Malignant Bowel Obstruction in Advanced Cancer

Management of inoperable malignant bowel obstruction using the 4-step BOUNCED diet

BACKGROUND

Malignant bowel obstruction (MBO) presents with multiple symptoms. The 4-step BOUNCED diet educates patients to self-manage oral intake according to symptoms. It includes clear fluids, thin liquids, purée and soft, sloppy foods, which are low in fibre.

METHODS

This mixed methods single-arm feasibility study aimed to establish if the diet could reduce MBO symptoms in patients with inoperable colorectal and gynaecological malignancies. The secondary objectives were to investigate if it was easily followed, improved quality of life (QOL) and reduced hospital admissions. Patients able to tolerate an oral diet with one or more symptoms (pain, bloating, early satiety, nausea and vomiting) were eligible. Following informed consent, an oncology dietitian took a diet history and determined which step of the diet they needed to follow using a detailed patient information leaflet. Patients remained on the trial for 28 days. Symptom and QOL data were collected on Days 1 and 28 using the Memorial Symptom Assessment Scale and the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC-QLQ-C30) questionnaires.

RESULTS

Thirty patients (24 female, 6 male) aged 18-85 years consented from March 2021 to November 2022. Twenty-six participants completed the trial and 25 found the diet very easy or easy to understand. There was a significant reduction in pain from 96% on Day 1 to 63% on Day 28 (p = 0.004). The mean increase of EORTC global health status/QOL was 23.5 points, 95% CI (12.4-32.5) (p ≤ 0.001). There was a significant difference between number of admissions (p = 0.018) and bed days (p = 0.004) in the 28 days prior to consent compared to the trial period.

CONCLUSIONS

A modified consistency low-fibre diet is easily followed, may reduce symptoms of MBO, admissions to hospital and improve QOL.

Can we improve the management of inoperable malignant bowel obstruction? Results of a feasibility study of elemental diet as an alternative to parenteral nutrition in patients with advanced gynaecological cancer

PURPOSE

Nutrition support in inoperable bowel obstruction (IBO) remains challenging. Parenteral nutrition (PN) is recommended if the prognosis is > 2 months. An elemental diet (ED) is licensed for strictures in Crohn's disease but has not been used in malignant bowel obstruction. The aim of this study was to evaluate the use of ED in patients with IBO and provide a proof of concept of ED as an acceptable feeding option.

METHODS

This was a mixed-methods single-arm feasibility study. The primary endpoint was to provide a 'proof of concept' of ED as an acceptable feeding option for patients with IBO. Secondary endpoints included taste acceptability, incidences of vomiting and pain, the proportion of women who tolerated ED, the number of cartons drunk, quality of life (QOL) and the number of women treated with chemotherapy. Patients (> 18 years) with CT-confirmed IBO who could tolerate 500 ml of liquid in 24 h remained on the trial for 2 weeks.

RESULTS

A total of 29 patients were recruited; of those, 19 contributed to the analysis for the primary endpoint; 13 (68.4%) participants tolerated the ED; 26 patients contributed to MSAS and EORTC QLQ questionnaires at baseline to allow for the assessment of symptoms. At the start of the study, 18 (69%) of patients experienced vomiting, reducing to 4 (25%) by the end of day 15 of the study; 24 (92%) of patients reported pain at consent, reducing to 12 (75%) by the end of day 15. QOL scores improved from 36.2 (95% CI 27.7-44.7) at baseline to 53.1 (95% CI 40.3-66) at the end of day 15; 16 (84%) participants commenced chemotherapy within the first week of starting ED. The number of cartons across all participants showed a median of 1.3 cartons per day (range 0.8 to 2.5).

CONCLUSION

ED is well tolerated by patients with IBO caused by gynaecological malignancies and may have a positive effect on symptom burden and QOL.

Malignant bowel obstruction: effectiveness and safety of systemic chemotherapy

OBJECTIVES

Although systemic chemotherapy is often administered to patients with malignant bowel obstruction (MBO), its benefit remains unknown. This study assessed the outcomes of patients who received systemic chemotherapy as part of MBO treatment.

METHODS

For this retrospective cohort study, data were extracted from records of patients hospitalised due to MBO in a tertiary cancer centre from 2008 to 2020. Eligible patients were not candidates for surgery and received systemic chemotherapy targeting the underlying malignancy causing MBO. Primary objective was to assess patient outcomes after chemotherapy; secondary objectives were rates of intestinal function recovery, hospital discharge and grade ≥3 toxicities. The primary endpoint was overall survival (OS).

RESULTS

A total of 167 patients were included: median age was 55 (18-81) years, 91% had an Eastern Cooperative Oncology Group (ECOG) performance status ≥2, 75.5% had gastrointestinal tumours and 70% were treatment-naive. The median OS after chemotherapy was 4.4 weeks (95% CI 3.4 to 5.5) in the overall population. No OS difference was observed according to treatment line (p=0.24) or primary tumour (p=0.13). Intestinal function recovery occurred in 87 patients (52%), out of whom 21 (24.1%) had a reobstruction. Hospital discharge was possible in 74 patients (44.3%). Grade≥3 adverse events occurred in 26.9% of the patients, and a total of 12 deaths (7%) attributed to toxicities were observed after chemotherapy.

CONCLUSIONS

MBO was associated with a dismal prognosis in this mostly treatment-naive population. The administration of chemotherapy yielded a significant risk of toxicities, whereas it did not appear to provide any relevant survival benefit in this scenario.

Management of Malignant Bowel Obstruction Associated With GI Cancers

For many patients with GI malignancies, the seeding of the abdominal cavity with tumor cells, called peritoneal carcinomatosis, is a common mode of metastases and disease progression. Prognosis for patients with this aspect of their disease remains poor, with high disease-related morbidity and complications. Uniform and proven practices that provide optimal palliative care and quality of life for these patients are needed. The objective of this review is to critically assess the current literature regarding palliative strategies in the management of peritoneal carcinomatosis and associated symptoms in patients with advanced GI cancers. Despite encouraging results in the select population where cytoreductive surgery and intraperitoneal chemotherapy are indicated, the majority of patients who develop peritoneal carcinomatosis in the setting of GI cancers have poor prognosis, with malignant bowel obstruction representing a common terminal phase of their disease process. For all patients with peritoneal carcinomatosis, aggressive symptom control and early multimodality palliative care as further outlined should be sought.