Chronic Diarrhea in Post-treatment Colorectal Cancer Survivors

Early detection of cancer and novel chemotherapy agents have resulted in longer survival following a colorectal cancer diagnosis. The American Cancer Society estimates that more than 1 million colorectal cancer survivors are living in the United States. The current 5-year survival rates for all stages of colon cancer and rectal cancer are 65% and 66%, respectively; therefore, monitoring patients for long-term sequelae of the cancer and its treatment is an essential need.[1] As people live longer, side effect management to ensure a good quality of life is paramount. This article will address the impact of chronic diarrhea in post-treatment colorectal cancer survivors.

Patient Overview

In March 2008, Mr. C., a 52-year-old school teacher, presented to his primary care physician with diarrhea and abdominal pain that had persisted over the past month. A colonoscopy revealed a 3-cm rectal lesion. Mr. C. underwent a transabdominal resection with colostomy and was diagnosed with T2, N2, M0 rectal carcinoma. He was enrolled in a clinical trial and received a regimen that included FOLFOX (5-FU, leucovorin, oxaliplatin [Eloxatin]) followed by continuous-infusion 5-FU and radiation therapy.

TABLE 1

Common Terminology Criteria for Diarrhea 3.0

While Mr. C. experienced Grade 1 diarrhea during treatment with the FOLFOX regimen, the problem intensified to Grade 3 toward the end of his radiation therapy (Table 1). The diarrhea improved throughout his recovery period, but as of March 2009, he continues to complain of four to six liquid stools per day. Mr. C. lives in a rural area and has been following up with his primary care physician. At this point, however, his diarrhea has been occurring for such a long period of time that he is reluctant to discuss it. The odiferous diarrhea occurs within an hour after eating, and he reports that it interferes significantly with his teaching position and social life. While he and his wife used to enjoy having dinner out with friends, he reports being reluctant to dine out. He has been staying at home on the weekends, and his wife is concerned that he is depressed.

Mr. C.'s social withdrawal prompted his wife to call the colorectal cancer navigator, a nurse whom they had met while Mr. C. was undergoing cancer treatment at the urban cancer center. The cancer navigator schedules an appointment for the couple to assess and discuss Mr. C.'s chronic diarrhea. Through comprehensive assessment, the navigator determines that Mr. C. has Grade 2 diarrhea that is affecting his activities of daily living. Diet history reveals that he drinks a double espresso latte each morning and a double iced coffee beverage at lunch each day. His diet is also low in fiber. The navigator discusses the influence of caffeine on bowel motility and recommends decaffeinated beverages until the diarrhea improves. She informs Mr. C. that milk products may also be contributing to the problem. The BRATTY diet (bananas, plain rice, applesauce, plain toast, tea, and yogurt) is discussed as a short-term intervention, along with a low-dose loperamide regimen.

Mr. C. returned home and tried the BRATTY diet for 4 days, in conjunction with a bulk-forming agent with adequate hydration, and a low-dose loperamide regimen. The frequency of his diarrhea decreased to once or twice daily. He gradually introduced other foods as tolerated but eliminated caffeine and milk from his diet. One year later, he is back teaching full time and reports good control of the diarrhea. He is no longer taking loperamide but continues with recommended dietary management. He and his wife are once again enjoying social time with friends.

Defining the Problem

Diarrhea is defined as a condition of frequent and watery bowel movements.[2] Unfortunately, limited research exists that examines chronic diarrhea in cancer survivors. The incidence of chronic diarrhea varies from 14% to 49% and episodes of diarrhea can persist for up to 10 years post-treatment.[3] Rectal cancer survivors report more chronic diarrhea than colon cancer survivors.

Several barriers may interfere with acknowledgement of and attention to this deleterious symptom. First, patients may become used to experiencing the diarrhea during treatment and may feel that it is a natural consequence of colorectal disease. Second, follow-up visits may continue with primary health care providers who are less familiar with long-term toxicities such as diarrhea and its management.[4]

Significance of the Problem

Managing a life with chronic diarrhea can be challenging both psychosocially and socially, and colorectal survivors report experiencing significant distress related to severe diarrhea.[4] One study noted that when respondents mentioned problems with chronic diarrhea, they also tended to report more frequent thoughts of dying, limits in their activities, and more discomfort which, in turn, had an impact on quality of life.[5] Patients who reported symptoms associated with diarrhea also reported other issues, including fear, poor body image, and problems with self-confidence.[3] In addition, persons who received radiation therapy for rectal cancer were at a higher risk of diarrhea, and this symptom had an impact on both their social functioning and ability to carry out activities of daily living. Another study reported that some patients who underwent radiation for rectal cancer developed a lumbosacral plexopathy which not only contributed to pain that was difficult to control, but also caused bowel dysfunction leading to fear of disease recurrence.[6]

Etiology

The problem of chronic diarrhea in colorectal cancer survivors is multifactorial. The greatest risks include a history of radiation therapy and the type of surgery employed. First, radiation effects such as cellular damage and scarring or fibrosis can lead to bowel absorption problems that contribute to diarrhea.[7] In rectal cancer treatment, both pre- and postoperative radiation increased the risk of chronic bowel problems.[8] These problems included increased frequency of bowel movements, incontinence, pad wearing, and inability to defer having a bowel movement. Symptoms can be apparent for up to 5 years post-treatment, with some individuals reporting anorectal dysfunction even 10 years post radiation.[9] Second, type of surgical intervention is important to note. One study revealed that those who underwent an anterior resection reported more diarrhea urgency and frequency, and those who had a stoma placed were also at greater risk.[10] The higher the stoma is located in the gastrointestinal tract, the greater the likelihood of diarrhea problems. Achieving bowel regularity and preventing odiferous diarrhea were reported difficulties in adapting to the ostomy. Education and provision of resources at time of surgery are imperative for patients who receive radiation therapy or have an anterior resection or permanent ostomy, as they may be more prone to frequent loose stools.[4]

Management of Diarrhea

Dietary modification, medications, and naturopathic alternatives are mainstay therapies to ameliorate the problem. The BRAT diet of bananas, plain rice, applesauce, and plain toast, recommended by the National Cancer Institute, or the BRATTY diet (BRAT plus tea and yogurt)[11] can be recommended. Both diets provide many beneficial nutrients and are fairly tolerable. Bananas replace potassium lost in the large volume of stool, while rice and toast contain healthy starches and sugars that normally bulk stool. Applesauce contains the natural bulking agent pectin. Yogurt in the BRATTY diet contains both protein and active cultures to maintain the natural flora in the colon, thereby promoting bowel movement regularity. It is important to confirm that the yogurt consumed does contain active cultures and that it is naturally sweetened, if possible, as artificial sweeteners can cause or exacerbate diarrhea. For both the BRAT and BRATTY diets, rice and toast should be eaten plain, because additives such as butter and spices may actually worsen diarrhea. Patients should drink decaffeinated rather than caffeinated teas, as caffeine can stimulate the bowel and increase the likelihood of diarrhea.

Food limitations and dietary management can be difficult, especially for those who will have permanent ostomies. Nurses must assess what portion of the intestine remains, to determine how best to educate patients about what foods may be appropriate or lead to diarrhea. In addition, dietary recommendations should be balanced and not lead to further malnutrition.[12]

TABLE 2

Antidiarrheal Agents

Medications[13] and naturopathic alternatives such as probiotics[14–16] can be explored to help prevent diarrhea and restore normal bowel function. While most antidiarrheal medications are not recommended for long-term use, loperamide, because of its low toxicity profile, has been used long-term at low doses.[17] If individuals use antidiarrheal agents, nurses and doctors should emphasize to these patients that they need to follow up closely and regularly with a physician, to explore alternative solutions to their diarrhea. Table 2 highlights a variety of agents that help to prevent or control diarrhea.

Nursing Implications

Because nurses are on the front lines of patient care, we must be aware of diarrhea as a long-term potential complication in colorectal cancer survivors. Diarrhea assessment, patient education, and psychosocial support are primary nursing responsibilities.

First, nurses should conduct a comprehensive diarrhea assessment in colorectal cancer survivors at each follow-up visit. Nurses should ask not only about the number of stools per day but also should inquire about the volume of diarrhea the patient is experiencing, and its impact on daily living. A grading scale such as the Common Terminology Criteria for Adverse Events (CTCAE) is often used to determine the severity of the patient's diarrhea (Table 1).[2]

TABLE 3

Dietary Recommendations for Diarrhea

Second, nurses should educate patients about the need to report diarrhea early in the course of their colorectal cancer management. Without education and encouragement to report symptoms, survivors may feel the problem is inevitable and may not address their concerns at follow-up visits. In addition, care and follow-up may be shifted from an oncologist to a primary care provider, who may not fully understand the side effects of treatments. This can create a barrier for cancer survivors seeking help for a chronic condition like diarrhea.[3] Resources regarding medication management, dietary modifications, and ostomy support also need to be given on initial diagnosis, to help survivors cope throughout the disease trajectory. A dietary guide is included in Table 3.

Third, dealing with chronic diarrhea and the many dietary and medical treatments to control it can be time-consuming and very difficult for survivors, leading to their withdrawal from normal activities of daily living and in turn resulting in social isolation. Therefore, nurses play a primary role in psychosocial care through acknowledgement of symptoms, guidance through treatment options, and support. While studies of the long-term side effect of diarrhea in colorectal cancer survivors are limited, there is a consistent negative correlation with quality of life for those who suffer from this chronic complication.[18]

Overall, as increasing numbers of patients live longer following a colorectal cancer diagnosis, it is important that physicians and nurses take steps to help them improve their quality of life. In the case of colorectal cancer survivors, this can often be achieved through optimal management of diarrhea.

Financial Disclosure:The authors have no significant financial interest or other relationship with the manufacturers of any products or providers of any service mentioned in this article.