Rates of Adverse IBD-Related Outcomes for Patients With IBD and Concomitant Prostate Cancer Treated With Radiation Therapy

Prostate and gut: Any relationship? A narrative review on the available evidence and putative mechanisms

BACKGROUND

Gut microbiome is a community of microorganisms that lives in the human intestine and exerts various functions on the host, including metabolic, immunoregulatory, and control over cell proliferation. Gut microbiome alterations have been associated with various pathological conditions, such as diabetes mellitus, obesity, and cardiovascular diseases. Gut-prostate axis is explained by the association between gut microbiome quantitative and functional alterations along with increased intestinal epithelial permeability with prostatediseases. However, the pathophysiological mechanisms and clinical importance of this association are not completely clarified yet.

METHODS

We conducted a narrative review of the most relevant articles in the Medline (US National Library of Medicine, Bethesda, MD, USA), Scopus (Elsevier, Amsterdam, The Netherlands) and Web of Science Core Collection (Thomson Reuters, Toronto, ON, Canada) databases. No chronological restrictions were applied, and the most related papers published until December 2023 were included.

RESULTS

Gut microbiota (GM) and its metabolites are capable of modifying host androgen level, as well as prostate cancer (PCa) therapy response. Moreover, patients with inflammatory bowel disease have higher rates of prostatitis-like symptoms and a potential risk of developing PCa.

CONCLUSIONS

There is evidence that interventions on the GM and its metabolites have a high potential to serve as diagnostic and therapeutic tools for prostate diseases, including PCa.

Rectal Cancer and Radiation in Colitis

Inflammatory bowel disease (IBD) is associated with an increased risk of colorectal cancer. When IBD patients develop a rectal cancer, this should be treated with the same oncological principles and guidelines as the general population. Rectal cancer treatment includes surgery, chemotherapy, and radiation therapy (RT). Many IBD patients will require a total proctocolectomy with an ileal-pouch anal anastomosis (IPAA) and others, restoration of intestinal continuity may not be feasible or advisable. The literature is scarce regarding outcomes of IPAA after RT. In the present review, we will summarize the evidence regarding RT toxicity in IBD patients and review surgical strategies and outcomes of IPAA after RT.

The Optimal Management of Inflammatory Bowel Disease in Patients with Cancer

Patients with inflammatory bowel disease (IBD) have an increased risk of cancer secondary to chronic inflammation and long-term use of immunosuppressive therapy. With the aging IBD population, the prevalence of cancer in IBD patients is increasing. As a result, there is increasing concern about the impact of IBD therapy on cancer risk and survival, as well as the effects of cancer therapies on the disease course of IBD. Managing IBD in patients with current or previous cancer is challenging since clinical guidelines are based mainly on expert consensus. Evidence is rare and mainly available from registries or observational studies. In contrast, excluding patients with previous/or active cancer from clinical trials and short-term follow-up can lead to an underestimation of the cancer or cancer recurrence risk of approved medications. The present narrative review aims to summarize the current evidence and provide practical guidance on the management of IBD patients with cancer.

Incidence and risk factors for neoplasia in inflammatory bowel disease

INTRODUCTION

Inflammatory Bowel Disease (IBD) patients may have an increased risk of neoplasia. The aim was to evaluate the incidence of malignant neoplasia in IBD patients, associated risk factors and therapy adjustments.

METHODS

Unicentric retrospective cohort study. All patients followed for IBD in a tertiary portuguese hospital and oncological centre during 2015-2020 were included.

RESULTS

318 patients were included female 55.0%, age at diagnosis = 37.24(±15,28), Crohn's disease 52.5%, Primary Sclerosing Cholangitis n = 7, family history of cancer n = 12, previous diagnosis of neoplasia n = 23(7.2%). 42 cancers were diagnosed in 35 patients (11.0%) - median of 12.0(IQR = 7.5-21.0) years after IBD diagnosis. Most affected organs were the skin (n = 15 in 11 patients; melanoma = 1), colon/rectum (n = 8 in 6 patients), prostate (n = 4), breast (n = 3) and anal canal (n = 2). In those with non-melanoma skin cancer, 6 were under active treatment with azathioprine and 2 had stopped it for more than two years. In the univariate analysis, the occurrence of neoplasia was positively associated with tobacco exposure (p = 0.022), age at IBD diagnosis (p = 0.021), and negatively with infliximab exposure (p = 0.046). In 9 cases, cancer treatment was different because of the IBD, while IBD treatment was changed in 9 patients. In those affected by cancer, in the univariate analysis, its cure/remission was negatively associated with tobacco exposure (p = 0.004) and positively with salicylates use (p = 0.007).

CONCLUSION

In IBD patients, cancer mostly affected the skin and the lower digestive system. As in the general population, tobacco exposure was a risk factor for the development of neoplasia.

Toxicity After Stereotactic Body Radiation Therapy for Prostate Cancer in Patients With Inflammatory Bowel Disease: A Multi-institutional Matched Case-Control Series

Purpose

To evaluate the safety of stereotactic body radiation therapy (SBRT) for prostate cancer in men with inflammatory bowel disease (IBD).

Methods and Materials

We queried a consortium database for patients with IBD receiving SBRT for prostate cancer between 2006 and 2012. Identified patients were matched with patients without a history of IBD in a 3:1 fashion based on dose, fractionation, use of androgen deprivation therapy, and age distribution. Logistic regression was used to evaluate the association between having IBD and experiencing acute and late gastrointestinal (GI) and genitourinary (GU) toxicities as scored on the Common Terminology Criteria for Adverse Events scale. Time to late toxicity was evaluated using proportional hazard Cox models. Our study was limited by absence of data on prostate size, baseline International Prostate Symptom Score, and rectal dose-volume histogram parameters.

Results

Thirty-nine patients with flare-free IBD at time of treatment (median follow-up 83.9 months) and 117 matched controls (median follow-up 88.7 months) were identified. A diagnosis of IBD was associated with increased odds of developing any late grade GI toxicity (odds ratio [OR] 6.11, P <.001) and GU toxicity (odds ratio 6.14, P < .001), but not odds of developing late grade ≥2 GI (P = .08) or GU toxicity (P = .069). Acute GI and GU toxicity, both overall and for grade ≥2 toxicities, were more frequent in men with IBD (P < .05). Time to late GI and GU toxicity of any grade was significantly shorter in patients with IBD (P < .001). Time to late grade ≥2 GU, but not grade ≥2 GI toxicity, was also shorter in patients with IBD (P = .044 for GU and P = .144 for GI).

Conclusions

Patients with IBD who received SBRT for PCa had a higher likelihood of developing acute GI and GU toxicity, in addition to experiencing lower grade late toxicities that occurred earlier. However, patients with IBD did not have a higher likelihood for late grade ≥2 GI or GU toxicity after SBRT compared with the control cohort. Interpretation of this data are limited by the small sample size. Thus, men with IBD in remission should be properly counseled about these risks when considering SBRT.

Rectal spacers in patients with prostate cancer undergoing radiotherapy: A survey of UK uro-oncologists

AIM

To understand the awareness and use of rectal spacers for prostate cancer patients undergoing radical radiotherapy in the United Kingdom.

METHODS

An expert-devised online questionnaire was completed by members of the British Uro-oncology Group (BUG).

RESULTS

Sixty-three specialists completed the survey (50% of BUG members at that point in time). Only 37% had used rectal spacers, mostly for private patients or those with pre-existing bowel conditions. However, many (68%) would like to use these devices in future. More than 70% of the uro-oncologists felt that bowel toxicity was underreported, but 60% believed that the use of radiotherapy without bowel toxicity was achievable with the use of rectal spacers.

CONCLUSIONS

The current use of rectal spacers by UK uro-oncologists for patients with localised or locally advanced prostate cancer receiving radiotherapy is low and largely restricted by resourcing issues.

Stereotactic body radiation therapy for the treatment of localized prostate cancer in men with underlying inflammatory bowel disease

BACKGROUND

Historically, IBD has been thought to increase the underlying risk of radiation related toxicity in the treatment of prostate cancer. In the modern era, contemporary radiation planning and delivery may mitigate radiation-related toxicity in this theoretically high-risk cohort. This is the first manuscript to report clinical outcomes for men diagnosed with prostate cancer and underlying IBD curatively treated with stereotactic body radiation therapy (SBRT).

METHODS

A large institutional database of patients (n = 4245) treated with SBRT for adenocarcinoma of the prostate was interrogated to identify patients who were diagnosed with underlying IBD prior to treatment. All patients were treated with SBRT over five treatment fractions using a robotic radiosurgical platform and fiducial tracking. Baseline IBD characteristics including IBD subtype, pre-SBRT IBD medications, and EPIC bowel questionnaires were reviewed for the IBD cohort. Acute and late toxicity was evaluated using the CTCAE version 5.0.

RESULTS

A total of 31 patients were identified who had underlying IBD prior to SBRT for the curative treatment of prostate cancer. The majority (n = 18) were diagnosed with ulcerative colitis and were being treated with local steroid suppositories for IBD. No biochemical relapses were observed in the IBD cohort with early follow up. High-grade acute and late toxicities were rare (n = 1, grade 3 proctitis) with a median time to any GI toxicity of 22 months. Hemorrhoidal flare was the most common low-grade toxicity observed (n = 3).

CONCLUSION

To date, this is one of the largest groups of patients with IBD treated safely and effectively with radiation for prostate cancer and the only review of patients treated with SBRT. Caution is warranted when delivering therapeutic radiation to patients with IBD, however modern radiation techniques appear to have mitigated the risk of GI side effects.

CISD2 plays a role in age-related diseases and cancer

CDGSH iron-sulfur domain 2 (Cisd2) is an evolutionarily conserved protein that plays an important regulatory role in aging-related diseases and cancers. Since its discovery, Cisd2 has been identified as a regulatory factor for the aging of the human body and the regulation of mammalian lifespan. Cisd2 is also an oncoprotein that regulates the occurrence and development of cancer. Cisd2 mediates the occurrence of diseases related to human aging and the proliferation, differentiation, metastasis, and invasion of various cancer cells through various mechanisms. Multiple studies have shown that Cisd2 expression is related to the clinical characteristics of aging-related diseases and patients with cancer, and its expression profile is a novel diagnostic and prognostic biomarker for a variety of human diseases. Modulating the expression or function of Cisd2 may be a potential treatment strategy for different diseases. In this review, we summarize the role of Cisd2 in human aging-related diseases and various cancers, as well as the biological functions, underlying mechanisms, and potential clinical significance.

Utilization of Iodinated SpaceOAR Vue™ During Robotic Prostate Stereotactic Body Radiation Therapy (SBRT) to Identify the Rectal-Prostate Interface and Spare the Rectum: A Case Report

We describe the utilization of SpaceOAR Vue™, a new iodinated rectal spacer, during Robotic Stereotactic Body Radiation Therapy (SBRT) for a Prostate Cancer Patient with a contraindication to Magnetic Resonance Imaging. A 69-year-old Caucasian male presented with unfavorable intermediate risk prostate cancer and elected to undergo SBRT. His medical history was significant for atrial fibrillation on Rivaroxaban with a pacemaker. He was felt to be at increased risk of radiation proctitis following SBRT due to the inability to accurately contour the anterior rectal wall at the prostate apex without a treatment planning MRI and an increased risk of late rectal bleeding due to prescribed anticoagulants. In this case report, we discuss the technical aspects of appropriate placement and treatment planning for utilizing SpaceOAR Vue™ with Robotic SBRT.

Ulcerative colitis that developed during radiotherapy for prostate cancer, deteriorated rapidly and required emergency surgery

Background

Although there are reports linking ulcerative colitis (UC) to prostate cancer (PC), those reports are of PC patients who were previously diagnosed with UC. There are no reports of the development of UC during radiotherapy. Here we describe the first case of a patient who developed UC during radiotherapy for PC. The UC progressed rapidly and required emergency surgery.

Case presentation

A 61-year-old Japanese man underwent a prostate biopsy at another hospital due to a high prostate-specific antigen level and was diagnosed with PC. Goserelin and bicalutamide treatment was initiated in 2019, and intensity-modulated radiotherapy (total of 60 Gy/20 Fr) was administered in 2020. Diarrhea began during the radiotherapy and bleeding began post-radiotherapy. He was admitted to another hospital 14 days after the end of the radiotherapy, and colonoscopy revealed a deep ulcer in the colon, which led to the suspicion of UC. He was transferred to our hospital, and colonoscopy showed a widespread map-like ulcer, pseudopolyposis, and very easy bleeding in the colon. We diagnosed severe UC, and it worsened rapidly with uncontrollable bleeding, which we considered an indication for surgery. Emergency surgery (a total colectomy and ileostomy creation) was performed. The specimens confirmed an extensively spreading ulcer throughout the colon. The pathological report was UC in the active phase. The postoperative course was good.

Conclusions

When a patient exhibits diarrhea while undergoing radiotherapy for PC, clinicians should be aware of the possibility of UC in addition to radiation colitis, and colonoscopy should be considered.

Should inflammatory bowel disease be a contraindication to radiation therapy: a systematic review of acute and late toxicities

Background:

Inflammatory bowel disease (IBD) [i.e., Crohn’s disease (CD) and ulcerative colitis (UC)] has been considered a relative contraindication for radiation therapy (RT) to the abdomen or pelvis, potentially preventing patients with a diagnosis of IBD from receiving definitive therapy for their malignancy.

Method:

Using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) conventions, a PubMed/MEDLINE literature search was conducted using the keywords RT, brachytherapy, inflammatory bowel disease, Crohn’s disease, ulcerative colitis and toxicity.

Results:

A total of 1,206 publications were screened with an addition of 8 studies identified through hand searching. Nineteen studies met the inclusion criteria for quantitative analysis. The total population across all studies was 497 patients, 50·5% having UC, 37% having CD and an additional 12·5% having unspecified IBD. Primary gastrointestinal malignancy (55%) followed by prostate cancer (40%) composed the bulk of the population. Acute and late grade 3 or greater gastrointestinal specific toxicity ranged from 0–23% to 0–13% respectively for those patients with IBD treated with RT to the abdomen or pelvis. In the literature reviewed, RT does not appear to increase fistula or stricture formation or IBD flares; however, one study did note RT to be a statistically significant risk factor for subsequent IBD flare on multivariate analysis.

Conclusions:

A review of reported acute and late toxicities suggests that patients with IBD should still be considered for definitive radiotherapy. Patient characteristics including IBD distribution relative to the irradiated field, inflammatory activity at the time of radiation, overall disease severity and disease phenotype in the case of CD (fistulising versus stricturing versus inflammatory only) should be considered on an individual basis when evaluating potential patients. When possible, advanced techniques with strict organ at risk dose constraints should be employed to limit toxicity in this patient population.

Managing Patients with Inflammatory Bowel Disease Who Develop Prostate Cancer

Prostate cancer is the most common cancer among men in the USA. Interestingly, recent studies suggest that patients with inflammatory bowel disease (IBD) are at increased risk of developing prostate cancer. Importantly, patients with IBD who develop prostate cancer require thoughtful care when using immunosuppressants to treat the IBD in the setting of malignancy. Further, consideration must be given to the proximity of the prostate to the gastrointestinal tract when treating with radiation where there is concern for the effects of inadvertent exposure of radiation to the diseased bowel. In general, management of immunosuppression after diagnosis of prostate cancer is contingent on the specific immunosuppressive agents, the duration of cancer remission and/or plans for cancer treatment, and the potential risks and benefits of stopping or altering the administration of those agents. Concerns that patients with IBD would have increased risk of disease exacerbation and gastrointestinal toxicity have previously limited the use of radiation. While currently no consensus has been reached regarding the safety of radiation therapy in patients with IBD, recent studies suggest that radiation therapy may be used safely in patients with IBD who develop prostate cancer, especially brachytherapy and intensity-modulated radiation therapy which may have less bowel toxicity compared to conventional methods of external beam radiation therapy. A multidisciplinary team approach including gastroenterologists, urologists, radiation oncologists, and medical oncologists should be undertaken to best treat patients with IBD and prostate cancer.