What is the most effective small cell lung cancer treatment-EPQ A Grade Example
Which Is The Most Effective Treatment For Small Cell Lung Cancer?
My aims and objectives of this project were to develop my understanding and knowledge on a topic which fascinates me-that of cancer research. Not only is it a topic which causes great distress to the individuals who have cancer but it also one which worries the public, since so little is known about it. By researching this project, I have found a way to stretch and challenge my knowledge of A level biology and chemistry, which is of upmost interest to me because I wish to continue my education into a biology degree.
I chose to study small cell lung cancer because not only does it affect a great number of people but it is also in the news quite frequently, because of a great deal of new research which is happening, much to the approval of the public and so the media. Thus, I thought I would be able to come across a great number of facts and figures.
Small cell lung cancer accounts for “about 20 out of every 100 lung cancers” (http://www.cancerhelp.org.uk/type/lung-cancer/about/types-of-lung-cancer, 23/09/10) and is usually caused through smoking. It is when the cells mutate and replicate at an uncontrollable rate in the cells, which are small.
To achieve my objectives, I chose to research the most common treatment types-chemotherapy, surgery and radiation. However I also decided to include two widely used methods which, although they are not cancer treatments, they help to relieve the symptoms of the cancers, thus treating these symptoms. I chose to include them because they are frequently used alongside the other methods as a way of curing pain, while the patient heals.
Before beginning the research for my data, I planned ahead. I found the treatment types (and improving methods) I wanted to use and created separate categories for my research to fall under. I had ‘the process’ to explain the treatment type and the administration, then I had the ‘advantages’ and then the ‘disadvantages’. As I researched webpages, I wrote down my finds into a table (which I later wrote up), cross-referencing to ensure the information offered was accurate and as unbiased as possible. I found my way of utilising this structure highly important for my project; it gave me the ability to quickly compare the treatments, thus enabling me to form a conclusion, in an organised fashion. Also while doing this, I ensured I completed my bibliography at the same time, to ensure no sources were missed from it, and were found in an organised and precise manner.
However I could not follow my ‘advantages’, ‘disadvantages’ layout with the symptom-improvement techniques, since they were not actually treatments in themselves and thus not strictly relevant to my question (which is treatment-focused). Although I do believed they added to the richness of my information range and so I decided to include them but not to rely on them to heavily to answer my question.
In an attempt to gather data, I also emailed many cancer-related and cancer research institutes, such as: ‘The Roy Castle lung Cancer Foundation’, ‘Tak Tent Cancer Support Scotland’, ‘Macmillan’, ‘The British Red Cross’, ‘The Patients Association’ and ‘Teenage Cancer Trust’. I did this in attempt to find out their own opinions about my drawn conclusions and to ask for any useful data which they might hold.
Introduction and Administration
The cancer treatment chemotherapy uses drugs to stop the growth of cancer cells by killing them or preventing their division. It is the main treatment type for small cell lung cancer because this type of cancer responds well to it. Also, the drugs circulate the blood stream, meaning that they can treat the cancerous cells- or micrometastases or microscopic spread- which are too small to see on scans, that have broken away from the lung tumour and are now elsewhere in the body (systemic chemotherapy). This make it highly effective, as shown by the information: “Response rates of 80 to 100 percent are seen in patients with limited disease, and approximately one-half of these are complete... With extensive stage disease, 60 to 80 percent of patients will respond to chemotherapy, and between 15 and 40 percent will have a complete response.”
There are many different drugs which can be used to treat this particular cancer type. To increase their effectiveness, they are taken in pairs, which is called combination chemotherapy. The major drugs used are: cisplatin and etoposide, otherwise known as EP, which I will be focussing on since they are the most common.
The drug is administered thorough a fine tube (cannula) into a hand or a vein, which is a little uncomfortable and painful to be put in, although it lasts only a short time. Firstly, anti-sickness (anti-emetic) drugs are given, to reduce nausea and vomiting, then sterile salt water (saline) is added (pre-hydrogenation), then the chemotherapy drugs are given. The saline is given because cisplatin can affect how the kidneys work and because taking in fluids can cause damage, so it helps to keep the kidneys working normally. The kidneys could even be permanently damaged. To prevent this, a blood test is usually done before treatment.
On the first day of treatment, both cisplatin and etoposide are infused. On days two and three, only etoposide is taken, in tablet form-meaning that it can be administered personally, at home- or via infusion- meaning that the patient would have to return to the hospital. Then there is a 18-day rest period, completing the 21 day treatment cycle. Normally, six cycles of treatments are given, over 4-5 months.
The treatment has progressed to the point where it has even been said that the benefits of today's chemotherapy outweigh the risks.
Chemotherapy is a highly useful development because not only can it cure a specific cancer but it can also control the tumour growth when a cure is not possible. The tumour can be shrunk by the drugs, to allow surgery or radiation therapy to be used. It can relieve symptoms, such as pain, which is extremely useful if there is no chance of survival for the patient-allowing them to live the rest of their life painlessly. Chemotherapy can also destroy the microscopic cancer cells that may be present after the known tumour is removed by surgery, which helps to prevent a possible cancer reoccurrence.
Common Side Effects
Since EP can reduce white blood cell production, it can make patients more prone to infection. This is a particular problem 10-14 days after the chemotherapy, since this is when resistance to infection is at its lowest. However, after this time, the number of white blood cells will increase at a steady rate and return to normal levels before the next chemotherapy cycle will begin.
Also, platelet production can be reduced, resulting in difficulties with blood stopping and clotting. Thus producing symptoms such as nose bleeds, bleeding gums and blood spots or rashes on the skin.
In addition, a low number of red blood cells could be caused, resulting in anaemia. This means that the patient could be tired and breathless.
Other Side Effects
The cisplatin can effect the nerves, causing numbness or tingling in the hands and feet, which can cause difficulties with doing fiddly tasks (peripheral neuropathy). However this issue usually improves slowly a few months after treatment is over.
Cisplatin can cause changes in hearing. Ringing in the ears (tinnitus) can occur, and usually improves toward the end of the treatment. Patients may lose the ability to hear some high-pitched sounds and if the dose becomes higher and the treatment courses longer, permanent and severe hearing loss could happen. This would also affect the patients' sense of balance, since they are closely connected.
The mouth can become sore and develop small ulcers during the treatment. The risk of this can be reduced by drinking plenty of fluids and cleaning the teeth regularly and gently with a soft toothbrush. If it does happen, doctors can prescribe special mouthwashes and medicines to clear and prevent the mouth infections.
Food tastes different however normal taste will return once the treatment has finished.
Diarrhoea can also occur. It can easily be controlled with medicine and plenty of water must be drank, to replaced the lost fluid.
Patients may also feel fatigued during the chemotherapy, particularly towards the treatment's end. The patient must allow themselves ample time to rest.
Etoposide can cause changes such as itchy rashes or darkening due to an excess in pigment production. However, when the treatment has finished, it usually returns to normal.
Allergic reaction could be caused, creating a variety of effects such as skin rashes, itching, high temperature, shivering, redness or darkening of the face, dizziness, a headache, breathlessness, anxiety and a need to pass urine. During the treatment, patients are monitored for any signs of an allergic reaction.
Although it is rare, etoposide can cause second cancer-usually a form of acute leukaemia- to develop in later years.
Also, all other medication is a potential hazard to the chemotherapy, even ones bought in a shop or herbal medicines.
Fertility and contraception is another issue. The patients ability to become pregnant or father a child could be effected and it is not advisable during the treatment, since the EP could harm the developing foetus.
Many of the elderly who have been diagnosed with lung cancer have to be left untreated because they are less tolerant of the chemotherapy drugs. They also have a shorter life expectancy, meaning that the potential survival benefits do not outweigh the side effects possible. Also, it is not as cost effective for the hospitals, since the cancer is more likely to re emerge and the patient more likely to die. Thus these drugs could be better used on a patient with greater chances of survival.
The financial costs of chemotherapy vary greatly, depending on: the types and doses of drugs used, how long and often chemotherapy is given, whether it is administrated at home, in a clinic or during a stay in hospital and the part of the country where the drugs are required.
Introduction and Administration
Before the surgery happens, tests need to be done to check the patients state of health and lung function to make sure that their body can withstand the effects of the surgery. If the test results confirm that the patient is in good health, the surgery can go ahead. The tests include: an electrocardiograph2 or ECG, where electrodes are used to monitor the electrical activity of the patients’ heart, and spirometry3, when the patient breaths into a machine called a spirometer, which measures the capacity of the lungs.
The operations occur when the patient is put under general anaesthesia, with a thorcotomy4a (a surgical incision between the ribs within chest).
There are many different types of surgery, the main ones being: pneumoniaen an entire lung is removed, lobectomy4b- when a section (lobe) of the lung is removed (generally preferred small cell lung cancer), segmentectomy or wedge resection4c- where part of a lobe is removed and sleeve resection-when a section of a large airway is removed and the lung is reattached. For all of the above, nearby lymph nodes are also removed to look for the possible spreading of the cancer.
In the absence of any complications, it is most likely that patients will be ready to go home about 5-10 days after their operation. However, it can take many weeks to recover fully from a lung operation. After the operation, it is extremely important that the patient will start moving about as soon as possible. Any movement is very important and, even if they have to stay in bed, the patient will need to keep doing regular leg movements to help improve circulation and prevent blood clots from forming. To prevent further complications, the patient is also shown breathing exercises by a physiotherapist. The small movements then progress to gentle exercises to build up the patient's strength and fitness, once they have returned home. Walking and swimming are good forms of exercise that are suitable for most people after treatment for lung cancer. Patients are usually given a care team which they can discuss with about which types of exercise are suitable for them, personally.
Small cell lung cancer is usually found in both lungs, because the disease is usually only discovered in later stages, allowing it time to spread, thus surgery is not often used. However surgery can be used to remove the cancerous cells if the tumour is small and localized to one lung or nearby lymph nodes. This is an effective means of getting rid of the cancer, it has been said that “Patients with small cell lung cancer who presents with a single small lung lesion may have 70 percent chance of 5-year survival after surgical removal of the tumour5”.
Surgery can also be useful for mediastinoscopy6. This is when a thoracic surgeon inserts a thin tube into the mediastinum (“the central portion of the chest that represents the space between the right and left lung”7), when the patient is under general anaesthesia. A tissue sample is withdrawn and examined under microscope to determine if cancerous cells are present. This is highly useful because “surgery appears to be most helpful for patients whose lymph nodes are not yet affected by the disease7” and so this surgery type can determine whether surgery would be a useful treatment or not.
The Yale New Haven Hospital website (<http://www.ynhh.org/healthlink/cancer/cancer_8_05.html>) mentioned the Anita trial: From December 1994 to December 2000, 840 patients were enrolled in the ANITA trial. The patients were well balanced for age, gender, type of surgery and stage of cancer. In the trial, 433 received chemotherapy following surgery and 407 did not. Chemotherapy consisted of the drugs vinorelbine tartrate (Navelbine ®) and cisplatin. The median amount of time patients were followed was greater than 70 months. It proves the effectiveness of this treatment type.
Unfortunately, surgery is not normally a viable option because cancer cells are left in other parts of the body. These cancerous cells can cause the cancer to re-emerge. Thus, after the surgery, patients are usually given chemotherapy or radiation therapy, which is called adjuvant therapy. However, surgery is a possibility even if there are metastasis (multiple tumours8), provided they are all close together at a site that the surgeon can reach.
Since the majority of patients are smokers aged 50+, they normally have other medical conditions that can increase the risks of the cancer.
After lung surgery common side effects include soreness in the chest and arms, also there can be shortness in breath. It is important to breath deeply, turn over and cough because air and fluid can collect in the chest, so this helps to remove the excess air and fluid. However after 1-3 months after the operation, the patient is usually recovered. The severity of these side effects is highly dependant on the condition on the lungs and the healthiness of the patient.
There are complications in 1 out of every 5 cases ( As found by the NHS, Treating Lung Cancer,14/10/09, <http://www.nhs.uk/conditions/cancer-of-the-lung/pages/treatment.aspx>) of lung surgery. These complications include: pneumonia (inflammation or infection of the lung9), excessive bleeding, a leak of air from the lung wall and deep vein thrombosis (a blood clot in the leg10) which can sometimes cause pulmonary embolism by travelling up to the lung. These complications mean that extra surgery or medication is required to treat these symptoms, meaning that an even longer stay in hospital is needed.
Introduction and Administration
Radiation therapy is a cancer treatment which uses pulses of high energy radiation, such as X-rays, to kill cancerous cells and stop them from forming. There are two types: external radiation therapy2, that uses a machine outside the body to send the radiation towards the cancer, prophylactic cranial radiation or irradiation (PCI)3, when radiation therapy is given to the brain to reduce the risk that the cancer will spread to the brain, as a preventative measure, since there is a risk that SCLC can spread to the brainand intensive radiation therapy, which uses radioactive substances sealed in an object (such as needles, seeds, wires or general radioactivematerials that are placed directly into or near the cancer, via insertion of a catheter (thin tube) down a bronchoscope into the lung. The material is positioned against the site of the tumour before being removed after several minutes.
Radiotherapy can be used to treat lung cancer and slow the spread of the cancer when a cure is not possible (palliative therapy4).It can also be used to cure symptoms by shrinking the cancer tumour or reducing the pressure. It is used in this way because then it can treat problems such as pain, or it can prevent problems such as blindness or loss of bowel and bladder control
There are several different ways that a course of radiotherapy treatment can be planned. Radical therapy is taken five days a week, with breaks at weekends. Each radiotherapy session lasts between 10-15 minutes. The course lasts between 3-7 weeks.
An alternative method of having radical radio therapy is continuous hyperfractionated accelerated radiotherapy or CHART.. It is given three times a day for 14 days in a row but is only available in specialist cancer centres, such as the Newcastle upon Tyne hospital5. This means that patients sometimes have to travel far, to another part of the country, to get this treatment
Palliative radiotherapy usually only requires one or two sessions to control the patents symptoms.
One course of internal radiotherapy takes 1-3 sessions to complete.
“Many people with cancer need radiation therapy. In fact, more than half (about 60 percent) of people with cancer get radiation therapy. Sometimes, radiation therapy is the only kind of cancer treatment people need.”10
Doctors are able to aim higher doses of radiating at the cancerous cells, while reducing the radiation to normal cells, therefore it being far more precise parts of the body. This is due to new techniques such as intensity-modulated radiation11 or IMRT, which is 3-dimensional radiation therapy that uses computer-generated images to show the tumour's size and shape and then destroys it with thin beams of radiation that are aimed at the tumour from many angles, and 3D conformal radiation therapy, or 3-dimensional radiation therapy, a procedure which created a 3D picture of the tumour to allow doctors to give the highest possible radiation dose while statingprecisely on the cancerous cells.
Although some of the potential side effects may hurt, the actual radiation therapy does not.
External radiotherapy usually causes side effects because the radiation can also damage healthy tissues and cells, while internal radiotherapy tends to cause fewer side effects because the radiation is beamed directly at the tumour.
The side effects of radiotherapy include: chest pain, fatigue, dysphagia (difficulties with swallowing6), redness, soreness of skin, hair loss on the chest and head (the latter only if the patient is receiving PCI) and a persistent coughing which may bring up blood-stainedphlegm.
These side effects should ass once the course has been completed, although sometimes they continue to exist even afterwards.
In an attempt to protect the healthy cells, doctors take many precautions. Thy use as low a dose of the radiation as possible, although it still has to be high enough to kill the cancerous cells. The treatment is spread out over time, to allow time for he normal cells to recover, while the cancer cells die.
Radiation therapy does not kill the cancerous cells immediately. It takes days or weeks of treatment before the cancer cells begin to die and they then continue dying for weeks or months after radiation therapy has been done.
Radiation therapy is expensive, since it uses complex machines and involves the services of many different care providers. The exact cost of the treatment depends on the cost of health care in that particular area, what kind of radiation therapy is required and how many treatments are needed.
Since the body uses up a lot of energy to heal itself, during radiation therapy, the patients’ diet must be carefully watched. They need to eat enough calories and proteins to maintain the same weight during and after treatments. A special diet may have to be considered, which are decided by the patients' doctor, nurse or dietician.
Once the radiation therapy is complete, follow-up care is needed for the rest of the patients' life. The radiation oncologist and nurse practitioner would have to do check ups frequently, which include seeing how well the radiation therapy worked, checking for more cancerous signs, looking for late side effects and discussing the patient's treatment and care. The doctor and nurse would examine andreview the patient, prescribingmedication if necessary. They would also do imaging tests, such as blood tests, x-rays, CT scan, MRI and PET.
Laser therapy is a SCLC treatment that uses a laser beam to kill cancerous cells. The powerful and hot beam of light is used to burn away the tumour or relieves breathlessness by clearing the airway. Although it can cure the symptoms of the cancer it is not useful for curing the cancer.
The patient is placed under strong sedation using general aesthetic. Next, the doctor does a bronchoscopy, which is when a narrow flexible tube called a bronchoscope is put down the throat, into the airway. The doctor looks down the tube's eyepiece, to make sure it is in the correct place and then passes the laser down the bronchoscope tube.
Since there are usually no side effects from laser treatment, the patients can go home the same evening. However if the blockage in the lungs has caused an infection, the patient may need to stay in the hospital a while longer, so they are able to receive antibiotics through a drip.
When laser treatment has been used and the tumour grows back, it is possible for patients to have laser treatmentagain, although it is sometimes also used with radiotherapy to slow down the growth of the cancer.
Endoscopic stent placement
Endoscopes are thin tube-like instruments which have a light and a lens. Some stents are rigid plastic tubes but are most often a wire mesh tube which expands outwards in the airway (also called an expandable stent).
The treatment is done under general anaesthetic. The doctor does a bronscopy to put the bronchoscope tube into place. The doctor then pushes the folded up stent down the tube. When it exits the tube the stent opens and pushes the airway walls open. When the patient is awakened, they can breath more easily, without being able to feel the stent.
The stent has no need tube placed since it can stay in the airway permanently.
They look at tissues inside the body and can also be used to place a stent in body structure to keep the structure open. In the lungs, it is used to keep airways open that have been blocked by abnormal tissue or a tumour.
Discussion of My Findings1
I have collated all of my gathered research and have formed an educatedconclusion from my in-depth findings into the treatment options, regarding small cell lung cancer.
The type of treatment which would be most effective is reliant on many different things, such as the age of the patient, general health of patient, the size of the tumour, the position of the tumour and how quickly the cancer has been detected, since this determines how far the cancer has spread.
I believe that, overall, the single most effective method of treating small cell lung cancer is surgery. This is because it completely destroys the tumour and has lower levels of side effects. However it is rarely used because of its need to be used when lung cancer is diagnosed very early on.
Thus, I believe the second best stand-alone treatment is chemotherapy because it can be used a great number of situations, on a great number of different people. I also think this because of the drugs' ability to circulate the blood stream, meaning that they can treat the microscopic spread of cancerous cells, elsewhere in the body. This method not only enables patients to live for longer but also allows them to have better control of their symptoms.
Also, the chemotherapy drugs are much improved today than they were years ago. They are far more active and less toxic- meaning fewer side effects and they cause less damage to the surrounding healthy cells, making recovery occur faster.
It can be said that the main disadvantage of chemotherapy is the amount of side effects which may occur, however the effects of these repercussions can be reduced by taking simple measures such as:
For the shortages of white blood cells, red blood cells and platelets can not be a problem if, while awaiting natural recovery, the patient maintains optimum hygiene rates-by washing their hands before preparing food and after using the toilet-, keeps away from people who have infections, take care to avoid injury, se a soft brush while brushing teeth and tell their doctor if they have any effects such as nosebleeds, bleeding gums, skin abnormalities and increased temperature (for which antibiotics would be prescribed).
To prevent or increase the speed of recovery of hair loss the patient could: use gentle hair products, avoid perming or colouring the hair, avoid using hairdryers, tongs or straightners, brush hair with a soft brush and cut the hair short before treatment starts, since the weight of long hair pulls on the scalp and may make it fall out sooner.
Fatigue would be less of a problem if: a regular sleep routine is kept to, no unnecessary tasks are done, periods of energy are used to perform necessary tasks and light exercise is regularly taken.
I think the best overall SCLC treatment would be chemoradiation-when chemotherapy and radiation are both administered. This is also backed up by “...standard therapy for LS-SCLC is concurrent chemoradiotherapy, and the 5-year survival rate observed in clinical trials is approximately 25%”2.
This is because of its high level of effectiveness. Thechemotherapy helps to shrink and isolate the tumour and then the main body can be removed by the radiation, meaning that fewer drugs are needed and so fewer of the side effects of chemotherapy occur.
However I do not thin this would be a good treatment plan for the elderly or people in the last stages of the cancer. This is because the radiation does not begin to kill the cancerous cells for a long time after surgery. Also, the effects of the possible side effects could be more harmful than the side effects of the cancer, causing them more pain before they die. Instead, palliative care should be given in the form of chemotherapy using drugs which have very few side effects and radiation throughout different areas of the body, to help reduce the pain further. Although endoscopic stent treatment and laser therapy can not cure the cancer or kill any cancerous cells, I think they also are usefultreatments, for easing the discomfort of patients who are not likely to be able to be cured. This is because they help to reduce the symptoms whilst creating no side effects of their own, therefore helping these patients greatly by, for example, easing pain and ensuring they can breath properly.
I believe that people with extensive-stage small cell lung cancer could also join a clinical trial.
Clinical trials are medical research trials, which involve patients. They help to: test new treatments, and to find better ones, compare the effectiveness of the drugs used for symptom control, see which treatments are most cost effective, understand which treatments provide less side effects, find out how these treatments work, see which of the treatments are most convenient for the patients and enable alterations to the treatments to be made, such as: altering existing treatment combinations, change the administration process, small ways to make them more effective and small ways to reduce side effects. “At the present time about 1 in 9 cancer patients take part in clinical trials.”3. Although it does raise many ethical issues such as what if it causes more side effects than a cure or the issue of cost to travel to the doctors or hospital more frequently, it can help patients too. This is because they have more medical profession attention and so if the cancer begins to worsen, they will know about it more quickly. Also the transport costs may be covered by the trial, thus meaning patients do not have to pay to be assessed more frequently.
To conclude, I do not think there is one definitive most effective treatment for small cell lung cancer because each patient has their own individual issues, requirements and illness, which can all affect the process, thus making it impossible to make such a sweeping generalisation even mildly accurate, because of these numerous variables involved.
I believe my project has been a success because I have found an answer to the question-and aim- of my choice:
“To conclude, I do not think there is one definitive most effective treatment for small cell lung cancer because each patient has their own individual issues, requirements and illness, which can all affect the process, thus making it impossible to make such a sweeping generalisation even mildly accurate, because of these numerous variables involved.”
However I do think I may have been able to create a slightly more decisive conclusion if I chose another, yet closely related, topic, such as NSCLC. One of the reasons I chose this cancer type was because it got a lot of publicity and was a major issue of current news. I believed that this would make my research more rich with facts and figures, from trials and case studies, thus making my report both objective and subjective. However, I found that it had the opposite outcome. Since the research was still on-going, I found it very difficult to obtain real data because the scientists were not yet in a position to release it because of the great amount of publicity it would immediately receive. The only information I could find was restricted to surgery in one table (1table, Http://www.cardiothoracicsurgery.org/content/4/1/30/table/T1), and I could not include this in my report because f the restriction to only one treatment type.
I also found myself in the same situation when I attempted to email the researches and organisations. All of them denied my requests and said they were not authorised to disperse such private and on-going information. Thus instead leaving me to seek information off websites for the public, which were likely to be highly biased and less prestigious.
Thus, if I repeated the project, I would pick a topic which is not a current issue but an issue which the public has just recently lost interest over, then I would be able to utilise the full amount of data which would have been more useful to back up my words. This would have enabled me to write a less indifferent conclusion to my question.
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2 The Free Dictionary, Electrocardiograph, <http://medical-dictionary.thefreedictionary.com/electrocardiograph> [assessed 29/08/10]
4a Encyclopaedia of Surgery, Thoracotomy, <http://www.surgeryencyclopedia.com/St-Wr/Thoracotomy.html> [assessed 29/09/10]
4b ibid, Lobectomy, Pulmonary [assessed 29/09/10]
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5 Medicine World.org, Treatments of Small Cell Lung Cancer: Surgery, <http://medicineworld.org/cancer/lung/small-cell/treatment-of-small-cell-lung-cancer-surgery.html> [assessed 24/07/10]
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9 Net Doctor, Pneumonia, Dr John Pillager, 24/11/08, <http://www.netdoctor.co.uk/diseases/facts/pneumonia.htm> [assessed 29/08/10]
010 Bupa, Deep Vein Thrombosis, June 09, <http://hcd2.bupa.co.uk/fact_sheets/html/Deep_Vein_Thrombosis.html> [accessed 29/08/10]
1 National Cancer Institute, Radiation Therapy for Cancer, 30/06/10, <http://www.cancer.gov/cancertopics/factsheet/Therapy/radiation> [assessed 29/08/10] 1 A Practical Guide to Tests and Treatments, Understanding Radiotherapy, (2008), 8th Edition,Guide by Macmillan Cancer Support
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3 The Oncologist, Prophylactic Cranial Irradiation in Small Cell Lung Cancer, Gary Y Yang, Richard H Mathews, August 2000 [http://theoncologist.alphamedpress.org/cgi/content/full/theoncologist;5/4/293> [assessed 29/08/10]
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