IGCS 2012 - Vancouver, BC, Canada

Late effects of treatment in gynaecological cancers

Dr Remi Nout – Leiden University Medical Center, Netherlands

Remi, thank you for calling here. It’s great to have the chance to talk with you about late effects of treatment because cancer doctors are very successful these days and in gynaecological cancers some of them are doing really well; things like endometrial cancer have improved a great deal, cervical cancer, of course, can be hugely successful so late effects of treatment are important. What are you covering in your session?

You hit on one of the key points of the session, is that there is an increasing amount of long term survivors out there, especially endometrial cancer in the Western world. There’s really an increasing amount of long term survivors and I think that one of the main messages is that the community should be aware, not only the healthcare providers but also the community physicians, because a lot of the patients aren’t in clinical follow-up anymore because we’re talking about late effects, ten years beyond the diagnosis. People should be aware that these patients have symptoms and signs and are coping with late effects of treatment.

Perhaps I should take some of these diseases one by one because there are late effects from chemotherapy also from your field of study, radiotherapy. Let’s look at endometrial cancer, for example. What are the challenges that are coming up for clinicians in late effects?

Radiotherapy plays an important role in the treatment of endometrial cancer and there is a shift going on in the reduction of the negations for adjuvant radiotherapy and there is also a shift going on from external beam towards brachytherapy. This is all to do with a reduction of the dose of radiotherapy and the area treated so I think we can see a decrease in the future of the amount of treatment related morbidity from radiotherapy in endometrial cancer. But now we see patients that were treated ten years ago so we are still dealing in the community with a lot of patients that have received treatment for this disease and then we’re talking about radiation-induced late effects. This can be, for instance, bowel related symptoms like diarrhoea and faecal leakage, that’s one of the things that came out of our quality of life studies. Also bladder functioning, higher use of incontinence materials, for instance. Those are just a few short items.

OK, but you can’t do very much about the historical damage that has been caused by the treatment that has cured the patient. You can do something about refining the increasingly tailored therapies that are available now.

Of course this is also a balance. We’re trying to improve treatment, that’s very important because that will be the way in the future we hope to reduce the amount of people that suffer from side effects but at the same time we now are confronted with patients that have been treated in the last two decennia because people survive longer and longer and they have been treated in a traditional way. So at the moment healthcare providers now are confronted with late effects from people who were treated a long time ago.

You talked about bowel problems, for example, but what are some of the others?

What I just told is also from the bladder incontinence problems, a higher use of incontinence material. Also we notice in quality of life studies that people indicate that these problems cause them to remain more close to the toilet and can limit in a social role physical functioning. So this really impacts. The endometrial cancer population is of course a different population than, for instance, cervical cancer patients.

Right, cervical cancer, then, is a different case; what are the things that go wrong there?

It’s of course a different population. The endometrial cancer patients are predominantly elderly ladies, post-menopausal, and the cervical population is also consisting of younger people and treatment induces… can cause infertility; treatment can cause an early onset of menopause. If we look at the role of radiotherapy, predominantly in these patients there is also concern about late effects of the vagina, sexual functioning. That’s why we have also a specific focus in the session on the use and new international guidelines on vaginal dilation. Those are just a few examples.

So what are the principle ways that clinicians can mitigate these late effects and minimise their impact?

For now, of course we try to treat patients more conformal but if you look there is quite some research going on on factors that can influence the late effects of treatment. For instance, patients continuing smoking, for instance, which can have a negative effect on their chances of having these problems. And if we look, for instance, at the role of dilation we think as a community that there is a role for dilation in maintaining optimal chance for vaginal patency, sexual functioning.