Editor’s note: One of a series of articles on managing cancer-related symptoms from the Oncology Nursing Society.

Constipation is a common but often unrecognized and undertreated problem for patients with cancer in the hospital, home, or palliative setting. Defined as a “decrease in the passage of formed stool characterized by stools that are hard and difficult to pass” (Bisanz, Woolery, & Eaton, 2009, p. 85), constipation symptoms often include abdominal pain, nausea and vomiting, abdominal distention, loss of appetite, and headaches (Cope, 2001; Petticrew, Rodgers, & Booth, 2001; Tamayo & Diaz-Zuluaga, 2004; Thompson, Boyd-Carson, Trainor, & Boyd, 2003), all of which have a negative effect on quality of life. The onset of constipation usually is linked to treatment, such as surgery or chemotherapy, and medications, diet, mobility, and care setting (that is, palliative or hospital). Constipation prevalence in oncology patients in palliative care settings may range as high as 40%-64% (McMillan, 2002; McMillan & Weitzner, 2000; Weitzner, Moody, & McMillan, 1997). That number increases to 70%-100% in hospitalized patients with cancer receiving treatment (McMillan & Tittle, 1995; McMillan & Williams, 1989; Tittle & McMillan, 1994). Patients suffering from constipation may have fewer than two or three bowel movements per week.

Oncology nurses may have difficulty determining if a patient is suffering from constipation. Self-report by patients would be the easiest determinant, but many patients self-manage their constipation and do not feel as if they need to report this sensitive issue to their healthcare providers. As constipation is very amenable to intervention, nurses must ask directed questions about bowel function.

Putting evidence into practice

To promote nursing practice that is based on evidence, the Oncology Nursing Society (ONS) launched the Putting Evidence Into Practice (PEP) program in 2005. ONS PEP teams consisting of advanced practice nurses, staff nurses, and a nurse scientist were charged with reviewing the literature to determine what treatments and interventions are proven to alleviate many cancer-related problems that are sensitive to nursing interventions. Each team classified interventions under the following categories: recommended for practice, likely to be effective, benefits balanced with harm, effectiveness not established, effectiveness unlikely, and not recommended for practice (Eaton & Tipton, 2009).

Recommended for practice

The ONS PEP team found that there was sufficient evidence from Portenoy et al. (2008) to recommend methylnaltrexone for opiod-induced constipation. Interventions categorized as recommended for practice are those for which there is strong evidence from rigorously designed studies, meta-analysis or systematic reviews and for which expectation of harm is small compared with the benefits.

Likely to be effective

The ONS PEP team found several avenues that were likely to be effective when treating patients with cancer suffering from constipation. To be classified as likely to be effective in the PEP program, an intervention must have effectiveness demonstrated by strong evidence from rigorously designed studies, meta-analyses, or systemic reviews. Also, expectation of harm must be small compared with benefits (Eaton & Tipton, 2009).

Polyethylene glycol: Evidence exists in the non-oncology population that supports the use of polyethylene glycol (PEG), with or without electrolytes, as a safe and effective way to treat constipation (Attar et al., 1999; Brandt et al., 2005; DiPalma, Cleveland, McGowan, & Herrera, 2006; Frizelle & Barclay, 2005; Petticrew et al., 2001; Ramkumar & Rao, 2005). However, a lack of evidence exists about this treatment’s effectiveness in patients with cancer. Electrolytes should not be administered if kidney function is compromised.

Prophylactic regimen for opioid-induced constipation: A proactive approach is recommended to prevent constipation in patients taking opioids (McNicol et al., 2003; Miaskowski et al., 2005; National Comprehensive Cancer Network [NCCN], 2009); however, the strength of the evidence in this area was not high enough to categorize it as recommended for practice.

Opioid rotation: Some opioids have less of a constipating effect than others (McNicol et al., 2003; Miaskowski et al., 2005; NCCN, 2009; Radbruch, Sabatwski, Loick, Kulbe, & Casper, 2000), and some research suggests that rotating opioid treatments may reduce this side effect. Examples include switching from a sustained-release oral morphine to a transdermal fentanyl patch (Ahmedzai & Brooks, 1997; Allan et al., 2001; McNicol et al., 2003; Miaskowski et al., 2005; Radbruch et al., 2000) or switching the opioid treatment to methadone to reduce laxative use (McNicol et al., 2003; Miaskowski et al., 2005).

Stimulant laxatives plus stool softeners: Although the approach of using a prophylactic regimen in patients receiving opioids is likely to be effective, the specific agents suggested are only based on expert opinion. In this area, it is suggested that 100-300 mg of docusate sodium in combination with senna (2-6 tablets twice a day) is a useful bowel regimen (Miaskowski et al., 2005). Specific laxative doses should be individually titrated for effectiveness (Bennet & Cresswell, 2003).

Other interventions

Many treatments in the ONS PEP resource are classified as benefits balanced with harms (healthcare providers must weigh the beneficial and harmful effects before initiating) or effectiveness not established (insufficient on conflicting data exist in the research). A full list can be found in Table 1.

Assessment

Because many patients fail to notify their healthcare providers about constipation, and because prevention is a key approach, nurses need to identify patients at risk for development of constipation. Several assessment tools are available to meet these needs, such as the Constipation Risk Assessment Scale (Richmond & Wright, 2008) and the Common Terminology Criteria for Adverse Events (National Cancer Institute Cancer Therapy Evaluation Program, 2006). In addition, follow-up monitoring is needed to evaluate the effectiveness of treatment.

Constipation will continue to be a poorly managed issue for patients with cancer unless oncology nurses use assessment tools to determine risk and if constipation is present, what the severity of it is, subsequently, how best to treat it, and how effective interventions are in preventing or managing it. Enacting evidence-based measures provided in the ONS PEP resources is a good first step in initiating care for patients with cancer suffering from constipation. PEP categories of recommended for practice and likely to be effective provide the best evidence currently available in this area.

Sean Pieszak is a copy editor in the publishing division at the Oncology Nursing Society in Pittsburgh, PA. More information about the ONS PEP classifications for constipation can be found at http://www.ons.org/Research/PEP/Constipation.

References

Ahmedzai, S., & Brooks, D. (1997). Transdermal fentanyl versus sustained-release oral morphine in cancer pain: Preference, efficacy, and quality of life. The TTS-Fentanyl Comparative Trial Group. Journal of Pain and Symptom Management, 13, 254-261.

Allan, L., Hays, H., Jensen, N.H., de Waroux, B.L., Bolt, M., & Donald, R. (2001). Randomised cross-over trial of transdermal fentanyl and sustained release oral morphine for treating chronic non-cancer pain. BMJ, 322, 1154-1158.

Attar, A., Lemann, M., Ferguson, A., Halphen, M., Boutron, M.C., Flourie, B., . . . Barthet, M. (1999). Comparison of a low dose polyethylene glycol electrolyte solution with lactulose for treatment of chronic constipation. Gut, 44, 226-230.

Bennett, M., & Cresswell, H. (2003). Factors influencing constipation in advanced cancer patients: A prospective study of opioid dose, dantron dose and physical functioning. Palliative Medicine, 17, 418-422.

Bisanz, A.K., Woolery, M.J., & Eaton, L.H. (2009). Constipation. In L.H. Eaton and J.M. Tipton (Eds.), Putting Evidence Into Practice: Improving oncology patient outcomes (pp. 93-104). Pittsburgh, PA: Oncology Nursing Society.

Brandt, L.J., Prather, C.M., Quigley, E.M., Schiller, L.R., Schoenfeld, P., & Talley, N.J. (2005). Systematic review on the management of chronic constipation in North America. American Journal of Gastroenterology, 100(Suppl. 1), S5-S21.

Cope, D.G. (2001). Management of chemotherapy-induced diarrhea and constipation. Nursing Clinics of North America, 36, 695-707.

DiPalma, J.A., Cleveland, M.B., McGowan, J., & Herrera, J.L. (2006). An open-labeled study of chronic polyethylene glycol laxative use in chronic constipation. Alimentary Pharmacology and Therapeutics, 25, 703-708.

Eaton, L.H., & Tipton, J.M. (Eds.). (2009). Putting Evidence Into Practice: Improving oncology patient outcomes. Pittsburgh, PA: Oncology Nursing Society.

Frizelle, F., & Barclay, M. (2005, December). Constipation in adults. Clinical Evidence, 2005, 557-566.

McMillan, S.C. (2002). Presence and severity of constipation in hospice patients with advanced cancer. American Journal of Hospice and Palliative Care, 19, 426-430.

McMillan, S.C., & Tittle, M. (1995). A descriptive study of the management of pain and pain-related side effects in a cancer center and a hospice. Hospice Journal, 10, 89-108.

McMillan, S.C., & Weitzner, M.A. (2000). How problematic are various aspects of quality of life in patients with cancer at the end of life? Oncology Nursing Forum, 27, 817-823.

McMillan, S.C., & Williams, F.A. (1989). Validity and reliability of the Constipation Assessment Scale. Cancer Nursing, 12, 183-188.

McNicol, E., Horowicz-Mehler, N., Fisk, R.A., Bennett, K., Gialeli-Goudas, M., Chew, P.W., . . . Carr, D. (2003). Management of opioid side effects in cancer-related and chronic noncancer pain: A systematic review. Journal of Pain, 4, 231-256.

Miaskowski, C., Cleary, J., Burney, R., Coyne, P., Finley, R., & Foster, R. (2005). Guideline for the management of cancer pain in adults and children. APS clinical practice guidelines [Series No. 3]. Glenview, IL: American Pain Society.

National Cancer Institute Cancer Therapy Evaluation Program. (2006). Common terminology criteria for adverse events [version 3.0]. Bethesda, MD: National Cancer Institute. Retrieved from http://ctep.cancer.gov/protocolDevelopment/electronic_applications/docs/ctcaev3.pdf

National Comprehensive Cancer Network. (2009). NCCN Clinical Practice Guidelines in Oncology™: Palliative care [v.1.2009]. Retrieved from http://www.nccn.org/professionals/physician_gls/PDF/palliative.pdf

Petticrew, M., Rodgers, M., & Booth, A. (2001). Effectiveness of laxatives in adults. Quality in Health Care, 10, 268-273.

Portenoy, R.K., Thomas, J., Boatwright, M.L., Tran, D., Galasso, F.L., & Stambler, N. (2008). Subcutaneous methylnaltrexone for the treatment of opoid-induced constipation in patients with advanced illness. A double-blind, randomized, parallel group, dose-ranging study. Journal of Pain and Symptom Management, 5, 458-468.

Radbruch, L., Sabatwski, R., Loick, G., Kulbe, C., & Casper, M. (2000). Constipation and the use of laxatives: A comparison between transdermal fentanyl and oral morphine. Palliative Medicine, 13, 111-119.

Ramkumar, D., & Rao, S.S. (2005). Efficacy and safety of traditional medical therapies for chronic constipation: Systematic review. American Journal of Gastroenterology, 100, 936-971.

Richmond, J.P., & Wright, M.E. (2004). Review of the literature on constipation to enable development of a constipation risk assessment scale. Clinical Effectiveness in Nursing, 8, 11-25.

Tamayo, A.C., & Diaz-Zuluaga, P.A. (2004). Management of opioid-induced bowel dysfunction in cancer patients. Supportive Care in Cancer, 12, 613-618.

Thompson, M.J., Boyd-Carson, W., Trainor, B., & Boyd, K. (2003). Management of constipation. Nursing Standard, 18(14-16), 41-42.

Tittle, M., & McMillan, S.C. (1994). Pain and pain-related side effects in an ICU and on a surgical unit. American Journal of Critical Care, 3, 25-30.

Weitzner, M.A., Moody, L.N., & McMillan, S.C. (1997). Symptom management issues in hospice care. American Journal of Hospice and Palliative Care, 14, 190-195.