Caroline C Henson

Gastrointestinal symptoms after pelvic radiotherapy: a national survey of gastroenterologists

PurposeSeventeen thousand patients receive treatment with radical pelvic radiotherapy annually in the UK. Up to 50% develop significant gastrointestinal symptoms. The National Cancer Survivorship Initiative has identified access to specialist medical care for those with complications after cancer as one of their four key needs. We aimed to determine the current practice of British gastroenterologists with regards to chronic gastrointestinal symptoms after pelvic radiotherapy.MethodsA questionnaire was developed and sent up to a maximum of five times to all UK consultant gastroenterologists.ResultsEight hundred sixty-six gastroenterologists were approached and 165 (20%) responded. Sixty-one percent saw one to four patients annually with bowel symptoms after radiotherapy. Eighteen percent rate the current treatments as effective “often” or “most of the time”. Forty-seven percent of gastroenterologists consider themselves “confident with basic cases”, with 11% “confident in all cases”. Fifty-nine percent thinks a gastroenterologist with a specialist interest should manage these patients. Although only 29% thinks a specific service is required for these patients, 34% rates the current service as inadequate. The ideal service was considered to be gastroenterology-led, multidisciplinary and regional. Low referral rates, poor evidence-base and poor funding are cited as reasons for the current patchy services.ConclusionsThe low response rate contrasts with that from a parallel survey of clinical oncologists. This may reflect the opinion that radiation-induced bowel toxicity is not a significant issue, which may be because only a small proportion of patients are referred to gastroenterologists. The development of new, evidence-based gastroenterology-led services is considered the optimal way to meet the needs of these patients.

Biomarkers of normal tissue toxicity after pelvic radiotherapy.

Purpose of reviewTo review the evidence for candidate biomarkers of gastrointestinal toxicity following pelvic radiotherapy to highlight recent findings of potential interest to those involved in the treatment of pelvic malignancies or the management of gastrointestinal consequences of cancer treatments. Recent findingsMultiple serum and faecal biomarkers have been studied for use in the detection of gastrointestinal toxicity following pelvic radiotherapy. There is no single biomarker that has been shown to be useful and studies have been hampered by the lack of a ‘gold standard’ test to confirm the presence of toxicity. Given the complex effects of pelvic radiotherapy on the gastrointestinal tract, it is likely that a panel of biomarkers would be necessary in clinical practice. SummaryBiomarkers for gastrointestinal toxicity have a potential role in determining the outcomes of current and evolving radiotherapy techniques, identifying those patients at risk of greater degrees of toxicity to facilitate individualized treatment and determining whether symptoms that develop following treatment are related to the previous radiotherapy. Outcome measurement of pelvic radiotherapy has been plagued by inaccurate terminology and crude outcome measures. An accurate and acceptable biomarker or panel of biomarkers has the potential to revolutionize cancer management from treatment planning to posttreatment care. Several candidate biomarkers show promising results, but further robust research is required to clearly identify reliable biomarkers that can be translated into clinical practice.

Interventions to reduce acute and late adverse gastrointestinal effects of pelvic radiotherapy

This is a protocol for a Cochrane Review (Intervention). The objectives are as follows: To determine which prophylactic interventions reduce the incidence, severity, or both of adverse gastrointestinal effects among adults receiving radiotherapy to treat primary pelvic cancers.

PTU-148 Does investigating chronic gastrointestinal symptoms following pelvic radiotherapy identify treatable diagnoses?

Introduction 17 000 patients are treated with radical pelvic radiotherapy per year in the UK. Although 50% develop significant chronic gastrointestinal (GI) symptoms, <20% are referred for gastroenterological evaluation. We aimed to determine the causes of GI symptoms in this patient group. Methods 60 patients with GI symptoms ≥6 months after radical pelvic radiotherapy were identified from oncology clinics. Those requiring urgent investigation via the 2-week wait pathway were excluded. Baseline characteristics including demographic data, cancer treatment details and symptoms were collected. Patients were referred for gastroenterological evaluation using an algorithmic approach, which involves the identification of all GI symptoms and investigation for all potential causes for the individual symptoms. Details of investigations and diagnoses were collected. Results 20 men and 36 women with primary gynaecological (31), urological (17) or lower GI (8) tumours were included, with a median age of 58.5 years (range 26.9–81.8). As part of their cancer treatment 15 patients also had brachytherapy, 28 had chemotherapy and 25 had surgery. Patients presented with multiple GI symptoms (median 8, range 4–16) including frequency (46), urgency (52), loose stool (50), faecal incontinence (40), flatulence (43), bloating/distension (38) and rectal bleeding (29). The median number of investigations per patient was 9 (range 1–17), including routine blood tests (47), coeliac screen (39), breath tests for small bowel bacterial overgrowth (21) and lactose intolerance (16), SeHCAT scans (27) and upper (27) and lower (38) GI endoscopy. Common diagnoses include radiation proctopathy (22) and bile acid mabsorption (12). Some diagnoses are unrelated to previous radiotherapy, for example, diverticulosis (9) and colonic polyps (8). No cause was found for symptoms in seven patients. 25 patients have 2 or more GI diagnoses. Conclusion Gastroenterological evaluation identifies significant and potentially treatable diagnoses in patients who develop chronic GI symptoms following pelvic radiotherapy. Some findings are incidental and some are unrelated to previous cancer treatment. GI symptoms in these patients have historically been considered “untreatable”. These data suggest that structured gastroenterological assessment has the potential to improve outcome by identifying these diagnoses and facilitating focussed treatment. Competing interests None declared.

PTU-147 Structured gastroenterological evaluation and improved outcomes for patients with chronic gastrointestinal symptoms following pelvic radiotherapy

Introduction 17 000 patients are treated with radical pelvic radiotherapy per year in the UK. 50% will develop chronic gastrointestinal (GI) symptoms that adversely affect quality-of-life, which have been shown to persist at the same level of severity for at least 3 years following treatment. Despite this, fewer than 20% are referred to a gastroenterologist. We aimed to determine if structured gastroenterological evaluation improves symptoms this patient group. Methods 60 patients with GI symptoms ≥6 months after radical pelvic radiotherapy were identified from oncology clinics. Those requiring urgent investigation via the 2-week wait pathway were excluded. They were assessed at baseline using patient-reported symptom-based questionnaires: inflammatory bowel disease questionnaire (IBDQ); Vaizey incontinence questionnaire (VIQ); and the Common Terminology Criteria for Adverse Events (CTCAE) pelvis questionnaire. Participants were then referred to and managed by gastroenterologists using an algorithmic approach, which involves the identification of all GI symptoms and investigation for all potential causes for these symptoms. Further assessments were made at 3 and 6 months using the questionnaires. Results 20 men and 36 women were included, with a median age of 58.5 years (range 26.9–81.8). Median time from radiotherapy to baseline gastroenterological assessment was 3.0 years (range 0.6–18.7). Median IBDQ score improved from 168 at baseline to 195 at 6 months (p=0.014). Median IBDQ bowel subset score improved from 41 at baseline to 50 at 6 months (p<0.0005). Significant improvement was also found in the median VIQ score from 11 at baseline to 8 at 6 months (p<0.0005). The median CTCAE rectum bowel mean score for men improved from 1.4 at baseline to 0.9 at 6 months and for women from 1.4 at baseline to 1.3 at 6 months. Pooling male and female data, the CTCAE mean score significantly improved comparing baseline with 6 month scores (p=0.001). Conclusion GI symptom questionnaire scores significantly improved from baseline to 6 months. This suggests that structured gastroenterological evaluation using an algorithmic approach may improve GI symptoms in this patient group, although a controlled study is necessary to confirm this. Competing interests None declared.

Late onset bowel dysfunction after pelvic radiotherapy: a national survey of current practice and opinions of clinical oncologists

Introduction 17,000 patients receive treatment with radical pelvic radiotherapy annually in the UK. Up to 50% of patients will develop bowel symptoms which affect quality of life. Services for this patient group are underdeveloped. Barriers to good clinical care include poor patient reporting, poor clinician recognition and a lack of established routes of referral. The National Cancer Survivorship Initiative (2007) has identified access to specialist medical care for those with complications that occur after cancer as one of the four key needs of cancer survivors. It is in this context that we aimed to determine the current practice of clinical oncologists in the UK. Methods A questionnaire was developed and sent to the 314 clinical oncologists in the UK who treat pelvic malignancies up to a maximum of three times by post. Results 190 (61%) responses were received. 76% of oncologists screen for GI dysfunction after pelvic radiotherapy. 85% screen for symptoms through history taking with only 11% using formal screening questionnaires. Clinical oncologists view toxicity as a significant problem, with 64% estimating that up to 24% patients have bowel symptoms at 1 year. 71% oncologists refer <50% of their symptomatic patients, with 48% referring <10%. These referrals are sent to a gastroenterologist from 31% of oncologists and to a GI surgeon from 23%, with 33% referring to either speciality. 58% do not have access to a gastroenterologist or GI surgeon with a specialist interest in their area. 65% of oncologists think a service is required specifically for patients with bowel dysfunction after pelvic radiotherapy, but 52% rate the current service in their area as inadequate. Oncologists state an ideal service would be gastroenterology-lead, multidisciplinary and accessible. It would have a strong research and education component. The current service was described as patchy, non-standardised, inconsistent and nihilistic. Conclusion Whilst British oncologists recognise bowel dysfunction after pelvic radiotherapy as a significant problem, they refer only a minority of patients for specialist evaluation. This may reflect the lack of clear routes of referral and access to GI expertise. The estimated proportion of patients affected was lower than that reported in the literature, which may reflect the lack of robust systems in routine practice to detect significant symptoms. The views expressed clearly highlight the need for a dedicated gastroenterology-lead multidisciplinary service to address the imbalance between this established unmet need and current service provision.

PTU-186 12 Month outcome and Patient Satisfaction with Structured Gastroenterological Evaluation for Chronic Gastrointestinal Symptoms following Pelvic Radiotherapy

Introduction Seventeen thousand patients are treated with radical pelvic radiotherapy annually in the UK.50% develop chronic GI symptoms. The structured approach to management used in this service evaluation has been shown to identify treatable diagnoses and improve symptoms in the short term. We report the first 12 month outcome data for the effect of structured gastroenterological evaluation on symptom burden and patient satisfaction. Methods Fifty-six patients with GI symptoms > 6 months after radical pelvic radiotherapy underwent structured gastroenterological assessment as part of a service evaluation. They were assessed using the following questionnaires: inflammatory bowel disease questionnaire(IBDQ); Vaizey incontinence questionnaire (VIQ); and the Common Terminology Criteria for Adverse Events (CTCAE)pelvic symptom questionnaire.12 month assessments were compared to the previously reported baseline and 6 month assessments to determine if the improvement in symptoms was sustained. Patient satisfaction with the service was assessed at 12 months by an in-house questionnaire. Results Forty patients(71%)completed the 12 month assessment and 37(66%) completed the patient satisfaction questionnaire. The initial statistically significant improvement in GI symptoms from baseline to 6 months in parallel to GI evaluation was sustained up to 12 months in all questionnaires (IBDQ p = 0.019, IBDQB and CTCAE rectum bowel subset p < 0.0005) except the VIQ (p = 0.098).There was also a clinically significant improvement as defined by an increase in IBDQ score of ≥0.5 points per question. Median total IBDQ and IBDQB score increased by 25 and 11 points respectively between baseline and 12 months.97% of patients found the appointments convenient, 97% felt their problems were understood; 86% were satisfied with the outcome and 89% with the service. Dissatisfaction related to communication (n = 3), travel (n = 2) and ongoing symptoms (n = 3). Conclusion The clinically and statistically significant improvement in GI symptoms found in parallel to structured gastroenterological evaluation for chronic GI symptoms following pelvic radiotherapy was sustained over 12 months follow up. These data suggest that structured investigation on the basis of the BSG guidelines can lead to a sustained improvement in symptoms and is acceptable to patients. Further research is essential to optimise patient care. Disclosure of Interest None Declared.