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This is the fourth and final article in a series on the gastrointestinal (GI) symptoms of pelvic radiation disease (PRD). Published studies and patient reports suggest that health professionals lack of awareness of PRD. This professional awareness can be improved with third-sector advocacy and provision of simple screening tools, such as Assessment of Late Effects of Radiotherapy-Bowel (ALERT-B). In South Wales, patients with suspected PRD are referred to a PRD specialist nurse in either a gastroenterology clinic or a gynae-oncology follow-up clinic. These two nurse-led clinics demonstrate different ways to identify, assess and manage patients with late GI effects of PRD. Data from these clinics suggest that systematic investigations based on appropriate guidance are effective in identifying these symptoms, many of which can be managed or treated. The rising incidence of PRD and lack of specialist services suggests that the NHS needs to provide more funding to care for patients beyond the end of their cancer treatment.

Anthracycline chemotherapy administered via a peripheral cannula results in severe anthracycline chemotherapy-induced phlebitis (ACIP) in about 20-30% of patients. Administering chemotherapy via a central venous catheter (CVC) prevents ACIP. However, CVCs are associated with an increased risk of thrombosis and sepsis. Our aim was to identify risk factors associated with severe ACIP and to provide evidence about the individual risk of developing symptoms.A prospective observational study of 263 women with breast cancer receiving peripheral administration of anthracycline chemotherapy at a UK cancer centre was conducted between May 2016 and January 2018. Data were collected at baseline and every 3 weeks following each chemotherapy treatment, using both healthcare professional- and participant-reported symptom assessments.After three cycles of chemotherapy, 27% of participants experienced severe ACIP. Factors associated with symptom severity were identified as: arm used for chemotherapy administration, epirubicin dose, age, pre-existing hypertension, comorbidity, ethnic group and pain during chemotherapy administration. The sequence of arm used for chemotherapy administration was the single most significant factor (P0.001). When alternating arms were used no other risk factor was influential. Where alternating arms were not used, younger age and higher dose were associated with higher-grade symptoms, with age being more influential than dose. The cumulative effect of increasing symptom severity with repeated cycles was also identified (P0.001).It is recommended that a CVC is not routinely required for women with breast cancer who have not undergone an axillary node clearance and receive chemotherapy in alternate arms. The need for a CVC for women who are planned to receive all anthracycline chemotherapy cycles in the same arm should be assessed in the light of peripheral venous access assessment and the key risk factors of age, dose and number of cycles.

Aims Pelvic radiotherapy adds significantly to the curative treatment of many pelvic malignancies. However, this cure comes at a cost for many patients, where late bowel toxicities, such as faecal incontinence, urgency and diarrhoea, adversely affect quality of life. Despite the implementation of advanced radiotherapy techniques in many centres, there are deficiencies in our knowledge of how to make best use of these techniques to minimise these late toxicities, with dose–volume constraints specifically for late effects needing definition. The aims of this study were to establish dose–volume predictors for patient-reported late bowel toxicities and derive constraints for clinical use to reduce the risk of these toxicities. Materials and methods All radiotherapy patients treated in our institution between 2012 and 2014 for gynaecological and urological cancers (bladder, prostate where pelvic nodes are treated) were identified. Patients were sent patient-reported toxicity questionnaires at 12 and 24 months after treatment. Planning computed tomography scans were retrospectively contoured with different definitions of bowel as organs at risk (OARs). Dose–volume data for each OAR were collected and predictors of these toxicities found using multivariate analysis. For those dose–volume predictors found to be significant on multivariate analysis, statistically significant and clinically relevant dose–volume constraints were derived. Furthermore, data collected were used to validate constraints from published studies. Results Faecal urgency, incontinence and diarrhoea rates were found in 52, 23.5 and 18.7% of the 203 patients included at 12 months following radiotherapy. Dose–volume parameters for sigmoid colon and large bowel were significant for these toxicities, and constraints for these OARs were derived, which are promising. A previously published constraint for bowel loops was validated with our data. Conclusions The sigmoid colon and large bowel are important OARs for the development of faecal urgency, incontinence and diarrhoea. Promising constraints for these OARs were derived, which require further validation before prospective clinical use.

Introduction/Background Patients who receive pelvic radiotherapy may develop gastrointestinal (GI) symptoms which impact on their quality of life (QoL). A GI Specialist Nurse (CNS) has attended our gynaecological follow up clinic since January 2018. This is a new service in addition to a Late GI Effects Clinic based in the local Gastroenterology Department. Methodology From January 2018 to March 2019, 185 patients had received pelvic radiotherapy. 35% (65) of patients with GI symptoms were identified using the ALERT-B (Taylor et al 2016), a quick and simple screening tool. Those who answered yes to any question were seen by the GI CNS and investigated using the ‘Guidance: The Practical Management of Gastrointestinal Symptoms of Pelvic Radiation Disease’ (Andreyev et al 2014). Results Some of the 65 patients had also previously been investigated in the main Late Effects Clinic. The most common findings are shown in table 1 below. Many patients reported more than one symptom. Table 2 below shows the most common abnormal investigation results It was also identified that 22% (14) of patients required specialist dietary advice including certain carbohydrate avoidance, low fat and/or a low FODMAP diet. Conclusion Late GI effects are not uncommon following pelvic radiotherapy and can have a significant impact on the patients QoL. A GI Late Effects CNS in a gynaeoncology follow-up clinic quickly identifies, investigates and treats affected patients thus avoiding further clinic referral and speeding up the patients recovery. Disclosure Nothing to disclose

OBJECTIVE To establish whether using alternating arms for peripheral intravenous epirubicin administration affects the severity or duration of epirubicin-induced phlebitis. METHODS An observational study of women with breast cancer (n = 237) in a UK Cancer Centre. Data were analysed after receiving three treatment cycles according to the arm used for epirubicin administration: same, alternating or mixed arm (two consecutive cycles in one arm and one in the alternate arm). Phlebitis severity was graded by clinical staff after each treatment; participants also self-reported symptoms during treatment and for up to 6 months after. RESULTS The alternating arm group experienced significantly less severe symptoms than the other arm use groups, 6% (4 of 64) compared with 34% (p

Background\ud\udAdvanced pelvic radiotherapy techniques aim to reduce late bowel toxicity which can severely impact the lives of pelvic cancer survivors. Although advanced techniques have been largely adopted worldwide, to achieve their aim, knowledge of which dose-volume parameters of which components of bowel predict late bowel toxicity is crucial to make best use of these techniques.\ud\udThe rectum is an extensively studied organ at risk (OAR), and dose-volume predictors of late toxicity for the rectum are established. However, for other components of bowel, there is a significant paucity of knowledge. The Quantitative Analyses of Normal Tissue Effects in the Clinic (QUANTEC) reviews recommend dose-volume constraints for acute bowel toxicity for peritoneal cavity and bowel loops, although no constraints are recommended for late toxicity, despite its relevance to our increasing number of survivors. This systematic review aims to examine the published literature to seek dose-volume predictors and constraints of late bowel toxicity for OARs (apart from the rectum) for use in clinical practice.\ud\ud\udMethods\ud\udA systematic literature search was performed using Medline, Embase, Cochrane Library, Web of Science, Cinahl and Pubmed. Studies were screened and included according to specific pre-defined criteria. Included studies were assessed for quality against QUANTEC-defined assessment criteria.\ud\ud\udResults\ud\ud101 studies were screened to find 30 relevant studies. Eight studies related to whole bowel, 11 to small bowel, and 21 to large bowel (including 16 of the anal canal). The anal canal is an important OAR for the development of late toxicity, and we recommend an anal canal Dmean

Purpose To assess the clinical outcomes after concurrent cisplatin chemotherapy and radiotherapy (RT) followed by high-dose-rate brachytherapy for locally advanced carcinoma of the cervix and perform a multivariate analysis of the prognostic factors. Methods and Materials The outcomes were analyzed for all women treated between 1999 and 2004 with concurrent cisplatin chemotherapy and RT followed by high-dose-rate brachytherapy. Kaplan-Meier analysis was used for overall survival (OS), local control (LC), and distant control (DC). The Cox proportional hazards model was used to perform multivariate analysis of the prognostic variables. Results The standard regimen comprised whole pelvic external RT 45 Gy in 25 fractions with concurrent weekly cisplatin 40 mg/m 2 , followed by four high-dose-rate brachytherapy insertions of 6 Gy. Patients with radiologically enlarged para-aortic lymph nodes underwent extended-field RT. Of 92 patients, the OS rate was 72% at 2 years and 55% at 5 years. The LC rate was 76% at 2 years and 67% at 5 years. The DC rate was 68% at 2 years and 48% at 5 years. The most important prognostic factor for OS, LC, and DC was the pretreatment hemoglobin. For OS, the tumor size and the presence of enlarged lymph nodes were also important. For LC, the number of brachytherapy insertions was important; and for DC, the number of chemotherapy treatments was important. Of the patients, 4% experienced late Grade 3 or 4 toxicity. Conclusion The results of our study have shown that the regimen is effective, with acceptable long-term side effects. In this cohort, the most important prognostic factor was the pretreatment hemoglobin level, a disease-related factor. However, more effective systemic treatments are needed.

Introduction It is important to understand the basic techniques of radiotherapy planning because these will help when developing complex plans. These techniques, which are taught at the First FRCR level (Royal College of Radiologists), are used by the treatment centre's Physics Department for checking the validity of calculations before they are applied to patients, and anyone interpreting plans will need to be familiar with them to know whether it is worth adjusting treatment plans during review. Advanced radiotherapy techniques will be discussed in Chapter 6. There are several useful reviews of radiotherapy physics in the literature. One by Shiu and Mellenberg (2001) includes sections on isodose planning. Another, by Purdy (2000), provides a perspective on future directions in 3D treatment planning. Radiotherapy is a rapidly developing field and it is important to ensure that new methods satisfy safety and effectiveness requirements before being adopted as routine treatments. This chapter will deal with the general principles of developing isodose plans that are suitable for treatment and will use specific examples to highlight particular points. It will focus mainly on external beam radiotherapy with megavoltage photons; there will be shorter sections on the use of electrons and brachytherapy. Some aspects of radiotherapy planning using lower energy (kilovoltage) photons will be discussed in Chapter 36. The use of unsealed radiation sources for prostate, thyroid and childhood cancers are discussed in Chapters 22, 38 and 40, respectively. Treatment planning overview Radiotherapy planning can be divided into stages as follows. • Patient preparation, position and immobilisation. • Localisation method (e.g. orthogonal films, CT scanning, and image co-registration). • Definition of target volumes and organs at risk. • Radiotherapy technique, including beam arrangements, beam energy, size and shape, weighting, wedges and production of isodose plan. • Prescription, including number of phases, dose, energy and fractionation. • Verification (i.e. checking the geometrical set-up of the treatment). This can take place before treatment in the simulator or CT simulator, and/or during treatment using portal imaging. Quality assurance (QA) is essential and it is of paramount importance for each member of the planning team to be familiar with the overall process. Patient position and immobilisation For radiotherapy to be effective it must be delivered accurately, and it is important to understand the methods of immobilisation and the inevitable uncertainties in the delivery of treatment.

Aims In small cell lung cancer (SCLC), consolidation thoracic irradiation (CTI) increases 3-year absolute survival by 5.4% in patients with limited disease and a complete response to chemotherapy. Early concurrent thoracic radiotherapy has been shown to improve local control and prolong survival compared with CTI in some trials. The standard management of patients with SCLC in southeast Wales is CTI in individuals with limited disease and a complete response to chemotherapy. A review of patients with SCLC was carried out to establish whether survival locally is comparable with that reported in published studies, and if patients given CTI have survival comparable with that reported in studies where early concurrent thoracic radiotherapy was used. Materials and methods Between January 2000 and December 2002, 303 patients were registered with SCLC in southeast Wales. One hundred and fifteen (47%) patients had limited disease and 60/115 (52%) received CTI. Results Patients with limited disease receiving CTI had a median survival of 17.7 months (95% confidence interval: 15–27.9 months). The 2- and 5-year survivals were 38 and 13%, respectively. Conclusions These results compare favourably with previously published studies on SCLC. There are no plans to change our current treatment policy for SCLC in southeast Wales.