Lung Cancer.pdf

246 A.A. Vaporciyan, J.F. Kelly, and K.M.W. Pisters
time to onset of pain relief and less flexibility in dose modification. Patients
treated with narcotic analgesics are counseled regarding opiate-induced
constipation and are instructed to take senna and docusate sodium
(Senokot-S) to maintain bowel regularity. Lactulose syrup is another option
for patients who tend towards obstipation.
Nutritional support plays an important role during radiation therapy
for lung cancer. All patients treated with definitive radiation therapy meet
with a staff dietician within the first 2 weeks after therapy is started. The
dietician explains that patients who avoid losing weight during radiation
therapy tolerate treatment better and have a better chance of avoiding
treatment interruption or prolonged recovery after treatment is completed.
The dietician reviews the patient’s protein and caloric intake, identifies
any areas requiring improvement, and recommends specific dietary
modifications to help patients maintain good nutrition during therapy.
When patients are eating less because of decreased appetite or esophagitis,
the foods they do eat need to be rich in protein and calories. For the
treatment and recovery period, no restrictions are placed on fat or oil intake.
Patients are advised that once swallowing starts to be difficult, they
should avoid eating foods that are hard or rough, heavily seasoned, or extreme
in temperature. Likewise, they are advised to avoid beverages with
alcohol, high acid content (e.g., citrus juice), or carbonation. Many commercial
dietary supplements are available (e.g., Ensure, Boost, and Ultracal)
to help patients maintain their weight during radiation therapy. Usually
6 to 8 cans per day are required if these are the sole source of calories.
Patients who lose more than 10% of their baseline body weight are eligible
to have a percutaneous endoscopic or fluoroscopic gastrostomy feeding
tube placed. Direct infusion of liquid nutrition enables patients to continue
their treatment program without needing an interval recovery time.
If anorexia is a problem, megestrol acetate (Megace) can be used. Dexamethasone
is not recommended during radiation therapy because of potential
problems with pneumonitis.
Postoperative Radiation Therapy
In the postoperative setting, patients usually start radiation therapy after
their first check-up with their surgeon, 4 to 6 weeks after surgery. To minimize
the risk of radiation-related dehiscence, radiation therapy is not
started less than 10 to 14 days after surgery. Whether a lobe or an entire
lung is removed must be taken into account when adjuvant mediastinal irradiation
is planned. The proportion of the total lung volume that receives
a dose of 20 Gy or higher must be kept as low as possible to decrease the
risk of acute radiation pneumonitis or late radiation fibrosis. As a general
guideline, the proportion of the total lung volume receiving 20 Gy or more
should be less than 40%. Since this percentage is recommended for patients
with normal lung capacity, the total lung volume treated to 20 Gy should
be proportionately less for patients who have undergone pulmonary resec-