• Reference Number: HEY-194/2018
• Departments: Radiotherapy

Introduction

Your doctor will have already informed you that all the tests carried out so far, have shown no signs that the cancer has spread anywhere else. Therefore, your cancer is at an early stage and there is a very good chance of curing it. Your doctor / surgeon has informed us that you fully understand that the standard treatment is major surgery and that:-

• He/she feels that you are not fit enough for the standard treatment due to your other medical problems which can put you at a very high anaesthetic risk or
• You do not want any surgery that involves either a permanent or a temporary stoma (bag).

We understand that either you or your doctor has requested information regarding alternative options.

It is important to help you understand that:

1. Not all rectal cancers are suitable for local treatment and therefore it may not be possible to offer you this.
2. There is a higher risk of local recurrence following local treatment. This is
   approximately 10% compared to 4% with standard treatment.
3. Should the cancer come back, (usually within the first 2-3 years), you will need to consider the standard surgery that may involve a permanent or a temporary stoma (bag)- Michelle has kept this for helping the patient understand?

Investigation at the start of treatment

You will have an MRI and a CT scan to find out the extent of your cancer and exclude spread of cancer. You will also have an intra-anal ultrasound scan (probe inserted into your back passage) to find out the depth of invasion of your tumour. You will also have some blood tests.

Local treatment options

Some patients will need to begin their treatment with local surgery and this will be followed by radiotherapy.

Surgery

If your rectal cancer is small (less than three centimeters) then it may be possible to remove this through your back passage without opening your abdomen. Your surgeon will discuss the options with you.

Radiotherapy using the Papillon technique (contact radiotherapy)

Contact radiotherapy (low energy X-rays treatment) is a recommendation for patients who are unfit for general anaesthesia or who do not want surgery and formation of a stoma (bag). If your cancer is small (less than three centimeters) and if the cancer is not too deep with no evidence of lymph node involvement, then local contact radiotherapy using the Papillon contact treatment can help. Unlike surgery, this treatment does not involve a general anaesthetic and may be more suitable for you. (Figure 1, Papillon X-ray Machine). However, not all rectal cancers treated with the Papillon method respond to the treatment. If you do not respond, you may need to go on and have external beam radiotherapy with or without chemotherapy (drug treatment). If there is still cancer remaining you may need local surgical resection.

Combination treatment

For larger cancers, (more than three centimeters) we need to shrink the cancer as much as possible before going on to surgery. This involves a course of radiotherapy or chemo-radiotherapy.

What happens if I have contact radiotherapy?

You may receive treatment as an outpatient. Upon arrival to the department, you will be given medication to clear your bowels before the treatment. We will also give you a local anaesthetic gel to apply around your anus to numb the area and ease any discomfort; and a cream to relax the muscles around your back passage.

A radiographer, who will also show you the position that you need to be in for the treatment, will explain the treatment procedure in more detail. The actual treatment usually takes about 1 – 2 minutes but you will be in the treatment room for about half an hour.

In order to maintain your privacy and dignity we will provide you with a pair of disposable shorts. We will ask you to kneel and bend over on the treatment couch. Your doctor will then examine your back passage to locate the cancer. They will then insert a small instrument (sigmoidoscope) to examine the cancer carefully. Your doctor will then remove the instrument and insert the treatment tube (applicator, See Figure 2), into your back passage placing it directly over the tumour. There is a camera within the treatment tube to check the position of the applicator. When the applicator is in the correct position, the radiographer will connect the applicator to the Papillon contact treatment machine (which uses low energy X-rays). The X-rays will only penetrate a few millimeters and therefore the deeper normal tissue is not affected. There are very few side-effects from this superficial X-ray treatment. The second treatment is usually about two weeks after the first treatment and we repeat the same procedure.

Each treatment destroys the cancer cells, layer by layer, while the normal tissues recover during the break between treatments.

If the tumour responds to the first two treatments and shrinks, a third treatment is given in a further two weeks time. Finally a fourth treatment is given in another two weeks (Four treatments in total).

If the tumour does not respond to the first two treatments then external beam radiotherapy is given with or without chemotherapy.

The equipment used in Papillon contact radiotherapy

Fig 1: The Papillon Contact Treatment Machine.
Papillon is the name of the French professor who popularised this technique.

Copyright: Images taken from the Papillon Instruction Booklet

Fig 2: Applicator and Insertion Tool.

Possible complications and side effects

Surgery

Any surgical procedure carries a risk of complications, and death.  Complications such as bleeding, pain, infections, delay in wound healing and fistulas (abnormal connection between front and back passage) are much lower with local treatment compared with standard treatment.

You may experience incontinence (loss of control) of your motions for a few weeks following local surgical treatment but this usually gets better for the majority of patients. We may advise you to do pelvic floor exercises to strengthen the muscles around the anus and help to prevent further leakage.

Radiotherapy

There have been no deaths reported as a direct result of this treatment. However radiation can cause some discomfort in the rectum due to inflammation caused by the radiation. This usually settles down 2 – 6 weeks after completion of treatment.

You may experience pain/discomfort around the back passage when the doctor inserts the rectal applicator. The local anaesthetic gel and cream used to relax the muscle will help to ease the discomfort, the pain/discomfort usually settles down within a few minutes.

Diarrhoea (loose motions) is not common after only contact radiotherapy, but can occur if you have external beam radiation especially when it is combined with chemotherapy. We will give you advice on what to eat and what foods to avoid. You may need some medication (e.g. Imodium) to control the frequency of motions.

Late side effects of radiation

This includes narrowing of the back passage. This can occur in about 1% of patients. Gently stretching (dilation) the narrowing may be necessary. Your surgeon will arrange this for you.

Persistent bleeding occurs in less than 5% of patients due to dilated blood vessels. Laser treatment may be used to control the bleeding.

Fistulas, (abnormal connection between front and back passage) are a rare radiation side effect less than 1 in 100.

Intestinal obstruction (blocked bowels) occurs in less than 5 in 100 patients and normally if you have had surgery and external beam radiation combined.

Do I need to prepare for the contact radiotherapy?

It is beneficial to ensure that your bowel is as empty as possible during your Papillon contact radiotherapy session. Having an empty bowel is helpful in a number of ways:

• It helps your doctor to see the area to be treated more easily
• Assists in making the procedure as straight forward as possible

You will need to modify your diet, starting three days before the day of the procedure. You will need to eat a diet that is low in fibre and avoid foods that increase the activity of your bowel. This type of diet is known as a ‘low residue diet’. See Table of ‘Dietary Advice for a Low Residue Diet’. You may notice that you need to empty your bowels less often and pass smaller amounts.

Before the procedure, you will have an enema (liquid into the lower bowel) to ensure that your bowel is as empty as possible. Please continue to take your usual medication unless we have told you not to.

On the day of the procedure

You should have a light breakfast e.g. cereal or white toast and a light lunch e.g. white bread sandwich with lean meat, cheese or egg. After your lunch take only clear fluids e.g. black tea or coffee, water and jelly.

After the procedure is complete you can return to your normal diet. It may take several days to return to your usual bowel habit.

Dietary advice for a low residue diet for Papillon contact radiotherapy

Food group	Foods allowed	Foods to avoid
Bread, other cereals & potatoes	White bread, chapatti, pitta White pasta White rice Refined cereals e.g. Rice Krispies©, Cornflakes© Cream crackers, rice cakes Boiled, mashed or roast potatoes (no skin) Yams, sweet potato (no skin)	Wholemeal/granary bread, added fibre white bread, brown chapatti, wholemeal pitta Wholegrain pasta Brown rice Wholegrain cereals e.g. Bran Flakes©, Weetabix©, muesli, porridge Rye crisp breads, wholemeal crackers, oatcakes Jacket potato skins
Fruit and vegetables	None	All fruit and vegetables to be avoided this includes fresh/tinned/stewed and frozen varieties.
Pulses and nuts	None	Ideally avoid all pulses/lentils/hummus even if vegetarian.
Meat, fish and eggs	Fish Poultry Lean meat All cooked, broiled, or roasted Quorn©, tofu and textured vegetable protein (TVP)	Avoid skin, gristle, bone and any dishes contain pulses e.g. chilli con carne
Milk and dairy products	Milk, including cows/goat and soya, cream Plain yoghurts Cheese	Yoghurts containing nuts or cereal
Miscellaneous	Butter, margarine, oil Plain biscuits e.g. Rich Tea© Morning Coffee© Cakes, puddings and pastries made with white flour Jelly, ice-cream, milk puddings, custard, sorbet Honey, sugar, syrup, ‘jelly’ type jams Tomato ketchup, brown sauce, mayonnaise Salt, pepper, herbs, spices Boiled sweets, chocolate, toffee or fudge without dried fruit or nuts Tea, coffee, sugar free or diet fruit squash and fizzy drinks, chocolate or malted milk drinks, Bovril©	Wholemeal biscuits e.g. digestives Biscuits containing dried fruit or nuts e.g. fig Rolls Cakes, puddings and pastries made with wholemeal flour, dried fruit or nuts Flapjacks, cake, biscuits or puddings made with oats Jams with seeds or skin, marmalade all varieties, sweet mincemeat Pickles or chutneys Sweets and chocolate with fruit or nuts, muesli bars Popcorn

What happens after I have completed Papillon contact radiotherapy?

You will have regular follow up appointments at each visit you will have blood tests and a clinical examination. You will have repeat MRI scans at 6, 12 and 24 months after the procedure.

Should you require further advice on the issues contained in this leaflet, please do not hesitate to contact the Radiotherapy Information and Support Team on telephone number: (01482) 461206, or Email: Radiotherapy.Info@hey.nhs.uk

Here are contact details of useful organisations that provide information about cancer including radiotherapy treatments:

Macmillan Cancer Support
Provides information from specialist nurses on all aspects of cancer and its treatment and on the practical and emotional aspects of living with cancer.

You can drop into the Macmillan Cancer Information Centre at the Queen’s Centre or call them on: (01482) 461154 (Monday – Friday 9.00 a.m. – 5.00 p.m.)
Alternatively freephone the national help line: 0808 808 0000 (Monday – Friday 9.00 a.m. – 8.00 p.m.)
Online: http://www.macmillan.org.uk
Write to: Macmillan Cancer Support, 89 Albert Embankment, London, SE1 7UQ

PALS (Patient Advice and Liaison Service)
Provide confidential advice and support, helping you to sort out any concerns you may have about the care we provide, guiding you through the different services available from the NHS.
Telephone: (01482) 623065 (Monday – Friday 9.00 a.m. – 4.00 p.m.)
Email: pals@hey.nhs.uk

General Advice and Consent

Most of your questions should have been answered by this leaflet, but remember that this is only a starting point for discussion with the healthcare team.

Consent to treatment

Before any doctor, nurse or therapist examines or treats you, they must seek your consent or permission. In order to make a decision, you need to have information from health professionals about the treatment or investigation which is being offered to you. You should always ask them more questions if you do not understand or if you want more information.

The information you receive should be about your condition, the alternatives available to you, and whether it carries risks as well as the benefits. What is important is that your consent is genuine or valid. That means:

• you must be able to give your consent
• you must be given enough information to enable you to make a decision
• you must be acting under your own free will and not under the strong influence of another person

Information about you

We collect and use your information to provide you with care and treatment. As part of your care, information about you will be shared between members of a healthcare team, some of whom you may not meet. Your information may also be used to help train staff, to check the quality of our care, to manage and plan the health service, and to help with research. Wherever possible we use anonymous data.

We may pass on relevant information to other health organisations that provide you with care. All information is treated as strictly confidential and is not given to anyone who does not need it. If you have any concerns please ask your doctor, or the person caring for you.

Under the General Data Protection Regulation and the Data Protection Act 2018 we are responsible for maintaining the confidentiality of any information we hold about you. For further information visit the following page: Confidential Information about You.

If you or your carer needs information about your health and wellbeing and about your care and treatment in a different format, such as large print, braille or audio, due to disability, impairment or sensory loss, please advise a member of staff and this can be arranged.