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  • Review Article
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Radiation enteropathy—pathogenesis, treatment and prevention

Nature Reviews Gastroenterology & Hepatology volume 11, pages 470–479 (2014)Cite this article

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A Correction to this article was published on 26 August 2014

This article has been updated

Key Points

  • Radiation therapy planning and delivery methods have improved substantially, but the risk of intestinal radiation injury remains the single most important dose-limiting factor in radiation therapy for abdominal and pelvic tumours

  • Early (acute) radiation enteropathy generally occurs during the course of radiation therapy, whereas delayed (chronic) radiation enteropathy develops after a latency period of variable length

  • Delayed radiation enteropathy is among the most common radiation-therapy-related adverse effects; the prevalence of radiation enteropathy exceeds that of IBD

  • The risk of radiation enteropathy limits the uncomplicated cancer cure rate and adversely affects the quality of life of cancer survivors

  • As the number of cancer survivors steadily increases, radiation enteropathy represents a significant challenge for future research

  • Finding safe and effective pharmacological methods to reduce the incidence and severity of radiation enteropathy is an unmet need

Abstract

Changes in cancer incidence and mortality have been modest during the past several decades, but the number of cancer survivors has almost tripled during the same period. With an increasing cohort of cancer survivors, efforts to prevent, diagnose and manage adverse effects of cancer therapy, in general, and those of radiation therapy specifically, have intensified. Many cancer survivors have undergone radiation therapy of tumours in the pelvis or abdomen, thus rendering the bowel at risk of injury. In fact, the current prevalence of patients who have long-term radiation-induced intestinal adverse effects exceeds that of IBD. Considerable progress towards reducing toxicity of radiation therapy has been made by the introduction of so-called dose-sculpting treatment techniques, which enable precise delivery of the radiation beam. Moreover, new insights into the underlying pathophysiology have resulted in an improved understanding of mechanisms of radiation-induced bowel toxicity and in development of new diagnostic strategies and management opportunities. This Review discusses the pathogenesis of early and delayed radiation-induced bowel toxicity, presents current management options and outlines priorities for future research. By adding insight into molecular and cellular mechanisms of related bowel disorders, gastroenterologists can substantially strengthen these efforts.

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Figure 1: Cancer survivors and cancer prevalence rates in the USA.
Figure 2: Radiation mucositis in the rat intestine.
Figure 3: Human endoscopic biopsy samples of rectal mucosa obtained from a patient before and during ongoing radiation therapy of prostate cancer.
Figure 4: Resection specimens of small intestine.
Figure 5: Involvement of the intestinal immune system and microvascular endothelium in the regulation of acute radiation mucositis and subsequent adverse tissue remodelling (intestinal fibrosis).
Figure 6: Radiation-induced changes in the proximal jejunum from non-human primates.
Figure 7: Algorithm depicting simplified principles of work-up and common approaches for managing patients with delayed gastrointestinal symptoms after radiation therapy used at the Royal Marsden Hospital, London, UK.

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Change history

  • 26 August 2013

    In the version of this article originally published online and in print, the definition for PAS was listed incorrectly as para-aminosalicylic acid instead of periodic acid–Schiff in the legend for Figure 3. The error has been corrected for the HTML and PDF versions of the article.

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Acknowledgements

M.H.-J. has received support related to the submitted work from the US NIH (grants R37 CA71382 and U19 AI67798), the US Biomedical Advanced Research and Development Authority (BARDA, contract HHSO100201100045C) and from the US Veterans Administration. All authors declare that there is no support from any other organization.

Author information

Authors and Affiliations

  1. Central Arkansas Veterans Healthcare System and Division of Radiation Health, Surgical Service, University of Arkansas for Medical Sciences, 4301 West Markham, Little Rock, 72205, AR, USA

    Martin Hauer-Jensen

  2. Department of Radiation Oncology, University of Newcastle, Newcastle, 2308, NSW, Australia

    James W. Denham

  3. Department of Medicine, Royal Marsden Hospital, Fulham Road, London, SW3 6JJ, UK

    H. Jervoise N. Andreyev

Authors
  1. Martin Hauer-Jensen
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  2. James W. Denham
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  3. H. Jervoise N. Andreyev
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Contributions

M.H.-J. contributed to all aspects in the preparation of this article. J.W.D. substantially contributed to the discussion of content and reviewed/edited the manuscript before submission. H.J.N.A. researched data for the article, substantially contributed to the discussion of content and reviewed/edited the manuscript before submission.

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Correspondence to Martin Hauer-Jensen.

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The authors declare no competing financial interests.

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Hauer-Jensen, M., Denham, J. & Andreyev, H. Radiation enteropathy—pathogenesis, treatment and prevention. Nat Rev Gastroenterol Hepatol 11, 470–479 (2014). https://doi.org/10.1038/nrgastro.2014.46

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