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Nisitha Sengottuvel
Cancer incites fear because of how sick it can make you and how deadly it can be. Even when cancer treatments succeed in curing a patient, the patient is still left with the aftermath of the cancer treatments.
A good example of a cancer that has relatively good prognosis is anal cancer. Anal cancer is a relatively rare cancer, affecting about 10,000 people each year in the United States. This is only about 0.5% of all new cancer cases in the U.S. For context, breast cancer, which is the most common cancer in the U.S., affects almost 300,000 new people each year. Less than 2,000 people died from anal cancer last year, suggesting good prognosis, with a 5-year survival rate of 70.4%. These statistics make anal cancer a prime candidate to study the effects of treatment on patients even after their cancer is no longer a major threat to their life.
Dr. Emma Holliday’s group at MD Anderson at the University of Texas studied the effects of pelvic chemoradiation (CRT), which is the main treatment to cure anal cancer that hasn’t spread to other parts of the body. Chemoradiation is having chemotherapy and radiation together. The group surveyed 248 patients who had anal cancer and were treated with CRT. The majority of the respondents were female and less than a quarter were male. Almost 95% considered themselves White and about 75% of the respondents were patients who had early stage anal cancer. The disparities in response by sex is moderately consistent with demographics of anal cancer since women are almost twice as likely as men to be diagnosed with anal cancer. The racial response is not consistent with demographics since blacks and whites are equally likely to get diagnosed with anal cancer. However, sex more than race has been shown to affect the likelihood of getting anal cancer. The goals of the study were to understand the changes in quality of life in long term anal cancer survivors.
In their quality of life questionnaire, Dr. Holliday’s team included questions regarding fatigue, pain, nausea, anxiety, sleep quality, and mood. The study found that the majority of patients do not report issues with energy, pain, or nausea. However, as we get into more emotional symptoms, such as anxiety about their health, sleep quality, enjoyment or feelings of content, the number of patients who report serious issues drastically increase.
The team also inquired about “late toxicities” which are side effects of treatments that occur months to years after the treatment has ended. Many patients described issues with bowels, urinary tract, and sexual function. These findings are especially important because radiation therapy, while non-invasive and powerful as a treatment option, has been known to lead to scarring, normal tissue disruption, and increased risk for future cancers over time.
For example, one patient reported: “Did not realize how life would revolve around my bowel movements. Must schedule all activity as to when I feel safe to leave home/bathroom.” Many patients, whenever they go anywhere, have to use a technique called bathroom mapping. That means wherever they go, the first piece of information they gather is knowing where the closest bathrooms are that they have access to, whether it be their child’s dance recital, a trip to the mall, or visiting their doctor’s office. Many of us don’t think about this at all as we go about our days, but for patients who have such toxicities, a large part of their mental energy can be spent on making sure they don’t have an accident. Similar to bowel toxicity, another patient commented on the urinary toxicity of the treatment by saying “I have to frequently urinate, I consistently drink water throughout the day. It gets to be very annoying as most days I will urinate about 3 times per hour and more depending on my water intake.” Constantly having to interrupt their day to use the restroom every 20 minutes significantly disrupts a patient’s quality of life even after their cancer is in remission.
Other patients comment on sexual side effects, fears, and the lack of education about what can and cannot be done after pelvic CRT treatments. A patient mentioned: “I am a gay man and I like to be on the receiving end of sexual penetration. There was no information given to me on when or if I could ever do that again after radiation treatment.” Sexual side effects have varying degrees of severity in impacting patient lives but can play a tremendous role in a patient’s relationship and well being.
It is important to remember that nearly every cancer treatment comes with an array of side effects. While radiation therapy tends to be thought of as modest in terms of side effects when compared with systemic chemotherapy, CRT administers chemotherapy and radiation in combination. Therefore, this study makes an important step towards understanding the long term side effects pelvic CRT may have on patients’ lives.
This isn’t meant to discourage patients from undergoing CRT. In fact, CRT revolutionized anal cancer treatment. Before CRT, surgery was used to cure anal cancer. This required cutting through a muscle called the anal sphincter which is what allows control of when we pass a bowel movement. Cutting through the sphincter required the use of a life-long ostomy bag to empty bowels. CRT allowed a curative modality of treatment that could bypass the loss of bowel control.
While the benefits of CRT are obvious to health care providers, the long term effects of this therapy specifically with patient quality of life is not trivial. Over half of patients in this study felt that there was insufficient upfront information about CRT and reported that they “had no idea that they would have lifelong ramifications after radiation.” The goal of Dr. Holliday’s research is to highlight the level of education needed to prepare patients for these long term side effects and the monitoring physicians need to do while using CRT to treat patients.
Edited by Michael Marand
References
- Corrigan, Kelsey L, et al. “Patient-Reported Outcomes after Chemoradiation in Patients with Anal Cancer: A Qualitative Analysis.” Advances in Radiation Oncology, U.S. National Library of Medicine, 30 Apr. 2022, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9157211/.
- SEER. “Cancer of the Anus, Anal Canal, and Anorectum – Cancer Stat Facts.” SEER, NCI, seer.cancer.gov/statfacts/html/anus.html. Accessed 30 Aug. 2023.
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