SURVIVORSHIP AFTER RADIATION THERAPY

The chronic and late effects of radiotherapy tend to be “very site-specific, unlike a lot of chemotherapy,” notes Tracy Gosselin, PhD, RN, AOCN®, Associate Chief Nursing Officer and Assistant Vice President of the Duke Cancer Institute in Durham, North Carolina. “Some key things patients might experience during treatment will subside and go away, but we have to look at what [organs and structures] were in the radiation treatment field that might have been impacted.”

Pain, fatigue, skin changes, disfigurement, psychosocial body image issues, and lymphedema should be considered when planning survivorship care for patients who have undergone radiotherapy, says Catherine Alfano, PhD, Vice President of Survivorship at the American Cancer Society (ACS) (See Radiotherapy survivorship issues).


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Radiotherapy-related survivorship issues

Depending on radiation fields, Cancer survivors who underwent radiotherapy should be prepared for late effects based on radiation fields involved in their treatment.

• Bladder pain
• Bowel changes and chronic diarrhea
• Cardiopulmonary pain and disease
• Changed sexual-organ anatomy and function
• Esophageal narrowing
• Fatigue
• Lymphedema (if axillary lymph nodes were irradiated as part of breast cancer treatment)
• Psychosocial distress, body-image anxiety
• Secondary, radiation-associated cancers
• Shortness of breath
• Skin changes (texture, color, telangiectasia)

“There might be ongoing fatigue that never seems to go away,” Gosselin says. “Really understanding the mechanism of that fatigue—Is it physical? Emotional?—is really important when making referrals and providing information on fatigue management. You’ve got to work through your differential diagnosis to know what’s really happening.”

Skin changes are common for cancer survivors who underwent radiotherapy. Covering and protecting irradiated skin from sunlight is important, Gosselin says. “We know radiotherapy causes skin fibrosis and that has sexual implications because of lost sensitivity,” adds Alfano.

Pelvic irradiation is associated with chronic pain, decreased quality of life, and psychosocial problems, Alfano notes. Radiotherapy for colorectal or gynecologic cancer can create sexual function issues for women because of long-term changes to vaginal anatomy and function. In men, postradiotherapy erectile or ejaculation problems are frequently seen. Especially for younger patients, it’s important to reiterate during survivorship planning that pelvic irradiation could have long-term reproductive implications. Studies have found almost a third of patients undergoing radiotherapy for rectal cancer give up on being sexually active within 2 years of treatment, Alfano notes. “It’s a profoundly big problem.”

Patients who have undergone radiotherapy for colorectal or a gynecologic cancer also frequently experience bowel changes, such as fecal incontinence or chronic diarrhea, that might not go away. “Teaching people how to do good self-care is really important,” Gosselin says. “Teaching a patient to manage diarrhea with over-the-counter products and dietary modification is a good role for nurses. This impacts self-care behaviors so patients do not have a vicious cycle of diarrhea and constipation.”

In breast cancer, radiotherapy carries increased lymphedema risk if the axillary nodes are irradiated, Alfano says. “That can affect not just a patient’s range of motion, but can increase her risk of infection,” she says.

Depending on radiation fields, cardiac and respiratory damage are also chronic or late effects to watch out for, Alfano says. That kind of damage can be a source of pain for cancer survivors. “We’re trying to minimize that with radiation shielding during treatment, but still, even after lower doses, radiation is still cardiotoxic,” Alfano cautions. “And that doesn’t show up for maybe a decade after radiotherapy. It can show up as heart failure or myocardial infarctions.”