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Pelvic Radiation Disease Article from Oncology Nurse Advisor

mp327's picture
mp327
Posts: 4395
Joined: Jan 2010

This is an interesting article from the website Oncology Nurse Advisor.

Radiotherapy side effects: Understanding pelvic radiation disease

 

 Understanding pelvic radiation disease
Radiotherapy side effects: Understanding pelvic radiation disease

As many as 50% of patients undergoing pelvic radiation therapy define their quality of life as degraded due to subsequent chronic changes to their bowel function, such as diarrhea or fecal incontinence.  These late effects are common—in some cases, even life-threatening—and clearly significant for patients. But frequently, they go clinically undetected or remain untreated.

This lack of posttreatment symptom management is due, in part, to a widespread use of symptoms-driven diagnoses (eg, chronic proctitis, enteritis, cystitis) rather than making a cause-describing diagnosis.  Persistent inflammation rarely underlies late radiation toxicities, leading some researchers to reject the use of terms denoting inflammatory conditions to describe late radiotherapy-associated toxicities. 


EVOLVING CLINICAL PERCEPTION 


Radiotherapy-associated chronic toxicity is frequently seen as an assemblage of indistinct complaints or symptoms, rather than a definable disease. Its effects are "rarely accurately measured or fully appreciated," reported an international team of researchers led by H. Jervoise N. Andreyev, PhD.  Late toxicities can be difficult to differentiate from other disorders.

For example, symptom-based (eg, rectal bleeding) toxicity checklists or scales do not measure the duration of symptoms, which is an important consideration when attributing symptoms to prior radiotherapy (eg, rectal bleeding is attributable to radiotherapy only if the anterior rectal wall was irradiated; in up to 33% of cases, postradiotherapy rectal bleeding is due to causes other than the radiotherapy).


Treatment success is typically defined in terms of tumor control or eradication, rather than the long-term well-being of the patient.   However, chronic toxicities can arise months or even years after radiotherapy is completed, so oncology treatment teams may never become aware of them, and other clinicians may not attribute them to a history of pelvic radiotherapy.


Experts have made a concerted effort to move away from describing chronic pelvic radiotherapy-associated toxicities as individual symptoms, recognizing them instead as manifestations of a single phenomenon referred to as pelvic radiation disease.   Andreyev's team defined pelvic radiation disease as transient or longer-term problems, ranging from mild to very severe, that arise in noncancerous tissues as a result of radiation treatments to tumors of pelvic origin.


DIVERSE SYMPTOMS


The development of new symptoms affecting the bowel, urinary tract, sex organs, bones, or skin during or after radiotherapy may be pelvic radiation disease, note Andreyev and colleagues.   Postradiotherapy rectal bleeding should prompt assessment of other potential manifestations of pelvic radiation disease, such as urinary or fecal incontinence.


The molecular and physiologic mechanisms leading to pelvic radiation disease are complex, and symptoms related to gastrointestinal and urinary tract dysfunction can be diverse, frequently arising from separate lesions within different parts of the GI tract.   Radiotherapy can cause ulceration, acute inflammation, cell death, and edema in healthy nontarget tissues, which can be investigated with flexible rectosigmoidoscopy.   These injuries can also lead to chronic ischemia and fibrosis, which are predominantly submucosal changes.


Objective clinical findings do not always match patient-reported symptoms.   Symptoms can include such problems as anal ulceration and bleeding, bloating and constipation, fatigue and lethargy, flatulence, hemorrhoids, insomnia, mucus discharge or steatorrhea (elevated levels of fat in feces caused by diminished intestinal absorption), nausea, abdominal or anal pain, and even the loss of a sense of taste.   Late rectal bleeding appears to be a direct, dose-dependent side effect of radiation therapy, whereas other chronic toxicities of the urinary tract and intestinal mucosa, including incontinence, appear to be long-term exacerbations of acute toxicities (sometimes referred to as consequential late effects) and are independent of radiation dose.  Bowel obstruction, fistulas, and secondary cancers triggered by radiation to nontarget tissues represent potentially life-threatening late toxicities stemming from pelvic radiotherapy.


The evidence base for pelvic radiation disease risks and treatments remains limited; few clinical trials or prospective studies of pelvic radiotherapy have been published. Irradiation of nontarget, healthy tissues ultimately underlies pelvic radiation disease; however, total and per-fraction radiation doses, the volume of irradiated tissues, and concomitant administration of chemotherapy or biologic agents all appear to modulate risk. 


RISK ASSESSMENT


 Few data are yet available about how widespread use of radiotherapeutic modalities with improved targeting, such as intensity-modulated radiotherapy (IMRT), will affect the incidence of pelvic radiation disease.   Early data suggest IMRT and 3D conformal radiotherapy are associated with late GI toxicity rates of 6% and 15%, respectively, among patients treated for prostate cancer; 3.6% and 3.0%, respectively, among patients treated for cervical cancer; 7% and 3%, respectively, among patients treated for anal tumors; and 9.5% and 20%, respectively, among rectal cancer patients also undergoing neoadjuvant chemotherapy.   In general, chemoradiotherapy and radiation dose intensification can improve tumor control rates, but these also increase the risk of acute and chronic toxicities.

Comorbidities and other patient factors also modulate risk. For example, diabetes nearly doubles the risk of pelvic radiation disease 5 years after radiotherapy. Tobacco use, inflammatory bowel disease, scleroderma, or a history of pelvic or abdominal surgery also appear to increase the risk of pelvic radiation disease.


Detecting late toxicities following pelvic radiotherapy traditionally depends primarily on patients completing symptoms-based questionnaires, but these tools are problematic for several reasons.   Questionnaire-based assessments cannot reliably distinguish symptoms that are radiotherapy-associated chronic toxicities from symptoms with other causes.   Patients' definitions of symptoms such as diarrhea can vary, as well; furthermore, patients sometimes deny stigmatizing conditions such as fecal incontinence. Patients should be educated before radiotherapy is undertaken and after its completion about the risks of late toxicity and that these effects may mimic other disorders.


"Patients may not be their own best advocates," cautions Andreyev. They may deny symptoms they have taken drastic measures to prevent to avoid social embarrassment. For example, patients experiencing debilitating urgency of defecation may prevent fecal incontinence by never leaving the house; thus staying, at most, only a few seconds away from the bathroom, or not eating for many hours before they go out.



MANAGEMENT


Symptom management is based on gastroenterologic assessments and nurse-led patient needs assessments. Some patients may need a referral to a urology or gastroenterology specialist, hyperbaric oxygen services, a pain management team, or psychological support.

In cases of extreme bowel obstruction, surgery may be necessary despite the fact that fibrotic scarring leaves patients with pelvic radiation disease at higher risk of complications from surgery.  Endoscopic thermal coagulation therapy using argon plasma, laser, or heater probe can reduce pelvic radiation disease-associated bleeding; however, these treatments may cause pain, strictures, fistula, and perforation.  Endoscopic formalin or cryoablation are also frequently used for bleeding, but these too have a risk of perforation, rectal ulcers, and pain.


The term radiation proctitis implies that late pelvic radiotherapy toxicities are driven by inflammation, and this sometimes leads to inappropriate treatments with corticosteroids or other antiinflammatory agents, such as 5-aminosalicylic acids.  These drugs do not offer any benefits to patients with pelvic radiation disease, according to a 2002 systematic review of clinical trial data.

Opiate antagonists can reduce diarrhea in these patients and bleeding can be ameliorated with a 4-week course of oral metronidazole or sucralfate enema treatments.  Fecal incontinence can be more challenging, although there is limited evidence that phenylephrine gel may help.  One very small prospective, controlled study of 19 patients
 found that fecal incontinence declined among patients who received oral vitamin A (retinol palmitate, 10,000 IU/d for 90 days).

eihtak
Posts: 1373
Joined: Oct 2011

Thank you,

We are told so little of what to expect down the road when first embarking on this journey. While I believe most of us would go along with treatment regardless, it would be nice to know what is ahead.  I feel like making copies and leaving them in the rad docs waiting room, lol.

katheryn

mp327's picture
mp327
Posts: 4395
Joined: Jan 2010

My radiation center gave me a stack of papers to sign on the very first day and one of them listed in detail all of the "possible" short and long term side effects of radiation.  I remember reading it about halfway through and then just signing it without reading it in its entirity.  I knew at that point that I was going through with radiation whether it cured me or killed me, no matter the side effects.  I was not given a copy of that sheet after I handed it back to the tech and now wish I had a copy of it, just so I would know all of the things listed there.  Perhaps there were some side effects listed that I haven't experienced (yet) and perhaps there were some not listed that I or others have dealt with.  It would be interesting to know.

It really gets my goat that so many of our doctors are almost in denial that some of our post-treatment issues could be related to our radiation treatment, so perhaps your idea is a good one!  I am going to see the nephrologist on Friday regarding my kidney disease and one of my questions to him is how the radiation could have affected my kidney function.  I don't know if correlation could ever be proven in my case, but I am going to ask for his opinion on this.   

Martha

 

eihtak
Posts: 1373
Joined: Oct 2011

I don't remember getting any info on possible side effects, but that doesn't mean I didn't, and like you I was going through with it either way. I agree that many doctors avoid agreement on the relation to post treatment issues. My PCP, a female doctor that I've had for years does at least seems open-minded to the idea that there is some possibility of that connection.

I'll be interested to hear what is said about any relation to your kidney disease.

Sometimes I wonder....why is this sort of thing not known and/or accepted and shared by all doctors at this point! Radiation has been around for a long time and surely we are not the first generation of people to question the side-effects.

Anyhow, as always....you are in my thoughts.

katheryn

mp327's picture
mp327
Posts: 4395
Joined: Jan 2010

Thank you for the good thoughts!  I am not looking forward to my appointment tomorrow, as it is likely to be the day that my kidney disease is confirmed to me by the doctor.

It seems quite simple to me that radiation has after-effects.  I cannot forget Chernobyl.  Of course, we were not exposed in the same way or to the same amounts, rather we were exposed with intent to radiate a specific site in our bodies to rid us of cancer in a controlled situation.  However, radiation is radiation and it is harmful to humans.  We are exposed to it daily in small amounts in ways we may not even realize, which I believe is the reason a lot of people end up getting cancer.

My theory is this about doctors' denial.  Radiation oncologists most likely tell patients about possible side effects to prepare the patient for treatment and what they might encounter, short-term and long-term.  The other reason probably has to do with protecting themselves from possible litigation.  I am betting that everyone who is about to receive radiation must sign something indicating that they have been made aware of possible side-effects.  I wish I had had the presence of mind to ask for a copy of the document that I signed.  That you don't remember signing one too may possibly be for the same reason I did not bother to read the entire sheet given to me--I was going to get it either way.  I also think there were so many things going through my mind at the time that I remember very little about that entire day.  

As for doctors who are not radiation oncologists, such as our medical oncologists, colorectal doctors, PCP's, etc., they are not likely to state to a patient their opinion that a treatment rendered by another doctor has done harm to their patient, even though that treatment was necessary and saved their patient's life.  Doctors do not like to say anything derogative about each other.  I worked for a doctor for 6 years and I saw this happen quite a few times.   Even the gastroenterologist that I saw recently said he did not think my gut issues were related to the radiation treatment.  I beg to differ.

Those are just my views and I may be way off base.  I'll let everyone know what the nephrologist has to say about this tomorrow.

Martha

 

AZANNIE's picture
AZANNIE
Posts: 443
Joined: Mar 2011

Thanks for posting this!  I should make a copy and send it to my primary care doctor. Common sense would tell a person that radiation causes damage. 

I vaguely remember signing a paper before radiation treatments started, but at that point I was feeling overwhelmed.

 

Ann

 

mp327's picture
mp327
Posts: 4395
Joined: Jan 2010

I believe that doctors are sometimes uninformed about the effects of radiation, especially the long-term side effects.  Feel free to copy this article and hand it to your PC!

Martha

AZANNIE's picture
AZANNIE
Posts: 443
Joined: Mar 2011

When my new radiation oncologist was reviewing my medical history, I mentioned an incomplete colonoscopy due to "stiffness" and asked him if it was from the radiation and he said yes whereas my medical oncologist said the radiation didn't "go that far up".  Hmm, then why does everyone leave the room when a person has radiation? I like my new radiation oncologist! 

Treatment begins next week - guess I can hop over to the breast cancer discussion group...

Ann

 

mp327's picture
mp327
Posts: 4395
Joined: Jan 2010

I naiively assumed that the radiation did not include my small intestine.  Then when I had the small bowel obstruction in January 2013 and asked if the radiation could possibly have included part of my small intestine, the doctor said "yes."  So, if the small bowel, or at least part of it, can get zapped, it stands to reason that the large intestine, which is what is viewed with colonoscopy, gets zapped too.  I like your new radiation oncologist too--it sounds like he's being totally honest with you.

I wish you all the best with your treatment and I hope you'll keep us posted as to how you are doing.  Hugs!

Martha

pializ
Posts: 465
Joined: Nov 2012

I was told at the outset that my small intestine would be in the radiation zone. I was also told of the possible late effects. In fact, she forgot to tell me about vaginal collateral damage and made another appointment to tell me. My 'zone' was higher than she was used to because of a random pelvic node that was enlarged, and she admitted she had some sleepless nights during the planning stage of my treatment. As it happens, it wasn't a lymph node, but my right ovary!!! It took almost a year after the original diagnosis & various scans to determine just that as that 'lymph node didn't respond to radiotherapy. At one point the only way forward suggested to know for certain was to remove my ovary surgically & then rescan. They said a needle biopsy was too risky due to the location. I had endometriosis previously with my ovaries stuck to my intestines & had adhesiolysis. When I reminded her of this, the idea to remove my ovary was binned as any surgery to irradiated tissue is risky anyway, without there being previous surgery. But anyway, I guess I was just saying that not only was I told about small intestine involvement, but that I was sure to have problems because of the radiation zone needed.......for my pesky ovary!!!

Ouch_Ouch_Ouch
Posts: 505
Joined: Aug 2014

The photo is of "telangiectasias", small permanently dilated veins. According to the old radiation oncologist, I have them, too, on the skin surrounding my anus. Not that I've looked myself.....

Red Sox Fan's picture
Red Sox Fan
Posts: 7
Joined: Sep 2012

Oh gosh!  Thank you so much for sharing this article.  Sometimes I feel like I'm imagining it, or I'm the only one.  It does seem that new after effects appear from time to time and it's nice to know I'm not the only one.

tallorder5793's picture
tallorder5793
Posts: 67
Joined: Oct 2014

In my opinion, with regard to post-radiiation issues, that's the attitude of doctors. I've struggled mightily this past year. When I returned to speak with radiation doctors regarding my issues, they claimed they'd "never seen this before in 16 years of practice." Mind you, my complaints/issues were fairly run of the mill. Anyway, after all this time, I am finally getting ready to see a "pelvic floor physical therapist." And so I am hopeful this will help me. Thanks for posting.

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