The use of steroids in the management of inoperable intestinal obstruction in terminal cancer patients: do they remove the obstruction?

Abstract

This multicentre, randomized double-blind study was undertaken to assess the efficacy of corticosteroids as a palliative treatment of intestinal obstruction due to advanced and incurable cancer. Thirty-one French palliative care units agreed to participate in the study and 12 actually recruited at least one patient. To be included, patients had to have an advanced cancer with a surgically inoperable bowel obstruction and to have received no specific anticancer therapy within the preceding 28 days. They had to fulfil at least three of the following criteria: vomiting at least twice a day; colicky abdominal pain; no flatus for 12 h or more; no stool for at least 4 days, faecal impaction being excluded; intestinal distension; air-fluid levels or absence of gas in the colon on an abdominal radiograph. Patients were randomized in three groups to receive either a placebo for 3 days (group A), or methylprednisolone 240 mg daily for 3 days (group B) or methylprednisolone 40 mg daily for 3 days (group C). Symptoms were assessed daily but success or failure of the treatment was assessed on day 4, according to the disappearance or persistence of symptoms. Fifty-eight patients were randomized, of whom 52 were able to be evaluated. Details of symptoms and associated treatments are described below. Of 40 patients without a nasogastric tube, symptoms were relieved in 68% of cases versus 33% among placebo-treated patients (P = 0.047). In 12 patients who had a nasogastric tube already in place, the results are less significant (60% versus 33% with P = 0.080). Because of the small sample size, no conclusions can be reached about the relative efficacy of low versus high-dose treatment regimes.

Predictors of survival in patients with non‐curative stage IV cancer and malignant bowel obstruction

“…Median survival for patients with an ECOG score of 0-1 (n ¼ 15) was 222 days, which is much higher than the predicted 1-to 3-month survival that is expected with a diagnosis of MBO [4][5][6][7][8][9]. However, perhaps the most important information that this study has generated is the attenuated survival for patients with an ECOG score of 2 despite the fact that 7/9 patients received further treatment.…”

“…Prolonged survival was demonstrated for select patients with an ECOG score of 0/1 and who were able to receive either surgery and/or chemotherapy as opposed to supportive care only with two patients living over 800 days (one had surgery alone, one had chemotherapy and surgery) compared to the reported median survival of 3 months of patients with non-curative cancer and a MBO [4][5][6][7][8][9]. We and others have previously demonstrated that patients who are able to receive palliative chemotherapy do have a prolonged survival and that surgery can act as a bridge to palliative chemotherapy [10] [11].…”

Role of Steroids in Malignant Bowel Obstruction

“…Laval et al 14 reported a randomized double-blind prospective study in patients with MBO. In this study, methylprednisolone 40 or 240 mg was administered once a day intravenously over 1 hour for 3 days.…”

“…Outcomes were not statistically significant and because of the small sample size, no conclusion was made regarding dosage and efficacy. 14 Laval et al 15 recommended use of steroids in peritoneal carcinomatosis with a dose of 1-4 mg/kg/day methylprednisolone and 0.25-1 mg/kg/day dexamethasone once a day intravenously or subcutaneously for a short course (5-10 days). They suggested steroids be started at the time of diagnosis and continued if symptoms improve or with resolution of bowel obstruction.…”

Treating Adult Cancer Pain in Primary Care

“…For patients with recurrent obstruction and advanced disease, medical management of symptoms is preferable [SORT B]. 33 Colicky pain responds to antispasmodic agents. Opioids relieve constant pain but also decrease peristalsis, which contributes to constipation.…”