Long-Term Perils of Pelvic Radiation
The medical field is making remarkable progress on the war against cancer. The death rate from cancer in the United States has continued to decline over the past decade. This includes a 2.4% decrease in 2018 based on the annual statistics reported by the American Cancer Society (https://www.cancer.org/research/cancer-facts-statistics/all-cancer-facts-figures/cancer-facts-figures-2021.html). With improved outcomes, cancer survivorship issues are coming to the forefront of attention and becoming a central component in the spectrum of cancer care. One can see the rising interest in cancer survivorship by researching the agenda for the next National Cancer Survivors Day on June 5, 2022 (https://ncsd.org/cancer-survivorship-issues).
In light of this, I would like to discuss an uncommon, under-recognized but highly debilitating disease that can affect cancer survivors who have received radiation to their abdomen and pelvis. The condition is called hemorrhagic cystitis and it can affect men after prostate cancer, women after cervical and uterine cancer and both men and women after colon cancer who received radiation as part of their treatment.
Radiation damage to the bladder is called radiation cystitis and symptoms of radiation cystitis
Including hematuria (urinary bleeding) and other voiding symptoms such as painful urination and incontinence. Hemorrhagic cystitis refers to similar urinary symptoms as radiation cystitis but also includes significant blood in the urine, and blood clots that can block the ability to urinate. Hemorrhagic cystitis is highly bothersome, potentially deadly and difficult to treat.
No matter what you call it, patients with radiation cystitis can often experience variations or flares of symptoms over time, potentially years after receiving radiation therapy. For a cancer survivor, it is assumed that as time passes from a person’s initial cancer diagnosis and treatment, the side effects and complications of treatment will diminish or resolve. This is mostly true after surgery, chemotherapy, and immunotherapy but after pelvic radiation for prostate, cervical, uterine and colon cancers, radiation cystitis can begin and even worsen several years after treatment. Serious cases of hemorrhagic cystitis can be life-threatening and there are no definitive treatments or cures. Existing options are costly and limited. The condition represents a significant unmet medical need worldwide.
In addition to radiation cystitis, radiation to the colon and rectum can also cause radiation proctitis. Some of the common symptoms of radiation proctitis include a continuous or frequent feeling that you need to have a bowel movement, mucus discharge from the rectum, rectal bleeding, rectal pain and/or pain with bowel movements. Given the close proximity of the bladder and colon, one can understand why a percentage of men and women who have radiation cystitis will also have radiation proctitis and vice versa. The long-term effects of pelvic radiation is under recognized. Radiation cystitis and proctitis are serious diseases that affect quality of life.
As a professor of urology and someone who has focused on helping patients with bladder problems and also focused on developing new treatment to help hemorrhagic cystitis, I realize that many patients and their family and friends are not well aware of available treatments and steps they can take to control the urinary bladder and painful bladder symptoms.
Conservative preventive measures which a patient can take on their own is often effective. A blog from Dr. John Patrick (johnrpatrick.com) and other educational material can be found on the Radiation Cystitis Foundation blog at https://radiationcystitis.org/blog.
Urologists are the main doctors treating radiation cystitis and some of the treatments include irrigation of the bladder to remove blood clots, endoscopic examination of the bladder (cystoscopy) and the use of laser or drugs to try and stop the bleeding. Hyperbaric oxygen therapy (HBO), often used for diabetic foot ulcers, can be helpful to prevent future recurrence of hemorrhagic cystitis. HBO is done by placing a patient into a pressurized hyperbaric chamber at approximately 2.5 atmosphere of pressure for about one hour. The treatment is not invasive but a course of treatment requires several dozen sessions over a 2 to 3 months period. HBO works better as a preventive therapy and compliments treatment that may be needed to stop the bleeding.
The cancer survivorship community of men and women who have been diagnosed and treated for pelvic cancer can be a great support. My hope is that with advances in radiation therapy, radiation cystitis and radiation proctitis will become less of a burden for cancer survivors in the future. A link to the Radiation Cystitis Patient Registry and other helpful resources can be found on the Radiation Cystitis Foundation's website. More research is needed to help control radiation cystitis and radiation proctitis.
Posted on behalf of Dr. Michael B Chancellor, MD - Professor of Urology.
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