Chest irradiation can damage any of the structures in the chest. For example, breast irradiation can in some cases interfere with lactation.31 Acute radiation pneumonitis can progress to long-term focal pulmonary fibrosis and decreased lung capacity in a minority of patients. Its risk is related to both the total dose delivered and the volume of lung treated.32 Dyspnea and cough are the most common symptoms, and imaging shows interstitial fibrosis which can be progressive. It can eventually lead to reduced diffusion capacity, lung volume, and compliance.33
Clinicians have long recognized that radiation can accelerate coronary artery disease. It is more recently being recognized, however, that it can lead to other cardiovascular sequelae, such as valvular disease, restrictive pericarditis, systolic and diastolic dysfunction, and conduction abnormalities.34 Patients that had radiation for a left-sided breast cancer are at higher risk of cardiac mortality than those with right-sided breast cancer.35,36 Radiation can also increase the risk of cardiomyopathy associated with anthracyclines (described below under systemic therapy). Patients who have had neck irradiation are at increased risk of stroke,37 and abdominal radiation can lead to renovascular hypertension. Newer techniques designed to minimize these effects have decreased the risk for patients in recent years.38 In addition to being aware of these problems, optimization of modifiable risk factors such as smoking and lipid levels should be encouraged.
Radiation fields that include elements of the gastrointestinal tract can cause scarring and strictures. These most commonly occur in the small bowel, but they can also occur in other areas like the esophagus. Strictures develop as a late effect and present with obstructive symptoms. Therefore, like adhesions, they can be confused clinically with possible cancer recurrence. It is important to recognize that radiation to the spleen can render patients functionally asplenic, with all the same implications for infectious risk as with surgical removal.
Pelvic radiation can cause long-term radiation proctitis in a minority of patients. Analogous to the symptoms of a bladder infection, the inflamed rectum seeks to immediately discharge any small amount of stool that enters it. As a result, these patients can have severe fecal urgency and frequency, with each movement consisting of a disappointingly small amount of stool. Antispasmodics like Levsin or Anusol suppositories can help, and symptoms usually improve over the course of a couple of years. However, some patients with persistent debilitating symptoms eventually elect colostomy.
The bladder can be scarred from radiation, resulting in persistent irritative symptoms or decreased capacity. These complications can actually sometimes worsen with time.39 Medications for urge incontinence like oxybutynin or tolterodine may be helpful. Brachytherapy, increasingly used in early stage prostate cancer, is less likely to cause bladder problems than is external beam radiation. Radiotherapy can also leave the vagina dry and scarred, requiring vaginal lubricants and dilatation procedures to ameliorate.
Pelvic radiation can damage fertility. Primary or adjuvant radiation for cancers of the pelvis will render most women infertile, even if ovaripexy (surgically moving the ovaries out of the radiation field) is performed, likely due to the scatter of radiation outside of the intended field.40 Unfortunately, there is often insufficient time to stimulate and harvest ova prior to therapy. Radiation doses to the ovaries as low as 20 Gy induces premature menopause in women under 40 years, and as little as 6 Gy will induce ovarian failure in women between 40 and 50 years.41 Male testicles are even more sensitive to radiation. Spermatogenesis will be affected with doses as low as 0.2 Gy, and may be permanent above 1.2 Gy.42 Gonadal shielding can be somewhat effective but cannot be relied upon to preserve fertility.
Pelvic radiation can damage the autonomic nerves responsible for erection. As a result, erectile dysfunction is common after radiation for prostate, rectal, and anal cancers.43 Improvement often occurs over the first year after treatment but then stabilizes. As important as evaluating the degree of erectile dysfunction is evaluating how much this bothers the patient; some patients are untroubled by complete loss of function while others are extremely distressed by even relatively subtle changes in sexual function such as retrograde ejaculation. Erectile dysfunction can be managed with oral agents like sildenafil, tadalafil, and vardenafil, but sometimes requires external suction devices, penile injection therapy, or implantation ofpenile prostheses. Referral to a urologist specializing in male sexual health can be very helpful.
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