Prophylaxis of diarrhoea in patients submitted to radiotherapeutic treatment on pelvic district: personal experience

doi:10.1016/S1590-8658(02)80173-6

Digestive and Liver Disease

Volume 34, Supplement 2, September 2002, Pages S84-S86

https://doi.org/10.1016/S1590-8658(02)80173-6 Get rights and content

Abstract

Diarrhoea is a severe side-effect of radiotherapy on the pelvic area. It is due to acute enteric damage. We aimed at determining the ability of a highly concentrated freeze-dried living bacteria compound (VSL/3) to reduce these side-effects in 990 patients receiving radio therapy on the pelvic area. A total of 95 patients received radiotherapy alone and 95 were also administered VSL/3 bags, at doses of one bag three times a day beginning on the first day of the radiotherapy treatment. The same diet was indicated for both groups. All patients were irradiated for 6 to 7 weeks, with Linac X-6 MV or 15 MV through a box multiportal technique with the lower limit of the fields below the obturator foramina, upper limit at L5-S1, lateral limit 1.5 cm beyond the innominate hip. The total radiated dose ranged from 60 to 70 Gy for a daily dose of 180 cGy. Gastroenteric toxicity was rated in WHO degrees. Two patients receiving radiotherapy alone had to discontinue the treatment due to acute enteritis. Toxicity was found in 52 (50.6%) patients with radiotherapy alone vs 36 (30.5%) patients receiving VSL/3. None of them had to discontinue radiotherapy. Toxicity of degrees 3 or 4 was found in 28 patients receiving radiotherapy alone vs 7 with VSL/3. These preliminary data suggest the effectiveness of VSL/3 in preventing the occurrence of diarrhoea in patients submitted to radiotherapy, with a direct and indirect improvement of their quality of life and a good tolerance.

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The efficacy and safety of probiotics for prevention of chemoradiotherapy-induced diarrhea in people with abdominal and pelvic cancer: A systematic review and meta-analysis based on 23 randomized studies
2020, International Journal of Surgery
Citation Excerpt :
By screening the titles and abstracts, 682 of 761 studies were excluded and 79 were selected for further assessment. After reading the full texts of the 79 studies, 56 were excluded, and so a total of 23 studies [24–46] (N = 2570 participants) was included in this meta-analysis. The sample sizes ranged from 24 [35] to 490 patients [26].
We evaluated the efficacy and safety of probiotics for prevention of chemoradiotherapy-induced diarrhea in patients with abdominal or pelvic cancer.
We searched the Cochrane Library, PubMed, EMBASE, Web of Science, Chinese National Knowledge Infrastructure (CNKI), Wanfang, and VIP databases up to August 2019. We also hand searched the citation lists of included studies and previous systematic reviews identified to identify further relevant trials. The primary outcome was the incidence of chemoradiotherapy-induced diarrhea of all grades. The secondary outcomes were improvement of antidiarrheal medication use, stool form (Bristol scale), response rate, and adverse events (AEs). Diarrhea was graded according to the Common Toxicity Criteria system. Two reviewers assessed trial quality and extracted data independently. The included studies were analyzed using Review Manager ver. 5.2.
Twenty-three randomized, placebo-controlled studies (N = 2570 participants) were included in the efficacy assessment. The incidence of all diarrhea (risk ratio [RR] 0.16; 95% confidence interval [CI] 0.51–0.73), grade ≥ 3 diarrhea (RR 0.36; 95% CI 0.18–0.72), and grade ≥ 2 diarrhea (RR 0.65; 95% CI 0.54–0.78), but not that of grade ≤ 2 diarrhea (RR 1.07; 95% CI 0.95–1.21), was significantly reduced in the probiotics compared to the placebo groups. No significant increase in the incidence of AEs was found in the probiotics group, although four studies reported a variety of AEs.
Probiotics prevented chemoradiotherapy-induced diarrhea, particularly high-grade diarrhea. Probiotics rarely cause AEs.
Gastrointestinal cancers: Influence of gut microbiota, probiotics and prebiotics
2014, Cancer Letters
Cancers of the gastrointestinal (GI) tract continue to represent a major health problem, despite progress in therapy. Gut microbiota is a key element related to the genesis of GI cancers, countless papers addressing this burning issue across the world. We provide an updated knowledge of the involvement of gut microbiota in GI tumorigenesis, including its underlying mechanisms. We present also a comprehensive review of the evidence from animal and clinical studies using probiotics and/or prebiotics in the prevention and/or therapy of GI tumours, of GI cancer therapy-related toxicity and of post-operative complications. We summarize the anticarcinogenic mechanisms of these biotherapeutics from in vitro, animal and clinical interventions. More research is required to reveal the interactions of microflora with genetic, epigenetic and immunologic factors, diet and age, before any firm conclusion be drawn. Well-designed, randomized, double blind, placebo-controlled human studies using probiotics and/or prebiotics, with adequate follow-up are necessary in order to formulate directions for prevention and therapy.
Diarrhoea and Pelvic Irradiation: A Neglected Issue
2014, Clinical Oncology
Diarrhoea in irradiated patients: A prospective multicentre observational study
2013, Digestive and Liver Disease
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Therefore, early intervention to prevent or reduce [18,19] acute toxicity may be worthwhile both during treatment and in the long term [20].
To determine the incidence of cancer treatment-induced diarrhoea in patients submitted to irradiation.
Forty-five Italian radiation oncology departments took part in this prospective observational study and a total of 1020 patients were enrolled. The accrual lasted three consecutive weeks; evaluation was based on diary cards filled in daily by patients during radiotherapy and one week after cessation. Diary cards recorded both the onset and intensity of diarrhoea.
A total of 1004 patients were eligible for this analysis. 147/1004 (14.6%) patients had diarrhoea. The median minimum number of daily events was 1 (range 1–7) with a median maximum events of 3 (range 1–23). 82/147 patients (56.2%) had a drug prescription for diarrhoea. In the evaluation of the onset of diarrhoea, in multivariate analysis, we found the following factors to be statistically significant predictors of an increased likelihood of diarrhoea: primitive tumour site, therapeutic purpose and field size.
Patients with abdominal-pelvic cancer, treated with curative purpose and using large field sizes are at high risk of cancer treatment-induced diarrhoea. Diarrhoea was also observed in patients treated at other sites. In this population group there is the need for more stringent monitoring during the delivery of radiation therapy.
A systematic review and meta-analysis of probiotics for the management of radiation induced bowel disease
2013, Clinical Nutrition
Citation Excerpt :
High risk is mainly associated with possible blinding issues, which have not been reported in some studies, and with the studies published only as abstracts. Also, the study by Delia, which indicates a double-blind randomization design, includes three interim reports,35–37 thus creating a high risk for randomization bias. Quality assessment revealed unclear risks because the handling of incomplete outcome data and performance of intention to treat analyses were not always unambiguous, and again because of blinding and randomization issues.
A meta-analysis to estimate the efficacy of probiotics in prevention of radiation-induced bowel disease after pelvic radiotherapy has been performed. Previous attempts have arguably failed to provide a comprehensive analysis of clinical trials and their outcomes.
We searched for studies indexed in Medline, EMBASE, Cochrane Library, and on-line clinical trials registers. There was no language or time limit. Each study was evaluated for methodological quality and outcomes. We identified four outcomes on which to perform meta-analysis: incidence of diarrhoea, loperamide use, watery, and soft stools (Bristol Stool Chart). Odds ratio (OR) was used to compare efficacy, and the pooled OR was estimated using a random effects model; heterogeneity was assessed with Cochran's Q and Higgins I² test. Analyses were performed using Review Manager 5.2.
Ten studies were included in our systematic review, of which six were subjected to meta-analysis to compare probiotics against placebo. Quality assessment showed an unclear risk due to incomplete outcome data and lack of performance of intention-to-treat analysis, while blinding and randomization issues were present in certain studies. Pooled results showed heterogeneity (Cochran's Q: p < 0.05; I²: high). However the pooled OR for the incidence of diarrhoea, synthesized from 6 studies, significantly favoured the use of probiotics over control (OR = 0.44, 95% CI 0.21–0.92). Numerically, but not statistically, probiotics seem to decrease loperamide use (OR = 0.29, 95% CI 0.01–6.80) and the incidence of watery stools (OR = 0.36, 95% CI 0.05–2.81).
In conclusion, probiotic supplementation shows a probable beneficial effect in the prevention, and possible benefit in the treatment, of radiation-induced diarrhoea.
Chronic Radiation Enteritis
2010, Clinical Oncology
Citation Excerpt :
Given the limited data and side-effects associated with corticosteroid use, these drugs cannot be routinely recommended in chronic radiation enteritis; larger studies are needed to evaluate whether aminosalicylates have prolonged beneficial effects in modifying disease progression in chronic radiation enteritis. Although probiotic-induced alteration of the intestinal microbial environment may prevent acute radiation enteritis [111,112], no studies have assessed the efficacy of these therapies in chronic radiation enteritis. On the other hand, as mentioned earlier, bacterial overgrowth is not uncommon in patients with chronic radiation enteritis and can respond to antibiotic therapy [66].
Chronic radiation enteritis is an increasing problem, as more patients receive radiotherapy as part of their cancer therapy and as the long-term survival of these patients improves. This review addresses the causes, investigation, treatment and prevention of this disease. A review of published studies was carried out using a variety of search terms, including radiation enteritis, investigation, treatment and prevention. Chronic radiation enteritis has been reported in up to 20% of patients receiving pelvic radiotherapy, although this may underestimate its true prevalence, as not all patients with gastrointestinal symptoms after radiotherapy will seek medical attention. Predisposing factors to chronic radiation enteritis include a low body mass index, previous abdominal surgery and the presence of co-morbid conditions; the radiation dose, fractionation and technique, as well as the concomitant use of chemotherapy, may also play a role. Clinical features of chronic radiation enteritis are multiple as the disease can affect any part of the gastrointestinal tract. Moreover, symptom aetiology within any one patient may be multifactorial and therefore it is important to adopt a structured approach when planning investigations. The evidence base for current therapies is limited, but nutrition, anti-diarrhoeals, anti-inflammatories, antibiotics, probiotics, pentoxifylline, tocopherol, cholestyramine, hyperbaric oxygen, endoscopic and surgical therapies have all received attention. Given the significant morbidity and mortality associated with chronic radiation enteritis, current available preventative strategies are reviewed, including tissue-sparing radiotherapy techniques. In conclusion, the evidence base for therapeutic and preventative strategies in treating chronic radiation enteritis is limited, but adopting a structured approach to investigating gastrointestinal symptoms after radiotherapy should allow better targeting of current therapies. Closer collaboration between oncologists and gastroenterologists will facilitate a more structured approach, not only in managing individual patients, but also in establishing clinical and research networks for this expanding disease, in order to improve the evidence base for its management.

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Prophylaxis of diarrhoea in patients submitted to radiotherapeutic treatment on pelvic district: personal experience

Abstract

Patologia iatrogena da terapia antineoplastica: chemio e radioterapia

Tipografia Messina

Radioterapia oncologica, basi logiche, tecniche, risultati. Traduzione italiana dalla V Edizione inglese a cura di Gian Luca Sannazzari

Selection criteria for microorganism for probiotic use

Probiotics in human medicine

Gut

Un nuovo prodotto probiotico per il trattamento delle malattie gastrointestinali

G Gastroenterol