Survivorship: Late Effects After Radiation Treatment for Pancreatic/Biliary Cancer

Side Effects After Cancer Treatment

There are different types of side effects you may have during or after cancer treatment.

• Short-term: side effects that happen while you are on treatment and end shortly after.
• Long-term: side effects that happen while you are on treatment and last for months to years. Some of these side effects will not go away. Example: neuropathy.
• Late effects: side effects that happen months to years after you have finished treatment. Example: scar tissue forming and causing health issues.

This article focuses on the late effects of radiation treatment for pancreatic/biliary cancer.

Late effects can be health issues or psychological, emotional, and practical challenges.

Late Effects After Radiation for Pancreatic/Biliary Cancer

Side effects from radiation treatment affect the area of the body in the treatment field. The treatment field includes the cancer and in some cases nearby healthy tissue. How radiation is given has changed over the years, leading to a lower risk of late effects. Talk with your radiation oncologist to find out which areas were in your treatment field.

Late effects of radiation treatment for pancreatic/biliary cancer include:

Bowel Problems

The bowel is sensitive to the effects of radiation. If the rectum, colon, or small bowel are in the treatment area, late effects can include:

• Scarring and strictures: Damage to the tissue of the bowel can lead to scar tissue. This scar tissue can lead to a stricture (narrowing of a part of the body) and cause a bowel obstruction. A bowel obstruction is when the normal movement of stool through the bowel is blocked. Call your provider if you are having any abdominal (belly) pain, constipation, vomiting, weight loss, or bloating. If you have severe abdominal pain with vomiting and constipation you should be seen by a provider right away.
• Ulceration and bleeding: Ulceration and bleeding can be caused by damage to the bowel tissues. Report any dark or black colored stools, bright red blood in your stools, in the toilet water, or on toilet paper to your provider right away. You may need testing with a colonoscopy to find the area that is bleeding.
• Chronic diarrhea: Report diarrhea that is causing weight loss to your care team. Medications to lessen diarrhea may be helpful. You may benefit from seeing a gastroenterologist (GI Doctor). You should also meet with a registered dietitian (RD) who can look at your diet and give you ideas to lessen diarrhea and maintain or gain weight.
• Fistula formation: A fistula is a connection (hole) between two parts of the body that are not normally connected. A fistula can form between the bowel and bladder, the bowel and female reproductive system (uterus/ vagina), or the bowel and the skin. If you have urine, feces, or blood coming out of any opening that it should not be, you should call your provider right away.
• Colon cancer: Radiation to the bowel can lead to colon cancer years after treatment.
  • If you were treated before the age of 18, you should begin colon cancer screening with colonoscopy or DNA stool testing 5 years after treatment or at age 30, whichever is later.
  • You may need earlier screening if you have irritable bowel disease, chronic diarrhea or bleeding, ulcerative colitis, colon cancer in your family, or previous gastrointestinal cancers or polyps.

Bladder Problems

Radiation to the pelvic area can cause late effects to the bladder including:

• Scar tissue: Can develop leading to a decrease in how much urine your bladder can hold.
• Hemorrhagic Cystitis: Inflammation inside of the bladder that can lead to bleeding. Signs of hemorrhagic cystitis include urinary frequency (needing to pee often) and urgency (needing to go quickly), blood in your urine, or pain when peeing. If you have any of these symptoms, tell your provider right away.
• Urinary Tract Infections: Radiation to the bladder may also make you more prone to urinary tract infections. This type of infection can be treated with antibiotics. If you have burning when urinating (peeing), urinary frequency (needing to go often), or see blood in your urine, call your provider.
• Bladder Cancer: Radiation to the bladder can increase your risk of developing bladder cancer. Signs include blood in the urine, urinary frequency (going often) and urgency (needing to go right away), urinating at night, and incontinence (loss of bladder control). Tell your provider if you have any of these symptoms.

These late effects all have similar signs. You may need urine tests or cystoscopy (inserting a small tube with a camera into the bladder) to figure out what is causing your issues. It is best to not drink alcohol or  smoke, because these irritate the bladder and increase your risk of bladder cancer.

Kidney Damage

When the radiation field includes the kidney(s), renal insufficiency (decreased kidney function) and hypertension (high blood pressure) can happen.

• Your risk for kidney problems after radiation is higher if you have diabetes, only have one kidney, have a history of high blood pressure, or if you have taken other medications that can cause kidney damage.
• Have your blood pressure checked at your annual check-ups. If needed, high blood pressure may be treated with medications.
• Your team will also watch your kidney function through blood testing (basic metabolic panel) and urine tests (urinalysis).
• Eating a balanced, healthy diet can support healthy blood sugar levels and help protect your kidneys from further damage.

Liver Damage

Radiation to the liver may be needed for cancer treatment but can cause damage to areas of the liver that are healthy.

• How your liver is working will be measured by a blood test (called LFTs) before and after treatment.
•  Avoid drinking alcohol; it can raise the risk of liver damage.
•  If you have yellowing of the eyes and/or skin (jaundice), pain or swelling in your belly, itchy skin, or dark-colored urine, call your care team. You may need to see a gastroenterologist (GI Doctor) for further evaluation.

Stomach Problems

Indigestion and heartburn can be late effects of radiation that included the stomach. You may be at risk for gastritis (irritation of the stomach wall), ulcers, and gastric outlet obstruction.

• Signs include new or worsening belly pain, frequent vomiting or heartburn, or blood in your vomit or stool. Call your care team right away if you have any of these problems.
• You may need to see a gastroenterologist (GI Doctor) to find the cause.
• If you have heartburn, your care team may prescribe medicine to lessen the amount of acid being made or to coat/protect your stomach.

Damage to the Spleen

The spleen is an organ in the upper abdomen (belly) that works like a filter, taking out bacteria and dead red blood cells from the bloodstream. Radiation to the spleen can cause it to not function. Damage to the spleen can mean a higher risk for certain infections caused by encapsulated bacteria (bacteria covered by a capsule). Streptococcus pneumoniae and Haemophilus influenzae type b are the most common. If your spleen doesn’t work due to radiation, it is important to know:

• An infection can quickly cause sepsis (life-threatening infection) and needs to be treated with antibiotics right away. In some cases, providers may give you antibiotics to have on hand to take at the first sign of infection, even before being seen by the healthcare team. You need to report a fever (100.4° F/ 38.0°C or higher) or any sign of infection to your team right away. If you can’t get in touch with your provider, go to an emergency room right away. You should tell any provider you see that you do not have a spleen. 
• You should wear a medic alert bracelet noting that you do not have a working spleen (asplenia). It is important for those involved in your care to know. 
• Have an annual flu vaccine as well as pneumococcal, Haemophilus influenza type b (Hib), meningococcal, and hepatitis vaccines (per CDC guidelines). Talk to your provider to see if you need other vaccines, including Tdap, zoster, HPV, MMR, and varicella. 
• If you are bitten by a dog, cat, or rodent, antibiotics are needed to prevent infection from Capnocytophaga canimorsus bacteria. 

If you are traveling to an area with malaria, take medication to prevent infection with malaria and use a mosquito repellent. If you are traveling to or living near Cape Cod or Nantucket Island in Massachusetts, Southern New England, and the Hudson Valley in New York, you may be more likely to get Babesia (an infection) caused by deer ticks. If you notice you have been bitten by a tick in this area, please contact your healthcare provider as soon as possible because this can cause a serious infection.

Spinal Cord Damage

The spinal cord may be in the field of radiation treatment. This can cause damage to the nerves in the spine.

• Signs of this can be loss of strength, feeling, or coordination of the arms or legs, paralysis (not being able to move), or problems with bowel or bladder control. Sometimes nerve damage can cause a feeling of electric shock spreading down the arms or legs.
• If you develop any of these, you may need imaging tests or to be seen by a neurologist for more testing.

Radiation can also damage the bones of the spine. This can make you shorter or have a change in the curve of your spine. Radiation to these bones can also put them at risk for fracture (breaks). If you have any new back pain, call your provider right away. You may need x-rays or other imaging tests.

Skin Changes

Radiation can lead to changes in the skin that don’t go away.

• You may find new scars or notice changes in the color or texture of your skin. Radiation can also change the color and texture of your hair or can cause hair loss in the treated area. Your hair might never grow back.
• The soft tissue and muscles under the skin can develop scarring and/or shrinkage, which can lead to a loss of flexibility and movement or chronic swelling in this area.
• You may get chronic or recurring ulcers of the skin in the area treated. Blood vessels of the skin may be dilated (larger) and more visible, but this is not harmful.
• If the skin feels tight or sore, you can put vitamin E on it.
• Use fragrance and dye-free soaps and moisturizers if your skin is sensitive after radiation.
• After radiation, the skin in the treated area is more sensitive to sunlight. This sensitivity will last for your lifetime. Practice sun safety, use plenty of sunscreen, wear a wide-brimmed hat, and keep skin in the treated area covered with clothing. Try not to be out in the sun between the hours of 10 am to 4 pm when it is the strongest.

If you notice any new or worsening skin issues, you should call your provider for an assessment.

Managing Late Effects

Tell your care team about any new or worsening symptoms. Some side effects need care from healthcare providers who specialize in working with cancer survivors. There are Interdisciplinary survivorship clinics at many cancer centers. If there is not a survivorship clinic near you, talk with your oncology care team about support for managing your late effects.

After treatment, talk with your oncology team about getting a survivorship care plan, which can help you in your transition to survivorship and learn about life after cancer. You can build your own survivorship care plan using the OncoLife Survivorship Care Plan.