managing chronic radiation side effects
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Oncology Nursing Society 44th Annual CongressApril 11–14, 2019 • Anaheim, CA
1Radiation
Hilda Haynes-Lewis, PhD, ANP-BC, AOCNP Montefiore Einstein Center for Cancer Care Bronx, NY hhaynes@montefiore.org
Key Session Takeaways1. Treatment technique and comorbidities have a significant impact
on the severity of chronic side effects.2. Nurses should work with the patient to develop a plan to manage
chronic side effects that optimizes quality of life.3. Nurses should be at the forefront of chronic side effect manage-
ment as part of survivorship care as the number of cancer survi-vors continues to increase.
Managing Chronic Radiation Side EffectsFriday, April 12 • 2:45–4 pm
Note one action you’ll take after attending this session: ________________________________________________________________________________________________________________________________________________
ONS 44th Annual Congress
Radiation 1
Hilda Haynes-Lewis, PhD, ANP-BC, AOCNPNurse Practitioner
Montefiore Einstein Center for Cancer Care, Bronx, NY.
Managing Chronic Radiation Side
Effects
April 12, 2019
ONS 44th Annual Congress
Radiation 2
• None
Disclosures
• 60% of patients with cancer receive radiation therapy• Can be used prophylactically, to cure or to palliate as a stand alone
therapy or in combination with chemotherapy or surgery• Multiple modes of delivery – external beam, internal placement or
systemic• The intent of therapy for 75%of patients treated with radiation
therapy is cure
Background
Radiation Therapy Mechanism
• Ionizing radiation induces cellular damage directly and indirectly• Damages DNA inside cells leading to inability
of cells to reproduce and cell death• Normal cells are have the ability to repair
damage caused by radiation therapy
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ONS 44th Annual Congress
Radiation 3
Long Term vs. Late Side Effects
Long term effects are prolonged effects that begin during treatment and continue beyond the end of treatment
Late side effects occur or begin after therapy is completed and may occur months to years post treatmentRodriguez, M. A., & Foxhall, L. E. (Eds.). (2018). Handbook of Cancer Survivorship Care. New York, NY: Springer Publishing Company
Sites
Central Nervous System• Disease sites:
Brain, Spinal cord
• Tissue in the brain and spinal cord are late reacting and late effects occur due to white matter changes that can be seen on imaging
• Radiation increases the risk of stroke and secondary brain tumors in long term survivorshttps://www.flickr.com/photos/internetarchivebookimages/14581683918/
https://archive.org/stream/cu31924031263597/cu31924031263597#page/n184/mode/1up
ONS 44th Annual Congress
Radiation 4
Side Effects
• Increased atherosclerosis of blood vessels in the brain• Increased incidence on secondary brain tumors• Radiation necrosis• Cognitive decline• Hormonal deficits• Vision changes• Hearing loss• Radiation myopathy
Management• Steroids• Bevacizumab• Hyperbaric oxygen therapy• Pentoxifylline• Surgical resection• Memantine• Donepezil• Cognitive rehabilitation• Cochlear implants• Hormonal replacement
Head and Neck
• Sites
• Nasopharynx, oral cavity, salivary glands, neck
• Radiation therapy alone or in combination
with surgery and/or chemotherapy is curative
• Side effects may be long term or late
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ead_anatomy.jpg/254px-Lateral_head_anatomy.jpg
ONS 44th Annual Congress
Radiation 5
Side effects
• Xerostomia• Dysgeusia• Fibrosis • Lymphedema• Dysphagia• Dental caries• Osteoradionecrosis• Hearing loss• Neuropathy• Changes in voice quality
Management
• Acupuncture, massage• Therapy• Physical therapy• Decongestive therapy• Swallowing rehabilitation
• Medications• Pentoxifylline• Vitamin E• Opioids• Saliva substitutes and stimulants
Management
• Conservative debridement• Hyperbaric oxygen • Surgical resection and reconstruction• Hearing aids• Tympanostomy and aspiration• Myringotomy and grommet insertion• Voice therapy• Injection laryngoplasty
ONS 44th Annual Congress
Radiation 6
Chest
• Sites
• Breast, lung ( primary or metastatic),
mediastinal or axillary adenopathy, esophagus
• Risk factors
• Age, gender
• Treatment technique
• Concurrent chemotherapy
• Lung disease ( COPD, emphysema)
• History of smoking
• Poor performance status
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Side Effects
• Exacerbation or worsening of underlying comorbid lung disease• Lung fibrosis• Chest wall fibrosis• Esophageal stricture• Telangiectasias• Pain• Lymphedema• Brachial plexopathy• Cardiotoxicity
Management
• Dietary and behavioral modifications• Pulmonary rehabilitation, physical therapy• Esophageal dilation• Medications• Steroids• Anti-inflammatories• Gabapentin • Pentoxifylline and vitamin E• Prokinetic agents• Oxygen therapy
ONS 44th Annual Congress
Radiation 7
Abdomen
• Sites• Gastric, liver , pancreas, colon, stomach,
small bowel
• Radiation therapy is commonly used in neoadjuvant and adjuvant treatment • Also used as effective palliation for
pain, bleeding and obstruction
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Side Effects
• Dysmotility • Stricture• Fistula• Obstruction• Ulceration or perforation• Bleeding
Management
• Dietary modification• Medications• Analgesics• Enzyme supplementation• Antidiarrheal• Antiemetic• PPI
• Endoscopic dilation• PEG tube• Surgical intervention
ONS 44th Annual Congress
Radiation 8
Pelvis• Sites
• Prostate, bladder, cervical ,
ovarian, colorectal
• Chronic toxicity is correlated
with volume of rectum
receiving 70 Gy or more
• In patients with gynecologic
tumors the use of IMRT for
whole pelvis radiation may
decrease acute and chronic GI
toxicity .
https://commons.wikimedia.org/wiki/File:Male_anatomy_en.svg#/media/File:Male_and_female_anatomy.svg
Side Effects- Gastrointestinal
• Diarrhea• Hemorrhoids• Proctitis• Leakage or fecal incontinence• Fistula or stricture• Obstruction
Management- Gastrointestinal
• Dietary modification• Bowel rest• Medications
• Antidiarrheal• Sucralfate enemas• Steroid suppositories and creams• Topical lidocaine
• Endoscopic intervention• Coagulation with formalin or APC laser
• Hyperbaric oxygen• Surgical resection
ONS 44th Annual Congress
Radiation 9
Side Effects -Genitourinary
• Incontinence • Cystitis• Fistula• Stricture
Management- Genitourinary
• Bladder irrigation and clot removal• Blood transfusions• Intravascular endoscopic intervention• Cystoscopy with fulguration• Argon plasma coagulation
• Hyperbaric oxygen• Surgical repair of fistulas or artery embolization• Stent placement• Cystectomy
Side Effects– Sexual Dysfunction
• Vaginal atrophy and stenosis• Vaginal or cervical necrosis ( rare)• Fistula formation (rare)• Menopause• Infertility• Erectile dysfunction• Anejaculation• Dyspareunia
ONS 44th Annual Congress
Radiation 10
Management -Sexual
• Vaginal dilator• Hormone replacement, serotonin reuptake inhibitors• Fertility counseling prior to therapy• Phosphodiesterase inhibitors ( PDE-5)• Prostaglandin injections( intraurethral or intracavernosal)• Penile implants or vacuum erection devices• Surgical repair of fistula• Counseling
Side Effects – Miscellaneous
• Lymphedema• Telangiectasia• Osteopenia• Fracture• Bone necrosis https://en.wikipedia.org/wiki/Lymphedema .
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Management• The goal is to maintain bone mineral density when possible with:
• Medications• Calcium and vitamin D supplements• Bisphosphonates• Estrogen
• Weight bearing exercise
• Immobilization• Surgery
ONS 44th Annual Congress
Radiation 11
Skin and Extremities
• Melanoma, nonmelanomatous skin cancers e.g. Basal cell carcinoma• Radiation therapy can be used as in a
curative or palliative setting• Skin is affected in the treatment of
other cancers such as prostate, anus and breast
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Side Effects
• Telangiectasia• Chronic dermatitis• Pigmentation changes• Atrophy, fibrosis• Ulceration• Bone fractures• Alopecia• Edema
Management
• Antihistamines• Colloidal oatmeal treatments , aloe• Massage• Physical therapy• Wound care- debridement
ONS 44th Annual Congress
Radiation 12
Global Side Effects
• Fatigue• Depression• Insomnia• Pain• Anxiety• Post traumatic stress
Management• Medications• Exercise• Energy conservation• Mind-body techniques
• Stress management• Relaxation
• Therapy• Art• Sleep• Cognitive behavior• Support group
• Referral to a survivorship program
Takeaways
• Treatment technique and comorbidities have a significant impact on the severity of chronic side effects• Nurses should work with the patient to develop a plan to manage
chronic side effects that optimizes quality of life• Nurses should be at the forefront of chronic side effect management
as part of survivorship care as the number of cancer survivors continues to increase
ONS 44th Annual Congress
Radiation 13
Berkey, F. J. (2010). Managing the adverse effects of radiation therapy. American Family Physician, 82(4), 381- 388.
Citrin, D. E., Prasanna, P. G., Walker, A. J., Freeman, M. L., Eke, I., Barcellos-Hoff, M. H., ... & Anscher, M. S. (2017). Radiation-Induced Fibrosis: Mechanisms and Opportunities to Mitigate. Report of an NC Workshop, September 19, 2016. Radiation Research, 188(1), 1-20.
Hall, S., Rudrawar, S., Zunk, M., Bernaitis, N., Arora, D., McDermott, C., & Anoopkumar-Dukie, S. (2016).Protection against radiotherapy-induced toxicity. Antioxidants, 5(3), 22.
Kenyon, M., Mayer, D. K., & Owens, A. K. (2014). Late and long-term effects of breast cancer treatment and surveillance management for the general practitioner. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 43(3), 382- 398.
Koontz,B.F. (Ed.).(2018). Radiation therapy treatment effects: An Evidence –based guide to managing toxicity. New York, NY: Springer Publishing Company.
Nicholas, S., Chen, L., Choflet, A., Fader, A., Guss, Z., Hazell, S., ... & Viswanathan, A. N. (2017). Pelvic radiation and normal tissue toxicity. Seminars in Radiation Oncology, 27(4),358-369.
Rodriguez, M. A., & Foxhall, L. E. (Eds.). (2018). Handbook of Cancer Survivorship Care. New York, NY: Springer Publishing Company.
Siddiqui, F., & Movsas, B. (2017). Management of radiation toxicity in head and neck cancers. Seminars in Radiation Oncology, 27(4), 340-349.
Sobecki-Ryniak, D., & Krouse, H. J. (2013). Head and neck cancer: historical evolution of treatment and patient self-care requirements. Clinical Journal of Oncology Nursing, 17(6), 659-663.
References
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