Radiation Oncology Nursing Guide

Ionising Radiation Types

X-rays & Gamma Rays

Electromagnetic, no mass or charge. X-rays from machines (linear accelerator); gamma from radioactive nuclei (cobalt-60, iridium-192). High penetrance — treat deep tumours.

Electrons

Charged particles; limited depth penetration. Ideal for superficial tumours (skin, chest wall). Bolus material used to push dose to surface. Energy 4–20 MeV.

Protons

Heavy charged particles; Bragg peak deposits maximum dose at tumour depth with minimal exit dose. Used for paediatric CNS, skull base tumours. Available at specialist GCC centres.

External Beam Radiotherapy (EBRT) Techniques

3D-CRT / IMRT / VMAT

3D-CRT — Conformal beams shaped to tumour volume; standard technique.
IMRT — Intensity-modulated; dose sculpted around organs at risk. Requires daily imaging (IGRT).
VMAT — Volumetric-modulated arc therapy; gantry rotates continuously, faster delivery (<2 min).

SBRT / SRS

SBRT (Stereotactic Body RT) — Extracranial; 3–5 high-dose fractions (e.g. 54 Gy in 3 fractions for lung). Lung, liver, spine, prostate.
SRS (Stereotactic Radiosurgery) — Intracranial; single/few fractions. GammaKnife or LINAC-based. Brain metastases, AVM, acoustic neuroma.

Fractionation Schedules

Schedule	Dose/Fraction	Fractions/Day	Common Use
Conventional	1.8–2 Gy	1 (Mon–Fri)	Most solid tumours
Hypofractionation	2.5–6 Gy	1	Breast (40 Gy/15#), prostate
Hyperfractionation	<1.8 Gy	2	Head & neck (CHART)
SBRT	7–20 Gy	1 (3–5 total)	Lung, liver, spine, prostate
SRS	15–24 Gy	1	Brain metastases
Palliative	8 Gy	Single fraction	Bone pain, bleeding

Radiobiology: The 4 Rs

Repair

Normal cells repair sublethal DNA damage between fractions. Rationale for fractionation — protects normal tissue. Tumour cells repair less efficiently.

Reassortment (Redistribution)

Cells in radio-resistant phases (S-phase) redistribute into more sensitive phases (G2/M) between fractions. Multiple fractions exploit cell-cycle heterogeneity.

Repopulation

Accelerated tumour cell proliferation during treatment. Prolonging treatment course >5 weeks may allow repopulation — nurse must minimise unplanned gaps/breaks.

Reoxygenation

Hypoxic tumour cells are 3× more radio-resistant. Fractionation allows reoxygenation of hypoxic core as outer cells die. Anaemia reduces effectiveness — monitor Hb.

Treatment Planning Process

CT Simulation & Immobilisation

CT Simulation: Patient positioned as for treatment; CT scan acquired for dose planning. IV/oral contrast may be used.
Immobilisation devices: Thermoplastic shell (head & neck, brain), wing board (breast/thorax), knee/foot stocks (pelvis/lower limb), vacuum bag. Reproducibility is critical (<3 mm).
Tattoo marks: Small permanent ink dots (2–3 mm) placed on skin to align patient with laser system daily. Explain cultural/religious sensitivities in GCC — document consent.
IGRT: Image-guided RT — daily imaging (CBCT or kV X-ray) before each fraction to verify position.
Target volumes: GTV (gross tumour) → CTV (microscopic spread) → PTV (setup margin). Organs at risk (OARs) delineated and dose constraints applied.

Nursing role at simulation: Consent verification, patient education (process, duration, marks), allergy history (contrast, thermoplastic), positioning assistance, privacy/dignity maintenance, answer questions about daily treatment routine.

CTCAE Grading Overview (v5.0)

Grade 1 — Mild

Asymptomatic or mild symptoms; clinical/diagnostic observation only; no intervention indicated.

Grade 2 — Moderate

Minimal, local or non-invasive intervention indicated; limiting age-appropriate instrumental ADL.

Grade 3 — Severe

Severe or medically significant; limiting self-care ADL; hospitalisation may be indicated. Report to oncologist — treatment break may be required.

Grade 4 — Life-threatening

Life-threatening consequences; urgent intervention indicated. Treatment interruption and emergency management.

Radiodermatitis — Skin Reactions

Grade 1 — Faint erythema / dry desquamation

Aqueous cream / emollient (unperfumed) — apply away from treatment times
Gentle washing with mild soap
Loose cotton clothing over area

Grade 2 — Tender/bright erythema, patchy moist desquamation

Mepitel One / Mepitel Film silicone dressing
Flaminal Forte for exudate management
Aloe vera gel (non-comedogenic)
Avoid sun, deodorant, shaving in field

Grade 3 — Confluent moist desquamation, skin folds, bleeding

Urgent referral to radiation oncologist
Treatment pause likely needed
Mepilex Border / Aquacel Ag dressings
Analgesia for pain management
Consider tissue viability nurse referral

Grade 4 — Ulceration, necrosis, full-thickness skin loss

Immediate medical review — may require admission
Wound specialist / plastic surgery input
Treatment suspended

Head & Neck RT Nursing Care Bundle ▶

Mucositis Management (WHO Grade 0–4)

Grade	Presentation	Nursing Intervention
0	Normal	Preventive oral hygiene, fluoride toothpaste, soft toothbrush
1	Soreness, erythema	Sodium bicarbonate rinses, 0.9% NaCl rinses 4–6x/day, cold fluids
2	Erythema, ulcers, able to eat solids	Magic mouthwash (lidocaine/antacid/diphenhydramine), soft diet, systemic analgesia
3	Ulcers, liquid diet only	PCA/IV morphine, nasogastric or PEG feeding, IV fluids, antifungal prophylaxis
4	Cannot eat, severe pain	Hospitalisation, TPN consideration, treatment pause

PEG Insertion Threshold: If >10% weight loss is anticipated during treatment (typically T3/T4 head & neck cancers, concurrent chemoradiotherapy), prophylactic PEG/RIG tube should be inserted before treatment commences. Document baseline weight at each fraction.

Radiation Oesophagitis

Dysphagia — start soft/pureed diet; nutritional supplementation (Ensure/Fortisip)
Proton pump inhibitors (omeprazole) and antacids for reflux
Topical anaesthetic (viscous lidocaine 2%) before meals
Sucralfate suspension coats mucosa — give 30 min before meals
Monitor hydration daily; IV fluids if oral intake inadequate

Xerostomia (Dry Mouth)

Parotid sparing IMRT reduces incidence — document salivary flow
Salivary substitutes (Biotene gel, water-based sprays)
Pilocarpine 5 mg TDS (if residual function remains) — monitor bradycardia
Dental review mandatory every 3 months — high caries risk

Pelvic Radiotherapy Acute Toxicities

Pelvic RT Dietary Management Guide ▶

Radiation-Induced Diarrhoea

Low-residue diet: white bread/rice/pasta, cooked vegetables (no skins), peeled fruit, lean meat, eggs
Avoid: raw vegetables, bran, wholegrain, legumes, fatty/spicy food, alcohol, caffeine
Loperamide 2 mg: after each loose stool (max 8 tablets/day); escalate to codeine if uncontrolled
Hydration: 2–3 L/day; oral rehydration salts if profuse diarrhoea
Grade 3+ diarrhoea (>7 episodes/day): IV fluids, electrolyte replacement, consider treatment pause
Perianal skin care: barrier cream (zinc oxide/Cavilon), gentle cleaning, avoid harsh wiping

Radiation Cystitis

Hydration: minimum 2 L/day to dilute urine
Urine dipstick to exclude UTI (common mimicker)
Alpha-blockers (tamsulosin 0.4 mg) for urinary hesitancy/incomplete emptying
Oxybutynin for urgency/frequency
Avoid caffeine, alcohol, spicy food
Haematuria: monitor; macroscopic haematuria → immediate oncology review

Sexual & Reproductive Effects

Vaginal dryness: topical oestrogen (if oncologically appropriate), lubricants
Vaginal dilator use from 4–6 weeks post-treatment (see Tab 4)
Erectile dysfunction in men post-prostate RT: refer to urology
Fertility counselling before pelvic RT in reproductive-age patients

Radiation-Induced Alopecia

Begins ~2–3 weeks after cranial RT starts
Reversible: doses <40 Gy — regrowth at 3–6 months (texture/colour may change)
Permanent: doses >45 Gy — pre-counsel patient; wig referral early
Head covering — cultural sensitivity in GCC (hijab accommodations)
Scalp care: mild shampoo, no heat, no harsh products

Fatigue Management

Most common symptom — affects up to 80% of patients
Energy conservation strategies: prioritise activities, plan rest periods
Low-intensity exercise reduces fatigue (evidence-based)
Exclude anaemia (Hb <10 g/dL worsens radiosensitivity)
Treat concurrent depression/anxiety
Fatigue persists 4–6 weeks post-treatment (acute) or longer (late)

Interactive Tool: Radiation Skin Reaction Grader

Radiation Skin Reaction Grader & Care Guide

Treatment Site

Skin Appearance

Symptoms (select all that apply)

Long-Term Radiation Effects

Radiation-Induced Fibrosis

Skin/subcutaneous: Induration, reduced elasticity, telangiectasia. Pentoxifylline + Vitamin E may reduce (evidence limited).
Pulmonary: Radiation pneumonitis (acute 4–12 weeks) → fibrosis (chronic). Cough, dyspnoea, fever. Treat with steroids (prednisolone 1 mg/kg).
Bowel: Stricture, fistula, malabsorption. Surgical referral if obstruction. Selenium supplementation under investigation.

Lymphoedema Post-RT

Post-axillary RT for breast cancer — arm lymphoedema risk
Post-groin/pelvic RT — lower limb lymphoedema
Refer to certified lymphoedema therapist early (prevention focus)
Compression garment fitting: Class 2 (23–32 mmHg) for moderate; measure circumference at multiple points
Manual lymphatic drainage (MLD) 2–3x/week initially
Exercise: arm/leg pumping, avoid prolonged dependency
Avoid cuts/infections in affected limb — high cellulitis risk

Radiation Necrosis — Brain

Occurs 6 months–2 years post-cranial RT
Headache, focal neurology, seizures, cognitive decline
MRI: enhancing lesion (may mimic recurrence — MR perfusion/spectroscopy)
Treatment: Dexamethasone (4–16 mg/day); bevacizumab (anti-VEGF) 7.5 mg/kg q3w for refractory cases
Hyperbaric oxygen — 30–40 sessions; may improve outcomes
Surgical debulking if mass effect

Cardiac Toxicity

Mediastinal RT (Hodgkin lymphoma, lung, oesophagus) — accelerated coronary artery disease
Latency 10–20 years; mean heart dose <4 Gy target
Pericarditis (acute), pericardial effusion, cardiomyopathy (late)
Annual cardiac review: ECG, lipid profile, BP monitoring
Left-sided breast RT: DIBH (deep inspiration breath hold) reduces heart dose
Counsel on cardiovascular risk factor modification

Organ-Specific Late Effects

Late Effect	Treatment Site	Onset	Key Management
Hypothyroidism	Neck/thyroid irradiation	6–24 months	Annual TSH; thyroxine replacement if TSH >4.5 mU/L
Radiation Proctitis	Pelvis (prostate/cervix)	Months–years	Sucralfate enemas; argon plasma coagulation (APC) for bleeding; rectal formalin instillation
Osteoradionecrosis (ORN)	Mandible (H&N RT)	Months–years	Dental hygiene pre-RT; avoid extractions post-RT; hyperbaric O2; surgery if refractory
Second Malignancy	Any RT field	10–20 years	Long-term surveillance; mammogram for chest RT; colonoscopy for pelvic RT
Cataract	Orbital/eye RT	1–5 years	Annual ophthalmology review; surgical removal if affecting vision
Avascular Necrosis	Hip/pelvis RT	Years	MRI hip; orthopaedic referral; hip replacement if severe
Lhermitte's Sign	Spinal cord RT	2–4 months post-RT	Usually self-limiting; reassurance; vitamin B12 check
Bowel Obstruction	Abdomen/pelvis	Years	Surgical review; adhesiolysis; endoscopy for stricture dilation

Osteoradionecrosis — Dental Protocol

Pre-RT Dental Protocol (Mandatory H&N RT):

Dental OPG and full examination before RT planning
Extract non-restorable teeth at least 14–21 days before RT commences (allow socket healing)
Fluoride trays fitted — daily application throughout and after RT
Post-RT: avoid dental extractions in irradiated field if possible
If extraction necessary post-RT: inform dentist — 20 sessions HBO pre- and 10 post-extraction protocol (Marx protocol)
Jaw exercises (trismus prevention): Therabite device; open/close exercises 20×, 3×/day

Brachytherapy Overview

HDR Brachytherapy — High Dose Rate

Source: Iridium-192 (activity ~370 GBq); dose rate >12 Gy/hour
Remote afterloading: Nucletron/Varian afterloader — source travels via tube from shielded safe into applicator. Staff NOT present during treatment — zero radiation exposure.
Treatment: multiple outpatient fractions (e.g. cervix: 7 Gy × 3–4; prostate: 15 Gy × 2)
Applicators: ring/tandem (cervix), multi-channel (breast), prostate needles
Patient in shielded room; viewed via CCTV; intercom communication

LDR Brachytherapy — Low Dose Rate

Source: Iodine-125 (prostate seeds), Caesium-137 (cervical)
Dose rate <2 Gy/hour; source remains in patient for days or permanently
Radiation precautions required: Time/distance/shielding principles apply
Prostate seeds: permanent implant; low-activity seeds; patient remains mildly radioactive for months
Cervical LDR: temporary 2–3 day implant; patient in single room; lead screens at bedside

Caesium Implants — Cervical Cancer Nursing

Nursing Care During Caesium LDR Implant

Pre-insertion: Bowel preparation (phosphate enema); IDC insertion; consent; explanation of isolation; leg exercises and DVT prophylaxis teaching
During implant: Patient in single shielded room; lead screen at bedside; limit nurse time at bedside (time principle); stand at foot of bed or shielded position
Restricted mobility: Patient must remain on bed rest with limited hip flexion to maintain applicator position; pressure area care with long-handled tools
Documentation: Nursing contact time log; dosimetry records

Monitoring: Check applicator position 4-hourly; report displacement immediately — do NOT attempt to reposition
Urine output monitoring via IDC (mucositis risk to bladder)
Constipation prevention — stool softeners; avoid straining
Analgesia — patient-controlled or regular opioids
Psychological support — isolation distress; family visits limited by radiation rules
Removal: Source removed by radiation oncologist/physicist; verify source count before and after removal

Vaginal Dilators Post-Cervical RT

Purpose: Prevents vaginal stenosis/fibrosis secondary to radiation. Fibrosis begins 4–6 weeks post-treatment.

Commence 4–6 weeks post-RT completion (or after brachytherapy applicator removal)
Use dilator for 10–15 minutes, 3× per week minimum
Progress through dilator sizes (Small → Medium → Large) as tolerated
Use water-based lubricant (avoid oil-based — degrades condom/silicone)
Continue for minimum 2 years (some guidelines: lifetime)
Document patient education in notes; provide written instructions
Cultural sensitivity in GCC: Ensure female nurse/counsellor delivers education for Muslim patients; explain medical necessity clearly; involve spouse if patient wishes

Radiation Protection Precautions for Ward Nurses — Implant Patients ▶

Time / Distance / Shielding Principles

Principle	Application
Time	Minimise time spent near patient; plan care in advance; consolidate nursing activities to reduce entries; document time spent in room
Distance	Inverse square law: doubling distance reduces dose by 75%. Stand at foot of bed or use long-handled equipment. Maintain ≥1 m distance when not performing direct care.
Shielding	Lead screen (0.5 mm Pb equivalent) between nurse station and patient. Lead apron if prolonged contact. Portable lead shield at bedside.

Specific Precautions by Source Type

Caesium-137 LDR (cervical): Wear TLD/film badge; no pregnant staff; visitor restrictions (no children <16, no pregnant persons); max visitor time 30 min/day at 1 m distance
Iodine-125 prostate seeds: Patient discharged with written precautions; avoid prolonged close contact with children/pregnant women for 2 months; use condom first 2 weeks (in case of expelled seed)
RAI (I-131 thyroid): See Tab 5 — isolation precautions for bodily fluids

Source Displacement Protocol: If applicator/seeds are found displaced — do NOT touch with hands. Alert Radiation Protection Officer (RPO) immediately. Use long forceps to place displaced source in lead pot. Clear area. Restrict room access until physicist confirms safety.

ALARA Principles

ALARA — As Low As Reasonably Achievable
The fundamental principle of radiation protection. All radiation exposures to staff and public must be kept as low as reasonably achievable, economic and social factors being taken into account. Governed by ICRP (International Commission on Radiological Protection) recommendations.

Time

Radiation dose is directly proportional to exposure time. Minimise time near active sources. Pre-plan all care tasks before entering room.

Distance

Dose rate decreases with the square of the distance (inverse square law). Doubling distance → 4× reduction in dose. Use remote handling tools where possible.

Shielding

Lead attenuates X-ray/gamma. Concrete/water for neutrons. Lead aprons (0.25–0.5 mm Pb) reduce dose. LINAC treatment rooms: 1.5–3 m concrete walls.

Radiation Monitoring Devices

Device	Type	Use	Notes
TLD (Thermoluminescent Dosimeter)	Passive	Occupational dose monitoring	Worn on chest/collar; read quarterly; aluminium oxide crystal
Film Badge	Passive	Historical standard; energy-dependent	Largely replaced by TLD/OSL in modern practice
OSL (Optically Stimulated Luminescence)	Passive	Most accurate passive device; re-readable	InLight dosimeters (Landauer); monthly or quarterly
Electronic Personal Dosimeter (EPD)	Active	Real-time dose reading during procedures	Alarming EPD for interventional/brachytherapy procedures
Geiger-Müller Counter	Active/Survey	Source/contamination survey	Used by physicist/RPO; not worn

Unsealed Sources — RAI Nursing Isolation

Radioactive Iodine (I-131) Therapy — Nursing Precautions

Isolation room: Single en-suite room; radiation warning sign on door; lead pot and forceps at bedside
Bodily fluid disposal: Urine, vomit, blood heavily contaminated for first 48 hours. Flush toilet 2–3 times; double flush policy. Use disposable items.
Linen: Store in sealed yellow radioactive waste bag; held 10 half-lives before disposal/laundry
Visitor restrictions: No children <16; no pregnant persons; adults max 30 min/day at >1 m distance for first 3–4 days

Staff precautions: Wear TLD badge; pregnant staff must not care for I-131 patients; minimise room time; gloves and apron for all contact
Encourage high fluid intake (minimum 2–3 L/day) to speed excretion
Low-iodine diet 2 weeks pre-treatment to maximise thyroid uptake
Discharge criteria: dose rate at 1 m <25 µSv/hour (or per local policy)
Sweat contains I-131: shower daily; change bed linen daily first 3 days

Occupational Dose Limits (ICRP 103)

Category	Annual Effective Dose Limit	Notes
Classified Radiation Worker	20 mSv/year (average over 5 years)	Not to exceed 50 mSv in any single year
Pregnant Radiation Worker	1 mSv to foetus during declared pregnancy	Declare pregnancy to RPO; reassignment if needed
General Public	1 mSv/year	Applies to family members of brachytherapy patients at home
Eye Lens (classified worker)	20 mSv/year (average over 5 years)	Updated 2011; interventional staff most at risk
Skin / Extremities	500 mSv/year	Localised exposure; nuclear medicine, brachytherapy staff

Radiation Emergency Procedures

Source Displacement / Stuck Source Protocol:

Do NOT touch displaced source with bare hands or unshielded instruments
Alert Radiation Protection Officer (RPO) immediately — keep their number accessible
Use long forceps (>30 cm) to retrieve source; place in designated lead pot
Evacuate non-essential personnel from area
Post radiation warning sign; restrict access
Contact medical physicist; complete incident report
Assess staff/patient dose if exposure occurred; arrange bioassay if contamination suspected

Pregnant Staff Restrictions: Pregnant healthcare workers must not care for: patients with unsealed radioactive sources (RAI), LDR brachytherapy patients with implants in situ, or patients who have received unsealed source therapy within the last 7 days. Inform occupational health and RPO immediately upon pregnancy notification.

Radiation Oncology Infrastructure in the GCC

Saudi Arabia

KFSH&RC Riyadh — King Faisal Specialist Hospital & Research Centre; leading comprehensive cancer centre; Varian TrueBeam, TomoTherapy, CyberKnife
National Guard Health Affairs oncology centres (King Abdulaziz Medical City)
SCFHS governs nursing certification including oncology specialisation
Radiation oncology nursing credential: Saudi Oncology Nursing Society (SONS) pathways

UAE

SKMC Abu Dhabi — Sheikh Khalifa Medical City; DOH-regulated; Varian TrueBeam, CyberKnife M6
Cleveland Clinic Abu Dhabi — comprehensive oncology
Mediclinic City Hospital Dubai; American Hospital Dubai
DHA (Dubai) and DOH (Abu Dhabi) separate licensing bodies — nurse must hold relevant emirate licence

Qatar / Kuwait / Bahrain / Oman

Qatar: National Centre for Cancer Care & Research (NCCCR, HMC); QCHP licensing; Varian EDGE LINAC
Kuwait: Kuwait Cancer Control Centre (KCCC); MOH licensing
Bahrain: King Hamad University Hospital oncology
Oman: Sultan Qaboos Comprehensive Cancer Care & Research Centre (SQCCCRC)

Professional Roles & Competencies

Radiation Therapy Technologist (RTT)

Operates LINAC and treatment equipment daily
Performs IGRT imaging and patient positioning
Verifies treatment fields and monitor units
Not responsible for clinical nursing care
Licensed under medical radiation sciences (separate from nursing)

Radiation Oncology Nurse (RON)

Holistic patient/family assessment and education
Toxicity assessment and management (CTCAE grading)
Symptom management: skin care, mucositis, nutrition
Radiation safety education to patients and families
Coordinates multidisciplinary team (MDT) care
Psychological support and survivorship planning

Cultural Considerations in Radiation Oncology — GCC

Modesty during simulation/treatment: Request same-gender RTT/nurse for positioning where possible; use gowns that minimise unnecessary exposure; explain what body areas must be exposed and why
Tattoo marks: Small permanent skin marks may be culturally/religiously sensitive; discuss with patient; offer temporary marks where clinically feasible (must document reproducibility limitations)
Language barriers: Use certified medical interpreters; do not rely on family members for clinical translation; translated patient information leaflets
Family involvement: Decisions may be family- rather than individually-led; ensure patient also has private opportunity to express own wishes
Vaginal dilators/pelvic examinations: Deliver education in private; offer female healthcare provider; explain medical necessity; documentation of consent and education provided

Ramadan & Radiation Treatment

Fatigue amplification: Fasting + daily RT causes compounding fatigue — schedule appointments ideally in early morning (after Suhoor) or evening (after Iftar)
Oral medications: Medications that must be taken with food should be timed for Suhoor or Iftar — liaise with pharmacist and patient
Hydration: Patients receiving pelvic RT need 2–3 L/day — advise concentrated fluid intake between Iftar and Fajr
Head & neck RT patients: Mucositis during Ramadan is particularly challenging — prophylactic mouth rinses can be used (not swallowed); seek religious guidance if rinses are swallowed by necessity
Religious exemption: seriously ill patients are exempt from fasting; Islamic scholars and hospital chaplains can advise; do not impose fasting advice either way

GCC Nursing Certification Pathways

Body	Country	Relevant Credential	Notes
SCFHS	Saudi Arabia	Saudi Oncology Nursing Certification	Continuing education requirements; SONS membership beneficial
DHA	Dubai, UAE	Dubai Health Authority Licence	Separate from DOH; annual renewal; oncology specialty endorsement
DOH	Abu Dhabi, UAE	DOH Healthcare Professional Licence	Prometric exam; Haad/DOH classification
QCHP	Qatar	Qatar Council for Healthcare Practitioners	Prometric exam; DataFlow verification; oncology specialty
MOH Kuwait	Kuwait	MOH Licence	Equivalency assessment; oncology nursing specialty

GCC Exam Preparation — MCQs

DHA · MOH · SCFHS · QCHP style questions. Attempt before viewing answer.

Q1. A patient undergoing pelvic radiotherapy reports 8 episodes of loose stool today. On examination, the perianal skin is intact. According to CTCAE v5.0, this is classified as:

Grade 1 diarrhoea — reassurance only
Grade 2 diarrhoea — loperamide and dietary modification
Grade 3 diarrhoea — IV fluids and consider treatment pause
Grade 4 diarrhoea — life-threatening, emergency management

Answer: C — Grade 3 diarrhoea is defined as >7 stools/day above baseline, incontinence, or limiting self-care ADL. IV fluids, electrolyte monitoring, and discussion with radiation oncologist regarding treatment pause are required.

Q2. A nurse is caring for a patient with a caesium-137 LDR brachytherapy implant for cervical cancer. Which action is MOST appropriate when the nurse notices the applicator has partially displaced?

Gently reposition the applicator using gloved hands to restore placement
Remove the applicator completely to prevent further displacement
Do not touch the source; alert the radiation oncologist and Radiation Protection Officer immediately
Apply extra tape to secure the applicator in its current position

Answer: C — A displaced brachytherapy source must never be touched without authorisation. The Radiation Protection Officer and radiation oncologist must be notified immediately. If the source is dislodged, use long forceps and a lead pot — never bare hands.

Q3. A head and neck cancer patient receiving concurrent chemoradiotherapy has lost 9% of his baseline body weight at week 3 of treatment. He is managing a soft diet. What is the PRIORITY nursing action regarding nutritional support?

Commence total parenteral nutrition (TPN) immediately via central line
Refer to dietitian for high-calorie oral supplementation and monitor closely for further weight loss — PEG threshold approaching
Reassure patient that weight loss is normal during treatment and no action is needed
Insert a nasogastric tube immediately without further assessment

Answer: B — PEG/RIG insertion threshold is anticipated weight loss >10% or inability to maintain adequate oral intake. At 9% loss the patient is approaching this threshold; urgent dietitian review, caloric supplementation optimisation, and daily weight monitoring are the priority. Prophylactic PEG should be discussed proactively with the oncology team.

Q4. Which of the following best describes the radiobiological principle of "Reoxygenation" in fractionated radiotherapy?

Normal cells repair sublethal DNA damage between fractions while tumour cells do not
Tumour cells in the radio-resistant S-phase move into the more sensitive G2/M phase between fractions
Hypoxic tumour cells, which are 3 times more radio-resistant, become oxygenated as peripheral cells die during treatment
Accelerated tumour repopulation during a prolonged treatment course reduces overall tumour control

Answer: C — Reoxygenation refers to the process by which hypoxic tumour cells (which are radioresistant, requiring 3× the dose for equivalent cell kill) become oxygenated between fractions as the surrounding oxygenated cells are killed. This is a key reason why fractionation improves tumour control. Answer A = Repair; B = Reassortment; D = Repopulation.

Q5. A nurse working in a radiation oncology ward is pregnant. She is informed she will be assigned to care for a patient who received I-131 therapy 2 days ago. What is the correct course of action?

She may care for the patient provided she wears a lead apron and limits her time in the room to 10 minutes per shift
She should decline this assignment; pregnant staff must not care for unsealed-source radioactive patients, and the Radiation Protection Officer and occupational health must be notified
She may care for the patient after day 3, as I-131 is cleared within 72 hours
She is only restricted from caring for sealed-source (LDR brachytherapy) patients, not unsealed-source patients

Answer: B — Pregnant healthcare workers must not be assigned to care for patients with unsealed radioactive sources (including I-131 therapy) for the duration of pregnancy. The foetal dose limit is 1 mSv for the declared pregnancy. This is a regulatory requirement under radiation protection guidelines (ICRP 103) and GCC local radiation regulations. Occupational health and RPO notification is mandatory.

Radiation Oncology Nursing GCC Edition