Effects of radiation
Effects of radiation on normal tissue
Effects of radiation on normal tissue: consequences and mechanisms – The Lancet
The use of radiation therapy to treat cancer inevitably involves exposure of normal tissues. As a result, patients may experience symptoms associated with damage to normal tissue during the course of therapy for a few weeks after therapy or months or years later.
Radiation injury is commonly classified as acute, consequential, or late effects, according to the time before appearance of symptoms.
Acute (early) effects are those that are observed during the course of treatment or within a few weeks after treatment.
Consequential effects (sometimes called consequential late effects) appear later, and are caused by persistent acute damage.
Late effects emerge months, years or even decades after radiation exposure.
Symptoms may be due to cell death or wound healing initiated within irradiated tissue, and may be precipitated by exposure to further injury or trauma. Many factors contribute to risk and severity of normal tissue reactions; these factors are site specific and vary with time after treatment.
Treatments that reduce the risk or severity of damage to normal tissue or that facilitate the healing of radiation injury are being developed.
These could greatly improve the quality of life of patients treated for cancer.
Causes of Fatigue - From MacMillan……
Radiotherapy| treats cancer by using high-energy rays to destroy cancer cells.
Fatigue caused by chemotherapy or radiotherapy usually improves after treatment, but sometimes it can be more of a long-term problem.
Many people find their normal levels of energy return within 6-12 months of the treatment ending.
However, some people find they still feel tired and have low energy levels a year or so later.
Sometimes, tiredness can continue for two years or more, although this is far less common.
Anaemia is a possible cause of fatigue in people with cancer.
Anaemia is a shortage of haemoglobin in the blood.
Haemoglobin (or Hb) is found in red blood cells and carries oxygen around the body.
As red blood cells circulate in the body, they give energy by carrying oxygen to all of the body’s cells.
If the number of red blood cells is low, there is less Hb, so less oxygen reaches the cells.
If the level of Hb in your blood drops below normal, you may feel tired and have less energy.
Doctors regularly check the levels of blood cells in people who have cancer and cancer treatments.
Brachial Plexus Neuropathy
Brachial Plexus Neuropathy
Late Effects in Normal Tissues – [LENT] Injuries / Radiotherapy Late Effects (RTLE) Injuries
The LENT injuries suffered by the original cohort of RAGE patients as a result of the delivery of high doses of radiotherapy for breast cancer in the 1970’s and 1980’s are detailed in Bates Evans Report for the Royal College of Radiologists in 1995:
Brachial Plexus Neuropathy following Radiotherapy for Breast Carcinoma.
https://www.rcr.ac.uk/sites/default/files/publication/batesevans.pdf
The management and treatment requirements for these chronic injuries was discussed in the Maher Committee Report of 1995 for the Royal College of Radiologists:
Management of Adverse Effects following Breast Radiotherapy - Maher Committee.
https://www.rcr.ac.uk/sites/default/files/publication/maher.pdf
https://www.rcr.ac.uk/maher-committee-management-adverse-effects-following-breast-radiotherapy
Among the prospects discussed by the Maher Committee was the establishment of a specialist, multi-disciplinary rehabilitation service……….
Through the tenacity of the RAGE Committee in pursuing this goal – and with grateful thanks to the Royal National Hospital for Rheumatic Diseases in Bath – the Breast Radiotherapy Injury Rehabilitation Service [BRIRS], at the was finally established in 2013.
Pelvic Radiation Disease
The Pelvic Radiation Disease Association
https://www.prda.org.uk/information-health-professionals/
Many of the 22,000 people treated each year with pelvic radiotherapy have debilitating side effects which reduce their quality of life, sometimes for many years or decades.
The Pelvic Radiation Disease Association (PRDA) estimates that at least 100,000 people in the UK experience ongoing problems due to the side effects of radiotherapy to the pelvic region.
PRDA has compiled a list of clinical guidance and information on Pelvic Radiation Disease for professionals and patients – download here.
PRDA’s definition of Pelvic Radiation Disease
(Download full version here. Download short version here.)
Pelvic Radiation Disease (PRD) is defined as one or more ongoing symptoms of variable complexity that may affect people who have previously had radiotherapy to the pelvic region to treat their cancer. This includes pelvic radiotherapy for cancers of the colon, rectum, anus, prostate, testes, bladder, cervix and womb, but also total body radiotherapy and radiotherapy in the pelvic area for other primary and secondary cancers.
Rehabilitation of Pelvic Radiation Disease
Many patients suffer late effects in normal tissue [LENT] injuries as a result of radiotherapy treatment for gynaecological and intestinal tract cancers or from whole body irradiation.
Professor HJN Andreyev, was Consultant Gastroenterologist in Pelvic Radiation Disease, at the Royal Marsden Hospital in London.
With support from patients he helped to found the PRDA - The Pelvic Radiation Disease Association
He specialises in treating radiation injuries of the intestinal tract.
Dr Andreyev is now based at Lincoln County Hospital, where he has been instrumental in setting up a regional Medical School. He also consults in the Republic of Ireland where he and others are developing Radiation Injury Protocols for the Irish Health Service.
Dr HJN Andreyev
Consultant Gastroenterologist,
Lincoln County Hospital
Greetwell Rd
Lincoln LN2 5QY
Tel: (Secretary) 01522 - 707473
Andreyev - Published Papers....
Gut 2012; 61:179 -192. doi:10.1136/gutjnl-2011-300563
Practice guidance on the management of acute and chronic gastrointestinal problems arising as a result of treatment for cancer
http://m.gut.bmj.com/content/61/2/179.full.pdf
Jervoise N Andreyev, Susan E Davidson, Catherine Gillespie, William H Allum, Edwin Swarbrick
Gut 2005; 54:1051–1054. doi: 10.1136/gut.2004.062596
Gastrointestinal complications of pelvic radiotherapy: are they of any importance?
http://m.gut.bmj.com/content/54/8/1051.1.full.pdf
H Jervoise N Andreyev
Radiation enteropathy—pathogenesis, treatment and prevention
http://www.nature.com/nrgastro/journal/v11/n8/full/nrgastro.2014.46.html
See also the Complete Healing section of this website - Anti-oxidant Treatments
Strahlenther Onkol 181: 606-614, 2005
Effect of pentoxifylline and tocopherol on radiation proctitis/ enteritis.
https://pubmed.ncbi.nlm.nih.gov/16170489/
Hille A, Christiansen H, Pradier O, et al.
See also - Complete Healing - section of this website - for Lumbo-sacral Neuropathy, Pelvic Insufficiency Fractures
Head and Neck Injuries.
Rehabilitation for Head and Neck radiation injuries.
A number of UK based Maxillo-Facial Surgeons are developing anti-oxidant treatments, for radiation induced injuries to the tongue, salivary glands and jawbone. These treatments are being considered as a complement for surgery, or as an alternative to surgery.
The authors are proposing a cautious approach to the use of these treatments by running a trial to support [or avoid] the inclusion of Clodronate with pentoxifylline and alpha-tocopherol (the vitamin E source). This is to replicate the PENTOCLO protocols currently being delivered by Delanian in Paris. (see – Complete Healing)
Professor James McCaul is helpful in setting out the four theories of LENT injuries in the jawbone, the fourth of which is the current Delanian theory on jawbone repair. His commentary on the classification of Clodronate as a First Generation, Non-nitrogenous, Bisphosphonate is also very important.
This is an immensely complex subject - hence the proposed UK trial. (The reporting of which will be a minimum of five years after any commencement date.)
The Mayo Clinic paper – link below - goes into considerable detail to explain the predicament surrounding clodronate and some of the other "non-nitrogenous" first generation bisphosphonates that are now used to counter the jawbone damaging action of the second generation "nitrogenous" bisphosphonates.
From - Royal Marsden Hospital, London:
Pharmacologic Modalities in the Treatment of Osteoradionecrosis of the Jaw.
Professor J A McCaul - Department of Oral & Maxillofacial Surgery, Royal Marsden NHS Foundation Trust, London
http://www.researchgate.net/publication/262054341_Pharmacologic_Modalities_in_the_Treatment_of_Osteoradionecrosis_of_the_Jaw
From - Queen Alexandra Hospital Portsmouth:
Pentoxifylline and tocopherol in the management of patients with osteoradionecrosis, the Portsmouth experience.
Dr N M H McLeod - Department of Oral & Maxillofacial Surgery, Queen Alexandra Hospital, Portsmouth and St Rishards Hospital, Chichester
http://www.bjoms.com/article/S0266-4356(10)00382-7/pdf
http://www.bjoms.com/article/S0266-4356(10)00382-7/fulltext
[Dr McLeod is now at John Radcliffe Hospital, Oxford.]
A Cautionary (but positive) Tale on the use of Bisphosphonates:
Recent recognition that bisphosphonate use is associated with pathologic conditions including osteonecrosis of the jaw has sharpened the level of scrutiny of the current widespread use of bisphosphonate therapy…….
Bisphosphonates: Mechanism of Action and Role in Clinical Practice
Matthew T. Drake, MD, PhD, Bart L. Clarke, MD, and Sundeep Khosla, MD
Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, MN
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2667901/
We hope that these head and neck treatments – when shown to be safe and effective – may become available for other patient groups.
See also the Complete Healing section of this website: – Radiation induced Neuropathy, Mandibular Fractures.
Personal Independence Payment [PIP]
Personal Independence Payment [PIP] - formerly - Disability Living Allowance [DLA]
Having survived cancer, patients will benefit from the ability to resume their normal, fully functional, “pre treatment” lives. Any failure to return to full health and employment results in social costs to the patient and financial costs for the NHS.
Increasingly the current Government is bearing down on social spending, most notably by the replacement of Disability Living Allowance (DLA) with Personal Incapacity Payments (PIPs). This has resulted in considerable difficulties for former cancer patients treated with radiotherapy and now suffering from LENT/ RTLE injuries.
Under the old DLA system the patient’s disability was assessed by the patient’s own GP, armed with the full knowledge of their medical history. Under the new PIPs scheme the patient is assessed according to prescribed testing criteria.
In our experience the knowledge and understanding of the severe disability resulting from these radiation injuries is currently extremely limited within the PIP’s system.
“Cured but at what cost”, by MacMillan
“Cured but at what cost”, by MacMillan, sets out the issues concerning Late Effects in Normal Tissue [LENT] injuries. Failure to resume full health and employment after radiotherapy treatment results in social and employment costs to the patient and financial costs for the NHS.
More than two million people living with cancer in the UK today,
Not all of them are living well.
Cancer and its treatment can leave a gruelling physical and mental legacy for many years afterwards.
Do we really understand the true cost of being cured?
Long-term consequences of cancer and its treatment - July 2013
http://www.macmillan.org.uk/Documents/AboutUs/Newsroom/Consequences_of_Treatment_June2013.pdf
“Throwing light on the consequences of cancer and its treatment”.
Macmillan Cancer Support published this extensive report for healthcare providers. It runs in parallel with “Cured but at what cost”
The report covers the long term consequences and costs of treatment for radiation induced injuries to both the patient, the NHS and the Treasury. The report warns that the NHS is woefully unprepared to help the rapidly growing number of cancer survivors injured by their treatment.
http://www.macmillan.org.uk/Documents/AboutUs/Research/Researchandevaluationreports/Throwinglightontheconsequencesofcanceranditstreatment.pdf