Side-effects after radiotherapy for cervical cancer affect quality of life

Disease and treatment 29. dec 2020 2 min PhD, Professor Kari Tanderup, MD, DMSc Jacob Christian Lindegaard Written by Morten Busch

Based on major and long-term international collaboration to improve the treatment of cervical cancer, a new study indicates that the extent of the side-effects following radiotherapy treatment has not been fully understood. The study used new methods to clarify persistent side-effects and showed that these strongly affect patients’ daily lives.

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Daily diarrhoea or regular use of diapers and pads because of incontinence is the reality for some patients who have undergone radiotherapy for cervical cancer. Discussing side-effects after cancer treatment can be a taboo. Some patients have to put up with symptoms that reduce their quality of life in the belief that these are normal after treatment. Healthcare systems around the world lack resources to give priority to following up on the severity and frequency of many of these side-effects. A major international research collaboration on the treatment of patients with cervical cancer has now focused on this.

“We are using a new method to determine how many patients have persistent treatment-related side-effects based on self-reporting. It turns out that persistent side-effects that were previously considered mild can strongly affect the quality of life,” explains Kari Tanderup, Professor, Department of Oncology, Aarhus University Hospital and Department of Clinical Medicine, Aarhus University.

Both the treatment of patients with cervical cancer and the follow-up place great demands on healthcare personnel. The treatment is technically challenging, and the follow-up is challenging because getting an overview of the extent and duration of the many types of side-effects that can occur after radiotherapy can be difficult.

“When we map side-effects, we also have the opportunity to identify patients who need help with treatment,” explain consultants Jacob Lindegaard and Lars Fokdal, Department of Oncology, Aarhus University Hospital.

Follow-up is equally important

An international research collaboration called EMBRACE examines the effects of image-guided adaptive brachytherapy, a type of radiotherapy that is suitable for treating patients with cervical cancer. Doctors place small tubes through which a radioactive source can be inserted into the cervix. The doctors use magnetic resonance imaging to distinguish between cancerous tissues and the surrounding organs. This enables oncologists to optimize the positioning of the radioactive source inside the tumour to distribute the radiation optimally.

“The introduction of image-guided adaptive brachytherapy has significantly improved radiotherapy treatment of patients with cervical cancer. However, cervical cancer in high-income countries is relatively rare and maintaining satisfactory quality in all hospitals can be difficult since the treatment is highly specialized,” says Jacob Lindegaard.

In Denmark, assessment and treatment are therefore centralized at Aarhus University Hospital, Odense University Hospital and Rigshospitalet in Copenhagen. Image-guided adaptive brachytherapy has improved survival and reduced serious and life-threatening side-effects, but it places great demands on the education and training of doctors and physicists to implement this type of tailored treatment.

“Through our collaboration, we have become aware that education and training is not the only requirement for providing radiotherapy. Following up is also very important, because even though brachytherapy is very targeted, it is still radiotherapy, and these patients are affected by treatment-related side-effects that can persist for the rest of their lives,” says Kari Tanderup.

“I probably cannot get help for this”

EMBRACE, which was launched in 2008 with the participation of 24 hospitals from around the world, is a collaboration to improve survival and reduce treatment-related side-effects after radiotherapy for cervical cancer. Since 2016, another 35 hospitals have joined, and everyone who needs it in Denmark can now receive this highly specialized treatment. Radiotherapy is constantly being developed and refined, and as fewer patients die from cervical cancer, more focus is shifting to persistent treatment-related side-effects.

“In the new study, we collected doctor- and patient-reported outcomes, and we clearly found that many hospitals only register the more serious side-effects. Our testing of self-reporting shows that some patients have symptoms such as diarrhoea and incontinence not only occasionally but more or less constantly, and this substantially worsens their quality of life. The mild symptoms are not even that mild,” explains Kari Tanderup.

The side-effects after radiotherapy such as incontinence and diarrhoea can be treated or minimized. But unfortunately, some people think that that they have to put up with them and that “I probably cannot get help for this”.

“Fortunately, there are now specialized clinics that diagnose and treat the side-effects. This also applies to other types of cancer, and so much can be gained by improving the follow-up process after cancer with greater focus on persistent side-effects,” says Kari Tanderup.

Fortunately, Denmark has increased its focus on treating side-effects in recent years by establishing clinics for cancer side-effects.

Initiatives for education, training, and dissemination of morbidity assessment and reporting in a multiinstitutional international context: Insights from the EMBRACE studies on cervical cancer” has been published in Brachytherapy in collaboration with Kathrin Kirchheiner, Department of Radiation Oncology, Medical University of Vienna, Austria. The EMBRACE study was launched in Denmark by: Jacob Lindegaard and Lars Fokdal and Kari Tanderup, Aarhus University Hospital; Hanne Mathiesen, Rigshospitalet, Copenhagen; and Gitte-Bettina Nyvang, Odense University Hospital. The Novo Nordisk Foundation awarded a grant in 2017 to Kari Tanderup for the project Ensuring Safety in Radiotherapy: a Prospective International Multicentre Study of In Vivo Dosimetry in Brachytherapy. The Foundation awarded a further grant in 2019 for the project Improving Patient Safety in Brachytherapy through Online Monitoring.

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