Q&A with Leo Raffi Doumanian, M.D., Associate Professor of Clinical Urology, Keck School of Medicine of USC, USC Institute of Urology
When a patient chooses radiotherapy as their primary or adjunctive treatment modality, the first order of business is to eradicate the cancer. The effectiveness of radiotherapy for the treatment of specific cancers has been proven. Direct fragmentation and damage to the cancer cell’s DNA is often the driving mechanism. However, on occasion, the delayed effects of radiotherapy can result in collateral damage to surrounding soft tissue and bone. Common immediate side effects of radiation include fatigue, hair loss, nausea and skin changes. Delayed side effects such as soft tissue and bone necrosis can present months to years later.
For patients who have had radiotherapy for pelvic malignancies (Bladder, Prostate, Cervical, Ovarian, etc), radiation cystitis can develop months to years after treatment causing significant detrimental impact on quality of life. Radiation cystitis symptoms include bladder pain, severe urinary frequency and urgency and significant blood in the urine directly caused by tissue necrosis resulting in a defunctionalized bladder. Hyperbaric oxygen therapy (HBOT) has been proven to be a very effective treatment for radiation cystitis. The mechanism of action includes revitalizing damaged tissue by bringing nutrients and oxygen to areas of poor perfusion, triggering the healing process and stimulating angiogenesis.
Our expert, Leo Raffi Doumanian, M.D., is fellowship trained in urologic trauma and genitourinary reconstruction and specializes in complex surgical management of traumatic, iatrogenic and radiation-induced genitourinary injuries and congenital and acquired diseases of the lower urinary tract and male genitalia. Below, he offers answers to common questions from fellow physicians and clinicians about the delayed effects of radiation and hyperbaric oxygen therapy.
Q1. What causes radiation damage and how does it present?
A1. For the sake of discussion, I will keep things simple. Radiation causes what is known as a vasculitis or inflammation of small blood vessels. This is effective when the damage to those vessels are directed toward the cancer cells, effectively cutting off blood flow. However, when there is radiation scatter to surrounding healthy tissues, there is collateral damage depriving oxygen and nutrients to neighboring organs that can manifest as deleterious symptoms in a delayed fashion.
Q2. What symptoms do patients with delayed radiation injuries typically report on first visit?
A2. Most patients report considerable pain and discomfort. My urological patients are miserable. Their bladder capacity can decrease with a severely limited ability to hold increasing volumes of urine. Stiff collagen replaces healthy bladder tissue which cannot accommodate or stretch. Oftentimes there is hematuria (blood in the urine), urgency and frequency of urination. Some patients report incontinence because their sphincter mechanism becomes defunctionalized with time and their bladders are hyperactive with little to no ability to store urine at increasing volumes.
Q3. What are the most common types of delayed radiation injuries you see and treat?
A3. We see a lot of radiation injuries from pelvic radiotherapy for treatments of cancer, namely gynecological, bladder and prostate. In my practice, I also see delayed tissue damage due to crush injuries and infections like necrotizing fasciitis or gas gangrene of the soft tissues.
Q4. What is the role of hyperbaric oxygen therapy (HBOT) in the treatment of the late effects of radiation? How effective is it, and does it work for all patients?
A4. The goal of HBOT is to heal wounds by providing nutrient-rich plasma and oxygen to the tissues while decreasing the damaging effects of reperfusion injury by scavenging damaging oxygen radicals. HBOT increases growth factors and angiogenesis promoting neovascularization, or increased growth of blood vessels to sites in desperate need. It’s important to note that HBOT is mostly reserved for outpatient treatment. This is a serious commitment of time and effort on the part of the patient, requiring daily appointments, sometimes for several weeks, for 35-40+ treatment sessions. If a patient is actively requiring treatment to stop significant bleeding or having life-threatening consequences, HBOT may not be for them.
Q5. Are most physicians, particularly urologists, aware that HBOT treatment is an option for their patients? Why or why not?
A5. I am extremely surprised how little HBOT it is utilized in urology and medicine. The indications for HBOT are multitude and can be expanded. I’ve performed major complex penile and scrotal surgeries where I’ve sent “healthy” men to the HBO chamber for increased and improved wound healing. It works very well. The Urological community knows about HBOT. However, for some reason, HBOT continues to be underutilized as an adjunctive wound healing intervention. Insurance will cover HBOT when proper documentation is in place. There is a huge potential benefit with low risk.
Q6. Do patients know and understand that HBOT is a treatment option? At what point should they ask their physician about it?
A6. No. Most patients have never heard of HBOT. There is minimal literature out there promoting HBOT, thus, society in general knows very little. Unfortunately, most patients don’t know enough about HBOT to ask their physician for an opinion. Studies consistently demonstrate that increasing oxygen concentrations in the blood can really help people with chronic wounds or radiation damage. Again: low risk, high benefit.
Q7. How many HBOT sessions are usually needed, and does insurance/Medicare cover it?
A7. With proper documentation in the chart, insurance will cover the treatments. There are many justifications for requesting insurance to cover HBOT. For most patients with significant radiation cystitis, for example, insurance will cover the initial 40-60 treatments. You will then need to reevaluate the patient and, if indicated, may need to repeat 40-60 more sessions.
Q8. How do Wound Care Advantage’s hospital partners work with you during the course of HBOT treatment for the patients you refer?
A8. We are in constant communication about the patient’s progress during the treatment regimen. It is a collaborative effort where we work together from different disciplines in order to produce the best outcome for the patient. We make sure the HBOT is well tolerated and there are no side effects or adverse events.
Q9. Tell us about your most interesting case with HBOT. What was the diagnosis, treatment course, and how is the patient doing today?
A9. I remember a young man who had a crush injury to the pelvis and pelvic organs. He had major trauma and suffered from non-healing wounds with a lot of pain. He was in and out of the hospital with infections, and we finally got to the point where we did a flap coverage of his wounds and sent him for HBOT. Now he’s a productive, happy father and an active member of society. He’s doing very well. There are numerous prostate cancer patients I remember who came in feeling miserable with no hope, in and out of the hospital having multiple operations for bleeding and clot retention. They were prescribed HBOT and they suddenly felt much better. They were able to regain control of their lives and are no longer hospital dependent. For the right patient and under the right circumstances, HBOT is extremely beneficial and improves their quality of life, which is our ultimate goal.