Survivorship: Late Effects After Radiation for Non-Hodgkin Lymphoma (Abdomen/Groin)
What is a late effect?
A late effect is as a side effect related to a cancer diagnosis or treatment that happens months to years after treatment. Some side effects that you develop during treatment can last for months to years after treatment is completed (for example, fatigue or neuropathy). These are often called long term side effects.
Late effects can be health issues or psychological, emotional and practical challenges.
Late Effects After Radiation for Non-Hodgkin Lymphoma (Treatment to Groin/Abdomen)
Side effects from radiation treatment are directly related to the area of the body being treated. Any area in the treatment field has a risk of being damaged, causing side effects. As radiation techniques have improved over the years, the risk of late effects has decreased.
Spinal Cord Damage
The spinal cord can be in the field of radiation treatment for “mantle field” therapy. This can cause damage to the nerves in the spine.
- Symptoms can include loss of strength, feeling, or coordination of the arms or legs, paralysis, or problems with bowel or bladder control. Sometimes nerve damage can cause a feeling of electric shock spreading down the arms or legs.
- If you develop these symptoms, you may need imaging tests or to be seen by a neurologist for further workup.
Radiation can also cause damage to the bones of the spine. This can result in a reduction in height or change in the curvature of the spine. Radiation to these bones can also put them at risk for fracture. If you have any new back pain you should call your provider right away. You may need x-rays or other imaging tests.
Radiation to the pelvic area can cause late effects to the bladder including:
- Developing scar tissue, which can lead to a decrease in how much urine your bladder can hold.
- If given with chemotherapy medicines known to cause bladder damage (cyclophosphamide, ifosfamide), late effects can include hemorrhagic cystitis that causes bleeding from the bladder lining. Symptoms of hemorrhagic cystitis include urinary frequency (needing to go often) and urgency (needing to go quickly), blood in the urine and pain. You should report these symptoms to your provider right away.
- Radiation to the bladder may also make you more susceptible to urinary tract infections. This type of infection can be treated with antibiotics. Any symptoms of urinary burning, frequency, or blood in the urine should be reported right away to your provider.
- Radiation to the bladder can increase the risk of developing bladder cancer. Symptoms may include blood in the urine, urinary frequency and urgency, urinating at night, and incontinence. Contact your care provider if you have any of these symptoms.
- These late effects all have similar symptoms. You may have urine tests or cystoscopy (inserting a small tube with a camera into the bladder) to figure out what is causing your symptoms. It is best to avoid alcohol use and smoking, as these irritate the bladder and increase the risk of bladder cancer.
The bowel is sensitive to the effects of radiation. The late effects that may occur after radiation including the rectum, colon, or small bowel include:
- Scarring and strictures: Damage to the tissue of the bowel can lead to scar tissue. This scar tissue can lead to bowel obstruction. A bowel obstruction is when the normal movement of the bowel is blocked. Call your provider if you are having any abdominal pain, constipation, vomiting, weight loss or bloating. If you have severe abdominal pain along with vomiting and constipation you should be seen by a provider right away, either in the office or the emergency department.
- Ulceration and bleeding: Ulceration and bleeding can be a side effect of damage to the bowel tissues. Report any bright red blood in your stools, toilet water, or on toilet paper, as well as dark black stools, to your provider right away.
- Chronic diarrhea: Report diarrhea that is causing weight loss to your care team. Medications to lessen diarrhea may be helpful. You may benefit from meeting with a gastroenterologist. You should also meet with a registered dietitian who can help evaluate your diet and give you suggestions to lessen diarrhea and maintain or gain weight.
- Fistula formation: A fistula is a connection (hole) between two parts of the body that are not normally connected. A fistula can form between the bowel and bladder, bowel and female reproductive system (uterus/ vagina), or the bowel and the skin. If you have urine, feces, or blood coming out of any opening that it should not be, you should call your provider right away.
- Secondary colon cancer: Radiation to the bowel can lead to colon cancer years after treatment is complete. If you were treated as a child or adolescent, it is recommended to begin colon cancer screening with colonoscopy or DNA stool testing 5 years after treatment or at age 30, whichever occurs later. Screening for the general population begins between the ages of 45-50. You should consider these 2 guidelines when deciding when to start colon cancer screening. You may need earlier screening if you have irritable bowel disease, chronic diarrhea or bleeding, ulcerative colitis, colon cancer in your family or previous gastrointestinal cancers or polyps.
Impact on Reproductive Organs, Sexual Function and Fertility (men)
Radiation to the pelvis in a man may cause issues with sexual health such as infertility, low testosterone levels, low sperm count or the inability to get and maintain an erection (erectile dysfunction).
- If you want to have a child, you may benefit from speaking to a fertility specialist. They can evaluate the health of your sperm and your ability to father a child.
- In some cases, the prostate gland is affected by radiation, which can lead to a decrease in seminal fluid. This can cause a man to have a “dry orgasm.” In these cases, the man is still able to achieve orgasm but will have little or no fluid released.
- You should try to speak openly with your provider about these issues. For those having erectile dysfunction, medications such as sildenafil (Viagra) may be useful. If these medicines are not helping, you should see a urologist. There are other ways that you can achieve an erection, such as using an implant or pump.
Impact to Reproductive Organs, Sexual Function and Fertility (Women)
You may have long term changes to your vagina and uterus after radiation to your pelvis. You may experience vaginal dryness, atrophy (shrinkage and thinning of the tissues), less feeling/sensation in the genital area, bleeding and painful intercourse.
- Personal water-based lubricants and moisturizers (such as Replens) can help to make sexual intercourse more comfortable.
- Regularly applying vitamin E to external tissues or using suppositories to apply to vaginal tissue may help to strengthen tissues and reduce friction and discomfort. Some women may benefit from low dose estrogen suppositories.
- Scarring in the vagina may cause the size of the vagina to narrow or shorten. Regular use of vaginal dilators, which are placed in the vagina for short periods of time, is recommended for all women who have had radiation to the pelvic area. This will help stretch the vaginal tissues and make intercourse and vaginal exams more comfortable.
- Physical therapy to strengthen pelvic floor muscles has been shown to decrease pain with intercourse and improve sexual health. Women with pain in the vulvar region may find relief with topical lidocaine (a numbing agent).
- If sexual health changes are affecting your quality of life, discuss them with your providers. You may find it helpful to see a therapist experienced in working with survivors with sexual concerns.
Fertility and Childbearing
- Radiation fields that include the ovaries can result in damage to a woman's supply of eggs (oocytes). The risk of infertility is increased with higher doses of radiation. Your period will likely stop during treatment but may return in women younger than 40. If it returns, you may still be at risk of going into menopause earlier than your peers. This can be important information for family planning.
- If you would like to become pregnant, seeking the opinion of a reproductive endocrinologist may be helpful. S/he can review the cancer treatments that you received, and review options with you.
- After ovarian radiation, some patients will experience early menopause (menopause that occurs before natural age). This can increase the risk of developing osteoporosis or heart disease. Young women who receive pelvic radiation may benefit from a consultation with an endocrinologist even if they do not wish to become pregnant. They can discuss ways to reduce these risks, including hormone supplements, calcium, vitamin D, and exercise, depending on your case.
- Radiation to the uterus (womb) can cause the uterus to shrink, have less elasticity (ability to stretch) and develop scar tissue. These changes in the uterus can cause an increased risk of miscarriage, preterm labor, and babies born at low birth weight. If you wish to become pregnant, you should be followed by a high-risk pregnancy specialist.
Damage to the Kidney
When the radiation field includes the kidney(s), renal insufficiency (decreased kidney function and hypertension (high blood pressure) can occur.
- The risk for kidney problems after radiation is increased if you have diabetes, only have one kidney, have a history of high blood pressure or if you have had other treatment with medications that can cause kidney damage.
- Have your blood pressure checked at your annual check-ups. If needed, your blood pressure may be treated with medications.
- Your team will also monitor your kidney function through blood testing (basic metabolic panel) and urine tests (urinalysis).
- Eating a balanced, healthy diet can promote healthy blood sugar levels and help to protect your kidneys from further damage.
Radiation to the liver can damage your liver.
- Your liver functions (LFT) will be measured by a blood test before and after treatment.
- Avoid drinking alcohol; it can increase the risk of liver injury.
- If you experience symptoms, including yellowing of the eyes and/or skin (jaundice), pain or swelling in your belly, itchy skin, and dark-colored urine contact your care team. You may need to be referred to a gastroenterologist for further evaluation.
Damage to the Spleen
The spleen is an organ located in the upper abdomen that works like a filter, removing bacteria and dead red blood cells from the bloodstream. Radiation to the spleen can cause it to not function. Damage to the spleen results in being at a higher risk for certain infections caused by encapsulated bacteria. Streptococcus pneumoniae and Haemophilus influenzae type b are the most common.
- An infection can quickly lead to sepsis and needs to be treated with antibiotics right away. In some cases, providers may prescribe you antibiotics to have on hand to take at the first sign of infection, even before being seen by the healthcare team. You need to report a fever (100.4° F/ 38.0°C or higher), or any sign of infection, to your team right away. If you can’t get in contact with your provider, go to an emergency room right away. You should tell any provider involved in your care that you do not have a spleen.
- You should wear a medic alert bracelet noting that you do not have a spleen (asplenia) as it is important for those involved in your care to be aware.
- Have an annual flu vaccine as well as pneumococcal, haemophilis influenza type b (HIb), meningococcal and hepatitis vaccines (per CDC guidelines). Talk to your provider to see if you need other vaccines, including Tdap, zoster, HPV, MMR, and varicella.
- If you are bitten by a dog, cat or rodent, antibiotics are necessary to prevent infection with Capnocytophaga canimorsus bacteria.
- If you are traveling to an area with malaria, take medication to prevent infection with malaria and use a mosquito repellent.
- If you are traveling to or living in Cape Cod or Nantucket Island in Massachusetts, you may be more likely to have issues from an infection called Babesia caused by deer ticks. If you notice you have been bitten by a tick in this area, please contact your healthcare provider as soon as possible.
Indigestion and heartburn care be late effects of radiation to the stomach. You may also be at a higher risk for gastritis (irritation of the stomach wall), ulcers, and gastric outlet obstruction.
- Symptoms include new or worsening belly pain, frequent vomiting or heartburn, or blood in your vomit or stool. Call your care team right away if you experience any of these symptoms.
- You may need a referral to a gastroenterologist to further evaluate your symptoms.
- If you are having heartburn, your care team may prescribe medications to reduce the amount of acid being made or to coat/protect the stomach.
Radiation can lead to permanent changes in the skin.
- You may develop new scars or notice changes in the color or texture of your skin. Radiation can also change the color and texture of your hair or can cause permanent hair loss in the treated area.
- The soft tissue and muscles under the skin can develop scarring and/or shrinkage, which can lead to a loss of flexibility and movement or chronic swelling in this area.
- You may develop chronic or recurring ulcers of the skin in the area treated. Blood vessels of the skin may become dilated and more visible, although this is not harmful.
- If the skin feels tight or sore, you can apply vitamin E to the skin.
- Use fragrance and dye-free soaps and moisturizers in the area if your skin is sensitive after radiation.
- After radiation, the skin in the treated area is more sensitive to sunlight. This sensitivity will last for your lifetime. Practice sun safety, using plenty of sunscreen, wear a wide-brimmed hat, and keep skin in the treated area covered with clothing. Try to avoid being out in the sun between the hours of 10 am-4 pm when it is the strongest.
If you notice any new or worsening skin issues anywhere on your body, you should contact your provider for an assessment.
Managing Late Effects
If you experience any concerning or persistent symptoms, contact your care team. Some side effects require specialized care from healthcare providers experienced in working with cancer survivors.
Interdisciplinary survivorship clinics are available at many cancer treatment sites. If a clinic is not available near you, talk with your oncology care team about resources for managing your late effects.
After treatment, talk with your oncology team about receiving a survivorship care plan, which can help you manage the transition to survivorship and learn about life after cancer. You can create your own survivorship care plan using the OncoLife Survivorship Care Plan.
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