Managing Constipation in the Cancer Care Setting

A cancer diagnosis brings many concerns to a patient’s mind, from the practical issues surrounding treatment and living with cancer to existential thoughts about mortality, legacy building, and what suffering or growth one might experience. Grappling with these challenges and changes and, at the same time, struggling with a basic bodily function— to have normal bowel movements—adds an unnecessary burden that diminishes the quality of life for our patients.

Despite the extensive literature and practice guidelines¹ that exist to manage constipation, this symptom is far too common; 60% of adult patients with cancer are constipated, as are up to 90% of patients with cancer taking opioids.² Nurses are instrumental to ensuring that a patient’s symptoms are assessed and managed to promote well-being, and patients with cancer who are experiencing constipation deserve our attention.

WHO IS AT RISK OF CONSTIPATION?

For patients with cancer, the many risk factors for constipation can be classified as organic, functional, or drug induced.^2,3 Organic causes of constipation often involve electrolyte abnormalities, neuropathies or myopathies, other diseases such as diabetes or Parkinson disease, and structural issues (eg, related to radiation or masses). Functional causes include decreased activity, reduced water or fiber intake, lack of privacy, and pain during defecation. Common categories of medications causing constipation are opioids, chemotherapy (alkylating agents, vinca alkaloids), antiemetics (5-HT3 receptor antagonists), antidepressants, anticholinergics, antacids, antihypertensives, diuretics, and iron-containing supplements.

Given the known symptom prevalence and risk factors above, can you think of a patient with cancer who should not be assessed for constipation?

ASSESSMENT—ROME III

Constipation is defined as incomplete defecation and/or infrequent bowel movements that are associated with persistent difficult and/or painful defecation, fecal incontinence, and abdominal pain.¹

A common tool for assessing constipation is the Rome III diagnostic criteria, in which a patient meeting any of these 2 symptoms for 12 or more weeks in the past year is considered to have functional constipation:

• Straining during bowel movements

• Lumpy or hard stool

• Sensation of incomplete evacuation

• Sensation of rectal blockage or obstruction

• Manual evacuation procedures

• Fewer than 3 bowel movements a week³

Other tools for assessing constipation exist, and there is no universally agreed-upon instrument to use in clinical practice. The criteria used should address the date of the patient’s last bowel movement, frequency of bowel movements, consistency of stool, recent changes in bowel patterns, the urge to defecate, sensation of evacuation, fecal incontinence, evidence of blood or mucus in the stool, current or previous laxative use, and the need for digital manipulation to facilitate evacuation.

Physical exam focuses on visualization of the abdomen, auscultation of bowel sounds, palpation, and a rectal exam. Contraindication to rectal exams include neutropenia and thrombocytopenia.

PREVENTION

If a patient is prescribed medications known to cause constipation, the nurse must advocate for preventative measures. Some nonpharmacologic interventions include increasing water intake, consuming foods high in soluble fiber, and getting physical exercise.²

When a patient is taking opioids, nurses should also advocate for pharmacologic intervention to prevent opioid-induced constipation. Recommended pharmacologic interventions can usually start with a stimulant laxative like oral senna (Senokot).

NUTRITIONAL HELP

Nurses can also advocate for increased roughage (found in high-fiber foods such as fruits, vegetables, dried fruits, and oatmeal) and increased fluid intake. The barriers to these suggestions may be that the patient may be experiencing anorexia, taste changes, or a decreased ability to consume adequate fluid intake.

BRINGING RELIEF TO PATIENTS

Nurses have an opportunity to champion the assessment and management of constipation, which causes distress and discomfort for so many patients with cancer. What elements of your practice could change to promote consistent and thorough assessment for constipation? Could the algorithm shared here be implemented in your practice setting?

References

• Tian H, Ding C, Gong J, et al. An appraisal of clinical practice guidelines for constipation: a right attitude towards to guidelines. BMC Gastroenterol. 2016;16(1):52. doi: 10.1186/s12876-016-0466-8.
• Wickham RJ. Managing constipation in adults with cancer. J Adv Pract Oncol. 2017;8(2):149-161.
• Larkin PJ, Cherny NI, La Carpia D, et al. Diagnosis, assessment and management of constipation in advanced cancer: ESMO Clinical Practice Guidelines. Ann Oncol. 2018;29(suppl 4):111-125. doi: 10.1093/annonc/mdy148.