Constipation, a frequent and distressing side effect of cancer treatment, remains underdiagnosed and undertreated—particularly when driven by opioids. Opioid-induced constipation is distinct from functional constipation and requires tailored approaches to assessment and management.
Florian Scotté, MD, PhD
Jo Thompson, RN
Sebastiano Mercadante, MD
During a recent webinar hosted by the Multinational Association of Supportive Care in Cancer (MASCC), a panel of experts explored unmet needs in constipation care, with a focus on opioid-related etiology in oncology. Florian Scotté, MD, PhD, of Gustave Roussy Cancer Center, France; Jo Thompson, RN, of the Royal Surrey NHS Foundation Trust, United Kingdom; and Sebastiano Mercadante, MD, of La Maddalena Cancer Center, Italy, offered complementary perspectives on symptom burden, screening strategies, and patient-centered interventions in the diagnosis and management of opioid-induced constipation.
A Need for Clear Definitions and Communication
Prof. Scotté, current President of MASCC, opened the session by underscoring the lack of a clear, patient-centered definition of constipation, particularly in the context of opioid-induced cases. Although the Rome IV criteria now include opioid-related etiology, these definitions remain largely clinical, “maybe more for professionals than for patients,” he noted.1 However, visual tools such as the Bristol Stool Chart may help to bridge this gap, offering a more intuitive reference for patient discussions.
In addition, Prof. Scotté emphasized a persistent disconnect between objective metrics (eg, stool form/frequency) and subjective experience, with discrepancies in perception complicating clinical management. For example, patients may report “normal” bowel patterns despite reduced frequency or increased straining, making systematic screening essential.
In terms of prevalence, constipation affects 40% to 90% of patients with advanced cancer, depending on individual and treatment-related factors.2 Prof. Scotté distinguished between three key presentations of constipation in oncology: de novo opioid-induced constipation, worsening of preexisting constipation, and multifactorial cases involving other medications, comorbidities, or individual situations. Recognizing these distinct etiologies is critical to tailoring management, he stressed.
De novo cases may respond well to prophylactic strategies initiated along with opioids, whereas patients with preexisting constipation may require a more aggressive or layered approach. Multifactorial cases—common in older adults or those on polypharmacy—require careful evaluation of all contributing factors, including diet, hydration, neurologic function, and drug interactions. Clarifying the root cause not only informs treatment selection but also helps to avoid undertreatment or inappropriate escalation of interventions.
The burden of constipation has a measurable impact on cancer pain management. Prof. Scotté pointed to a study of 703 patients receiving opioid therapy for chronic pain and taking laxatives. A total of 81% reported constipation, 92% reported worsening pain from reduction or discontinuation of opioid treatment as a result of constipation, and 86% reported a moderate-to-severe impact on quality of life.3
These patterns were echoed in a 2021 survey of approximately 600 participants with cancer-related or chronic pain.4 Many patients reported skipping or reducing opioid doses because of constipation, even when experiencing ongoing pain. Of note, about 40% of those with cancer pain expressed dissatisfaction with how their constipation was managed—most often citing a lack of education or support from the health-care system. According to Prof. Scotté, these findings highlight a critical need for clearer, more proactive communication among patients, caregivers, and their care teams.
Listening, Normalizing, and Empowering
Ms. Thompson drew from her hands-on experience in oncology nursing to highlight practical challenges and opportunities in identifying and managing opioid-induced constipation. In both inpatient and outpatient settings, she often encounters two main patient profiles: those who have been taking opioids but are unknowingly constipated, and those who intentionally avoid opioids because of past distressing bowel symptoms, despite having uncontrolled pain.
“Some patients don’t realize they’re constipated,” she said, “because they’re still passing stool occasionally.” But a closer look often uncovers red flags such as incomplete evacuation, bloating, straining, and disrupted bowel patterns—classic signs of opioid-induced constipation. As Ms. Thompson emphasized, it’s not enough to ask, “Are you opening your bowels?” Instead, clinicians need to probe for changes in function since starting opioids.
One persistent theme, she noted, was the lack of prophylactic laxative prescribing at opioid initiation. “Patients simply weren’t advised to start laxatives,” she said. Ms. Thompson described how this oversight may trigger a cascade of symptoms that escalate pain, discourage adherence, and isolate patients socially. In her experience, many patients end up staying close to home out of anxiety.
The psychological toll is significant. “Many patients talk about the pain of straining; they talk about bloating,” she added, “but emotionally, they talk about not wanting to go out or be far from their own toilet.” For these patients, education and reassurance are essential. “They need to know it’s possible to manage both their pain and their bowels,” she said, an approach that can dramatically shift the trajectory of care.
Ms. Thompson shared a case study of “John,” a patient with metastatic lung cancer who was experiencing infrequent, incomplete bowel movements despite being on several laxatives. Rather than escalating treatment, the team first clarified his baseline bowel habits and simplified his overcomplicated regimen. Once the foundation was reset, they introduced naloxegol, a peripherally acting μ-opioid receptor antagonist designed to counteract opioid-induced bowel dysfunction, resulting in rapid symptom relief.
Ms. Thompson stressed that beyond medication, team communication and patient education were crucial. “It’s not just about the medications,” she noted. “It’s about listening to what the patient is telling us and aligning the entire team around a shared plan.” The case highlighted how personalized, coordinated care may restore function and improve quality of life, even in complex settings.
Therapeutic Options and Tailored Approaches
Dr. Mercadante addressed nonpharmacologic interventions, which are often underused but evidence-supported. “Besides drugs, simple advice and behavioral strategies may help,” he said. Dietary fiber combined with hydration may improve frequency and consistency of stool, though not all patients tolerate high-fiber diets.5
Physical activity also may play a meaningful role. “Encouraging light exercise may improve bowel function and overall well-being,” he said, citing controlled studies in cancer survivors.6 Additional tactics include scheduled toileting, biofeedback training, and pelvic floor exercises, with randomized data supporting their use.7,8
Finally, Dr. Mercadante emphasized that individualization must be at the heart of every treatment plan. “Always tailor interventions to the tumor type, treatment side effects, and overall health,” he advised. He also highlighted the importance of multimodal strategies that blend lifestyle changes, patient education, and pharmacologic therapies, coupled with ongoing reassessment to meet evolving needs.
Dr. Mercadante’s message echoed a central theme of the MASCC webinar: opioid-induced constipation is a common, complex, and often underaddressed issue in cancer care. From inconsistent definitions and subjective symptom reporting to gaps in prophylaxis and communication, the challenges are wide-ranging. Yet the tone remained one of pragmatic optimism. With simple language, systematic assessment, appropriate therapies, and coordinated care, clinicians can ease the burden of constipation—supporting both effective pain management and a better quality of life.
DISCLOSURE: Prof. Scotté has received a consultant or advisory board honoraria from Sanofi, Roche, MSD, Gilead Sciences, Helsinn, ProStrakan, LEO Pharma, Janssen, Viatris, Pharmanovia, Amgen, Immedica Pharma, La Roche-Posay, Pfizer, BMS, Daiichi Sankyo, Fresenius Kabi, Menarini, and Stemline Therapeutics. Ms. Thompson has served as a consultant, advisor, or speaker for Molteni, Gentili, and Sandoz; has received research grants from EU Horizon (2021–2024); and has reported affiliated associations with MASCC and the Serious Illness Care Program. Dr. Mercadante reported no conflicts of interest.
REFERENCES
1. Tack J, Drossman DA: What’s new in Rome IV? Neurogastroenterol Motil 29:10.1111/nmo.13053, 2017.
2. Larkin PJ, Cherny NI, La Carpia D, et al: Diagnosis, assessment and management of constipation in advanced cancer: ESMO Clinical Practice Guidelines. Ann Oncol 29(suppl 4):iv111-iv125, 2018.
3. Bell TJ, Panchal SJ, Miaskowski C, et al: The prevalence, severity, and impact of opioid-induced bowel dysfunction: Results of a US and European Patient Survey (PROBE 1). Pain Med 10:35-42, 2009.
4. Varrassi G, Banerji V, Gianni W, et al: Impact and consequences of opioid-induced constipation: A survey of patients. Pain Ther 10:1139-1153, 2021.
5. Carter HE, et al: Effect of dietary fiber supplementation on constipation in patients with cancer receiving palliative care: A randomized controlled trial. Support Care Cancer 22:87-91, 2014.
6. Buhmann H, Sorensen M, Tange UB, et al: Physical activity and bowel function in cancer survivors: A population-based study. Cancer Nursing 42:E22-E29, 2019.
7. Luo J, Song L, Li J, et al: Effectiveness of bowel training and toileting routine among hospitalized patients with cancer. J Palliat Care 33:95-99, 2018.
8. Müller B, Wendt M, Groneberg DA, et al: Biofeedback training for constipation in patients with cancer: A pilot study. Neurogastroenterol Motil 27:1045-1051, 2015.
