it had after giving birth.
However, the third session was very different. I was left on the ward much longer before going for the treatment. The epidural was beginning to wear off and I could feel the rods and was slightly uncomfortable.
During the treatment I could feel the rods moving slightly but again it was just a bit uncomfortable.
Once the treatment was finished a doctor came to remove the rods and the catheter. I can honestly say I had never felt pain like it. It felt like someone was dragging rolls of barbed wire from in me. I was screaming, crying and was physically sick. I will never be able to explain how horrendous the pain was.
Afterwards the doctor walked out of the room and didn't say a word to me. I had told him the epidural was wearing off and I think he realised he had fucked up. I went into shock and was crying, shaking and vomiting. I had nightmares about it for months afterwards.
Had this happened during my first session there is absolutely no way I would have continued with the course.

@TimeForBedSaidZebadee thank you so much for sharing and I'm sorry it was such a painful experience for you with such an emotional impact. The pain management and communication issues aside, when you were lying flat for the 5 or 6 hours, how did you feel? Did you have any support available or anything to distract you, would you have wanted such things? Did you feel safe?

@JlL2013 I'm interested to hear that women have had such vastly different experiences to each other. How long were your applicators in place for at a time? Was there anything in place to alleviate discomfort or was it the sedation and sleeping that helped best? Thanks for answering my questions.

I had cervical brachy three years ago. I was an in-patient for four nights and had four doses of brachy.

Similar to TimeForBedSaidZebadee, it was possibly the worst experience of my life. The removal of the equipment and of the packing at the end was the absolute worst bit. I was given just one painkiller about half an hour beforehand and that’s all. I have a high threshold for pain, but I was screaming and crying throughout the removal. As my skin was red raw from the external beam, the packing had fused to my skin and they had to literally tear it off and probably my raw skin with it. I’d agree that having the equipment itself removed was like having barbed wire ripped out from my insides. It was like I was actually being tortured.

I was told by a friend afterwards that I should have received gas and air throughout, but that wasn’t offered to me. I wish they’d have given me the option of a general anaesthetic. I don’t know why they don’t.

The rest of the experience wasn’t exactly a walk in the park either, it was incredibly painful at times and I could feel the equipment being scraped around inside me. More practically, trying to eat when you’re flat on your back is extremely difficult. I found it all deeply humiliating and traumatising from start to finish. I can’t even talk about the brachy now without welling up... and I have a strong constitution.

Obviously I’m still glad I had it because it prolonged my life, but it was honestly the most traumatising aspect of the whole nightmare.

I'm sorry you experienced that pain as well, it really was horrific. I was given gas and air but it made no difference at all, like you I have a high pain tolerance but brachytherapy was a whole other level.

I didn't mind having to lie down.
I was brought lunch but trying to eat while flat on my back seemed like a recipe for disaster so I didn't bother. I drank lots of tea from a soppy cup and my television could be angled so I could watch if I wanted.
I spent most of my time chatting to the lady in the bed next to me. She was a long term patient with a cancer (I think spinal) that meant she always had to lay flat. I was always in the bed next to her so we became hospital buddies.
I felt safe, I had no worries about that.
I also found the whole process very humiliating.
And the male nurse who told me "brachytherapy is no different to inserting a tampon" was lucky to finish his shift in one piece that day 😀

Sippy cup