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Giridhar P, Pradhan S, Dokania S, Venkatesulu B, Sarode R, Welsh JS. Microbiome and Abdominopelvic Radiotherapy Related Chronic Enteritis: A Microbiome-based Mechanistic Role of Probiotics and Antibiotics. Am J Clin Oncol 2024; 47:246-252. [PMID: 38193365 DOI: 10.1097/coc.0000000000001082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2024]
Abstract
Chronic diarrhea and abdominal pain after radiotherapy continue to be a problem in cancer survivors. Gut microbiomes are essential for preventing intestinal inflammation, maintaining intestinal integrity, maintaining enterohepatic circulation, regulating bile acid metabolism, and absorption of nutrients, including fat-soluble vitamins. Gut microbiome dysbiosis is expected to cause inflammation, bile acid malabsorption, malnutrition, and associated symptoms. Postradiotherapy, Firmicutes and Bacteroidetes phylum are significantly decreased while Fusobacteria and other unclassified bacteria are increased. Available evidence suggests harmful bacteria Veillonella, Erysipelotrichaceae, and Ruminococcus are sensitive to Metronidazole or Ciprofloxacin. Beneficial bacteria lactobacillus and Bifidobacterium are relatively resistant to metronidazole. We hypothesize and provide an evidence-based review that short-course targeted antibiotics followed by specific probiotics may lead to alleviation of radiation enteritis.
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Affiliation(s)
| | | | | | - Bhanuprasad Venkatesulu
- Department of Radiation Oncology, Loyola University Chicago, Stritch School of Medicine, Cardinal Bernardin Cancer Center, Maywood
- Department of Radiation Oncology, MPMMCC/HBCH Varanasi Edward Hines Veteran Affairs Hospital, Chicago, IL
| | - Rahul Sarode
- Department of Microbiology, Mahamana Pandit Madanmohan Malaviya Cancer Centre/Homi Bhabha Cancer hospital, Tata Memorial Centre, Varanasi, India
| | - James S Welsh
- Department of Radiation Oncology, Loyola University Chicago, Stritch School of Medicine, Cardinal Bernardin Cancer Center, Maywood
- Department of Radiation Oncology, MPMMCC/HBCH Varanasi Edward Hines Veteran Affairs Hospital, Chicago, IL
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2
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Berntsson H, Thien A, Hind D, Stewart L, Mahzabin M, Tung WS, Bradburn M, Kurien M. Interventions for Managing Late Gastrointestinal Symptoms Following Pelvic Radiotherapy: a Systematic Review and Meta-analysis. Clin Oncol (R Coll Radiol) 2024; 36:318-334. [PMID: 38431427 DOI: 10.1016/j.clon.2024.02.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Revised: 01/04/2024] [Accepted: 02/15/2024] [Indexed: 03/05/2024]
Abstract
AIMS Pelvic radiotherapy can induce gastrointestinal injury and symptoms, which can affect quality of life. We assessed interventions for managing these symptoms. MATERIALS AND METHODS A review of randomised controlled trials published between January 1990 and June 2023 from databases including MEDLINE, EMBASE, CENTRAL, CINAHL, clinicaltrials.gov, ISRCTN and grey literature sources was conducted. Meta-analyses were carried out using the DerSimonian and Laird random effects model to produce overall treatment differences with 95% confidence intervals. RESULTS Twenty-eight studies (2392 participants) of varying methodological quality were included. 4% formalin was superior to sucralfate for improving gastrointestinal symptom score (standardised mean difference [SMD] -1.07, 95% confidence interval -1.48 to -0.65). Argon plasma coagulation (APC) was inferior to sucralfate (SMD 1.22, 95% confidence interval 0.84 to 1.59). Counselling positively influenced symptom score (SMD -0.53, 95% confidence interval -0.76 to -0.29), whereas hyperbaric oxygen therapy showed conflicting results. Sucralfate combined with APC increased endoscopic markers of moderate-severe bleeding versus APC alone (risk ratio 2.26, 95% confidence interval 1.12 to 4.55). No definite conclusions on pain, incontinence, diarrhoea, tenesmus or quality of life interventions were confirmed. CONCLUSIONS Small study sizes, methodological quality and heterogeneity limit support of any individual intervention. APC and 4% formalin seem to be promising interventions, with further larger randomised controlled trials now warranted.
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Affiliation(s)
- H Berntsson
- Sheffield Centre for Health and Related Research, University of Sheffield, Sheffield, UK.
| | - A Thien
- Department of General Surgery, Raja Isteri Pengiran Anak Saleha Hospital, Bandar Seri Begawan, Brunei
| | - D Hind
- Sheffield Centre for Health and Related Research, University of Sheffield, Sheffield, UK
| | - L Stewart
- The Medical School, University of Sheffield, Sheffield, UK
| | - M Mahzabin
- The Medical School, University of Sheffield, Sheffield, UK
| | - W S Tung
- The Medical School, University of Sheffield, Sheffield, UK
| | - M Bradburn
- Sheffield Centre for Health and Related Research, University of Sheffield, Sheffield, UK
| | - M Kurien
- The Medical School, University of Sheffield, Sheffield, UK
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3
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Sanguineti G, Pavarini M, Munoz F, Magli A, Cante D, Garibaldi E, Gebbia A, Noris Chiorda B, Girelli G, Villa E, Faiella A, Magdalena Waskiewicz J, Avuzzi B, Pastorino A, Moretti E, Rago L, Statuto T, Gatti M, Rancati T, Valdagni R, Luigi Vavassori V, Gisella Di Muzio N, Fiorino C, Cozzarini C. Worsening of 2-year patient-reported intestinal functionality after radiotherapy for prostate cancer including pelvic node irradiation. Radiother Oncol 2024; 192:110088. [PMID: 38199284 DOI: 10.1016/j.radonc.2024.110088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 12/31/2023] [Accepted: 01/02/2024] [Indexed: 01/12/2024]
Abstract
BACKGROUND AND PURPOSE To quantify patient-reported 2-year intestinal toxicity (IT) from pelvic nodal irradiation (PNI) for prostate cancer. The association between baseline/acute symptoms and 2-year worsening was investigated. MATERIALS AND METHODS Patient-reported IT was prospectively assessed through the Inflammatory Bowel Disease Questionnaire (IBDQ), filled in at baseline, radiotherapy mid-point and end, at 3 and 6 months and every 6 months until 5 years. Two-year deterioration of IBDQ scores relative to the Bowel Domain was investigated for 400 patients with no severe baseline symptoms and with questionnaires available at baseline, 2 years, RT mid-point and/or end and at least three follow-ups between 3 and 18 months. The significance of the 2-year differences from baseline was tested. The association between baseline values and ΔAcute (the worst decline between baseline and RT mid-point/end) was investigated. RESULTS In the IBDQ lower scores indicate worse symptoms. A significant (p < 0.0001) 2-year mean worsening, mostly in the range of -0.2/-0.4 points on a 1-7 scale, emerged excepting one question (IBDQ29, "nausea/feeling sick"). This decline was independent of treatment intent while baseline values were associated with 2-year absolute scores. The ΔAcute largely modulated 2-year worsening: patients with ΔAcute greater than the first quartile (Q1) and ΔAcute less or equal than Q1 showed no/minimal and highly significant (p < 0.0001) deterioration, respectively. Rectal incontinence, urgency, frequency and abdominal pain showed the largest mean changes (-0.5/-1): risk of severe worsening (deemed to be of clinical significance if ≤ 2) was 3-5 fold higher in the ΔAcute ≤ Q1 vs ΔAcute > Q1 group (p < 0.0001). CONCLUSION A modest but significant deterioration of two-year patient-reported intestinal symptoms from PNI compared to baseline was found. Patients experiencing more severe acute symptoms are at higher risk of symptom persistence at 2 years, with a much larger prevalence of clinically significant symptoms.
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Affiliation(s)
- Giuseppe Sanguineti
- Radiotherapy, IRCCS Istituto Nazionale dei Tumori "Regina Elena", Roma, Italy
| | | | - Fernando Munoz
- Radiotherapy, Ospedale Regionale Parini-AUSL Valle d'Aosta, Aosta, Italy
| | - Alessandro Magli
- Radiotherapy, Azienda Ospedaliero Universitaria S. Maria della Misericordia, Udine, Italy
| | | | | | - Andrea Gebbia
- Medical Physics, IRCCS San Raffaele Scientific Institute, Milano, Italy
| | | | | | - Elisa Villa
- Radiotherapy, Cliniche Gavazzeni-Humanitas, Bergamo, Italy
| | - Adriana Faiella
- Radiotherapy, IRCCS Istituto Nazionale dei Tumori "Regina Elena", Roma, Italy
| | | | - Barbara Avuzzi
- Radiotherapy, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
| | | | - Eugenia Moretti
- Medical Physics, Azienda sanitaria universitaria Friuli Centrale, Udine, Italy
| | - Luciana Rago
- Radiotherapy, Centro di Riferimento Oncologico della Basilicata (IRCCS-CROB), Rionero in Vulture, Italy
| | - Teodora Statuto
- Laboratory of Clinical Research and Advanced Diagnostics, Centro di Riferimento Oncologico della Basilicata (IRCCS - CROB), Rionero in Vulture, Italy
| | - Marco Gatti
- Radiotherapy, Istituto di Candiolo - Fondazione del Piemonte per l'Oncologia IRCCS, Candiolo, Italy
| | - Tiziana Rancati
- Unit of Data Science, Department of Epidemiology and Data Science, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
| | - Riccardo Valdagni
- Radiotherapy, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
| | | | - Nadia Gisella Di Muzio
- Radiotherapy, IRCCS San Raffaele Scientific Institute, Milano, Italy; Medicine and Surgery, Vita-Salute San Raffaele University, Milano, Italy
| | - Claudio Fiorino
- Medical Physics, IRCCS San Raffaele Scientific Institute, Milano, Italy
| | - Cesare Cozzarini
- Radiotherapy, IRCCS San Raffaele Scientific Institute, Milano, Italy.
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4
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Biran A, Dobson C, Rees C, Brooks-Pearson R, Cunliffe A, Durrant L, Hancock J, Ludlow H, Neilson L, Wilson A, Sharp L. From pelvic radiation to social isolation: a qualitative study of survivors' experiences of chronic bowel symptoms after pelvic radiotherapy. J Cancer Surviv 2024:10.1007/s11764-023-01527-6. [PMID: 38182936 DOI: 10.1007/s11764-023-01527-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 12/20/2023] [Indexed: 01/07/2024]
Abstract
PURPOSE We explored survivors' experiences of chronic bowel symptoms following pelvic radiotherapy, strategies employed in living with these symptoms, effects on daily activities, and roles at home and in the workplace. METHODS Semi-structured interviews were conducted with 28 individuals (10 gynaecological, 14 prostate, four anal/rectal cancer survivors) who had completed pelvic radiotherapy at least six months prior to data collection and who had experience of bowel symptoms during this post-treatment period. Reflexive thematic analysis was undertaken. RESULTS We propose four themes describing a process leading from experience of symptoms to withdrawal from activities and roles. These are (1) losing control (the experience of unintended anal leakage or discharge); (2) experiencing embarrassment and fear (the experience of embarrassment or fear of embarrassment as a result of discharge becoming public); (3) managing and reacting (acting to reduce the likelihood of discharge or to prevent this becoming public); and (4) restriction and withdrawal (avoiding specific activities or situations so as to reduce or remove the risk of embarrassment). Returning to the workplace presented additional challenges across these themes. CONCLUSIONS Impacts of chronic bowel symptoms can be severe. Survivors employ a variety of methods and strategies in living with their symptoms. Some of these support continued role fulfilment but some constitute a withdrawal from pre-treatment roles. Current healthcare provision and statutory protections fail to fully meet needs following pelvic radiotherapy. IMPLICATIONS FOR CANCER SURVIVORS There is a need to develop and implement evidence-based services and supported self-management programmes for survivors experiencing chronic bowel problems post-radiotherapy.
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Affiliation(s)
- A Biran
- Population Health Sciences Institute, Newcastle University, Newcastle Upon Tyne, UK
| | - C Dobson
- Population Health Sciences Institute, Newcastle University, Newcastle Upon Tyne, UK
| | - C Rees
- Population Health Sciences Institute, Newcastle University, Newcastle Upon Tyne, UK
| | - R Brooks-Pearson
- Northern Centre for Cancer Care, The Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - A Cunliffe
- South East London Cancer Alliance, London, UK
| | - L Durrant
- Somerset NHS Foundation Trust, Taunton, UK
| | - J Hancock
- North Tees and Hartlepool NHS Foundation Trust, Stockton-On-Tees, UK
| | - H Ludlow
- Cardiff & Vale University Health Board, Cardiff, UK
| | - L Neilson
- Department of Gastroenterology, South Tyneside and Sunderland NHS Foundation Trust, South Shields, UK
| | - A Wilson
- The Royal Marsden NHS Foundation Trust, London, UK
| | - L Sharp
- Population Health Sciences Institute, Newcastle University, Newcastle Upon Tyne, UK.
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5
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Qin Q, Huang B, Wu A, Gao J, Liu X, Cao W, Ma T, Kuang Y, Guo J, Wu Q, Shao B, Guan Q, Yao H, Zhang X, Wang H. Development and Validation of a Post-Radiotherapy Prediction Model for Bowel Dysfunction After Rectal Cancer Resection. Gastroenterology 2023; 165:1430-1442.e14. [PMID: 37625498 DOI: 10.1053/j.gastro.2023.08.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 05/22/2023] [Accepted: 08/13/2023] [Indexed: 08/27/2023]
Abstract
BACKGROUND & AIMS The benefit of radiotherapy for rectal cancer is based largely on a balance between a decrease in local recurrence and an increase in bowel dysfunction. Predicting postoperative disability is helpful for recovery plans and early intervention. We aimed to develop and validate a risk model to improve the prediction of major bowel dysfunction after restorative rectal cancer resection with neoadjuvant radiotherapy using perioperative features. METHODS Eligible patients more than 1 year after restorative resection following radiotherapy were invited to complete the low anterior resection syndrome (LARS) score at 3 national hospitals in China. Clinical characteristics and imaging parameters were assessed with machine learning algorithms. The post-radiotherapy LARS prediction model (PORTLARS) was constructed by means of logistic regression on the basis of key factors with proportional weighs. The accuracy of the model for major LARS prediction was internally and externally validated. RESULTS A total of 868 patients reported a mean LARS score of 28.4 after an average time of 4.7 years since surgery. Key predictors for major LARS included the length of distal rectum, anastomotic leakage, proximal colon of neorectum, and pathologic nodal stage. PORTLARS had a favorable area under the curve for predicting major LARS in the internal dataset (0.835; 95% CI, 0.800-0.870, n = 521) and external dataset (0.884; 95% CI, 0.848-0.921, n = 347). The model achieved both sensitivity and specificity >0.83 in the external validation. In addition, PORTLARS outperformed the preoperative LARS score for prediction of major events. CONCLUSIONS PORTLARS could predict major bowel dysfunction after rectal cancer resection following radiotherapy with high accuracy and robustness. It may serve as a useful tool to identify patients who need additional support for long-term dysfunction in the early stage. CLINICALTRIALS gov, number NCT05129215.
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Affiliation(s)
- Qiyuan Qin
- Department of General Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China; Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, Biomedical Innovation Center, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Binjie Huang
- Department of General Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China; Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, Biomedical Innovation Center, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Aiwen Wu
- State Key Laboratory of Holistic Integrative Management of Gastrointestinal Cancers, Beijing, China; Key Laboratory of Carcinogenesis and Translational Research, Unit III, Gastrointestinal Cancer Center, Peking University Cancer Hospital and Institute, Beijing, China
| | - Jiale Gao
- Department of General Surgery, Beijing Friendship Hospital, Capital Medical University, Beijing, China; National Clinical Research Center for Digestive Diseases, Beijing, China
| | - Xinzhi Liu
- State Key Laboratory of Holistic Integrative Management of Gastrointestinal Cancers, Beijing, China; Key Laboratory of Carcinogenesis and Translational Research, Unit III, Gastrointestinal Cancer Center, Peking University Cancer Hospital and Institute, Beijing, China
| | - Wuteng Cao
- Department of Radiology, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Tenghui Ma
- Department of General Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China; Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, Biomedical Innovation Center, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Yingyi Kuang
- Department of General Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Jirui Guo
- Department of General Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China; Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, Biomedical Innovation Center, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Qian Wu
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, Biomedical Innovation Center, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Biyan Shao
- Department of General Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Qi Guan
- Department of General Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Hongwei Yao
- Department of General Surgery, Beijing Friendship Hospital, Capital Medical University, Beijing, China; National Clinical Research Center for Digestive Diseases, Beijing, China.
| | - Xiaoyan Zhang
- Department of Radiology, Peking University Cancer Hospital and Institute, Beijing, China; Key Laboratory of Carcinogenesis and Translational Research, Ministry of Education Beijing, Beijing, China.
| | - Hui Wang
- Department of General Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China; Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, Biomedical Innovation Center, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.
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6
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Zhang L, He Y, Dong L, Liu C, Su L, Guo R, Luo Q, Gan B, Cao F, Wang Y, Song H, Li X. Perturbation of intestinal stem cell homeostasis and radiation enteritis recovery via dietary titanium dioxide nanoparticles. Cell Prolif 2023:e13427. [PMID: 36798041 PMCID: PMC10392070 DOI: 10.1111/cpr.13427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 01/30/2023] [Accepted: 02/02/2023] [Indexed: 02/18/2023] Open
Abstract
Small intestinal health and enteritis incidence are tightly coupled to the homeostasis of intestinal stem cells (ISCs), which are sensitive to dietary alterations. However, little is known about the impact of food additives on ISC pool. Here, we demonstrate that chronic exposure to low-dose TiO2 NPs, a commonly used food additive, significantly hampers primary human and mouse ISC-derived organoid formation and growth by specifically attenuating Wnt signal transduction. Mechanistically, TiO2 NPs alter the endocytic trafficking of the Wnt receptor LRP6 and prevent the nuclear entry of β-catenin. Notably, dietary TiO2 NPs elicit modest chronic stress in healthy intestines and considerably impede the recovery of radiation enteritis by perturbing the homeostasis of ISCs in vivo. Our results identify a health concern of TiO2 NP exposure on ISC homeostasis and radiation enteritis recovery. These findings suggest extra precaution during the treatment of radiation enteritis and provide new insights into food additive-ISC interaction.
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Affiliation(s)
- Linpei Zhang
- BioBank, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Yinli He
- BioBank, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Lele Dong
- Department of Pharmacy, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Chang Liu
- School of Public Health, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Lin Su
- BioBank, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Ruirui Guo
- BioBank, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Qinying Luo
- BioBank, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Baoyu Gan
- BioBank, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Fang Cao
- Center for Translational Medicine, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Yawen Wang
- BioBank, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Haiyun Song
- School of Public Health, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xiaojiao Li
- BioBank, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
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7
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Spampinato S, Tanderup K, Lindegaard JC, Schmid MP, Sturdza A, Segedin B, Jürgenliemk-Schulz IM, De Leeuw A, Bruheim K, Mahantshetty U, Chargari C, Rai B, Cooper R, van der Steen-Banasik E, Sundset M, Wiebe E, Villafranca E, Van Limbergen E, Pieters BR, Tee Tan L, Lutgens LCHW, Hoskin P, Smet S, Pötter R, Nout R, Chopra S, Kirchheiner K. Association of persistent morbidity after radiotherapy with quality of life in locally advanced cervical cancer survivors. Radiother Oncol 2023; 181:109501. [PMID: 36720348 DOI: 10.1016/j.radonc.2023.109501] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 01/13/2023] [Accepted: 01/22/2023] [Indexed: 01/31/2023]
Abstract
PURPOSE To quantify the association of persistent morbidity with different aspects of quality of life (QOL) in locally advanced cervical cancer (LACC) survivors. MATERIAL AND METHODS Longitudinal outcome from the EMBRACE-I study was evaluated. Patient-reported symptoms and QOL were prospectively scored (EORTC-C30/CX24) at baseline and regular follow-ups. Physician-assessed symptoms were also reported (CTCAEv.3). Persistent symptoms were defined if present in at least half of the follow-ups. QOL items were linearly transformed into a continuous scale. Linear mixed-effects models (LMM) were applied to evaluate and quantify the association of persistent symptoms with QOL. Overall QOL deterioration was evaluated by calculating the integral difference in QOL over time obtained with LMM for patients without and with persistent symptoms. RESULTS Out of 1416 patients enrolled, 741 with baseline and ≥ 3 late follow-ups were analyzed (median 59 months). Proportions of persistent EORTC symptoms ranged from 21.8 % to 64.9 % (bowel control and tiredness). For CTCAE the range was 11.3-28.6 % (limb edema and fatigue). Presence of any persistent symptom was associated with QOL, although with varying magnitude. Role functioning and Global health/QOL were the most impaired aspects. Fatigue and pain showed large differences, with reductions of around 20 % for most of the QOL aspects. Among organ-related symptoms, abdominal cramps showed the largest effect. CONCLUSION Persistent symptoms are associated with QOL reductions in LACC survivors. Organ-related symptoms showed smaller differences than general symptoms such as fatigue and pain. In addition to optimizing treatment to minimize organ-related morbidity, effort should be directed towards a more comprehensive and targeted morbidity management.
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Affiliation(s)
- Sofia Spampinato
- Danish Center for Particle Therapy, Aarhus University Hospital, 8200 Aarhus, Denmark.
| | - Kari Tanderup
- Danish Center for Particle Therapy, Aarhus University Hospital, 8200 Aarhus, Denmark; Department of Clinical Medicine, Aarhus University, 8200 Aarhus, Denmark.
| | - Jacob C Lindegaard
- Department of Oncology, Aarhus University Hospital, 8200 Aarhus, Denmark.
| | - Maximilian P Schmid
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, 1090 Vienna, Austria.
| | - Alina Sturdza
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, 1090 Vienna, Austria.
| | - Barbara Segedin
- Department of Radiotherapy, Institute of Oncology, 1000 Ljubljana, Slovenia; Faculty of Medicine, University of Ljubljana, 1000 Ljubljana, Slovenia.
| | - Ina M Jürgenliemk-Schulz
- Department of Radiation Oncology, University Medical Centre Utrecht, 3584 CX Utrecht, the Netherlands.
| | - Astrid De Leeuw
- Department of Radiation Oncology, University Medical Centre Utrecht, 3584 CX Utrecht, the Netherlands.
| | - Kjersti Bruheim
- Department of Oncology, Oslo University Hospital, 0450 Oslo, Norway.
| | - Umesh Mahantshetty
- Department of Radiation Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai and Homi Bhabha Cancer Hospital and Research Centre, Visakhapatnam, Andhra Pradesh 530053, India.
| | - Cyrus Chargari
- Department of Radiation Oncology, Gustave Roussy Cancer Campus, 94805 Villejuif, France.
| | - Bhavana Rai
- Department of Radiotherapy and Oncology, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India.
| | - Rachel Cooper
- Leeds Cancer Centre, St James's University Hospital, Leeds LS9 7LP, United Kingdom.
| | | | - Marit Sundset
- Clinic of Oncology and Women's Clinic, St. Olavs Hospital, 7030 Trondheim, Norway.
| | - Ericka Wiebe
- Department of Oncology, Cross Cancer Institute and University of Alberta, Edmonton AB T6G 1Z2, Canada.
| | - Elena Villafranca
- Department of Radiation Oncology, Hospital of Navarra, 31008 Pamplona, Navarra, Spain.
| | - Erik Van Limbergen
- Department of Radiation Oncology, University Hospital Leuven, 3000 Leuven, Belgium.
| | - Bradley R Pieters
- Department of Radiation Oncology, Amsterdam University Medical Centers, University of Amsterdam, 1081 HV Amsterdam, the Netherlands; Cancer Center Amsterdam, Cancer Treatment and Quality of Life, 1081 HV Amsterdam, the Netherlands.
| | - Li Tee Tan
- Oncology Centre, Cambridge University Hospitals NHS Foundation Trust, Cambridge CB2 0QQ, United Kingdom.
| | - Ludy C H W Lutgens
- Maastricht Radiation Oncology (MAASTRO) clinic, 6229 ET Maastricht, the Netherlands.
| | - Peter Hoskin
- Mount Vernon Cancer Centre, Mount Vernon Hospital, Northwood HA6 2RN, United Kingdom.
| | - Stéphanie Smet
- Department of Radiation Oncology, Algemeen Ziekenhuis Turnhout, 2300 Turnhout, Belgium.
| | - Richard Pötter
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, 1090 Vienna, Austria.
| | - Remi Nout
- Department of Clinical Oncology, Leiden University Medical Center, 2333 ZA Leiden, the Netherlands.
| | - Supriya Chopra
- Department of Radiation Oncology, Advanced Centre for Treatment Research and Education in Cancer, Tata Memorial Centre, Homi Bhabha National Institute, Navi Mumbai 410210, India.
| | - Kathrin Kirchheiner
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, 1090 Vienna, Austria.
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8
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Mekhael M, Larsen HM, Lauritzen MB, Thorlacius-Ussing O, Laurberg S, Krogh K, Drewes AM, Christensen P, Juul T. Bowel dysfunction following pelvic organ cancer: a prospective study on the treatment effect in nurse-led late sequelae clinics. Acta Oncol 2023; 62:70-79. [PMID: 36757368 DOI: 10.1080/0284186x.2023.2168214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/10/2023]
Abstract
BACKGROUND Bowel dysfunction following treatment of pelvic organ cancer is prevalent and impacts the quality of life (QoL). The present study aimed to evaluate the feasibility and effects of treating bowel dysfunction in two nurse-led late sequelae clinics. MATERIAL AND METHODS Treatment effects were monitored prospectively by patient-reported outcome measures collected at baseline and discharge. Change in bowel function was evaluated by 15 bowel symptoms, the St. Mark's Incontinence Score, the Patients Assessment of Constipation-Symptoms (PAC-SYM) score and self-rated bowel function. QoL was evaluated by the EuroQol 5-dimension 5-level (EQ-5D-5L) utility score and by measuring the impact of bowel function on QoL. RESULTS From June 2018 to December 2021, 380 cancer survivors (46% rectal, 15% gynaecological, 13% anal, 12% colon, 12% prostate, and 2% other cancers) completed a baseline questionnaire and started treatment for bowel dysfunction. At referral, 96% of patients were multisymptomatic. The most frequent symptoms were faecal urgency (95%), fragmented defaecation (93%), emptying difficulties (92%), flatus/faecal incontinence (flatus 89%, liquid 59%, solid 33%), and obstructed defaecation (79%). In total, 169 patients were discharged from the clinics in the follow-up period. At discharge, 69% received conservative treatment only and 24% also received transanal irrigation; 4% were surgically treated; 3% discontinued treatment. Improvements were seen in all 15 bowel symptoms (p < 0.001), the mean St. Mark's Incontinence Score (12.0 to 9.9, p < 0.001), the mean PAC-SYM score (1.04 to 0.84, p < 0.001) and the mean EQ-5D-5L utility score (0.78 to 0.84, p < 0.001). Self-rated bowel function improved in 56% (p < 0.001) of cases and the impact of bowel function on QoL improved in 46% (p < 0.001). CONCLUSION Treatment of bowel dysfunction in nurse-led late sequelae clinics is feasible and significantly improved bowel function and QoL.
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Affiliation(s)
- Mira Mekhael
- Department of Surgery, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Danish Cancer Society Centre for Research on Survivorship and Late Adverse Effects after Cancer in the Pelvic Organs, Aarhus and Aalborg University Hospitals, Aarhus and Aalborg, Denmark
| | - Helene M Larsen
- Department of Surgery, Aarhus University Hospital, Aarhus, Denmark.,Danish Cancer Society Centre for Research on Survivorship and Late Adverse Effects after Cancer in the Pelvic Organs, Aarhus and Aalborg University Hospitals, Aarhus and Aalborg, Denmark.,Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - Michael B Lauritzen
- Danish Cancer Society Centre for Research on Survivorship and Late Adverse Effects after Cancer in the Pelvic Organs, Aarhus and Aalborg University Hospitals, Aarhus and Aalborg, Denmark.,Department of Gastrointestinal Surgery, Aalborg University Hospital, Aalborg, Denmark
| | - Ole Thorlacius-Ussing
- Danish Cancer Society Centre for Research on Survivorship and Late Adverse Effects after Cancer in the Pelvic Organs, Aarhus and Aalborg University Hospitals, Aarhus and Aalborg, Denmark.,Department of Gastrointestinal Surgery, Aalborg University Hospital, Aalborg, Denmark.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Søren Laurberg
- Department of Surgery, Aarhus University Hospital, Aarhus, Denmark.,Danish Cancer Society Centre for Research on Survivorship and Late Adverse Effects after Cancer in the Pelvic Organs, Aarhus and Aalborg University Hospitals, Aarhus and Aalborg, Denmark
| | - Klaus Krogh
- Danish Cancer Society Centre for Research on Survivorship and Late Adverse Effects after Cancer in the Pelvic Organs, Aarhus and Aalborg University Hospitals, Aarhus and Aalborg, Denmark.,Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - Asbjørn M Drewes
- Danish Cancer Society Centre for Research on Survivorship and Late Adverse Effects after Cancer in the Pelvic Organs, Aarhus and Aalborg University Hospitals, Aarhus and Aalborg, Denmark.,Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
| | - Peter Christensen
- Department of Surgery, Aarhus University Hospital, Aarhus, Denmark.,Danish Cancer Society Centre for Research on Survivorship and Late Adverse Effects after Cancer in the Pelvic Organs, Aarhus and Aalborg University Hospitals, Aarhus and Aalborg, Denmark
| | - Therese Juul
- Department of Surgery, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Danish Cancer Society Centre for Research on Survivorship and Late Adverse Effects after Cancer in the Pelvic Organs, Aarhus and Aalborg University Hospitals, Aarhus and Aalborg, Denmark
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9
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The Role of the Human Gut Microbiome in Inflammatory Bowel Disease and Radiation Enteropathy. Microorganisms 2022; 10:microorganisms10081613. [PMID: 36014031 PMCID: PMC9415405 DOI: 10.3390/microorganisms10081613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2022] [Revised: 08/04/2022] [Accepted: 08/08/2022] [Indexed: 12/04/2022] Open
Abstract
The human gut microbiome plays a key role in regulating host physiology. In a stable state, both the microbiota and the gut work synergistically. The overall homeostasis of the intestinal flora can be affected by multiple factors, including disease states and the treatments given for those diseases. In this review, we examine the relatively well-characterised abnormalities that develop in the microbiome in idiopathic inflammatory bowel disease, and compare and contrast them to those that are found in radiation enteropathy. We discuss how these changes may exert their effects at a molecular level, and the possible role of manipulating the microbiome through the use of a variety of therapies to reduce the severity of the underlying condition.
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10
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Laurberg T, Frandsen S, Larsen HM, Lehrskov LL, Graversen SB, Drewes AM, Emmertsen KJ, Krogh K. The impact of type 2 diabetes on long-term gastrointestinal sequelae after colorectal cancer surgery: national population-based study. BJS Open 2022; 6:6673944. [PMID: 35998089 PMCID: PMC9397505 DOI: 10.1093/bjsopen/zrac095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Revised: 06/16/2022] [Accepted: 06/26/2022] [Indexed: 12/24/2022] Open
Abstract
Background Long-term gastrointestinal sequelae are common after colorectal cancer surgery, but the impact of type 2 diabetes (T2D) is unknown. Methods In a cross-sectional design, questionnaires regarding bowel function and quality of life (QoL) were sent to all Danish colorectal cancer survivors, who had undergone surgery between 2001 and 2014 and had more than 2 years follow-up without relapse. The prevalence of long-term gastrointestinal sequelae among colorectal cancer survivors with and without T2D were compared while stratifying for type of surgical resection and adjusting for age, sex, and time since surgery. Results A total of 8747 out of 14 488 colorectal cancer survivors answered the questionnaire (response rate 60 per cent), consisting of 3116 right-sided colonic, 2861 sigmoid, and 2770 rectal resections. Of these, 690 (7.9 per cent) had a diagnosis of T2D before surgery. Survivors with T2D following rectal resection had a 15 per cent (95 per cent c.i. 7.8 to 22) higher absolute risk of major low anterior resection syndrome, whereas survivors with T2D following right-sided and sigmoid resection had an 8 per cent higher risk of constipation (P < 0.001) but otherwise nearly the same long-term risk of bowel symptoms as those without T2D. For all types of colorectal cancer resections, T2D was associated with a 6–10 per cent higher risk of severe pain (P < 0.035) and a 4–8 per cent higher risk of impaired QoL. Conclusion T2D at time of surgery was associated with a higher risk of long-term bowel dysfunction after rectal resection, but not after colon resection excluding a higher risk of constipation. T2D was associated with a slightly higher frequency of severe pain and inferior QoL after both rectal and colonic cancer resection.
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Affiliation(s)
- Tinne Laurberg
- Steno Diabetes Center Aarhus, Aarhus University Hospital , Aarhus , Denmark
| | | | - Helene M Larsen
- Danish Cancer Society Centre for Research on Survivorship and Late Adverse Effects after Cancer in the Pelvic Organs , Aarhus/Aalborg , Denmark
- Department of Emergency, Regional Hospital Horsens , Horsens , Denmark
| | - Louise L Lehrskov
- The Centre for Physical Activity Research, Copenhagen University Hospital – Rigshospitalet , Copenhagen , Denmark
| | | | - Asbjørn M Drewes
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital , Aalborg , Denmark
| | - Katrine J Emmertsen
- Danish Cancer Society Centre for Research on Survivorship and Late Adverse Effects after Cancer in the Pelvic Organs , Aarhus/Aalborg , Denmark
- Department of Surgery, Regional Hospital Randers , Randers , Denmark
| | - Klaus Krogh
- Steno Diabetes Center Aarhus, Aarhus University Hospital , Aarhus , Denmark
- Department of Hepatology and Gastroenterology, Aarhus University Hospital , Aarhus , Denmark
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11
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Pelvic Floor Rehabilitation After Rectal Cancer Surgery: A Multicenter Randomized Clinical Trial (FORCE Trial). Ann Surg 2022; 276:38-45. [PMID: 34966064 DOI: 10.1097/sla.0000000000005353] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To investigate the effects of PFR after LAR compared to usual care without PFR. SUMMARY OF BACKGROUND DATA Functional complaints, including fecal incontinence, often occur after LAR for rectal cancer. Controversy exists about the effectiveness of PFR in improving such postoperative functional outcomes. METHODS This was a multicenter, randomized controlled trial involving 17 Dutch centers. Patients after LAR for rectal cancer were randomly assigned (1:1) to usual care or PFR and stratified by sex and administration of neoadjuvant therapy. Selection was not based on severity of complaints at baseline. Baseline measurements were taken 3 months after surgery without temporary stoma construction or 6 weeks after stoma closure. The primary outcome measure was the change in Wexner incontinence scores 3 months after randomization. Secondary outcomes were fecal incontinence-related quality of life, colorectal-specific quality of life, and the LARS scores. RESULTS Between October 2017 and March 2020, 128 patients were enrolled and 106 randomly assigned (PFR n = 51, control n = 55); 95 patients (PFR n = 44, control n = 51) were assessable for final analysis. PFR did not lead to larger changes in Wexner incontinence scores in nonselected patients after LAR compared to usual care [PFR: -2.3, 95% confidence interval (CI) -3.3 to -1.4, control: -1.3, 95% CI -2.2 to -0.4, P = 0.13]. However, PFR was associated with less urgency at follow-up (odds ratio 0.22, 95% CI 0.06-0.86). Patients without near-complete incontinence reported larger Wexner score improvements after PFR (PFR: -2.1, 95% CI -3.1 to -1.1, control: -0.7, 95% CI -1.6 to 0.2, P = 0.045). For patients with at least moderate incontinence PFR resulted in relevant improvements in all fecal incontinence-related quality of life domains, while the control group deteriorated. These improvements were even larger when patients with near-complete incontinence were excluded. No serious adverse PFR-related events occurred. CONCLUSION No benefit was found of PFR in all patients but several subgroups were identified that did benefit from PFR, such as patients with urgency or with at least moderate incontinence and no near-complete incontinence. A selective referral policy (65%-85% of all patients) is suggested to improve postoperative functional outcomes for patients after LAR for rectal cancer. TRIAL REGISTRATION Netherlands Trial Registration, NTR5469, registered on 3 September 2015.
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12
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Takenaka M, Hosono M, Rehani MM, Chiba Y, Ishikawa R, Okamoto A, Yamazaki T, Nakai A, Omoto S, Minaga K, Kamata K, Yamao K, Hayashi S, Nishida T, Kudo M. Comparison of radiation exposure between endoscopic ultrasound-guided drainage and transpapillary drainage by endoscopic retrograde cholangiopancreatography for pancreatobiliary diseases. Dig Endosc 2022; 34:579-586. [PMID: 34107099 PMCID: PMC9292288 DOI: 10.1111/den.14060] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 05/24/2021] [Accepted: 06/08/2021] [Indexed: 02/08/2023]
Abstract
OBJECTIVES The transpapillary drainage by endoscopic retrograde cholangiopancreatography (ERCP-D) cannot be performed without fluoroscopy, and there are many situations in which fluoroscopy is required even in endoscopic ultrasound-guided drainage (EUS-D). Previous studies have compared the efficacy, but not the radiation exposure of EUS-D and ERCP-D. While radiation exposure in ERCP-D has been previously evaluated, there is a paucity of information regarding radiation doses in EUS-D. This study aimed to assess radiation exposure in EUS-D compared with that in ERCP-D. METHODS This retrospective single-center cohort study included consecutive patients who underwent EUS-D and ERCP-D between October 2017 and March 2019. The air kerma (AK, mGy), kerma-area product (KAP, Gycm2 ), fluoroscopy time (FT, min), and procedure time (PT, min) were assessed. The invasive probability weighting method was used to qualify the comparisons. RESULTS We enrolled 372 and 105 patients who underwent ERCP-D and EUS-D, respectively. The mean AK, KAP, and FT in the EUS-D group were higher by 53%, 28%, and 27%, respectively, than those in the ERCP-D group, whereas PT was shorter by approximately 11% (AK, 135.0 vs. 88.4; KAP, 28.1 vs. 21.9; FT, 20.4 vs. 16.0; PT, 38.7 vs. 43.5). The sub-analysis limited to biliary drainage cases showed the same trend (AK, 128.3 vs. 90.9; KAP, 27.0 vs. 22.2; FT, 16.4 vs. 16.1; PT, 32.5 vs. 44.4). CONCLUSIONS This is the first study to assess radiation exposure in EUS-D compared with that in ERCP-D. Radiation exposure was significantly higher in EUS-D than in ERCP-D, despite the shorter procedure time.
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Affiliation(s)
- Mamoru Takenaka
- Departments ofGastroenterology and HepatologyKindai University Faculty of MedicineOsakaJapan
| | - Makoto Hosono
- Department ofRadiologyKindai University Faculty of MedicineOsakaJapan
| | - Madan M. Rehani
- Global Outreach for Radiation Protection ProgramRadiation Safety CommitteeMassachusetts General HospitalBostonUSA
| | - Yasutaka Chiba
- Clinical Research CenterKindai University HospitalOsakaJapan
| | - Rei Ishikawa
- Departments ofGastroenterology and HepatologyKindai University Faculty of MedicineOsakaJapan
| | - Ayana Okamoto
- Departments ofGastroenterology and HepatologyKindai University Faculty of MedicineOsakaJapan
| | - Tomohiro Yamazaki
- Departments ofGastroenterology and HepatologyKindai University Faculty of MedicineOsakaJapan
| | - Atsushi Nakai
- Departments ofGastroenterology and HepatologyKindai University Faculty of MedicineOsakaJapan
| | - Shunsuke Omoto
- Departments ofGastroenterology and HepatologyKindai University Faculty of MedicineOsakaJapan
| | - Kosuke Minaga
- Departments ofGastroenterology and HepatologyKindai University Faculty of MedicineOsakaJapan
| | - Ken Kamata
- Departments ofGastroenterology and HepatologyKindai University Faculty of MedicineOsakaJapan
| | - Kentaro Yamao
- Departments ofGastroenterology and HepatologyKindai University Faculty of MedicineOsakaJapan
| | - Shiro Hayashi
- Department of GastroenterologyToyonaka Municipal HospitalOsakaJapan,Department of Gastroenterology and Internal MedicineHayashi ClinicOsakaJapan
| | - Tsutomu Nishida
- Department of GastroenterologyToyonaka Municipal HospitalOsakaJapan
| | - Masatoshi Kudo
- Departments ofGastroenterology and HepatologyKindai University Faculty of MedicineOsakaJapan
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13
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Jervoise N Andreyev H, Matthews J, Adams C, Gothard L, Lucy C, Tovey H, Boyle S, Anbalagan S, Musallam A, Yarnold J, Abraham D, Bliss J, Ahmed Abdi B, Taylor A, Hauer-Jensen M. Randomised single centre double-blind placebo controlled phase II trial of Tocovid SupraBio in combination with pentoxifylline in patients suffering long-term gastrointestinal adverse effects of radiotherapy for pelvic cancer: the PPALM study. Radiother Oncol 2022; 168:130-137. [DOI: 10.1016/j.radonc.2022.01.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 01/13/2022] [Accepted: 01/16/2022] [Indexed: 02/07/2023]
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14
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Çolak S, Vural F. Effect of
nurse‐led
interventions on patient outcomes in patients with prostate cancer: A systematic review. INTERNATIONAL JOURNAL OF UROLOGICAL NURSING 2021. [DOI: 10.1111/ijun.12310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Sevgi Çolak
- Department of Surgical Nursing Health Sciences Institute, Dokuz Eylul University Izmir Turkey
| | - Fatma Vural
- Department of Surgical Nursing, Faculty of Nursing Dokuz Eylul University Izmir Turkey
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15
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Takenaka M, Hosono M, Hayashi S, Nishida T, Kudo M. The radiation doses and radiation protection on the endoscopic retrograde cholangiopancreatography procedures. Br J Radiol 2021; 94:20210399. [PMID: 34379457 DOI: 10.1259/bjr.20210399] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Although many interventions involving radiation exposure have been replaced to endoscopic procedure in the gastrointestinal and hepatobiliary fields, there remains no alternative for enteroscopy and endoscopic retrograde cholangiopancreatography (ERCP), which requires the use of radiation. In this review, we discuss the radiation doses and protective measures of endoscopic procedures, especially for ERCP. For the patient radiation dose, the average dose area product for diagnostic ERCP was 14-26 Gy.cm², while it increased to as high as 67-89 Gy.cm² for therapeutic ERCP. The corresponding entrance skin doses for diagnostic and therapeutic ERCP were 90 and 250 mGy, respectively. The mean effective doses were 3- 6 mSv for diagnostic ERCP and 12-20 mSv for therapeutic ERCP. For the occupational radiation dose, the typical doses were 94 μGy and 75 μGy for the eye and neck, respectively. However, with an over-couch-type X-ray unit, the eye and neck doses reached as high as 550 and 450 μGy, with maximal doses of up to 2.8 and 2.4 mGy/procedure, respectively.A protective lead shield was effective for an over couch X-ray tube unit. It lowered scattered radiation by up to 89.1% in a phantom study. In actual measurements, the radiation exposure of the endoscopist closest to the unit was reduced to approximately 12%. In conclusion, there is a clear need for raising awareness among medical personnel involved endoscopic procedures to minimise radiation risks to both the patients and staff.
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Affiliation(s)
- Mamoru Takenaka
- Department of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Osaka-sayama, Japan
| | - Makoto Hosono
- Department of Radiation Oncology, Kindai University Faculty of Medicine, Osaka-sayama, Japan
| | - Shiro Hayashi
- Department of Gastroenterology, Toyonaka Municipal Hospital, Toyonaka, Japan.,Department of Gastroenterology and Internal Medicine, Hayashi Clinic, Suita, Japan
| | - Tsutomu Nishida
- Department of Gastroenterology, Toyonaka Municipal Hospital, Toyonaka, Japan
| | - Masatoshi Kudo
- Department of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Osaka-sayama, Japan
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16
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Assessment and management of low anterior resection syndrome after sphincter preserving surgery for rectal cancer. Chin Med J (Engl) 2021; 133:1824-1833. [PMID: 32604174 PMCID: PMC7469998 DOI: 10.1097/cm9.0000000000000852] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Many patients develop a variety of bowel dysfunction after sphincter preserving surgeries (SPS) for rectal cancer. The bowel dysfunction usually manifests in the form of low anterior resection syndrome (LARS), which has a negative impact on the patients’ quality of life. This study reviewed the LARS after SPS, its mechanism, risk factors, diagnosis, prevention, and treatment based on previously published studies. Adequate history taking, physical examination of the patients, using validated questionnaires and other diagnostic tools are important for assessment of LARS severity. Treatment of LARS should be tailored to each patient. Multimodal therapy is usually needed for patients with major LARS with acceptable results. The treatment includes conservative management in the form of medical, pelvic floor rehabilitation and transanal irrigation and invasive procedures including neuromodulation. If this treatment failed, fecal diversion may be needed. In conclusion, Initial meticulous dissection with preservation of nerves and creation of a neorectal reservoir during anastomosis and proper Kegel exercise of the anal sphincter can minimize the occurrence of LARS. Pre-treatment counseling is an essential step for patients who have risk factors for developing LARS.
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17
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Fernandes DCR, Andreyev HJN. Gastrointestinal Toxicity of Pelvic Radiotherapy: Are We Letting Women Down? Clin Oncol (R Coll Radiol) 2021; 33:591-601. [PMID: 33985867 DOI: 10.1016/j.clon.2021.04.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 03/16/2021] [Accepted: 04/20/2021] [Indexed: 12/23/2022]
Abstract
For all cancers there are four areas of importance: prevention, early diagnosis, optimising therapy and living with and beyond. For women diagnosed with gynaecological cancers, progress in these first three areas has been immense. However, living with and beyond has largely been ignored as a significant issue. As a group, patients treated for gynaecological cancer are more often young and more often suffer the most difficult long-term issues. Despite the growing number of long-term survivors, little has been done to ensure appropriate assessment and treatment of side-effects of cancer therapies, especially when radiotherapy has been used. For many affected patients their symptoms become part of everyday life, 'normality' is adjusted and these changes are tolerated even when severely limiting activities. Data show that even expert clinicians frequently do not appreciate the true impact of these problems and the focus of treatment and of follow-up remains fixed on 5-year survival and cancer recurrence, respectively. Many clinicians are unaware of what experts can do for toxicity and do not know where to refer their patients. However, rapid identification of patients with significant symptoms can lead to earlier diagnosis of treatable pathologies and improvement in patients' quality of life. In addition, the underlying pathophysiology of radiation-induced damage is potentially amenable to disease-modifying therapies. This review focuses on the factors that contribute to patients developing pelvic radiation disease, what can be done to mitigate the toxicity of treatment and highlights the challenges that must be addressed to reduce the gastrointestinal toxicity of pelvic radiotherapy.
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Affiliation(s)
- D C R Fernandes
- Department of Gastroenterology, United Lincolnshire NHS Trust, Lincoln County Hospital, Lincoln, UK
| | - H J N Andreyev
- Department of Gastroenterology, United Lincolnshire NHS Trust, Lincoln County Hospital, Lincoln, UK; The Biomedical Research Centre, Nottingham Digestive Diseases Centre, School of Medicine, University of Nottingham, Nottingham, UK.
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18
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Andreyev HJN, Lalji A, Mohammed K, Muls ACG, Watkins D, Rao S, Starling N, Chau I, Cruse S, Pitkaaho V, Matthews J, Caley L, Pittordou V, Adams C, Wedlake L. The FOCCUS study: a prospective evaluation of the frequency, severity and treatable causes of gastrointestinal symptoms during and after chemotherapy. Support Care Cancer 2021; 29:1443-1453. [PMID: 32676853 PMCID: PMC7843552 DOI: 10.1007/s00520-020-05610-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Accepted: 06/29/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND The underlying mechanisms of chemotherapy-induced gastrointestinal (GI) symptoms are poorly researched. This study characterised the nature, frequency, severity and treatable causes for GI symptoms prospectively in patients undergoing chemotherapy for GI malignancy. METHODS Patients receiving chemotherapy for a GI malignancy were assessed pre-chemotherapy, then monthly for 1 year using the Gastrointestinal Symptom Rating Scale, a validated patient-reported outcome measure. Patients with new, troublesome GI symptoms were offered investigations to diagnose the cause(s). Their oncologist was alerted when investigations were abnormal. RESULTS A total of 241 patients, 60% male, median age 63 years (range 30-88), were enrolled; 122 patients were withdrawn, 93%, because of progressive disease or death. During the study, > 20% patients reported chronic faecal incontinence and > 10% reported moderate or severe problems with taste, dysphagia, belching, heartburn, early satiety, appetite, nausea, abdominal cramps, peri-rectal pain, rectal flatulence, borborygmi, urgency of defecation or tenesmus. Thirty percent reported continuing passage of hard stools and 30% on-going diarrhoea. Moderate or severe fatigue affected 40% participants at its peak and persisted in 15% at 1 year. Toxicity dictated change in chemotherapy for 13-29% patients/month. Common Terminology Criteria for Adverse Events underestimated gastrointestinal morbidity. Pre-chemotherapy screening identified previously undiagnosed pathology: exocrine pancreatic insufficiency (9%), vitamin B12 deficiency (12%) and thyroid dysfunction (20%). Patients often refused investigations to diagnose their chemotherapy-induced symptoms; however, for every three investigations performed, one treatable cause was diagnosed: particularly small intestinal bacterial overgrowth (54%), bile acid malabsorption (43%), previously not described after chemotherapy, and unsuspected urinary tract infection (17%). CONCLUSIONS Patients undergoing chemotherapy for GI malignancy commonly have difficult GI symptoms requiring active management which does not occur routinely. The underlying causes for these symptoms are often treatable or curable. Randomised trials are urgently needed to show whether timely investigation and treatment of symptoms improve quality of life and survival. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02121626.
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Affiliation(s)
- H Jervoise N Andreyev
- The Department of Gastroenterology, Lincoln County Hospital, United Lincolnshire Hospitals Trust, Greetwell Rd, Lincoln, LN2 5PT, UK.
- The Biomedical Research Centre, Nottingham Digestive Diseases Centre, The School of Medicine, University of Nottingham, Nottingham, UK.
| | - Amyn Lalji
- The Department of Medicine, The Royal Marsden NHS Foundation Trust, Sutton, London, UK
| | - Kabir Mohammed
- Clinical Research and Development Department, The Royal Marsden NHS Foundation Trust, Sutton, London, UK
| | - Ann C G Muls
- The Department of Medicine, The Royal Marsden NHS Foundation Trust, Sutton, London, UK
| | - David Watkins
- The Department of Medicine, The Royal Marsden NHS Foundation Trust, Sutton, London, UK
| | - Sheela Rao
- The Department of Medicine, The Royal Marsden NHS Foundation Trust, Sutton, London, UK
| | - Naureen Starling
- The Department of Medicine, The Royal Marsden NHS Foundation Trust, Sutton, London, UK
| | - Ian Chau
- The Department of Medicine, The Royal Marsden NHS Foundation Trust, Sutton, London, UK
| | - Sarah Cruse
- The Department of Medicine, The Royal Marsden NHS Foundation Trust, Sutton, London, UK
| | - Ville Pitkaaho
- The Department of Medicine, The Royal Marsden NHS Foundation Trust, Sutton, London, UK
| | - Jennifer Matthews
- The Department of Medicine, The Royal Marsden NHS Foundation Trust, Sutton, London, UK
| | - Laura Caley
- The Department of Medicine, The Royal Marsden NHS Foundation Trust, Sutton, London, UK
| | - Victoria Pittordou
- The Department of Medicine, The Royal Marsden NHS Foundation Trust, Sutton, London, UK
| | - Carolyn Adams
- The Department of Medicine, The Royal Marsden NHS Foundation Trust, Sutton, London, UK
| | - Linda Wedlake
- Royal Marsden Clinical Trials Unit Royal Marsden NHS Foundation Trust, Sutton, UK
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19
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Bresolin A, Faiella A, Garibaldi E, Munoz F, Cante D, Vavassori V, Waskiewicz JM, Girelli G, Avuzzi B, Villa E, Magli A, Noris Chiorda B, Gatti M, Ferella L, Maggio A, Landoni V, Aimonetto S, Sini C, Rancati T, Sanguineti G, Valdagni R, Di Muzio N, Fiorino C, Cozzarini C. Acute patient-reported intestinal toxicity in whole pelvis IMRT for prostate cancer: Bowel dose-volume effect quantification in a multicentric cohort study. Radiother Oncol 2021; 158:74-82. [PMID: 33639190 DOI: 10.1016/j.radonc.2021.02.026] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2020] [Revised: 02/16/2021] [Accepted: 02/17/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE To assess bowel dose-volume relationships for acute patient-reported intestinal symptoms of patients treated with whole-pelvis intensity-modulated radiotherapy (WPRT) for prostate cancer. MATERIALS AND METHODS Complete data of 415 patients enrolled in a multi institute, prospective trial (#NCT02803086) treated with radical (31%), adjuvant (33%) and salvage (36%) intent at a median dose to pelvic nodes/lymph-nodal area of 53 Gy were available. The most severe changes between baseline and radiotherapy mid-point/end toxicity assessed by Inflammatory Bowel Disease Questionnaire (only Bowel Domain) were considered (ΔIBDQ). The 25th percentile values of these score variations were set as endpoints. DVHs of bowel loops for patients with/without toxicity were compared for each endpoint, having excluded patients with baseline scores <5 (rate ranging between 2% and 7% according to the endpoint): the resulting best dosimetric predictors were combined with selected clinical parameters through multivariate logistic regression (MVA) to derive predictive models. RESULTS ΔIBDQ ranged between 0.2-1.5 points considering separately each IBDQ symptom. Only four symptoms (IBDQ1 = frequency, IBDQ5 = diarrhea, IBDQ17 = gas passage, IBDQ24 = urgency) showed a median worsening ≥ 1; DVH predicted the risk of worse symptoms for IBDQ5, IBDQ24 and overall Bowel Domain. At multivariable analysis DVHs (best cut-off: V46Gy ≥80 cc) and baseline scores (Odd-Ratio:0.35-0.65) were independently associated to the three end-points. The resulting models were reliable (H&L test: 0.453-0.956), well calibrated (calibration plot: slope = 0.922-1.069, R2 = 0.725-0.875) and moderately discriminative (Area Under the Curve:0.628-0.669). A bootstrap-based validation confirmed their robustness. CONCLUSION Constraining the bowel loops (V46 < 80 cc) may reduce the risk of several moderate intestinal symptoms, with a much greater impact for patients with lower IBDQ baseline scores.
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Affiliation(s)
- Andrea Bresolin
- San Raffaele Scientific Institute, Milan, Italy; Fondazione Centro San Raffaele, Milan, Italy
| | - Adriana Faiella
- IRCCS Istituto Nazionale dei Tumori "Regina Elena", Rome, Italy
| | | | - Fernando Munoz
- Ospedale Regionale Parini-AUSL Valle d'Aosta, Aosta, Italy
| | | | | | | | | | - Barbara Avuzzi
- Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Elisa Villa
- Cliniche Gavazzeni-Humanitas, Bergamo, Italy
| | - Alessandro Magli
- Azienda Ospedaliero Universitaria S. Maria della Misericordia, Udine, Italy
| | | | - Marco Gatti
- Istituto di Candiolo - FPO-IRCCS, Candiolo, Italy
| | | | | | - Valeria Landoni
- IRCCS Istituto Nazionale dei Tumori "Regina Elena", Rome, Italy
| | | | - Carla Sini
- San Raffaele Scientific Institute, Milan, Italy
| | - Tiziana Rancati
- Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy; Fondazione IRCCS Istituto Nazionale dei Tumori, Prostate Cancer Program, Milan, Italy
| | | | - Riccardo Valdagni
- Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy; Fondazione IRCCS Istituto Nazionale dei Tumori, Prostate Cancer Program, Milan, Italy
| | - Nadia Di Muzio
- San Raffaele Scientific Institute, Milan, Italy; Dept. of Oncology and Hemato-Oncology, University Vita-Salute San Raffaele, Milan, Italy
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20
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Mahmood S, Bollipo S, Steele S, Bristow RG, Choudhury A, Oakland K, Martin J. It's All the RAVE: Time to Give up on the "Chronic Radiation Proctitis" Misnomer. Gastroenterology 2021; 160:635-638. [PMID: 33096102 DOI: 10.1053/j.gastro.2020.09.054] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 09/17/2020] [Accepted: 09/21/2020] [Indexed: 01/16/2023]
Affiliation(s)
- Sultan Mahmood
- Department of Medicine, University at Buffalo, Buffalo, New York
| | - Steven Bollipo
- School of Medicine and Public Health, University of Newcastle and, Department of Gastroenterology, John Hunter Hospital, Newcastle, New South Wales, Australia
| | - Scott Steele
- Department of Colorectal Surgery, Cleveland Clinic, Cleveland, Ohio
| | | | | | - Kathryn Oakland
- Department of Digestive Diseases, HCA Healthcare UK, London, UK
| | - Jarad Martin
- School of Medicine and Public Health, University of Newcastle, Newcastle, New South Wales, Australia
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21
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Essential oncology nursing care along the cancer continuum. Lancet Oncol 2020; 21:e555-e563. [PMID: 33212045 DOI: 10.1016/s1470-2045(20)30612-4] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 09/25/2020] [Accepted: 10/06/2020] [Indexed: 12/24/2022]
Abstract
Oncology nurses are at the heart of tackling the increasing global burden of cancer. Their contribution is unique because of the scale and the diversity of care roles and responsibilities in cancer care. In this Series paper, to celebrate the International Year of the Nurse and Midwife, we highlight the contribution and impact of oncology nurses along the cancer care continuum. Delivering people-centred integrated care and optimal communication are essential components of oncology nursing care, which are often played down. More oncology nurses using, doing, and leading research will further show the key nursing impact on care as part of a team. The oncology nurse influence in saving lives through prevention and early detection of cancer is noteworthy. Supportive care, the central pillar of oncology nursing, enables and empowers people to self-manage where possible. Globally, oncology nurses make a great positive difference to cancer care worldwide; their crucial contribution throughout the continuum of care warrants the inclusion and promotion of nursing in every country's cancer strategy. 2020 is the year of the nurse: let us take this learning to the future.
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22
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Fernando A. Mental Health and Cancer: Why It Is Time to Innovate and Integrate-A Call to Action. Eur Urol Focus 2020; 6:1165-1167. [PMID: 32680828 PMCID: PMC9972363 DOI: 10.1016/j.euf.2020.06.025] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Accepted: 06/30/2020] [Indexed: 01/16/2023]
Abstract
Surgical, radio-oncological, and medical anti-cancer therapies have developed at pace and scale in recent years, yet there remains a huge unmet need for mental health in cancer care. Recent experience in the COVID-19 pandemic has added to recognition of this unmet need. There needs to be more effective clinical integration of relevant services, which must be informed by patient choice and clinical need, and accessible throughout the patient's whole cancer journey. This needs to be accompanied by training and research integration as well as more effective and creative use of technology such as virtual reality and simulation, quality assuring apps, and mobile technologies. Finally, as a clinical community we need to drive a shift in culture towards measurement of patient quality of life as a marker of treatment effectiveness. We also need to support our own clinical workforce with their own mental health needs so that we prevent the alarming rates of burnout prevalent among clinicians treating cancer. The call to action for innovation and staff support has been amplified by experience in the COVID-19 pandemic. PATIENT SUMMARY: This report highlights the unmet need for mental health in cancer care. Patients need effective access to psychological support and mental health services throughout their cancer journey, including better use of technology. There is also a need to support the psychological wellbeing of cancer clinicians.
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Affiliation(s)
- Asanga Fernando
- Cancer Services, St. George's University Hospitals NHS Foundation Trust, London, UK.
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23
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Chronic diarrhoea in an oncology patient - Clinical assessment and decision making. Best Pract Res Clin Gastroenterol 2020; 48-49:101708. [PMID: 33317791 DOI: 10.1016/j.bpg.2020.101708] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 10/21/2020] [Accepted: 11/05/2020] [Indexed: 01/31/2023]
Abstract
Cancer survival is improving rapidly due to advances in treatments that will often involve radiotherapy, chemotherapy and novel biological agents in addition to surgery. This comes at the price of living with chronic symptoms, of which diarrhoea is particularly common. There is good evidence that for many patients these symptoms become part of everyday life, their "normality" is adjusted and symptoms are tolerated even when limiting activities severely. Clinicians often fail to appreciate the impact of these problems, as the focus of follow up tends to be on cancer recurrence. However, the rapid identification of patients in significant trouble can lead to earlier diagnosis of treatable pathologies and improvement of patients' symptoms. The aim of this review is to highlight the mechanisms which cause oncology patients to develop diarrhoea and highlight useful investigational and treatment strategies.
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24
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K Jensen NB, Pötter R, Spampinato S, Fokdal LU, Chargari C, Lindegaard JC, Schmid MP, Sturdza A, Jürgenliemk-Schulz IM, Mahantshetty U, Segedin B, Bruheim K, Hoskin P, Rai B, Wiebe E, Cooper R, Van der Steen-Banasik E, Van Limbergen E, Sundset M, Pieters BR, Nout RA, Kirisits C, Kirchheiner K, Tanderup K. Dose-Volume Effects and Risk Factors for Late Diarrhea in Cervix Cancer Patients After Radiochemotherapy With Image Guided Adaptive Brachytherapy in the EMBRACE I Study. Int J Radiat Oncol Biol Phys 2020; 109:688-700. [PMID: 33068689 DOI: 10.1016/j.ijrobp.2020.10.006] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 09/30/2020] [Accepted: 10/06/2020] [Indexed: 02/07/2023]
Abstract
PURPOSE To evaluate patient- and treatment-related risk factors associated with incidence and persistence of late diarrhea after radiochemotherapy and image guided adaptive brachytherapy (IGABT) in locally advanced cervical cancer. MATERIALS AND METHODS Of 1416 patients from the EMBRACE I study, 1199 were prospectively evaluated using physician-reported (Common Terminology Criteria for Adverse Events version 3 [CTCAEv3]) assessment for diarrhea; median follow-up 48 months. Patient-reported outcome (EORTC) was available in 900 patients. Incidence of CTCAE G≥2, G≥3, and EORTC "very much" diarrhea was analyzed with Cox proportional hazards regression. Binary logistic regression was used for analysis of persistent G≥1 and EORTC "quite a bit" - "very much" (≥"quite a bit") diarrhea, defined if present in at least half of all follow-ups. RESULTS Crude incidences of G≥2 and G≥3 diarrhea were 8.3% and 1.5%, respectively, and 8% of patients reported "very much" diarrhea. Persistent G≥1 and ≥"quite a bit" diarrhea was present in 16% and 7%, respectively. Patient-related risk factors were baseline diarrhea, smoking, and diabetes with hazard ratios of 1.4 to 7.3. Treatment-related risk factors included prescribed dose, V43 Gy, V57 Gy (lymph node boost), and para-aortic irradiation for external beam radiation therapy (EBRT). G≥2 diarrhea at 3 years increased from 9.5% to 19.9% with prescribed dose 45 Gy versus 50 Gy, 8.7% to 14.0% with V43 Gy <2500 cm3 versus >3000 cm3 and 9.4% to 19.0% with V57 Gy <165 cm3 versus ≥165 cm3. Brachytherapy-related bowel and rectum D2cm3 were also associated with diarrhea. CONCLUSION Dose and volume effects have been established for late diarrhea after radiochemotherapy and IGABT in both CTCAE and EORTC reporting. The risk of diarrhea was lower with a pelvic EBRT prescription of 45 Gy, and higher with larger lymph node boosts volumes (ie, ≥165 cm3). The importance of EBRT volumes as determinants of late toxicity underline the need for continuous quality assurance of target contouring, dose planning, and conformity. The findings of brachytherapy dosimetric factors related to the intestines may become more important with highly conformal EBRT.
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Affiliation(s)
- Nina B K Jensen
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark.
| | - Richard Pötter
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Sofia Spampinato
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - Lars U Fokdal
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - Cyrus Chargari
- Department of Radiotherapy, Gustave-Roussy, Villejuif, France
| | | | - Maximilian P Schmid
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Alina Sturdza
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | | | - Umesh Mahantshetty
- Department of Radiation Oncology, Tata Memorial Hospital, Mumbai, Homi Bhabha National Institute, India
| | - Barbara Segedin
- Department of Radiotherapy, Institute of Oncology Ljubljana, Ljubljana, Slovenia
| | - Kjersti Bruheim
- Department of Oncology, Oslo University Hospital, Oslo, Norway
| | - Peter Hoskin
- Mount Vernon Cancer Centre, Mount Vernon Hospital, Northwood, United Kingdom
| | - Bhavana Rai
- Department of Radiotherapy and Oncology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ericka Wiebe
- Department of Oncology, Cross Cancer Institute and University of Alberta, Edmonton, Canada
| | - Rachel Cooper
- Leeds Cancer Centre, St James's University Hospital, Leeds, United Kingdom
| | | | - Erik Van Limbergen
- Department of Radiation Oncology, University Hospitals Leuven, Leuven, Belgium
| | - Marit Sundset
- Clinic of Oncology and Women's Clinic, St. Olavs Hospital, Trondheim, Norway
| | - Bradley R Pieters
- Department of Radiation Oncology, Amsterdam University Medical Centers, University of Amsterdam, The Netherlands
| | - Remi A Nout
- Department of Radiation Oncology, Leiden University Medical Center, Leiden, The Netherlands; Department of Radiotherapy, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, the Netherlands
| | - Christian Kirisits
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Kathrin Kirchheiner
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Kari Tanderup
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
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25
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Muls A, Taylor A, Lalondrelle S, Kabir M, Norton C, Hart A, Andreyev HJ. A proposed tailored investigational algorithm for women treated for gynaecological cancer with long-term gastrointestinal consequences. Support Care Cancer 2020; 28:4881-4889. [PMID: 31997018 PMCID: PMC7447625 DOI: 10.1007/s00520-020-05309-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Accepted: 01/14/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND AND AIM Long-term changes in gastrointestinal function impacting quality of life after treatment for cancer are common. Peer reviewed guidance to investigate and manage GI dysfunction following cancer treatment has been published. This study reviewed gastrointestinal symptoms of women previously treated for gynaecological cancer and considered whether suggested algorithms could be amended to optimise management for this cohort. METHODS Demographic and clinical data recorded for patients attending a specialist consequences of cancer treatment gastroenterology service prospectively are reported using median and range. The Wilcoxon signed rank test analysed changes in symptoms between initial assessment to discharge from the service. RESULTS Between April 2013 and March 2016, 220 women, with a median age of 57 years (range 24-83 years), treated for gynaecological cancer (cervical (50%)), endometrial (28%), ovarian (15%), vaginal or vulval (7%) attended. Twelve gastrointestinal symptoms were statistically significantly reduced by time of discharge from the specialist gastroenterology clinic including bowel frequency ≥ 4/day (88%), type 6 or 7 stool consistency (36%), urgency (31%) and incontinence (21%). General quality of life improved from a median score of 4 at first assessment to a median of 6 at discharge (p < 0.001). A median of four (range, 1-9) diagnoses were made. CONCLUSION Women with gastrointestinal symptoms after cancer treatment benefit from a systematic management approach. After excluding disease recurrence, a proposed investigational algorithm and the oncology team includes FBC, U&Es, LFTs, thyroid function test, vitamin B12, vitamin D, a hydrogen methane breath test and a SeHCAT scan. If rectal bleeding is present, iron studies, flexible sigmoidoscopy or colonoscopy should be performed. Patients with normal investigations or symptoms not responding to treatment require gastroenterology input.
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Affiliation(s)
- Ann Muls
- The Royal Marsden NHS Foundation Trust, 203 Fulham Road, London, SW3 6JJ, UK.
- Department of Nursing, King's College London, Waterloo, London, UK.
| | - Alexandra Taylor
- The Royal Marsden NHS Foundation Trust, 203 Fulham Road, London, SW3 6JJ, UK
| | - Susan Lalondrelle
- The Royal Marsden NHS Foundation Trust, 203 Fulham Road, London, SW3 6JJ, UK
| | - Mohammed Kabir
- The Royal Marsden NHS Foundation Trust, 203 Fulham Road, London, SW3 6JJ, UK
| | - Christine Norton
- Department of Nursing, King's College London, Waterloo, London, UK
| | - Ailsa Hart
- Faculty of Medicine, department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
| | - H Jervoise Andreyev
- The Department of Gastroenterology, Lincoln County Hospital, Lincoln and The School of Medicine, University of Nottingham, Nottingham, UK
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26
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Kirchheiner K, Smet S, Spampinato S, Jensen NBK, Vittrup AS, Fokdal L, Najjari-Jamal D, Westerveld HG, Lindegaard JC, Kirisits C, De Leeuw A, Schmid MP, Tan LT, Nout RA, Jürgenliemk-Schulz IM, Pötter R, Tanderup K. Initiatives for education, training, and dissemination of morbidity assessment and reporting in a multiinstitutional international context: Insights from the EMBRACE studies on cervical cancer. Brachytherapy 2020; 19:837-849. [PMID: 32978080 DOI: 10.1016/j.brachy.2020.08.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 07/17/2020] [Accepted: 08/11/2020] [Indexed: 11/17/2022]
Abstract
In 2008, the GEC ESTRO Gyn network launched the first multiinstitutional, observational, and prospective international study on MRI-guided brachytherapy in locally advanced cervical cancer patients (EMBRACE-I). EMBRACE-I was followed by EMBRACE-II from 2016 and ongoing. Among the aims of the EMBRACE studies are to benchmark morbidity outcomes and develop dose-volume effects and predictive models for morbidity. The EMBRACE studies collect both physician (CTCAE v.3) and patient (EORTC QLQ-C30/CX24) reported outcomes, including baseline information, in a regular follow-up schedule. The EMBRACE studies feature high numbers of patients (EMBRACE-I N = 1416, EMBRACE-II N = 1500 expected) enrolled from many institutions worldwide (EMBRACE-I n = 23, EMBRACE-II n = 45). This large-scale multiinstitutional approach offers a unique opportunity to investigate and develop new strategies for improving the quality of assessment and reporting of morbidity. This report presents an overview of the challenges and pitfalls regarding the assessment and reporting of morbidity encountered during more than a decade of development and research activities within the EMBRACE consortium. This includes the recognition and evaluation of inconsistencies in the morbidity assessment, and consequently, the provision of assistance and training in the scoring procedure to reduce systematic assessment bias. In parallel, a variety of methodological approaches were tested to comprehensively summarize morbidity outcomes, and a novel approach was developed to refine dose-effect models and risk factor analyses. The purpose of this report is to present an overview of these findings, describe the learning process, and the strategies that have consequently been implemented regarding educational activities, training, and dissemination.
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Affiliation(s)
- Kathrin Kirchheiner
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria.
| | - Stéphanie Smet
- Department of Radiation Oncology, AZ Turnhout, Turnhout, Belgium
| | - Sofia Spampinato
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - Nina B K Jensen
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | | | - Lars Fokdal
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - Dina Najjari-Jamal
- Department of Radiation Oncology, Catalan Institute of Oncology, University of Barcelona, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Henrike G Westerveld
- Department of Radiation Oncology, Amsterdam University Medical Centers, AMC, Amsterdam, the Netherlands
| | | | - Christian Kirisits
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Astrid De Leeuw
- Department of Radiation Oncology, University Medical Center, Utrecht, the Netherlands
| | - Maximilian P Schmid
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Li Tee Tan
- Department of Oncology, Cambridge University Hospitals, Cambridge, UK
| | - Remi A Nout
- Department of Radiation Oncology, Erasmus Medical Center, Rotterdam, the Netherlands
| | | | - Richard Pötter
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Kari Tanderup
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
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27
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Abstract
Abdominal pelvic radiation therapy can induce acute or chronic lesions in the small bowel wall, called radiation enteritis. Treatment of acute radiation enteritis is essentially symptomatic; symptoms regress when radiation is discontinued. Conversely, late toxicity can occur up to 30 years after discontinuation of radiation therapy, posing diagnostic problems. Approximately one out of five patients treated by radiation therapy will present clinical signs of radiation enteritis, including obstruction, malabsorption, malnutrition and/or other complications. Management should be multidisciplinary, centered mainly on correction of malnutrition. Surgery is indicated in case of complications (i.e., abscess, perforation, fistula) and/or resistance to medical treatment; intestinal resection should be preferred over internal bypass. The main risk in case of iterative resections is the short bowel syndrome and the need for definitive nutritional assistance.
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Affiliation(s)
- L Loge
- Department of digestive surgery, CHU de Caen, avenue de la Côte-de-Nacre, 14033 Caen cedex, France
| | - C Florescu
- Department of radiotherapy, centre François-Baclesse, avenue du Général-Harris, 14045 Caen cedex, France
| | - A Alves
- Department of digestive surgery, CHU de Caen, avenue de la Côte-de-Nacre, 14033 Caen cedex, France; ANTICIPE Inserm U 1086, centre François-Baclesse, avenue du Général-Harris, 14045 Caen cedex, France; Health Training and Research Center, 2, rue des Rochambelles, 14032 Caen cedex, France
| | - B Menahem
- Department of digestive surgery, CHU de Caen, avenue de la Côte-de-Nacre, 14033 Caen cedex, France; ANTICIPE Inserm U 1086, centre François-Baclesse, avenue du Général-Harris, 14045 Caen cedex, France; Health Training and Research Center, 2, rue des Rochambelles, 14032 Caen cedex, France.
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28
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Gadhok R, Paulon E, Tai C, Olushola T, Barragry J, Rahman F, Di Caro S, Mehta S. Gastrointestinal consequences of cancer treatment: evaluation of 10 years' experience at a tertiary UK centre. Frontline Gastroenterol 2020; 12:471-477. [PMID: 34712464 PMCID: PMC8515283 DOI: 10.1136/flgastro-2020-101430] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Revised: 06/09/2020] [Accepted: 06/21/2020] [Indexed: 02/04/2023] Open
Abstract
OBJECTIVE Up to 90% of patients treated for pelvic cancers experience chronic gastrointestinal (GI) symptoms. This study characterises this patient cohort at a single centre, addressing a paucity of publications reporting 'real-world' experiences. METHOD Outpatient referrals, from oncology to the gastroenterology and nutrition services, at a tertiary London hospital from 2006 to 2016, were retrospectively identified. Patient characteristics, reported symptoms, investigations, diagnoses, response to therapeutics and follow-up were recorded. RESULTS Of 269 patients referred, 81% were within the latter 5 years. A total of 260 patients had diagnoses of pelvic cancers (prostatic (52%), cervical (19%) and endometrial (19%)). Among 247 treated with radiotherapy, the median time from radiotherapy to symptom onset was 8 months. Common symptoms were rectal bleeding (51%), diarrhoea (32%), faecal urgency (19%) and pain (19%). Patients underwent a median of three investigations including lower GI endoscopy (86%), thyroid function tests (33%) and glucose hydrogen breath test (30%). Diagnoses included radiation proctopathy (39%), colonic polyps (16%), pelvic floor dysfunction (12%), bile acid malabsorption (BAM) (8%), small intestinal bacterial overgrowth (SIBO) (8%), vitamin D deficiency (7%) and iron deficiency (7%). Among 164 discharged patients, the time to discharge was 7 months, after a median of two appointments. CONCLUSIONS This unique patient group reports a complex mix of symptoms and requires specialist review and consideration of often uninvestigated diagnoses (pelvic dysfunction, BAM, SIBO and nutritional deficiencies). Such patients are often overlooked, compared with those suffering many other chronic GI disorders. Further reports from non-dedicated centres treating patients with pelvic radiation disease will aid in understanding of secondary GI diagnoses and variation in practice.
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Affiliation(s)
- Radha Gadhok
- Department of Gastrointestinal Services, University College London Hospitals, NHS Foundation Trust, London, UK
| | - Emma Paulon
- Department of Gastrointestinal Services, University College London Hospitals, NHS Foundation Trust, London, UK
| | - Chehkuan Tai
- Department of Gastrointestinal Services, University College London Hospitals, NHS Foundation Trust, London, UK
| | - Tomisin Olushola
- Department of Gastrointestinal Services, University College London Hospitals, NHS Foundation Trust, London, UK
| | - John Barragry
- Department of Gastrointestinal Services, University College London Hospitals, NHS Foundation Trust, London, UK
| | - Farooq Rahman
- Department of Gastrointestinal Services, University College London Hospitals, NHS Foundation Trust, London, UK
| | - Simona Di Caro
- Department of Gastrointestinal Services, University College London Hospitals, NHS Foundation Trust, London, UK
| | - Shameer Mehta
- Department of Gastrointestinal Services, University College London Hospitals, NHS Foundation Trust, London, UK
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29
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Li Y, Xiao H, Dong J, Luo D, Wang H, Zhang S, Zhu T, Zhu C, Cui M, Fan S. Gut Microbiota Metabolite Fights Against Dietary Polysorbate 80-Aggravated Radiation Enteritis. Front Microbiol 2020; 11:1450. [PMID: 32670255 PMCID: PMC7332576 DOI: 10.3389/fmicb.2020.01450] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Accepted: 06/04/2020] [Indexed: 12/12/2022] Open
Abstract
Radiation therapy is a cornerstone of modern management methods for malignancies but is accompanied by diverse side effects. In the present study, we showed that food additives such as polysorbate 80 (P80) exacerbate irradiation-induced gastrointestinal (GI) tract toxicity. A 16S ribosomal RNA high-throughput sequencing analysis indicated that P80 consumption altered the abundance and composition of the gut microbiota, leading to severe radiation-induced GI tract injury. Mice harboring fecal microbes from P80-treated mice were highly susceptible to irradiation, and antibiotics-challenged mice also represented more sensitive to radiation following P80 treatment. Importantly, butyrate, a major metabolite of enteric microbial fermentation of dietary fibers, exhibited beneficial effects against P80 consumption-aggravated intestinal toxicity via the activation of G-protein-coupled receptors (GPCRs) and maintenance of the intestinal bacterial composition in irradiated animals. Moreover, butyrate had broad therapeutic effects on common radiation-induced injury. Collectively, our findings demonstrate that P80 are potential risk factors for cancer patients during radiotherapy and indicate that butyrate might be employed as a therapeutic option to mitigate the complications associated with radiotherapy.
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Affiliation(s)
- Yuan Li
- Tianjin Key Laboratory of Radiation Medicine and Molecular Nuclear Medicine, Institute of Radiation Medicine, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
| | - Huiwen Xiao
- Tianjin Key Laboratory of Radiation Medicine and Molecular Nuclear Medicine, Institute of Radiation Medicine, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
| | - Jiali Dong
- Tianjin Key Laboratory of Radiation Medicine and Molecular Nuclear Medicine, Institute of Radiation Medicine, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
| | - Dan Luo
- Tianjin Key Laboratory of Radiation Medicine and Molecular Nuclear Medicine, Institute of Radiation Medicine, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
| | - Haichao Wang
- Tianjin Key Laboratory of Radiation Medicine and Molecular Nuclear Medicine, Institute of Radiation Medicine, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China.,Department of Emergency Medicine, North Shore University Hospital, Manhasset, NY, United States.,Laboratory of Emergency Medicine, The Feinstein Institute for Medical Research, Manhasset, NY, United States
| | - Shuqin Zhang
- Tianjin Key Laboratory of Radiation Medicine and Molecular Nuclear Medicine, Institute of Radiation Medicine, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
| | - Tong Zhu
- Tianjin Key Laboratory of Radiation Medicine and Molecular Nuclear Medicine, Institute of Radiation Medicine, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
| | - Changchun Zhu
- Tianjin Key Laboratory of Radiation Medicine and Molecular Nuclear Medicine, Institute of Radiation Medicine, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
| | - Ming Cui
- Tianjin Key Laboratory of Radiation Medicine and Molecular Nuclear Medicine, Institute of Radiation Medicine, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
| | - Saijun Fan
- Tianjin Key Laboratory of Radiation Medicine and Molecular Nuclear Medicine, Institute of Radiation Medicine, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
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Wiltink LM, White K, King MT, Rutherford C. Systematic review of clinical practice guidelines for colorectal and anal cancer: the extent of recommendations for managing long-term symptoms and functional impairments. Support Care Cancer 2020; 28:2523-2532. [PMID: 32025805 PMCID: PMC7181546 DOI: 10.1007/s00520-020-05301-7] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Accepted: 01/09/2020] [Indexed: 12/18/2022]
Abstract
PURPOSE Due to increasing numbers of colorectal and anal cancer survivors, more individuals are living with long-term symptoms after treatment. A systematic review was undertaken to assess the extent to which practice guidelines for colorectal and anal cancer provide recommendations for managing long-term symptoms and functioning impairments. METHODS Four electronic databases and websites of 30 international cancer societies were searched for clinical practice guidelines, consensus statements, or best practice recommendations for colorectal or anal cancer. Quality of included guidelines was evaluated with the Appraisal of Guidelines for Research & Evaluation II tool. Results were narratively summarized. RESULTS We included 51 guidelines or consensus statements. Recommendations for managing long-term symptoms or functioning impairments were reported in 13 guidelines (25.4%). All 13 recommend a healthy lifestyle, diet, body weight, and physical activity. The ASCO Colorectal Cancer Survivorship Care Guideline is the most comprehensive, including interventions targeting sexual and bowel function to pain and cognitive issues, and also highlights limited evidence for informing management strategies. Other guidelines recommend treating incontinence, chronic diarrhea, and distress, and stress the need for greater awareness for sexual dysfunction, survivorship clinics, and referrals to specific supportive care interventions. CONCLUSIONS Few clinical practice guidelines include recommendations for managing long-term symptoms and functioning impairments. It is unclear if this is due to limited evidence or absence of management strategies and interventions. Clear recommendations for managing long-term symptoms and functioning to help health professionals in supporting colorectal and anal cancer survivors are needed.
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Affiliation(s)
- Lisette M Wiltink
- School of Psychology, Quality of Life Office, Faculty of Science, The University of Sydney, Level 6 North, Chris O'Brien Lifehouse C39Z, Sydney, NSW, 2006, Australia.
- Susan Wakil School of Nursing and Midwifery, Cancer Nursing Research Unit (CNRU), Faculty of Medicine and Health, The University of Sydney, Sydney, Australia.
- Department of Radiation Oncology, Leiden University Medical Center, Leiden, Netherlands.
| | - K White
- Susan Wakil School of Nursing and Midwifery, Cancer Nursing Research Unit (CNRU), Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - M T King
- School of Psychology, Quality of Life Office, Faculty of Science, The University of Sydney, Level 6 North, Chris O'Brien Lifehouse C39Z, Sydney, NSW, 2006, Australia
| | - C Rutherford
- School of Psychology, Quality of Life Office, Faculty of Science, The University of Sydney, Level 6 North, Chris O'Brien Lifehouse C39Z, Sydney, NSW, 2006, Australia
- Susan Wakil School of Nursing and Midwifery, Cancer Nursing Research Unit (CNRU), Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
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Abstract
PURPOSE OF REVIEW As cancer treatments improve more patients than ever are living for longer with the side effects of these treatments. Radiation enteritis is a heterogenous condition with significant morbidity. The present review aims to provide a broad overview of the condition with particular attention to the diagnosis and management of the condition. RECENT FINDINGS Radiation enteritis appears to be more prevalent than originally thought because of patient underreporting and a lack of clinician awareness. Patient-related and treatment-related risk factors have now been identified and should be modified where possible. Medical and surgical factors have been explored, but manipulation of the gut microbiota offers one of the most exciting recent developments in disease prevention. Diagnosis and treatment are best approached in a systematic fashion with particular attention to the exclusion of recurrent malignancy and other gastrointestinal conditions. Surgery and endoscopy both offer opportunities for management of the complications of radiation enteritis. Experimental therapies offer hope for future management of radiation enteritis but large-scale human trials are needed. SUMMARY Radiation enteritis is an important clinical problem, but awareness is lacking amongst patients and physicians. Clinical guidelines would allow standardised management which may improve the burden of the disease for patients.
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Ribas Y, Bonet M, Torres L, Núñez M, Esther Jovell-Fernández E, Aranda E, Andreyev HJ. Bowel dysfunction in survivors of gynaecologic malignancies. Support Care Cancer 2020; 28:5501-5510. [PMID: 32172408 DOI: 10.1007/s00520-020-05402-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Accepted: 03/04/2020] [Indexed: 12/17/2022]
Abstract
PURPOSE To assess the prevalence of bowel dysfunctions after treatment for gynaecological cancer and the impact on the quality of life. METHODS We identified a cohort of 217 eligible women treated with radiotherapy (RT) with curative intention, alone or as combined treatment, for gynaecological malignancies at three institutions in Catalonia (Spain). Demographic, diagnosis and treatment modality were reviewed. Patients were sent validated questionnaires to assess bowel function and a set of questions asking on the changes after RT in bowel function, urinary function, sexuality, pain and lymphoedema. RESULTS Questionnaires were returned by 109 patients (50.2%) with a mean age of 65 ± 11 years. Of them, 71.8% had been treated for endometrial cancer and 28.2% for cervical cancer. Overall, 42.7% of patients reported bowel dysfunction, affecting their quality of life in 36% of cases. Symptoms were more frequent in patients who had undergone external beam RT compared to brachytherapy. The most common symptom was defecatory urgency which was reported by more than 40% of patients according to the St Mark's score, although it was less common in other questionnaires. Overall, faecal incontinence ranged between 10 and 15%, and usual loose stools and diarrhoea were reported by 13.5% and 5.1%, respectively. CONCLUSION Prevalence of bowel symptoms after treatment of gynaecological malignancies is high. A systematic evaluation using validated questionnaires should be performed in order to allow the decision-making process and also because there are a number of treatments available to improve the quality of life of cancer survivors.
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Affiliation(s)
- Yolanda Ribas
- Department of Surgery, Consorci Sanitari de Terrassa, 08227, Terrassa, Barcelona, Spain.
| | - Marta Bonet
- Department of Radiation Oncology, Hospital Universitari Sant Joan de Reus, Reus, Spain.,Department of Radiation Oncology, Hospital Universitari Arnau de VIlanova, Lleida, Spain
| | - Laura Torres
- Department of Radiation Oncology, Hospital Universitari Sant Joan de Reus, Reus, Spain
| | - Miriam Núñez
- Department of Radiation Oncology, Consorci Sanitari de Terrassa, Terrassa, Spain.,Department of Radiation Oncology, Institut Català d'Oncologia, L'Hospitalet de LLobregat, Spain
| | | | - Eduard Aranda
- Facultat de Medicina i Ciències de la Salut, Universitat Internacional de Catalunya, Barcelona, Spain
| | - H Jervoise Andreyev
- Department of Gastroenterology, Lincoln County Hospital, United Lincolnshire Hospitals Trust, Lincoln, UK
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Farnell DJJ, Staffurth J, Sivell S, Ahmedzai S, Andreyev J, Green J, Sanders DS, Ferguson CJ, Pickett S, Muls A, O'Shea R, Campbell SH, Taylor SE, Nelson A. The ALERT-B questionnaire: A screening tool for the detection of gastroenterological late effects after radiotherapy for prostate cancer. Clin Transl Radiat Oncol 2020; 21:98-103. [PMID: 32072031 PMCID: PMC7016329 DOI: 10.1016/j.ctro.2020.02.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Accepted: 02/02/2020] [Indexed: 01/03/2023] Open
Abstract
ALERT-B provides an effective screening tool for gastroenterological late effects. 84.4% and 95.7% of patients demonstrated complications at 6 and 12 months post-treatment. ROC curves at baseline indicated an AUC of 0.867 compared to the GSRS diarrhoea subscale. ROC curves at baseline indicated an AUC of 0.765 compared to the EPIC bowel subscale.
There is an increasing need to measure treatment-related side effects in normal tissues following cancer therapy. The ALERT-B (Assessment of Late Effects of RadioTherapy - Bowel) questionnaire is a screening tool that is composed of four items related specifically to bowel symptoms. Those patients that respond with a “yes” to any of these items are referred on to gastroenterologist in order to improve the long-term consequences of these side effects of radiological treatment. Here we wish to test the ability of this questionnaire to identify these subsequent gastroenterological complications by tracking prostate cancer patients that were positive with respect to ALERT-B. We also carry out receiver-operator curve (ROC) analysis for baseline data for an overall ALERT-B questionnaire score with respect to subscale data for the Gastrointestinal Symptom Rating Scale (GSRS) and the Expanded Prostate Cancer Index Composite (EPIC-26) questionnaire. 84.4% and 95.7% of patients identified by the ALERT-B questionnaire demonstrated complications diagnosed at 6 and 12 months post-treatment, respectively. ROC curve analysis of baseline data showed that ALERT-B detected clinically relevant levels of side effects established at baseline by the GSRS diarrhoea subscale (AUC = 0.867, 95% CI = 0.795 to 0.926) and at the minimally important level of side effects for the EPIC bowel subscale (AUC = 0.765, 95% CI = 0.617 to 0.913). These results show that ALERT-B provides a simple and effective screening tool for identifying gastroenterological complications after treatment for prostate cancer.
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Affiliation(s)
- D J J Farnell
- School of Dentistry, Cardiff University, Cardiff, United Kingdom
| | - J Staffurth
- Velindre Cancer Centre, Cardiff, United Kingdom.,Cardiff University, Cardiff, United Kingdom
| | - S Sivell
- Marie Curie Palliative Care Research Centre, Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, United Kingdom
| | - S Ahmedzai
- National Institute for Health Research, Clinical Research Network - Cancer Cluster Office, University of Leeds, Leeds, United Kingdom
| | - J Andreyev
- Department of Gastroenterology, Lincoln County Hospital, Lincoln, United Kingdom
| | - J Green
- Institute of Medical Education, School of Medicine, Cardiff University and Department of Gastroenterology, University Hospital Llandough, Cardiff and Vale UHB, Vale of Glamorgan, Cardiff, United Kingdom
| | - D S Sanders
- University of Sheffield Medical School, Sheffield, United Kingdom
| | - C J Ferguson
- University of Sheffield Medical School, Sheffield, United Kingdom
| | - S Pickett
- Swansea Centre for Health Economics, Swansea University, Swansea, United Kingdom
| | - A Muls
- Royal Marsden Hospital, Fulham Road, London, United Kingdom
| | - R O'Shea
- Marie Curie Palliative Care Research Centre, Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, United Kingdom
| | - S H Campbell
- Marie Curie Palliative Care Research Centre, Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, United Kingdom
| | - S E Taylor
- Macmillan Cancer Survivorship Research Group, Faculty of Health Sciences, University of Southampton, Southampton, United Kingdom
| | - A Nelson
- Marie Curie Palliative Care Research Centre, Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, United Kingdom
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Macnair A, Sharkey A, Le Calvez K, Walters R, Smith L, Nelson A, Staffurth J, Williams M, Bloomfield D, Maher J. The Trigger Project: The Challenge of Introducing Electronic Patient-Reported Outcome Measures Into a Radiotherapy Service. Clin Oncol (R Coll Radiol) 2020; 32:e76-e79. [DOI: 10.1016/j.clon.2019.09.044] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Revised: 07/26/2019] [Accepted: 08/14/2019] [Indexed: 11/26/2022]
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Sakr A, Yang SY, Kang JH, Cho MS, Han YD, Min BS, Thabet W, Elbanna HG, Morshed M, Kim NK. Oncologic safety and bowel function after ultralow anterior resection with or without intersphincteric resection for low lying rectal cancer: Comparative cross sectional study. J Surg Oncol 2020; 121:365-374. [PMID: 31797383 DOI: 10.1002/jso.25791] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Accepted: 11/19/2019] [Indexed: 01/24/2023]
Abstract
BACKGROUND Despite acceptable oncologic outcomes of sphincter preserving surgeries for low rectal cancer, bowel dysfunction occurs. This study aimed to compare the oncologic and functional bowel outcomes between ultralow anterior resection (ULAR) and intersphincteric resection (ISR) for low rectal cancer. METHODS One hundred sixty-four patients who underwent ULAR with or without ISR for low rectal cancer between December 2010 and May 2018 were included. The Wexner and Memorial Sloan Kettering Cancer Center (MSKCC) scores were used to evaluate the bowel function of patients. Overall survival (OS) and disease-free survival (DFS) were compared between patients. RESULTS The ISR group had higher incidence of major fecal incontinence than the ULAR group (75.9% vs 49.3%; P = .016). The median Wexner score decreased from 12 to 9 (P = .062) at 1-year follow-up. However, the frequency and urgency/soilage subscales of MSKCC score improved significantly in the ULAR group. ISR and follow-up interval less than 1-year significantly increased the major incontinence risk. The OS in the ULAR and ISR groups was 91.4% and 91.7%. Whereas the DFS in both groups was 79% and 79.2%, respectively. CONCLUSION ULAR and ISR are comparable in oncologic outcomes. Severe bowel dysfunctions and major incontinence were noted in ISR group. Careful selection of patients is mandatory.
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Affiliation(s)
- Ahmad Sakr
- Division of Colorectal Surgery, Department of Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea.,Colorectal Surgery Unit, Department of General Surgery, Mansoura Faculty of Medicine, Mansoura University Hospitals, Mansoura, Egypt
| | - Seung Yoon Yang
- Division of Colorectal Surgery, Department of Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jae Hyun Kang
- Division of Colorectal Surgery, Department of Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Min Soo Cho
- Division of Colorectal Surgery, Department of Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Yoon Dae Han
- Division of Colorectal Surgery, Department of Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Byung Soh Min
- Division of Colorectal Surgery, Department of Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Waleed Thabet
- Colorectal Surgery Unit, Department of General Surgery, Mansoura Faculty of Medicine, Mansoura University Hospitals, Mansoura, Egypt
| | - Hosam Ghazy Elbanna
- Colorectal Surgery Unit, Department of General Surgery, Mansoura Faculty of Medicine, Mansoura University Hospitals, Mansoura, Egypt
| | - Mosaad Morshed
- Colorectal Surgery Unit, Department of General Surgery, Mansoura Faculty of Medicine, Mansoura University Hospitals, Mansoura, Egypt
| | - Nam Kyu Kim
- Division of Colorectal Surgery, Department of Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
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Reis Ferreira M, Andreyev HJN, Mohammed K, Truelove L, Gowan SM, Li J, Gulliford SL, Marchesi JR, Dearnaley DP. Microbiota- and Radiotherapy-Induced Gastrointestinal Side-Effects (MARS) Study: A Large Pilot Study of the Microbiome in Acute and Late-Radiation Enteropathy. Clin Cancer Res 2019; 25:6487-6500. [PMID: 31345839 DOI: 10.1158/1078-0432.ccr-19-0960] [Citation(s) in RCA: 114] [Impact Index Per Article: 22.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Revised: 06/18/2019] [Accepted: 07/22/2019] [Indexed: 11/16/2022]
Abstract
PURPOSE Radiotherapy is important in managing pelvic cancers. However, radiation enteropathy may occur and can be dose limiting. The gut microbiota may contribute to the pathogenesis of radiation enteropathy. We hypothesized that the microbiome differs between patients with and without radiation enteropathy.Experimental Design: Three cohorts of patients (n = 134) were recruited. The early cohort (n = 32) was followed sequentially up to 12 months post-radiotherapy to assess early radiation enteropathy. Linear mixed models were used to assess microbiota dynamics. The late cohort (n = 87) was assessed cross-sectionally to assess late radiation enteropathy. The colonoscopy cohort compared the intestinal mucosa microenvironment in patients with radiation enteropathy (cases, n = 9) with healthy controls (controls, n = 6). Fecal samples were obtained from all cohorts. In the colonoscopy cohort, intestinal mucosa samples were taken. Metataxonomics (16S rRNA gene) and imputed metataxonomics (Piphillin) were used to characterize the microbiome. Clinician- and patient-reported outcomes were used for clinical characterization. RESULTS In the acute cohort, we observed a trend for higher preradiotherapy diversity in patients with no self-reported symptoms (P = 0.09). Dynamically, diversity decreased less over time in patients with rising radiation enteropathy (P = 0.05). A consistent association between low bacterial diversity and late radiation enteropathy was also observed, albeit nonsignificantly. Higher counts of Clostridium IV, Roseburia, and Phascolarctobacterium significantly associated with radiation enteropathy. Homeostatic intestinal mucosa cytokines related to microbiota regulation and intestinal wall maintenance were significantly reduced in radiation enteropathy [IL7 (P = 0.05), IL12/IL23p40 (P = 0.03), IL15 (P = 0.05), and IL16 (P = 0.009)]. IL15 inversely correlated with counts of Roseburia and Propionibacterium. CONCLUSIONS The microbiota presents opportunities to predict, prevent, or treat radiation enteropathy. We report the largest clinical study to date into associations of the microbiota with acute and late radiation enteropathy. An altered microbiota associates with early and late radiation enteropathy, with clinical implications for risk assessment, prevention, and treatment of radiation-induced side-effects.See related commentary by Lam et al., p. 6280.
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Affiliation(s)
- Miguel Reis Ferreira
- The Institute of Cancer Research, London, United Kingdom. .,The Royal Marsden NHS Foundation Trust, London, United Kingdom.,Guys and St Thomas NHS Foundation Trust, London, United Kingdom.,King's College London, London, United Kingdom
| | | | - Kabir Mohammed
- The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Lesley Truelove
- The Institute of Cancer Research, London, United Kingdom.,The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Sharon M Gowan
- The Institute of Cancer Research, London, United Kingdom
| | - Jia Li
- Imperial College, London, United Kingdom
| | - Sarah L Gulliford
- The Institute of Cancer Research, London, United Kingdom.,University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | - Julian R Marchesi
- Imperial College, London, United Kingdom. .,Cardiff University, Cardiff, United Kingdom
| | - David P Dearnaley
- The Institute of Cancer Research, London, United Kingdom.,The Royal Marsden NHS Foundation Trust, London, United Kingdom
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Late, Persistent, Substantial, Treatment-Related Symptoms After Radiation Therapy (LAPERS): A New Method for Longitudinal Analysis of Late Morbidity-Applied in the EMBRACE Study. Int J Radiat Oncol Biol Phys 2019; 106:300-309. [PMID: 31669565 DOI: 10.1016/j.ijrobp.2019.10.027] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Revised: 09/30/2019] [Accepted: 10/18/2019] [Indexed: 11/21/2022]
Abstract
PURPOSE Current incidence methods for reporting mild or moderate symptoms capture the (first) occurrence of an event and do not allow distinguishing between patients who suffer from long-lasting versus transient morbidity. This paper introduces a new methodological approach that identifies cancer survivors who have clinically relevant, long-lasting symptoms (patients with late, persistent, substantial and treatment-related symptoms, [LAPERS]). METHODS AND MATERIALS LAPERS can be evaluated in patients with baseline information and at least 3 late follow-up assessments after treatment. LAPERS identifies individual patients with a given symptom that is substantial (above a predefined clinically relevant threshold) and must be present in at least half of the follow-ups. Baseline morbidity is accounted for by requiring the median of the late symptom score to be worse than the baseline condition. The LAPERS approach was applied to 4 relevant patient-reported genito-urinary/gastrointestinal symptoms within the prospective, longitudinal EMBRACE study (An intErnational study on MRI-guided BRachytherapy in locally Advanced CErvical cancer, www.embracestudy.dk). LAPERS was compared with crude incidence and prevalence rates. RESULTS Within the EMBRACE cohort, 651/1044 patients (62%) had baseline and long-term follow-up available (median follow-up: 42 months). There was a considerable gap between LAPERS, crude incidence, and prevalence rates. The proportion of patients with LAPERS events was 3.8-4.8 times lower than crude incidences. The highest prevalence rates across follow-up times were 1.8-2.6 times lower than crude incidences. CONCLUSIONS These findings indicate limitations of incidence methods for reporting substantial patient-reported symptoms because a considerable proportion of patients with symptoms do not experience them persistently over time, as they may fluctuate or get successfully treated. In contrast, the LAPERS method for longitudinal analysis identifies patients with clinically relevant, long-lasting symptoms.
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Savoie MB, Laffan A, Brickman C, Daniels B, Levin A, Rowen T, Smith J, Van Blarigan EL, Hope TA, Berry-Lawhorn JM, Anwar M, Van Loon K. A multi-disciplinary model of survivorship care following definitive chemoradiation for anal cancer. BMC Cancer 2019; 19:906. [PMID: 31510960 PMCID: PMC6737598 DOI: 10.1186/s12885-019-6053-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Accepted: 08/19/2019] [Indexed: 12/13/2022] Open
Abstract
Following definitive chemoradiation for anal squamous cell carcinoma (ASCC), patients face a variety of chronic issues including: bowel dysfunction, accelerated bone loss, sexual dysfunction, and psychosocial distress. The increasing incidence of this disease, high cure rates, and significant long-term sequelae warrant increased focus on optimal survivorship care following definitive chemoradiation. In order to establish our survivorship care model for ASCC patients, a multi-disciplinary team of experts performed a comprehensive literature review and summarized best practices for the multi-disciplinary management of this unique patient population. We reviewed principle domains of our survivorship approach: (1) management of chronic toxicities; (2) sexual health; (3) HIV management in affected patients; (4) psychosocial wellbeing; and (5) surveillance for disease recurrence and survivorship care delivery. We provide recommendations for the optimization of survivorship care for ASCC patients can through a multi-disciplinary approach that supports physical and psychological wellness.
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Affiliation(s)
- Marissa B Savoie
- School of Medicine, University of California, San Francisco, USA
| | - Angela Laffan
- Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, USA
| | - Cristina Brickman
- Department of Medicine, Division of Infectious Diseases, University of California, San Francisco, USA
| | - Bevin Daniels
- Department of Physical Therapy, University of California, San Francisco, USA
| | - Anna Levin
- Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, USA
- Department of Psycho-Oncology, University of California, San Francisco, USA
| | - Tami Rowen
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, USA
| | - James Smith
- Department of Urology, University of California, San Francisco, USA
| | - Erin L Van Blarigan
- Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, USA
- Department of Urology, University of California, San Francisco, USA
- Department of Epidemiology and Biostatistics, University of California, San Francisco, USA
| | - Thomas A Hope
- Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, USA
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, USA
| | - J Michael Berry-Lawhorn
- Department of Medicine, Division of Hematology/Oncology, University of California, San Francisco, USA
| | - Mekhail Anwar
- Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, USA
- Department of Radiation Oncology, University of California, San Francisco, USA
| | - Katherine Van Loon
- Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, USA.
- Department of Medicine, Division of Hematology/Oncology, University of California, San Francisco, USA.
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Faisal A, Baber W, Rana Z, Andreyev J. Gastrointestinal side effects of cancer treatment: are we making any progress? Clin Med (Lond) 2019. [DOI: 10.7861/clinmedicine.19-3-s61] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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40
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Liu Z, Jiang J, He Q, Liu Z, Yang Z, Xu J, Huang Z, Wu B. β-Arrestin1-mediated decrease in endoplasmic reticulum stress impairs intestinal stem cell proliferation following radiation. FASEB J 2019; 33:10165-10176. [PMID: 31207192 DOI: 10.1096/fj.201900376rrr] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Gastrointestinal toxicity limits the clinical application of abdominal and pelvic radiotherapy and currently has no effective treatment. Intestinal leucine-rich-repeat-containing GPCR 5 (Lgr5)-positive stem cell depletion and loss of proliferative ability due to radiation may be the primary factors causing intestinal injury following radiation. Here, we report the critical role of β-arrestin1 (βarr1) in radiation-induced intestinal injury. Intestinal βarr1 was highly expressed in radiation enteritis and in a radiation model. βarr1 knockout (KO) or knockdown mice exhibited increased proliferation in intestinal Lgr5+ stem cell, crypt reproduction, and survival following radiation. Unexpectedly, the beneficial effects of βarr1 deficiency on intestinal stem cells in response to radiation were compromised when the endoplasmic reticulum stress-related protein kinase RNA-like ER kinase (PERK)/eukaryotic initiation factor-2α (eIF2α) pathway was inhibited, and this result was further supported in vitro. Furthermore, we found that βarr1 knockdown with small interfering RNA significantly enhanced intestinal Lgr5+ stem cell proliferation after radiation via directly targeting PERK. βarr1 offers a promising target for mitigating radiation-induced intestinal injury.-Liu, Z., Jiang, J., He, Q., Liu, Z., Yang, Z., Xu, J., Huang, Z., Wu, B. β-Arrestin1-mediated decrease in endoplasmic reticulum stress impairs intestinal stem cell proliferation following radiation.
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Affiliation(s)
- Zhihao Liu
- Division of Emergency Medicine, Department of General Internal Medicine, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.,Department of Emergency Intensive Care Unit, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Jie Jiang
- Department of Gastroenterology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Qiong He
- Department of Pathology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Zhigang Liu
- Department of Head and Neck Oncology, Phase 1 Clinical Trial Ward, The Cancer Center of The Fifth Affiliated Hospital of Sun Yat-sen University, Zhuhai, China
| | - Zhen Yang
- Division of Emergency Medicine, Department of General Internal Medicine, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.,Department of Emergency Intensive Care Unit, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Jia Xu
- Division of Emergency Medicine, Department of General Internal Medicine, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.,Department of Emergency Intensive Care Unit, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Zhenhua Huang
- Division of Emergency Medicine, Department of General Internal Medicine, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.,Department of Emergency Intensive Care Unit, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Bin Wu
- Department of Gastroenterology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
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Faisal A, Baber W, Rana Z, Andreyev J. Gastrointestinal side effects of cancer treatment: are we making any progress? Clin Med (Lond) 2019. [DOI: 10.7861/clinmedicine.19-3s-s61] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Caring for Survivors of Gynecologic Cancer: Assessment and Management of Long-term and Late Effects. Semin Oncol Nurs 2019; 35:192-201. [DOI: 10.1016/j.soncn.2019.02.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Methods of assessing late radiotherapy effects on bowel function. Curr Opin Support Palliat Care 2019; 13:134-141. [PMID: 30925532 DOI: 10.1097/spc.0000000000000422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Pelvic radiation disease in the form of chronic radiation-induced consequences of treatment is under recognized by healthcare professionals and under reported by patients. Gastrointestinal symptoms are not routinely assessed, and may not be causally associated with previous radiotherapy. These symptoms are therefore often under treated. RECENT FINDINGS A literature search was conducted in Ovid Medline, which included Epub Ahead of Print, In-Process & Other Non-Indexed Citations and Ovid Embase for articles published between 2016 and April 2018. A total of 11 articles were selected for review. A wide range of patient reported outcome measure instruments are used in research and practice. Clinical symptom grading is restricted to a fewer number of tools but may not always capture issues, such as urgency, that are important to the patient. Clinician and patient concordance in the assessment of outcomes is limited. Initiatives to prompt communication of the relative risks of the late consequences of treatment and comparative effectiveness of treatments decisions are developing, as are new techniques to limit irradiation of healthy tissue. SUMMARY Nonstandardized outcome measurement reduces the ability to aggregate toxicity and patient outcomes across clinical trials. The development of standardized screening and treatment algorithms for gastrointestinal symptoms can systematically locate and treat gastrointestinal late effects of treatment.
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Turner A. Sexual Health Issues in Patients with Cancer-An Exploratory Mixed Methods Study of the Awareness Levels of Radiation Therapists. J Med Imaging Radiat Sci 2019; 50:106-112. [PMID: 30777230 DOI: 10.1016/j.jmir.2018.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Revised: 08/24/2018] [Accepted: 08/28/2018] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Patients with cancer report dissatisfaction with care they receive in relation to changes affecting intimacy and relationships. Health care professionals describe barriers in providing support in these areas due to lack of time, training, education, and privacy. Radiation therapists (RTs) play a key role in cancer care, but there is little evidence in the literature of their role in sexual health care. This project investigated awareness levels of RTs in sexual health issues related to patients with cancer receiving radiation therapy. METHODS A prospective mixed methods approach was used for this investigation. Quantitative data was collected via an online questionnaire developed from the literature. Two hundred eighty-four RTs from two large cancer centers were eligible to participate; 84 responded (29%). Two focus groups were conducted with 15 volunteer RTs to validate questionnaire data and further explore the topic. Content analysis was used to identify key themes from the qualitative data. RESULTS RT respondents acknowledged the complexity of sexual health issues in patients with cancer. Eighty-five percent (n = 56) strongly agreed/agreed that all patients with cancer, regardless of cancer site, can experience issues which may affect sexual health. Ninety-two percent (n = 61) strongly agreed/agreed that sexual health is important for a persons' quality of life. As part of the radiation therapy treatment planning process, 54.5% of RTs (n = 31) strongly agreed/agreed that they consider the impact of physical side effects of radiation therapy on the sexual health of patients; during treatment delivery, 56% (n = 36) agreed/strongly agreed that they consider the physical side effects on their patients' sexual health. CONCLUSIONS Data indicated that RTs are aware that a cancer diagnosis and the subsequent treatments may lead to issues that affect sexual health. They are aware of the complex nature of sexual health and understand its importance in a persons' quality of life and that all patients with cancer regardless of site may experience issues which can impact their sexual health. Their responses suggest that they can relate their training and clinical practice to sexual health issues experienced by patients in their care. Current RT involvement in sexual health care is limited due to various process and environmental factors similar to those found in other health care professionals practice. By eliminating these barriers and supporting the inclusion of sexual health into the clinical practice of RTs, health care resources can be maximized to support the resolution of unmet needs of patients and their partners. In that way the quality of patient care services can be improved.
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Affiliation(s)
- Angela Turner
- Sunnybrook Health Sciences Centre, Odette Cancer Centre, Toronto, Ontario, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada.
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Verrijssen AS, Opbroek T, Bellezzo M, Fonseca GP, Verhaegen F, Gerard JP, Sun Myint A, Van Limbergen EJ, Berbee M. A systematic review comparing radiation toxicity after various endorectal techniques. Brachytherapy 2019; 18:71-86.e5. [DOI: 10.1016/j.brachy.2018.10.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Revised: 09/19/2018] [Accepted: 10/01/2018] [Indexed: 01/29/2023]
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Bossi P, Antonuzzo A, Cherny NI, Rosengarten O, Pernot S, Trippa F, Schuler U, Snegovoy A, Jordan K, Ripamonti CI. Diarrhoea in adult cancer patients: ESMO Clinical Practice Guidelines. Ann Oncol 2018; 29:iv126-iv142. [PMID: 29931177 DOI: 10.1093/annonc/mdy145] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Affiliation(s)
- P Bossi
- Head and Neck Medical Oncology Department, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano
| | - A Antonuzzo
- U.O. Oncologia Medica 1, Polo Oncologico Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - N I Cherny
- Oncology Institute, Shaare Zedek Medical Center, Jerusalem, Israel
| | - O Rosengarten
- Oncology Institute, Shaare Zedek Medical Center, Jerusalem, Israel
| | - S Pernot
- Department of Hepato-Gastroenterology and Digestive Oncology, Georges Pompidou European Hospital, APHP, Université Paris Descartes, Sorbonne Paris Cité, Paris, France
| | - F Trippa
- Radiation Oncology Centre, "S. Maria" Hospital, Terni, Italy
| | - U Schuler
- Department of Internal Medicine I, Palliative Care Centre, University Hospital Carl Gustav Carus, Dresden, Germany
| | - A Snegovoy
- N.N. Blokhin Russian Cancer Research Center, Moscow, Russia
| | - K Jordan
- Department of Medicine V, Hematology, Oncology and Rheumatology, University of Heidelberg, Heidelberg, Germany
| | - C I Ripamonti
- Oncology-Supportive Care in Cancer Unit, Department Onco-Haematology, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
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Jensen NBK, Pötter R, Kirchheiner K, Fokdal L, Lindegaard JC, Kirisits C, Mazeron R, Mahantshetty U, Jürgenliemk-Schulz IM, Segedin B, Hoskin P, Tanderup K. Bowel morbidity following radiochemotherapy and image-guided adaptive brachytherapy for cervical cancer: Physician- and patient reported outcome from the EMBRACE study. Radiother Oncol 2018; 127:431-439. [PMID: 29880222 DOI: 10.1016/j.radonc.2018.05.016] [Citation(s) in RCA: 64] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2017] [Revised: 05/17/2018] [Accepted: 05/17/2018] [Indexed: 01/12/2023]
Abstract
BACKGROUND/PURPOSE This study describes late bowel morbidity prospectively assessed in the multi-institutional EMBRACE study on MRI-guided adaptive brachytherapy in locally advanced cervical cancer (LACC). MATERIALS/METHODS A total of 1176 patients were analyzed. Physician reported morbidity (CTCAE v.3.0) and patient reported outcome (PRO) (EORTC QLQ C30/CX24) were assessed at baseline and at regular follow-up. RESULTS At 3/5 years the actuarial incidence of bowel morbidity grade 3-4 was 5.0%/5.9%, including incidence of stenosis/stricture/fistula of 2.0%/2.6%. Grade 1-2 morbidity was pronounced with prevalence rates of 28-33% during follow-up. Diarrhea and flatulence were most frequently reported, significantly increased after 3 months and remained elevated during follow-up. Incontinence gradually worsened with time. PRO revealed high prevalence rates. Diarrhea ≥"a little" increased from 26% to 37% at baseline to 3 months and remained elevated, difficulty in controlling bowel increased from 11% to 26% at baseline to 3 months gradually worsening with time. Constipation and abdominal cramps improved after treatment. CONCLUSION Bowel morbidity reported in this large cohort of LACC patients was limited regarding severe/life-threatening events. Mild-moderate diarrhea, flatulence and incontinence were prevalent after treatment with PROs indicating a considerable and clinically relevant burden. Critical knowledge based on the extent and manifestation pattern of treatment-related morbidity will serve future patient management.
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Affiliation(s)
| | - Richard Pötter
- Department of Radiation Oncology, Medical University of Vienna, Austria
| | | | - Lars Fokdal
- Department of Oncology, Aarhus University Hospital, Denmark
| | | | | | - Renaud Mazeron
- Department of Radiation Oncology, Gustave-Roussy, Villejuif, France
| | - Umesh Mahantshetty
- Department of Radiation Oncology, Tata Memorial Centre, HBNI, Mumbai, India
| | | | - Barbara Segedin
- Department of Radiation Oncology, Institute of Oncology Ljubljana, Slovenia
| | - Peter Hoskin
- Mount Vernon Cancer Centre, Northwood, United Kingdom
| | - Kari Tanderup
- Department of Oncology, Aarhus University Hospital, Denmark
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Larsen T, Hausken T, Otteraaen Ystad S, Hovdenak N, Mueller B, Lied GA. Does the low FODMAP diet improve symptoms of radiation-induced enteropathy? A pilot study. Scand J Gastroenterol 2018; 53:541-548. [PMID: 29113519 DOI: 10.1080/00365521.2017.1397186] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
RATIONALE Patients with radiation-induced enteropathy (RE) after cancer treatment show similar symptoms as patients with irritable bowel syndrome (IBS). The low fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (FODMAP) diet (LFD) is a widespread management strategy for IBS. We aimed to investigate if there may be a positive effect of LFD on symptoms and health-related quality of life (HRQOL) in patients with RE. METHODS In an open non-controlled pilot study, 11 patients (all female) with RE-related IBS symptoms were recruited largely based on own initiative. All followed LFD for four weeks. IBS Severity Scoring System (IBS-SSS) and IBS Symptom Questionnaire (IBS-SQ) were used to assess symptoms. Short Form Nepean Dyspepsia Index (SF-NDI) and 12-item Short Form Health Survey (SF-12) evaluated HRQOL. A three day food record was used to estimate baseline intake of FODMAPs and to reveal dietary changes. RESULTS FODMAP intake was successfully reduced, although LFD was found a burdensome intervention. IBS symptoms improved significantly based on mean total score of IBS-SSS and IBS-SQ, which changed from 310.2 ± 60.7 to 171.4 ± 107.2 (p = .001) and 27.4 ± 4.1 to 15.7 ± 10.1 (p = .002). HRQOL improved based on SF-NDI total score (30.5 ± 9.4 to 18.3 ± 8.2, p = .001) and based on mental (p = .047) and physical (p = .134) score of SF-12. Main additional dietary changes were reduced intake of energy, carbohydrates, and fiber. CONCLUSION Our findings from this small-scaled pilot study indicate that the LFD may alleviate symptoms and improve HRQOL in patients with RE. Further controlled studies with larger sample size should be conducted to verify our results and hopefully enable implementation of LFD as a future part of the management strategy for RE.
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Affiliation(s)
- Trine Larsen
- a Center for Nutrition, Department of Clinical Medicine , University of Bergen , Bergen , Norway
| | - Trygve Hausken
- a Center for Nutrition, Department of Clinical Medicine , University of Bergen , Bergen , Norway.,b Section of Gastroenterology, Department of Medicine , Haukeland University Hospital , Bergen , Norway.,c National Centre of Functional Gastrointestinal Disorders , Haukeland University Hospital , Bergen , Norway
| | - Synne Otteraaen Ystad
- a Center for Nutrition, Department of Clinical Medicine , University of Bergen , Bergen , Norway.,c National Centre of Functional Gastrointestinal Disorders , Haukeland University Hospital , Bergen , Norway
| | - Nils Hovdenak
- a Center for Nutrition, Department of Clinical Medicine , University of Bergen , Bergen , Norway
| | - Bernd Mueller
- d Hyperbaric Medical Unit , Haukeland University Hospital , Bergen , Norway
| | - Gülen Arslan Lied
- a Center for Nutrition, Department of Clinical Medicine , University of Bergen , Bergen , Norway.,b Section of Gastroenterology, Department of Medicine , Haukeland University Hospital , Bergen , Norway.,c National Centre of Functional Gastrointestinal Disorders , Haukeland University Hospital , Bergen , Norway
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A fusion protein composed of the DSL domain of Dll1 and RGD motif protects cryptic stem cells in irradiation injury. Biosci Rep 2018; 38:BSR20171255. [PMID: 29444821 PMCID: PMC5843746 DOI: 10.1042/bsr20171255] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Revised: 02/14/2018] [Accepted: 02/14/2018] [Indexed: 12/31/2022] Open
Abstract
Intestine is vulnerable to irradiation injury, which induces cell death and compromises regeneration of intestinal crypts. It is well accepted that cryptic stem cells, which are responsible for cryptic regeneration under physiological and pathological conditions, are controlled by multiple cell-intrinsic and environmental signals such as Notch signaling. Therefore, in the present study, we tested whether a soluble Notch ligand tethered to endothelial cells-mD1R-the Delta-Serrate-Lag2 (DSL) domain of mouse Notch ligand Delta-like1 fused with a RGD motif could protect cryptic cells from irradiation-induced intestinal injury. The result showed that administration of mD1R, which activated Notch signaling in intestinal cells, ameliorated loss of body weight and reduction of cryptic structures in intestine after total body irradiation (TBI) in mice. Histological staining showed that injection of mD1R after TBI promoted cryptic cell proliferation and reduced cell apoptosis in crypts. Immunofluorescence staining and reverse transcription (RT)-PCR showed that mD1R increased the level of Lgr5, Bmi1, Olfactomedin-4 (OLFM4), and IRIG1 in crypts, suggesting a protective effect on cryptic stem and progenitor cells after irradiation. Moreover, we found that administration of mD1R increased the number of Paneth cells and the mRNA level of Defa1, and the number Alcian Blue+ Goblet cells decreased first and then increased after irradiation, suggesting that mD1R promoted the maturation of the intestinal crypt after irradiation injury. Our data suggested that mD1R could serve as a therapeutic agent for the treatment of irradiation-induced intestinal injury.
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Ludmir EB, Kachnic LA, Czito BG. Evolution and Management of Treatment-Related Toxicity in Anal Cancer. Surg Oncol Clin N Am 2018; 26:91-113. [PMID: 27889040 DOI: 10.1016/j.soc.2016.07.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Over the past several decades, clinical trials have demonstrated improved disease-related outcomes in the definitive treatment of anal cancer. Although treatment with radiation and concurrent chemotherapy results in high rates of cure, significant acute and late toxicities are seen. This review focuses on the evolution of treatment-related toxicity for anal cancer. Management of these adverse effects is reviewed, as are future directions in anal cancer treatment and their impact on toxicity.
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Affiliation(s)
- Ethan B Ludmir
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, 1400 Pressler St, Unit 1422, Houston, TX 77030, USA
| | - Lisa A Kachnic
- Department of Radiation Oncology, Vanderbilt University Medical Center, 2220 Pierce Avenue, Suite B1034, Nashville, TN 37232, USA
| | - Brian G Czito
- Department of Radiation Oncology, Duke University Medical Center, Box 3085, Durham, NC 27710, USA.
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