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MASCC Recommendations for the Management of Constipation in Patients with Advanced Cancer

October 2019
Constipation is a common problem among patients with advanced cancer, with a reported prevalence of 32–87% in this group, in whom it also causes significant morbidity. Opioid-induced constipation appears to be a chronic side effect and is more common in patients with cancer pain than in those with nonmalignant pain. It may be influenced by the type of opioid involved, as well as by genetic factors, but does not appear to be particularly influenced by the dose of opioid.

MASCC’s Palliative Care Study Group formed a subgroup to develop evidence-based recommendations for the management of constipation in patients with advanced cancer. Following a search of Medline, the Cochrane Database of Systematic Reviews, and the Cochrane Central Register of Controlled Trials, recommendations were categorized by level of evidence as either “recommendation,” "suggestion,” or "no guideline possible.” The results, published in Supportive Care in Cancer (Davies et al, 20191), include 15 recommendations relating to the assessment, treatment, and re-assessment of constipation. The resulting paper gives an overview of constipation in patients with advanced cancer, the methodology involved in developing the recommendations, and the evidence to support the recommendations and grading of the evidence. These recommendations provide a framework for managing constipation in advanced cancer.

At the time the group started the project, there were no up-to-date guidelines on the management of constipation in patients with advanced disease. However, in the interim, the European Society for Medical Oncology (ESMO) published analogous guidelines. The MASCC recommendations complement the ESMO guidelines but provide more detailed guidance on the pharmacological management of refractory constipation.

Two recommendations were made with the highest level of evidence:

  • Conventional laxatives should be considered first-line treatment for patients with functional constipation.
  • Peripherally acting mu-opioid receptor antagonists (PAMORAs) should always be considered for patients with opioid-induced constipation.

The paper also contains numerous suggestions, including among others, that all patients with advanced cancer be regularly assessed for constipation and that management be individualized. Other suggestions pertain to re-assessment and/or management of patients with secondary, refractory, or resistant constipation, treatment of reversible causes, and lifestyle changes.

The authors note that the recommendations, whenever possible, were based on studies of patients with advanced cancer. When such data was not available, extrapolations were made from other groups of patients. They caution, however, that patients with advanced cancer are different from other groups of patients, including those with other life-limiting conditions. Further research is required to validate their recommendations.

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1Davies A, Leach C, Caponero R, Dickman A, Fuchs D, Paice J, Emmanuel A. MASCC recommendations on the management of constipation in patients with advanced cancer. Support Care Cancer. 2019 Aug 9 [Epub ahead of print]. The authors include Andrew Davies, MD, (Royal Surrey County Hospital, Guildford, UK), Charlotte Leach (Royal Surrey County Hospital, Guildford, UK), Ricardo Caponero (Hospital Alemão Oswaldo Cruz, São Paulo, Brazil), Andrew Dickman (Royal Liverpool Hospital, Liverpool, UK), D Fuchs (Kepler University Hospital, Linz, Austria), Judith Paice (Northwestern University, Chicago, IL, USA), and Anton Emmanuel (University College London Hospitals, London, UK).