Long-Term Side Effects of Cancer Treatment

Podcast Transcript

Scott Steele:  Butts and Guts, a Cleveland Clinic podcast exploring your digestive and surgical health from end to end.

Welcome everybody to another episode of Butts and Guts. I'm your host, Scott Steele, the chairman of colorectal surgery here at the Cleveland Clinic in beautiful Cleveland, Ohio. And today we're very excited to have our first radiation oncologist here, Dr. Sudha Amarnath. Sudha is an assistant professor of medicine at Lerner College of Medicine here at the Cleveland Clinic. She's the associate program director of radiation oncology at Cleveland Clinic. She's also the director of colorectal in GYN malignancy for the department of radiation oncology at Cleveland Clinic. Sudha, welcome to Butts and Guts.

Sudha Amarnath:  Thanks so much.

Scott Steele:  So we always like to start out all of these podcasts with just telling us a little bit about yourself. Where were you born? Where you're from? Where'd you train? How did it come to the point that you came here to the Cleveland Clinic?

Sudha Amarnath:  I grew up in beautiful Lansing, Michigan and was there through high school and then moved to the East coast to attend college at the Massachusetts Institute of Technology, where I was very interested in engineering. So I was a chemical engineering and a biology major, but ultimately decided that med school was the right path for me.

So I came back to Michigan and studied at the University of Michigan for medical school. And then I think based off of my engineering background, decided that radiation oncology was going to be the right field for me. So then I moved to the West coast and did my internship at Scripps Mercy Hospital in San Diego and then trained at the University of Washington for radiation oncology. And then coming to the Cleveland Clinic was my first job out of residency. I've been here now for six years and again, I was just blown away by the Cleveland Clinic so that's what brought me here.

Scott Steele:  Well, we're excited to have you here and we're going to talk a little bit about radiation therapy and this is our first podcast on radiation therapy. So let's start very broadly at first. What is radiation therapy?

Sudha Amarnath:  That's a great question. So a lot of times people think about the different treatments that we can use to treat cancer and they automatically think about things like surgery, which obviously you do, as well as chemotherapy. But radiation is that third piece of the puzzle which we can use to treat patients either what we say definitively, which basically means as a curative treatment for cancer, we can use it before or after surgery, which is called neoadjuvant or adjuvant therapy. Or we can use it for palliative treatments, which essentially means that we're treating symptoms that can be related to cancer, things like bleeding or pain.

So when we think about radiation, what it really is is very high energy X-rays that are essentially delivered typically from outside of the body to target tumors within the body and essentially damage the DNA within those cells and that essentially leads to cancer death.

Scott Steele:  Okay. So I know there's going to be a lot of questions about this particular podcast because I know patients often ask, they're saying, "Listen, you're going to put in a CAT scan or an MRI or something like that, and now you're talking about killing cells with radiation oncology." What is the difference between the two? Are they similar and we just use different dosages or what's this all about?

Sudha Amarnath:  They're very different in many ways. So when we think about diagnostic radiology, which is when you think about getting regular X-rays or CT scans, ultimately they're using very, very low doses of radiation, but typically to larger areas of the body. And the way that that works from a physics standpoint, it interacts with the cells in your body in a very different way. So we get great images which show us if there are any issues that we need to deal with, but it doesn't cause cell death, to essentially to cells that are inside of the body.

But with therapeutic radiation that we're talking about here, we're using much, much higher energies of radiation to much more focused areas. And essentially when we use those higher doses, the physics of how that interacts with cells within the body is very different, and ultimately that causes those cells to die off.

Scott Steele:  So how does that exactly work though? You talk about these high energy systems and how does that affect either the cancer cells and not the normal cells or does it affect both?

Sudha Amarnath:  Yeah. So it does affect both. Essentially what happens is you have these very high energy X-rays that come through the body and they interact with molecules within ourselves. Primarily, it interacts with water, which makes up the vast majority of our cells. That water, when it gets hit with a very high energy photon source, essentially becomes what we call a free radical. A lot of times people have heard about free radicals because we think about them as something that can cause cancer. So antioxidants mop up free radicals and we think about antioxidants as being something that can prevent cancer.

But in the case of therapeutic radiation, we actually use those free radicals to our advantage. So those little free radical water molecules, they can go off and they can actually damage the DNA directly within a cell. Ultimately, when the cell recognizes that there's damage to that DNA, it can't continue to reproduce and ultimately that cell dies off over time. So when we think about therapeutic radiation, if it's coming through the outside of your body, it clearly has to go through some normal tissue cells as well. But our normal tissue cells are much better able to repair that damage that occurs in those DNA strands. And ultimately that tissue can repair over time, but the cancer cells are unable to do so and therefore they die off.

Scott Steele:  So is there a way that you have that you can just target, and my disclaimer to this is we're going to focus obviously on your specialized part of the body down in the lower GI tract and in the GYN-oncology field that we know that radiation is used in other aspects, but do we target the cancer cells to minimize some of the damage? And we'll talk a little bit about some of the other side effects of radiation, but do you have the ability to do that?

Sudha Amarnath:  Yeah, absolutely. So radiation has come a very, very long way over really the last 30 years and essentially in the last even five to 10 years. There have been a lot of big technological advances that allow us to much better target the areas that we want to treat and minimize damage to the surrounding normal tissues. When we use external beam radiation, which is what we've been describing here, there is no way to completely exclude the normal tissue, but with a lot of the techniques and tools that are available to us nowadays, we're really able to minimize that as much as possible.

Scott Steele:  So let's go on both ends. What are the benefits of radiation and what are the risks and the downside of radiation?

Sudha Amarnath:  So if we're talking about, let's say tumors that are in the pelvis, when we think about erectile cancer, for example. Dr. Steele can do a really fantastic job of taking out the tumor itself as well as some of the surrounding normal tissues. But if he went in and tried to take out all of the areas where there could be microscopic cells in the pelvis, that would be a really morbid surgery for patients.

So that's the advantage of radiation, is that radiation, we can come in before surgery and ultimately really treat a much broader swath of tissue, essentially everywhere where we're concerned that there could be little microscopic cells that are hiding out and we can be really effective at killing those cells and then preventing that cancer from coming back in the long-term. So that's really where radiation comes in those settings, is to treat areas that are larger than what a surgeon can get at.

Scott Steele:  What about the risks and the downsides of radiation therapy?

Sudha Amarnath:  So the risks and the downsides are ultimately related to the fact that, as I mentioned before, we can't fully escape the idea of normal tissues seeing radiation. So there are some side effects that are related to the radiation and we typically break those down into two different time points. So there are acute side effects of radiation and these are things that can happen while a patient is undergoing radiation and sometimes for a couple of weeks after. They're mostly related to inflammatory effects of the radiation. So ultimately, anytime the body has some sort of trauma that's going to throw off its normal rhythms, a lot of times our body responds to that by getting inflamed.

So that can lead to things, when we're talking about the pelvis, with organs like the bladder, things like increased urinary frequency or urgency or sometimes having some burning with urination and feeling like, ultimately, it can almost be like a urinary tract infection. When we're talking about the rectum, that can mean inflammation, which ultimately leads to people having a sensation of having to go more frequently, loose stools, diarrhea, sometimes pain because of changes that can occur to the lining of the rectum as they're going through treatment. And then when we think about the small intestine, a lot of similar things to what we think about with the rectum. So those are some of the short-term side effects that we think about with radiation.

Also, most people will generally get some element of fatigue as they're going through the treatment and they tend to build up over the course of the treatment. So most people feel pretty good during the beginning portions of their treatment and then as they get towards the end in a week or two after those side effects do tend to build up a little bit more. But most people recover from those side effects of radiation. So generally within about four to six weeks after finishing their treatment, most people are feeling like they're generally back to baseline. However, there's also long-term effects of radiation that can occur and those are the side effects that can happen sometimes months to years after someone has had radiation and ultimately those are related primarily to chronic inflammation and scar tissue formation.

And I always describe to patients that just like when a surgeon goes in and there's inflammation that can be caused by doing the surgery and in the long-term there can be scar tissue that can be generated over time just from the body healing, the same thing can happen with radiation. So all of that inflammation that gets caused during the treatment itself for some patients is going to lead to long-term scar tissue formation. The hard part for us is we can't necessarily predict who those patients are that are going to have those effects of the long-term scar tissue formation or inflammation, but that being said, we try to minimize those effects as much as possible when we do all of our upfront mapping and planning of the treatment to minimize the amount of radiation that those normal tissues are seeing.

Scott Steele:  So you mentioned a little bit about some of the side effects. Let's stick with that theme for a second. So how does radiation affect the sexual health of patients?

Sudha Amarnath:  So that is a great question and that's something that honestly has not been studied as much as I would have hoped for. So it's an area of interest that we have here at the Cleveland Clinic. So when we think about sexual health and pelvic tumors, unfortunately when we think about female patients, the vagina sits right next to a lot of the organs that we would treat. So it's right next to the anal canal, right next to the rectum when we think about those types of cancers. And of course for gynecologic cancers, it's a big part of what we're treating because it's part of the gynecologic tract. After a woman goes through menopause, they generally have a lot of changes in their vagina because of decreased estrogen exposure and that can mean that the vagina can get less elastic, tighter, and sometimes even a little bit smaller.

But when we have younger patients as well as older patients, the radiation that they get for their other cancers, even if it's unrelated to the vagina in that area, can ultimately lead to some of those same changes. So that can lead to things like pain with intercourse and difficulty having pelvic exams moving forward and it can really diminish the quality of life of a lot of patients. And unfortunately, a lot of patients are not told about those side effects upfront because there are ways that we can help to minimize those side effects as well as to try to help prevent them in the long-term, but patients need to be informed of what can happen.

Scott Steele:  And for men, do they have a problem associated with either erectile or ejaculatory function?

Sudha Amarnath:  So that's a great question. For male patients, it's been studied a little bit more in depth and ultimately we know that the nerve function is very much related to the amount of dose that they receive. So generally when we're thinking about rectal cancer and anal cancer, the doses that are used generally are not high enough to affect the nerve function that affects erectile function in men. However, with prostate cancers, sometimes those doses can be much higher and therefore those nerves could potentially be affected in the long-term.

Scott Steele:  So let's dive a little bit into some of the specifics of the disease processes you treat. Before we go there, I want you to first say what's the difference between external beam radiation therapy and brachytherapy and what's the stereotactic type thing? Is it gamma knife radiation therapy? What do all these different terminologies mean?

Sudha Amarnath:  So I always think of these as just various tools that are in our toolkit. So external beam radiation is what we've mostly been talking about today, which is the high energy X-rays that come from the outside, go into the body from the outside and ultimately treat something that's internal to the body. Brachytherapy is essentially using an actual radioactive isotope and we use applicators usually directly into body cavities. So when we think about gynecologic cancers, we do a lot of this where we'll place applicators directly into the vagina to get at our various tissues that need to be treated like the cervix or the uterus, and ultimately a little radioactive isotope source can be used to treat those areas much more directly. We don't have to go through the normal tissues in order to treat those areas. So there are some great advantages there if it's in a location that's accessible to those applicators.

Gamma knife is a specifically meant for tumors that are in the brain, so it's not typically something we think about a whole lot for pelvic tumors. And then stereotactic body radiation therapy is basically an offshoot of gamma knife, which is essentially very, very high doses of radiation that essentially can ablate small tumors. So it really was used essentially most frequently first in the brain and then moved to other body sites like the lung and the liver. Those were really the places where we probably have the most data as well as the spine, but we're seeing a little bit more of it in the pelvis now as well. So there are SBRT treatments to the prostate gland as well as for tumors that sometimes have come back in other parts of the pelvis and we want to focus on there with a very, very high dose of radiation.

Scott Steele:  And just to close out some of the terminology and definitions, although you may not use this a lot, a proton beam. What is it, where is that used and do we have one here at the Cleveland Clinic?

Sudha Amarnath:  Yeah. So proton beam radiation is a different particle that's used to deliver radiation. In many ways, it's very similar to the external beam type of radiation that I described, although that's photon radiation as opposed to proton radiation, so a subtle difference there. The difference with protons is that the way that they're delivered, the physical properties are a little bit different. So protons enter into the body, they deliver a high dose of radiation to where you would like to target, and then instead of having to exit the body like a normal photon would have to do, it actually has something called a Bragg peak, which basically is the high energy deposition and then a very sharp falloff in the dose. It's a little hard to describe without pictures, but ultimately, the advantages of protons have really been seen primarily in areas like the brain STEM and the spinal cord where ultimately, you really have a very sensitive organ to radiation and you want to make sure that you can spare that tissue or spare that organ as best as possible.

It's also very helpful in pediatric patients because we know one of the long-term side effects of radiation can ultimately be a secondary cancer from the radiation itself. The chance of that happening is extraordinarily rare, and if it occurs, it's typically 10, 15, 20 years after someone has had radiation exposure. But when we think about young patients, that's obviously something we think about a whole lot more. So if we can minimize the amount of other normal tissues that a pediatric patient is seeing, then sometimes protons really have an advantage there. But I would say at this point, what we're finding in the data is that the use of protons is a little bit more limited than what was thought might be the case. We currently do not have protons. We've chosen not to invest in protons at this time just because there are limited applications. However, there is a proton facility in Cleveland for those patients who may need them.

Scott Steele:  So although the treatment regimens may differ between different disease process, anal cancer, GYN cancer, prostate cancer, walk me through your patient that says, "I was told I got to go see a radiation oncologist." What can they expect and then take us through a little bit about a typical treatment regimen. Let's pick rectal cancer.

Sudha Amarnath:  Essentially, the first step is to see your radiation oncologist for a consultation. So the same as you would see any other physician, we typically will see our patients in the clinic and we'll have a discussion talking about the history, the pathology of their tumor. We tend to like to show a lot of pictures, so we'll go over all of the imaging with our patients and essentially talk about if there's an indication for radiation and why we would use the radiation and what we would ultimately be targeting as well as the side effect profile that we would expect. We know with radiation that the side effects are very much related to the dose of radiation that we need to give for a particular indication as well as the amount of tissue that we're going to treat. So it can really vary depending on what it is that we're treating.

So that's step one. Then step two is if you're considered a candidate for radiation, then we would bring you back for what we call a simulation or a planning scan for the radiation, which is essentially a CT scan in a particular position. We call it the position that you would be immobilized in for your radiation treatments and ultimately because radiation is given over an extended duration of time. So let's say for example rectal cancer, we do that over the course of typically about five weeks. We want to make sure that that radiation is being delivered very accurately and precisely for each and every single one of the 25 treatments that a patient would receive. So in order to do that, that planning scan allows us to set up a patient in a very specific way using specific immobilization devices that can be reproduced on a daily basis. On that day, typically patients do get a few tattoos and they are permanent and those tattoos help our therapists who deliver the radiation daily to line patients up in the exact right position.

Scott Steele:  How long does a typical therapy or session take?

Sudha Amarnath:  The planning scan is usually the longest appointment. That's usually about 35 to 40 minutes. However, when you come in for your first treatment, that's typically about 10 to 15 minutes for daily treatments. I always tell patients most of that time is spent setting you up in the right position. Ultimately the radiation is only on for one to two minutes as part of that whole 15 minute appointment.

Scott Steele:  Can they move at all in the scanner? What happens if they got an itch or something?

Sudha Amarnath:  Usually we want patients to try to hold still as best as they can during that entire duration of treatment, but we have cameras in the treatment rooms as well as speaker system so they can communicate with the therapists who are delivering their radiation. So if a patient really needed to cough or itch or something like that, we can pause the treatments midway, allow them to do that and then continue on with treatment.

Scott Steele:  So they're just a few more questions to wrap this up. First of all, do all types of cancer need radiation therapy?

Sudha Amarnath:  So it really varies depending on the type of cancer. We have a lot of indications in the pelvis for treating with radiation. We treat a lot of lung cancers, cancers in the liver, cancers in the brain, cancers in the spine. So we do treat cancers that are all over the body, but it really depends on the particular type of cancer it is and ultimately where it's located.

Scott Steele:  And second, do patients who have somewhat of an inability to go into close spaces who feel a little claustrophobic, are they still able to undergo radiation therapy?

Sudha Amarnath:  Yeah. So that's a really common question that comes up. With radiation machines, it's generally not claustrophobic. People are in a large room and essentially there's a machine that moves around them. So it's almost a little bit more like a CAT scanner as opposed to an MRI scanner, which more patients tend to have claustrophobia with. However, sometimes with our mobilization devices there can be a little bit of a feeling of claustrophobia and in those cases, we tend to try to coach patients in advance through what that process is going to be like. And at that planning scan, we try to make sure that a patient is in a position that they're going to be able to tolerate for the duration of treatment in the best way possible. So we have a lot of things that we can do to help.

Scott Steele:  And I know we've been focusing on cancer, but is radiation used for benign disease, non-malignant disease?

Sudha Amarnath:  There are a few benign indications for radiation, but those are pretty few and far between. So in general, we call ourselves radiation oncologist because ultimately the vast majority of what we treat is cancer.

Scott Steele:  A lot of people out there are scared of radiation therapy and they're scared of some of the side effects. So are there resources out there that are offered to help patients cope with these type of side effects that we talked about earlier?

Sudha Amarnath:  Absolutely. So I think the American Cancer Society actually has a lot of really great information on radiation. The Cleveland Clinic website actually has a fair bit of helpful information as well. They're actually a lot of really great videos even just on YouTube that are out there that show patients what that process is like, just so that there is a little bit less anxiety going in. And I will say for all of our patients, I think this is true at most radiation centers. When patients come in for their planning scan, we like to give them a tour of the department so that they know exactly what it is that they should expect, and we like to see our patients very regularly. I always tell my patients, "We schedule you to see us once a week for what we call an on treatment visit but ultimately, you're coming in for treatment five days a week. We're there five days a week." So if something comes up, we're always there to help take care of any side effects or anything that might be bothering a patient.

Scott Steele:  And are there any developments on the horizon for the future of radiation therapy?

Sudha Amarnath:  I think from a technology standpoint, we just continue to get better and better in terms of how we're able to target tumors. There's a lot of changes that have occurred in terms of trying to shorten radiation treatment schedules. So instead of having all patients go through five weeks of radiation, there are a lot more courses of treatment now that are closer to one to two weeks of treatment. So there's a lot of that that's on the horizon. There's also a lot of combinations of radiation with other modalities of treatments. So we haven't talked a lot about radiation with chemotherapy, but there's a lot of that that we do, and then radiation with immunotherapy and a lot of things that we know are essentially going to make all of these treatments work more effectively together.

Scott Steele:  Well that is just great stuff, and we like to end up all of our guests with a couple of quick hitters. So number one, what's your favorite meal?

Sudha Amarnath:  So I grew up eating Indian food my entire life. So I'd have to say that I do love Indian food and a good samosa is always going to put a smile on my face.

Scott Steele:  Number two, your favorite sport.

Sudha Amarnath:  Oh. My favorite sport to watch would be basketball, to play would be soccer.

Scott Steele:  Number three, what is the last nonmedical book that you have read?

Sudha Amarnath:  I am a pretty avid novel reader. So most recently I've been reading My Brilliant Friend by Elena Ferrante.

Scott Steele:  And finally, tell me one thing that you like about living here in Cleveland.

Sudha Amarnath:  So Cleveland is a surprising city. I didn't grow up here and didn't expect to love it to be honest and I am a total convert. So I would say one of my favorite things about the city is Severance Hall and the Cleveland orchestra. It's just amazing.

Scott Steele:  Well that is awesome. And so to learn more about radiation and our cancer programs at the Cleveland Clinic, please visit clevelandclinic.org/cancer, that's clevelandclinic.org/cancer. C-A-N-C-E-R. And to schedule an appointment with a Cleveland Clinic specialist, call the cancer answer line at 866-223-8100. That's 866-223-8100. Sudha thanks so much for joining us on Butts and Guts.

Sudha Amarnath:  Thanks so much.

Scott Steele:  That wraps things up here at Cleveland Clinic. Until next time, thanks for listening to Butts and Guts.