Every week, I help patients address one of the most distressing symptoms of cancer and its treatment -- constipation.
Constipation is a distressing symptom often complicating the lives of people with specialist supportive and palliative care needs. Aside from pain and discomfort, it can cause nausea/vomiting, anorexia, urinary retention, anal fistulas, bowel obstruction, and in severe cases, even death.
Prevalence reports vary between studies and stages of illness, ranging from 50 percent of patients in the community, up to 90 percent of people at the time of admission in an inpatient setting. Other observational studies document that 60 percent of people in an inpatient setting were charted regular laxatives, despite only 30 percent of people having constipation listed as a problem on admission. More than 50 percent of this same group received more than two laxatives simultaneously.
What are the current approaches to addressing the symptom, and is there an alternative approach from a gastroenterology point of view? Despite the frequency with which constipation complicates the lives of cancer patients, the current approach to management is most remarkable for the number of people who fail to achieve adequate symptom control.
Reports suggest that:
- 40-70 percent of cancer patients treated with laxatives continue to experience symptoms
- 19 percent of people treated with laxatives continue to experience fewer than 3 bowel actions per week, regardless of which laxatives were prescribed
Laxatives are prescribed with the aim of restoring regular soft bowel actions, but they do not seem to be helpful for a lot of cancer patients. This is troubling, considering the negative impact of poorly treated constipation may be serious.
Aside from physical and personal costs, poorly treated constipation has a high social cost. Constipated cancer patients receive more community nursing support and present more often in the emergency department. When hospitalized, constipated patients have a longer length of stay and receive more nursing time.
Cancer Care Consensus practice guidelines recommend diagnosis and treatment based on the report of patients. History taking is important, including factors such as medications, reduced oral intake, and deteriorating status, and physical examination can be used to exclude rectal impaction. In addition, biochemistry and abdominal radiographs may be useful in diagnosing a bowel obstruction.
Once I have excluded bowel obstruction in a patient, I would commence the patient on stool softeners such as Lactulose, in combination with a stimulant (Senna). I would also correct under-hydration, tell the patient to have gentle exercises and sit in a position with their knees up on the toilet. If unsuccessful, I use rectal interventions or agents such as methylnaltrexone -- although I have experienced this not to be effective for all opioid-induced constipated patients.
Certain patients who have naturally slow transit colons, patients with irritable bowel syndrome, or a combination of both, may need regular enemas or suppositories.
Constipation remains a troublesome symptom among cancer patients. Increasingly, I feel this problem needs to be tailored towards each patient individually. What are your ideas surrounding this issue?
- Clark K, Currow DC, Talley NJ. The use of digital rectal examinations in palliative care in-patients. Journal of Palliative Medicine 2010; 13(7): 797-797
- Clark K, Currow DC. Plain radiographs to diagnose constipation in palliative care. Journal of Pain and Symptom Management 2011.
- Clark K, Lam L, Chye R, Currow D. Pilot study to document colonic slow transit times in palliative care inpatients. Asia-Pacific Journal of Clinical Oncology 2009;5(Suppl 2)