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I’ve seen patients come in crying because they’re scared of radiation, and at their last treatment, they’re crying because they’re [no longer] going to see the team of people who have cared for them.
Kristi Tonning, Director of the Radiation Therapy Program at Oregon Health Sciences University (OHSU)
The National Cancer Institute (NCI) has estimated that about 39.5 percent of the adult population of the United States will be diagnosed with cancer at some point during their lives. In 2020 alone, the NCI predicts 1,800,000 new cancer cases, leading to over 600,000 deaths. However, there is a silver lining to this story. Since the early 1990s, the number of overall cancer deaths in the U.S. has actually declined, a trend we definitely want to see continue.
There are a range of treatments for cancer including: surgery; chemotherapy, radiation therapy, and hormone therapy; immunotherapy; stem cell transplants; targeted therapy; and precision medicine.
And there are a growing number of preventive measures available to mitigate risk for cancer, as well as methods offering alternative or complementary care to ease symptoms and side effects for individuals going through cancer treatment. Some of these include nutrition therapy; aromatherapy, acupuncture, massage, and energy work; hypnosis, guided imagery, and music therapy; supportive psychotherapy and cognitive behavioral therapy; and meditation, yoga, tai chi, and qi gong, among others.
Fifty-percent of cancer patients currently receive radiation therapy, most often in the form of external beam radiation, a treatment during which a machine aims high-energy beams at a precise point on the body. These beams of concentrated energy (high energy x-rays or gamma rays) kill cancer cells by destroying their DNA. Forms of internal radiation therapy include brachytherapy (solid) and systemic therapy (liquid).
Radiation is used to cure cancer, prevent recurrence, or slow cancer growth. It is also used palliatively to ease symptoms such as pain or breathing difficulties. Using evidence-based practice, radiation therapy is adjusted over the course of treatment based on side effects and outcomes.
Kristi Tonning, director of the radiation therapy program at Oregon Health Sciences University (OHSU), explained that, “It’s a treatment that is less well known than others, but it is effective. Side effects [only occur] in the area we treat, so it’s not systemic like chemo.”
Read on to discover what to expect from a career in radiation therapy through an expert interview, including professional challenges and opportunities, advocacy issues, and advice for aspiring RTs.
Meet the Experts: OHSU’s Kristi Tonning and Maria Thompson
Kristi Tonning is assistant professor and director of the radiation therapy program at Oregon Health Sciences University (OHSU). Prior to joining the OHSU staff in 2015, she worked as a radiation therapist and dosimetrist at Stavanger University Hospital in Norway for 14 years, where she also served as interim department manager.
Ms. Tonning holds degrees in radiation therapy (BS, OHSU) and change management (Msc, University of Stavanger). She is currently working on her PhD in education and leadership (Pacific University). Her areas of professional interest include patient education, radiation therapy, interprofessional education (IPE), youth outreach, and virtual reality.
Maria Thompson is a simulation therapist and has served as the clinical coordinator of the radiation therapy program at OHSU since 2016. Prior to occupying this role, Ms. Thompson worked as a radiation therapist for Legacy Health in Portland, Oregon and at Salem Health in the state’s capital city. She holds degrees in radiation therapy (BS, OHSU) and educational leadership and policy (MEd, Portland State University).
The Scope: A Day in the Life of a Radiation Therapist
Radiation therapy consists of two main areas: technology and patient care. Tonning explained that the primary responsibility of radiation therapists is “to administer radiation in an accurate way, give [patients] the treatment that has been prescribed, follow-up [on] their side effects, and provide patient education and patient care.”
The technology used within the radiation therapy scope of practice may include:
- Linear accelerators – Used in the most prevalent form of radiation therapy, these machines deliver photon and electron radiation therapy treatments.
- Digital imaging
- Brachytherapy – Administered by physicians and medical physicists with the assistance of radiation therapists, this technology delivers high-dose radiation using a radioactive seed.
- Proton therapy machines
Tonning went on to emphasize , “Not only is much of their job about running the machines and being very accurate and making sure things line up and imaging, a great portion of their job is patient care.” The role of patient-care in radiation therapy is multifaceted, and includes:
- Taking vital signs and placing IV lines
- Positioning patients for their treatments
- Explaining how to manage side effects
- Listening to patients’ concerns and questions
- Documenting issues discussed with patients
- Observing changes in a patient’s demeanor, radiation site, side effects
- Connecting patients with members of the radiation therapy team and other resources as needed
A lot happens before patients come for their first treatment, however. To prepare for radiation therapy, patients work with a team of medical professionals, each with an important role in planning and administering the treatment.
For radiation therapists like Maria Thompson, clinical coordinator of the radiation program at OHSU, the scope of work differs greatly from the daily routine of others in the field. As a simulation therapist, which focuses on the first meeting with a new radiation patient, Thompson has the unique task of orienting patients to the treatment they are about to begin. About her specific role as a simulation therapist, Thompson explained,
[Simulation] is the appointment when it is decided how a patient is going to be set up every single day for their treatment. They have a consult with a physician before, but they really haven’t explored the different areas of the department, and some of these meetings can happen really suddenly. From diagnosis to the time that they’re in that room with a simulation therapist, it can be just a matter of a couple of days, or it’s towards the end of a very long treatment … So, you really get a sense of going at the pace that that specific patient needs to orient them to the entire process.
Tonning further described the process from diagnosis to beginning radiation treatment:
Patients will have gone through [what] we call the interprofessional team where they will have spoken to a physician, [and] found out that radiation is a good treatment option. They will have gone to a CT simulation appointment where the radiation therapist will have taken a CT and positioned them and tattooed them. Those images will be sent to dosimetry, [and this] team member will plan the treatment. The doctor will approve it, the physicist will check it, and after all that’s happened, the patient then will be ready for their first treatment.
From that point on, depending on the type of cancer and stage of the disease, patients will have radiation therapy consistently for a designated period of time.
The Knight Cancer Center at OHSU typically treats cancer patients undergoing radiation therapy five days a week for five to eight weeks. Once they have been through simulation, patients won’t see other members of their radiation oncology team except at designated appointments. They will meet with their physician weekly, but they will see their radiation therapist every day they come in for treatment: “[Patients] can come anywhere from five to 35 times and everyday they come, they see the therapist team,” Tonning said.
Radiation Therapy: The Importance of Treating the Whole Patient
The work of a radiation therapist is multifaceted and takes into account what is referred to in holistic medicine as “the whole patient.” This includes consideration of the medical and psychosocial aspects of care, in addition to patients’ attitudes and beliefs and information and communication preferences.
As the team member seen by patients every day, radiation therapists are responsible for positioning patients, setting them up for treatment, and making sure that the area being treated is exactly where the physician prescribed, while also monitoring their mental, social, and emotional needs.
Both Tonning and Thompson spoke of patient vulnerability and the need to be sensitive to a patient’s background, experiences, and circumstances throughout the course of treatment. For example, patients may have already gone through surgeries and other treatments or therapies, or they may be facing them after radiation. Tonning explained, “Every patient doesn’t just come and get their treatment and leave. They have many other things they’re wondering [about] and different options.”
Thompson added that due to the frequency of interactions with patients, therapists “see them at particularly vulnerable points in their continuum of care.” Radiation therapy is used for both palliative and curative purposes, and so patients may be at all different points in their fight with cancer. Tonning shared,
They come with lived experiences … and so realizing their whole story, [that] there’s been a whole bunch of stuff before they meet us and that they’ll continue to deal and live with the disease afterwards, is important for a radiation therapist.
In addition to emotional vulnerability, therapists need to be sensitive to the physical vulnerability patients experience due to what their bodies have and are currently going through. Tonning elaborated,
Therapists see the patients everyday and they [are] hands-on, touching and adjusting and working with patients in vulnerable positions … if you have breast cancer, your chest is bare and your arms are above your head, and the therapist will touch, so they have to be very comfortable and have trust with the patients … They often will have surgery and chemo, and so radiation is one of a bundle of treatments, and so they come already having been part of the health system for a long time.
Radiation therapists also need to be skilled in how to position patients to receive radiation treatment as effectively and safely as possible. Accuracy is key as healthcare professionals are treating the cancer to the millimeter. The dosage and duration of treatment prescribed is determined in part by the proximity of the radiation site to other organs in the body.
Professional Ethics and Advocacy Issues in Radiation Therapy
It goes without saying that working with vulnerable populations such as individuals undergoing cancer treatment would warrant particular attention be given to ethical standards and advocacy within the field. Areas of ethical consideration and advocacy in radiation therapy include connecting patients to resources and support, maintaining the scope of practice, and maintaining the autonomy of patients. These three areas are closely interconnected.
As mentioned earlier, radiation therapists see their patients daily throughout the course of treatment. Thus, observing patients and advocating on their behalf is an integral part of patient care. Therapists use what they learn from observing and talking to patients to connect them with the services they need: “Therapists can see changes in patients over time. They can connect them to other support,” Tonning explained.
Forms of support can include referring patients to other professionals, such as nurses or social workers, or to resources such as nutrition services. Thompson elaborated further, “It’s the radiation therapist’s job to connect that patient with the right avenues to get support during their cancer care. So, even though patients know that those services are available, they don’t [always] seek it out for themselves. But, seeing that friendly face everyday and being able to recognize a point of contact is where those things are revealed.”
Advocating for patients can also entail talking to family members or getting them in to see their physician. Thompson continued, “If you see a change in status, you [have] that ethical responsibility of alerting someone that the patient needs to be seen.”
Alternatively, a patient may reveal in conversation that they are thinking about stopping their treatment. In this case, too, the role of the therapist is to connect the patient with their doctor. Thompson explained, “They meet with the physician once a week, but they meet with you every single day, so sometimes you hear things that they’re pondering from their own care [and] you can help connect them to the resources.”
Additionally, maintaining scope of practice is embedded in patient advocacy within the field. Tonning related that,
Radiation oncology is … interprofessional is the word we use now, but it’s a team where each profession can’t do the other profession’s job. So the radiation therapist is the one that administers the radiation. We have a license in our state. We have a national board we take. We can administer the radiation. We shouldn’t be talking through treatment options [though]. That’s what a physician does. But, since we’re the front line, we may have those types of conversations, then we can connect them with the right person.
Knowing the scope of the work is vital, as is being present in daily interactions with patients in order to connect them with the appropriate medical professionals, resources, and services essential to their care.
The final ethical consideration Tonning brought to light is in regards to patient autonomy:
Radiation therapy is a very technical, very science-based field, and you’ll meet patients that have chosen alternative methods of treatment. It’s very important as a therapist to respect and honor a patient’s choices all the while … providing the treatment that’s within our scope … Patients come to you autonomous as an individual and we need to meet them there and support them in a way that works for them. And it can be difficult, if someone does different treatments that maybe aren’t proven to work like radiation and chemo, to balance that perspective.
Challenges: Radiation Therapy in the Time of COVID-19
The challenges of delivering cancer care through radiation therapy during the coronavirus outbreak are many.
First, Tonning points out that while other members of the radiation oncology team, such as the physicians, medical physicists, and dosimetrists, have the option of working remotely, the role of radiation therapists is hands-on, up close and personal. She explained, “Therapists are the ones that come everyday and treat the patients even in this unprecedented time we live in. Face to face. If you’re at a large center, you can have a hundred patients in and out everyday.”
Cancer treatment can’t stop because of COVID … If we were to stop a treatment, we would have a less than desirable outcome. With each treatment, radiation becomes more effective … so that cannot stop in COVID. What this has made therapists and even us in this program realize [is] how important they are as frontline workers. They are very close to the patients. They touch them, they see them everyday, and if they couldn’t go and do their jobs, patients’ treatments would either not be started or would be halted in the middle, and potentially, you could see some very poor outcomes from that. So, therapists have been working very hard during COVID.
Furthermore, cancer patients may have compromised immune systems placing them at higher-risk during this pandemic. Tonning points out that therapists have (and will continue) to treat patients that are positive for COVID-19 and that the team-oriented care model and nature of the work make it difficult to maintain social distance. She emphasized that virtually no one in healthcare has the option to be six feet apart, and as such, radiation therapists are working on the front lines alongside doctors, nurses, and other medical professionals—doing their essential service while putting their own health, and that of their families, in jeopardy.
However, in the same breath, she added that COVID has stressed the importance of working in collaborative teams more than ever, with patients in the center of the care continuum.
What Does the Future Hold for Radiation Therapists?
Both Tonning and Thompson point to the fact that, as a technology-based career, radiation therapy and the work of radiation therapists will continue to change dramatically in coming years:
When I graduated in 2001, the field was completely different. It was a very manual field … we had to make blocks to block the radiation, and now it’s integrated into the machine, and they’ll move by themselves. We had to manually process the film from images, and now in a brief moment you can take a quick CT on the machine and get a 3D image of the patient. So things have changed in the 19 years dramatically, and since it’s technology and cancer-driven, I suspect it will continue to change.
Thompson echoed that sentiment, sharing,
I’ve also seen [the field] change over the years, I think more targeted therapies is where it’s going … That’s what they’ve been working towards. More targeted therapies not only on the actual delivery of the machine, but also the way that we’re able to accurately align the patients everyday, so that the target can become smaller because we can line the patients up more accurately or more specifically. Those are the two areas of advancements that they’ve already made huge leaps on, and I see further development in that area as we continue on.
That translates to good news for cancer patients: “If we get more targeted, more accurate, less side-effects, combinations of medicines, then we can … treat to a higher [dose] and see better outcomes,” Tonning stated.
Despite the promise of targeted therapies and how they can be used to more effectively work with radiation therapies, Tonning pointed to lack of awareness of the field and fears that surround the treatment option for many:
Patients and health professionals alike don’t know a lot about radiation therapy, so it’s not sometimes utilized as much as it should be … sometimes because patients are scared of it. We hear our whole lives, ‘Stay away from radiation.’ Why would we ever want radiation then? … We’re trying to get the word out that it’s a good treatment for curative and pain relief for patients. And they tolerate it very well.
Advice for Aspiring Radiation Therapists
The predictable hours, team-environment, and relationships with patients make radiation therapy an attractive career for compassionate individuals with an interest in healthcare, science, and technology.
Both Tonning and Thompson revealed that people tend to go into the field and stay there due to the regular schedule (M-F, 8-5) and fulfilling nature of the work. Before enrolling in a radiation therapy program, however, Thompson advises prospective students to observe the work in practice:
Most programs are very small, the cost of education is high, and time is valuable. So if you think it’s a career choice for you, before you invest a lot of time, money, and effort, go and spend eight hours or six hours shadowing a radiation therapist over a couple different days, and see if the idea of what you have of the profession actually lends to how you see yourself in a career.
Tonning agreed and added,
There are various routes to becoming a radiation therapist. You can do it fairly quickly or you can take a little longer route, but reaching out to programs for advice and assistance is very beneficial. When people think ‘healthcare,’ they think doctors and nurses. There are many professions that we don’t think about, and this is one that is very patient-focused, very fulfilling, new technology all the time, and you work with teams. If you don’t like people, don’t go into radiation therapy because you’re with your team members and your patients all day. You don’t have your own office!
Not wishing to deter anyone contemplating a career in radiation therapy, she added,
But you need all types too. Some patients want a quiet therapist that can support them silently, and other patients want a therapist that can chat nonstop until they get through their treatment. So, you definitely need a variation of personalities and backgrounds and experiences.
Emphasizing the rewards of the therapist/patient relationship, Tonning shared a final thought: “I’ve seen patients come in crying because they’re scared of radiation, and at their last treatment, they’re crying because they’re [no longer] going to see the team of people who have cared for them.”
Cevia Yellin is a freelance writer based in Eugene, Oregon. She studied English and French literature as an undergraduate. After serving two years as an AmeriCorps volunteer, she earned her master of arts in teaching English to speakers of other languages. Cevia’s travels and experiences working with students of diverse linguistic and cultural backgrounds have contributed to her interest in the forces that shape identity. She grew up on the edge of Philadelphia, where her mom still lives in her childhood home.