Treatment Stage - Radiotherapy Planning

November 3: Today was my first visit with Mom to the oncologist, Dr Kamal upon referral from Dr Amin. (Apparently Dr Ahmad Kamal Mohamed – Consultant Clinical Oncologist and Radiotherapist of Sime Darby Medical Centre Subang Jaya was Dr Amin’ senior back in his UKM days). Upon learning of my case, Dr Kamal had suggested the TomoTherapy®-based IMRT (Intensity-Modulated Radiation Therapy) with concurrent cisplatin chemotherapy, he felt very strong about it - to reduce the chance of recurrence. Plus, there's only so many operation one neck can sustain (and I had two already!) - it's best to do everything to avoid having to have any more. I was shocked to hear the word ‘chemo’. He advised us that some had refused it and had done okay, but that I would possibly always wonder if I should have; especially if there was a recurrence later on. He explained that the rationale for combining chemotherapy and radiotherapy is because the chemotherapy acts as a sensitizer to the radiotherapy by sterilizing micrometastatic disease outside of the radiation fields and decreasing any tumour mass, which leads to improved blood supply and reoxygenation. TomoTherapy® is a very new treatment and not widely available in Malaysia - there are only TWO treatment centre in Malaysia – Prince Court Medical Centre and Sime Darby Medical Centre. Guess we are at the right place!

Radiotherapy primarily works by damaging the DNA of cancer cells. It is often used as an adjuvant to surgery in the head and neck area to treat areas at high risk for disease spread. It is particularly effective in sterilizing small numbers of tumour cells left behind after surgery. While there have been no randomized trials that directly test how effective this adjuvant treatment is, there is historical data that shows for properly selected patients, it reduces the risk of the tumor recurring.

I’d told Dr Kamal about my ICAEW exam this December and asked him whether it is possible for me to sit for the exams. He advised me not to; as the side effects of radiotherapy will only be felt in the second week onwards. So as for now, I am still undecided on the papers I will take this December. My radiotherapy is scheduled to start on November 18 (a day after Raya Haji, thank God!) for 30 sessions every day (excluding weekends). Phew, what a way to end 2010! I was asked to come again next Monday for my Radiotherapy planning.

November 8: Mom, Dad and Sara accompanied me to my Radiotherapy Planning at SDMC today. The radiotherapy assistant, Miss Eng greeted us and explained what will occur during the planning session and told me that from now on, she will be with me through my anxiety-filled first week all the way up to my bittersweet final week. Her remark puts a smile on my face. Later, I was given my very own personal radiotherapy diary to record all my 30 sessions of radiotherapy.

The picture above was taken in front of the Cancer & Radiosurgery Centre. Anyway, I have a funny story to share. Or rather, an ironic one. Few months ago, back in August 2010, I was in the Sime Darby Medical Centre Subang Jaya Sdn Bhd audit team, auditing the hospital for almost two months. During the time, I had to perform a physical sighting on the hospital' newly acquired equipments. So there I was, selecting samples to sight and of course I had chosen the very expensive TomoTherapy® Hi-Art treatment system as one of my sample - it cost SDMC a whooping RM15 million! So being the auditor that I am, browsing through TomoTherapy® Hi-Art' capital expenditure request form, board minutes approval for the purchase, etc., I wondered why do they need such an expensive machine, it's going to be obsolete anyway in the near future. Well, now I know why...... :)

The planning session today is a very important part of radiotherapy as careful planning ensures the radiotherapy rays are aimed precisely at the cancer and cause the least possible damage to the surrounding healthy tissues. The planning was done by a senior therapy radiographer, Miss Lau.

During the treatment planning, I was asked to lie on a fairly hard table in the Simulator Room. Miss Eng and another radiotherapy assistant, Rizwan helped adjusted my head rest and asked me every now and then whether or not I felt uncomfortable. Then I had to lie VERY still on the Simulator for a few minutes so that accurate measurements can be taken and my exact position was recorded; they’d made a few marks on my face, neck and shoulder with permanent marker ink. It felt as if I'm doing planning for cosmetic surgery!

Me in the Simulator Room.

With Miss Lau - Senior Therapy Radiographer.

It is important that I lie still during the treatment, even more important in the case of head and neck area. This is because even a tiny movement could change the area that gets treated. To help ensure that I am positioned in exactly the same place every time I am treated, a radiotherapy mask is custom-made for me to be worn during the treatment as it reduces the possibility of any movement while radiotherapy is given. The mask will be placed on my face and fixed to the table so that my head doesn’t move during the radiotherapy. Before the mask can be made, my head/neck position was checked on the Simulator. Once my head position had been confirmed the mask was made in the Mould Room by Miss Lau.

The mask was made from clear plastic and covered my head, face and shoulders during the treatment. This technique uses a special kind of plastic. The plastic was heated in warm water so that it becomes soft and pliable. I was asked to lie in the same position I’d adopted in the Simulator and then the warm, wet, perforated plastic was put onto my face and pressed into the contours of my face. There were 4 people in the room (including Miss Lau and Miss Eng) making sure that the mask was fixed onto the treatment tabletop and fitted into the contours and around the desired area. A hole for my mouth was made – I was able to breathe normally, though I do feel anxious and worried about the procedure (but still I need to put a mouthpiece, which was moulded by Miss Lau into my mouth every time I go for treatment). The mask was then left for a short time to cool (approximately 15 minutes) and after the mask became hard, it was then removed. Voila! Now I have a mask that is ready to be used when I have my treatment.

My mouthpiece with my teeth markings.

My cool, custom-made mask!

In goes the mouthpiece.

After that, Miss Lau made two “tattoo” marks on both my shoulder. These were permanent, but they are the size of a pinpoint (it looks like a mole!). According to her, this was a good way of making sure that my body is symmetrical and aligned correctly for treatment.

All in all, the whole procedure took around two hours and was painless though it was quite messy.

Before I left, I was given my next appointment schedule: November 18, 2010 – My first radiotherapy session!

After the Planning session - mask marks on my forehead.