Assessment, Investigation and Management of Late Bowel Toxicity Following Radical Radiotherapy to the Prostate

This audit examines the recording and assessment of late bowel toxicity following prostate radiotherapy, investigation of these symptoms and subsequent management against national guidance [5].

Late bowel toxicity is a recognized and important complication of radical radiotherapy to the prostate. Its incidence, assessment and investigation can vary within departments and NICE guidance aims to ensure this toxicity is detected and appropriately investigated. There is an absence of clear consensus on how radiation induced late bowel toxicity should be managed, though it is thought the use of steroid enemas is not appropriate.

The standard: 

1. Published literature 1-4 demonstrates late bowel toxicity using conformal radiotherapy occurs in 8-38%

2. Patients symptomatic of radiation-induced enteropathy should be investigated using flexible sigmoidoscopy to exclude malignancy and to ascertain radiation injury [5]

3. Men treated with prostate radiotherapy should be offered sigmoidoscopy every 5 years [5]

4. Steroid enemas should not be used for radiation proctopathy [5]

Target: 

1. Less than 38% rates of late bowel toxicity with conformal radiotherapy

2. 100% of patients symptomatic of radiation-induced enteropathy should be investigated using flexible sigmoidoscopy to exclude malignancy and to ascertain radiation injury

3. 100% of men treated with prostate radiotherapy should be offered sigmoidoscopy every 5 years

4. 0% of radiation proctopathy should be treated using steroid enemas

Indicators: 

1. Proportion of patients post radiotherapy with documented late bowel toxicity symptoms

2. Proportion of patients with late bowel toxicity symptoms referred for flexible enteropathy

3. Proportion of patients at 5 years, and then 10 years offered sigmoidoscopy

4. Proportion of patients treated with steroid enemas

Data items to be collected: 

As above.

Also: if documented RTOG or LENT SOMA grading of toxicity

• Age of patient and stage of disease

• Dose and fractionation patient treated with V50, V60 to rectum

Suggested number: 

Annual audit may be appropriate, with 50-100 patients of post radiotherapy patients

• Identify reasons for poor documentation of toxicity - ?could proformas in clinic or used by specialist nurses be helpful

• Identify reasons for lack of referral for flexible sigmoidoscopy, is there a clear pathway? Are there particular consultants within gastro-enterology or surgery who may be identified as having a specialist interest in radiation induced toxicity

• Ensure departmental policy to have 5 yearly flexible sigmoidoscopy (?as routine at discharge) at 5 years and for increased liason with general practice for further future flexible sigmoidoscopies

• If steroid enemas are frequently used for discussion and education with gastroenterology team

• Personnel: Clinical oncologist, Gastroenterologists, Specialist Nurse

• Time: 20-30 hours to review notes (both oncology and gastroenterology), collect data and prepare report

1. Dearnaley, DP Sydes MR Escalated-dose versus standard-dose conformal radiotherapy in prostate cancer: first results from the MRC RT01 randomised controlled trial. The Lancet Oncology,2007 June 8:6: 475 – 487

2. Peeters, ST, Heemsbergen WD Dose response in Radiotherapy for localized prostate cancer: results of the Dutch Multicenter Randomized Phase III Trial Comparing 68Gy or Radiotherapy with 78Gy Journal of Clinical Oncology, 2006 May 24;13: 1990-1996

3. Zietman, AL; DeSilvio, ML Comparison of Convetnioal-Dose vs High-Dose Conformal Radiation Therapy in Clinically Localized Adenocarcinoma of the Prostate JAMA 2005; 294: 1233-1239

4. Dearnaley, DP; Khoo VS "Comparison of radiation side-effects of conformal and conventional radiotherapy in prostate cancer: a randomised trial" Lancet. 1999 Jan 23;353 (9149):267-72

5. NICE guideline CG58 Feb 2008; [http://www.nice.org.uk/cg58]

Rashmi Jadon