PowerPoint Slides

Colorectal Cancer Survivorship: Late Effects of Radiation Therapy

English Text Colorectal cancer Survivorship: Late Effects of Radiation Therapy VideoTranscript Professional Oncology Education Colorectal Cancer Survivorship: Late Effects of Radiation Therapy Time: 14:14 Daniel Malatek, PA-C Physician Assistant Radiation Oncology – GI Service The University of Texas, MD Anderson Cancer Center Hi. My name is Daniel Malatek. I’m a Physician's Assistant that works at the University of Texas MD Anderson Cancer Center in the GI Service of the Radiation Oncology Department. Today, we’re going to talk about the late effects of radiation therapy.

Spanish Translation Supervivencia al cáncer colorrectal: Efectos tardíos de la radioterapia Transcripción del video Educación Oncológica Profesional Supervivencia al cáncer colorrectal: Efectos tardíos de la radioterapia Duración: 14:14 Daniel Malatek, PA-C Asistente Médico Servicio de Oncología Radiológica Gastrointestinal MD Anderson Cancer Center de la Universidad de Texas Hola. Mi nombre es Daniel Malatek y soy asistente médico en el Servicio de Oncología Radiológica Gastrointestinal en el MD Anderson Cancer Center de la Universidad de Texas. Hoy vamos a hablar de los efectos tardíos de la radioterapia.

Daniel Malatek, PA-C Physician Assistant Radiation Oncology – GI Service

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Objectives

At the conclusion of this lesson, the participant will be able to: • Appreciate the risk of late effects of radiation therapy for colorectal cancer (CRC)

At the conclusion of this lesson, the participant will be able to appreciate the risk of late effects of radiation therapy when treatments for the colo --- for colorectal cancer. You can identify organs at risk from pelvic radiation therapy; recognize acute and late effects of radiation therapy; and identify management strategies of late effects from radiation treatment.

Al término de esta charla, el participante podrá valorar el riesgo de los efectos tardíos de la radioterapia en el tratamiento del cáncer colorrectal, identificar los órganos en riesgo debido a la radioterapia pélvica, reconocer los efectos agudos y tardíos de la radioterapia, e identificar estrategias para controlar los efectos tardíos de la radioterapia.

The organs at risk when treated with pelvic radiation therapy are the colon, small bowel, the bladder, ureters, urethra, the genital organs and spinal cord, skin, soft tissue, muscles, bones, vasculature, nerves in the radiation field, and the lymph --- lymphatic system.

Los órganos en riesgo cuando se es tratado con radioterapia pélvica son: el colon, el intestino delgado, la vejiga, los uréteres, la uretra, los órganos genitales y la médula espinal, la piel, tejidos blandos, músculos, huesos, vasos, nervios en el campo de radiación y el sistema linfático.

• Identify organs at risk from pelvic radiation therapy • Recognize acute and late effects of radiation therapy • Identify management strategies of late effects from radiation therapy

Organs at Risk from Pelvic XRT • Organs in the radiation field – Colon – Small bowel – Bladder, ureters, urethra – Genital organs – Spinal cord – Skin, soft tissue, muscles, bones, vasculature, nerves – Lymphatic system

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Acute Effects of Radiation Therapy • Most people suffer some acute side effects • Self-limiting and usually resolve 2 - 3 weeks after treatments • Occur with both external beam and brachytherapy

Now, there’re two types of effects of radiation therapy, acute effects and late side effects. Most people suffer some acute side effects. They are self-limiting and usually resolve two to three weeks after treatments. They will occur with both external beam and brachytherapy treatments. And there is no way to determine who will or will not suffer side effects, or which side effects, as well as the severity of the side effects.

Hay dos tipos de efectos de la radioterapia: los efectos agudos y los efectos secundarios tardíos. La mayoría sufre efectos secundarios agudos, que son autolimitados y por lo general se resuelven de dos a tres semanas después del tratamiento. Pueden ocurrir con los tratamientos de haz externo y braquiterapia, y no hay manera de determinar quién sufrirá los efectos secundarios, cuáles, ni su gravedad.

They include fatigue, nausea, vomiting, abdominal cramping and diarrhea, dysuria, hematuria, rectal bleeding, discharge, proctitis, and skin reactions that are similar to a sunburn.

Entre ellos se cuentan fatiga, náuseas, vómitos, calambres abdominales y diarrea, disuria, hematuria, sangrado rectal, descargas, proctitis y reacciones cutáneas similares a una quemadura de sol.

• No way to determine who will or will not suffer side effects or which ones

Acute Side Effects • Fatigue • Nausea/vomiting • Abdominal cramping/diarrhea • Dysuria/hematuria • Rectal bleeding/discharge/proctitis • Skin reactions

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Management of Acute Effects • Fatigue – usually mild and managed with longer nightly sleep or a nap during the day; exercise can also lessen the affects of fatigue • Nausea/vomiting – eating bland, small meals throughout the day +/- antiemetics • Abdomen cramping/diarrhea – avoiding high fat and greasy foods +/- anti-diarrhea medications such as loperamide and diphenoxylate with atropine (better for abdomen cramps)

Management of Acute Effects • Dysuria – Phenazopyridine • Hematuria – obtain UA with culture and if positive for UTI prescribe appropriate Antibiotic therapy • Proctitis – barrier creams; Hydrocortisone Cream ointment or suppositories; Pramoxine • Skin Reactions – ointments as recommended/prescribed by radiation oncologist only

Now, the management of the acute side effects, including fatigue har --- which is usually mild and managed with longer nightly sleep or a nap during the day. Exercise can also lessen the effects of fatigue. For nausea and vomiting, instructing the patient to eat bland small meals throughout the day, with or without antiemetics as needed, is the treatment choice. For abdomen cramping and diarrhea, having the patient avoid high fat and greasy foods, plus using antidiarrhea medication, such as loperamide and diphenoxylate with atropine, which is better for treatment of abdomen cramps.

Uno de los efectos secundarios agudos es la fatiga, generalmente leve, y se supera con un largo sueño durante la noche o una siesta durante el día. El ejercicio también puede disminuir la fatiga. El tratamiento preferido para las náuseas y los vómitos es instruir al paciente a ingerir pequeñas comidas blandas a lo largo del día, con o sin antieméticos, según sea necesario. Para los calambres abdominales y la diarrea, se recomienda que el paciente evite los alimentos grasos y altos en grasa, además del uso de antidiarreicos, como la loperamida y el difenoxilato con atropina, que es mejor para tratar los calambres.

For dysuria, phenazopyridine is used. It does not completely take away the burning with urination. However, it does help. If hematuria is observed by a patient, an ar --- a urinalysis with culture and sensitivity is obtained, and if positive for a urinary tract infection, the appropriate antibiotic therapy is prescribed. For radiation-induced proctitis, barrier creams are used, such as hydrocortisone cream ointment or suppositories, or pra --- pramoxine. For skin reactions, emollients are used, as recommended by the radiation oncologist and as needed throughout treatments.

Para la disuria, se utiliza fenazopiridina. No quita por completo el ardor al orinar, pero sí ayuda. Si un paciente tiene hematuria, se obtiene un análisis de orina que incluya cultivo y susceptibilidad, y en caso de una infección de las vías urinarias, se prescribe una terapia antibiótica adecuada. En caso de proctitis inducida por la radiación, se utilizan cremas protectoras tales como ungüento o supositorios de hidrocortisona, o pramoxina. Para las reacciones cutáneas, se utilizan emolientes según lo recomendado por el radiooncólogo y según sea necesario a lo largo de los tratamientos.

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Late Effects of Radiation Therapy • 10% or less of patients suffer one or more late side effects • Can occur several months or years after treatments • Can occur with both external beam radiation and brachytherapy

Now, the late side effects of radiation therapy: Ten percent or less of patients suffer one or more late side effects. They can occur several months or many, many years after treatments. They can occur with both external beam radiation and brachytherapy. Unfortunately, there’s no way to know which patients will suffer late side effects.

Veamos los efectos secundarios tardíos de la radioterapia. El 10% o menos de los pacientes padecen uno o más de estos efectos. Pueden ocurrir varios meses o muchos años después de los tratamientos, tanto con radioterapia de haz externo como con braquiterapia. Desafortunadamente, no hay manera de saber qué pacientes los sufrirán.

In no particular order, the most common side effects that happen in the late event are bone fractures, which growth arrest is believed to be caused by a combination of cellular injury to the chondrocytes and damage to the blood vessels. There’s a possibility of small bowel obstructions, either partial or complete. And these are caused by inflammation or damage to muscles, nerves, and/or blood flow that’s been damaged to the bowel or scar tissue.

Sin ningún orden en particular, los efectos secundarios tardíos más comunes son las fracturas de huesos, cuya detención de crecimiento se cree es causada por una combinación de lesiones celulares a los condrocitos y daño a los vasos sanguíneos. Es posible que ocurran obstrucciones intestinales, ya sean parciales o completas, causadas por inflamación o daños a los músculos, los nervios o el flujo sanguíneo del intestino, o por tejido cicatricial.

• No way to know which patients will suffer late side effects

Late Effects • Bone fractures – Growth arrest believed to be caused by a combination of cellular injury to chondrocytes and damage to the blood vessels

• Small bowel obstructions – Caused by inflammation or damage to muscles, nerves and/or blood flow to the bowel, or scar tissue

Baxter NN et al., JAMA 2005 294(20):2587

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Late Effects • Fistulas – Caused by damage/weakening of the tissue and structures between organs

• Sexual dysfunction – Caused by damage to the blood vessels supplying the nerves responsible for erections in males

Fistulas are caused by the damage or weakening of the tissue and linings of structures between organs. Sexual dysfunction is caused by damage to the blood vessels supplying the nerves responsible for erection in males, and it causes vaginal stenosis or fibrosis, shortening of the vaginal vault, and dryness, which can cause pain in females with sexual function. And non-function ovaries cause loss of hormones, thus, a loss of desire or interest in intercourse.

Las fístulas son causadas por daño o debilitamiento de los tejidos y revestimientos de las estructuras entre órganos. La disfunción sexual en los hombres es causada por daño a los vasos sanguíneos que irrigan los nervios responsables de la erección, y en las mujeres, por estenosis o fibrosis vaginal, reducción de la cavidad vaginal y sequedad, lo cual puede causar dolor en la función sexual. Los ovarios no funcionales provocan pérdida de hormonas y la pérdida de deseo o interés en las relaciones sexuales.

The infertility and sterility is caused by the destruction of immature oocytes in females. Radiation therapy affects any rapidly dividing cells. So, cells that produce sperm are quite sensitive to radiation damage. The vaginal stenosis and dryness is caused by scarring and fibrosis from radiation therapy and loss of hormones from nonfunctioning ovaries, as mentioned earlier.

En las mujeres, la destrucción de ovocitos inmaduros provoca infertilidad y esterilidad. La radioterapia afecta las células en rápida división. Por ello, las células espermáticas son muy sensibles al daño por radiación. La estenosis y la sequedad vaginal son causadas por la cicatrización, la fibrosis por la radioterapia, y la pérdida de hormonas por ovarios no funcionales.

– Caused by vaginal stenosis/fibrosis, shortening of the vaginal vault, and dryness causing pain in females; and non-functioning ovaries cause loss of hormones, thus loss of desire/interest in intercourse Wolf JK. Community Oncol 2006 3(10):665 www.NCCN.org; NCCN GuidelinesTM Rectal Cancer Version 4.2011

Late Effects of Radiation Therapy • Infertility/sterility – Caused by the destruction of immature oocytes in females – Radiotherapy affects any rapidly dividing cells, so cells that produce sperm are quite sensitive to radiation damage

• Vaginal stenosis/dryness – Caused by scarring/fibrosis from radiotherapy and loss of hormones from non-functioning ovaries

Wolf JK. Community Oncol 2006 3(10):665 Cox J and Ang KK. Radiation Oncology: Rationale, Technique, Results, 9th ed. 2010: 653-8, 733-4, 774-5, 798, 812-3

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Late Effects of Radiation Therapy • Chronic diarrhea or poor absorption of food – Caused by radiation damage to the small bowel

• Radiation proctitis - bowel urgency, bleeding and/ or incontinence

There can also be chronic diarrhea or poor absorption of food. And this is caused by radiation damage to the small bowel, especially to the lining of the intestines. Radiation proctitis, which includes bowel urgency, bleeding, and --- and/or incontinence, is caused by radiation damage to the distal rectum, the anal canal, and sphincter muscles and nerves.

Puede haber diarrea crónica o absorción deficiente de alimentos causadas por daño de radiación al intestino delgado, especialmente en el revestimiento intestinal. La proctitis por radiación, que incluye urgencia intestinal, sangrado o incontinencia, es causada por daños al recto distal, el canal anal y los músculos y nervios del esfínter.

Now, there are some uncommon late effects of radiation therapy. These include recurrent urinary tract infections, strictures of the ureters or the urethra. And, this is caused by radiation damage to the lining of the urinary tract system. There can be long term fatigue, which is caused by the toxicity of radiation, and possibly lymphedema of the lower extremities, which is caused by scarring of the lymph vessels.

Existen algunos inusuales efectos tardíos de la radioterapia, como infecciones recurrentes de las vías urinarias y estenosis de los uréteres o la uretra. Esto es causado por daños de radiación al revestimiento del aparato urinario. Puede haber fatiga a largo plazo, causada por la toxicidad de la radiación, y posiblemente linfedema de las extremidades inferiores, causado por la cicatrización de los vasos linfáticos.

– Caused by radiation damage to the distal rectum, anal canal and sphincter muscle and nerves

Gami B et al., Aliment Pharmacol Ther 2003 18(10):987

Uncommon Late Effects of Radiation Therapy • Recurrent UTI’s, strictures of the ureters or urethra – Caused by radiation damage to the lining of the urinary tract system

• Fatigue – Caused by the toxicity of radiation

• Lymphedema of the bilateral lower extremities – Caused by scarring of the lymph vessels

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Late Effects of Radiation Therapy • Note: less common side effects such as recurrent UTI’s, strictures of the ureters/urethra, lower extremity lymphedema, fatigue and persistent rectal bleeding need to first not be attributed to radiation treatments •

Now, note: since these are less common side effects, they shouldn’t first be attributed to radiation treatments. Other causes should be investigated or ruled out. For example, if a patient’s treatments are longer than ten years ago, a recurrent cancer or second primary cancer is possible. And these need to be ruled out before attrib --- ignoring these symptoms and attributing them to previous radiation.

Tenga en cuenta que estos efectos secundarios inusuales no deben atribuirse de antemano a la radioterapia, sino que otros factores deben ser investigados o descartados. Por ejemplo, si el tratamiento de un paciente fue hace más de diez años, un cáncer recurrente o un segundo cáncer primario son posibles. Estos factores deben ser descartados antes de ignorar los síntomas y atribuirlos a una radiación anterior.

The management of these uncommon late effects are as follows: For recurrent urinary tract infections, prophylactic antibiotics. Stricture of the urethra, dilatation is indicated. If there is stricture of the ureters, stents may have to be placed. Fatigue, a daily exercise regimen can help, and possibly referral to physical therapy. And lymphedema of the lower extremities, elevation helps, daily exercise, possibly physical therapy, and use of compression stockings is useful.

Los métodos de control de estos inusuales efectos tardíos son los siguientes: Para las infecciones recurrentes de las vías urinarias, antibióticos preventivos. Para la estenosis de la uretra, se indica dilatación. En el caso de la estenosis de uréteres, pueden colocarse stents. Para la fatiga, pueden ayudar un régimen de ejercicio diario y la terapia física. Para el linfedema de las extremidades inferiores, ayudan la elevación, el ejercicio diario, la terapia física y el uso de medias de compresión.

Other causes should be investigated for/ruled out – i.e. recurrent cancer or a second primary cancer that can occur ~10 years (+/-) after treatments

Management of Late Effects of Radiation Therapy • Recurrent UTI’s – prophylactic antibiotics • Stricture of the urethra – dilatation • Stricture of the ureters – stents placement • Fatigue – daily exercise regimen, physical therapy • Lymphedema of the lower extremities – elevation, daily exercise, physical therapy, compression stockings

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Management of Late Effects of Radiation Therapy • Chronic diarrhea or poor absorption of food – Diet changes to foods that don’t induce diarrhea including low fiber, low fat and high protein – Daily psyllium use with only half the prescribed amount of water to help bulk stools – Over-the-counter loperamide either as-needed or prophylactically – i.e. one tablet daily, BID, etc.

Now, let’s go to the management of the more common late effects of radiation therapy. Chronic diarrhea or poor absorption of food is one of the common late side effects of radiation. It can usually be managed with diet changes that include going to foods that don’t induce diarrhea, including low fiber, low fat, and high protein foods. And an example would be reducing the amount of salads the patient eats. Daily psyllium is used with only half the prescribed amount of water to help bulk stools in certain cases. And over-the-counter loperamide either is needed or prophylactically. For example, one tablet daily or twice daily can be used to help produce the amount of bowel movements per day.

Veamos ahora los métodos de control de los efectos tardíos más comunes de la radioterapia. La diarrea crónica o una absorción deficiente de los alimentos son algunos de los efectos más comunes. Suelen controlarse con cambios en la dieta por alimentos que no provoquen diarrea, bajos en fibras y grasas, y ricos en proteínas. Un ejemplo sería reducir la cantidad de ensaladas que el paciente come. Utilizar diariamente psyllium con sólo la mitad de la cantidad indicada de agua para lograr volumen. Y loperamida de venta libre, según necesidad o preventivamente. Un comprimido tomado una o dos veces al día puede facilitar el movimiento intestinal.

Proctitis is treated with hydrocortisone cream, ointments, or suppositories. Usually no greater than a two-weeks' duration for each occurrence is recommended, or with pramoxine with or without hydrocortisone as needed. For bowel urgency and incontinence, sphincter tone strengthening is required, and this involves Kegel exercises. Also, a patient can do bowel training. And this is training your bowel to defecate at the same time period each day. Also, it's helpful for patients to investigate where bathrooms are when they’re in new locations. And for long trips or where a bathroom is not ready available, adult diapers or prophylactic loperamide can be used.

La proctitis es tratada con supositorios, ungüentos o cremas de hidrocortisona. Se recomiendan no más de dos semanas en cada caso, aunque también se puede utilizar pramoxina con o sin hidrocortisona según necesidad. Para la urgencia e incontinencia intestinal se requiere fortalecer el tono del esfínter con ejercicios de Kegel y el entrenamiento intestinal para defecar dentro del mismo período todos los días. Además, puede resultar útil averiguar dónde están los baños en los lugares desconocidos. Para los viajes largos o cuando no haya un baño disponible, se pueden utilizar pañales para adultos o loperamida preventiva.

Rodríguez ML et al., Clin Transl Oncol 2010 12(8):554

Management of Late Effects of Radiation Therapy • Proctitis – Hydrocortisone cream suppositories (no greater than 2 weeks duration each occurrence) or pramoxine with or without HC as-needed

• Bowel urgency and incontinence – Sphincter tone strengthening (Kegel exercises) – Bowel training – defecation same time period each day – Investigate where bathrooms are at new locations – Adult diapers or prophylactic loperamide use for long trips

Rodríguez ML et al., Clin Transl Oncol 2010 12(8):554

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Management of Late Effects of Radiation Therapy • Bone fractures – Usually insufficiency fractures of the sacrum or pelvis – Conservative treatment with rest, no heavy lifting, pelvic rest, pain medications for pain for several weeks – Kyphoplasty

Bone fractures usually occur at the sacrum or the pelvis, and they’re usually insufficiency fractures. They can be treated with conservative treatment most times, which includes rest, no heavy lifting, pelvic rest, pain medications for pain for several weeks. In the event, the fracture does not heal, kyphoplasty can be considered. Also, an orthopedics consult is required if conservative treatments do not heal the fracture, so that surgical treatment options can be investigated.

Las fracturas normalmente ocurren en el sacro o la pelvis, y por lo general son por insuficiencia. Suelen recibir un tratamiento conservador, que incluye descanso, no levantar objetos pesados, reposo pélvico y medicación para el dolor durante varias semanas. En caso de que la fractura no sane, se puede considerar la cifoplastia. Si los tratamientos conservadores no curan la fractura, debe consultarse a un ortopedista para investigar las opciones de tratamiento quirúrgico.

For small bowel obstructions, this usually requires hospitalization for conservative treatments that includes bowel rest and nutritional supplementation. If not responsive to conservative treatments, or if there is a com --- a complete obstruction, surgery is indicated. Fistulas or holes are again treated with conservative treatments initially. However, if they do not resolve, surgery can be performed usually if necessary.

Para las obstrucciones del intestino delgado, los tratamientos conservadores requieren hospitalización, con reposo intestinal y suplementos nutricionales. De no responder a los tratamientos conservadores, o si hay una obstrucción completa, se indica la cirugía. Para las fístulas o perforaciones, inicialmente se aplican tratamientos conservadores. Si no se resuelven, puede realizarse una cirugía.

– Orthopedics consult if refractory to conservative treatments for surgical treatment options

Baxter NN et al., JAMA 2005 294(20):2587

Management of Late Effects of Radiation Therapy • Small bowel obstruction – Usually requires hospitalization for conservative treatments including bowel rest and nutritional supplementation – Surgery if not responsive to conservative treatments or if complete obstruction

• Fistulas – conservative treatments initially however, surgery usually can be performed if necessary

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Management of Late Effects of Radiation Therapy • Sexual dysfunction – males – Medications – sildenafil, tadalafil, etc. or surgical implants for erectile dysfunction – Psychotherapy for loss of desire and/or anxiety

• Usually more of a risk of sexual dysfunction in older males secondary to other age-related factors that can affect sexual function and libido

Management of Late Effects of Radiation Therapy • Sexual dysfunction – females – Dilator use for vaginal stenosis causing dyspareunia – recommended 2 - 3 times weekly if not sexually active. Surgery for severe stenosis. – Vaginal dryness/thinning – estrogen therapy or estrogen creams applied to lining of vagina if not contraindicated – Psychotherapy for loss of interest and/or anxiety – Hormonal replacement therapy if not contraindicated secondary to hormonally sensitive cancer or other comorbidities

Now, dys --- sexual dysfunction can affect both males and females. In males, medications are available, such as sildenafil, tadalafil, etc., or surgical implants for erectile dysfunction. Psychotherapy is also useful for loss of desire and/or anxiety. Now to note, older males are usually at more of a risk for sexual dysfunction when they receive radiation treatments secondary to their other age-related factors that can already affect sexual function and libido.

La disfunción sexual puede afectar a hombres y mujeres. En los hombres, hay medicamentos como el sildenafil, tadalafil, etc., e implantes quirúrgicos para la disfunción eréctil. La psicoterapia también es útil para la ansiedad o pérdida del deseo. Por lo general, los hombres de más edad poseen un riesgo mayor de disfunción sexual con la radioterapia secundaria a otros factores relacionados con la edad que ya afectan la función sexual y la libido.

For the management of late side effects in females of sexual dysfunction, dilator use for vaginal stenosis which causes dyspareunia is recommended two to three times weekly if not sexually active. For severe stenosis, surgery can be considered. For vaginal dryness and thinning, estrogen therapy or estrogen creams can be applied to the lining of the vagina, if not contraindicated for a hormonally sensitive cancer or other comorbidities. Psychotherapy is also available for loss of interest and/or anxiety. Hormonal replacement therapy can also be considered, if not contraindicated secondary to a hormonally sensitive cancer or other comorbidities.

Para la disfunción sexual en las mujeres se recomienda el uso de dilatadores de dos a tres veces por semana para la estenosis vaginal que causa dispareunia, de no ser sexualmente activa. En la estenosis grave, se puede considerar la cirugía. Para la sequedad y el adelgazamiento vaginal, se puede aplicar terapia de estrógeno o cremas con estrógeno al revestimiento vaginal, si no está contraindicado para un cáncer sensible a las hormonas u otras comorbilidades. La psicoterapia también puede resultar útil para la ansiedad o pérdida del interés. También puede considerarse la terapia de reemplazo hormonal, si no está contraindicada en el cáncer sensible a las hormonas u otras comorbilidades.

Wolf JK. Community Oncol 2006 3(10):665

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Management of Late Effects of Radiation Therapy • Infertility/sterility – Sperm banking for males prior to treatments – Egg harvesting for females prior to treatments – will need a surrogate for implantation of eggs as uterus in most females is atrophied following treatments and cannot carry fetus – Ovarian relocation out of radiation fields prior to treatments, but often times not successful secondary to inadequate blood supply to the ovaries

For infertility and sterility, these things need to be addressed prior to start of radiation treatments. Once the testes and ovaries have received radiation, if there is damage, this cannot be reversed. Some options are sperm banking for males prior to treatments and egg harvesting for females prior to treatments. The female needs to remember she will need a surrogate for implantation of eggs, as the uterus in most females is atrophied following treatments and cannot carry a fetus to term. Ovarian relocation out of the radiation fields prior to treatments has been tried, but oftentimes this is not successful, secondary to the inadequate blood supply to the ovaries during this time.

La infertilidad y la esterilidad deben abordarse antes de comenzar la radioterapia. Una vez que los testículos y los ovarios reciben radiación, si ocurre algún daño, no podrá revertirse. Algunas opciones para antes del tratamiento son los bancos de esperma y la recolección de óvulos. La mujer debe recordar que necesitará una sustituta para la implantación de óvulos, ya que luego del tratamiento el útero suele atrofiarse e impedir que el feto llegue a término. Se ha intentado la reubicación de ovarios fuera de los campos de radiación antes del tratamiento, pero muchas veces no funciona debido a una irrigación insuficiente durante este lapso.

When to refer to a specialist: You should consider referral to a specialist --- if trea --- if not responsive to conservative management for the following: persistent bowel dysfunction or symptoms of malabsorption, you should refer to a bowel management specialist and/or a dietitian. For urinary symptoms, erectile dysfunction, and decreased libid --- libido, a urologist who is familiar with treatment of these side effects. For vaginal stenosis, dryness, or dyspareunia and decreased libido in females, a gynecologist who is also familiar with cancer-related side effects should be refer --- consulted. For insufficiency fractures that do not respond to conservative treatments, refer to an orthopedist.

¿Cuándo consultar a un especialista? Cuando el paciente no responda al tratamiento conservador, en los siguientes casos: Para la disfunción intestinal persistente o síntomas de malabsorción, un especialista en cuidado intestinal o un dietista. Para los síntomas urinarios, disfunción eréctil y disminución de la libido, un urólogo familiarizado con estos efectos secundarios. Para la estenosis y sequedad vaginal, dispareunia y disminución de la libido en las mujeres, un ginecólogo familiarizado con los efectos secundarios del cáncer. Para las fracturas por insuficiencia que no responden a los tratamientos conservadores, un ortopedista.

Cox J and Ang KK. Radiation Oncology: Rationale, Technique, Results, 9th ed. 2010: 653-8, 812-3

When to Refer • Consider referral to a specialist if not responsive to conservative management for: – Persistent bowel dysfunction or symptoms of malabsorption • Bowel management specialist • Dietician

– Urinary symptoms, erectile dysfunction, decreased libido* • Urologist

– Vaginal stenosis, dryness or dyspareunia, decreased libido* • Gynecologist

– Insufficiency fracture • Orthopedist * Also consider referral to psychotherapist for decreased libido

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When to Refer

(continued)

Referral is also indicated for fistulas and small bowel obstructions. This requires a surgeon to evaluate for treatment options. For rectal bleeding, a gastroenterologist should be consulted.

El referido también se indica para las fístulas y obstrucciones intestinales, con un cirujano que evalúe las opciones de tratamiento. Para el sangrado rectal se debe consultar a un gastroenterólogo.

In summary, acute reactions from radiation therapy can usually be managed conservatively and will resolve in two to three weeks after treatment. The late side effects of radiation therapy are not common, but they do occur in a small percentage of patients. However, there are effective treatments for most of these late side effects. And remember, recurrent cancer or a second primary can mimic the less common side effects of radiation therapy, so should be given more attention. Thank you. That’s the end of my talk for today. I appreciate your attention, and if you have any feedback, that would be appreciated.

En resumen, las reacciones agudas a la radioterapia se pueden controlar de forma conservadora y ser resueltas de dos a tres semanas después del tratamiento. Los efectos secundarios tardíos de la radioterapia no son comunes, pero ocurren en un pequeño porcentaje de pacientes. Existen tratamientos efectivos para la mayoría de ellos. Un cáncer recurrente o un segundo cáncer primario pueden imitar los efectos secundarios menos comunes de la radioterapia, por lo que se les debe prestar más atención. Gracias. Este es el final de mi charla de hoy. Agradezco su atención y apreciaremos cualquier comentario.

• Referral also indicated for: – Fistula and small bowel obstruction • Surgeon

– Rectal bleeding • Gastroenterologist

Summary • Acute reactions from radiation therapy can usually be managed conservatively and will resolve in 2-3 weeks after treatment • Late side effects are not common, but do occur in a small percentage of patients • There are effective treatments for most late side effects • Recurrent cancer or a second primary can mimic the less common side effects of radiation therapy

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