Gastrointestinal Symptoms After Pelvic Radiotherapy Should Be Explored

TON - October 2011 Vol 4 No 7 — October 19, 2011

STOCKHOLM—After radiation to the pelvic area, gastrointestinal symptoms are common and can be severe. Jervoise Andreyev, MD, consultant gastroenterologist in pelvic radiation disease at the Royal Marsden Hospital in the United Kingdom, maintained that such patients are not given the attention they deserve, leading to unnecessary suffering.

“Curing patients inevitably risks damage to the normal tissue. Your job is to actively seek out these problems, identify patients, and develop pathways for referral to a gastroenterologist,” Andreyev told attendees. “It’s time for a culture change. We must start offering solutions to these patients.”

Typical Aftereffects of Pelvic Radiotherapy

Take the case of Sarah, a 38-year-old diagnosed with cervical cancer in 2001. She underwent surgery and radiotherapy and had 5 different clinicians involved in her care, yet she was left with nearly incapacitating symptoms. Her bowels moved up to 12 times a day, including several times during the night. She had liquid stool, urgency, and daily incontinence with intermittent steatorrhea, plus subacute obstructive symptoms every 6 weeks. She had lost 35% of her body weight by the time she saw Andreyev and had repeatedly been told there was no treatment for her condition.

Sarah is typical of patients who undergo radiotherapy for pelvic cancer, he said. In surveys, physicians estimate that moderate-to-severe toxicity occurs in 5% to 15% of patients, but, in patient surveys, 90% report a permanent change in bowel habits, 50% say their daily activities are impacted, 30% report that symptoms are moderate to severe, and 15% eventually resort to surgery for these problems.

In the United States, some 5 million cancer survivors have undergone pelvic radiotherapy; these statistics mean that nearly 2 million have moderate to severe symptoms such as Sarah’s, Andreyev said.

Symptoms “Mean Very Little”

After pelvic radiotherapy, men report an average of 6 symptoms and women report 11. An incomplete list includes diarrhea, bleeding pain, urgency, frequent defecation, loss of rectal sensation, incontinence, and weight loss. Andreyev uses a comprehensive checklist and asks patients about each possible symptom.

But Andreyev cautioned that such symptoms should never be assumed to be caused by the cancer treatment. “Why do patients get symptoms? It depends on where the physiologic damage occurs,” he said. “Many patients have more than one cause for each symptom, and different causes can produce the same symptom. If you can identify the symptoms accurately, you can arrange for appropriate testing, diagnosis, and treatment.”

For example, the potential causes of chronic loose stool are numerous: bile acid malabsorption, large bowel strictures, bacterial overgrowth, diverticular disease, lactose intolerance, pelvic sepsis, irritable bowel disease, proctopathy, new neoplasia or disease relapse, and drugs.

For Sarah, the case he described, testing revealed bile acid malabsorption, which was treated with colesevelam (oral bile acid sequestrant); small bowel bacterial overgrowth, which responded to ciprofloxacin; and free fatty acid malabsorption, which was managed with a diet containing 50 g of fat.

Within 4 days, she formed stool twice a day, had no more urgency or fecal incontinence, and no further obstructive episodes. Within 3 weeks, she felt completely normal, and declared her new health to be “a miracle.”

“It was not a miracle. It was pathetic she had put up with these symptoms for such a long time,” he commented.

Andreyev did not suggest that oncology clinicians manage these patients themselves—just that they become aware of the frequency with which side effects of pelvic radiotherapy occur and to ask patients about them.

“Identify patients in trouble and refer them to an expert,” he advised. “And be aware that most of these patients have urinary and sexual problems as well. These are global issues that need to be addressed.”

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