British Society of Gastroenterology practice guidance on the management of acute and chronic gastrointestinal symptoms and complications as a result of treatment for cancer

Abstract

Background: Survival rates after a diagnosis of cancer are improving. Poorly managed gastrointestinal (GI) side effects can interfere with delivery of curative cancer treatment. Long-term physical side effects of cancer therapy impinge on quality of life in up to 25% of those treated for cancer, and GI side effects are the most common and troublesome.

Aim: To provide comprehensive, practical guidance on the management of acute and chronic luminal gastrointestinal symptoms arising during and after treatment for cancer METHODS: A multidisciplinary expert group including patients treated for cancer, divided into working parties to identify, and synthesise recommendations for the optimal assessment, diagnosis and appropriate interventions for luminal GI side effects of systemic and local cancer therapies. Recommendations were developed using the principles of the BMJ AGREE II reporting.

Results: 103 recommendations were agreed. The importance of the patient perspective and what can be done to support patients are emphasised. Key physiological principles underlying the development of GI toxicity arising from cancer therapy are outlined. Individual symptoms or symptom clusters are poor at distinguishing the underlying cause(s), and investigations are required if empirical therapy does not lead rapidly to significant benefits. Patients frequently have multiple GI causes for symptoms; all need to be diagnosed and optimally treated to achieve resolution. Investigations and management approaches now known to be ineffective or of questionable benefit are highlighted.

Conclusions: The physical, emotional and financial costs to individuals, their families and society from cancer therapy can be considerable. Identifying and signposting affected patients who require specialist services is the role of all clinicians. Progress in the treatment of cancer increasingly means that patients require expert, multidisciplinary supportive care providing effective and safe treatment at every stage of the cancer journey. Development of such expertise should be prioritised as should the education of health professionals and the public in what, when and how acute and chronic gastrointestinal symptoms and complications should be managed.

Keywords: bleeding; cancer; chemotherapy; diarrhoea; radiotherapy.

Figure 1. Extent of the holistic issues which may arise even after targeted therapy and should be considered in all patients after cancer treatment (adapted from the Pelvic Radiation Disease Association best practice pathway)

Figure 2. Abnormal GI symptoms develop as a result of changes to GI physiology.

Figure 3. A management approach to patients with faecal incontinence. SIBO, small intestinal bacterial overgrowth.

Figure 4. A management approach to those with constipation developing during or after cancer therapies. BAD, bile acid diarrhoea; FIT, faecal immunochemical test; RT, radiotherapy; SIBO, small intestinal bacterial overgrowth.

Figure 5. A recommended management approach to patients with acute, severe diarrhoea developing during chemotherapy. In patients with chronic symptoms consider whether any of the physiological abnormalities described as occurring during chemotherapy (table 3) have developed. CRP, C-reactive protein; FBC, full blood count; Mg, magnesium; MCS, microscopy, culture & sensitivity; OGD, oesophagogastroduodenoscopy; SI, small intestine; U&E, urea and electrolytes.

Figure 6. A management approach for those developing diarrhoea during or after checkpoint inhibitor therapy. CRP, C-reactive protein; CTC, common toxicity criteria; FBC, full blood count; LFT, liver function test; MC&S, microscopy, culture & sensitivity ; OGD, oesophagogastroduodenoscopy; TFT, thyroid function test; U&E, urea and electrolytes; VTE, venous thromboembolism.

Figure 7. A management approach to dysphagia after treatment for upper GI cancer. MDT, multidisciplinary team; NJ, nasojejunal; OGD, OGD, oesophagogastroduodenoscopy; OGJ, oesophago-gastric junction; PEG, percutaneous endoscopic gastrostomy; PEJ, percutaneous endoscopic jejunostomy; SIBO, small intestinal bacterial overgrowth .

Figure 8. A management approach to patients with rectal bleeding developing after pelvic radiotherapy for a cancer in the pelvis. MDT, multidisciplinary team.