VCOM Carolinas Research Day 2023

Clinical Studies

The Effects of Physical Activity Level on Successful Image Guided Radiation Therapy Set-up in Prostate Cancer Patients Barsoumian, I. OMS-III, Jackson S. MPH, OMS-III, Curtis, A. MD, Monitto, D, MD. Kilburn, J. MD, Heather Bendyk Edward Via College of Osteopathic Medicine, Spartanburg, SC. Spartanburg Regional Healthcare System, Spartanburg, SC. Abstract Results Results

Abstract # CLIN-15

• Prostate cancer is the most common non-cutaneous cancer in males. 1 • Side effects due to radiation treatment of the prostate can include diarrhea, fecal incontinence, and rectal bleeding. • Rectal gas can shift the rectal wall into a higher radiation dose region. 2 • Image-guided radiation therapy (IGRT) is commonly used in prostate cancer patients to improve the precision and accuracy of treatment during delivery. 3 • Radiation oncologists can detect changes in location of the prostate and rectum at each visit by a CT scan and adjust beams accordingly. 4 • Studies have found evidence in the significance of rectal and bladder preparation to decrease biochemical and clinical failures in patients treated with IGRT. 5 • Mild physical activity has been found to enhance intestinal gas clearance and reduces symptoms in patients complaining of abdominal bloating. 6 • Aimed to determine the effects of physical activity on successful IGRT in prostate patients. • We hypothesized that those who do more physical activity will have less unsuccessful setups during IGRT than those who do less physical activity • Successful set-up were defined as NOT requiring a second CT scan before continuing with radiation therapy. Context : Prostate cancer is the most common non-cutaneous cancer in males. Potential side effects after radiation treatment for prostate cancer are diarrhea, fecal incontinence, and rectal bleeding. Image-guided radiation therapy (IGRT) is commonly used in the treatment of prostate cancer to improve the precision accuracy of radiation beams and decrease potential side effects. One of the variables in IGRT is positioning of the rectum wall. Rectal wall positioning can be related to rectal distention and result in significant displacement of the prostate gland. The hypothesis is that physical activity can enhance intestinal gas clearance and lower the variation in rectal wall position caused by gas, but there have been no studies on physical activity levels in relation to IGRT. Objective : To determine the effects of the level of physical activity on successful IGRT set-up in prostate cancer patients. Methods : Participants were required to be over the age of 18, receiving IGRT at Spartanburg Gibbs Cancer Center & Research Institute for prostate cancer, and willing to participate. At initial visit, participants were asked to sign consent forms and complete a pre-treatment survey including demographics and current exercise habits. Participants were given a pedometer to wear on the weekdays they were receiving treatment and record their steps two times a day, before receiving radiation treatment and at the end of the day, using the provided Step Log. A member of the research team called them weekly to gather step counts for that week. This process continued each week for the duration of their IGRT treatment. Results : Nine participants completed the study. The Wilcoxon Rank Sum Test compared the total steps in the two groups and derived a p-value of 0.1416. The difference among the two groups were not significant, therefore the null hypothesis cannot be rejected. The Fisher’s Exact Test comparing the two groups’ pre -treatment surveys were found to be insignificant, therefore their demographic and previous activity level likely did not contribute to the success of the setups. These results may suggest that activity is not the main variable contributing to the buildup of gas in the rectal vault. Conclusion : This study shows further research should be conducted regarding IGRT in prostate cancer patients. A larger, multi-facility study should be conducted to detect further differences. Physical activity levels, additional dietary counseling, and Osteopathic Manipulation Treatment in conjunction with one another could be further investigated in patients receiving IGRT to improve set-ups. Larger studies should be conducted in the future to further assess the correlation between step counts and set-ups. • Prostate cancer patients over the age of 18 receiving Image Guided Radiation Therapy at Gibb’s Cancer Center Spartanburg, SC were eligible to participate. • At the initial planning visit, participants received their initial CT, completed their informed consent and study survey (demographic and baseline exercise questions), and received their pedometer. • Participants were asked to complete the their step log on the days they received IGRT. The log included information about date, time of appointment, steps prior to appointment, and steps at end of day. • Participants were asked to continue walking and exercising as normal. • The study team had weekly check-in calls with patients asking for their step counts over the past week. • The study team collected CT scans at each IGRT visit for each participant. Introduction Methods

Successful set-up: CT showing a non-distended rectum with contours aligned acceptably

• Eleven patients were recruited for this study, only nine completed the entirety of the study. • Five patients had one or more unsuccessful set-up(s). • Four patients had unsuccessful setup first week of treatment.

Figure 2.

Figure 1.

Table 1. Comparison of demographic information .

Unsuccessful set-up: CT showing a distended rectum filled with gas and stool. Contours not aligned acceptably. Figure 3.

Figures 1, 2, and 3 courtesy of Amy Curtis, MD, Gibbs Cancer Center & Research Institute, Spartanburg, SC


Table 2 . Comparing the successful set-up group to the unsuccessful set-up group’s pre - treatment surveys (Fisher’s Exact Test)

• Results suggest activity level is not the only variable contributing to buildup of gas in the rectal vault. • Four of the seven incorrect set-ups were within the first week of treatment, suggesting patients were not properly counseled before start of treatment. • Osteopathic Manipulation Treatments aimed at increasing parasympathetic tone in the digestive tract to encourage flatulence should be studied. • Dietary factors in combination with exercise in IGRT patients should be further studied. • Larger studies should be conducted to assess the correlation between step counts and set-ups.

1.00 0.2781 0.2005 0.1416

• The comparison among the two groups were found to be insignificant. • The demographics and previous activity levels likely did not contribute to the success of their set-ups.


Table 3 . Comparing the successful set-up group to the unsuccessful set-up group’s pre -treatment surveys

1. Key Statistics for Prostate Cancer: Prostate Cancer Facts. American Cancer Society. cancer/about/key-statistics.html#:~:text=Risk%20of%20prostate%20cancer,rare%20in%20men%20under%2040. Accessed May 7, 2021. 2. HAUERJENSEN, M., WANG, J., & DENHAM, J. (2003). Bowel injury: Current and evolving management strategies. Seminars in Radiation Oncology , 13 (3), 358 – 371. 3. Gupta, T., & Narayan, C. A. (2012). Image- guided radiation therapy: Physician′s perspectives. Journal of Medical Physics , 37 (4), 174. 4. Bohrer, M., Schröder, P., Welzel, G., Wertz, H., Lohr, F., Wenz, F., & Mai, S. K. (2008). Reduced rectal toxicity with ultrasound-based image guided radiotherapy using Bat ™ (B-Mode Acquisition and targeting system) for prostate cancer. Strahlentherapie Und Onkologie , 184 (12), 674 – 678. 5. Maggio A, Gabriele D, Garibaldi E, et al. Impact of a rectal and bladder preparation protocol on prostate cancer outcome in patients treated with external beam radiotherapy. Strahlentherapie und Onkologie . 2017;193(9):722-732. doi:10.1007/s00066-017-1163-4 6. Villoria A, Serra J, Azpiroz F, Malagelada J-R. Physical Activity and Intestinal Gas Clearance in Patients with Bloating. The American Journal of Gastroenterology . 2006;101(11):2552-2557. doi:10.1111/j.1572-0241.2006.00873.x





534 – 17,154

191 – 19,520

• The unsuccessful setup group had on average more steps prior to treatment in each day and more steps at the end of each treatment day. • The successful setup group had a larger maximum number of steps in each day, and the unsuccessful group had a larger minimum number of steps in a given day. • p-value = 0.1416 • The results were not significant, therefore the null hypothesis cannot be rejected. Wilcoxon Rank Sum Test

IRB approval obtained by Spartanburg Regional Healthcare System IRB, Spartanburg, SC. IRB number: 1760609-4 IRB Date: September 9, 2021 Edward Via College of Osteopathic Medicine funded the pedometers Acknowledgements


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