Gastrointestinal consequences of cancer treatment: evaluation of 10 years' experience at a tertiary UK centre

Abstract

Objective: Up to 90% of patients treated for pelvic cancers experience chronic gastrointestinal (GI) symptoms. This study characterises this patient cohort at a single centre, addressing a paucity of publications reporting 'real-world' experiences.

Method: Outpatient referrals, from oncology to the gastroenterology and nutrition services, at a tertiary London hospital from 2006 to 2016, were retrospectively identified. Patient characteristics, reported symptoms, investigations, diagnoses, response to therapeutics and follow-up were recorded.

Results: Of 269 patients referred, 81% were within the latter 5 years. A total of 260 patients had diagnoses of pelvic cancers (prostatic (52%), cervical (19%) and endometrial (19%)). Among 247 treated with radiotherapy, the median time from radiotherapy to symptom onset was 8 months. Common symptoms were rectal bleeding (51%), diarrhoea (32%), faecal urgency (19%) and pain (19%). Patients underwent a median of three investigations including lower GI endoscopy (86%), thyroid function tests (33%) and glucose hydrogen breath test (30%). Diagnoses included radiation proctopathy (39%), colonic polyps (16%), pelvic floor dysfunction (12%), bile acid malabsorption (BAM) (8%), small intestinal bacterial overgrowth (SIBO) (8%), vitamin D deficiency (7%) and iron deficiency (7%). Among 164 discharged patients, the time to discharge was 7 months, after a median of two appointments.

Conclusions: This unique patient group reports a complex mix of symptoms and requires specialist review and consideration of often uninvestigated diagnoses (pelvic dysfunction, BAM, SIBO and nutritional deficiencies). Such patients are often overlooked, compared with those suffering many other chronic GI disorders. Further reports from non-dedicated centres treating patients with pelvic radiation disease will aid in understanding of secondary GI diagnoses and variation in practice.

Keywords: cancer; enteropathy; radiation enteritis.

Figure 1

Number of patients referred over the study period and the ages of patients. Histograms showing: (A) the number of referrals received grouped into 12-month periods over the course of the study (figures above column denote % of the total population, n=269); (B) the number of referrals received grouped by the age of patients at the time of referral (figures above column denote % of the total population, n=269).

Figure 2

Original oncological diagnoses and treatment modalities. (A) Pie chart showing the original oncological diagnoses of referred patients (figures on chart denote the number of patients, total n=269); other cancers (5, 1.9%) included biliary, bladder, gastric and cancer of unknown primary. (B) Bar chart showing the percentage of patients receiving each modality of treatment for their primary cancer diagnosis (figures above columns denote the number of patients, n=269) and (C) a table showing the number of patients undergoing combination therapy (n=265, with 4 patients in whom previous treatment was not documented).

Figure 3

Symptom frequency. Bar chart showing the frequency of reporting of a range of symptoms at presentation (figures above columns denote number of patients, n=269); ‘other symptoms’ included high stoma output, dysphagia, abnormal imaging findings and symptoms of small bowel obstruction.

Figure 4

Investigations undertaken and diagnoses made. Bar charts showing (A) the frequency and spectrum of investigations undertaken. Other investigations included: barium follow-through, BTs for lactase deficiency, abdominal CT, CT colonography, gastric emptying studies, MRI abdomen, abdominal ultrasound and videocapsule enterography. (B) The frequency and spectrum of endoscopic diagnoses made. (C) The frequency and spectrum of non-endoscopic diagnoses made. (In all charts the figures above the column denote the number of patients, n=269). BAM, bile acid malabsorption; BSS, bile salt sequestrant; BT, breath test; EAU, endoanal ultrasound; SIBO, small intestinal bacterial overgrowth; TTG, tissue transglutaminase.