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

https://creativecommons.org/licenses/by-sa/3.0/deed.en

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 .

Copyright 2017 by Creative Commons Attribution- Share Alike 4.0 International

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