Professor El-Omar has selected Professor Jervoise Andreyev from the United Lincolnshire Hospitals NHS Trust, Lincoln, UK and the University of Nottingham Medical School, Nottingham, UK, to do the next #GUTBlog. Professor Andreyev is the first author on this paper.

The #GUTBlog focusses on the guideline paper entitled “British Society of Gastroenterology practice guidance on the management of acute and chronic gastrointestinal symptoms and complications as a result of treatment for cancer” which was published in paper copy in GUT in July 2025.

Professor Jervoise Andreyev writes:

“For most of history, a diagnosis of cancer presaged an early death. So, understandably, in recent decades as oncological practice developed, research has almost entirely focussed on two areas, earlier diagnosis and better treatments. This approach has worked. Increasingly large numbers of people are surviving their cancer diagnosis for long periods.

However, the radical treatments which aim to cure cancer have a high risk of side effects. If severe, this often curtails or stops effective anti-cancer treatment. If ongoing, this may impact on life after cancer, have profound psychological effects and increase costs for individuals, families, society and healthcare. The costs of disability following cancer, dwarfs the costs of cancer treatment itself.

Of all side effects, gastrointestinal toxicities are frequent but often need a multidisciplinary approach. So, this guidance was co-authored by a 26 strong group which included gastroenterologists, surgeons, oncologists, palliative care physicians, nurses, dietitians and crucially, five people who have had cancer. These patients repeatedly reminded the professionals to keep this guidance practical and focused on patients’ priorities. Patients are not just interested in a treatment plan for their cancer, they need help for a variety of short and long-term issues caused by the cancer and its treatment.

While randomised trial data are scant, reflecting how neglected this aspect of care has been, the available data all point to the fact that standard assessment and treatment approaches that gastroenterologists use in other patient groups, if applied appropriately in affected patients can make a large difference and either allow cancer treatment to continue uninterrupted or improve impaired quality of life due to gastrointestinal dysfunction after the treatment has stopped.

This BSG-endorsed guidance document emphasises first, that specific symptoms are a very poor guide to the underlying cause. Secondly, that it is common for patients treated for cancer to have several causes for their symptoms simultaneously and that thirdly, unless all causes are identified and treated, people will not get better. Fourth, that accurate diagnosis of the reasons for new onset symptoms allows precise targeting of the treatment. “Typical” symptoms due to individual cancer treatments have long been believed to be inevitable and that symptomatic treatment is adequate; increasing evidence suggests that this is not correct; we should target the underlying mechanisms whereby these abnormal symptoms develop.

Cancer therapies frequently disrupt normal gastrointestinal physiological processes. It is the disruption of normal physiology which causes symptoms. Different treatments for cancer may trigger different physiological changes, but effective treatments for most of these are available once they are correctly diagnosed. The key is to be systematic and arrange the tests that people need at an early stage. Some examples: chemoradiation for pelvic cancer often causes lactose intolerance and/or bile acid diarrhoea and/or small intestinal bacterial overgrowth. Early diagnosis of these conditions even while the cancer treatment is ongoing, improves patient outcomes. While 80% of patients developing diarrhoea during immunotherapy have an inflammatory colitis, 20% do not and instead have issues such as exocrine pancreatic insufficiency and/or non-coeliac gluten sensitivity and/or microscopic colitis. Corticosteroids will not help them, instead a correct diagnosis can prevent interruption or discontinuation of the immunotherapy. Targeted cancer therapies such as Lenalidomide (an E3 ligase modulator) and Sorafenib (a widely used tyrosine kinase inhibitor) commonly cause GI symptoms. Lenalidomide causes diarrhoea by triggering (irreversible) bile acid malabsorption; while exocrine pancreatic insufficiency is frequently diagnosed in patients taking Sorafenib. Many cancer treatments are needed long-term, so it is essential that unpleasant side effects are minimised quickly.

This guidance document is patient focused and practical. It identifies the questions to identify patients who would benefit from gastroenterological assessment. It presents step by step management approaches for thorny issues: severe acute diarrhoea after chemotherapy; a rational approach for persistent diarrhoea after checkpoint inhibitor therapy; flow charts for assessing and treating patients with dysphagia, faecal incontinence, constipation, lower anterior resection syndrome and for those with bleeding radiation proctopathy. It has a section on the GI issues which occur after treatment for neuroendocrine tumours and one on managing GI symptoms in patients approaching the end of life. It lists 103 recommendations. Supportive care for patients with and after cancer could be a lot better. A step in the right direction will be when every unit has a gastroenterologist who says this is their specialist interest.”

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