Pelvic radiation disease: ask an expert

Cancer treatment has come a long way. Nowadays, many cancers can be treated successfully with techniques such as chemotherapy or radiotherapy. However, for some patients, radiotherapy can have some less-than-pleasant side-effects that linger long after the treatment. Dr Shameer Mehta is here to explain pelvic radiation disease (PRD).

What is pelvic radiation disease (PRD)?

Patients with cancer of the abdomen and pelvis are often treated with radiotherapy. This treatment, either alone or in combination with surgery or chemotherapy, is becoming more successful, meaning that patients are living for longer than ever before.

This is obviously fantastic news, but unfortunately, up to half of these patients will suffer with long-term gut symptoms affecting their quality of life as a direct result of their cancer treatment. These symptoms include diarrhoea, bloating, flatulence and rectal bleeding. This is a hugely under-recognised problem, sometimes because patients don’t report these symptoms to their cancer teams as they’re not aware that anything can be done about them.

These long-term gut complaints come about as a direct result of damage to the bowel from previous radiotherapy, and can occur some years after the treatment has ended.

Why is it associated with cervical cancer treatment?

Many women with cervical cancer are treated with radiotherapy, which is very effective at targeting cancerous tissue. However, the small intestine can dip down into the pelvis from the abdomen, meaning some parts can fall within the radiotherapy field. For this reason, parts of the small intestine can become damaged inadvertently, causing symptoms such as diarrhoea, pain and bloating, as well as reduced absorption of important nutrients.

In addition, the lower end of the large bowel (the rectum) is also located close to radiotherapy fields for cervical cancer. Damage of the lining of the rectum, close to the anus, can cause bleeding from a condition called radiation proctopathy. This is not a serious condition at all, and in most cases does not require treatment. In some patients with heavy or recurrent bleeding despite measures to regulate their bowel habits, I usually offer sucralfate enemas or newer endoscopic treatments.

Can PRD be avoided during cervical cancer treatment?

Much research has focused on whether PRD can be avoided completely and how. Unfortunately, there is no good quality evidence to show that any one therapy or strategy reduces the risk of developing PRD, apart from radiotherapy techniques such as conformal radiotherapy which are already widely used. Some evidence suggests increasing dietary fibre may help, but further research is required in this area. Similarly, probiotics may help reduce the severity of PRD symptoms, but it is not clear which probiotic preparation is the most effective for all patients. In general, ensuring your nutritional health is as good as it can be when undergoing radiotherapy is likely to help reduce the likelihood of developing PRD.

How can you manage PRD?

Often, the effects of cancer treatments such as radiotherapy on the bowel are irreversible. However, a number of gut conditions can occur as a result of these treatments, which themselves lead to unpleasant symptoms. These conditions are entirely benign and not worrying at all, but need to be given specific consideration if they are to be tested for and treated appropriately. These include, but are not limited to, conditions termed bile salt diarrhoea, small intestinal bacterial overgrowth, pancreatic insufficiency and radiation proctopathy. The specific treatments for these are usually very effective at improving symptoms and patients’ overall quality of life.

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