Nutrition in Oncology

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Nutrition in Oncology

Dr. Anushree LoyalAssistant ProfessorDepartment of Radiation OncologySri Ram Cancer Centre, Mahatma Gandhi Hospital

Introduction

• Most common question asked by the cancer patients in clinics: “What should I be eating?”

• Zebrack surveyed 879 young adult cancer patients and survivors. Most of them stated need for more instruction on diet and nutrition. Yet, surprisingly, approximately 50% of respondents voiced that their educational needs regarding nutrition remained unmet.

Zebrack B. Information and service needs for young adult cancer survivors. Support Care Cancer 2009; 17:349–357

Significance of nutrition in oncology

• One of the significant nutritional issue that arise during cancer is malnutrition.

• The salient point is that, unlike simple malnutrition, the negative energy balance and skeletal muscle loss observed in cancer patients is driven by a combination of reduced food intake and metabolic derangements which may be host- or tumor-derived

Magnitude of Problem in cancer patients

• Regardless of cancer type, the overall prevalence of malnutrition in cancer is about 40%, and has remained constant for last 30 years.

• Malnutrition alone is the cause of death in 5-25% patients.

• Independently of treatment, weight loss greater than 15% in a cancer patient is constantly associated with poorer prognosis.

Righini CA et al. Assessment of nutritional status at the time of diagnosis in patients treated for head and neck cancer. Eur Ann Otorhinolaryngol Head Neck Dis.2013;130(1):8-14

P. Senesse et al. Nutritional support during curative treatment of patients with gastrointestinal(GI) cancer:who could benefit? Cancer Treat Rev 34(2008),pp.568-575

Impact of Malnutrition

• Impairment of immune functions• Depression, fatigue and malaise• Decreased performance status, muscle function, and quality of life.• Responses to treatment are decreased• Treatment induced toxicity and complications are more frequent and

severe• Metabolic derangements like obesity and insulin resistance are associated

with increased risks of cancer recurrence • Survival times are shortened• Significant healthcare-related costs (High rates of hospital re-admission and

longer Hospital stays)

Causes of Malnutrition

• Disease Related:

• Decreased dietary intake

• Increased requirements

• Increased loss of nutrients

• Impaired nutrient digestion / absorption

• Treatment Related

• Host response to the tumour

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Anorexia

• “A” – “without”, “o and rexis” Greek word for “appetite”; anorexia; meaning to be without appetite

• Anorexia is defined as the loss of the desire to eat and may result from theoccurrence of changes in smell, generalized alterations of taste (i.e.,dysgeusia), specific alterations of taste (e.g., meat aversion), early satiety,or nausea and vomiting.

Cancer cachexia

• Derived from the Greek ‘kakos’ meaning bad & ‘hexis meaning condition.

• Occurs in ~ 70% of patients during the terminal course of disease

• Cachexia : complex metabolic events

• Anorexia : simple nutritional deficiency

Cachexia vs anorexia (starvation)

• Glucose homeostasis• Increase gluconeogenesis• Increase glycolysis from muscle and

tumour• Glucose intolerance:Insulin resistance

• Altered Protein Metabolism• Increase muscle catabolism• Decrease muscle protein synthesis:

Muscle wasting : asthenia• Negative nitrogen balance

• Altered Lipid Metabolism • Increase lipolysis• Decrease lipogenesis• Hypertriglyceridemia

METABOLIC DYSREGULATION

Screening and assessment

B1-1 Screening

Strength of recommendation

STRONG

To detect nutritional disturbances at an

early stage, we recommend to regularly

evaluate nutritional intake, weight change

and BMI, beginning with cancer diagnosis

and repeated depending on the stability of

the clinical situation.

Level of evidence Very low

Questions for research relationship of screening to assessment

Interventions and clinical outcomes

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Screening Tools

• Aims to increase awareness and allow early recognition and treatment.

• Brief, inexpensive, and highly sensitive and specificity.

• For this purpose BMI (body mass index = body weight/length2), weight loss, and an index of food intake may be obtained directly

• Validated nutrition screening tools:

• Nutrition Risk Screening 2002 (NRS-2002)- Inpatient

• Malnutrition Universal Screening Tool (MUST)- Ambulatory

• Mini Nutritional Assessment Short Form Revised- Geriatric patients

B1-2 Assessment


STRONG

In patients with abnormal screening, we

recommend objective and quantitative

assessment of nutritional intake, nutrition

impact symptoms, muscle mass, physical

performance and the degree of systemic

inflammation.


Questions for research Linking outcomes from current and future

intervention trials with appropriate screening

and assessment tools

Nutritional AssessmentNutritional Assessment• Anthropometric measurements: Weight, Amount of weight change, BMI –

Weight (kg )/height (m2), Body circumference and areas.• Assessment of muscle and fat reserves

• Dual X-ray absorptiometry (DEXA)• Computed tomography scans at lumbar level 3• Bioimpedance analysis (BIA)

• Biochemical analysis: Laboratory tests (Albumin, Prealbumin, Transferrin, Retinol binding protein)

• Clinical Evaluation: • Historic information: Medical/health, Medication, Social and personal

history• Physical examinations

• Dietary Assessment (Food and fluid records, diet history, food recalls /visual/verbal analogue scales.)

Malnutrition Score for at risk patients• Assessment of Body Resource and Function: Frequently used nutrition

assessment tools :

• Subjective Global Assessment (SGA)

• Patient Generated Subjective Global Assessment (PG-SGA)

• Minimal Nutrition Assessment (MNA)

• Combine qualitative and semi-quantitative data to yield a comprehensive “malnutrition score”.

• The extent of systemic inflammation :

• Serum C-reactive protein (CRP) and albumin

• Modified Glasgow Prognostic Score (mGPS)

Energy and substrate requirements

B2-1 Energy Requirements


STRONG

We recommend, that total energy expenditure of cancer patients, if not measured individually, be assumed to be similar to healthy subjects and generally ranging between 25 and 30 kcal/kg/day.

Level of evidence Low

Questions for research improve prediction of energy requirements in the individual patient

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Nutrition prescription

Estimation of nutrient needs

• Indirect Calorimetry

• Harris Bennedict uses age , height and weight to estimate BEE ,the minimum amount of energy needed by body at rest in fasting state

• BEE is multiplied by activity factor and injury factor to predict total daily energy expenditure.

• This is important because feeding malnourished patinets with hypercaloric diet will not increase weight but lead to undesired metabolic effects.

B2 - 2 Protein requirement


STRONG

We recommend that protein intake

should be above 1 g/kg/day and, if

possible up to 1.5 g/kg/day

Level of evidence Moderate

Questions for research effect on clinical outcome of increased

supply (1-2 g/kg/day) and composition of

protein/amino acids

• In patients with acute or chronic renal failure protein supply should not exceed 1.0 or 1.2 g/kg/d, respectively.•The role of supplementation with glutamine is still

controversial.

B2 - 3 Choice of energy substrates


STRONG

In weight-losing cancer patients with insulin resistance

we recommend to increase the ratio of energy from fat to

energy from carbohydrates. This is intended to increase

the energy density of the diet and to reduce the glycemic

load.


Questions for research effect of a high fat diet on clinical outcome in patients

with systemic inflammation/insulin resistance effect of

varying the fat composition

• Fat emulsions supply essential fatty acids,: energy dense (low energy dense intake limited due to low appetite, early satiety, reduced bowel motility in cancer patients)

• N-6 PUFA: associated with an increase in the production of proinflammatory eicosanoids eg soybean and olive oil emulsions

• N-3 fatty acids enriched emulsions: Competitive antagonism with N-6 fatty acids, decrease inflammatory activity.

• Replacing glucose with fat in PN: Less chances of infection and deleterious effect of glucose on positive water balance is negated

• American Cancer Society: In view of the restricted dietary pattern of tumor patients, the use of a multivitamin-multimineral supplement in physiological doses, i.e. nutrient amounts that approximately equal the recommended daily allowance, is a useful and safe measure.

• The supplementation of vitamins and trace elements is obligatory after a parenteral nutrition of more than 1 week.

• Use of single high-dose micronutrients should be avoided (eg alternative medicine: in meta-analysis found no protective effects of antioxidants but a slightly raised mortality in subjects consuming b-carotene, vitamin A, or vitamin E)

• Abrogation by the vitamins of the exercise-induced improvement in insulin resistance.

• Failed trials: Vit D, Vit E, Selenium, Vitamin C

B2 -4 Vitamins and trace elements


STRONG

We recommend that vitamins and minerals be

supplied in amounts approximately equal to the

RDA and discourage the use of high-dose

micronutrients in the absence of specific

deficiencies.


Questions for research Assessment of micronutrient status in cancer

patients and effect of supplementation

• Specific harms may include secondary micronutrient deficiency, exacerbation of malnutrition, and high cost.

• There are no diets known to reproducibly cure cancer or prevent cancer recurrence

B3-2 Potentially harmful diets


STRONG

We recommend to not use dietary

provisions that restrict energy intake in

patients with or at risk of malnutrition.


Questions for research Effects of fasting or fasting mimicking

diets on wanted and unwanted effects of

anticancer agents

Nutrition interventions

B3 -1 Efficacy of nutritional intervention


STRONG

We recommend nutritional intervention to

increase oral intake in cancer patients who are able

to eat but are malnourished or at risk of

malnutrition. This includes dietary advice, the

treatment of symptoms and derangements

impairing food intake (nutrition impact symptoms),

and offering oral nutritional supplements.


Questions for research effect of dietary advice and ONS on clinical

outcome

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Guidelines for the use of parenteral and enteral nutrition in adult and pediatric patients. JPEN 17 (Suppl 4): 7SA, 1993

Forms of nutritional support

• Nutrition counselling : First form of nutritional support

• Nutritional counselling includes nutritional history, diagnosis, and nutrition therapy by trained nutrition professionals

• Offering supportive interventions to improve oral food intake (egtreating mucositis and other symptoms), digestion (e.g. pancreatic enzymes) or absorption (e.g. slowing of rapid gastrointestinal transit), antiemetics, and other relevant conditions.

• Additional use of oral nutritional supplements (ONS) is advised when an enriched diet is not effective in reaching nutritional goals.

When to Escalate

B3 -3 Modes of nutrition: when to escalate


STRONG

If a decision has been made to feed a patient,

we recommend enteral nutrition if oral

nutrition remains inadequate despite

nutritional interventions (counselling, ONS),

and parenteral nutrition if enteral nutrition is

not sufficient or feasible.


Questions for research effect of EN or PN or combinations on clinical

outcome in patients with inadequate food

intake

Enteral Nutrition• Nutrition delivered via the gut

• Patients with an accessible and functional gastrointestinal tract, enteral nutrition should be used

• Benefit over Parenteral nutrition:

• Supports gut immune function

• Maintains balanced luminal microfloral environment.

• Prevents cholelithiasis

• Improves outcome after chemo- and radiation therapy

• Disadvantages:

• GI, metabolic, and mechanical complications—tube migration; increased risk of bacterial contamination; tube obstruction.

• Costs more than oral diets (not necessarily)

• Labor-intensive assessment, administration, tube patency and site care, monitoring

Contraindications for enteral nutrition

• Mechanical obstruction of GIT

• Prolong ileus

• Severe GI haemorrhage

• High-output GIT fistula (>500 ml/day)• Severe acute pancreatitis

• Inability to gain access

• Intractable vomiting or diarrhea

• Inadequate resuscitation or hypotension; hemodynamic instability

• Expected need less than 5-7 days if malnourished or 7-9 days if normally nourished

Access for Enteral Nutrition

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Methods of delivery

• Bolus feeding: Infusion of up to 500 ml of enteral formula into the stomach over 15-20 minutes, usually by gravity or with a large-bore syringe.• Recommended for gastric feedings, Requires intact gag reflex and Normal gastric function

• Intermittent bolus feeding: Typically 200-300 ml is given over 30-60 minutes q 4-6 hours• Intolerance to bolus administration• Initiation of support without pump

• Continuous feeding: Initiation of tube feeding range from 20-50ml/hr and progression of 10-20ml/hr every 8-24 hrs until the desired volume is attained.• Compromised gastric function • Feeding into small bowel

Enteral Feeding protocol

• Starter regimens using reduced initial feed volumes are unnecessary in patients who have had reasonable nutritional intake in the last week. Diluting feeds risks infection and osmolality difficulties.

• Both inadequate or excessive feeding may be harmful. Dietitians or other experts should be consulted on feed prescription

• Switch to a calorically dense product to decrease total volume needed

• Tighten glucose control to <200mg% to avoid gastroparesis from hyperglycemia

• Flush the feeding tube, especially before and after medication administration and bolus/intermittent feedings

• Use liquid formulations of medicines where possible and avoid crushing sustained-release or enteric-coated tablet

• To avoid risk of aspiration:

• Keep head of bed elevated 30-45 degrees during and 30-40 minutes after feedings• Use of promotility agents

Selection Of Feeding Formula

• The suitability of a feeding formula should be evaluated based on

• Functional status of GI tract

• Physical characteristics of formula (osmolality, fiber content, caloricdensity, viscosity)

• Macronutrient ratios

• Digestion and absorption capability of patient

• Specific metabolic needs

• Contribution of the feeding to fluid and electrolyte needs or restriction

• Cost effectiveness

ENTERAL FORMULA : CATEGORIES

• Standard/ Polymeric formulas

• Elemental and semi-elemental Formulas

• Disease Specific Formula

• Modular diet

Polymeric/Standard Formula

•Polymeric formulas are lactose-free and most of them containno gluten. Since nutrients are not hydrolyzed, the osmolality isreasonably close to the physiological levels (300 mOsmol l1),which is a plus for enhanced tolerance

•Nutritionally complete enteral formulas when provided inadequate volume, usually meet 100% of the RDA forvitamins,minerals and trace elements.

• Choose full strength, isotonic formulas for initial feeding regimen.

• Diluting formulas may increase the risk of microbial contamination → intolerance due to diarrhea.

Elemental Formulas

• Nutritionally complete

• Protein equivalent and fats (medium chain triglycerides – MCTs) are broken down to their simplest form, making them easier to digest.

• Pre-digested formulas; which is why they require minimal digestive function (intestinal fistula, radiation enteritis, short bowel syndrome)

• Are Fiber Free

• Due to multiple small particles, it is highly osmotic 500-900 mOsm/L causing osmotic diarrhea.

• Poor taste (caused by amino acids) usually compromises oral ingestion

• Higher cost when compared to polymeric formulas

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Semi-Elemental Formulas

• Contain amino acids of varying length, simple carbohydrates, and MCTs

• Partially pre-digested but not fully pre-digested.

• Low osmolality

• Peptamen AF®

Specialized Formulas

• Nutritionally complete products

• Designed to meet the needs of individuals with specific health conditions

• Cancer Induced Weight Loss Recommendations :

• High protein and Zn to build muscle

• Low fat to avoid early satiety

• Low in sucrose for better patient acceptance

• High in fermentable fibers, Eicosapentaenoicacid (EPA), Antioxidants (vitamins A, C, E and Se), Folate and iron for anemia

Modular Formula

• Contain macronutrients either as single agents or in combination

Parenteral Nutrition

• Total Parenteral Nutrition:

• Indications:• Severely malnourished patients in whom gastrointestinal or other toxicities preclude

adequate enteral intake for 7 to 10 days or longer• Enterocutaneous fistula.• Patients with hepatic or renal failure.• Acute radiation and chemotherapy enteritis. • Use of perioperative total parenteral nutrition. • Short bowel syndrome.

• Not Indicated:• In well-nourished or mildly malnourished patients undergoing chemotherapy, radiation

therapy, or surgery. • In patients with rapidly progressive malignant disease who fail to respond to treatment. • TPN should NOT be used to prolong life if death is inevitable

Delivery of TPN

• For energy only, intravenous sugar solutions with dextrose or glucose are generally used. This is not considered to be parenteral nutrition as it does not prevent malnutrition when used on its own.

• The ratio of calories to nitrogen must be adequate (at least 100 to 150 kcal/g nitrogen)

• Two materials must be infused simultaneously as there is significant decrease in nitrogen utilization if they are infused at different times.

• The basic solution should contain 20% to 25% dextrose and 3% to 5% crystalline amino acids from the commercially available kits/solutions.

• If unavailable, use D5W at the same rate of infusion.

• Lipid emulsions are not only an important source of energy, but also prevent development of essential fatty acid deficiency.

• Rate of TPN should be based on the severity of undernourishment for moderate- to high-risk patients. TPN should be initiated slowly and titrated up for four to seven days. All patients require close monitoring of electrolytes (daily for one week, then usually three times/week).

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Complications of TPN

• Mechanical (pneumothorax, laceration of the subclavian artery, air embolism, brachial plexus injury, chylothorax, hemothorax),

• Metabolic (hyperglycemia, fluid overload, hypertriglyceridemia, hypercalcemia, hypoglycemia),

• Infectious (catheter sepsis)- frequent cause for febrile neutropenia. Most common by staph epidermidis & Staph aureus.

• Thrombotic (catheter occlusion, subclavian vein thrombosis).

• Hepatobiliary complications: Raised ALP, aminotransferases, cholecystitis, cholelithiasis.

• Changes in gut microflora and Impaired gut immune function

• Metabolic bone disease (>3months TPN)

Refeeding Syndrome

• Refeeding syndrome is caused by rapid refeeding after a period of malnutrition, which leads to metabolic and hormonal changes characterized by electrolyte shifts (decreased phosphate, magnesium, and potassium in serum levels) that may lead to widespread cellular dysfunction.

• High-risk patients include the chronically undernourished and those with little intake for more than 10 days.

• The syndrome usually occurs 24 to 48 hours after refeeding has started.

• Lead to muscle weakness, respiratory failure, paralysis, coma, cranial nerve palsies, and rebound hypoglycemia.

B3 -4 Refeeding syndrome


STRONG

If oral food intake has been decreased severely

for a prolonged period of time, we recommend to

increase (oral, enteral or parenteral) nutrition only

slowly over several days and to take additional

precautions to prevent a refeeding syndrome.


Questions for research Assessment of phosphate, potassium and

magnesium levels in malnourished cancer patients

and response to artificial feeding

Partial Parenteral Nutrition

• Simultaneous intravenous nutrition with enteral nutrition

• Critically ill patients without symptoms of malnutrition, who probably cannot be adequately nourished enterally for a period of <5 days, do not require full PN but should be given at least a basal supply of glucose.

• Critically ill patients should be nourished parenterally from the beginning of intensive care if they are unlikely to be adequately nourished orally or enterally even after 5–7 days.

• Energy supply should not be constant, but should be adapted to the stage, the disease has reached.

• Hyperalimentation should be avoided at an acute stage of disease in any case.

Home Artificial Nutrition

B3-5 Home artificial nutrition


STRONG

In patients with chronic insufficient dietary

intake and/or uncontrollable malabsorption,

we recommend home artificial nutrition

(either enteral or parenteral) in suitable

patients


Questions for research Effect of long-term EN and PN on clinical

outcome

Exercise Training

• Supervised or home-based moderate-intensity training (50-75% of baseline maximum heart rate or aerobic capacity), three sessions per week, for 10-60 min per exercise session.

B4-1 Exercise in combination with nutrition


STRONG

We recommend maintenance or an increased level of

physical activity in cancer patients to support muscle

mass, physical function and metabolic pattern.

Level of evidence High

Questions for research effect of physical activity before, during and after

anticancer treatment on clinical outcome, effect of

combining an exercise program with nutritional support

in curative and palliative settings

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• Physical activity decreases muscle catabolism and increase anabolism and also has the potential to reduce inflammation, all important pathophysiological factors in cancer cachexia.

B4-2 Type of exercise recommended


WEAK

We suggest individualized resistance

exercise in addition to aerobic exercise to

maintain muscle strength and muscle mass.


Questions for research Differential and combined effects of

resistance and endurance exercise on clinical

outcome during anticancer therapy, in

survivors and as a component of supportive

and palliative care

Pharmaconutrients and pharmacological agents• “Pharmaconutrients” are nutrients supplied in pharmacological doses to

modulate immune and metabolic functions and exert effects on clinical outcome.• Pharmacological Agents: Following categories of agents:

• Antiemetics• Antimicrobials• Analgesics• Agents to induce saliva production in xerostomia• Anti-secretory agents to diminish excessive saliva production or vomiting in

cases of impaired intestinal transport• Inhibitors of gastric acid secretion • Agents to maintain or normalize intestinal motility and to treat or avoid

constipation or diarrhoea• Antidepressants, agents that relieve anxiety, mood modulators

Corticosteroids

• The anti-anorectic effect of corticosteroids is transient (for a few weeks)

• Corticosteroids may be more suitable for patients with a short life expectancy, especially if they have other symptoms that may be alleviated by this class of drugs such as pain or nausea

B5-1 Corticosteroids to increase appetite


WEAK

We suggest considering corticosteroids to

increase the appetite of anorectic cancer

patients with advanced disease for a restricted

period of time (1-3 weeks) but to be aware of

side effects (e.g. muscle wasting, insulin

resistance, infections).


Progestins

• Progestins (megestrol acetate and medroxyprogesterone acetate) increase appetite and body weight but not fat-free mass; they may induce impotence, vaginal spotting, and thromboembolism.

• Optimal dose is between 480 and 800mg per day.

B5-2 Progestins to increase appetite


WEAK

We suggest considering progestins to

increase the appetite of anorectic cancer

patients with advanced disease but to be

aware of potential serious side effects (e.g.

thromboembolism).


N-3 Fatty Acids

• EPA and fish oil: Data suggest that at least 2 g/day are required for clinical benefit on nutrition-related endpoints

• Mixed results

• Systematic review published in 2007 included non-randomized clinical trials in addition to RCT and concluded that an intake of >1.5 g/day of long-chain fatty acids improved appetite, bodyweight, post-surgical morbidity, and quality of life in weight-losing cancer patients

• Ibrutinib has been associated with epistaxis in patients taking fish oil supplements; therefore, patients receiving ibrutinib should be counselled to avoid fish oil supplements.

B5-7 N-3 fatty acids to improve appetite and body weight


WEAK

In patients with advanced cancer undergoing

chemotherapy and at risk of weight loss or

malnourished, we suggest to use supplementation with

long-chain N-3 fatty acids or fish oil to stabilize or

improve appetite, food intake, lean body mass and body

weight.


Questions for research Effect of long chain N-3 fatty acids on clinical outcome

in cancer patients undergoing antineoplastic treatment

and QOL

B5-8 Prokinetic drugs to improve early satiety


WEAK

In patients complaining about early satiety,

after diagnosing and treating constipation, we

suggest to consider prokinetic agents, but to be

aware of potential adverse effects of

metoclopramide on the central nervous system

and of domperidone on cardiac rhythm


Questions for research Effect of prokinetics on oral nutritional intake

in the context of optimal nutritional counselling

Prokinetics

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B5-3 Cannabinoids to improve appetite


e

There are insufficient consistent clinical

data to recommend cannabinoids to

improve taste disorders or anorexia in

cancer patients


B5-5 Amino acids to increase fat free mass


e


data to recommend the

supplementation with branched-chain or

other amino acids or metabolites to

improve fat free mass.


B5-6 Non steroidal antiinflammatory drugs

(NSAID) to increase body weight


e

There are insufficient consistent clinical data

to recommend non-steroidal antiinflammatory

drugs to improve body weight in weight losing

cancer patients.


Interventions relevant to specific patient categories• Surgery

• Chemotherapy

• Radiotherapy

Surgery

• Data from Vanderbilt University demonstrate that nutritional deficiency preoperatively is a strong predictor of 90-day mortality and poor overall survival.

• Insulin resistance is a major variable influencing length of stay , poor wound healing and increased risk of infective complications

• Methods which reduce the insulin resistance include adequate pain relief, avoiding a prolonged period when oral intake is interrupted, and the use of carbohydrate loading.

C1-1 Enhanced recovery after surgery (ERAS) care


STRONG

For all cancer patients undergoing either curative or

palliative surgery we recommend management within

an enhanced recovery after surgery (ERAS) program;

within this program every patient should be screened for

malnutrition and if deemed at risk, given additional

nutritional support.


• The key domains of such a programme include minimal opiate-based pain control, early mobilisation, early return of GI function and, where possible, minimal access (laparoscopic) surgery.

• Nutritional components of ERAS include avoiding fasting, pre-operative fluid and carbohydrate loading, and recommencement of oral diet on the first postoperative day

C1-2 Surgery: Multimodal oncological pathway


STRONG

For a patient undergoing repeated surgery as part of a

multimodal oncological pathway, we recommend

management of each surgical episode within an ERAS

program.


C1-3 Postsurgical care and care after hospital

discharge


STRONG

In surgical cancer patients at risk of malnutrition

or who are already malnourished we recommend

appropriate nutritional support both during

hospital care and following discharge from

hospital.


C1-4 Immunonutrition (arginine, N-3 fatty acids,

nucleotides) in perioperative care


STRONG

In upper GI cancer patients undergoing surgical

resection in the context of traditional

perioperative care we recommend oral/enteral

immunonutrition.


Radiotherapy

• Individualized nutritional counselling by a trained professional

• The aims of the nutritional counselling should be to supply energy and protein requirements, to minimize weight loss, and to maintain quality of life; there are no recommendations for specific foods or supplements like antioxidants.

• In RCT, compared to standard care, counselling or ONS alone improved energy intake, protein intake, and quality of life during treatment. However, only the counselled patients maintained this improved status for 3 months after radiotherapy.

• Follow-up for a mean of 6.5 years in the colorectal cancer patients demonstrated an improved survival in the patients who received nutrition counselling during radiotherapy.

• The guideline of the Clinical Oncological Society of Australia recommends weekly contacts by dieticians during radiotherapy of head and neck cancers and follow-up every 2 weeks for at least 6 weeks

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C2-1 Radiotherapy: Ensuring adequate nutritional

intakeStrength of recommendation

STRONG

We recommend that during radiotherapy (RT) e

with special attention to RT of the head and neck,

thorax and gastrointestinal tract e an adequate

nutritional intake should be ensured primarily by

individualized nutritional counselling and/or with

use of oral nutritional supplements (ONS), in order

to avoid nutritional deterioration, maintain intake

and avoid RT interruptions


C2 e 2 Radiotherapy: Use of tube feeding


STRONG

We recommend enteral feeding

using naso-gastric or percutaneous

tubes (e.g. PEG) in radiation-induced

severe mucositis or in obstructive

tumors of the head-neck or thorax.


C2-3 Radiotherapy: Maintaining swallowing function


STRONG

We recommend to screen for and manage dysphagia and

to encourage and educate patients on how to maintain their

swallowing function during enteral nutrition.


• Dysphagia or swallowing dysfunction has been reported in 30-50% of head and neck cancer patients treated with intensive radio(chemo)therapy. These patients are at risk of pneumonia and sepsis.

• Assessment of all patients at risk for swallowing difficulties before and during treatment and regularly during follow-up, and that all patients with dysphagia be prescribed professionally supervised swallowing exercises.

• If enteral nutrition is required, patients should be encouraged to continue to swallow and patients should be weaned from artificial nutrition as quickly and safely as possible

C2-4 Radiation-induced diarrhea: glutamine


e


data to recommend glutamine to prevent

radiation-induced enteritis/diarrhea,

stomatitis, esophagitis or skin toxicity.


C2 e 5 Radiation-induced diarrhea:

probiotics


e


data to recommend probiotics to reduce

radiation-induced diarrhea.


• Unconditional use of PN in all patients undergoing radiotherapy carries more risk of harm than benefit and, therefore, is not recommended.

• The use of PN is indicated if oral/enteral food tolerance is insufficient to supply the required amounts of energy and nutrients. This is the case with chronic severe enteral food intolerance (like untreatable nausea, vomiting, abdominal pain, malabsorption, or diarrhea) that cannot be overcome by tube feeding.

C2-6 Radiotherapy: Use of parenteral nutrition


STRONG

We do not recommend parenteral nutrition (PN) as a

general treatment in radiotherapy but only if adequate

oral/enteral nutrition is not possible, e.g. in severe

radiation enteritis or severe malabsorption


Medical OncologyC3 -1 Medical oncology: Ensuring adequate

nutrition


STRONG

During anticancer drug treatment we

recommend to ensure an adequate

nutritional intake and to maintain physical

activity.


Questions for research Effects of nutritional intervention during

cytostatic and targeted therapies on

treatment tolerance, response to

treatment and overall survival

• Weight stabilisation for patients with gastro-intestinal and lung cancers is correlated with significant improvements in survival.

• In patients undergoing allogeneic bone marrow transplantation for hematologic malignancies, reduced rates of lethal acute graft-versus-host disease were observed with parenteral nutrition regimens containing a high content of long-chain fatty acids.

C3-2 Medical oncology: Use of enteral and

parenteral nutrition


STRONG

In a patient undergoing curative anticancer drug

treatment, if oral food intake is inadequate despite

counselling and oral nutritional supplements (ONS),

we recommend supplemental enteral or, if this is not

sufficient or possible, parenteral nutrition.


C3-3 Medical oncology: Use of glutamine


e

There are insufficient consistent

clinical data to recommend glutamine

supplementation during conventional

cytotoxic or targeted therapy.


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• Factors responsible for muscle weakness and muscle loss: Malignancy, pre-HCT therapy, immobilization during HCT, and side-effects of drugs like corticosteroids.

• RCT: after high-dose chemotherapy and autologous HCT, patients assigned to daily 30-minute ergometer training responded with higher maximal physical performance, but also less neutropenia, thrombopenia, diarrhoea, and pain at discharge as well as a shorter length of hospital stay.

• Therefore, it is recommended that patients be encouraged and supported to perform muscle training and to increase their physical activity before, during, and after HCT

Medical oncology: High-dose chemotherapy andhematopoietic stem cell transplantation (HCT)

C4 -1 High-dose chemotherapy and HCT: Ensuring

adequate nutrition and physical activity


STRONG

During intensive chemotherapy and after stem

cell transplantation we recommend to maintain

physical activity and to ensure an adequate

nutritional intake. This may require enteral

and/or parenteral nutrition.


Questions for research Effects of physical activity on clinical outcome

C4-2 High-dose chemotherapy and

HCT:

Enteral and parenteral

nutrition

Strength of

recommendation

WEAK

If oral nutrition is inadequate

we suggest preferring enteral

tube feeding to parenteral

nutrition, unless there is severe

mucositis, intractable vomiting,

ileus, severe malabsorption,

protracted diarrhea or

symptomatic gastrointestinal

graft versus host disease

(GvHD).


Questions for

research

Comparing efficacy of enteral

vs parenteral nutrition on

clincal outcome and

complication rates

C4-4 High-dose

chemotherapy and

HCT: Glutamine

Strength of

recommendation

e

There are insufficient

consistent clinical data to

recommend glutamine to

improve clinical outcome

in patients undergoing

high-dose chemotherapy

and hematopoetic stem

cell transplantation.


Questions for

research

Effect of glutamine on

mucositis, diarrhea, clinical

infections, graft versus

host disease and

malignancy relapse rate

C4-3 High-dose chemotherapy and HCT:

Low bacterial diet


e

There are insufficient consistent clinical data to

recommend a low bacterial diet for patients more than 30

days after allogeneic transplantation


Questions for research Definition of factors predicting beneficial effects of a low

bacterial diet

Comparing benefits of food safety guidelines vs

neutropenic diet

• The guidelines for infection prevention of the U.S. Centers for Disease Control (CDC) recommend no special food after the neutropenic phase of HCT.

• There is no published evidence to support a low bacterial diet during the neutropenic phase, and it is, therefore, difficult to argue for a germ-free diet after leucocyte engraftment.

• However, as opposed to the use of neutropenic diets, the emerging practice to minimize the risk of food borne infections appears to be to emphasise strict adherence to food safety guidelines, which recommend hand washing and also safe steps in food shopping, storage, preparation, thawing, cooking, serving, refreezing, and cold storage

Cancer SurvivorsC5-1 Cancer survivors: Physical

activity


STRONG

We recommend that cancer

survivors engage in regular

physical activity.


C5 e 2 Cancer survivors: Body weight and

lifestyle


STRONG

In cancer survivors we recommend to

maintain a healthy weight (BMI 18.5-25 kg/m2)

and to maintain a healthy lifestyle, which

includes being physically active and a diet

based on vegetables, fruits and whole grains

and low in saturated fat, red meat and alcohol.


C6 -1 Advanced cancer: Screening and assessment


STRONG

We recommend to routinely screen all patients with advanced

cancer for inadequate nutritional intake, weight loss and low body

mass index, and if found at risk, to assess these patients further for

both treatable nutrition impact symptoms and metabolic

derangements.


C6 -2 Nutrition support in patients with

advanced cancer

Strength of

recommendation

STRONG

We recommend offering and

implementing nutritional interventions

in patients with advanced cancer only

after considering together with the

patient the prognosis of the malignant

disease and both the expected benefit

on quality of life and potentially survival

as well as the burden associated with

nutritional care.


C6-3 Very advanced terminal phase

Strength of

recommendation

STRONG

In dying patients, we recommend

that treatment be based on comfort.

Artificial hydration and nutrition are

unlikely to provide any benefit for

most patients. However, in acute

confusional states, we suggest to use

a short and limited hydration to rule

out dehydration as precipiting cause.


Advanced cancer receiving no anticancertreatment

.

13

Nutrition care process Suggested Reading

• ESPEN: Home Enteral Nutrition

• ESPEN: Home Parenteral Nutrition

• ESPEN: Critical ill patients

• Enteral Formula Selection: A Review of Selected Product Categories;

Carol Rees Parrish, R.D., MS, Series Editor; Nutrition issues in

gastroenterology

• ESMO handbook of nutrition and cancer (2011)

• Home blenderised formula

Thank You

Documents

Nutrition in Oncology