Rectal spacers in patients with prostate cancer undergoing radiotherapy: A survey of UK uro‐oncologists

Abstract

Radical radiotherapy and brachytherapy are recommended in guidelines for the management of patients with localised or locally advanced prostate cancer. 1,2 However, the prostate is a mobile structure, 3 which means that movement during focal treatments can increase the field of exposure, including the rectum and bladder, resulting in potentially serious toxicities.Bowel toxicities include urgency, loose stools, increased frequency of bowel movements, rectal bleeding and faecal incontinence, which can all impact patients' lives. 4 According to the 2020 National Prostate Cancer Audit in England and Wales, 11% of men who had received radical radiotherapy experienced severe bowel toxicity within 2 years of treatment. 5 Additionally, published studies have reported rates of late grade 2 or worse bowel toxicity following intensity-modulated radiation therapy (IMRT) or stereotactic body radiation therapy (SBRT), including hypofractionation regimens, of between 1% and 14%. 6-10 Brachytherapy boost with external beam radiation therapy (EBRT) increases the rate of late genitourinary and gastrointestinal adverse effects compared with EBRT alone. 11,12 It has been shown that rectal spacer devices (endorectal balloons, biodegradable balloons or hydrogel spacers) can help stabilise the prostate during local therapy, by increasing the space between Denonvillier's fascia and the rectal wall, thereby decreasing radiation exposure. 13,14 SpaceOAR hydrogel is the most widely studied rectal spacer, which maintains a stable separation between the prostate and rectum for up to 12 weeks, before hydrolysis, absorption and renal excretion. [13][14][15] In the prospective pivotal phase III study, 222 patients with T1-2 prostate cancer were randomised to SpaceOAR or no spacer during treatment with IMRT; there was a 74% reduction in rectal radiation dose. 15 Although acute (3-month) grade 2 or worse rectal toxicity was reported by approximately 4% of patients in both groups, after a median follow-up of 37 months, grade 2 or above rectal toxicity was reported in 6% of patients in the control arm and none in the SpaceOAR arm. 16 However, several retrospective

Expanding access to rectal spacers in the United Kingdom: an examination of current evidence and an early review of data from a single institution

“…A questionnaire sent to urologists within the United Kingdom indicated that only 37% of surgeons had inserted a rectal spacer, despite 68% saying that they would be open to using them in the future. 21 Furthermore, most of those who had inserted spacers before had used them within the private sector or for those with pre-existing bowel conditions. This is forcing many patients to apply to the private sector to get a spacer or to travel long distances to undergo spacer insertion in the public health service.…”