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. 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.
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.
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. 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. 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.
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. 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. Patients who reported symptoms associated with diarrhea also reported other issues, including fear, poor body image, and problems with self-confidence. 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.