Systematic review for non-surgical interventions for the management of late radiation proctitis

Chronic radiation proctitis produces a range of clinical symptoms for which there is currently no recommended standard management. The aim of this review was to identify the various non-surgical treatment options for the management of late chronic radiation proctitis and evaluate the evidence for their efficacy. Synonyms for radiation therapy and for the spectrum of lower gastrointestinal radiation toxicity were combined in an extensive search strategy and applied to a range of databases. The included studies were those that involved interventions for the non-surgical management of late radiation proctitis. Sixty-three studies were identified that met the inclusion criteria, including six randomised controlled trials that described the effects of anti-inflammatory agents in combination, rectal steroids alone, rectal sucralfate, short chain fatty acid enemas and different types of thermal therapy. However, these studies could not be compared. If the management of late radiation proctitis is to become evidence based, then, in view of its episodic and variable nature, placebo controlled studies need to be conducted to clarify which therapeutic options should be recommended. From the current data, although certain interventions look promising and may be effective, one small or modest sized study, even if well-conducted, is insufficient to implement changes in practice. In order to increase recruitment to trials, a national register of cases with established late radiation toxicity would facilitate multi-centre trials with specific entry criteria, formal baseline and therapeutic assessments providing standardised outcome data

Chronic radiation proctitis: issues surrounding delayed bowel dysfunction post-pelvic radiotherapy and an update on medical treatment

Late onset bowel dysfunction post-pelvic radiotherapy is an increasingly common clinical scenario which is related to improved oncological treatments and cancer survival. 50% of patients develop bowel symptoms after pelvic radiotherapy which affects quality of life. Historically, bowel symptoms post-pelvic radiotherapy have been labelled ‘chronic radiation proctitis’, although it is increasingly recognised that these symptoms are due to dysfunction of the gastrointestinal (GI) tract at numerous points. The evidence-base is poor and comprises often small, heterogenous, single centre unblinded studies. This article critically reviews the evidence for the medical treatment options for ‘chronic radiation proctitis’, which include anti-inflammatory drugs, antibiotics, sucralfate, formalin and hyperbaric oxygen. The difficulties in extrapolation from the literature to clinical practise are also explored. From the available evidence, rectal sucralfate appears to have greater efficacy than anti-inflammatory agents, which are more effective if used with oral metronidazole. Furthermore, hyperbaric oxygen is emerging as promising treatment for radiation toxicity. However, bowel dysfunction post-pelvic radiotherapy is a complex clinical condition which reflects multi-site GI tract pathologies both related and unrelated to previous oncological treatments. From this review article a clear need for an adjustment to both diagnosis and treatment of these patients, as well as for further research, emerges

Systematic review of agents for the management of gastrointestinal mucositis in cancer patients

<p>The aim of this study was to review the available literature and define clinical practice guidelines for the use of agents for the prevention and treatment of gastrointestinal mucositis.</p><p>A systematic review was conducted by the Mucositis Study Group of the Multinational Association of Supportive Care in Cancer/International Society of Oral Oncology (MASCC/ISOO). The body of evidence for each intervention, in each cancer treatment setting, was assigned an evidence level. Based on the evidence level, one of the following three guideline determinations was possible: recommendation, suggestion, and no guideline possible.</p><p>A total of 251 clinical studies across 29 interventions were examined. Panel members were able to make one new evidence-based negative recommendation; two new evidence-based suggestions, and one evidence-based change from previous guidelines. Firstly, the panel recommends against the use of misoprostol suppositories for the prevention of acute radiation-induced proctitis. Secondly, the panel suggests probiotic treatment containing Lactobacillus spp., may be beneficial for prevention of chemotherapy and radiotherapy-induced diarrhea in patients with malignancies of the pelvic region. Thirdly, the panel suggests the use of hyperbaric oxygen as an effective means in treating radiation-induced proctitis. Finally, new evidence has emerged which is in conflict with our previous guideline surrounding the use of systemic glutamine, meaning that the panel is unable to form a guideline. No guideline was possible for any other agent, due to inadequate and/or conflicting evidence.</p><p>This updated review of the literature has allowed new recommendations and suggestions for clinical practice to be reached. This highlights the importance of regular updates.</p>