Welcome everyone, my name is Anne Mellon and I'm the co-chair of the IGCS Nursing Work Group and a gynaecology clinical nurse consultant in Australia. I would like to welcome you today to today's webinar, Radiation Treatment for Gynaecological Malignancies and the Vital Role of Nursing. We are thrilled to have you with us today. Before we get started I want to mention a few housekeeping items. There will be ample time for discussion today so we encourage you to submit your questions by the Q&A feature at the bottom of your screen. We will do our best to address as many questions as possible. A recording of this webinar will be available on the IGCS Education 360 Learning Portal tomorrow. Now it is my honour to introduce my co-chair and co-moderator Chrissy Donovan. Thank you Anne, I'm Chrissy Donovan and I am also an IGCS Nursing Work Group co-chair and an oncology RN from the US. It is my honour to introduce today's speakers. Joining us are Kayla Kafka-Peterson, the Nursing Supervisor of Radiation Oncology at UCLA and Pooja Venkat, the Assistant Clinical Professor of Radiation Oncology at UCLA. Thank you both for joining us today. Kayla and Pooja will explain the rationale behind radiation treatment for gynaecologic malignancies, different treatment modalities including both external beam radiation and brachytherapy, as well as how to care for patients undergoing radiation therapy. Nursing care will be covered in depth with a special emphasis on patient education and side effects management. This webinar will focus heavily on external beam radiation therapy. Without further ado, let's get started. I will turn this webinar over to Kayla and Pooja. Alright, thank you for having us. We're very excited to be here. One moment and I'll share my slides. All right. Can you see the slides okay? Looks great. All right. Well, thank you again for everybody for having us. We're very excited to come today to speak to you about radiation treatment and how we use it for gynecologic malignancies, and of course, the vital role that nurses play in the care of these patients. I have no disclosures. Dr. Venkat also has no disclosures. Some objectives for today's webinar. We want to do a brief overview of principles of radiation and its general use in treating cancer. You can have an entire webinar on that, but we'll just introduce the basic concepts of radiation. We'll discuss indications for its use in the treatment of GYN malignancies. We'll review side effects experienced by patients undergoing radiation therapy and provide education for nurses on side effect management and tools for patient education. So with that, I'll jump in and I'll start by discussing some basics of radiation therapy. So what is radiation and how is it used as a cancer treatment? So radiation therapy is a treatment that can be used for malignant and benign condition, and it really has high doses of ionizing radiation. That radiation goes into the body, it's directed into the body and it often damages DNA, and that's really how it kills cancer cells. We'll go into a little more specifics. When I say ionizing radiation, there are many different types of radiation, but ionizing radiation is important because it actually is able to remove electrons from atoms and those electrons then go in to cause damage within tissue. There are many different types of ionizing radiation. There are gamma or X-rays. Those are wave-like types of radiation, but they're also particle types of radiation, which include protons, electrons, and heavy ions such as neutrons and carbon ions. So how does ionizing radiation work? Really, I think of it as damaging DNA. So radiation doesn't immediately kill a cancer cell, but once that DNA is damaged, when that cancer cell tries to replicate, it can't and it can die in many different ways. So radiation can do a number of things to DNA. It can change the chemical structure of the bases as seen in the number 1 here. It can also break the sugar-phosphate backbone of DNA as in 2. Lastly, it can break the hydrogen bonds that are connecting the base pairs in the DNA. It can also create something called free radicals, which are generally things we don't want in the body. They damage the body, the damaged cells, but in the case of radiation, they're actually used to damage cancer cells. So they can be a good thing and something we want to happen. Moving on to an overview of different types of radiation therapy, and I could talk about this for an hour, and I know there's a lot on this slide, but I will just touch on a few things. I really break up radiation in terms of therapy into external radiation, internal radiation. External radiation is pictured here, where the radiation is delivered with these giant machines. Typically, we're using linear accelerators. They can be cobalt-60 machines. This is a fancy new linear accelerator pictured here at UCLA. The machine rotates around the patient, and it can rotate in 360 degrees, and it can deliver radiation from any degree, and it also has lead collimators, and we can be blocking the radiation as it's being delivered, and we can really control the radiation we're delivering and treat what we want and block what we don't want. There are many different types of external beam radiation. Some are listed here. 3D conformal radiation is a somewhat older type where we put fields on for the pelvis. Since we're talking about gynecologic cancers, this typically involves something called a four-field box, and I'll show you some images of that later. A more fancy, newer type of technology is intensity-modulated radiation therapy, or IMRT, and that's when we're really shaping our fields as we're delivering them. We have a little more control of that radiation dose. Another really important concept is image-guided radiation therapy, where we can't target radiation if we can't see what we're targeting. So we have a number of different technologies that allow us to see anatomy, see tumor, and see normal structures on the treatment machine every day when we're delivering treatment, and that's super important for us to give really good radiation doses and minimizing side effects. There's other types of radiation such as stereotactic radiosurgery, which is often used to treat brain lesions in the brain or stereotactic body radiation therapy, which is a newer technology that delivers high doses of targeted radiation of lesions. All of those types are delivered externally. Something that we specialize in here, Kayla and I specialize here at UCLA, is brachytherapy, and that is really our love and our passion. We are going to do another webinar about brachytherapy in the future, so I'm not going to talk too much about it today, but there are many different types, high dose rate, low dose rate, pulse dose rate. You can also, how it's delivered gives it a, there's an intracavitary where we put brachytherapy within anatomical cavities. There's interstitial where we put needles through tissue directly into tumors, and then there's surface mold applicators that we can use for skin cancers or even vulvar cancers. And then there's a third type of radiation, which we really label as systemic radiation where we actually inject radioactive material into the body, and it can be, it can target certain types of cancer cells, ideally, because we can attach the radiation to monoclonal atom bodies. We use this for thyroid cancer when we use radioactive iodide. We use it for bone mets when we use radium-223, which is a cool treatment that targets the bone, and we use it for prostate cancer with some very new technologies as well. And then yttrium-90 or Y-90 is something we use in the liver where we actually inject radioactive beads directly into the liver vasculature, and it's picked up by cancer cells in the liver, which is super cool. As I said, I'm not gonna talk too much about brachytherapy, so I just have some pictures here so we can get a sense of what it is. Over here, we see a vaginal cylinder. These are applicators that are simply placed into the vagina, and the radiation is delivered through the cylinder, and this is something we use very commonly for adjuvant endometrial cancer. This is a tandem and ring applicator, which is a intracavitary applicator that we use for cervical cancer. This small tandem here goes through the cervical os into the uterus, and this ring sits up against the cervix, and the radioactive seeds are delivered right through that applicator. What we typically do here at UCLA is a little more complex, where we put these little tubes or catheters directly into the tumors, and then we deliver the radiation right there, and you can see that in these pictures, this is the rectum and stigmoid, this is the bladder and bowel, and we're able to deliver really good dose right in between all these normal structures right where we need to get them. A little bit, this is a slide that helps us compare how is radiation delivered differently with these techniques. So over here, you see an IMRT plan. This is an external beam radiation technique, pretty new technology, and we see that the dose is coming in from all these different angles, and it's going through all this external tissue, but most of the dose is targeted right in the center. It's kind of like spokes on a wheel. So yes, there's dose coming in all over, but it's targeting right in the center where we want it, and definitely has its role, but what we love about brachytherapy is that we are actually putting the dose right through these catheters, right into the tumor, and we don't have as much dose coming in from externally because we're treating from inside out. To go backwards a little bit, I just want to talk a little about radiation dosing and what we call fractionation. So what is radiation dose? What do we call it? We use this term gray, which is a complex idea of a unit of absorbed radiation equal to the dose of one joule of energy absorbed per kilogram of matter, or 100 rads. This is something I had to memorize for my physics boards. I don't want any of you to worry about it. Just know that we use the term gray. That's how we talk about the dose delivered, and fractionation refers to that. We tip often with external beam, give a small dose per day over a few weeks. It can be one week to eight weeks, depending on what we're doing, but that idea of fractionating the total dose into multiple treatments is where that term fractionation comes from. The reason this was developed is because cancer cells do not have the same healing mechanisms that normal tissue has. So we want to give that normal tissue time to heal between fractions and take advantage of this key difference between cancer and normal tissue cells. So let's focus a little bit on gynecologic malignancies and indications for radiation. We basically treat all gynecologic malignancies with radiation at different times. For cervical cancer, we treat locally advanced disease. We are actually the primary treatment. It's a combination of concurrent chemotherapy with external beam radiation, followed by brachytherapy. And then for early stage cervical cancer, we play a key role for adjuvant treatment to prevent the cancer from coming back. Endometrial cancer, we generally treat adjuvantly as well, but there are some patients who cannot undergo surgery, and we do treat primarily with radiation. For vulvar cancer, vulvar cancer is much more rare cancer, as you all probably know. And we take a lot of our vulvar treatment paradigms from cervical cancer, because they are in some ways very similar. They have very similar biological courses. So we do treat for adjuvantly to prevent it from coming back, but we also treat definitively as well for more advanced vulvar cancers. And vaginal cancers, also quite rare. We also treat cervical cancers generally, unless the two vaginal cancers are found very early and are very small. These are not respectable, so we often treat these with radiation. I'm gonna focus a lot on cervical cancer and endometrial cancer for this talk, because that's generally what's more common. That's what you'll mostly see in your clinic. So for early stage cervical cancer, the treatment paradigm involves surgery. That would be a radical hysterectomy, pelvic lymph node dissection. And then we think about adjuvant treatments such as radiation and or chemotherapy, depending on the pathologic findings during surgery. For some early stage cancers, we do choose to actually treat with definitive chemo, radiation with brachytherapy, as opposed to surgery, just depending on also some of those pathologic findings and imaging findings, exam findings. And then definitely for all locally advanced diseases, we really take a radiation approach. We did a study years ago, started in the 1970s, that really compared a surgical versus radiation approach. And we found that there was no difference in cure rates between the two for advanced diseases, but patients had less side effects if we just proceeded with radiation to begin with, rather than combining treatments. So that's why we typically treat with radiation for more advanced tumors. So a little more specifics for early stage cervical cancer, we do a radical hysterectomy with a pelvic lymph node dissection. You should also consider sampling the periodic lymph nodes. And what does this mean? The uterus, cervix, perimetria, upper vagina are removed and those lymph nodes are sampled or removed as well. We want to add adjuvant treatments when we have certain pathologic characteristics. So we add external beam radiation. If we have two of the three below findings, one is the tumor is greater than four centimeters. The second is that this cancer has invaded to one third depth of that stromal invasion or more. And we look at that under the microscope, the pathologist will give us that finding. And also we look for lymphovascular space invasion, which is also a pathologic finding that our pathology colleagues will discuss with us. We also sometimes add chemotherapy to this external beam radiation. And we do that if we have one of the three following findings, a positive margin, perimetrial involvement, or a positive lymph node. Both of these recommendations really come out of two main studies that looked at adjuvant treatments, the Sedliff's and Peter's studies. And then finally, I recommend adding vaginal brachii to the external beam if there's a positive vaginal margin to just get a little extra dose right where we need it. For locally advanced cervical cancer, and this is probably the disease that I, oh, we lost our slides. It's probably the disease I spend most of my time focused on. This is a preventable cancer that really, yes, just has such a horrid and tremendous impact on our world. It's something we spend a lot of time treating here. And the treatment paradigm is definitive chemo radiation with a brachii boost. I emphasize that brachii boost. It is an integral part of the treatment. In fact, literally half of the radiation dose is delivered with the external beam. The other half is delivered with the brachii therapy. So this is an integral component that is required for curative treatment and should be discussed with your patient from day one of consultation. The chemotherapy component is weekly cisplatin 40 milligrams per meter squared for five to six weeks during the external beam radiation. That chemotherapy is intended to make the radiation more effective, as it is a radiation sensitizer. So it's important that we don't just give the cisplatin on its own. It should only be given while that external beam radiation is being given. And that external beam radiation is 40, is what we deliver is 45 grades of the pelvis in 1.8 grade per fraction, which is a total of 25 fractions. So we can deliver it in five weeks, Monday through Friday with that weekly cisplatin. And this should be followed by a brachii therapy boost. There are many different ways to deliver the brachii therapy. We're gonna talk about it next time. So we're gonna jump ahead. On to endometrial cancer. So a lot of different treatment paradigms to discuss with endometrial cancer. I'll try to keep it simple, even though it is quite complex. So for early stage, low risk patients, we hope and we want to be able to get away with surgery alone. What is that surgery? A total abdominal hysterectomy, bilateral salpingo-opherectomy with some sort of pelvic lymph node sampling as well. That is our hope always to be able to go to surgery and say, we got it all. There's no adverse pathologic features. You're good to go. Unfortunately, some of our patients, we find some slightly adverse risk factors and we classify them as an intermediate risk patients. And often for those patients, we follow the surgery with adjuvant vaginal brachii therapy. And we'll discuss that a little bit more. If patients have higher risk features, we will want to add even more treatment adjuvantly. Sometimes that's external beam, plus or minus vaginal brachii therapy. Sometimes that's chemotherapy and vaginal brachii therapy. It depends on a lot of different factors. And then when the tumors are locally advanced, we still start with surgery for endometrial cancer. That really is an important part of endometrial cancer treatment, regardless of how advanced the tumor is. And we follow that by chemo radiation and adjuvant chemo, plus or minus vaginal brachii therapy. Although you can also do just chemo adjuvantly. You can do chemo, then radiation, then chemo. You can do all sorts of different things. You can add immunotherapy in there. So it's getting quite complex in that endometrial cancer world, which is actually great because that means we have a lot of new data and trials coming out. So a little bit about the chemotherapy and what to watch out for during treatment. This is the concurrent chemotherapy given for cervical cancer and sometimes endometrial cancer. I'm focused more on the cisplatin, 40 milligrams per meter squared weekly for five to six cycles during the cervical cancer treatment. And what side effects are we looking out for as clinicians? A big one for us is bone marrow suppression. So we're gonna do a weekly CBC. We need to take, we make interventions as needed. Sometimes patients need blood transfusions. We're watching their platelets. And if their white counts, particularly their neutrophils get too low, we need to give them neupogen. Really the important point here is we need to get these patients through treatment without delays. For radiation treatment for cervical cancer, the total treatment time is extremely important. And new data suggests we should be completing all treatment from first day of radiation to last day of brachytherapy in 49 days. That's not a lot of time. So we can't have big delays because someone's hemoglobin six. Like we have to be proactive about this. So we're checking every week and we're making sure we're optimizing our patients. Nausea is a big side effect. We're pretty aggressive with our anti-nausea meds. And then other things we watch out for is renal toxicity. So I'm checking a basic metabolic panel every week if available. And then I ask the patient to watch out for ototoxicity, any ringing in the ear or muffled sounds because that can be a permanent side effect of cisplatin. And we would want to dose reduce that chemo or even stop that chemo if that started. Okay. So we're going to look at kind of just a general flow of external beam treatment. Where do we start with? So for us in radiation, the first thing and one of the most important things we do is a CT simulation. I tell my patients, it's just a planning scan. What we do is we make for GYN cancers, we make a beanbag mold for the patient's lower pelvis and legs to lay in every day. It conforms to the patient's body that kind of keeps them in the same position every day. We also, of course, for our GYN patients, if they're of age, we want to check if they're pregnant because radiation and pregnancy do not go well together. I like to put markers directly into the cervical tumor or the vaginal tumor, or even the endometrial tumor if that's what I'm looking for. Neutral tumor if that's what I'm treating because those are gold or platinum markers that I can see every day on my treatment machine. That helps me target my radiation a little better. I generally use IV contrast when available and when kidney function allows for my CT simulations. Oral contrast is something we'll discuss. I do not use this routinely, but some people recommend it. And one thing I really think is important is getting a bladder full and bladder empty scans, particularly, but really all the time in the pelvis. When someone has an intact uterus, the uterus moves a ton as the bladder fills and empties. And you're not going to be able to see that very well on your daily imaging. So you want to account for that movement. So it's really important to see how the anatomy changes with those two scans. Also, we want the rectum as empty as possible to minimize dose to the rectum. When available, I do love for cervix patients to get a diagnostic PET CT. And I personally really find MRI pelvis is very valuable to really understand the relationship of tumor to tissues such as the bladder, rectum, and bowel. If you don't have availability of those, ultrasound has been shown to be a really great alternative and it's something we use in brachytherapy a lot and I do find it quite helpful. So why do we use fiducials? This is one of my patients and I just wanted to show on a CT sim, this is I'm treating a vaginal cuff. This must be probably post-op endometrial patient. And I put these markers right in here, right into the cuff. I do this with a speculum exam and I just poke them in really. And on the CT sim, you can see them really well and you can see the bladder and you can see the rectum. But on my daily imaging, when you do a daily combium CTs, these aren't gonna be as good of images as a diagnostic CT. So you can't really see a cuff. I see a rectum, I see a bladder. I know there's a cuff somewhere in there but I can't really see it, but I can see my fiducial. So I can make sure I'm treating the area I wanna treat just a little bit easier. I can put smaller margins on my target which I find really helpful. IV contrast, I really think is important for me when I can get it. Basically, if you look here in this scan, everything's gray. I don't really know where the vessels are, what's bowel. Really can't tell much, but over here with the contrast in place, maybe it's not that clear but I feel like I can see it. There's like two vessels right here and I know the lymph nodes run along the vessels. So when I'm doing my contouring, I can know exactly where to contour and you can see the vessels right here as well. So I find it very helpful. It also helps me to find any lymph nodes that might be enlarged that maybe I wanna give a little extra dose to. And I mentioned, I don't use oral contrast, but I do think it's very helpful in this picture. Once again, everything looks great. What is what, who really knows. Here, it's so obvious. This is oral contrast in the small bowel and makes it super clear what you're looking at. Just really helps you tell what you're treating and what you wanna avoid. And okay, here we go. Got our images here. So this is also just kind of showing how to see the difference between bowel and tumor in this picture. I don't know, it's all gray. I think there's probably a bladder up here. It's a rectum down here and there's just a bunch of stuff in between, which is a mixture of bowel and tumor. When you add contrast, I just feel like you get a much better sense of what you're looking at. You can see your bowel here and that leaves your tumor right in the middle here. So it just kind of helps you know what you're treating. And then this is to show why I do a bladderful and empty scan. This is particularly true if you're using intensity modulated radiation therapy. Because when we do intensity modulated therapy, we draw out our uterus here, our cervix here and the top of our vagina. And that's what we tell our system to treat. And we tell it also to avoid the bladder here and the rectum here and the sigmoid here and the bones. We wanna spare that bone marrow. But the concern is if the bladder is empty on one day, that uterus can drop down and now it's not in my target and I could actually be missing tumor. So I think it's extremely important if you're gonna use a targeted treatment like IMRT that you have imaging and you can see that you're hitting what you wanna treat. So this is kind of showing with a bladderful that uterus is pushed up a little with the bladder empty that uterus drops down and you really don't wanna miss that. And why do I... The other thing I do routinely is I ask my patients to fill their bladder comfortably for treatment every day. And it's not an easy thing for patients to do particularly after hysterectomy and they're getting radiation and they're getting all this chemo with all this IV fluids, but it's really important. And the reason is when we fill this bladder, it actually pushes a bowel right here up out of my pelvis and I can just avoid it with radiation. It's just not in the pelvis. It's not gonna be in my field. When that bladder is empty, now the bowel is falling down and it's gonna get more radiation dose. The bowel, all of this is now falling down right into my pelvis, right where I'm trying to treat. You're gonna get more dose of the bowel, more side effects, short-term and long-term for your patients. So that's really important. I did wanna show some different plans. I mentioned 3D conformal versus IMRT. So this is a four field box, 3D conformal plan. This is the probably 95% dose. And then this is showing the 50% dose and you can see the fields come in. So it's called a four field box because there's four fields in a box like formation and the dose really covers everything that's centrally in the pelvis. This red here, that is the 95% dose. It's fully covered. You're not sparing much of the bladder. You're not sparing much of the rectum, but you're hitting your tumor. When you do IMRT, what you see in CND here, you see we're really scooping the dose out of our bladder. We're scooping the dose out of our rectum. This is our 99% dose here, but it's not like the dose just gets there magically. It goes through all this normal tissue as well. This is the 30% isodose line. You see dose coming in from 360 degrees. That dose has to get in there somewhere, but the high dose is spared out of your organs much better. But like I said, when you do these techniques, the concern is that you're gonna miss your target. So you need to be generous with your margins and you need to have good image guidance. So just a brief treatment summary. Cervical cancer is often treated with the definitive radiation. We give 1.8 gray times 25 fractions for 45 gray. I have the target listed here, but we won't go through details. When there are enlarged lymph nodes, either that are active on PET or just enlarged by CT, I do wanna boost them. I do what I call a simultaneous integrated boost where I give the lymph nodes just a slightly bigger dose per treatment than I give the full volume. I often give 2.3 gray per fraction to a total of 57.5 gray. And then I just wanna re-emphasize, you must account for uterus motion with bladder and rectal filling and emptying. You do not wanna miss your tumor. So the goals of radiation therapy often are definitive. We're trying to cure patients, but we also have to think about palliative roles of radiation. One of the reasons I got interested in radiation oncology is because I saw the magic of a patient with an extreme bone pain that was so extreme. It was one of the hardest things I've ever watched as a medical student, and radiation magically took it away within hours. We really play a really important role with palliation. It's also extremely effective for bleeding. Any vaginal bleeding that's uncontrollable, you should really talk to your radiation oncologist. Just a few doses can often stop that bleeding. And then I also think of palliation in terms of preventing morbidity as well. Uncontrolled cancer in the pelvis can lead to some of the worst quality of life outcomes, such as fistulas, rectovaginal fistulas, or vesicovaginal fistulas, or even bowel vaginal fistulas. Many of you on this call probably have experience with these and know that these are some of the worst outcomes for our patients, and we should do our best to avoid them. I'm gonna wrap up there right on time and turn it over to Kayla, who's gonna talk a little bit more about side effect management. Sounds good, thank you. Okay, scoot in the frame here. We're in the same room, so. All right, hi, everybody. So yes, part two of our talk, side effect management for patients receiving RT for gynecologic malignancies. So in order to understand side effects, first, a little summary again on radiobiology. Dr. Venkat talked quite a bit at the start of how radiation can damage DNA and also regular cells. But regular cells have the ability to heal, but you still get some side effects. So radiobiology is understanding how radiation therapy works, and it requires, this requires basic understanding of radiobiology, which is the branch of science that deals with the action of ionizing radiation on biological tissues and their cellular and molecular components. Just as Dr. Venkat said, direct DNA damage as well as indirect DNA damage can occur, and it can occur over time. So side effects are a result of this. Both malignant cells as well as regular healthy cells can be damaged by radiation, which leads to side effects. But again, healthy tissues do have the ability to heal themselves. Radiosensitivity is a really interesting topic. This is something you could have an entire talk on, and it's something I get kind of excited about. But in summary, all tissues have a certain susceptibility to radiation. Some cells are very heavily influenced by radiation, and other ones are pretty resistant to radiation. And so radiosensitivity is the innate sensitivity of cells, tissues, or tumors to the effects of radiation. And it's a relation between the turnover rate of cells and the sensitivity to radiation. The higher the turnover rate, your cells that turn over really quickly, such as mucosa or epithelium or like gonads, they're incredibly susceptible to radiation. Versus something like bones or connective tissues, they turn over at a much slower rate, so they're a little bit more resistant to the effects of radiation. Radiosensitivity of tissues and where you're treating in the body can be a main predictor of RT-related side effects. So factors that influence radiosensitivity, again, the speed of cell division. The faster cells turn over, depending on what tissues they're in, the more radiosensitive they are. And you usually see those side effects pop up first. Your bladder, your urethra, like at the lining of the mouth, if you're treating somebody in their head and neck, those cells break down quickly because they turn over very quickly. So slower cellular turnover, again, more radio-resistant. Presence of oxygen can also affect radiosensitivity. The presence of oxygen enhances radiation effectiveness. Hypoxia can lead to decreased radiosensitivity, such as setting up necrosis. And then cellular differentiation, the less differentiated cells are, the more radiosensitive and vice versa. So I made a chart out of just literature that's out there of kind of categorizing the different tissues and how sensitive they are to radiation. So from very radio-resistant up to highly radiosensitive. So from radio-resistant, you've got muscles, mature bones. Pediatrics falls under a different category because those bones are growing. But mature bones, muscles, and connective tissues are fairly radio-resistant. Mildly radiosensitive, brain, heart, peripheral nerves. And then starting to get more sensitive to radiation is the skin, kidneys, liver, lungs, vasculature, and growing bones. And then highly radiosensitive, again, mucosal, mucous membranes, GI epithelium, salivary glands if we're treating a head and neck patient, bone marrow, lymphatic tissues, erythroblasts, lymphocytes, gonads, and also embryos. So there's acute versus a chronic side effects from radiation. Radiation changes happen over time, and that damage to DNA happens over time. So most side effects are acute, and most of them resolve themselves when the radiation is done. Usually when a patient's on external beam radiation, average onset for in the pelvis, since we're discussing gynecologic malignancies today, about 10 to 14 days is usually when side effects are really kind of in full swing. First couple of days, patients usually feel okay. Again, there's always exceptions, but once that dose starts to build, especially when you factor in concurrent chemotherapy, the side effects do start to build. The side effects can continue for two to four weeks after RT is complete, but most are self-limiting. For the late and chronic side effects, which we'll break down in later slides, the radiation changes can continue over time, and some late side effects can occur that can last for even years, or even permanent in some cases. So side effects, acute side effects to the pelvis. And again, note that this is to any treatment in the pelvis. This can apply to somebody with rectal cancer, prostate cancer, GYN cancers, as well as bladder. Radiation side effects are specific to the region being treated. But acute side effects in the pelvis for the gynecologic population, fatigue and anxiety and depression, that happens a lot. Fatigue is very frequently reported during radiation. It often doesn't depend what part of the body we're treating. Patients report being tired. A lot of mixed literature on why this is. Lots of things out there, lots of different hypotheses, but patients get tired, and we will have a slide on that. Anxiety and depression, those are obvious. Those go hand-in-hand with stress and cancer diagnoses, and our patients need a lot of support. And it also gets compounded whenever they don't feel good, and that can make anxiety and depression obviously much worse. Dysuria or cystitis. The bladder is very sensitive to radiation, so you can get that urinary burning or frequency. Nausea and diarrhea, especially when they're getting concurrent chemotherapy. Sexual dysfunction, skin reaction, especially if the vulva or the lower vagina is receiving that dose. If the tumor is in that area, the skin does need to get the dose because the tumor is right there, and the skin will react, and it can actually be very painful. Late side effects of being treated in the pelvis. Vaginal stenosis and fibrosis. The vagina, it can narrow and develop fibrosis over time. And there's something we can actually do about it called vaginal dilation, which we'll talk about in another slide. What happens is if the walls of the vagina are not kept open, they will narrow, they will become hardened, they will stick to themselves, or adhesions. And those adhesions can make pelvic exams very challenging, they can lead to bleeding, pain, and just impaired function of the vagina. So vaginal dilation is very important, and we will speak to that. Chronic cystitis, chronic proctitis again can happen. Weakening of pelvic floor muscles. Formation of fistulas is rare but serious, and small bowel obstruction. So fatigue. Kind of go through the side effects one at a time. Fatigue is frequently reported in patients receiving radiation regardless of where you're treating them. Things that make fatigue worse. Concurrent chemo. It works well for its purpose, but it makes patients not feel good, and it worsens fatigue. Nutritional deficiencies, especially if they're having nausea and diarrhea, their electrolytes start getting out of balance, they start getting dehydrated, that will make fatigue worse. Anemia, especially from concurrent chemo, or if they're having a lot of blood loss from their pelvic tumor, that can lead to fatigue. Sleep disturbances. Again, emotional distress, anxiety, or depression. And comorbidities. So managing fatigue during radiation. What do we tell patients to do? We need to assess for and address treatable causes, such as the anemia. If their hemoglobin gets below eight, either we or their med-onc can transfuse PRBCs. Insomnia. Pain. Helping address their pain in different ways. Nutritional deficiencies, nausea, or diarrhea. Some of these can be corrected with altering their diet, with medication, so we will counsel them. Encouraging regular sleep-wake cycles and limiting naps is good as well. We want them to rest, but not stay in bed, because that also will make you more tired. And we encourage a balance of physical activity and rest, not complete elimination of physical activity. We say, get outside, go around the block, walk the dog, listen to your body, but try to keep moving. And then there's always the opportunity for non-pharmacologic interventions, such as meditation, relaxation, aromatherapy, family support, friend support. And of course, even though our lives are very busy, balancing schedule or obligations as much as possible during treatment. So anxiety, depression, and emotional distress are very, very real, and they are commonly reported in patients receiving cancer diagnoses and treatment. It's important for us to remember as nurses and as healthcare providers that our patients are often experiencing the highest moment of stress that they may experience in their lives, or one of them, while they're underneath or under our care. So slowing down, being present with our patients, and being empathetic and supportive in the moment can make such a tremendous difference in the patient's experience. And having access to nurses regularly can be incredibly comforting for patients. Social workers are great. If you have access to them, they are wonderful. Our social worker is like a walking human miracle. She's just relaxing to be around, she's relaxing to talk to, and she really does amazing things with our patients. Therapy referrals, support groups, all very helpful for patients, and personal support networks. So dysuria and cystitis management during radiation. This happens with external beam, this happens with brachytherapy. It's frequently experienced by those receiving radiation to the pelvis because the bladder will get some dose, especially if the tumor is right next to the bladder or invading the bladder. So the cells of the urethelial lining in the urinary tract are very radiosensitive and urination can start to hurt. It can be burning frequency urgency. So tips, promote hydration. A lot of patients, I find this a lot for some reason in our patients getting prostate treatment, they tend to not wanna drink because it burns. And it actually makes your urine more concentrated, more acidic, which makes it burn worse. So we always encourage them, drink, drink, drink water. Minimizing spicy or acidic food or drink intake does make a difference. They're not on any restrictions, but if they're having burning, your juices, your berries, your coffees, spicy stuff, eliminating those from the diet temporarily will really help. And I had a mystery patient once who was having burning, we tried everything, crazy burning, and I had a light bulb go off after a couple of days. Now I know to look for it, but cranberry supplements are something patients take that are into holistic treatment because it's good for your urinary tract. And this patient actually, his wife was giving him lots of cranberry supplements because he was having so much burning. He was taking more and more of them. They are good for urinary health, but not after radiation for a little bit. And as soon as he stopped those, his burning went away. So watch out for cranberry. It's very good for you, but it's not good for urinary burning after radiation. Utilizing medications such as anazapyridine to help relieve discomfort can turn the urine bright orange. Always counsel patients on that so they don't get startled. And of course, ruling out UTI with UA. We don't want to miss a UTI, but a lot of times they don't have an infection, but we'll make sure. So nutritional issues and managing nausea during RT or chemo-RT. It occurs frequently, especially when patients are receiving concurrent chemotherapy. And as we all know, nausea can lead to dehydration, nutritional deficiencies, electrolyte imbalances, especially potassium, worsening anxiety or emotional distress. It just, it's all kind of one big circular thing. So tips for managing nausea is several small meals a day, sip on fluids throughout the day, consume bland foods that are easily digested like crackers or dry bread or, you know, those types of things. Prescriptions such as undansetron or prochlorperazine. Every time I try to say that I get stuck on it. Also, you can use metoclopramide or Reglan, but it's not our first go-to because it can promote GI motility. So if diarrhea is present, it can trigger bowel movements. That's why it works so great to migrate feeding tubes where you need them in the stomach, but it can trigger bowel movement. So I usually will start with undansetron before I give Reglan. And then use of ginger or peppermint involving a nutritionist. Those all can help with nausea. So diarrhea can occur as well. We're treating in the pelvis. There's bowel in that area. And despite our best attempts to avoid bowel, as Dr. Venkat was talking about, you know, the patients do still get diarrhea and it can also be from the chemotherapy. So tips, promote hydration. Again, limit high fiber foods, such as even though they're healthy for you, limiting, you know, beans and vegetables and, you know, raw fruits until the diarrhea gets better because they can promote diarrhea further. Limiting dairy, alcohol, using medications like gloperamide. And then especially if they're being treated in their vulvar region or their lower vagina and they're having that skin reaction, promoting good hygiene as much as possible if they're having frequent bowel movements. Even if they don't have skin breakdown. For some of our older patients who can't clean themselves very well, hygiene is something to consider as well. So sexual dysfunction occurs in our GYN population. Acute side effects include epithelial inflammation in the vagina and the urethra, decreased libido, and your ovaries are very highly sensitive to radiation. Chronic side effects, again, vaginal stenosis, infertility. Some patients, especially younger patients, may consider ovarian transposition where the ovaries are moved out of the radiation field for fertility preservation. That is an option for some patients. Vaginal adhesions, and then again, we always want to do pregnancy screening prior to starting RT. Pregnancy testing is highly recommended. Practice caution with using pregnancy testing waivers, but of course there is a time where the patient says, there's no way I can be pregnant. I don't want to test. I'll sign a waiver and, you know, it will be appropriate. But we do encourage testing. So supporting patients after RT, minimizing vaginal stenosis and adhesions is one of the main things that nurses and providers can do by use of vaginal dilators on a regular basis or participating in intercourse if desired. It helps maintain the function of the tissue and helps ensure thorough and more comfortable future pelvic examinations because it prevents the adhesions. Prior to radiation therapy, again, fertility options should be discussed with patients and referrals placed if there is time. You know, sometimes the treatment time is so critical that there is a risk to waiting to then do fertility preservation first. So it's case-by-case basis, but there are options. And then after radiation therapy, additional resources exist, such as menopause referral clinics, fertility clinics, and therapy and emotional support for individuals or couples. All right, probably one of the most important slides, Dr. Venkat is nodding on the side here. I agree. You will see mixed data on this, but we completely disagree. It is incredibly important to use dilators in the care of our patients. It applies to any patient with a vagina that has had a course of pelvic radiation therapy, including not only GYN patients, but rectal cancer patients or patients with RT to the bladder or other tissues in the pelvis. The consistency of using the dilator is key for success, and it should be done long-term. We always tell patients to do it indefinitely until the physicians tell them that they can stop, which, what would you say is your average for stopping? I think it depends a little on what you're treating. If you've treated definitively for cervical cancer per se, you're gonna be giving a much higher dose to the vagina than if you're treating adjuvantly. So for my adjuvant patients, I typically think I can get patients off by a year and follow up, but for my definitive patients, it's really variable. It can honestly be never. Some women need it for life. And like Kayla said, case by case. Thank you, Dr. Minkett. It's so helpful having a doctor here right next to me. Patients should base the size that they use on comfort. So it comes in a kit and it has all these different sizes that just kind of fit inside of each other. And using the dilator should cause the sensation of stretching, but should not be painful. And they usually, we tell them to start maybe with the second to smallest if they're able to tolerate it, and then increase only if it's not accompanied by pain. They do not need to increase to the largest size. It's usually somewhere kind of in the middle. That is a good long-term size. We teach patients to wash them according to the directions. Most of the time it's soap and water and lay it to dry. And then using it in the shower is helpful for some patients. The water kind of lubricates it. And again, you may see stuff out there that says it's not effective. We completely disagree, and we strongly encourage this for all patients getting RT to the pelvis that have a vagina. So additional pelvic care after radiation, bathing, sitz baths can be very soothing after radiation therapy, especially after brachytherapy if we use interstitial needles. As long as the skin is intact, little needle punctures don't count, but as long as they're not having a big skin reaction. If skin is not intact, we advise them to avoid hot tubs, chlorinated water, or swimming in natural bodies of water until it's healed. And then just good routine skincare, cotton underwear. If incontinence is present, changing the pads or the diapers regularly. And then vaginal dryness can occur after radiation. So lubricants can be helpful, water silicone-based or oil-based are available. Also there's vaginal moisturizers, which can help maintain moisture in the vaginal and vulvar tissues. And then hormonal replacement has a place with some patients, but should be discussed with the Gynonc team to assess for other risk factors. So we'll just add with that, there is data that hormonal replacement is underutilized particularly for cervical cancer patients. So this is something you should discuss with your patients and assess whether it's safe, because it can actually help increase a patient's life expectancy hormonal replacement. So just think about it. Thank you, Dr. Brinkett. Skin reaction during radiation. So it occurs at a higher frequency when the vulva, lower vagina, groin are in the target treatment area, especially if the tumor is right there, because the skin has to get some dose and it will break down, but it does heal. It can be very painful. It can get infected and it can lead to treatment breaks or delays. Also anatomical challenges of the pelvis. There's a lot of folds naturally in the skin in that region. And especially if somebody is obese, you start to get more folds and more moisture. So high amounts of friction in that area. So it's a tricky area to treat skin reactions, but it can be treated and it's case by case. We do like regular general skincare tips, but a lot of these are a little different for the pelvis. So things we tell patients in general is during RT, avoid sun exposure, avoid picking or itching the skin, avoid shaving, avoid use of hot or cold packs, and then minimize friction. And then if it's a vulvar skin reaction, again, it'll be case by case. Sometimes you can put a dressing on it. Sometimes you can't. There are some creams that we can use, but it's really case by case basis. And it's important to educate these patients before it happens, during, as well as after, because it can be pretty startling for all side effects. So if they have more knowledge that they know going into it, they're gonna report the side effects earlier because they're going to anticipate or know that it's normal and we might be able to intervene before it gets too severe. Use of approved creams or moisturizers during the course of RT is good for the skin. If the skin is dry or intact, we'll use like a petroleum jelly or Aquaphor or Vaseline. Moist desquamation, we need to do wound care dressings. And then there's certain creams that contain silver that are good for healing. And then there's some anti-microbial, but don't want to use it during radiation, but we'll start after. So pain is commonly experienced in the oncology population. Pain is very individualized, should be taken very seriously and with compassion. We want to make sure we promote a multimodal pain approach to try to minimize side effects from any one category. Don't forget about the power of acetaminophen or non-narcotic pain medications, as well as sometimes they need narcotic pain medication, but they have a lot of side effects. Holistic approach to pain management as well, important to encourage and promote emotional support, support from family and friends, pets, hobbies, anything that makes them happy can all play a part in pain control. Additional late side effects, these are rare, but they're very serious, are rectovaginal fistulas. There's a couple other types of fistulas. It is a rare risk with chemo-RTs to the pelvis. And because those tissues have been radiated, they don't heal as well in the future. So surgical repair, it can be tricky due to impaired wound healing if it's within the radiated field. So these patients can get literally a hole between the rectum and the vagina. They might have stool coming out of their vagina. It's rare, but you do see it. And these patients may need a surgical diversion. I'll just add, for many of you on the call, it is rare in countries where we screen for cervical cancer with pap smear programs or other screening methods. It is not as rare, unfortunately, in countries that don't have access to screening methods or access to preventative care, such as HPV vaccines. So we are not the expert on fistulas. I think many of you out there know more about this than we do. In this here, we tend to divert either with a colostomy or a suprapubic catheter or nephrostomy tubes when fistulas do occur. And then also small bowel obstruction is another severe, rare, but it can happen late side effect. Any patient having radiation or surgery in the pelvis has a lifelong risk for SBO. And so educating patients on the risk and signs of SBO so they know what steps to take if symptoms arise. As Dr. Venkat put it when we were building this talk, you know, a stomachache or flu-like symptoms is going to be needed to be taken a little bit more seriously in somebody with this history than somebody who does not have this history. Other additional late side effects, pelvic floor muscle weakness. Patients can be encouraged to do Kegel exercises or pelvic floor PT. And then chronic proctitis can occur three plus months after RT and continue long-term. There's dietary medication modifications that can be done. And then rectal bleeding can occur, which can be managed medically, but sometimes do require argon laser coagulation. So when do we educate our patients? Again, we need to educate them multiple times. Education should be provided at minimum at the time of consultation, at the start of treatment, and during weekly check-ins we have with them called OTVs or on-treatment visits throughout their course of RT. And then side effects should be presented as being expected to minimize fear and give patients information and tips. And they're going to be more likely to report them to you because they know that it's within what is expected and there's something we can actually do about it. Multiple educational formats should be used, verbal, written, online, if they have access to a computer. And then open-door policy with nursing in the clinic during the daily RT courses is great. And then again, OTV with the physician weekly. So in conclusions, patients receiving treatment for gynecologic cancer have complex care needs. Nurses play an irreplaceable role in providing education, support, and bedside care to patients undergoing GYN, radiation therapy, and general cancer care. And nurses can empower patients receiving pelvic radiation as they process and progress through what is likely one of the highest stress periods of their lives. Symptom-based clinical management, case-by-case basis, proactive healthcare, emotional support, empathy, and compassion are critical for these patients. Lots of resources out there. IGCS has been amazing. So many good things on their site as well as their new nursing certification program. And then some other radiation resources as well like ASTRO, ESTRO, American Brachytherapy Society, and then ONS as well. Next webinar, we will talk about brachytherapy. We love it. It's wonderful. We use it to treat and treat patients with gynecologic cancer every single day where we work. We believe in it and it's in the data. It works great. Several techniques and applicators are used. And yes, it has a place in almost all gynecologic cancer treatment. So stay tuned. Are there any questions? Before we go to questions, I would just like to add that I think one of the main reasons I love my job is the multidisciplinary care of gynecologic oncology. I'm working with our gynecologic oncologists, our medical oncologists, radiologists, pathologists, nurses, therapists. It's really makes it a team-based approach. I'm working with brilliant and caring people every day and we all have this same goal to take care of our patients the best of our ability. And it's a real joy. So thank you for having us. Yeah, thank you very much. Thank you so much, Pooja and Kayla. Some excellent information there and some great practical ideas for us caring for our patients. And I agree, it really is a multidisciplinary team approach looking after these patients with gynecological cancers. So please, if you have any questions, enter them in the Q&A function at the bottom of your screen. But I might start us off with a question. I'll start with you, Pooja, if that's okay. My first question is, you talked about radiation fractionation and you said we didn't need to know the formula or anything like that, but how is it decided what's the total gray that people receive and how much per fraction? And is it based on the size of the tumor, the location of the tumor? It's based on a lot of different research, where we used to just degradate cells. We'd radiate different cancer cells, we'd radiate different normal tissues and get a sense of how they respond to tumors, how much dose needed to eradicate specific tumors, but also how much the normal tissues can tolerate. So it depends where I'm treating, what the normal anatomy is around. And we do know that microscopic cancer cells, this is very general, need a certain amount of dose. Typically, that's about 45 to 50 gray. Macroscopic cancer cells, tumors that I can see either on imaging or on exam that are larger need cervical cancer, for example, needs at least 85 to 90 gray. So it really just depends on the situation, but we really think about it as microscopic, mid-dose, 45, 50, macroscopic, 70 to 90 gray. With brachytherapy, we can actually get 90 gray into these tumors, which is why we do have some pretty good outcomes. Right, thank you. So would that be an example of brachyboost also, you're saying, that's how you're able to get to? Exactly, because with external beam, it's very difficult for us to get over 70 gray in general, but with a brachytherapy boost, we can often go to 90 gray or higher. Perfect. Taylor, a question for you about the use of vaginal dilators. You talked about using them on a regular basis and possibly lifelong or long-term. Are there any published guidelines that we can follow in relation to the use of vaginal dilators? Because people often ask, how often should I be using them? Do I have to do this for life or is it just a certain period of time? And how do you provide the education to women around the use of vaginal dilators? Is it face-to-face or what other sort of formats can you use to provide education to these women about the use of vaginal dilators? Yes, okay, so there's mixed data out there and that's why we wanna acknowledge that because you'll see all sorts of different things from it doesn't work at all to this is really important. We have always treated it as very important and we see a difference when patients aren't using them. So we believe in it wholeheartedly. Whenever we train patients to use it, we do do it in person and we give them a kit and then we have a sample kit and we show them how it goes together and we give them instructions. And then there's also some manufacturer instructions that we will send as well with instructions for how to use it. They're not specific to radiation therapy. They're for multiple different uses, but we kind of tailor it to our purposes. What are your thoughts on dilators, Dr. Venkat? I have so many thoughts. She has a lot of thoughts. I think it's really important to bring it up at consult. This is a late effect that will happen if we don't prevent it. So if you're doing a consult as a radiation oncologist, you need to bring it up. And the worst thing you can do to your nursing team is not mention it and have them walk in like after treatment's done and start talking about these weird dilator things they're supposed to put in their vaginas. They don't love it. They wanna be done with everything and then you come in with this thing. So what are you talking about? So I bring it up on day one. I think it needs to come from the physician as well. I also, I explain the anatomy. Like why am I asking you to do this? So I explain it. I make sure they understand why I'm asking them to do it. And a lot of patients tell me, well, I'm not sexually active. So why does this matter to me? First of all, I tell them, you may not be sexually active now, but you do not know your future. But I also point out that it's really important for exams so that we can find recurrences as soon as humanly possible because we will find them on exam before we can see them on imaging. Even the magical PET scans and MRIs, we will find them sooner on exam if we can do a proper vaginal exam. Thirdly, I say, and this is a new thing I've really started stressing. It's just important for the health of the tissue. Just like we worry about the health of the brain or the health of the heart, the vagina matters too. It is an organ and we should respect it and value it. So I did come up with my own dilator protocol talking to patients. So I really do recommend doing it in the shower. I find that that's really mentally easier for patients rather than, hey, let me go do my weird cancer thing right now for five, 10 minutes. I have them start doing it every day in the shower just as like, hey, there's another weird thing I have to do in the shower and try to get it into a general routine. So I have them do it every day. They get really used to doing it. I've had patients take their dilators on mountain treks up Mount Kilimanjaro. Really? Yes, yes. I've had a patient do that. If you talk to your patients, they will do this. The rate of use should be a hundred percent. And there is literature out there that is reporting 50% use. That is just unacceptable. Yeah, absolutely. It's all about normalizing it, isn't it? Yeah. Dr. Venkat could give an entire talk on vaginal dilators. We might hold you to that one. Yeah. I have a question actually, just talking about the showers and those sorts of things. Are there recommendations for temperature? Because I know you said no hot or cold packs, but then what about other like, you know, heat application or why no heat or cold application? That was a few questions. I apologize. With our skin reactions. Yeah. We just know that the extreme hot or cold can aggravate the skin even more. It can also affect kind of drawing immune cells to the area in different ways or not. And we find it's just better to keep things a little tepid during radiation. There's some more scientific answers to that that I won't get into today. And that's only during treatment and when things are aggravated. After that, I think it's fine to do. And were there more questions there? I have a question for you. Okay. What are your thoughts on antioxidants during radiation therapy? We do not recommend patients to take large amounts of antioxidants during radiation because as I mentioned in the beginning, we actually use free radicals created by radiation to kill cancer cells. So in theory, taking a lot of vitamins and antioxidants and going on crazy like juice or fruit fasts, it's just not ideal. And all the randomized data during radiation, we didn't allow patients to do that. So I just encourage my patients, and in LA, we have many people who are on many of these things. So I ask them to please stop during treatment. As soon as we're done with treatment, we can go back on them. And I kind of explained that we actually want those free radicals to work in our favor. Absolutely. Another question to both of you, actually. You didn't mention lymphedema as one of the side effects of treatment. And obviously, women are having radiotherapy to the groin nodes. Or even if women are having pelvic radiotherapy, whether there'd be some lower limb lymphedema or vulval area lymphedema, do you see much of that? And what sort of management techniques do you use for that? Is that more from the cancer than the treatment, correct? Or can we aggravate it? We definitely can, particularly with vulvar radiation or vaginal cancers involving the distal vagina or cervical cancers involving the distal vagina. Anytime we have to treat the inguinal nodes or the groin nodes, that's when we have that greatest risk of lymphedema. I find it to be pretty rare, to be honest, with the pelvis, even when those nodes are surgically removed and we radiate. The risks are pretty low, but when it happens, which it does, I do generally recommend, my first go-to is physical therapy. I think that can help a lot. Other than that, obviously like compression stockings and elevation, the usual things, I don't have any great, great solutions. Other than that, I've had very few patients with severe lymphedema on the legs though. It's much less common than with breast cancer, for example, in the arms. Absolutely, thank you. Those were some great questions. I think you answered all of them within some of the other responses too. So that's great. Does anyone else in the audience have any questions or anything that they're just wondering, wanna ask Kayla and Dr. Venkat? I was gonna say, if you do pop any questions in, we can always get those answered offline after today's webinar and send the answers through as well. Yes, we're happy to answer anything, even more technical or more, whatever, any questions you have, please feel free to reach out and we'll get back to you via email. There is one question that's just popped up. How do you prevent long-term radiation proctitis? Great question. That's basically our job as radiation oncologists. And really the way to do that is to minimize the dose to the rectum as much as possible. And there's a number of ways we can do that. Some of which we talked about today using intensely modulated radiation therapy and curving that dose out of the rectum, using daily image guidance and not treating. If the rectum is really full of air or stool and it's going right up into your target, don't treat. Get your patient off the table, do what you need to evacuate and get the patient back on the table. They don't love it, but you explain why you're doing it and they're usually on board. And the number one thing you can do is interstitial brachytherapy. So doing high quality targeted brachytherapy because that is where you're gonna, half the dose is coming from this treatment and this procedure. If you can spare the rectum and the new data says we really need to push that dose on the rectum really low, less than 65 grade total. If you do that, if you can spare the rectum, you will decrease that risk of radiation proctitis. And other than that, there's not really a way. Once that radiation has damaged the rectum, you can't prevent it other than doing high quality radiation. I see an add on to that question also in regard to radiation cystitis. Well, I'm gonna say much of the same answer for that. It's really about the radiation. Luckily the bladder can tolerate much higher doses of radiation than the rectum and bowel. So you can go up to 80 grade total dose to that bladder, just do good radiation, do good brachytherapy. I don't think there's much a patient or medical management to prevent that. It's really radiation damage that causes it. I do have patients who struggle with urgency post radiation, either bladder or bowel. I find pelvic floor rehab has been extremely valuable for my patients. If urgency is their biggest complaint post-treatment. Do you have resources if you don't have PT available to you? Are there resources that you go to that you're able to give the patient pamphlets that say, look, this is kind of how to practice it, how to explain? I give all my patients, I'll put together Kegel, like very basic Kegel exercise information with some resources as well for more technical and even some video links. I think maybe moving forward, one thing I could do is I do work with five very skilled physical therapists who specialize in pelvic floor. I'd be happy to reach out to them and see if they can give us some more detailed, specific recommendations or resources. That's a great idea. Great, well, I think that covers a lot of information today. Thank you all for joining and we look forward to joining you again soon. Yeah, I would like to thank our expert presenters, Kayla and Dr. Venkat, Pooja Venkat and my co-chair and we are excited to share that we have a future nursing webinar that will cover brachytherapy in depth, which I know Kayla and Dr. Venkat are even more excited than I am. The recording of today's session will be available on the IGCS Education 360 Learning Portal tomorrow. We invite you all to come and complete the IGCS Nursing Certificate Program. We in the IGCS Nursing Workgroup have developed a self-paced program that provides nurses with the necessary knowledge to provide evidence-based nursing care to patients with gynecologic cancers and empowers them to advocate for the best possible health outcomes. We wish you all continued health and safety. Stay well.

radiation treatment

gynecological malignancies

nurses

patient education

side effect management

external beam radiation

brachytherapy

ionizing radiation

cancer cells' DNA

treatment protocols

pelvic radiation therapy