Cancer: disease and nutrition are key determinants of patients' quality of life

New perspective for nutritional support of cancer patients: Enteral/parenteral nutrition

Cancer and its treatment result in severe biochemical and physiological alterations associated with a deterioration of quality of life (QoL). Cancer-related malnutrition may evolve into cancer cachexia due to complex interactions between pro-inflammatory cytokines and the host metabolism. Depending on the type of cancer treatment (either curative or palliative), the clinical condition of the patient and nutritional status, adequate and patient-tailored nutritional intervention should be prescribed (diet counseling, oral supplementation, enteral or total parenteral nutrition). Nutritional support has been widely advocated as adjunctive therapy for a variety of underlying illnesses, including surgery and medical oncotherapy (radiation or chemotherapy for cancer). Glutamine, n-3 fatty acids and probiotics/prebiotics are therapeutic factors that potentially modulate gastrointestinal toxicity related to cancer treatments. Enteral and parenteral nutrition may help improve patient survival, functional status and QoL, yet the benefits appear to be primarily limited to patients with good functional status and with gastrointestinal disease affecting nutritional intake. Parenteral nutrition offers the possibility of increased or maintenance of the nutrient intake in patients for whom normal food intake is inadequate and for whom enteral nutrition is not feasible, is contraindicated or is not accepted by the patient. This article reviews evidence on issues relevant to enteral and parenteral nutrition in patients with cancer.

Nutrition economics - characterising the economic and health impact of nutrition

There is a new merging of health economics and nutrition disciplines to assess the impact of diet on health and disease prevention and to characterise the health and economic aspects of specific changes in nutritional behaviour and nutrition recommendations. A rationale exists for developing the field of nutrition economics which could offer a better understanding of both nutrition, in the context of having a significant influence on health outcomes, and economics, in order to estimate the absolute and relative monetary impact of health measures. For this purpose, an expert meeting assessed questions aimed at clarifying the scope and identifying the key issues that should be taken into consideration in developing nutrition economics as a discipline that could potentially address important questions. We propose a first multidisciplinary outline for understanding the principles and particular characteristics of this emerging field. We summarise here the concepts and the observations of workshop participants and propose a basic setting for nutrition economics and health outcomes research as a novel discipline to support nutrition, health economics and health policy development in an evidence and health-benefit-based manner.

Role of esophageal stents in the nutrition support of patients with esophageal malignancy

Endoluminal stents are commonly used for palliative treatment of dysphagia in patients with advanced esophageal malignancies. The most frequently used esophageal stents are self-expanding metal stents. Removable self-expanding plastic stents have recently been used in the management of esophageal cancer patients treated with curative intent. Esophageal stents effectively alleviate dysphagia in most patients, and stent placement is associated with a low rate of complications. This article reviews the use of self-expanding esophageal stents in patients with esophageal cancer. Nutrition considerations following stent placement are addressed.

Validation of reaction time as a measure of cognitive function and quality of life in healthy subjects and patients

OBJECTIVE

Malnutrition is a common problem in hospitalized patients and is related to decreased cognitive function and impaired quality of life (QoL). We investigated the validity of reaction time as a simple bedside tool for measuring cognitive function in healthy subjects and patients, and additionally the relationships with QoL and malnutrition in patients.

METHODS

Healthy subjects (N = 130) were assessed for simple and complex reaction time and cognitive function (Addenbrooke cognitive examination, ACE). Patients (N = 70) were assessed for simple and complex reaction time, cognitive function (ACE), and QoL (short-form health survey) (N = 40).

RESULTS

Reaction time was related to cognitive function in both healthy subjects and patients. Reaction time was inversely related to the physical component summary of QoL in patients (r = -0.42, P < 0.001). Five of eight QoL scales and the mental component summary of QoL were significantly lower in malnourished patients. Reaction time and ACE were impaired in patients compared to healthy subjects, but not further impaired in malnourished patients.

CONCLUSION

Simple reaction time test is related to cognitive function in healthy subjects and patients and to QoL in patients. Complex reaction time test is related to more components of cognitive function. Thus, simple and complex reaction time tests could serve as bedside measurements reflecting, respectively, QoL or cognitive function.

Can nutritional status influence the quality of life of cancer patients?

Objective This study aimedto evaluate the influence of nutritional status on the quality of life of a cohort of cancer patients submitted to chemotherapy. Methods Patients receiving chemotherapy for the first time in a University Hospital in Pelotas (RS), Brazil, were evaluated prospectively. Their nutritional risk was determined by the Patient-Generated Subjective Global Assessment scores and their quality of life by the World Health Organization's quality of life questionnaire, administered at the beginning and end of the study. Results One hundred and forty-three patients were studied, 76.2% being females. The prevalence of malnutrition at baseline was 14.0%. The present study found that malnourished patients had a poor quality of life. The nutritional risk of 41.6% of the patients increased after chemotherapy. A significant association was found between the presence of symptoms and increased nutritional risk (p<0.001). Additionally, there was a significant negative correlation between physical domain and nutritional risk scores, showing that quality of life increases as nutritional risk decreases. Conclusion Nutritional risk is inversely associated with quality of life in cancer patients after chemotherapy. Early nutritional interventions could minimize the side effects of treatment with a positive impact on quality of life.

Cancer-related anorexia-cachexia syndrome

Cancer-related anorexia-cachexia syndrome (CACS) is an under-recognized component of accelerated mortality and morbidity in patients with advanced cancer. The lack of desire to eat also can create tension and conflict between patients and their families. Advanced practice nurses play a vital role in ensuring early assessment and interventions for patients with CACS.

Pretreatment malnutrition and quality of life - association with prolonged length of hospital stay among patients with gynecological cancer: a cohort study

Background

Length of hospital stay (LOS) is a surrogate marker for patients' well-being during hospital treatment and is associated with health care costs. Identifying pretreatment factors associated with LOS in surgical patients may enable early intervention in order to reduce postoperative LOS.

Methods

This cohort study enrolled 157 patients with suspected or proven gynecological cancer at a tertiary cancer centre (2004-2006). Before commencing treatment, the scored Patient Generated - Subjective Global Assessment (PG-SGA) measuring nutritional status and the Functional Assessment of Cancer Therapy-General (FACT-G) scale measuring quality of life (QOL) were completed. Clinical and demographic patient characteristics were prospectively obtained. Patients were grouped into those with prolonged LOS if their hospital stay was greater than the median LOS and those with average or below average LOS.

Results

Patients' mean age was 58 years (SD 14 years). Preoperatively, 81 (52%) patients presented with suspected benign disease/pelvic mass, 23 (15%) with suspected advanced ovarian cancer, 36 (23%) patients with suspected endometrial and 17 (11%) with cervical cancer, respectively. In univariate models prolonged LOS was associated with low serum albumin or hemoglobin, malnutrition (PG-SGA score and PG-SGA group B or C), low pretreatment FACT-G score, and suspected diagnosis of cancer. In multivariable models, PG-SGA group B or C, FACT-G score and suspected diagnosis of advanced ovarian cancer independently predicted LOS.

Conclusions

Malnutrition, low quality of life scores and being diagnosed with advanced ovarian cancer are the major determinants of prolonged LOS amongst gynecological cancer patients. Interventions addressing malnutrition and poor QOL may decrease LOS in gynecological cancer patients.

The diversity of nutritional status in cancer: new insights

OBJECTIVE

Nutritional status in cancer has been mostly biased toward undernutrition, an issue now in dispute. We aimed to characterize nutrition status, to analyze associations between nutritional and clinical/cancer-related variables, and to quantify the relative weights of nutritional and cancer-related features.

METHODS

The cross-sectional study included 450 nonselected cancer patients (ages 18-95 years) at referral for radiotherapy. Nutritional status assessment included recent weight changes, body mass index (BMI) categorized by World Health Organization's age/sex criteria, and Patient-Generated Subjective Global Assessment (PG-SGA; validated/specific for oncology).

RESULTS

BMI identified 63% as >or=25 kg/m(2) (43% overweight, 20% obese) and 4% as undernourished. PG-SGA identified 29% as undernourished and 71% as well nourished. Crossing both methods, among the 319 (71%) well-nourished patients according to PG-SGA, 75% were overweight/obese and only 25% were well nourished according to BMI. Concordance between BMI and PG-SGA was evaluated and consistency was confirmed. More aggressive/advanced stage cancers were more prevalent in deficient and excessive nutritional status: in 83% (n = 235/282) of overweight/obese patients by BMI and in 85% (n = 111/131) of undernourished patients by PG-SGA. Results required adjustment for diagnoses: greater histological aggressiveness was found in overweight/obese prostate and breast cancer; undernutrition was associated with aggressive lung, colorectal, head-neck, stomach, and esophageal cancers (p < .005). Estimates of effect size revealed that overweight/obesity was associated with advanced stage (24%), aggressive breast (10%), and prostate (9%) cancers, whereas undernutrition was associated with more aggressive lung (6%), colorectal (6%), and head-neck (6%) cancers; in both instances, age and longer disease duration were of significance.

CONCLUSION

Undernutrition and overweight/obesity have distinct implications and bear a negative prognosis in cancer. This study provides novel data on the prevalence of overweight/obesity and undernutrition in cancer patients and their potential role in cancer histological behavior.

Non-surgical oncology - Guidelines on Parenteral Nutrition, Chapter 19

Reduced nutritional state is associated with unfavourable outcomes and a lower quality of life in patients with malignancies. Patients with active tumour disease frequently have insufficient food intake. The resting energy expenditure in cancer patients can be increased, decreased, or remain unchanged compared to predicted values. Tumours may result in varying degrees of systemic pro-inflammatory processes with secondary effects on all significant metabolic pathways. Therapeutic objectives are to stabilise nutritional state with oral/enteral nutrition and parenteral nutrition (PN) and thus to prevent or reduce progressive weight loss. The maintenance or improvement of quality of life, and the increase in the effectiveness and a reduction in the side-effects of antitumor therapy are further objectives. Indications for PN in tumour patients are essentially identical to those in patients with benign illnesses, with preference given to oral or enteral nutrition when feasible. A combined nutritional concept is preferred if oral or enteral nutrition are possible but not sufficient. There are generally no accepted standards for ideal energy and nutrient intakes in oncological patients, particularly when exclusive artificial nutrition is administered. The use of PN as a general accompaniment to radiotherapy or chemotherapy is not indicated, but PN is indicated in chronic severe radiogenic enteritis or after allogenic transplantation with pronounced mucositis or GvH-related gastrointestinal damage for prolonged periods, with particular attention to increased risk of bleeding and infection. No PN is necessary in the terminal phase.

Re-organisation of oesophago-gastric cancer care in England: progress and remaining challenges

Background

Oesophago-gastric cancer services in England have been extensively reorganised since 2001 to deliver a centralised, specialist-led service. Our aim was to assess how well the National Health Service (NHS) in England met organisational standards for oesophago-gastric cancer care.

Methods

Questionnaires that asked about the provision of staging investigations, curative and palliative treatments and key personnel were sent in September 2007 to the lead clinician for oesophago-gastric cancer at all 30 cancer networks and 156 NHS acute trusts in England.

Results

Responses were received from all networks and 81% of NHS trusts. All networks provided essential staging investigations and a range of endoscopic palliative therapies. Only 16 of the 30 cancer networks discussed all patients at the specialist multi-disciplinary team meeting and 11 networks had not fully centralised curative surgery. There was also variation between NHS trusts in the integration of the palliative care team, the availability of nurse specialists and the use of dieticians to provide nutritional support.

Conclusion

There has been considerable progress in reforming oesophago-gastric cancer services but the process of reorganisation is still incomplete and regional differences in service provision exist that may lead to variation in patient outcomes.

Perception of head and neck cancer quality of life within the medical world: a multicultural study

BACKGROUND

Physician's perception of quality of life of patients with cancer is unclear. No reports have evaluated its influence on patient management.

METHODS

Five hundred otolaryngologists completed a questionnaire regarding the quality of life of patients with head and neck cancer.

RESULTS

Seventy-eight percent of responders thought that quality of life must be considered when choosing treatment, even if this meant decreased survival. Seventy-five percent thought it justified to withhold curative treatment if this would lead to impaired quality of life. Pain and breathing were the most important symptoms to consider. The perception was worse for physicians practicing in Latin culture, working in private practice, or with no personal acquaintance with a head and neck cancer victim and was better after radiotherapy than after surgery and chemotherapy.

CONCLUSION

Quality of life is important for physicians and is considered as essential as survival by many physicians. The perception of patient's quality of life influences the treatment choice.

Clinical application of subjective global assessment in Chinese patients with gastrointestinal cancer

AIM

To investigate the role of subjective global assessment (SGA) in nutritional assessment and outcome prediction of Chinese patients with gastrointestinal cancer.

METHODS

A total of 751 patients diagnosed with gastrointestinal cancer between August 2004 and August 2006 were enrolled in this study. Within 72 h after admission, SGA, anthropometric parameters, and laboratory tests were used to assess the nutritional status of each patient. The outcome variables including hospital stay, complications, and in-hospital medical expenditure were also obtained.

RESULTS

Based on the results of SGA, 389 (51.8%), 332 (44.2%), and 30 (4.0%) patients were classified into well nourished group (SGA-A), mildly to moderately malnourished group (SGA-B), and severely malnourished group (SGA-C), respectively. The prevalence of malnutrition classified by SGA, triceps skinfold thickness (TSF), mid-upper arm muscle circumference (MAMC), albumin (ALB), prealbumin (PA), and body mass index (BMI) was 48.2%, 39.4%, 37.7%, 31.3%, 21.7%, and 9.6%, respectively. In addition, ANOVA tests revealed significant differences in body mass index (BMI), TSF, PA, and ALB of patients in different SGA groups. The more severely malnourished the patient was, the lower the levels of BMI, TSF, PA, and ALB were (P < 0.05). Chi2 tests showed a significant difference in SGA classification between patients receiving different types of treatment (surgery vs chemotherapy/radiotherapy). As the nutritional status classified by SGA deteriorated, the patients stayed longer in hospital and their medical expenditures increased significantly. Furthermore, multiple regression analysis showed that SGA and serum ALB could help predict the medical expenditures and hospital stay of patients undergoing surgery. The occurrence of complications increased in parallel with the increasing grade of SGA, and was the highest in the SGA-C group (23.3%) and the lowest in the SGA-A group (16.8%).

CONCLUSION

SGA is a reliable assessment tool and helps to predict the hospital stay and medical expenditures of Chinese surgical gastrointestinal cancer patients.

Colorectal Cancer: Intrinsic Characteristics Modulate Cancer Energy Expenditure and the Risk of Cachexia

PURPOSE

To conduct a prospective longitudinal study in colorectal cancer (CRC) patients: 1) to evaluate resting energy expenditure (REE), weight/dietary intake changes, and response to treatment, taking into consideration cancer stage and histology; 2) to determine their potential interrelations; and 3) to quantify the relative contributions to REE of cancer/nutrition/treatment.

PATIENTS AND METHODS

101 CRC patients proposed for neoadjuvant radiotherapy (RT) were evaluated before and after RT: REE (indirect calorimetry measurements), percentage of weight loss, usual diet (diet history), current diet (24 hour recall), and treatment response.

RESULTS

REE was higher in Stages III/IV versus I/II, at the RT onset (p < 0.002) and end (p = 0.02), and in moderately/poorly/undifferentiated cancers vs well differentiated (onset, p < 0.001) and (RT end, p = 0.01); weight/intake reductions were also greater in Stages III/IV versus I/II (p < 0.01) and in moderately/poorly/undifferentiated cancers versus well differentiated (p < 0.02). According to patients' response to treatment, REE was increased in Stage III/IV (p < 0.005) and Grade 2/3 histology (p < 0.003). In nonresponders, REE increased 7.2 +/- 1.3 kcal/kg/day and decreased 2.8 +/- 0.4 kcal/kg/day in responders. REE changes were not-significantly influenced by weight/intake. Relative contributions to baseline REE were determined in 25 percent by stage, in 25 percent by histology, in 3 percent by intake and in 4 percent by weight loss. At the end of RT, higher REE was attributed in 26 percent to stage, in 27 percent to histology, in 30 percent to nontreatment response, in 9 percent to intake, and in 8 percent to weight loss.

CONCLUSIONS

In this CRC patient population, higher metabolic rates were mainly determined by the tumor burden and aggressiveness in association with response to treatment clearly disclaiming the effect of weight loss and/or dietary intake reductions.

Evaluation of quality of life related to nutritional status

The way in which the quality of life related to health (HRQoL) is affected by the nutritional status of the patient is a subject of constant interest and permanent debate. The purpose of the present paper is to review those studies that relate HRQoL to nutritional status and examine the tools (questionnaires) that they use to investigate this relationship. A critical review of published studies was carried out via an investigation of the following databases: MEDLINE (via PubMed); EMBASE; The Cochrane Library; Cumulative Index to Nursing and Allied Health Literature (CINAHL); Institute for Scientific Information (ISI) Web of Science; Latin American and Caribbean Health Sciences Literature (LILACS); Spanish Health Sciences Bibliographic Index (IBECS). The search was carried out from the earliest date possible until July 2007.The medical subject heading terms used were ‘quality of life’, ‘nutritional status’ and ‘questionnaires’. The articles had to contain at least one questionnaire that evaluated quality of life. Twenty-eight documents fulfilling the inclusion criteria were accepted, although none of them used a specific questionnaire to evaluate HRQoL related to nutritional status. However, some of them used a combination of generic questionnaires with the intention of evaluating the same. Only three studies selectively addressed the relationship between nutritional status and quality of life, this evaluation being performed not by means of specific questionnaires but by statistical analysis of data obtained via validated questionnaires.

Economic impact and quality of life as endpoints of nutritional therapy

PURPOSE OF REVIEW

The present review exposes why considering primary endpoints such as cost-effectiveness and quality of life in wasting disease research is critical for promoting medical nutrition therapy.

RECENT FINDINGS

Despite growing evidence that nutritional support improves patients' clinical outcome, its use is not widely considered as a routine by most healthcare professionals. Many factors, depending on physicians, patients and institutions, could explain such a resistance to implement nutritional therapy in routine care. One of these factors is the lack of indisputable evidence that nutritional intervention improves patients' quality of life and is cost-effective.

SUMMARY

In today's resource-constrained environment, disease management strategies are judged in terms of not only clinical efficacy and safety but also patient satisfaction and economic dimensions. The demonstration of a positive costs/saving ratio is crucial to obtain the political backing of health administrators and sustain further investment in research. Moreover, improving patients' quality of life promotes their capacity to cope with psychological distress, increases their tolerance and response to treatments, and enhances the global image of the healthcare system. In wasting diseases research, there is a need for well designed clinical trials from which cost-utility performance of nutritional interventions could be assessed in order to convince all the stakeholders and to get support from clinicians and patients themselves.

The prevalence of nutrition impact symptoms and their relationship to quality of life and clinical outcomes in medical oncology patients

GOALS OF WORK

The aims of this secondary analysis were to determine the prevalence of nutrition impact symptoms in medical oncology patients at 1, 6, and 12 months after commencement of chemotherapy and to investigate the relationship of these symptoms to quality of life (QoL) and performance status.

MATERIALS AND METHODS

A prospective longitudinal survey was conducted in 219 medical oncology patients who had commenced chemotherapy in the past month. The Rotterdam Symptom Assessment scale assessed the number and distress level of symptoms. The association between symptoms and global QoL and performance status as measured by the Life Satisfaction Scale was investigated.

MAIN RESULTS

Symptom prevalence as determined by the proportion of patients experiencing at least one nutrition impact symptom was 79% and 72% at 1 and 6 months after starting chemotherapy. Even at 12 months, symptom prevalence was 46%. The most common symptoms included dry mouth, nausea, and constipation with the most distressing symptoms reported as dry mouth, diarrhea, and stomach pain. A higher number of symptoms was associated with lower QoL (T1: r = -0.35, n = 217, P < 0.05; T2: r = -0.406, n = 194, P < 0.001; T3: r = -0.353, n = 157, P < 0.001). Patients experiencing more symptoms were more likely to have lower performance status at T2 and T3 (T2: n = 189, P = 0.019; T3: n = 143, P = 0.003).

CONCLUSION

Nutrition impact symptoms were commonly experienced, even 12 months following commencement of chemotherapy, and were associated with poorer QoL and performance status. This highlights the importance of early identification and management of nutrition impact symptoms with adequate follow-up in order to provide optimal care for people with cancer.

A systematic review of the use of quality of life measures in colorectal cancer research with attention to outcomes in elderly patients

PURPOSE

Quality of life (QOL) measures are critical to the evaluation of new cancer treatments, particularly for elderly patients. Our intent was to assess patterns of use of QOL endpoints in colorectal cancer (CRC) treatment research and to summarize current knowledge about how CRC treatment affects elderly patients.

PATIENTS AND METHODS

We searched MEDLINE for English-language, human trials published from 1995 to 2005 that met the following criteria: reported on patients with CRC, were not surgery-only cohorts, and included a QOL or functional endpoints. Trials specifically reporting data on elderly patients were reviewed in depth and summarized.

RESULTS

One hundred twenty-one eligible studies and 10 trials with elderly-specific data were found. The median number of trials published annually increased from 5 (range, 4-8 trials) between 1995 and 1999 to 14.5 (range, 11-22 trials) between 2000 and 2005. Chemotherapy was the most commonly studied treatment (55%), and metastatic CRC (55%) was the most commonly studied population. The European Organization for Research and Treatment of Cancer C30, with or without C38, was the most frequently used instrument (49%). Studies reporting on elderly patients showed that many patients experience a decline in physical function immediately after surgery and have increased need for supportive services. Little information is available on the effect of chemotherapy in elderly patients. Use of QOL and functional measures in treatment-related CRC research has increased; however, it continues to be hampered by a lack of dissemination and methodologic problems.

CONCLUSION

Missing data from patient attrition, limitations of assessment methods, and a small number of patients treated with chemotherapy in the trials reporting on elderly patients seriously limit our ability to draw conclusions from this survey about how treatment affects QOL or function in CRC.

Baseline nutritional status is predictive of response to treatment and survival in patients treated by definitive chemoradiotherapy for a locally advanced esophageal cancer

OBJECTIVES

To assess the impact of baseline nutritional status on treatment response and survival in nonmetastatic patients with a locally advanced esophageal cancer (LAEC) treated with definitive chemoradiotherapy (CRT).

METHODS

One hundred five patients with LAEC treated by definitive CRT were retrospectively included. The CRT regimen was based on an external radiotherapy (RT) delivered concomitantly to a cisplatin-based chemotherapy (CT). Patients were considered to have a complete response (CR) to CRT when no residual tumor was detected on CT scan and esophagoscopy performed 2 months after the end of CRT. Multivariate analysis of predictive factors of response to CRT and survival were performed using a logistic regression and a Cox model, respectively.

RESULTS

Mean value of baseline nutritional parameters was significantly different between nonresponder (N = 42) and responder (N = 63) patients to CRT (weight loss 10%vs 5.8%, P= 0.0047; serum albumin level 35 g/L vs 38.7 g/L, P= 0.0004; BMI 22.8 kg/m2vs 25.2 kg/m2, P= 0.01). In multivariate analysis, serum albumin level > 35 g/L was the only independent predictive factor of CR to CRT (P= 0.009). Independent prognostic factors of survival were BMI > 18 kg/m2 (P= 0.003), dysphagia Atkinson score <2 (P= 0.008), dose of RT > 50 Grays (Gy) (P < 0.0001) and CR to CRT (P < 0.0001).

CONCLUSIONS

Survival was influenced by baseline nutritional status as well as dysphagia, dose of RT, and CR to CRT. Despite the retrospective design of the study, our results may provide the concept basis for performing a prospective nutritional intervention study in patients treated by definitive CRT for an esophageal cancer.

Critical Evaluation of Nutrition Screening Tools Recommended for Oncology Patients

Malnutrition ranges from 20% to 80% in oncology patients. Malnutrition has been associated with reduced response to treatment, survival, and quality of life. Therefore, screening for malnutrition in patients with cancer is recommended by clinical practice groups including the Oncology Nursing Society. Nurses are in an ideal position to carry out nutrition screening. Three nutrition screening tools that have been recommended for use with oncology patients by the Oncology Nursing Society are critically evaluated. The Patient Generated-Subjective Global Assessment has demonstrated diagnostic value in oncology patients at risk of malnutrition or who are malnourished.

Stress, self-efficacy and quality of life in cancer patients

The purpose of the study was to examine the effect of different stressors on various domains of quality of life (QOL) in cancer patients. The study focused on testing a model describing interrelations between two kinds of stress antecedents, two mediating variables--perceived stress and self-efficacy--and QOL. The participants were 60 cancer patients of both genders and various diagnoses. They were administered questionnaires of background information, QOL, perceived stress and general self-efficacy. Two stress indices were defined empirically: health stress (based on advanced disease stage, long disease duration, and undergoing treatment) and social stress (based on unemployment, recent immigration, and older age). Confirmatory factor analysis enabled defining five factors of QOL. Hierarchical regression analyses showed that the index of social stress was related to more QOL scales than the index of health stress and very few interactions with the mediating variables. Structural equation modeling provided a more comprehensive and accurate view. It showed that the index of health stress affected QOL mainly through perceived stress, and that self-efficacy affected QOL by reducing perceived stress and increasing QOL. The major conclusions are that QOL is affected negatively by both health stresses and social stresses, but the former are mediated primarily by the experience of perceived stress.

Impact of nutrition on quality of life during cancer

PURPOSE OF REVIEW

This review addresses the relationship between nutritional intervention and quality of life in oncology patients.

RECENT FINDINGS

Nutrition related symptoms, such as anorexia and weight loss, reflect impaired nutritional status, which is often associated with reduced quality of life. Malnutrition can be related to reduced response or tolerance to cancer treatment. Early nutritional intervention may positively impact on quality of life and enhance clinical response in oncology patients.

SUMMARY

Nutritional intervention should be considered as a supportive measure within the global oncology strategy. In curative oncology care, it contributes to reduced postoperative infection rate, better control of cancer-related symptoms, shortened length of hospital stay and improved tolerance to treatment. In palliative care, the nutritional intervention focuses on controlling symptoms, thus improving quality of life. The evaluation of nutritional status should include an assessment of quality of life in order to optimize nutritional treatment for patients' individual requirements. Because of the potentially clinically relevant impact of nutritional intervention on quality of life, nutritional care should be included in any antineoplastic strategy.

Objective physical activity and self-reported quality of life in patients receiving palliative chemotherapy

There is little objective data on how cancer and its therapy affect physical activity. The main aims of this pilot study were 1) to compare physical activity in patients receiving palliative chemotherapy and healthy controls, and 2) to explore the relationship between patients' activity, quality of life (QoL), and clinical performance status. A miniaturized electronic meter objectively recorded activity for one week in 20 patients with upper gastrointestinal cancer receiving palliative chemotherapy and in 13 age-matched healthy controls. Patients also completed the European Organization for Research and Treatment of Cancer (EORTC) QLQ-C30, Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-F; fatigue), and Functional Assessment of Anorexia and Cachexia Therapy (FAACT; anorexia/cachexia) quality-of-life questionnaires. The patients' median estimated total energy expenditure was 8% lower (P=0.0003), median time spent upright was approximately two hours/day less (P=0.0002), and median steps taken/day was 43% lower (P=0.002) than that of the control group. Neither estimated energy expenditure nor average steps taken/day correlated significantly with EORTC QLQ-C30 physical functioning, fatigue, or global health status/QoL. There was no correlation with the FAACT "Trial Outcome Index" (TOI), but the FACIT-F TOI and both estimated energy expenditure and the average steps taken/day correlated significantly (r=0.59, P=0.009 and r=0.59, P=0.008). It is concluded that patients receiving palliative chemotherapy were less active than healthy controls; however, the relationship between physical activity and QoL requires further characterization.

Nutritional intervention and quality of life in adult oncology patients

The evaluation of quality of life (QoL) assesses patients' well-being by taking into account physical, psychological and social conditions. Cancer and its treatment result in severe biochemical and physiological alterations associated with a deterioration of QoL. These metabolic changes lead to decreased food intake and promote wasting. Cancer-related malnutrition can evolve to cancer cachexia due to complex interactions between pro-inflammatory cytokines and host metabolism. Beside and beyond the physical and the metabolic effects of cancer, patients often suffer as well from psychological distress, including depression. Depending on the type of cancer treatment (either curative or palliative) and on patients' clinical conditions and nutritional status, adequate and patient-tailored nutritional intervention should be prescribed (diet counselling, oral supplementation, enteral or total parenteral nutrition). Such an approach, which should be started as early as possible, can reduce or even reverse their poor nutritional status, improve their performance status and consequently their QoL. Nutritional intervention accompanying curative treatment has an additional and specific role, which is to increase the tolerance and response to the oncology treatment, decrease the rate of complications and possibly reduce morbidity by optimizing the balance between energy expenditure and food intake. In palliative care, nutritional support aims at improving patient's QoL by controlling symptoms such as nausea, vomiting and pain related to food intake and postponing loss of autonomy. The literature review supports that nutritional care should be integrated into the global oncology care because of its significant contribution to QoL. Furthermore, the assessment of QoL should be part of the evaluation of any nutritional support to optimize its adequacy to the patient's needs and expectations.

Cancer wasting and quality of life react to early individualized nutritional counselling!

To devise a meaningful nutritional therapy in cancer, a greater understanding of nutritional dimensions as well as patients' expectations and disease impact is essential. We have shown that nutritional deterioration in patients with gastrointestinal and head and neck cancer was multifactorial and mainly determined by the tumour burden and location. In a larger cohort, stage and location were yet again the major determinants of patients' quality of life (QoL), despite the fact that nutritional deterioration combined with intake deficits were functionally more relevant than cancer stage. Based on this framework, the potential role of integrated oral nutritional support on outcomes was investigated. In a pilot study using individualized nutritional counselling on a heterogeneous patient population, the achieved improvement of nutritional intake was proportional to a better QoL. The role of early nutritional support was further analysed in a prospective randomized controlled trial in head and neck cancer patients stratified by stage undergoing radiotherapy. Pre-defined outcomes were: nutritional status and intake, morbidity and QoL, at the end and 3 months after radiotherapy. Nutritional interventions, only given during radiotherapy, consisted of three randomization arms: (1) individualized nutritional counselling vs. (2) ad libitum diet+high protein supplements vs. (3) ad libitum diet. Nutritional interventions 1 and 2 positively influenced outcomes during radiotherapy; however, 3 months after its completion individualized nutritional counselling was the single method capable of sustaining a significant impact on patients' outcomes. The early provision of the appropriate mixture of foods and textures using regular foods may modulate outcomes in cancer patients.

Malnutrition affects quality of life in gastroenterology patients

AIM: To investigate the association between malnutrition and quality of life in patients with benign gastrointestinal disease.

METHODS: Two hundred patients (104 wellnourished and 96 malnourished) were assessed according to the Subjective Global Assessment, anthropometric measurements and bioelectrical impedance analysis. Quality of life was determined with the validated Medical Outcomes Study 36-item Short-Form General Health Survey (SF 36). Muscle function was assessed by hand grip strength and peak flow.

RESULTS: Body mass index, body cell mass, arm muscle area and hand grip strength were significantly lower in the malnourished patients. Quality of life was generally lower when compared to norm values. Seven out of eight quality of life scales (excluding bodily pain) were significantly reduced in the malnourished patients. Comparing patients with liver cirrhosis and inflammatory bowel disease (IBD), patients with IBD experienced significantly lower values in the perception of bodily pain,social functioning and mental health. Malnourished liver cirrhotics suffered reductions in more scales (six out of eight) than malnourished IBD patients did (four out of eight).

CONCLUSION: Quality of life is generally low in benign gastrointestinal disease and is further reduced in patients who are classified as malnourished. It appears that liver cirrhosis patients experience a higher quality of life than IBD patients do, but the impact of malnutrition seems to be greater in liver cirrhosis than in IBD.

Malnutrition affects quality of life in gastroenterology patients

AIM: To investigate the association between malnutrition and quality of life in patients with benign gastrointestinal disease.

METHODS: Two hundred patients (104 wellnourished and 96 malnourished) were assessed according to the Subjective Global Assessment, anthropometric measurements and bioelectrical impedance analysis. Quality of life was determined with the validated Medical Outcomes Study 36-item Short-Form General Health Survey (SF 36). Muscle function was assessed by hand grip strength and peak flow.

RESULTS: Body mass index, body cell mass, arm muscle area and hand grip strength were significantly lower in the malnourished patients. Quality of life was generally lower when compared to norm values. Seven out of eight quality of life scales (excluding bodily pain) were significantly reduced in the malnourished patients. Comparing patients with liver cirrhosis and inflammatory bowel disease (IBD), patients with IBD experienced significantly lower values in the perception of bodily pain,social functioning and mental health. Malnourished liver cirrhotics suffered reductions in more scales (six out of eight) than malnourished IBD patients did (four out of eight).

CONCLUSION: Quality of life is generally low in benign gastrointestinal disease and is further reduced in patients who are classified as malnourished. It appears that liver cirrhosis patients experience a higher quality of life than IBD patients do, but the impact of malnutrition seems to be greater in liver cirrhosis than in IBD.

A prospective study on weight loss and energy intake in patients with head and neck cancer, during diagnosis, treatment and revalidation

BACKGROUND & AIMS

Patients with head and neck carcinomas often loose a significant percentage of weight, which correlates with the complication rate. Only limited information is available on the moment and extent of weight loss and energy intake in time and the relation with type of treatment. The aim of this study was to describe the moment and extent of weight loss and nutritional energy intake in patients with tumors in oral cavity, oropharynx and hypopharynx during diagnosis, treatment and revalidation.

METHODS

An observational, prospective study on weight changes and nutritional intake in these patients was carried out during diagnosis, treatment and revalidation in relation to the type of treatment.

RESULTS

Forty-seven patients successfully completed the study. A significant difference in mean bodyweight was found for patients treated by radiotherapy during treatment (-3.3 kg, P=0.01) and the early revalidation period (-3.4 kg, P=0.01) and for patients treated with surgery during diagnoses (-1.5 kg, P=0.001) and early revalidation period (1.6 kg, P=0.02). Overall patients lowered their energy intake by 122 kcal/day followed by a significant increase in energy intake during revalidation 326 kcal/day (P=0.04).

CONCLUSIONS

The radiotherapy and the concomitant radio-chemotherapy group lost most body weight during treatment and early revalidation. All treatment groups experienced a decrease in energy intake during treatment followed by a significant increase during revalidation.

Impact of nutrition on outcome: a prospective randomized controlled trial in patients with head and neck cancer undergoing radiotherapy

BACKGROUND

We aimed to determine the effect of dietary counseling or oral supplements on outcome for patients with cancer, specifically, nutritional outcome, morbidity, and quality of life (QOL), during and 3 months after radiotherapy.

METHODS

Seventy-five patients with head and neck cancer who were referred for radiotherapy (RT) were randomized to the following groups: group 1 (n = 25), patients who received dietary counseling with regular foods; group 2 (n = 25), patients who maintained usual diet plus supplements; and group 3 (n = 25), patients who maintained intake ad lib. Nutritional intake (determined by diet history) and status (determined by Ottery's Subjective Global Assessment), and QOL (determined by the European Organization for the Research and Treatment of Cancer Quality of Life Questionnaire version 3.0 [EORTC QLQ-C30]) were evaluated at baseline, at the end of RT, and at 3 months.

RESULTS

Energy intake after RT increased in both groups 1 and 2 (p < or = .05). Protein intake also increased in both groups 1 and 2 (p < or = .006). Both energy and protein intake decreased significantly in group 3 (p < .01). At 3 months, group 1 maintained intakes, whereas groups 2 and 3 returned to or below baseline levels. After RT, >90% of patients experienced RT toxicity; this was not significantly different between groups, with a trend for reduced symptomatology in group 1 versus group 2/group 3 (p < .07). At 3 months, the reduction of incidence/severity of grade 1+2 anorexia, nausea/vomiting, xerostomia, and dysgeusia was different: 90% of the patients improved in group 1 versus 67% in group 2 versus 51% in group 3 (p < .0001). After RT, QOL function scores improved (p < .003) proportionally with improved nutritional intake and status in group 1/group 2 (p < .05) and worsened in group 3 (p < .05); at 3 months, patients in group 1 maintained or improved overall QOL, whereas patients in groups 2 and 3 maintained or worsened overall QOL.

CONCLUSIONS

During RT, nutritional interventions positively influenced outcomes, and counseling was of similar/higher benefit; in the medium term, only counseling exerted a significant impact on patient outcomes.

Malnutrition was associated with poor quality of life in colorectal cancer: a retrospective analysis

BACKGROUND AND OBJECTIVE

Malnutrition is a significant cause of morbidity and mortality in advanced colorectal cancer, and little is known about its relationship with quality of life (QoL). We investigated the relationship between nutritional status and QoL in colorectal cancer.

METHODS

We examined a case series of 58 stage III-IV colorectal cancer patients treated at Cancer Treatment Centers of America. Nutritional status was evaluated using laboratory measures of serum albumin, prealbumin, and transferrin, subjective global assessment (SGA) and bioelectrical impedance analysis. QoL was evaluated using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30 (QLQ-C30).

RESULTS

The prevalence of malnutrition, as determined by SGA, was 41% (24 of 58). Well-nourished patients had statistically significantly better QoL scores on the global, physical, and role functions compared to malnourished patients. Interestingly, the median role function score in well-nourished patients was 41.6 points higher than the corresponding score in malnourished patients, indicating a "much better" functioning from a patient's perspective. Similarly, QoL scores on multiple symptom scales were statistically significantly better among well-nourished patients.

CONCLUSION

This study suggests that malnutrition is associated with poor QoL, as measured by the QLQ-C30 in colorectal cancer.

The causes and consequences of cancer-associated malnutrition

Cancer-associated malnutrition can result from local effects of a tumour, the host response to the tumour and anticancer therapies. Although cancer patients often have reduced food intake (due to systemic effects of the disease, local tumour effects, psychological effects or adverse effects of treatment), alterations in nutrient metabolism and resting energy expenditure (REE) may also contribute to nutritional status. Several agents produced by the tumour directly, or systemically in response to the tumour, such as pro-inflammatory cytokines and hormones, have been implicated in the pathogenesis of malnutrition and cachexia. The consequences of malnutrition include impairment of immune functions, performance status, muscle function, and quality of life. In addition, responses to chemotherapy are decreased, chemotherapy-induced toxicity and complications are more frequent and severe, and survival times are shortened. Depression, fatigue and malaise also significantly impact on patient well-being. In addition, cancer-related malnutrition is associated with significant healthcare-related costs. Nutritional support, addressing the specific needs of this patient group, is required to help improve prognosis, and reduce the consequences of cancer-associated nutritional decline.

Review article: anorexia and cachexia in gastrointestinal cancer

In patients with gastrointestinal malignancies, i.e. cancers of the stomach, colon, liver, biliary tract or pancreas, progressive undernutrition can be regularly observed during the course of illness. Undernutrition significantly affects the patients' quality of life, morbidity and survival. Pathogenetically, two different causes are relevant in the development of undernutrition in patients with gastrointestinal cancer. One cause is reduced nutritional intake. This condition is referred to as anorexia and can be worsened by the side effects of cancer therapy. The other cause is the release of endogenous transmitters and/or other products of the tumour leading to the cachexia syndrome, which is characterized by loss of body weight, negative nitrogen balance and fatigue. Cancer anorexia and cancer cachexia may have synergistic negative effects in affecting the patients' status. In this review, current nutritional support strategies with respect to different clinically relevant situations are described. An algorithm of the treatment strategies, including dietetic counselling, oral supplements, enteral and parenteral nutritional support is given. One focus is the approach of nutrition-focused patient care, which shows promising results. In addition, the possibilities of pharmacological intervention are discussed.

Branched-chain amino acids: the best compromise to achieve anabolism?

PURPOSE OF REVIEW

The anorexia-cachexia syndrome is highly prevalent in patients suffering from acute and chronic diseases, including cancer, chronic renal failure and liver cirrhosis. Once it has developed, it significantly influences the clinical course of the underlying disease, simultaneously impinging on patients' quality of life. Unfortunately, currently available therapeutic strategies do not appear to greatly impact on patients' morbidity, mortality and quality of life. More effective therapies are needed to promote appetite and food intake, to preserve lean body mass, and to ameliorate patients' psychological distress.

RECENT FINDINGS

Branched-chain amino acids are neutral amino acids with interesting and clinically relevant metabolic effects. Their potential role as antianorexia and anticachexia agents was proposed many years ago, but only recent experimental studies and clinical trials have tested their ability to stimulate food intake and counteract muscle wasting in anorectic, weight-losing patients. By interfering with brain serotonergic activity and by inhibiting the overexpression of critical muscular proteolytic pathways, branched-chain amino acids have been shown to induce beneficial metabolic and clinical effects under different pathological conditions.

SUMMARY

Based on the available data, branched-chain amino acids appear to exert significant antianorectic and anticachectic effects, and their supplementation may represent a viable intervention not only for patients suffering from chronic diseases, but also for those individuals at risk of sarcopenia due to age, immobility or prolonged bed rest, including trauma, orthopedic or neurologic patients.

Nutritional status and quality of life of the gastric cancer patients in Changle County of China

AIM: To analyze the relation between nutrition and quality of life in the stomach cancer patients, evaluate the intake of daily nutrition of the patients, and study the feasibility of nutrition intervention in improving quality of life of the stomach cancer patients.

METHODS: A total of 285 surgical stomach cancer patients reported in the Changle Cancer Registry from 2002 to 2003 were investigated with respect to their diet and quality of life. Daily nutrition intakes of the patients were calculated according to the Food Composition Database, and these data were compared with the reference values proposed by the Chinese Nutrition Society. The partial correlation was used to analyze the relationship between nutrition and quality of life in the patients. Stepwise multiple regression analyses were conducted to analyze the factors influencing nutrition intake in stomach cancer patients.

RESULTS: Except vitamin C, there were statistical correlations between the nutrition and quality of life in stomach cancer patients, and differences of the daily nutrition intake among three groups (good, modest and bad quality of life) of the patients were significant. Most of the stomach cancer patients had a lower daily nutrition intake than the reference values. At the significance level α = 0.05, the factors influencing the daily nutrition intake of the patients were number of meals a day, family income, way of operation, exercise and age.

CONCLUSION: The nutritional status of the operated patients with stomach cancer may impact on their quality of life. The stomach cancer patients in Changle County have a low level of daily nutrition intake, which suggests that they have a bad nutritional status. To improve the quality of life of the patients, the nutrition intervention should be conducted. Increasing times of meals a day and having a high-protein, high-calorie foods can improve the nutritional status of the stomach cancer patients. Moreover, exercise for rehabilitation can whet the appetite of the patients and recover their body function, which in turn may improve the quality of life of the stomach cancer patients.

Therapy Insight: cancer anorexia–cachexia syndrome—when all you can eat is yourself

Tumor growth is associated with profound metabolic and neurochemical alterations, which can lead to the onset of anorexia-cachexia syndrome. Anorexia is defined as the loss of the desire to eat, while cachexia results from progressive wasting of skeletal muscle mass--and to a lesser extent adipose tissue--occurring even before weight loss becomes apparent. Cancer anorexia-cachexia syndrome is highly prevalent among cancer patients, has a large impact on morbidity and mortality, and impinges on patient quality of life. However, its clinical relevance is frequently overlooked, and treatments are usually only attempted during advanced stages of the disease. The pathogenic mechanisms of cachexia and anorexia are multifactorial, but cytokines and tumor-derived factors have a significant role, thereby representing a suitable therapeutic target. Energy expenditure in anorexia is frequently increased while energy intake is decreased, which further exacerbates the progressive deterioration of nutritional status. The optimal therapeutic approach to anorectic-cachectic cancer patients should be based on both changes in dietary habits, achieved via nutritional counseling; and drug therapy, aimed at interfering with cytokine expression or activity. Our improved understanding of the influence a tumor has on the host's metabolism is advancing new therapeutic approaches, which are likely to result in better preservation of nutritional status if started concurrently with specific antineoplastic treatment.

Dietary counseling improves patient outcomes: a prospective, randomized, controlled trial in colorectal cancer patients undergoing radiotherapy

PURPOSE

To investigate the impact of dietary counseling or nutritional supplements on outcomes in cancer patients: nutritional, morbidity, and quality of life (QoL) during and 3 months after radiotherapy.

PATIENTS AND METHODS

A total of 111 colorectal cancer outpatients referred for radiotherapy, stratified by staging, were randomly assigned: group 1 (G1; n = 37), dietary counseling (regular foods); group 2 (G2; n = 37), protein supplements; and group 3 (G3; n = 37), ad libitum intake. Nutritional intake (diet history), status (Ottery's Subjective Global Assessment), and QoL (European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire version 3.0) were evaluated at baseline, at the end, and 3 months after radiotherapy.

RESULTS

At radiotherapy completion, energy intake increased in G1/G2 (P < or = .04), G1 more than G2 (P = .001), and decreased in G3 (P < .01). Protein intake increased in G1/G2 (P < or = .007), G1 less than G2 (not significant), and decreased in G3 (P < .01). At 3 months, G1 maintained nutritional intake and G2/G3 returned to baseline. After radiotherapy and at 3 months, rates of anorexia, nausea, vomiting, and diarrhea were higher in G3 (P < .05). At radiotherapy completion, in G1 all QoL function scores improved proportionally to adequate intake or nutritional status (P < .05); whereas in G2 only three of six function scores improved proportionally to protein intake (P = .04), and in G3 all scores worsened (P < .05). At 3 months, G1 patients maintained/improved function, symptoms, and single-item scores (P < .02); in G2, only few function and symptom scales improved (P < .05); in G3, QoL remained as poor as after radiotherapy. In G1/G2, respectively, improvement/deterioration of QoL correlated with better or poorer intake or nutritional status (P < .003).

CONCLUSION

During radiotherapy, both interventions positively influenced outcomes; dietary counseling was of similar or higher benefit, whereas even 3 months after RT, it was the only method to sustain a significant impact on patient outcomes.