Non surgical interventions for late radiation proctitis in patients who have received radical radiotherapy to the pelvis (Cochrane Review)

A substantive amendment to this systematic review was last made on 04 September 2001. Cochrane reviews are regularly checked and updated if necessary.

Background: Chronic radiation proctitis (rectal inflammation) may develop after the completion of pelvic radiotherapy. Presently there is no recommended standard management.

Objectives: To assess the effects of various non-surgical options for managing late chronic radiation proctitis.

Search strategy: We searched the Cochrane Controlled Trials Register, issue 1, 2001, MEDLINE 1966 to 2001, EMBASE 1980 to 2001, CANCERCD 1980 to 2001, Science Citation Index 1991 to 2001, CINAHL 1982 to 2001, and sources of grey literature. We also handsearched textbooks and contacted experts in the field.

Selection criteria: Studies (preferentially randomised controlled trials) of interventions for the non-surgical management of late radiation proctitis in patients who have undergone pelvic radiotherapy for cancer.

Data collection and analysis: Inclusion criteria were independently applied by two reviewers (AD and EJM) and any disagreement resolved by involving a third reviewer.

Main results: Six randomized controlled trials were included. None compared anti-inflammatories with placebo. However, rectal sucralfate showed greater clinical improvement for proctitis than anti-inflammatories (odds ratio (OR) 14.00, 95% confidence interval (CI) 1.46 to 134.26; n=1 study) , though no difference was seen for endoscopic improvement (OR 2.74, 95% CI 0.64 to 11.76, n=1 study). The addition of metronidazole to the anti-inflammatory regime also appeared to improve the response rate, as measured by reduction in rectal bleeding, diarrhoea, erythema and ulceration (n=1 study). Similarly rectal hydrocortisone appeared to be more effective than rectal betamethasone for clinical improvement although no difference was seen in endoscopic improvement (n=1 study). Short chain fatty acid enemas did not appear to be effective compared to placebo (n=2 studies). Comparing the heater probe and bipolar electrocautery (n=1 study), there was no discernible difference for severe bleeding after one year, but the heater probe demonstrated a greater increase in the haematocrit and reduced transfusion requirements.

Reviewers' conclusions: Late radiation complications are relatively rare, involving potential carers and poor diagnostic criteria. Although certain interventions look promising (e.g. rectal sucralfate, adding metronidazole to the anti-inflammatory regime and heater probes), single small studies, even if well conducted provide insufficient evidence. The episodic and variable nature of late radiation proctitis requires placebo-controlled studies to establish whether particular treatments are effective. Regional or centralised registers of radiation toxicity should be established so interventions can be administered in the setting of multi-centre trials with specific entry criteria, formal baseline and therapeutic assessments providing standardised outcome data including quality of life evaluations.

Citation: Denton A, Forbes A, Andreyev J, Maher EJ. Non surgical interventions for late radiation proctitis in patients who have received radical radiotherapy to the pelvis (Cochrane Review). In: The Cochrane Library, Issue 3, 2003. Oxford: Update Software.

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This is an abstract of a regularly updated, systematic review prepared and maintained by the Cochrane Collaboration. The full text of the review is available in The Cochrane Library (ISSN 1464-780X).

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