The prevalence of chronic radiation enteritis following radiotherapy for cervical or endometrial cancer and its impact on quality of life

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Abstract

Background

Studies suggest that 50% of people may suffer from chronic radiation enteritis (CRE) (Andreyev, J., 2005. Gastrointestinal complications of pelvic radiotherapy: are they of any importance? Gut 54, 1051–1054). Gami et al. (Gami, B., Harrington, K., Blake, P., Dearnaley, D., Andreyev, H.J.N., 2003. How patients manage gastrointestinal symptoms after pelvic radiotherapy. Alimentary Pharmacology and Therapeutics 18, 987–994) argue that this is unimportant if quality of life is unaffected. The aim of this study was to identify how many women experience CRE following radiotherapy and to investigate whether women who have higher doses of radiotherapy or more advanced stage of cancer are more at risk.

Methods

Women (=117) who had completed radiotherapy for cervical or endometrial cancer were asked to complete a validated questionnaire exploring bowel problems and quality of life. Responses were scored and compared to scores for women with known faecal incontinence (Bugg, G.J., Kiff, E.S., Hosker, G., 2001. A new condition-specific health-related quality of life questionnaire for the assessment of women with anal incontinence. British Journal of Obstetrics and Gynaecology 108 (10), 1057–1067).

Results

Using a score of ‘0’ to indicate no symptoms, 47% of women gained scores indicative of CRE (>0), range 20–85 (mean 34, SD 14.4). Younger women (p < 0.001) and women with cervical cancer (p < 0.05) were more likely to score for CRE. No significant relationship was observed between score and either radiotherapy dose or stage of cancer.

Conclusions

Scoring suggests that about half of woman treated with radiotherapy develop CRE. Quality of life is affected, particularly regarding tiredness and coping behaviours due to lack of warning signs for CRE.

Introduction

Radical radiotherapy is commonly used (alone, or in conjunction with surgery and/or chemotherapy) to treat pelvic cancers such as cervical, endometrial, bladder and prostate. Approximately 12,000 individuals undergo radical radiotherapy in the UK every year with a curative aim (Andreyev, 2005, Putta and Andreyev, 2005). Some part of the bowel is inevitably affected during this process and the rapidly dividing intestinal mucosa is highly susceptible to ionising radiation causing side-effects (McGough, 2007). Gami et al. (2003) report that 80% of all patients will experience a permanent change in bowel habit after radiotherapy, but argue that this is unimportant if quality of life is unaffected. Abayomi et al. (2005) and Wilson (2006) both found that chronic radiation enteritis (CRE) symptoms were distressing and significantly impaired quality of life.

Commonly reported side-effects include: abdominal pain, urgency, diarrhoea, faecal incontinence and bloating (Andreyev, 2005, Abayomi et al., 2005, Putta and Andreyev, 2005). During the course of treatment around 80% of patients will experience bowel symptoms (Andreyev, 2005, Putta and Andreyev, 2005), often referred to as ‘Acute Radiation Enteritis’. Symptoms usually resolve spontaneously within 8 weeks (O'Brien et al., 1987). Symptoms that persist or appear more than 3 months after treatment is completed are known as ‘Chronic Radiation Enteritis’ (CRE).

Previously, it was thought that only a minority of patients (5–15%) suffered CRE (Yeoh and Horowitz, 1987). More recent studies suggest that as many as 50% (6000 people in the UK) may suffer the disabling side-effects of CRE (Andreyev, 2005). However, the reliability of published data is weak as sufferers often do not disclose faecal incontinence, possibly due to embarrassment and because there are insufficient prospective studies assessing faecal incontinence using adequate, validated and reproducible methodology (Putta and Andreyev, 2005). The symptoms can have a significant impact on quality of life. Abayomi et al. (2005) interviewed women about their symptoms and found that CRE affected physical, psychological and social aspects of their lives, enforcing some to be virtually housebound. Some women described the destructive impact on family life and the need to withdraw from normal roles. Goode et al. (2006) made similar findings, with 16 out of 36 patients reporting a negative impact on quality of life. Moreover, 12 people claimed to have developed emotional problems, including six people with depression and three were unable to work as a result of CRE. However, published data show considerable variation with 8–56% of patients admitting reduced quality of life due to faecal incontinence (Putta and Andreyev, 2005).

Despite the severity of symptoms, and the considerable number of sufferers, CRE prevention and treatment receive very little attention. Putta and Andreyev (2005) claim many clinicians do not consider faecal incontinence to be a common problem following pelvic radiotherapy. Andreyev (2005) argues that inflammatory bowel disease (IBD) has very similar symptoms to CRE and yet unlike IBD, there are no dedicated research funds or support groups to help CRE sufferers. The two main gastrointestinal charities in the UK spent in the region of half a million pounds researching IBD in 2006.

Perrin et al. (1999) estimate that one-third of patients with CRE will require surgery. This may include intestinal resection, bypass or stoma formation to remove the injured section of bowel. However, very few CRE sufferers are referred to gastroenterologists for assessment and specialist treatment. Andreyev (2005) suggests that less than 20% will ever be referred and that very few gastroenterologists have confidence in treating CRE. This is exacerbated by the fact that no recommended standard management of CRE currently exists (Denton et al., 2002). There are a number of reasons for these low referral rates: Abayomi et al. (2005) found that many women were embarrassed to talk about their symptoms or were reluctant to ‘complain’. Yeoh and Horowitz (1987) agree, stating:

“The prevalence of CRE has been underestimated in most surgical series and the majority of patients with symptoms probably do not seek medical advice until a serious complication occurs.”

Other studies show that patients believed their symptoms to be untreatable or unavoidable (Faithfull, 1995).

In order to plan the care of women with CRE and to ensure they receive appropriate advice regarding management of symptoms, it is important to know which women are likely to be affected and how many. The previous study at Liverpool Women's Hospital (Abayomi et al., 2005) helped to describe the symptoms women were experiencing in their own words, and gave insight into the impact these symptoms had on quality of life. Nonetheless, it did not indicate the number of women likely to be affected by these symptoms, nor did it suggest which women were at increased risk of developing them.

Section snippets

Aim

To identify how many women experience symptoms of CRE following radiotherapy for cervical or endometrial cancer and to investigate whether women who have higher doses of radiotherapy or more advanced stage of cancer are more at risk.

Sample and setting

Following approval from Liverpool Regional Ethics Committee, women were recruited from the joint oncology clinic at Liverpool Women's Hospital. A statistical power calculation suggested that if the actual proportion of women with CRE was at least 50%, a sample size of 110 would be large enough to estimate a two-sided 95% confidence interval where the lower limit is within 10 percentage points of the value. Therefore the aim was to recruit 110 women into the study.

Design

The questionnaire was based on

Results

Between April 2006 and December 2007, 117 women were approached and asked to take part in the study. Of these, 109 (95.2%) agreed to take part and 86 completed and returned the questionnaire. The questionnaire was resent to 18 women (two had since died), who had consented to take part but failed to send back the questionnaire. This resulted in a further nine questionnaires being returned, giving an overall total of 95 (87.2%) for analysis.

Discussion

Scoring the questionnaire suggests that 47% of women had symptoms of CRE, similar to the findings of Andreyev (2005), with 53% of women experiencing no CRE symptoms at all (score = 0). There was a wide variation in scores ranging from 20% to 85%, mean 34% (SD 14.4), indicating a wide variation in symptoms and their impact on quality of life. On comparing these mean scores for each domain (study group) to the mean scores obtained by Bugg et al. (2001) for women with known faecal incontinence

Limitations

There were a number of limitations to this study, particularly regarding recruitment which involved one particular clinic, with input from a team of eight oncology consultants, in one particular city. Therefore the results do not necessarily represent all women who have experienced pelvic radiotherapy. Men may also experience CRE following radiotherapy (for prostate cancer for example) but no men were included in this study as it was conducted in a women's hospital.

Furthermore, two women from

Conclusion

This study has found that almost half of women suffer distressing and debilitating symptoms of CRE following radiotherapy treatment. However it is difficult to predict who they are likely to be in terms of treatment dose, cancer type, cancer stage or length of time since treatment, suggesting that screening is necessary. Comparing questionnaire scores with Bugg et al. (2001) demonstrates that women in the study group score higher for self-perception of health, sleep/energy levels and coping

Conflicts of interest

All authors declare that there are no conflicts of interest.

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