Patient-related risk factors for late rectal bleeding after hypofractionated radiotherapy for localized prostate cancer: a single-center retrospective study

Abstract

Background Several studies have reported patient-related risk factors for late rectal bleeding following conventionally fractionated radiotherapy for prostate cancer. We investigated patient-related risk factors for late rectal bleeding after hypofractionated radiotherapy. Methods A total of 231 patients with local or locally advanced prostate cancer treated with hypofractionated radiotherapy (70 or 67.2 Gy in 28 fractions) were evaluated retrospectively. All patients received intensity-modulated radiotherapy with daily image guidance. The relationships between late rectal bleeding and risk factors like diabetes, hypertension, cirrhosis, and anticoagulant use were analyzed. Results During a median follow-up of 23 months, the crude rates of grade ≥ 1, grade ≥ 2, and grade ≥ 3 late rectal bleeding were 23.8%, 16.9%, and 9.5%, respectively. Cirrhosis and anticoagulant use predicted an increased risk of grade ≥ 3 rectal bleeding in multivariable analyses (hazard ratio [HR] 14.37, 95% confidence interval [CI] 3.09–66.87, P = 0.001, and HR 2.93, 95% CI 1.14–7.55, P = 0.026, respectively). The non-anticoagulant group had a significantly superior 5-year freedom from grade ≥ 3 bleeding compared to the anticoagulant group in a propensity-weighted log-rank analysis (88.0% vs. 76.7%, P = 0.041). A receiver operating characteristic curve analysis revealed that rectal bleeding was minimized in the anticoagulant group if the equivalent dose at fractionation of 2 Gy (EQD2) V77 Gy of the rectum was < 4.5% or if the EQD2 V8.2 Gy was < 71.0%. Conclusions Patients taking anticoagulants or those with cirrhosis had a significantly higher risk of severe late rectal bleeding than other patients after hypofractionated radiotherapy for prostate cancer in the present study. The bleeding risk could be lowered by minimizing hotspots in patients taking anticoagulants.

Long-term findings of rectal endoscopy and rectal bleeding after moderately hypofractionated, intensity-modulated radiotherapy for prostate cancer

“…Takeda et al reported that using anticoagulants or antiaggregants resulted in increased late rectal toxicity after radiotherapy for prostate cancer 30 . The ndings were identical in a study by Kim et al, who reported an increased risk of grade ≥ 3 rectal bleeding for patients taking anticoagulants 4 . Unlike previous studies, as shown in Table 3, the use of antithrombotic medication was not a signi cant risk factor for rectal bleeding in the current study (HR 1.683, P = 0.196).…”

“…Prostate cancer was the second most common cancer and the fth leading cause of cancer-related deaths in men in 2020 Sung, et al 1 . Radiotherapy is a standard treatment option for localized and locally advanced prostate cancer [2][3][4] . As prostate cancer has low α/β ratio, larger dose per fraction for prostate cancer is potentially associated with increased therapeutic effects 5 .…”

Chinese clinical practice guidelines for the prevention and treatment of radiation‐induced rectal injury

“…Patients aged >60 years with gastrointestinal dysfunction, hemorrhoids, or smokers are at a higher risk of radiation‐induced intestinal injury 26 . Rectal bleeding is more likely to occur in patients taking anticoagulants and those with liver cirrhosis 30 . Patients with collagen vascular illnesses, such as systemic lupus erythematosus, scleroderma, and rheumatoid arthritis, have an increased risk of developing radiation‐induced proctitis 31 .…”

Comprehensive 3DCRT Hypofractionated Radiotherapy Schedule for Localized Prostate Adenocarcinoma in the Era of IMRT: Dosimetric and Endoscopic Analysis

“…Currently, scarce data exist on rectal mucosal injury related to radiotherapy in the setting of the hypofractionation [ 28 ]. In addition, rectal injury after pelvic radiotherapy could be related to other clinical patient-specific factors such as age, diabetes, and anticoagulant drugs [ 29 , 30 , 31 , 32 ]. Rectosigmoidoscopy findings have been reported elsewhere but have not been correlated with late toxicity or dosimetric factors [ 33 ].…”