Avoiding long-lasting symptoms from the bowel and the anal-sphincter region after radiotherapy for prostate cancer

There are an increasing number of irradiated prostate-cancer survivors in the world today. For many of these men survival comes at a cost: unwanted debilitating side effects due to exposure of healthy normal tissue to ionizing radiation. Identifying clinical and dosimetric factors associated with these long-lasting side effects could provide a way of attaining the ultimate goal – curing prostate cancer with radiotherapy while restoring physical and psychological health for the prostate-cancer survivor. Following a preparatory qualitative phase, we constructed a study-specific questionnaire. In addition, we conducted a pilot study to evaluate the variation in position and volume of the organs at risk in the small pelvis. We received filled-in questionnaires from 874/985 (89%) prostate-cancer survivors and from 243/332 (73%) population-based controls. We found that prostate-cancer survivors who smoked had an increased risk of long-lasting defecation urgency, diarrhea, the sensation of bowel not completely emptied after defecation and sudden emptying of all stools into clothing without forewarning compared to never smokers. We also found that men with loose stools and abdominal distension at least once a week had a higher prevalence of several long-lasting symptoms, such as defecation urgency, fecal leakage and sudden emptying of all stools into clothing compared to those with regular stools. Prostate-cancer survivors with abdominal distension at least once a week had an increased prevalence of unexpected passing of gas compared to those with regular stools. Finally, our data showed that mean absorbed dose of ionizing radiation to the anal-sphincter region of more than 40 Gy causes an increased occurrence of fecal leakage among irradiated prostate-cancer survivors

Partnership status affects the association between gastrointestinal symptoms and quality of life after radiation therapy for prostate cancer

<div><p></p><p><i>Purpose.</i> To study if partnership modifies the effect of gastrointestinal symptoms on quality of life after radiation therapy for prostate cancer. <i>Material and methods.</i> Using a study-specific questionnaire we conducted a cross-sectional follow-up of the occurrence gastrointestinal symptoms and quality of life after radiation therapy for prostate cancer. We obtained information from 874 prostate cancer survivors treated with radiation therapy at the Sahlgrenska University Hospital, Sweden between 1994 and 2006. In this paper we describe how partnership status affects the association between gastrointestinal symptoms and quality of life. <i>Results.</i> We found that unpartnered men with gastrointestinal symptoms reported a lower quality of life than unpartnered men without such symptoms. Unpartnered men with symptoms had an excess risk of low quality of life compared with unpartnered men without symptoms for those experiencing altered composition of stools, prevalence ratio 3.8 (95% CI 1.1–13.1), leakage, 3.6 (1.3–10.1), sensory bowel symptoms, 4.5 (1.6–12.8), and for urgency, 4.2 (1.2–15.1). We also found that unpartnered men with symptoms had an excess risk of low quality of life compared with partnered men with symptoms for those experiencing altered composition of stools, prevalence ratio 2.9 (95% CI 1.4–5.8), leakage 2.8 (1.2–6.4), sensory bowel symptoms 3.4 (1.5–7.4), urgency 2.6 (1.2–5.8), and for any gastrointestinal symptom 2.5 (1.3–4.9). <i>Conclusion.</i> Unpartnered men may represent a group that is specifically vulnerable to the distressful effects of gastrointestinal symptoms after radiation therapy for prostate cancer.</p></div

Risk Factors of Developing Long-Lasting Breast Pain After Breast Cancer Radiotherapy

Purpose: Postoperative radiotherapy decreases breast cancer mortality. However, studies have revealed a long-lasting breast pain among some women after radiotherapy. The purpose of this study was to identify risk factors that contribute to breast pain after breast cancer radiotherapy. Methods and Materials: We identified 1,027 recurrence-free women in two cohorts of Swedish women treated for breast cancer. The women had breast-conserving surgery and postoperative radiotherapy, the breast was treated to 48 Gy in 2.4-Gy fractions or to 50 Gy in 2.0-Gy fractions. Young women received a boost of up to 16 Gy. Women with more than three lymph node metastases had locoregional radiotherapy. Systemic treatments were given according to health-care guidelines. Three to 17 years after radiotherapy, we collected data using a study-specific questionnaire. We investigated the relation between breast pain and potential risk modifiers: age at treatment, time since treatment, chemotherapy, photon energy, fractionation size, boost, locoregional radiotherapy, axillary surgery, overweight, and smoking. Results: Eight hundred seventy-seven women (85%) returned the questionnaires. Among women up to 39 years of age at treatment, 23.1% had breast pain, compared with 8.7% among women older than 60 years (RR 2.66; 95% CI 1.33-5.36). Higher age at treatment (RR 0.96; 95% CI 0.94-0.98, annual decrease) and longer time since treatment (RR 0.93; 95% CI 0.88-0.98, annual decrease) were related to a lower occurrence of breast pain. Chemotherapy increased the occurrence of breast pain (RR 1.72; 95% CI 1.19-2.47). In the multivariable model only age and time since treatment were statistically significantly related to the occurrence of breast pain. We found no statistically significant relation between breast pain and the other potential risk modifiers. Conclusions: Younger women having undergone breast-conserving surgery with postoperative radiotherapy report a higher occurrence of long-lasting breast pain compared to older women. Time since treatment may decrease the occurrence of pain. (C) 2012 Elsevier Inc

A method to estimate composite doses for organs at risk in prostate cancer patients treated with EBRT in combination with HDR BT

<div><p></p><p><b>Background.</b> When evaluating late toxicity after combined external beam radiation therapy (EBRT) and high-dose rate brachytherapy (HDR BT) prostate cancer treatments, it is important that the composite dose distribution is taken into account. This can be challenging if organ-at-risk (OAR) dose data are incomplete, i.e. due to a limited ultrasound imaging field-of-view in the HDR BT procedure. This work proposes a method that provides estimates of composite OAR doses for such situations.</p><p><b>Material and methods.</b> Original EBRT, simulated HDR BT, and composite dose-volume histograms (DVHs) for 10 pelvic OARs in 30 prostate cancer cases were used for method implementation and evaluation (EBRT: 25 × 2.0 Gy + BT: 2 × 10.0 Gy). The proposed method used information from the EBRT DVH to estimate OAR BT doses (with or without fractionation correction). Coefficients of determination (R²) were calculated for linear relationships between several EBRT DVH parameters and a BT DVH parameter of interest. The largest R² value decided the relationship that best predicted the BT DVH parameter. The composite dose value was then calculated by adding the EBRT DVH and the estimated BT DVH parameter values and was compared to the reference composite value (in 1200 OAR/patient/parameter cases).</p><p><b>Results.</b> The linear relationships had an average R² of 0.68 (range 0.42–0.88). Only one ninth of the 1200 estimated composite DVH values differed more than 2 Gy from their reference values.</p><p><b>Conclusion.</b> Given a successful implementation, the proposed method only requires original or simulated BT plan data for a subset of patients to estimate composite doses for large study populations in a time-efficient manner. This can assist in evaluating radiation-induced late toxicity in multimodality treatments with limited OAR dose data.</p></div

Symptoms 10-17 years after breast cancer radiotherapy data from the randomised SWEBCG91-RT trial

Background: Postoperative radiotherapy decreases the risk for local and improves overall survival in women with breast cancer. We have limited information on radiotherapy-induced symptoms 10-17 years after therapy. Material and methods: Between 1997 and 1997, women with lymph node-negative breast cancer were randomised in a Swedish multi-institutional trial to breast conserving surgery with or without postoperative radiotherapy. In 2007, 10-17 years after randomisation, the group included 422 recurrence-free women. We collected data with a study-specific questionnaire on eight pre-selected symptom groups. Results: Fox six symptom group (oedema in breast or arm, erysipelas, heart symptoms, lung symptoms, rib fractures, and decreased shoulder mobility) we found similar occurrence in both groups. Excess occurence after radiotherapy was observed for pain in the breast or in the skin, reported to occur "occasionally" by 38.1% of survivors having undergone radiotherapy and surgery versus 24.0% of those with surgery alone (absolute difference 14.1%; p = 0.004) and at least once a week by 10.3% of the radiotherapy group versus 1.7% (absolute difference 8.6%; p = 0.001). Daily life and analgesic use did not differ between the groups. Conclusion: Ten to 17 years after postoperative radiotherapy 1 in 12 women had weekly pain that could be attributed to radiotherapy. The symptoms did not significantly affect daily life and thus the reduced risk for local recurrence seems to outweight the risk for long-term symptoms for most women. (C) 2010 Elsevier Ireland Ltd. All rights reserved. Radiotherapy and Oncology 97 (2010) 281-28

Relationships between dose to the gastro-intestinal tract and patient-reported symptom domains after radiotherapy for localized prostate cancer

<div><p>ABSTRACT</p><p><b>Background.</b> Gastrointestinal (GI) morbidity after radiotherapy (RT) for prostate cancer is typically addressed by studying specific single symptoms. The aim of this study was to explore the interplay between domains of patient- reported outcomes (PROs) on GI morbidity, and to what extent these are explained by RT dose to the GI tract.</p><p><b>Material and methods.</b> The study included men from two Scandinavian studies (N = 211/277) who had undergone primary external beam radiotherapy (EBRT) for localized prostate cancer to 70–78 Gy (2 Gy/fraction). Factor analysis was applied to previously identified PRO-based symptom domains from two study-specific questionnaires. Number of questions: 43; median time to follow-up: 3.6–6.4 years) and dose-response outcome variables were defined from these domains. Dose/volume parameters of the anal sphincter (AS) or the rectum were tested as predictors for each outcome variable using logistic regression with 10-fold cross-validation. Performance was assessed using area under the receiver operating characteristic curve (A_z) and model frequency.</p><p><b>Results.</b> Outcome variables from <i>Defecation urgency</i> (number of symptoms: 2–3), <i>Fecal leakage</i> (4–6), <i>Mucous</i> (4), and <i>Pain</i> (3–6) were defined. In both cohorts, intermediate rectal doses predicted <i>Defecation urgency</i> (mean A_z: 0.53–0.54; Frequency: 70–75%), and near minimum and low AS doses predicted <i>Fecal leakage</i> (mean A_z: 0.63–0.67; Frequency: 83–99%). In one cohort, high AS doses predicted <i>Mucous</i> (mean A_z: 0.54; Frequency: 96%), whereas in the other, low AS doses and intermediate rectal doses predicted <i>Pain</i> (mean A_z: 0.69; Frequency: 28–82%).</p><p><b>Conclusion.</b> We have demonstrated that <i>Defecation urgency, Fecal leakage, Mucous</i>, and <i>Pain</i> following primary EBRT for localized prostate cancer primarily are predicted by intermediate rectal doses, low AS doses, high AS doses, or a combination of low AS and intermediate rectal doses, respectively. This suggests that there is a domain-specific dose-response for the GI tract. To reduce risk of GI morbidity, dose distributions of both the AS region and the rectum should, therefore, be considered when prescribing prostate cancer RT.</p></div