In the wake of a cancer diagnosis, women will find themselves facing many questions about the journey that lies ahead. Among the decisions to be made are those related to treatment options. When it comes to making these important choices, women can empower themselves by becoming educated about the possible impact that each potential treatment may have on her quality of life.
For women diagnosed with some forms of cancer, treatment can affect pelvic health, resulting in side effects that have an impact on function and quality of life. The female pelvis houses and supports the reproductive organs and portions of the urinary and gastrointestinal tracts. The uterus, ovaries, fallopian tubes, vagina, bladder, and rectum—all are in the pelvis.
The support system in the pelvis includes a number of muscles and ligaments that serve as a hammock to hold these organs in place.
The primary cancer treatments that can affect the pelvis include radiation therapy and hormonal therapy. In addition, some chemotherapeutic agents can affect the bladder, and some treatments for breast cancer may also have an impact on the function of the female pelvis.
Treatment of malignancies of the uterus, cervix, vagina, and ovaries may involve radiation. Ionizing radiation is toxic to cancer cells and normal cells alike. Fortunately, today’s techniques for the delivery of radiation to specific organs are so targeted that side effects to normal tissues are minimized.
There are two ways to deliver radioactivity to cancerous tissues: external beam therapy, wherein a machine outside the body delivers external beam radiation to the targeted organ, and brachytherapy, wherein an implant composed of radioactive material is placed in or adjacent to the cancerous tissue.
In external beam therapy, the skin and all other tissues between the machine and the targeted organ are affected to some degree. Skin changes can include redness, blistering, and peeling. Any muscles and ligaments in the path of the radiation beam can undergo fibrous changes resulting in a loss of elasticity. These less-pliable tissues can cause a number of problems, including urinary or fecal incontinence, pelvic organ prolapse, and vaginal, urethral, and anal stenosis. In years past the toxic effects of radiation to normal tissues adjacent to cancer were widespread. Today the use of imaging and dosimetry techniques significantly limits radiation exposure of tissues other than the tumor. It is important to realize, however, that the effect of radiation on cells is a lasting one, and patients who have undergone radiation therapy in the past may experience problems indefinitely.
Brachytherapy techniques have likewise advanced, with the goal of delivering more-intense radiation to cancer cells and less to the surrounding tissues. The localization of radiation in affected tissues suggests fewer effects on adjacent tissues, but it is not possible to prevent some “scatter” of the radioactive beam. Radioactive implants are placed adjacent to the cancerous tissue, and the patient frequently must be in isolation for a few days so that exposure of others is minimized.
Effects of Radiation on Tissue
Ionizing radiation causes cellular changes that result in “oxidative stress.” This means that the volume of free radicals in the cells increases, and these toxic free radicals damage intracellular processes. Radiation can also result in breaks in the DNA chain, and this phenomenon is partially responsible for the anti-tumor effects. Acute radiation exposure affects rapidly dividing cells, such as tumor cells, and those in the gastrointestinal tract. This phenomenon is responsible for the nausea and the vomiting that frequently occur after acute radiation poisoning. This discussion divides radiation side effects on normal tissues into three categories: fibrosis, inflammation, and radiation cystitis.
Fibrosis. Replacement of normally soft, pliable structures can result in a narrowing of structures or abnormal connections between body cavities. An example of the former type of change can be seen in vaginal stenosis, or narrowing, that occurs after brachytherapy for vaginal, cervical, or uterine cancer. Normal tissues are replaced with fibrotic ones that, over time, can narrow the vaginal opening. A decrease in normal vaginal lubrication can also occur as glandular structures are destroyed. These conditions can make sexual activity uncomfortable and, in extreme cases, painful. Most radiation oncologists recommend that women self-dilate with vaginal dilators, either at the onset or completion of treatment. If a woman is able to be sexually active, intercourse itself may be helpful. For those women in whom estrogen is not contraindicated, the use of topical estrogen and/or oral hormone replacement therapy may provide significant relief.
Anal and urethral stenosis may occur, as well. Typically, a physician treats these conditions with dilations. In select cases estrogen treatment may be of considerable help.
In generalized pelvic fibrosis, therapies such as acupuncture and pelvic physical therapy may be useful. Myofascial massage with trigger-point release is a particular type of physical therapy that can be done by specially trained therapists.
Abnormal connections between body cavities are called fistulas. The scarring that can occur after radiation can lead to fistulas between the rectum and the vagina or the bladder and the vagina. Rarely, an abnormal connection between the small bowel and the vagina occurs. Fistulas are uncommon but serious consequences of radiation treatment for cancer. Fecal and urinary incontinence into the vagina is a very distressing consequence of fistulas and must almost always be dealt with surgically.
Radiation scientists and physicians are actively investigating products that will minimize radiation damage to non-cancerous tissues. There are several protective skin creams available as well as a systemic drug called Ethyol® (aminothiol amifostine). Ethyol neutralizes free radicals and detoxifies the breakdown products created by radiation and some chemotherapeutic drugs and is available for intravenous injection.
Inflammation. Radiation proctitis (inflammation of the rectum) and cystitis (urinary bladder inflammation) may occur immediately following radiation therapy or years later and may be intermittent or continuous. Radiation proctitis causes diarrhea, which may be bloody and painful, and a strong urge to defecate. It may be accompanied by intestinal blockage or fistula, as the rectal lining is replaced with abnormal tissues. In most series, the incident of proctitis ranges from 2 to 20 percent. Treatment is supportive initially, including hydration, nonsteroidal anti-inflammatory agents, and antioxidants. Blood transfusions may be necessary. Hyperbaric treatment has been shown to reduce the symptoms of radiation proctitis, and invasive treatments such as formalin instillation, or coagulation of bleeding points, is reserved for the most severe cases. Surgery is advisable only when all other treatments have failed.
Radiation cystitis. Bladder responses to radiation injury include urinary frequency, urgency, painful urination, increased bladder infections, and, in the most severe form, hemorrhage. Urinary frequency and urgency can be treated with medications for overactive bladder, and bladder infections can be prevented with low-dose antibiotics. Analgesics for the bladder, such as nonsteroidal anti-inflammatory agents, and Pyridium® (phenazopyridine) are used to manage painful urination. Elmiron® (pentosan polysulfate) has been successfully used in cases of severe bladder pain. Hemorrhagic radiation cystitis almost always occurs as a delayed response to treatment and can be very difficult to treat. Fortunately, the incidence of hemorrhagic cystitis is less than 5 percent. Preventive agents include the antioxidant orgotein, conjugated oral estrogens, and the blood thinner Trental® (pentoxifylline). If blood loss is severe, intravenous hydration and blood transfusions may be needed. Drugs that can be instilled into the bladder include formalin, alum (aluminum potassium sulfate), and Amicar® (aminocaproic acid). In severe cases surgery may be required.
The two chemotherapeutic drugs that can cause bladder problems are Cytoxan® (cyclophosphamide) and Ifex® (ifosfamide). They are used to treat lymphoma and leukemia as well as solid tumors such as brain, testes, breast, bone, lung, cervical, and ovarian cancer. Both drugs can cause hemorrhagic cystitis, and Cytoxan is known to cause bladder cancer. Mesnex® (mesna) is given preventively to minimize the risk of hemorrhagic cystitis when these two chemotherapeutic drugs are used. It is highly effective but must be given before hemorrhagic cystitis occurs.
Because some forms of cancer are hormonally dependent, therapy for these malignancies may include estrogen deprivation. Breast cancer is often estrogen dependent, and some uterine and ovarian cancers are also treated with anti-estrogen drugs. Tamoxifen is the most commonly used anti-estrogen, and its side effects can include hot flashes, irregular menses, vaginal dryness, pelvic pain, decreased libido, and urinary frequency and urgency. Some women also experience an increased incidence of bladder infections. A tendency toward blood clots and an increased risk of endometrial cancer are also seen with anti-estrogen therapy. To combat these side effects, some physicians recommend dietary changes, such as limiting or eliminating caffeine, alcohol, and spicy foods. Smoking cessation, aerobic exercise, stress reduction, vitamin E oil, acupuncture, and omega-3 fatty acids are also helpful in some cases.
The goal of all cancer treatment is cure. Radiation treatment and some chemotherapies and hormonal therapies can cause significant side effects. Solutions are available though, and a woman diagnosed with cancer should familiarize herself with them. Then treatment should be individualized and discussed with her oncologist for maximum relief. Most often these side effects are transient and manageable.
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