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Diarrhea Assessment and Control:
Critical to Patient Quality of Life
and Treatment Outcomes
Diarrhea can commonly be observed in patients diagnosed with cancer, with the reported prevalence
varying based on the type of cancer.1 In colorectal cancer, for example, chronic recurrent diarrhea
is reported in approximately 50% of patients.2 Diarrhea is also observed in 30% to 66% of patients
with advanced medullary thyroid cancer (MTC).3,4 In addition to being associated with the underlying disease, diarrhea may also be related to cancer treatment. In the case of colorectal cancer, for
instance, the incidence of diarrhea of all grades may reach 82% during chemotherapy.5,6 In advanced
MTC, the frequency of diarrhea of any grade is reported up to 63% with targeted therapy.7,8
Impact of Diarrhea
T
he sequela of effects resulting from persistent diarrhea can be physiologically and psychologically
challenging, affecting overall quality of life (Table
1).1,9-13 If diarrhea is inadequately managed, secondary effects may be life-threatening.1,10
Diarrhea related to anticancer treatment may result in
dose reductions, treatment delays, or discontinuation of
treatment—which can ultimately affect survival.14,15 This
was demonstrated by studies in different tumor types, which
showed a relationship between decreased overall and diseasefree survival and reductions in medication dose intensity.16,17
Assessment of Diarrhea
Because of the numerous significant clinical implications,
thorough assessment is imperative to minimize the effects of
diarrhea and its potentially serious consequences.1,18 Given
that various factors can contribute to diarrhea in cancer patients, this assessment should include careful evaluation of
the underlying cause. In the case of advanced MTC, it is important to distinguish whether diarrhea is a manifestation of
the disease or is related to treatment with targeted therapy.14
To this end, a baseline assessment of bowel patterns prior to
initiation of treatment is imperative in advanced MTC.1,10,12
Role of the Oncology Nurse
The oncology nurse can play an important role in optimizing assessment of diarrhea, and thereby potentially minimize
the worsening of symptoms and/or avoid discontinuation of
therapy.14 Key steps in this optimization may include obtaining a detailed medical history of the patient, performing a
physical examination, and conducting laboratory tests.1,12
Patient medical history and evaluation
A detailed medical history of the patient should be obtained,
along with1:
• Background information about the patient’s disease
(eg, type and extent of cancer)
• Anticancer therapy
•Comorbidities
• Coexisting symptoms
• Complete medication list, including1,19,20:
–Laxatives
– Regular/as needed prescription medications
– Over-the-counter medications
– Recent antibiotic therapy
– Opioids (gastrointestinal function modulators)
– Herbal and vitamin supplements
The hallmark assessment tool is a patient’s report. The practitioner must probe for specific information, including1,10,13,21:
• Onset of diarrhea
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Diarrhea Assessment and Control • Summer 2014
• Frequency of diarrhea over the last 24 hours
• Volume of diarrhea
• Duration of diarrhea
• Consistency and color of stool
• Presence of blood
• Distinct odor change
•Incontinence
Published guidelines can aid in the appropriate assessment
of cancer- or cancer treatment-related diarrhea. Guidelines
available from the American Society of Clinical Oncology
(ASCO)10 and the Oncology Nursing Society (ONS)22 provide
a standardized approach for diagnosis and management of
diarrhea. The National Cancer Institute Common Terminology Criteria for Adverse Events (NCI CTCAE)23 provide the
standard classification and severity grading scale for adverse
events.12
NCI CTCAE define diarrhea as an abnormal increase in
the liquidity and frequency of stools.23 This standardized
scale grades diarrhea by the number of stools per day, incontinence, and increase in ostomy output compared to baseline
(Table 2).23
In addition to being assigned a clinical grade, diarrhea may
be categorized as uncomplicated or complicated (typically
applied to treatment-related diarrhea)19 to guide decisions on
appropriate interventions.10,12
• Uncomplicated diarrhea is described as grade 1 or 2 diarrhea with no other complicating signs or symptoms1,10
• Complicated diarrhea is described as grade 3 or 4 or grade
1 or 2 with additional symptoms, such as fever, sepsis, neutropenia, dehydration, and moderate-to-severe cramping1,10
Physical assessment allows for the identification of potential causes of diarrhea and its complications.10 Abdominal
examination includes1,19:
• Palpation for tenderness, distension
• Percussion for dullness, which may indicate obstruction,
fecal impaction
• Auscultation for bowel sound
The patient should also be assessed for abdominal pain or
cramping, nausea, vomiting, and fever.1,10
Additionally, hydration status should be evaluated because
it can be compromised in a person experiencing diarrhea.
Table 1. Potential Consequences
of Diarrhea1,12,13
Fatigue/lethargy
Fluid depletion
Dehydration
Electrolyte imbalances
Malnutrition
Renal insufficiency
Cardiovascular compromise
Hospitalization
Subjective symptoms of dizziness, weakness, excessive thirst,
and decreased urination are potential indicators of dehydration.1,10,13 These dehydration indicators may be confirmed by
objective assessment for orthostatic hypertension, weight
loss, skin turgor, and dry mucous membranes.1,10 It is recommended that patients be evaluated for dehydration throughout
their treatment.13
Laboratory analyses should include stool cultures to assess
for bacterial, fungal, and viral pathogens, as well as urinalysis
to aid in evaluating hydration status. In addition, a complete
chemistry panel and hematologic profile should be done to
provide information about the effect of diarrhea on kidney
function and electrolytes. It can also identify changes in white
blood cell count in response to infection.1
Upon diagnosis and initiation of treatment, patients should
understand the definition of diarrhea and when to report their
symptoms to their healthcare provider.24 Oncology nurses
should encourage patients to maintain a self-care log or diary
that tracks1,12:
• The number and consistency of stools
• Dietary intake
• Medications to manage diarrhea
• Associated symptoms
This information can provide additional clues regarding the
etiology of the diarrhea and its severity, assisting in the choice
of optimal treatment measures. Prompt reporting of symptoms
by the patient can also help minimize worsening of symptoms
and/or interruptions in therapy.14
Oncology nurses not only play a vital role in assessing cancer patients at risk for diarrhea, but also in implementing early
management and treatment approaches. With the appropriate
evidence-based practice and multidisciplinary approach, diarrhea in cancer patients may be managed effectively.12
Management of Diarrhea
Current evidence-based guidelines on the management of
treatment-related diarrhea are provided by ASCO and ONS.
While ONS guidelines outline only pharmacologic interventions for the management of diarrhea,13 ASCO guidelines provide pharmacologic and nonpharmacologic interventions for
uncomplicated and complicated diarrhea.10 Both guidelines
recommend dietary modifications and loperamide as first-line
treatment of diarrhea.12 Loperamide is also recommended by
the American Thyroid Association (ATA) guidelines for firstline management of MTC-related diarrhea.9 Alternative therapies may include treatment with somatostatin analogs or local
therapy to treat advanced MTC, which is often associated with
development of repetitive diarrhea.9 While guideline recommendations are summarized below, the reader is encouraged
to refer to the original guidelines for further details. Additionally, it is important to note that these guidelines address
the management of chemotherapy-induced diarrhea. Clinical
research in management of targeted therapy-related diarrhea
is lacking and could produce relevant management results.13
Uncomplicated mild-to-moderate diarrhea. The initial,
nonpharmacologic management of cancer-related, uncomplicated mild-to-moderate diarrhea is often empiric and non-
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Diarrhea Assessment and Control • Summer 2014
specific. In addition to being advised to eat frequent, small
meals,24 patients experiencing diarrhea should modify their
diet and fluid intake.
• Foods to avoid include all lactose-containing products,
alcohol, and sorbitol-containing products (eg, sugar-free
gum and candy) because they can cause diarrhea.10,13,24 Additional foods to eliminate are those that are spicy, fried,
greasy, or gas-inducing24,25
• Foods to eat: The patient may follow the BRAT (bananas,
rice, applesauce, toast) diet to decrease the frequency of
stools1,24,25
• Fluids to avoid include alcoholic beverages, as well as caffeinated and acidic drinks24
• Fluid intake: For rehydration and electrolyte repletion, the
patient should be instructed to increase clear fluid intake
(eg, water, apple juice, clear broth, sports drinks) to about
3 L each day1,13,24
As previously mentioned, aside from dietary modifications,
loperamide is recommended as the standard first-line therapy for
diarrhea.9,10,13,25 Loperamide may be given as a loading dose of
4 mg followed by 2 mg every 4 hours. According to ASCO
guidelines, treatment with loperamide may be discontinued
when the patient is diarrhea-free for 12 hours.10 If, however,
mild-to-moderate diarrhea persists for:
• >24 hours, the loperamide dose may be increased to 2 mg
every 2 hours. Oral antibiotics may also be initiated as
prophylaxis for infection10
• >48 hours while on loperamide (24 hours on high-dose),
treatment should be discontinued and a second-line antidiarrheal agent, such as octreotide (a somatostatin analog)
should be started.10 Depending on the type of anticancer
therapy and the patient’s constellation of symptoms, further
evaluation may be required with a complete stool and blood
workup to test for infections and electrolyte imbalances,
respectively10
Complicated or severe cases of diarrhea require aggressive
management. Patients with complicated or severe cases of
diarrhea are at high risk for dehydration, infection, and other
potentially life-threatening complications.10 If the patient
is severely dehydrated, administration of intravenous (IV)
fluids is recommended.10,26 Therapy with octreotide (100 to
150 µg subcutaneous 3 times a day or IV [25 to 50 µg/hour]
with dose escalation up to 500 µg until diarrhea is controlled)
and antibiotics (eg, fluoroquinolone) may be appropriate.10
Any patient who progresses to grade 3 or 4 diarrhea after
24 or 48 hours on loperamide should be treated as described
above.10
Depending on the type of anticancer treatment and the
patient’s symptoms, a full workup that includes a complete
blood count, electrolyte profile, and stool studies may be
conducted. For select patients, hospitalization may also be
necessary, or alternatively, intensive home nursing or management in an outpatient facility.10
Additional management approaches. Anticancer therapy
dose modifications or discontinuations may be necessary in
severe (ie, grade 3 or higher) cases of diarrhea.25 Careful monitoring of serum electrolytes and electrocardiograms may also
minimize risks associated with diarrhea, such as dehydration
Table 2. Common Terminology Criteria
for Adverse Events (v.4.03): Diarrhea23
GradeCharacteristic
1
Increase of <4 stools per day over
baseline; mild increase in ostomy output
compared to baseline
2
Increase of 4 to 6 stools per day over
baseline; moderate increase in ostomy
output compared to baseline
3
Increase of >7 stools per day over
baseline; incontinence; hospitalization
indicated; severe increase in ostomy
output compared to baseline; limited
self-care activities of daily living
4
Life-threatening consequences; urgent
intervention indicated
5Death
Adapted from the U.S. Department of Health and
Human Services. Common Terminology Criteria for
Adverse Events, version 4.03.2011
or cardiovascular morbidity. In addition, there is emerging
evidence for the potential efficacy of probiotics as pharmacologic intervention in patients with treatment-related diarrhea.13,27 Further studies are needed, however, to determine
the probiotic strain(s), dosage, and timing of administration
that would be most effective. Similarly, studies suggest that
fiber supplementation may be an effective approach for the
management of diarrhea but additional research is warranted
to assess the type and dosage of fiber.13
In summary, diarrhea can be an ongoing challenge for
cancer patients and may be life-threatening if inadequately
managed. Despite the high incidence and potential severity
of diarrhea in cancer patients, the condition is often underrecognized.
Oncology nurses are at the forefront of patient care and play
a vital role in the assessment and management of diarrhea. A
thorough evaluation of the patient combined with nutritional
management and pharmacologic measures may effectively
reduce complications associated with cancer- and treatmentrelated diarrhea. Vigilant monitoring and early intervention
can also minimize dose modifications or discontinuations of
anticancer therapies.
Finally, patient education, an open dialogue between the
patient and the healthcare team, and consistent incorporation
of evidence-based guidelines into clinical practice can further
optimize the management of diarrhea.
©2014 MedImmune, Specialty Care Division of AstraZeneca.
All rights reserved. 2988915 Last Updated 7/14
Expert content review was provided by Carolyn M. Grande,
CRNP, AOCNP, Nurse Practitioner, University of Pennsylvania
Abramson Cancer Center, Philadelphia, PA.
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Diarrhea Assessment and Control • Summer 2014
References
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2 Ramsey SD, Berry K, Moinpour C, Giedzinska A, Andersen MR.
Quality of life in long term survivors of colorectal cancer. Am J Gastroenterol. 2002;97(5):1228-1234.
3 Schlumberger MJ, Elisei R, Bastholt L, et al. Phase II study of safety
and efficacy of motesanib in patients with progressive or symptomatic, advanced or metastatic medullary thyroid cancer. J Clin Oncol.
2009;27(23):3794-3801.
4 National Cancer Institute. Genetics of endocrine and neuroendocrine
neoplasias (PDQ®). Multiple endocrine neoplasia type 2. http://www.
cancer.gov/cancertopics/pdq/genetics/medullarythyroid/HealthProfessional/page3. Accessed June 9, 2014.
5 Maroun JA, Anthony LB, Blais N, et al. Prevention and management
of chemotherapy-induced diarrhea in patients with colorectal cancer: a
consensus statement by the Canadian Working Group on Chemotherapy-Induced Diarrhea. Curr Oncol. 2007;14(1):13-20.
6 Kabbinavar F, Hurwitz HI, Fehrenbacher L, et al. Phase II, randomized
trial comparing bevacizumab plus fluorouracil (FU)/leucovorin (LV)
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Oncol. 2003;21(1):60-65.
7 Elisei R, Schlumberger MJ, Muller SP, et al. Cabozantinib in progressive medullary thyroid cancer. J Clin Oncol. 2013;31(29):3639-3646.
8 Wells SA, Jr, Robinson BG, Gagel RF, et al. Vandetanib in patients with
locally advanced or metastatic medullary thyroid cancer: a randomized,
double-blind phase III trial. J Clin Oncol. 2012;30(2):134-141.
9 Kloos RT, Eng C, Evans DB, et al. Medullary thyroid cancer: management guidelines of the American Thyroid Association. Thyroid.
2009;19(6):565-612.
10 Benson AB, III, Ajani JA, Catalano RB, et al. Recommended guidelines
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11 Tong H, Isenring E, Yates P. The prevalence of nutrition impact symptoms and their relationship to quality of life and clinical outcomes in
medical oncology patients. Support Care Cancer. 2009;17(1):83-90.
12 Shaw C, Taylor L. Treatment-related diarrhea in patients with cancer.
Clin J Oncol Nurs. 2012;16(4):413-417.
13 Muehlbauer PM, Thorpe D, Davis A, Drabot R, Rawlings BL, Kiker E.
Putting evidence into practice: evidence-based interventions to prevent,
manage, and treat chemotherapy- and radiotherapy-induced diarrhea.
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Support Oncol. 2005;3(3):227-232.
16 Kim SJ, Kim YJ, Kim JH, et al. Safety, compliance, and predictive
parameters for dosage modification in adjuvant S-1 chemotherapy for
gastric cancer. Cancer Sci. 2013;104(1):116-123.
17 Landgren O, Algernon C, Axdorph U, et al. Hodgkin’s lymphoma in the
elderly with special reference to type and intensity of chemotherapy in
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18 Morturano R. Management of chemotherapy-induced diarrhea. http://
www.oncolink.org/resources/article.cfm?id=1055. Accessed June 9,
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19 Furlow B. Assessing and treating radiotherapy-associated diarrhea.
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20 Chan LN. Opioid analgesics and the gastrointestinal tract. Pract Gastroenterol. 2008;32(8):37-50.
21 American Society of Clinical Oncology. Cancer.net. Diarrhea. http://
www.cancer.net/navigating-cancer-care/side-effects/diarrhea. Accessed
June 9, 2014.
22 Oncology Nursing Society. Preventing and treating diarrhea related
to chemotherapy and/or radiation therapy: Systematic review/metaanalysis table. http://www.ons.org/Research/PEP/media/ons/docs/
research/outcomes/diarrhea/review-table.pdf. Accessed June 9, 2014.
23 US Department of Health and Human Services. Common Terminology
Criteria for Adverse Events (CTCAE) v4.0. http://evs.nci.nih.gov/ftp1/
CTCAE/About.html. Accessed June 9, 2014.
24 American Cancer Society. Caring for the Patient With Cancer at Home:
A Guide for Patients and Families. http://www.cancer.org/acs/groups/
cid/documents/webcontent/002818-pdf.pdf. Accessed June 9, 2014.
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26 Cascinu S, Bichisao E, Amadori D, et al. High-dose loperamide in
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patients. Support Care Cancer. 2000;8(1):65-67.
27 FAO/WHO Joint Working Group. Guidelines for the Evaluation of
Probiotics in Food. http://www.who.int/foodsafety/fs_management/en/
probiotic_guidelines.pdf?ua=1. Accessed June 9, 2014.
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