Survivorship: Late Effects After Radiation for Stomach Cancer
What is a late effect?
A late effect is a side effect that is caused by cancer treatment but happens months to years after cancer treatment has finished. 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 called long-term side effects.
Late effects can be health issues or psychological, emotional, and practical challenges.
Late Effects After Radiation for Stomach (Gastric) Cancer
The physical side effects of 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.
Indigestion and heartburn can 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 (something blocking food from exiting your stomach).
- Signs of these issues 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 to see a gastroenterologist (GI doctor) to further evaluate your symptoms.
- If you are having heartburn, your care team may prescribe medications to lower the amount of acid being made or to coat/protect your stomach.
The bowel is sensitive to the effects of radiation. The late effects that may occur after radiation treatment that includes 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 cause a bowel obstruction. A bowel obstruction is when the normal movement of stool through 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. You may need to be admitted to the hospital for treatment.
- Ulceration and bleeding: Ulceration and bleeding can be caused by damage to the bowel tissues. Report any dark/black colored stools, bright red blood in your stools, or in the toilet water, or on the toilet paper, to your provider right away. These can be signs of bleeding. You may need testing with a colonoscopy to find the area that is bleeding.
- 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 (GI Doctor). You should also meet with a registered dietitian (RD) 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 the bladder or the bowel and the skin. A fistula between the bowel and bladder can cause you to pass gas through the urethra (the tube that drains urine). If you have urine, feces, or blood coming out of any opening that it should not be, you should call your provider right away.
- Colon cancer: Radiation to the bowel can lead to colon cancer years after treatment is complete. If you were treated before the age of 18, 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.
Damage to the Kidney
When the radiation field includes the kidney(s), renal insufficiency (decreased kidney function) and hypertension (high blood pressure) can happen. The kidneys are not typically included in the bladder radiation field but may be in some cases. Ask your radiation oncologist about what organs were in your treatment field.
- 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 taken other 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 may be necessary for cancer treatment but also can cause damage to areas of the liver that are healthy.
- 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 cause sepsis (life-threatening infection) 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 working spleen (asplenia) as it is important for those involved in your care to know.
- Have an annual flu vaccine as well as pneumococcal, Haemophilus 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 near Cape Cod or Nantucket Island in Massachusetts, Southern New England, and the Hudson Valley in New York, 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.
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, use 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 lasting symptoms, contact your care team. Some side effects require specialized care from healthcare providers experienced in working with cancer survivors. Interdisciplinary survivorships 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.
Bonanni, P., Grazzini, M., Niccolai, G., Paolini, D., Varone, O., Bartoloni, A., ... & Zini, P. (2017). Recommended vaccinations for asplenic and hyposplenic adult patients. Human vaccines & immunotherapeutics, 13(2), 359-368.
Centers for Disease Control. (2016). Asplenia and Adult Vaccinations. Retrieved 16 Dec 2019 from https://www.cdc.gov/vaccines/adults/rec-vac/health-conditions/asplenia.html
Children’s Oncology Group. (2018). Colorectal cancer: are you at risk? Retrieved 27 June 2019 from: http://www.survivorshipguidelines.org/pdf/2018/English%20Health%20Links/10_colorectal_cancer%20(secured).pdf
Feuerstein, M., & Nekhlyudov, L. (2018). Handbook of Cancer Survivorship, 2nd. Ed. Springer, https://doi.org/10.1007/978-3-319-77432
Gulliford, S. L., Murray, J. R., & Ebert, M. A. (2019). Pelvis: Rectal and Bowel Toxicity. In Modelling Radiotherapy Side Effects (pp. 75-112). CRC Press
Jaszczyński, J., Kojs, Z., Stelmach, A., Wohadło, Ł., Łuczyńska, E., Heinze, S., … Chłosta, P. (2016). Post-Irradiation Bladder Syndrome After Radiotherapy of Malignant Neoplasm of Small Pelvis Organs: An Observational, Non-Interventional Clinical Study Assessing VESIcare®/Solifenacin Treatment Results. Medical science monitor: International Medical Journal of Experimental and Clinical research, 22, 2691–2698. DOI:10.12659/msm.899327
Jorgenson, K., & Bridgen, D. M. (2015). The Riddle of the Vanishing Spleen. MEDICAL POST, 9. Retrieved from: https://www.researchgate.net/profile/Malcolm_Brigden/publication/294738374_The_Riddle_of_the_Vanishing_Spleen-A_Case_Report/links/56c3c3f508ae8a6fab5a2c47/The-Riddle-of-the-Vanishing-Spleen-A-Case-Report.pdf
Nelson, A., Mann, M., & Staffurth, J. (2019). Methods of assessing late radiotherapy effects on bowel function. Current Opinion in Supportive and Palliative care, 13(2), 134-141.
Rapariz-González, M., Castro-Díaz, D., & Mejía-Rendón, D. (2014). Evaluation of the impact of the urinary symptoms on quality of life of patients with painful bladder syndrome/chronic pelvic pain and radiation cystitis: EURCIS study. Actas Urológicas Españolas (English Edition), 38(4), 224-231.
Wei, J., Meng, L., Hou, X., Qu, C., Wang, B., Xin, Y., & Jiang, X. (2018). Radiation-induced skin reactions: Mechanism and treatment. Cancer Management and Research, 11, 167–177. https://doi.org/10.2147/CMAR.S188655
Zwaans, B. M. M., Nicolai, H. G., Chancellor, M. B., & Lamb, L. E. (2016). Challenges and Opportunities in Radiation-induced Hemorrhagic Cystitis. Reviews in Urology, 18(2), 57–65. https://doi.org/10.3909/riu0700