Survivorship: Late Effects After Radiation Treatment for Pancreatic/Biliary 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 the 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 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.
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.
- Ulceration and bleeding: Ulceration and bleeding can be caused by damage to the bowel tissues. Report any dark or black colored stools, bright red blood in your stools, in the toilet water, or on the toilet paper to your provider right away. 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 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.
- 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.
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. Signs of hemorrhagic cystitis include urinary frequency (needing to pee often) and urgency (needing to go quickly), blood in your urine, or pain when peeing. You should report any of these things to your provider right away.
- Radiation to the bladder may also make you more prone to urinary tract infections. This type of infection can be treated with antibiotics. If you have burning when urinating (peeing), frequency (needing to go often), or see blood in your urine, call your provider.
- Radiation to the bladder can increase the risk of developing bladder cancer. Signs of this include blood in the urine, urinary frequency (going often) and urgency (needing to go right away), urinating at night, and incontinence. Contact your care provider if you have any of these.
- These late effects all have similar signs. You may have urine tests or cystoscopy (inserting a small tube with a camera into the bladder) to figure out what is causing your issues. It is best to not drink alcohol and or to smoke, as these irritate the bladder and 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 happen.
- 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, high 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 needed for cancer treatment but also can cause damage to areas of the liver that are healthy.
- Your liver function will be measured by a blood test (called LFTs) before and after treatment.
- Avoid drinking alcohol; it can raise the risk of liver damage.
- If you have yellowing of the eyes and/or skin (jaundice), pain or swelling in your belly, itchy skin, or dark-colored urine, call your care team. You may need to see a gastroenterologist (GI Doctor) for further evaluation.
Indigestion and heartburn can be late effects of radiation including the stomach. You may also be at risk for gastritis (irritation of the stomach wall), ulcers, and gastric outlet obstruction.
- Signs 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 problems.
- You may need a referral to a gastroenterologist (GI Doctor) to find the cause.
- If you are having heartburn, your care team may prescribe medicine to lessen the amount of acid being made or to coat/protect your 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 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.
Spinal Cord Damage
The spinal cord can be in the field of radiation treatment. This can cause damage to the nerves in the spine.
- Signs of this 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 any of these issues, you may need imaging tests or to be seen by a neurologist for further testing.
Radiation can also cause damage to the bones of the spine. This can cause you to be shorter or have a change in the curve of your spine. Radiation to these bones can also put them at risk for fracture (breaks). If you have any new back pain, you should call your provider right away. You may need x-rays or other imaging tests.
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 centers. 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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