Can an over-the-counter (OTC) enema pose a problem for a patient with colon and rectal cancer undergoing chemotherapy (chemo) and radiation therapy who is experiencing constipation?

From the Guidelines

I strongly advise against using an over-the-counter (OTC) enema for a patient with colon and rectal cancer undergoing chemotherapy and radiation therapy without first consulting their oncologist or healthcare provider. The patient's condition and ongoing treatments can cause inflammation and sensitivity in the rectal and colon tissues, making them more susceptible to complications from an enema, such as bleeding or perforation 1.

Considerations for Constipation Management

When managing constipation in patients with colon and rectal cancer, it is crucial to follow a stepwise approach that prioritizes assessment and treatment of underlying causes, as outlined in the NCCN clinical practice guidelines in oncology: palliative care 1. This includes:

• Assessing for cause and severity of constipation
• Ruling out impaction, especially if diarrhea accompanies constipation
• Treating other causes, such as hypercalcemia, hypokalemia, hypothyroidism, diabetes mellitus, and medications
• Adding and titrating bisacodyl 10-15 mg daily tid with the goal of 1 non-forced bowel movement every 1-2 days

Alternative Interventions

Instead of using an OTC enema, patients should consult their oncology team about their constipation, as they can recommend safer options, such as:

• Stool softeners (e.g., docusate sodium)
• Osmotic laxatives (e.g., polyethylene glycol)
• Prescription medications specifically tailored to their condition
• Adjusting pain medications if opioids are contributing to constipation
• Increasing fluid intake and adding fiber gradually to the diet
• Encouraging light physical activity if possible

Importance of Healthcare Provider Guidance

Given the potential risks and the need for personalized management, it is essential for patients to work closely with their healthcare team to develop a constipation management plan that is safe and effective in the context of their cancer treatment 1.

From the Research

Potential Risks of OTC Enemas for Patients with Colon and Rectal Cancer

• Patients with colon and rectal cancer undergoing chemotherapy and radiation therapy may experience constipation as a side effect of their treatment 2, 3.
• The use of over-the-counter (OTC) enemas to relieve constipation in these patients may pose a problem, as it can potentially disrupt the treatment regimen or exacerbate existing conditions.
• There is limited research specifically addressing the safety and efficacy of OTC enemas in patients with colon and rectal cancer undergoing chemotherapy and radiation therapy.

Treatment Considerations for Colon and Rectal Cancer

• Treatment for colon and rectal cancer often involves a combination of surgery, chemotherapy, and radiation therapy 3, 4, 5.
• The management of rectal cancer typically involves neoadjuvant radiation, either as long-course chemoradiotherapy or short-course radiation, followed by surgery and adjuvant chemotherapy 3.
• Patients with stage III colon cancer may receive adjuvant therapy with 5-fluorouracil and levamisole, while those with rectal cancer may receive combined modality therapy with radiation and chemotherapy 4, 5.

Risks and Complications Associated with Treatment

• Patients undergoing neoadjuvant chemotherapy for high-risk colon cancer may be at risk of bowel obstruction, with certain clinical and radiologic features increasing this risk 6.
• The use of radiation therapy and chemotherapy can also lead to other complications, such as toxicity and decreased quality of life 2, 3, 4, 5.
• It is essential to carefully consider the potential risks and benefits of any treatment, including the use of OTC enemas, in patients with colon and rectal cancer undergoing chemotherapy and radiation therapy.