Survivorship: Health Concerns After TBI
Total body irradiation (TBI) may be used to treat leukemias and lymphomas or may be given to patients who are undergoing bone marrow transplant. Although radiation is given to every part of the body during TBI, doses are much lower than those used to treat some other cancers. As a result, the side effects may be different.
Head & Neck Issues
Total body irradiation can affect the organs and glands within your head and neck. It may damage the salivary glands and cause dry mouth which increases the risk of cavities. You should have regular dental visits with cleanings every 6 months, exams, fluoride treatments, and x-rays yearly. Artificial saliva may also be helpful. You may also have dry eyes. Artificial tears can be used for comfort. TBI also puts you at increased risk for the development of cataracts, so you should see an ophthalmologist yearly.
Total body irradiation can result in thyroid problems, including hypothyroidism, hyperthyroidism, and thyroid nodules/tumors. Symptoms of hypothyroidism (the most common issue) include fatigue, weight gain, constipation, dry skin, brittle hair, or cold intolerance. You should have your thyroid checked each year and have thyroid function testing (TSH level) done.
Total body irradiation can also cause long-term damage to the liver. Signs of liver damage are abdominal pain, swelling of the abdomen (ascites), weight gain, and/ or yellowing of the skin (jaundice). You should call your provider right away if you have these symptoms. You should have yearly blood tests done to evaluate liver function and should be seen by a specialist for any issues. You should avoid alcohol use, as this may increase the risk of liver disease.
Total body irradiation may cause long-term damage to the kidneys. This can result in renal insufficiency (decreased kidney function) and hypertension (high blood pressure). This risk is increased if you have diabetes or if you have received cisplatin or carboplatin chemotherapies. At your annual physical you should have your blood pressure checked. Kidney function should be checked using blood tests. Hypertension should be treated with medication. If you have diabetes, you should have strict control of blood sugar levels.
TBI can cause scarring of the lungs. You are strongly encouraged not to smoke, as this increases the risk of lung issues. Yearly history and physical by a healthcare provider should include a pulmonary exam and review of possible symptoms (cough, shortness of breath, wheezing). You should receive an annual flu vaccine and the pneumococcal vaccine. You may need chest x-rays or pulmonary function tests if you are at high risk or have a change in how your lungs are working.
Total body irradiation almost always causes damage to the reproductive organs.
Fertility & Sexuality for Men
For men, the primary concerns are the risk of infertility caused by damage to germ cells (which become sperm) and damage to the Leydig cells, which produce testosterone. Without testosterone, a young boy may not achieve puberty or an adult male may have a loss of secondary sex characteristics (facial hair, mature genitals, and a deep voice) or loss of sexual function. If you are experiencing any of these changes, you should be seen by an endocrinologist (hormonal specialist).
Fertility & Sexuality for Women
For women, damage to the ovaries may cause infertility and premature ovarian failure. Failure of the ovaries to produce enough hormones may cause a survivor to experience symptoms of menopause, such as loss of periods, hot flashes, vaginal dryness, and loss of bone density (osteoporosis). Female survivors who experience these symptoms should be counseled about their risk of developing osteoporosis.
After radiation, the skin is more sensitive to sunlight, and you should be especially cautious to use sunscreen, wear hats and protect yourself from sun exposure when outdoors.
TBI and chemotherapy can increase your risk of developing a second cancer. You should undergo all recommended cancer screening tests. For people treated with abdominal radiation under age 18, it is recommended to begin colon cancer screening with colonoscopy or DNA stool testing 5 years after radiation or at age 30, whichever occurs later. The American Cancer Society recommends that the general public begin screening at age 45. There are no specific guidelines for screening after TBI. You and your provider should discuss these recommendations and the risks and benefits of these tests and decide when you should begin screening. Report any new, unusual, or persistent symptoms to your provider.
Cancer Screening after TBI
TBI and chemotherapy can increase your risk of developing a second cancer. You should have all cancer screening tests recommended by your providers. These include breast and cervical cancer screening for women, and colorectal cancer screening for men and women.
If you were treated with abdominal (belly) radiation before you were 18 years old, you should start colon cancer screening with colonoscopy or DNA stool testing 5 years after radiation or at age 30, whichever occurs later. The American Cancer Society recommends that the general public begin colon cancer screening at age 45. You and your provider should discuss these recommendations and the risks and benefits of these tests and decide when you should begin screening. Report any new, unusual, or persistent symptoms to your provider.
Daly, P. E., Samiee, S., Cino, M., Gryfe, R., Pollett, A., Ng, A., … Hodgson, D. C. (2017). High prevalence of adenomatous colorectal polyps in young cancer survivors treated with abdominal radiation therapy: Results of a prospective trial. Gut, 66(10), 1797–1801.
Levy, J. M., Tello, T., Giller, R., Wilkening, G., Quinones, R., Keating, A., & Liu, A. K. (2013). Late Effects of Total Body Irradiation and Hematopoietic Stem Cell Transplant in Children Under Three Years of Age. Pediatric Blood & Cancer, 60(4), 700–704.
Majhail NS, Rizzo JD, Lee SJ, et al. Recommended screening and preventive practices for long-term survivors after hematopoietic cell transplantation; Center for International Blood and Marrow Transplant Research (CIBMTR), American Society for Blood and Marrow Transplantation (ASBMT), European Group for Blood and Marrow Transplantation (EBMT), Asia-Pacific Blood and Marrow Transplantation Group (APBMT), Bone Marrow Transplant Society of Australia and New Zealand (BMTSANZ), East Mediterranean Blood and Marrow Transplantation Group (EMBMT) and Sociedade Brasileira de Transplante de Medula Ossea (SBTMO). Co-published in Biol Blood Marrow Transplant, 2012; 18(3): 348-371; Bone Marrow Transplant, 2012; 47(3): 337–341; and Hematol Oncol Stem Cell Ther, 2012; 5(1): 1-30.
Teepen, J. C., Kok, J. L., van Leeuwen, F. E., Tissing, W. J. E., Dolsma, W. V., van der Pal, H. J., … Zsíros, J. (2018). Colorectal Adenomas and Cancers After Childhood Cancer Treatment: A DCOG-LATER Record Linkage Study. JNCI: Journal of the National Cancer Institute, 110(7), 758–767.
Thomas, O., Mahé, M.-A., Campion, L., Bourdin, S., Milpied, N., Brunet, G., … Cuillière, J.-C. (2001). Long-term complications of total body irradiation in adults. International Journal of Radiation Oncology • Biology • Physics, 49(1), 125–131.