During radiation therapy, you may experience a range of adverse reactions, including systemic reactions, hematologic toxicity, and local reactions. Hematologic toxicity and systemic adverse reactions are often the first to occur; then local adverse reactions such as dysphagia, radiation esophagitis, and dry cough may also occur slowly. However, the order of appearance of these adverse reactions is not fixed.
Next, we will give you an overview of when and how common adverse reactions to radiation therapy appear, and what you can do and what your doctor can do for you.
Systemic reactions
They usually occur at the beginning of radiotherapy or 1 to 2 weeks into radiotherapy and may last until the end of radiotherapy.
Systemic reactions include malaise, decreased appetite, nausea and vomiting. Symptoms are usually mild and do not require management. These adverse reactions may be exacerbated when concurrent chemotherapy (also known as simultaneous radiotherapy) is given.
When these adverse reactions affect your life, please inform your doctor promptly so that he or she can manage them for you and try to reduce your discomfort.
During radiation therapy, it is recommended that you get plenty of rest, while exercising and eating as well as possible. Doing so has the potential to ease the level of systemic adverse effects and allow you to live a more comfortable life.
Hematologic toxicity
Including reduced white blood cells, hemoglobin, and platelets.
White blood cell depression is usually seen first during radiation therapy; it is more pronounced in combination with chemotherapy and may persist until the end of radiation therapy. When you have hypocellularity, your doctor will treat it promptly to prevent infection due to low white blood cells.
Low hemoglobin is anemia. Because of bleeding, malnutrition, and other factors, patients with esophageal cancer are themselves highly susceptible to anemia, which can be exacerbated by radiation therapy. As the number of radiotherapy sessions increases, the anemia may gradually worsen. If the anemia is severe, it will negatively affect the effect of radiotherapy. Your doctor will use the appropriate medication to treat the symptoms and correct the anemia for you in a timely manner.
Low platelets are rare and usually may occur late in the course of radiation therapy. If platelets are too low, it may lead to bleeding and other risks. When a routine blood test reveals hypoplastic platelets during treatment, again, this will be addressed by your doctor.
During radiation therapy, you will need to review your blood work and liver and kidney function weekly, rest, and take nutritional supplements.
Local reactions
Difficulty swallowing
You may already have difficulty swallowing before radiation therapy, but some patients do not have this symptom.
But during radiation therapy, the irradiated esophagus may become edematous, causing further narrowing of the lumen and making dysphagia symptoms worse. Symptoms may persist for 1 to 2 months after the end of radiation therapy until the mass subsides and the edema disappears. When combined with radiation esophagitis, it is more likely to result in inadequate nutritional intake.
Before radiation therapy begins, your doctor will assess your nutritional status and how much risk there is for radiation therapy to cause swallowing difficulties. If necessary, your doctor will place a gastric tube in advance to ensure adequate nutritional intake during radiation therapy.
The details are the same as for preoperative nutritional support.
Radiation esophagitis
Usually appears about 2-3 weeks after the start of radiotherapy and often lasts until the end of radiotherapy or 1-2 months after the end of radiotherapy.
The main manifestations are discomfort and painful swallowing, which can interfere with eating and even cause inadequate nutritional intake and lead to weight loss when symptoms are severe.
Before radiation therapy, your doctor will assess your nutritional status and the risks of eating that may come with radiation therapy. If your swallowing pain is severe enough to interfere with eating, your doctor will give appropriate esophageal mucosal protection and pain medications to improve your pain symptoms and quality of life. If you have poor nutritional scores, your doctor will prepare you for nasal nutrition in advance of treatment.
Dry cough
Usually occurs 2 to 3 weeks after radiation therapy begins, and some may persist until the end of radiation therapy.
Dry cough is usually an inflammatory response of the tracheal mucosa caused by radiation, mostly manifesting as an irritating dry cough or a small amount of white sputum. If the symptoms are mild, no treatment is needed; if the symptoms are significant, cough suppressants, phlegm-suppressants, or nebulized inhalation therapy can be administered under the guidance of a physician to help expel sputum.
Radiation pneumonia
It usually occurs during or within 3 to 6 months after radiation therapy.
Since the lungs are located on either side of the esophagus, some exposure to radiation is inevitable. When the area irradiated increases, the incidence of radiation pneumonia also increases. In general, the incidence of radiation pneumonitis is relatively low in esophageal cancer radiotherapy, but is generally more likely to occur in patients with extensive lesions that require extensive radiotherapy.
Radiation pneumonia is diagnosed when you have a cough, fever, shortness of breath, other factors such as bacterial, fungal, or viral infections are ruled out, and interstitial inflammatory changes are found on CT in areas of the chest that are more consistent with the radiotherapy area.
Prevention of this adverse reaction is important, and the occurrence of radiation pneumonia can be minimized by strict control of the radiotherapy target area and plan design by the physician. It can be observed when symptoms are mild and needs to be actively managed by the physician when symptoms are more severe.
Skin reactions
Most often manifests as localized skin hyperpigmentation in the radiotherapy area, usually appearing late in the course of radiotherapy and tending to fade 1 to 3 months after the end of radiotherapy, with slower recovery of the hyperpigmentation.
If you are sensitive to radiation, you may also experience dry peeling of the skin and, in severe cases, ulcers, which may be accompanied by local pain.
Your doctor will evaluate your condition before radiation therapy. If a severe skin reaction is expected, radiation protection or epidermal growth-promoting medications may be applied during radiation therapy to reduce the skin reaction.
What you can do: Do not wear clothing that is too tight around the radiation site; do not scrub or scratch the skin, but gently rinse with warm water; do not apply hot or cold compresses to the skin at the radiation site without your doctor’s approval; and consult your doctor before using skin care products such as moisturizers and toners.
Fistula
Fistulas include esophageal mediastinal fistulas and esophagotracheal fistulas, which may occur later in the course of radiation therapy or after tumor regression at the end of radiation therapy.
Very few patients are at risk for fistula. It is worth stating that the occurrence of fistulae is instead an indication of better treatment outcomes. In general, patients with deeper invasive esophageal cancer lesions that are better treated are more likely to have fistulas. The cavity occurs because the tumor is rapidly controlled and retreating, but the normal tissue structure has been destroyed by the tumor and the body is too late to fill the destroyed location with new tissue. At this point, your doctor will treat you aggressively on a case-by-case basis.
Co-written by: Dr. Rong Yu Dr. Jing You, Peking University Cancer Hospital