Radiation-induced bowel injury: the impact of radiotherapy on survivorship after treatment for gynaecological cancers

Abstract

Background:The number of women surviving cancer who live with symptoms of bowel toxicity affecting their quality of life continues to rise. In this retrospective study, we sought to describe and analyse the presenting clinical features in our cohort, and evaluate possible predictors of severity and chronicity in women with radiation-induced bowel injury after treatment for cervical and endometrial cancers.Methods:Review of records of 541 women treated within the North London Gynaecological Cancer Network between 2003 and 2010 with radiotherapy with or without chemotherapy for cervical and endometrial cancer identified 152 women who reported significant new bowel symptoms after pelvic radiation.Results:Factor analysis showed that the 14 most common and important presenting symptoms could be ‘clustered' into 3 groups with predictive significance for chronicity and severity of disease. Median follow-up for all patients was 60 months. Univariate analysis showed increasing age, smoking, extended field radiation, cervical cancer treatment and the need for surgical intervention to be significant predictors for severity of ongoing disease at last follow-up. On multivariate analysis, only age, cancer type (cervix) and symptom combinations/‘cluster' of (bloating, flatulence, urgency, rectal bleeding and per-rectal mucus) were found to be significant predictors of disease severity. Fifteen (19%) women in the cervical cancer group had radiation-induced bowel injury requiring surgical intervention compared with five (6.7%) in the endometrial cancer group.Conclusion:Women with cervical cancer are younger and appear to suffer more severe symptoms of late bowel toxicity, whereas women treated for endometrial cancer suffer milder more chronic disease. The impact of radiation-induced bowel injury and the effect on cancer survivorship warrants further research into investigation of predictors of severe late toxicity. There is a need for prospective trials to aid early diagnosis, while identifying the underlying patho-physiological process of the bowel injury.

Rectal bleeding after radiation therapy for endometrial cancer

“…EBRT+VB did not significantly increase RB rates when compared to EBRT, though the absolute rate of higher-degree rectal bleeding (RB scale 2–3) was 2.3% greater in the EBRT+VB group (4.7% vs. 2.4%). The absolute rate of RB Scale 3 bleeding requiring argon laser coagulation after EBRT+VB was 1.9%, which is less than the 5% previously published [14]. This may be due to the lower dose of 16 Gy in 4 Gy fractions used in this series while the previously published series administered brachytherapy at 15 Gy in 7.5 Gy fractions [14].…”

“…al. that younger age was an independent predictor of post-pelvic radiation bowel toxicity in uterine-cancer patients [14]. The reasons for this are unclear.…”

“…With gastrointestinal toxicities being a well known complication of pelvic radiation, it is important to understand the potential long-term burden of more aggressive adjuvant therapy [11–14]. Randomized trials have established that VB is very well tolerated.…”

“…When administered without EBRT in PORTEC-2, rectal bleeding was reported as a possible but rare complication [11,13]. In contrast, one retrospective series found that up to 5% of endometrial-cancer patients receiving VB after EBRT had rectal bleeding severe enough to require argon laser coagulation [14]. The goals of the current study are to investigate rectal-bleeding rates after radiation therapy for endometrial cancer and to establish possible predictors of bleeding.…”

Management of toxicities following pelvic irradiation for gynaecological cancers

“…In a retrospective review, Kuku et al [28] reported late bowel effects in 28% women treated for gynaecological cancer with the most common symptoms being faecal urgency, diarrhoea, faecal incontinence and rectal bleeding. Benton et al have developed a comprehensive algorithm for investigation and management of 23 individual symptoms.…”