Understanding the Management of Chronic AEs After Radiation Therapy

Nurses play a key role in helping to manage the chronic adverse events (AEs) associated with radiation, even into survivorship, according to Hilda Haynes-Lewis, PhD, ANP-BC, AOCNP.

“Treatment techniques and comorbidities have a significant impact on the severity of chronic side effects,” said Haynes-Lewis, a nurse practitioner at Montefiore Einstein Center for Cancer Care. “Nurses should work with the patients to develop a plan to manage chronic side effects that optimize quality of life.”

To start, she added, knowing the difference between late AEs (those that occur or begin after therapy is completed and may occur months to year post-treatment) and long-term AEs (prolonged effects that begin during treatment and continue beyond the end of treatment) is important.

In her presentation, Haynes-Lewis focused on the management of chronic late side effects among patients with cancer.

Central Nervous System

Disease sites under this category can include the brain and spinal cord, from which the tissue are late reacting. Therefore, these changes are found, not in the clinic, but through imaging.

AEs of the central nervous system include increased atherosclerosis of the blood vessels in the brain, increased incidence of secondary brain tumors, radiation necrosis, cognitive decline, hormonal deficits, vision changes, hearing loss, and radiation myopathy.

“This is where nurses come in because we really need to educate, educate, educate the patients and their families,” Haynes-Lewis said. “We need to talk to them about the symptoms of stroke, incidents of what it looked like if you had a tumor — headaches, changes in vision, changes in gait, changes in mental status – those are all things that we need to talk to the patient about. A lot of times I tell them, maybe you just don’t feel right because there aren’t any words. And if they don’t feel right, I tell them to call their provider. Sometimes that is what happens.”

AEs associated with the central nervous system are often treated with steroids, bevacizumab (Avastin), hyperbaric oxygen therapy, surgical resection, memantine, donepezil (Aricept), cognitive rehabilitation, cochlear implants, hormonal replacement, and pentoxifylline.

Head and Neck

These AEs can occur in the nasopharynx, oral cavity, salivary glands, or neck. They include xerostomia, dysgeusia, fibrosis, lymphedema, dysphagia, dental caries, osteoradionecrosis, hearing loss, neuropathy, and changes in voice quality.

“These side effects affect every part of your life and your quality of life,” Haynes-Lewis said.

Management of these AEs can include acupuncture and massage, therapy (physical therapy, decongestive therapy, swallowing rehabilitation), and medications such as pentoxifylline, vitamin E, analgesics, saliva substitutes and stimulants, conservative debridement, hyperbaric oxygen, surgical resection and reconstruction, hearing aids, tympanostomy and aspiration, myringotomy and grommet insertion, voice therapy, and injection larynoplasty.

“You need to help (the patients) by just putting 2 and 2 together,” Haynes-Lewis said. “If you have a dry mouth, what does that do? It can affect your teeth, so we need to make sure (the patient) is seeing the dentist, that they are doing good oral hygiene and that they understand what that is and how to do it.”

Chest

AEs of the chest can occur in the breast, lung, mediastinal or axillary adenopathy, or esophagus. In this area of the body, risk factors for chronic AEs include age, gender, treatment techniques, concurrent chemotherapy, lung disease, history of smoking, and poor performance status.

Chest AEs from radiation include exacerbation or worsening of underlying comorbid lung disease, lung fibrosis, chest wall fibrosis, esophageal stricture, telangiectasias, pain, lymphedema, brachial plexopathy, and cardiotoxicity. These can be managed with dietary and behavioral modifications, pulmonary rehabilitation and physical therapy, esophageal dilation, and medications such as steroids, anti-inflammatories, gabapentin, pentoxifylline, vitamin E, prokinetic agents, and oxygen therapy.

Abdomen

In disease sites of the abdomen (gastric, liver, pancreas, colon, stomach, and small bowel), radiation therapy is commonly used in neoadjuvant and adjuvant treatment, as well as effective palliation for pain, bleeding, and obstruction.

AEs include dysmotility, stricture, fistula, obstruction, ulceration or perforation, and bleeding. To manage these, Haynes-Lewis recommended for dietary modifications; medications like analgesics, enzyme supplementation, anti-diarrheal, antiemetics, and proton pump inhibitors; endoscopic dilation; percutaneous endoscopic gastrostomy tube; and surgical intervention.

Pelvis

Sites for these AEs can include the prostate, bladder, cervix, ovaries, and colon, for which chronic toxicity can be correlated with the volume of radiation received.

These AEs—including diarrhea, hemorrhoids, proctitis, leakage of fecal incontinence, fistula or stricture, and obstruction–can be managed with dietary modifications; bowel rest; medications such as anti-diarrheal, sucralfate enemas, steroid suppositories and creams, and topical lidocaine; endoscopic interventions; hyperbaric oxygen therapy; and surgical resection.

Skin and Extremities

These AEs can include telangiectasia, chronic dermatitis, pigmentation changes, atrophy, fibrosis, ulceration, bone fractures, alopecia, and edema. In addition, they are often managed with antihistamines, colloidal oatmeal treatments, aloe, massages, physical therapy, and wound care.

In addition, Haynes-Lewis noted that global chronic AEs, such as fatigue, depression, insomnia, pain, anxiety, and post-traumatic stress disorder, exist across all cancer types, adding that these can be managed with medications, exercise, energy conservation, mind-body techniques, therapy, and referral to a survivorship program.

“Nurses should be at the forefront of chronic side effect management as part of survivorship care as the number of cancer survivors continue to increase,” she concluded.