Survivorship: Late Effects After Radiation Treatment for Pancreatic/Biliary Cancer

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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 Pancreatic/Biliary Cancer

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.

Bowel Problems

The bowel is sensitive to the effects of radiation. The late effects that may occur after radiation to 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. You may need to be admitted to the hospital for treatment.
  • 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. These may be signs of inflammation, and you may need testing with a colonoscopy.
  • Chronic diarrhea: Report diarrhea that is causing weight loss or malnutrition to your care team. You may need a referral to a gastroenterologist. Medications to lessen diarrhea may be helpful. You should also meet with a registered dietitian who can help evaluate your diet and give you suggestions to maintain or gain weight.
  • Fistula formation: A fistula is a connection 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 lead to passing 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.
  • 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.

Bladder Problems

Radiation can cause late effects to the bladder including:

  • Scarring can lead to a decrease in how much urine your bladder can hold.
  • If given with chemotherapy agents 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 and urgency, 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. You may need a cystoscopy to determine what is causing your symptoms. It is best to avoid alcohol use and smoking, as these increase the risk of bladder cancer. 

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 functions 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.

Liver 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.

Stomach Problems

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.

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 influenzaetype 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.

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.

Skin Problems

Radiation can lead to permanent changes in the skin.

  • There may be changes in the color or texture of your skin or new scars. It 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.
  • 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. Make sure to use plenty of sunscreen, wear a hat, and keep the skin 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.

References

Baradaran-Ghahfarokhi, M. (2012). Radiation-induced kidney injury. Journal of Renal Injury Prevention1(2), 49–50. https://doi.org/10.12861/jrip.2012.17

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 & immunotherapeutics13(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

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 Research22, 2691–2698. doi:10.12659/msm.899327

Jorgenson K., & Brigden, D. M. (2015). The Riddle of the Vanishing Spleen. MEDICAL POST9. 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 care13(2), 134-141.

Koontz, B. F. (2017). Radiation Therapy Treatment Effects: An Evidence-based Guide to Managing Toxicity. Springer Publishing Company.

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 Research11, 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 Urology18(2), 57–65. https://doi.org/10.3909/riu0700

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