CHART is a particular way of giving radiotherapy. The initials stand for Continuous Hyperfractionated Accelerated Radiotherapy. CHART may be given to some people with a type of lung cancer called non-small cell lung cancer (NSCLC).

Studies have shown that CHART may work better for some people with inoperable non-small cell lung cancer (NSCLC) than standard daily radiotherapy does.

Radiotherapy is the use of x-rays and similar rays (such as electrons) to treat disease. It works by damaging DNA (our genetic material) in the cancer cells. By damaging the DNA, the cancer cells are no longer able to divide and grow.

Each radiotherapy treatment is called a fraction. In standard radiotherapy for lung cancer, one fraction or treatment is given daily from Monday to Friday – usually for several weeks. In CHART, more than one fraction is given each day (hyperfractionation). Reducing the time between fractions means that there is less time between treatments for the fast growing cancer cells to recover.

Unlike standard radiotherapy, where there is a break from treatment at the weekend, people having CHART are given treatment every day including weekends. A modified type of CHART, called CHARTWEL, gives a break at the weekend.

In CHART, the number of treatments will be about the same as standard radiotherapy but the course will be completed sooner (accelerated treatment). The total dose of radiotherapy is similar to that given with standard radiotherapy.

At the moment, CHART radiotherapy is only available in some hospitals. Where it is available, it can be offered in particular situations to people with certain stages of NSCLC. The stage of a cancer is a term used to describe its size, position and whether it has spread beyond where it started in the body. 

CHART radiotherapy can be offered to people with stage 1 and 2 NSCLC whose tumour can't be operated on, or who can’t (or don’t want to) have surgery. It can also be given to those with stage 3A or 3B NSCLC who aren't fit enough (or don't want) to have both chemotherapy and radiotherapy.

Stage 1A – the cancer is no bigger than 3cm (1¼in) in size.

Stage 1B is when either:

• the cancer is larger than 3cm
• the cancer is growing into the main airway of the lung (bronchus)
• the cancer has spread into the inner covering of the lung (pleura).

Stage 2A the cancer measures 3cm (1¼in) or less in size and nearby lymph nodes are affected.

Stage 2B is when either:

• the cancer is larger than 3cm (1¼in) and in the nearby lymph nodes,
• there is no cancer in the lymph nodes, but the tumour has grown into the chest wall, the outer covering of the lung (pleura), or the muscle layer below the lungs (diaphragm).

Stage 3A is when either:

The cancer is of any size and has spread into the lymph nodes in the middle of the chest (mediastinum), but not to the other side of the chest.

The cancer has spread into tissue around the lung near to where it started. This can be into the:

• chest wall
• the covering of the lung
• the middle of the chest (mediastinum)
• other lymph nodes close to the affected lung.

Stage 3B is when either:

• the cancer has spread to lymph nodes on either side of the chest or above the collar bone
• the cancer has spread into another important area; such as the gullet (oesophagus), the heart, windpipe or a main blood vessel
• there are two or more tumours in the same lung
• there is a collection of fluid around the lung, containing cancer cells.

Sometimes it is not possible to give CHART; for example if the tumour is too near the spinal cord, or if the tumour and affected lymph nodes are too far apart.

Treatment planning

To make sure that the radiotherapy works as well as possible, it has to be carefully planned. On your first few visits to the radiotherapy department, you will be asked to lie under a machine called a simulator. This takes x-rays of the area to be treated. Sometimes, a CT scanner can be used for the same purpose. Treatment planning is a very important part of radiotherapy, and it may take a couple of visits.

Pinprick ‘tattoos’ or marks may be drawn on your skin to help the radiographer, who gives you your treatment, to position you accurately, and to show where the rays are to be directed. These marks are often permanent because they must remain visible throughout your treatment, but occasionally they can be washed off once your radiotherapy is finished. At the beginning of your treatment, you will be given instructions on how to look after your skin.

CHART treatment

Before each session of radiotherapy, the radiographer will position you carefully lying on the couch and make sure that you are comfortable. You will be left alone in the room during your treatment (which only takes a few minutes), but will be able to talk to the radiographer, who will be watching you from the next room. Radiotherapy is not painful, but you do have to stay still for a few minutes while the treatment is being given.

A typical schedule would be to give treatment three times a day for 12 days in a row, including the weekends. Each treatment has to be given at least six hours apart. This is to allow the normal cells which have suffered damage to recover between treatments. This reduces the chance of long-term damage to normal tissues.

The first treatment is given early in the morning (about 8am) followed by one around lunchtime (about 2pm) and another in the early evening (about 8pm). This means that people usually have to stay in the hospital, or nearby, while having their radiotherapy.

Giving radiotherapy over two weeks should allow the radiotherapy to be completed before side effects develop. However, there are a few side-effects which may develop towards the end of treatment or after it is finished.

Problems with swallowing The main side effect of CHART is a sore gullet (oesophagitis). This may make swallowing more difficult. You might also have heartburn or indigestion if the gullet is narrowed during treatment. This tends to develop towards the end of treatment and may be at its worst during the first few weeks after treatment before gradually improving.

Let your doctor know if you’re having problems swallowing, as they can give you medicine to help. Some liquid medicines may be helpful as they create a protective layer over sore areas and soothe the lining of the gullet. If you don’t feel like eating, or have problems swallowing, you can replace meals with thick fluids (such as soups and puddings) or nutritious, high-calorie drinks. These drinks are available from most chemists and can be prescribed by your GP.

Tiredness You may find that you feel tired during your radiotherapy. This may get worse as you go through treatment, but should improve over the first few weeks and months after it finishes. Pay attention to how you feel, and if necessary, allow yourself extra time to rest, perhaps by taking a nap in the afternoons.

Cough Radiotherapy may irritate the chest. This means you may develop a cough during or after your treatment. You can ask your doctor for something to help with this. It usually improves when the treatment finishes.

Breathlessness This may get slightly worse during treatment but usually improves when treatment is finished.

If you have any breathing problems which get worse after finishing your treatment it’s important to let your doctors at the hospital know as soon as possible. This is because it could be due to inflammation of the lungs (known as pneumonitis) which may need immediate treatment.

Skin reaction Some people may also find that they get a mild skin reaction (like mild sunburn) on the area being treated, although this is unusual. You will be given advice on how to look after your skin by the radiographer giving your treatment.

Long-term side effects

Lung fibrosis Radiotherapy can cause some damage to the normal lung tissue around the tumour. This can sometimes result in scarring of the lung (fibrosis) which develops between 6–9 months after radiotherapy and can cause breathlessness.

The frequency of lung fibrosis is slightly higher in people having CHART radiotherapy compared to those having standard radiotherapy treatment.

You may have many different emotions, including anxiety and fear. These are normal reactions and are part of the process many people go through in trying to come to terms with their condition.

Everybody has their own way of coping with difficult situations; some people find it helpful to talk to friends or family, while others prefer to seek help from people outside their situation. Some people prefer to keep their feelings to themselves. There is no right or wrong way to cope, but help is available if you need it.

This section has been compiled using information from a number of reliable sources, including:

• Management of patients with lung cancer: a national clinical guideline. SIGN. 2005
• The Diagnosis and Treatment of Lung Cancer. NICE. February 2005
• Saunders M, et al. Continuous, Hyperfractionated, accelerated radiotherapy (CHART) versus conventional radiotherapy in non-small cell lung cancer: mature data from the randomised multicentre trial. Radiotherapy and Oncology. 1999. 52:137-148.
• Syrigos KN , Nutting CM and Roussos, Newbold K. Radical radiotherapy in the management of Locally Advanced Non-Small-Cell Lung Cancer. 2006. Springer.
• Lung cancer intensive radiotherapy for non-smallcell lung cancer. British Medical Journal. 2006.