G.I. E18C: Rectal Cancer Part 4C: Toxicity, Follow-Up & Survivorship

Today, in our final episode on rectal cancer, we'll equip you with practical strategies for managing acute on-treatment toxicities. We'll then delineate evidence-based follow-up schedules, contrasting operative and non-operative approaches. Finally, we'll explore key survivorship considerations, including fertility preservation, bone health, and the crucial role of pelvic floor rehabilitation.

Episode Transcript

(00:00):
Welcome, everyone. Today we're taking a closer look
at rectal cancer management, butmaybe shifting the focus a bit
from the initial diagnosis and planning.
That's right, we're diving into what happens during and
crucially, after treatment. Things like managing those tough
on treatment toxicities, figuring out the best follow up
plan and really supporting our patients in their survivorship

(00:22):
journey. Exactly.
Because, you know, we spend so much time on the technical
stuff, staging, anatomy, neoadjuvant approaches, planning
the radiation fields. Absolutely essential groundwork.
But our job doesn't end when thetreatment machine switches off,
does it? Managing the patient's whole
experience, that's a huge part of what we do.
It really is. To make this concrete, let's

(00:42):
think about a patient, say Miss Chen.
She's 42, just finished long course chemo, radiation for AT3
and one tumor, part of a TNT protocol.
OK, so she's been through a lot already.
Definitely. And now in these last few weeks
of radiation, she's really struggling.
Significant skin irritation, pretty bad diarrhea, and she's
anxious. Understandably, what she worried

(01:04):
about. She's asking those key
questions. What happens after my surgery?
How are you going to watch me? Will you know if it comes back?
And what's life going to be likeafter all this?
Yeah. Those are the questions, aren't
they? And they perfectly frame our
discussion today. It really highlights how our
role goes way beyond just delivering those Grays.
Absolutely. It's about guiding her and

(01:24):
patients like her through everything that follows.
So let's start with those acute side effects.
Pelvic radiation, especially with chemo, it causes issues.
No doubt proactive management and just good patient education
seem critical here. They're absolutely crucial.
It helps patients get through treatment, improves compliance.
It really matters. So let's tackle some specifics.

(01:46):
Anal and rectal pain to Ness miss that awful feeling of
needing to go constantly. What are we seeing and what are
the practical tips? Yeah, those are very common.
Patients describe a sharp or burning pain and that tenesimus
is just incredibly frustrating for them, like they can never
fully empty their bowels. So what can we actually do about
the pain? A really effective practical

(02:06):
thing is topical lidocaine ointment.
We usually tell patients to mix it one to one with something
like Desitin or Aquaphor. OK, one to one.
Yep, and apply it right to the anal canal and the surrounding
skin. You know, as needed for relief.
It can make a big difference. That sounds like a great
clinical Pearl. Simple but effective.
What about the tenesimus itself?That feeling of urgency.

(02:28):
Well, the tenismus, while reallyuncomfortable, often tends to
eak maybe a week or so after short course route finishes, and
then it usually resolves on its own.
Ah. OK, so it gets better.
It generally does, so a big partof managing that is actually
just patient education and reassurance, letting them know
what to expect, that it's likelytemporary.
Setting expectations OK, let's move to another big one.

(02:51):
Diarrhea. Almost universal, right?
Oh absolutely. Diarrhea is something nearly
everyone experiences to some degree.
The first step is always dietarychanges, recommending a low
fiber, low residue diet. Right, reduce the load on the
bowel. Exactly.
Then pharmacologically loppermide is the go to first
line agent. We tell patients to titrate it

(03:11):
based on their symptoms, how frequent the stools are.
And what if that's not enough, say Miss Chen is taking, I don't
know, 810 Loppermide tablets a day and still having major
issues? Yeah, if you're getting up to
needing more than 8 Loppermide tablets a day, that's
significant. The next step pharmacologically
would be to consider diphenox late at roping Lomatil.

(03:32):
OK, Lomatil. But here's a really critical
point. If the diarrhea is severe like
grade 3 and refractory to these measures, you need to talk to
medical oncology about potentially holding or reducing
the dose of the concurrent chemotherapy like a Pepsi to
buy. Before stopping radiation.
Absolutely, before considering aradiation therapy treatment.
Break radiation dose intensity is just so critical for local

(03:56):
control and rectal cancer. We really want to protect that
radiation schedule if at all possible.
Talk to Medonex first. That's such an important
clinical decision point. Protect the RT dose.
Anything else in the toolkit forreally stubborn diarrhea?
For very severe refractory cases, yeah there are other
options like tincture of opium or sometimes anti fertility
agents like dicyclomine or hyoscyamine might be considered,

(04:18):
but those are usually further down the line.
Got it. OK, how about skin reactions?
Perineal dermatitis can be really miserable for patients.
It really can, especially in that area.
It can range from just some redness erythema all the way to
moist exclamation. Moist exclamation sounds rough
where the skin actually breaks down.
Exactly. It's weepy, painful, and

(04:39):
definitely increases the risk ofinfection.
So how do we manage that? Cleaning.
Healing. What works best?
Sits baths are fantastic, just warm water, sometimes with
little dilute hit up, cleanse added help soothe and clean the
area. We also encourage frequent
showers or tub baths. Just gentle cleansing.
And topicals, does it differ fordry versus moist disquamation?

(05:02):
It does. For dry disquamation, simple
emollients usually do the trick.Things like Aquaphor A&D
ointment to keep the skin moisturized and protected.
For moist disquamation you need something more.
Dressings like Aqua Cell Silver can be helpful because they're
absorbent and have antimicrobialproperties.
Or sometimes a mix like 1 to 1 zinc oxide and basitracean can

(05:22):
create a good barrier. Zinc oxide and mesitracein, OK.
And sometimes if there's sloughing skin, you might need
to do some general debridement with tweezers, just carefully
removing the dead tissue to allow for healing underneath.
Right, get rid of the barrier tohealing.
Precisely and look if it's really severe, not healing,
seems infected. Don't hesitate to get a
dermatology oncology consult, they can be incredibly helpful.

(05:44):
Good. Point OK, Last acute toxicity
area, urinary symptoms, burning frequency.
What's the approach? Yeah, dysteria and frequency are
pretty common too. First thing always is rule out a
UPI. Get a urine screen and culture
right away. Standard procedure.
Yep, if the culture is negative then it's likely radiation
cystitis for symptomatic relief.Phenazopyridine Pyridium is a

(06:08):
common brand name. Works well for the burning.
The one that turns urine orange.That's the one you absolutely
have to warn patients about the orange urine or they'll get
quite a shock. Definitely anything else for
urinary issues. For male patients specifically,
if they're having trouble with urination like hesitancy or
retention, tamsulosin or Flomax,it can often help relax the

(06:29):
bladder neck and improve flow. OK, great practical tips for
getting patients through treatment.
Now let's shift gears. Treatments done.
Miss Chen has had her surgery. What's next?
Surveillance and survivorship? This seems like where the path
really diverges depending on treatment, right?
It absolutely does. Post treatment surveillance
looks very different if the patient had surgery like a TME

(06:50):
versus if they pursued a non operative management or watch
and wait approach after a clinical complete response.
The NCCN guidelines are our mainguide here.
So let's start with the more common scenario, probably
surveillance after surgery afterTME, assuming no known residual
disease like for Miss Chen. What do the NCCN guidelines REC

(07:11):
10 I think you mentioned recommend?
That's right, REC 10. For these patients, it involves
several components. First, a history and physical
exam. HMP every three to six months
for the first two years. OK.
Pretty frequent early on. Yes.
Then it goes to every six monthsfor a total of five years.
Same frequency for the carcinowembryonic antigen, the
CEA blood test every three to six months for two years, then

(07:35):
every six months up to Year 5. Why that intensity early on?
Because the highest risk of recurrence, particularly distant
metastatic recurrence, is withinthose first two to three years.
So you're watching most closely then?
Makes sense? What about imaging?
Imaging is typically ACT scan ofthe chest, abdomen and pelvis.
The recommended frequency is every six to 12 months for a

(07:57):
total of five years. 6 to 12 months, so maybe annually, maybe
twice a year depending on risk factors.
Exactly. It allows for some physician
discretion based on the individual patients risk
profile. And colonoscopy, crucial for
local surveillance, I imagine. Very crucial.
The recommendation is a colonoscopy one year after
surgery. If that's normal, the next one

(08:18):
is in three years and then everyfive years thereafter.
What if they find something on that one year scope like an
advanced adenoma? Good question.
If an advanced adenoma is found,you'd repeat the colonoscopy in
one year. And another key point, if the
preoperative colonoscopy wasn't complete, maybe because the
tumor was blocking the scope. Right happens sometimes.
Then you need to ensure a complete colonoscopy is done

(08:40):
within three to six months afterthe surgery.
OK, that covers the bases. Just to be crystal clear, PET
scans, are they part of routine surveillance after surgery?
No, not routinely. The NCCN guidelines don't
recommend routine PECT for surveillance outside of a
clinical trial. It's usually reserved for
problem solving like at the CEA is rising but CTS are negative,

(09:02):
or for initial staging but not standard follow up.
Got it. Now let's flip to the other
path, non operative management or watch and wait.
This is for patients who achievethat clinical complete response
CCR after for neoadjuvant therapy, you said the
surveillance is much more intense.
Why? It is definitely more intensive.
The rationale based on the international consensus

(09:23):
recommendations from 2021 is that you've left the rectum in
place. So while you're watching for
distant math like in the post OPsetting, you have the added
critical task of watching very closely for any local regrowth
at the original tumor site. So what does that entail?
H&T and CEA the same. Yes, H&P and CEA follow a
similar schedule every three to six months for two years, then

(09:47):
every six months for a total of five years.
But the local surveillance must be different.
Radically different. This is where the intensity
ramps up. Digital rectal exam, the Dre and
either proctoscopy or flexible sigmoidoscopy actually looking
inside the rectum are recommended every three to four
months for the first two years. Wow.
Every three to four months. Yes, very frequent.

(10:08):
Then if things remain stable, itcan be spaced out to every six
months for a total of five years.
This frequent endoscopic evaluation is absolutely key to
catching local regrowth early when it's potentially
salvageable with surgery. And imaging for watch and wait.
Is it just CT's? No, there's more.
A rectal MRI is recommended every six months for up to three

(10:28):
years. The MRI is particularly good at
looking for subtle changes or early regrowth in the rectal
wall at the treated site. OK.
MRI every six months for three years and CTS.
CTS of the chest and abdomen arestill done similar frequency to
post op every six to 12 months for five years looking for
distant disease. The guidelines also suggest

(10:49):
including a pelvic CT once you stop doing the routine rectal
MRI. 'S I see and colonoscopy.
Colonoscopy schedule is similar to post TME recommended one year
after finishing therapy and thenfrequency depends on the
findings. Usually every three to five
years if normal. That is a lot to keep track of,
especially those first couple ofyears for watch and wait.
Any tricks to remember it? Yeah, it's definitely complex.

(11:10):
A little memory aid I use is theintensive 2.
Think of those first two years as the intensive 2 period.
Intensive 2. I like it.
During those first two years, you're doing the Dre, the scope
and the MRI frequently. Like every three to six months.
That's your hyper vigilant phase.
After year 2, if everything looks good and stable, you can
start spacing things out a bit, maybe to every six or 12 months.

(11:31):
The intensive, too, that's helpful.
It really highlights where the focus needs to be.
What's the biggest challenge with keeping patients on that
demanding schedule? I think compliance can be tough.
It's a lot of appointments, invasive procedures.
It really comes down to communication, explaining why
it's so intensive, reminding them that this close
surveillance is a trade off for potentially avoiding major

(11:53):
surgery. Empowering them with the
rationale helps. Makes sense.
OK, we've covered acute issues and surveillance.
Let's move into the really long term view survivorship.
Beyond just monitoring for recurrence, what are the key
aspects of supporting patients like Miss Chen for years down
the road? Survivorship care is incredibly
important and it's gaining more focus thankfully.

(12:14):
It's about managing long term side effects.
Monitor from recurrence, Yes, but also promoting overall
health and quality of life. So what are the big pillars of
survivorship care after rectal cancer treatment?
One huge area is pelvic health and sexual function.
Treatment, especially radiation,can have significant long term

(12:34):
impacts. Here, we strongly, strongly
recommend pelvic health physicaltherapy PT for essentially all
patients, male and female. For everyone, why is it so
beneficial? Yes, for everyone.
Pelvic LPT can make a massive difference with things like
chronic bowel dysfunction, including low anterior resection
syndrome, or Lars, which is a collection of bowel symptoms

(12:56):
after surgery. Right urgency, frequency,
incontinence. Exactly.
BT also helps with sexual dysfunction, both male and
female, and chronic pelvic pain.It's often underutilized, but
could be truly transformative for quality of life.
That's a really important point.What about the specifics for
female patients like Misses Chen?
Vaginal health after radiation. Absolutely critical for women,

(13:18):
vaginal dilator use is essentialto prevent or treat vaginal
stenosis. That's the narrowing and
shortening of the vagina from radiation scar tissue.
Which can make intercourse painful or impossible.
Precisely. Patients need education on this.
They should ideally start using dilators about four weeks after
finishing radiation, maybe for five to 10 minutes three times a

(13:38):
week. And then for how long?
For at least 12 months. But ideally, it should be
ongoing, lifelong maintenance for many women to preserve
function. It takes commitment.
Commitment but worth it for quality of life.
You mentioned dose earlier. Yes, there's data for instance
from MD Anderson back in 2023 showing a pretty clear
correlation. Higher radiation doses to the
anterior vaginal wall, specifically AD 50% greater than

(14:02):
about 48 Gray, were linked to worse sexual dysfunction.
Wow, so our planning really matters there.
Every Gray counts. It really does.
And beyond dilators, we need to proactively discuss sexual
health. Ask about potential issues like
erectile dysfunction in men or despair union, painful
intercourse and vaginal dryness in women.
Don't wait for them to bring it up.

(14:24):
Definitely not. Many patients are hesitant.
Bringing it up, normalizing the conversation and offering
resources or referrals to specialists like gynecologists
or sex therapists is part of comprehensive care.
OK, pelvic health is key. What else falls under long term
survivorship? Bone health is another important
one. Often overlooked, pelvic

(14:44):
radiation can weaken the bones in the pelvis, increasing the
risk of insufficiency fractures.Fractures not from a fall, but
just from weakened. Bone exactly.
Stress fractures in the sacrum or pubic ramy are the common
ones, so we need to counsel patients on bone health.
What do you recommend? Adequate calcium and vitamin D
intake is fundamental. Aim for about 1000 to 1200

(15:06):
milligrams of calcium per day and 800 to 1000 IU's of vitamin
D daily, mostly through diet andsupplements if needed.
And any specific screening. Yes, especially for
postmenopausal women. We should encourage them to get
Dick exis scans with their primary care doctor to screen
for osteoporosis. Catching it early allows for
treatment to strengthen bones. Good advice, now a really

(15:28):
sensitive topic especially for younger patients like Miss Chen
at 42 fertility. Hugely important and the timing
of this discussion is critical. It has to happen before
treatment starts. Pelvic radiation can cause
premature ovarian failure, leading to infertility and early
menopause. So what can be done?
For premenopausal women who desire future fertility, ovarian

(15:52):
transposition is a key procedureto discuss.
What does that involve? It's a surgical procedure, often
done laparoscopically, where thesurgeon physically moves the
ovaries out of the expected highdose radiation field.
Where do they move them? Typically they're tacked up
superiorly, often into the paracolic gutters alongside the
colon high up in the abdomen. This drastically reduces the

(16:14):
radiation dose they receive. Thereby preserving ovarian
function and fertility potentially.
Exactly. It's not guaranteed, but it's
significantly increases the chances.
Referrals to reproductive endocrinology before any
treatment starts are absolutely essential for these patients.
That really underscores the needfor multidisciplinary
coordination right from the beginning for Miss Chen.

(16:35):
Unfortunately, that ship might have sailed if the discussion
didn't happen. Pretreatment.
It highlights a potential gap weneed to be vigilant about
closing. It should be part of the initial
consultation for any premenopausal woman facing
pelvic radiation. OK.
Last big area of survivorship lifestyle.
What are the key modifications we should be emphasizing?

(16:55):
Some fundamental health behaviors make a big difference.
Smoking cessation is paramount. Huge impact on overall health
and cancer outcomes. Non negotiable.
Pretty much. Alcohol should be consumed
sparingly, if at all, and physical activity is incredibly
important. How much activity are we talking
about? Even just brisk walking for at
least 30 minutes on most days ofthe week can have significant

(17:18):
benefits. There's strong evidence
supporting exercise. You mentioned evidence.
Wasn't there a trial, the challenge trial maybe looking at
exercise in colon cancer survivors?
Yes, exactly. The Challenge trial published in
the New England Journal of Medicine, I believe in 2025.
It showed that a structured exercise program significantly
improved outcomes for colon cancer survivors.

(17:39):
What were the numbers again? They were quite striking.
They were. It showed an improvement in five
year disease free survival, 80% in the exercise group versus 74%
in the control group and also better eight-year overall
survival, 90% versus 83%. That's really compelling.
It's not just about feeling better.
It actually impacts survival. It really underscores the

(18:01):
therapeutic value of exercise. Beyond that, diet matters too.
Emphasize a plant based diet, reducing red meat intake and
maintaining a healthy body weight.
These are all things patients can control.
It gives them agency in their own health.
Exactly. You know, I sometimes think of
survivorship care like the comprehensive support an athlete
gets after a major competition. The treatment was the main

(18:23):
event, the win, but the follow up Care, rehab nutrition
monitoring ensures their long term health and ability to keep
performing well in life. That's a great analogy.
It's about sustained well-being,not just crossing the finish
line of treatment. OK, this field is always
changing. Any quick thoughts on major
controversies or trials coming down the Pike that might change

(18:44):
practice? Definitely a few things to
watch. There's the ACO slash AR
O/AIO-18 trial, NCT number 04246684.
What's that one looking at? It's a big phase 2/3 trial
comparing long course versus short course radiation, but both
arms get extensive consolidationchemo and have a really

(19:04):
prolonged time before surgery, like 22 to 24 weeks could really
change how we sequence TNT. Interesting.
Anything on re irradiation for recurrence?
Always a tough scenario. Yeah.
The ARROW retry study NTT 05481757 is looking specifically
at that a perspective observational study on re
irradiation for locally recurrent rectal cancer.

(19:24):
We need more data in that space.Absolutely.
And metastatic disease. There are several trials like
Grek, R8 Chiro 4, Climat. They're exploring systemic
therapy with or without upfront resection of the primary tumor
in patients who present with synchronous, unresectable Mets,
challenging the old dogma that you always have to take out the
primary. Fascinating.
Lots to keep an eye on. OK, let's transition to our

(19:47):
board blitz segment. Quick questions, high yield
answers, perfect for consolidating knowledge.
Ready. Let's do it.
Question one. Acute diarrhea during pelvic
radiation. What's the initial management
strategy? Start with a low residue diet
and loperamide, and crucially only consider holding concurrent
chemo like capacitabine after discussing with medical oncology

(20:09):
and before holding radiation therapy, especially for severe
refractory cases. Perfect question 2.
Patient had a TME, no known residual disease.
Outline the key components and timing of their NCCN post op
surveillance. OK.
Post TME, H&P and CEA every three to six months for two
years, then every six months to five years.

(20:29):
CT, chest, abdomen, pelvis everysix to 12 months for five years.
Colonoscopy at one year, then usually every three to five
years if normal. Excellent question 3.
Now switch to watch and wait surveillance after a clinical
complete response. What are the key differences
that make it more intensive? The intensity comes from local
surveillance, Dre and proctoscopy or Flex SIG every

(20:51):
three to four months for two years, then every six months
plus rectal MRI every six monthsfor up to three years.
That close watch on the primary site is the main difference.
Great question 4. Ovarian transposition.
What's the rationale and where are the ovaries typically moved?
Rationale is to preserve fertility and ovarian hormone
function by moving the ovaries out of the high dose pelvic RT

(21:13):
field. They're typically relocated
superiorly into the paracolic gutters.
Perfect. First question 5 Why is pelvic
health PT so crucial as a survivorship recommendation for
both men and women? It's crucial for managing common
long term issues like bowel dysfunction, Lars, sexual
dysfunction and pelvic pain, significantly improving quality
of life for both sexes. And question 6.

(21:34):
Bone health after pelvic radiation.
Key recommendations to mitigate pelvic fracture risk.
Recommend adequate calcium about1000 to 1200 milligrams a day
and vitamin DA 100 to 1000 IU per day, and strongly consider
DXA scans for postmenopausal women to screen for
osteoporosis. Fantastic.
That was a great rapid review. Now let's apply this knowledge
in a few clinical decision making scenarios, OK?

(21:57):
Case time. Case one, a 35 year old woman is
about to start pelvic radiation for rectal cancer.
She's very concerned about infertility.
What intervention should be prioritized for discussion to
mitigate this risk? Options are a hormone
replacement during RTB ovarian suppression with GNRH agonists,
C ovarian transposition, or D post treatment egg retrieval.

(22:23):
OK well post treatment egg retrieval might not be possible
if the ovaries have failed. Hormone replacement during RT
isn't standard for fertility preservation.
Suppression might offer some protection, but the most
definitive way to reduce ovariandose is C ovarian transposition.
C Ovarian transposition final answer.
Yes, surgically moving the ovaries is the most effective
strategy discussed here to minimize radiation dose and

(22:45):
preserve function. Excellent reasoning.
Case 2. A 63 year old man had a TME for
T3N1 rectal cancer six months ago.
He's starting routine surveillance per NCCN
guidelines. What's the recommended frequency
for his CEA test and his CT? Chest, abdomen, pelvis for the
first two years, ACEA annually, CT annually, BCEA every three to

(23:05):
six months, CT every six to 12 months, CCEA every six months,
CT annually, or D both CEA and CTE every three months.
OK. First two years post TME
surveillance CEA is the more frequent 1 early on every three
to six months. CD because diabetic and pelvis
is every six to 12 months. That matches option B.
BCEA every three to six months, CT every six to 12 months.
You're confident? Yes, that aligns with the NCC

(23:26):
and RAC 10 guidelines for that initial intensive phase.
Correct final case Case 3A patient on pelvic radiation with
concurrent capestabine develop severe grade 3 diarrhea.
What's the most appropriate initial management strategy?
A Immediately hold RT until symptoms resolve.
B Discontinue capacitabine immediately.

(23:47):
C Initiate aggressive anti diarrheals.
A&D Consider capacitabine dose modification with medical
oncology or D Switch from capacitabine to infusional 5 FU.
Right. Grade 3 diarrhea.
Holding RT is a last resort. Discontinuing chemo immediately
might be needed, but the first step involves optimizing
supportive care and discussing the chemo with medical oncology.

(24:08):
Switching chemo isn't the initial step either, so C seems
most appropriate. Maximize the anti diarrheals and
have that crucial conversation with Med onsaic about the
capacity in doser schedule. C It is great job working
through those cases. Hey there.
So just to quickly recap our discussion today, effective
management of those on treatmenttoxicities is just so vital.
It helps patients tolerate treatment, stay on schedule and
get the full benefit. Absolutely.

(24:29):
And we saw how surveillance schedules are really tailored
different paths for post operative versus nonoperative
management, both focused on catching recurrence early.
Precision matters there. And finally, that comprehensive
survivorship care addressing pelvic health, fertility, bone
health, lifestyle, it's not an afterthought.
It's absolutely critical for ensuring our patients have the

(24:50):
best possible long term quality of life.
It truly is about treating the whole person long after the
radiation beams are off. It really challenges us to think
beyond the tumor, doesn't it, Tobe partners in our patients long
term journey. Something to reflect on.
What aspect of this extended patient care, toxicity
management, surveillance, survivorship will you focus on

(25:11):
strengthening in your practice this week?
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