Critical evaluation of the role of nutritional support with chemotherapy

Change in Body Weight and Serum Albumin Levels in Febrile Neutropenic Lung Cancer Patients

Although advances have been made in the treatment and prevention of febrile neutropenia (FN) in cancer patients treated with chemotherapy, it is still a complication that requires clinical attention. Impaired nutritional status in patients who develop FN can affect the continuation of cancer treatment, but it has not been investigated. We conducted a retrospective longitudinal study in order to clarify (1) if body weight and serum albumin levels change in lung cancer patients who do and do not develop FN, and (2) if these indicators are more likely to worsen in patients with FN than in patients without FN. Patients undergoing cytotoxic chemotherapy between January 2011 and June 2020 were consecutively included in the study. Changes in body weight and serum albumin levels were investigated in a case-control study of patients with FN, and control patients without FN who were matched by age, gender, histopathology, and stage of lung cancer, at a ratio of 1:2. During the study period, 226 patients received cytotoxic chemotherapy. Among those, 33 (14.6%) patients developed FN during the first course of cytotoxic chemotherapy. We found a more pronounced decrease in both body weight and serum albumin level at four weeks after the initiation of chemotherapy in FN patients. In order to safely administer effective chemotherapy, medical staff need to pay close attention to the nutritional status of patients receiving chemotherapy.

Nutrition Intervention in Cancer

Nutrition intervention supports the patient with malnutrition secondary to cancer and its treatment and has been used in the primary and secondary prevention of common forms of cancer. During the emotional stress of dealing with cancer at any stage, patients derive increased quality of life and a sense of control over their lives as the result of receiving supportive advice on diet and lifestyle. Therefore, the use of nutrition intervention in cancer patients is justified in the absence of absolute proof of efficacy as long as it is done safely and with the consent of the cancer patient.

Metabolic responses to tumour disease and progression: tumour-host interaction

The progressive nutritional deterioration frequently found in cancer patients, is often referred to as cancer cachexia. In contrast to starvation, where it is possible to reverse the body composition changes by the provision of extra calories, in cancer cachexia this reversal is not observed, suggesting that anorexia alone is unlikely to be responsible for this wasting syndrome. Over the past decades a number of studies have focused on the possible mediators which may be responsible for metabolic abnormalities observed in cancer patients. Pro-inflammatory cytokines have been strongly implicated, but evidence supporting such a direct role is lacking. Recently, exciting work regarding molecules produced by tumour cells, and which may induce lipolysis and proteolysis, has been published. There is also evidence that increased metabolism of host resources may provide substrates which might promote tumour growth. A number of studies have demonstrated that polyunsaturated fatty acids, such as linoleic and arachidonic acid, are able to promote tumour cell growth either by directly stimulating mitosis or by inhibiting apoptosis. Even more interesting is the discovery of antagonists of these catabolic factors such as eicosapentanoic acid for the lipolytic factor, which may play a role in the treatment of these patients in the near future.

Pharmacological interference with tissue hypercatabolism in tumour-bearing rats

Marked loss of body weight and profound waste of both skeletal muscle and white adipose tissue occur in rats into which the ascites hepatoma Yoshida AH-130 has been transplanted, associated with marked perturbations in the hormonal homoeostasis and the presence of circulating tumour necrosis factor and high plasma levels of prostaglandin E2 [Tessitore, Costelli and Baccino (1993) Br. J. Cancer 67, 15-23]. On the basis of previous findings, the present study examined whether the development of cachexia in this model system could be significantly affected by adrenalectomy or by pharmacological treatments that may interfere with proximal or distal mediators of tissue hypercatabolism. In no instance was tumour growth modified. Medroxyprogesterone acetate, an anabolic-hormone-like drug, was completely ineffective. In adrenalectomized animals, although changes such as the elevation of plasma triacylglycerols and corticosterone were corrected, the general course of cachexia was not modified. A partial prevention of muscle waste was observed with acetylsalicylic acid, a non-steroidal anti-inflammatory drug, or with leupeptin, a proteinase inhibitor. Insulin afforded the most significant preservation of muscle protein and adipose-tissue mass, which were maintained close to control values even 10 days after transplantation. The effects of insulin on gastrocnemius muscle and liver protein content were exerted by slowing down protein turnover, mainly enhancing synthesis. Consistently, the total free amino acid concentration in the gastrocnemius of insulin-treated rats 10 days after tumour transplantation was close to that of controls. Although treatment with insulin decreased plasma corticosterone to normal values, it did not modify the circulating level of tumour necrosis factor. On the whole these data show that it seems possible to prevent, at least in part, the tissue waste that characterizes cancer cachexia by purely pharmacological means.

Suramin interferes with interleukin-6 receptor binding in vitro and inhibits colon-26-mediated experimental cancer cachexia in vivo

Neoplastic diseases are frequently associated with metabolic changes collectively known as cancer cachexia. The presence of cachexia complicates therapeutic intervention and is an important cause of death in cancer patients. At present there is no effective treatment for cachexia. Recently, the involvement of interleukin-6 (IL-6) in the wasting of colon-26 adenocarcinoma-bearing mice was demonstrated. The research presented here establishes an anticachectic role for the experimental drug suramin, since it partially blocks (up to 60%) the catabolic effects associated with the growth of this tumor in vivo. Suramin prevents the binding of IL-6 to its cell surface receptor subunits, as demonstrated by radioreceptor binding assay and affinity crosslinking experiments. Furthermore, the uptake of radioactive IL-6 by the liver is significantly reduced in suramin-treated mice. On the other hand, the drug is approximately 10-fold less potent in inhibiting the binding of tumor necrosis factor-alpha to indicator cell line in vitro and fails to block liver uptake of this cytokine in vivo. Collectively, these results suggest that suramin inhibits cancer-associated wasting, in part by interfering with the binding of IL-6 to its receptor. Whether suramin inhibits the action of other factors/cytokines that may also participate in colon-26-mediated cachexia is not yet known.

Plasma amino acids in patients with acute nonlymphocytic leukemia receiving parenteral nutrition

OBJECTIVE

To assess the effect of parenteral amino acid solutions on plasma amino acid concentrations in patients with acute nonlymphocytic leukemia (ANLL) receiving parenteral nutrition (PN).

DESIGN

Ten patients were studied at diagnosis, on the morning PN was started, and three times during PN therapy coinciding with the sequential administration of three different amino acid solutions (Aminosyn, FreAmine HBC, and TrophAmine). The order of amino acid solution administration in each patient was by a randomized, block design.

RESULTS

The patients were undergoing identical intensive induction therapy. There was no significant difference in the number of days they received PN or the amount of protein or calories received during the three PN study periods. At diagnosis, phenylalanine and glutamic acid concentrations were elevated compared with previously published normal values and remained elevated at all observation times. During PN, asparagine, aspartic acid, and tyrosine concentrations were significantly lower with all three amino acid solutions compared with their concentrations at diagnosis. Glycine and threonine concentrations were also significantly lower with FreAmine HBC and TrophAmine administration and cysteine concentrations were significantly lower with FreAmine HBC administration than at the time of diagnosis. Aminosyn was associated with plasma amino acid concentrations most similar to those measured at diagnosis.

CONCLUSIONS

These results indicate that most amino acid concentrations fall within the normal range at diagnosis in the ANLL patients studied. Plasma concentrations for certain amino acids can be influenced by the amino acid solution used in PN. Further understanding of the derangements in amino acid metabolism and the influence of parenterally administered amino acid solutions on plasma amino acid concentrations may lead to improvements in the nutritional support of cancer patients.

Interaction between cytostatics and nutrients

Cancer patients have the highest prevalence of malnutrition of any group of hospitalized patients. The presence of the tumor alone may lead to reduced intake of different nutrients and treatment modalities such as surgery, chemotherapy and radiation therapy may further exacerbate nutritional disturbances. Dietary manipulation in experimental systems has shown improvement of tumor response to cancer therapy. Drug pharmacokinetics has been shown to be altered by changes in nutritional delivery. This article reviews the present knowledge, from experimental and clinical standpoints, of the potential role of different nutritional factors on the specific cancer treatment. It is obvious that alteration of at least some dietary factors affect the outcome of different forms of cancer treatment. Indeed, although interest in the clinical significance of optimal dietary intake and supplementation during cancer therapy so far remain marginal, accumulating data indicate that this area deserves further research attention.

Lipid mobilising factors specifically associated with cancer cachexia

Both urine and plasma from mice and humans with cancer cachexia have been shown to contain higher levels of lipid mobilising activity than normal controls, even after acute starvation. There was no significant increase in the urinary lipid mobilising activity of either mice or humans after acute starvation, suggesting that the material in the cachectic situation was probably not due to an elevation of hormones normally associated with the catabolic state in starvation. Further characterisation of the lipid mobilising activity in the urine of cachectic mice using Sephadex G50 exclusion chromatography showed four distinct peaks of activity of apparent molecular weights of greater than 20, 3, 1.5 and less than 0.7 kDa. No comparable peaks of activity were found in the urine of a non tumour-bearing mouse. The high molecular weight activity was probably formed by aggregation of low molecular weight material, since treatment with 0.5 M NaCl caused dissociation to material with a broad spectrum of molecular weights between 3 and 0.7 kDa. Lipolytic species of similar molecular weights were also found in the urine of cachectic cancer patients, but not in normal urine even after 24 h starvation. The lipid mobilising species may be responsible for catabolism of host adipose tissue in the cachectic state.

Cancer cachexia

Cancer cachexia has been listed as a major cause of death in cancer patients. In order to investigate the metabolic effects of the tumor on the host, we have evaluated an experimental model of cancer cachexia in the mouse (MAC16 colon adenocarcinoma), in which weight loss can reach 30-40% of initial weight with a tumor burden of only 2.5%, without a reduction in the intake of either food or water. The weight loss appears not to arise from tumor necrosis factor production, which is associated with a marked reduction in both food and water intake, but may be a result of catabolic factors produced by the tumor and present in the circulation. Both insulin and 3-hydroxybutyrate are effective inhibitors of the tumor catabolic factors in vitro and protect, to some extent, weight loss in vivo. However, whereas 3-hydroxybutyrate was associated with a reduction in tumor weight, insulin caused an enhancement, suggesting that the former may be more appropriate than the latter in the clinical treatment of cancer cachexia.

Effect of chemotherapy on resting energy expenditure in patients with non-Hodgkin's lymphoma. Results of a sequential study

This study compared the resting energy expenditure (REE) modifications observed during successive intensive identical chemotherapy courses in non-Hodgkin's lymphoma patients to assess indirectly the metabolic changes induced by the cytotoxic effect of drugs on the tumor. With this therapeutic regimen, reduction of tumor mass is mostly achieved during the first course of chemotherapy. The study included 10 non-Hodgkin's lymphoma adult patients receiving three intensive 5-day courses of Adriamycin (doxorubicin; Adria Laboratories, Columbus, OH), cyclophosphamide, vindesine, and bleomycin. Resting energy expenditure was evaluated by indirect calorimetry during each course, first within the first 2 days before chemotherapy and then on days 2, 3 and 5. Initial REE (day 0) on entry into the study (21.8 +/- 1.2 kcal/kg.d-1) represented 99 +/- 6.7% of theoretical REE. Resting energy expenditure on day 0 was lower during course 2 and 3 (19.1 +/- 0.7 and 18.4 +/- 1.8 kcal/kg/d) than during course 1 (21.8 +/- 1.2 kcal/kg/d). The REE profile was different among the 3 courses: course 1 induced a significant REE decrease on days 3 and 5 (P less than 0.01); during course 2, REE remained stable and was lower than during course 1; during course 3, REE increased on days 2, 3, and 5 (P less than 0.05). Energy balance was positive during the three courses and nutritional status remained stable. The REE decrease observed during course 1 may be regarded as the metabolic effect of chemotherapy on the tumor metabolism.

Dietary influences on cell proliferation in bone marrow

Oral dietary protein-calorie malnutrition was used in rats to study the influence of malnutrition on the distribution of the dividing cells in the bone marrow (stem cells) over the compartments of the cell cycle. A 5-day period of malnutrition induced an increase in the percentage of cells in the G0/G1 phase of the cell cycle while simultaneously inducing a statistically significant decrease in the percentage of cells in S phase. Similar results were obtained after a 14-day period of malnutrition. Nutritional replenishment after 5 and 14 days of dietary deprivation induced a rapid recovery of the percentage of S phase cells and a decrease in the percentage of cells in the G0/G1 phase of the cell cycle. Malnutrition and nutritional replenishment did not influence hemoglobin concentration and platelet numbers in the peripheral blood, but leucocyte numbers increased significantly after short-term replenishment. These results demonstrate a decrease in the percentage of proliferating bone marrow cells after short periods of deficiency and general malnutrition. The results also demonstrate that bone marrow cells recover quickly after nutritional replenishment. In malnourished cancer patients, suspected of bone marrow insufficiency and receiving therapy that potentially impairs bone marrow proliferation, a short period of nutritional replenishment preceding treatment could possibly be marrow-protective.

Alterations in serum levels, anti-tumor activity and toxicity of methotrexate in rats after a short period of nutritional depletion

The alterations in serum levels, anti-tumor activity and host toxicity of methotrexate (MTX) were tested in tumor bearing rats following a period of dietary manipulation. A protein deprived (PD) diet or a diet containing a normal protein content (NP) was administered for 5 days and MTX injected intra-peritoneally (i.p.) at the end of the 5 day period. The MTX serum levels were significantly elevated in rats which received the PD diet, as compared to NP dietary rats. This elevation correlated with an enhanced tumor response to MTX administration. In addition, bone marrow toxicity and intestinal tract toxicity, measured with flow cytometry (FCM) of the bone marrow and morphometry of the jejunal mucosa respectively was increased in rats receiving the PD diet. These results indicate that the serum clearance of MTX is delayed in animals suffering from malnutrition, leading to both enhanced tumor response and increased host toxicity.

Symptoms potentially influencing weight loss in a cancer population. Correlations with primary site, nutritional status, and chemotherapy administration

A nutritional assessment including determination of symptoms potentially influencing weight loss was prospectively performed on 254 consecutive cancer patients with favorable performance scores (Eastern Cooperative Oncology Group [ECOG] level 0 to 2). Primary cancer sites included the following: non-small cell lung (n = 93), colon (n = 50), prostate (n = 23), oropharyngeal (n = 18), breast (n = 15), gastrointestinal (n = 13), and other (n = 42). Thirty-nine percent of patients had received no prior chemotherapy or radiation therapy. Common symptoms in the population were abdominal fullness (61%), taste change (46%), constipation (41%), mouth dryness (40%), nausea (39%), and vomiting (27%). Current caloric intake was surprisingly similar in 170 patients with weight loss (percent usual body weight [PUBW], less than or equal to 95%) compared with 84 without weight loss (PUBW, greater than 95%; 31.4 +/- 1.5 versus 30.5 +/- 2.1 kcal/kg/d, respectively). Symptoms identified by multivariate analysis as occurring significantly more frequently in populations with weight loss included abdominal fullness (P less than 0.001), taste change (P less than 0.002), vomiting (P less than 0.005), and mouth dryness (P less than 0.02). There was no difference in frequency of symptoms between patients with or without prior chemotherapy. These results indicate that gastrointestinal/oral symptoms potentially influencing weight loss are prevalent early in the course of cancer patients with unresectable disease, regardless of current nutritional status, caloric intake, or prior therapy experience.

Change in energy and protein status during chemotherapy in patients with acute leukemia

The energy and protein status of 12 adult patients with acute leukemia (AL) was investigated during induction chemotherapy. Parenteral nutrition (PN) (nonprotein [NP], 31.4 kcal/kg/d; nitrogen [N], 0.177 g/kg/d) was started on day 6 after the beginning of chemotherapy and continued through all of the cytopenic phase. A clinical and metabolic evaluation, including measurement of resting energy expenditure (REE) by indirect calorimetry, was performed on each patient within the 2 days before beginning chemotherapy (D0), on the third day of chemotherapy (D3), and then weekly from day 7 until the end of the cytopenic phase. Measured REE at day 0 (29.5 +/- 1.4 kcal/kg/d) was significantly higher (+34 +/- 6%) than theoretical REE. Chemotherapy induced a significant decrease in REE at day 3 (26.2 +/- 1.7 kcal/kg/d; P less than 0.05), but during the cytopenic phase REE was not different significantly from its initial values (D0). A positive energy balance was observed during the whole study after the beginning of PN. In contrast, mean nitrogen balance remained negative always, due to a sharp increase in urinary nitrogen loss during the cytopenic phase. The fact that nutritional support falls short of its goal may explain why no improvement in tumor response to therapy has been described in most studies.

Hydrazine sulfate in cancer patients with weight loss. A placebo-controlled clinical experience

Hydrazine sulfate was evaluated using 24-hour dietary recalls and body weight determinations before and after 30 days of either placebo or hydrazine (60 mg, 3 times/d) oral administration in 101 heavily pretreated cancer patients with weight loss. After 1 month, 83% of hydrazine and only 53% of placebo patients completing repeat evaluation maintained or increased their weight (P less than 0.05). In addition, appetite improvement was more frequent in the hydrazine group (63% versus 25%, P less than 0.05). Although caloric intake was only slightly greater in hydrazine-treated patients, an increased caloric intake was more commonly associated with weight gain in patients receiving hydrazine compared with those receiving placebo (81% versus 53%, respectively). Hydrazine toxicity was mild, with 71% of patients reporting no toxic effects. Hydrazine sulfate circulatory levels were obtained from a subset of 14 patients who completed 30 days of treatment, with a single sample obtained in the morning at least 9 hours after the last dose. Mean maintenance hydrazine sulfate levels, determined using a spectrofluorometric assay, ranged from 0 to 89 ng/ml (mean 45 +/- 16 ng/ml). These data, which demonstrate an association between 1 month of hydrazine sulfate administration and body weight maintenance in patients with cancer, suggest future clinical trials of hydrazine sulfate are indicated to definitively assess its long-term impact on important clinical outcome parameters in defined cancer populations.

Hydrazine sulfate: a current perspective

Hydrazine sulfate is an anticachexia agent which interrupts host energy wasting as a result of the malignant process. An inhibitor of gluconeogenesis at the phosphoenolpyruvate carboxykinase (PEP CK) reaction, this agent has been shown in randomized, placebo-controlled, double-blind trials to improve glucose tolerance, reduce glucose turnover, increase caloric intake, and increase or stabilize weight; in single-arm controlled trials, this agent has been shown to increase appetite, improve performance status, decrease pain, diminish anorexia, normalize laboratory indices, stabilize tumor growth, induce tumor regression, and promote survival, while inducing little to no important clinical side effects. In view of its demonstrated capacity to effect anticancer response, this drug is suggested for trial as a sole agent in early drug-resistant cancer, in combination with cytotoxic and related therapies, and in conjunction with total parenteral nutrition. It is postulated that effective control of the mechanisms associated associated with cancer cachexia may contribute to control of malignant disease.

Weight change and peptide hormone responses in patients receiving interferon

The purpose of this pilot study was to describe body weight status and peptide hormone responses in patients receiving interferon (IFN) therapy for renal cell carcinoma. Eighteen patients were on therapy for approximately two to three months. Mean weight loss of the patients was 2.2 +/- 0.9 kg (mean +/- SEM) or 4.9 +/- 0.9% of prestudy weight. Of the 18 patients, 6 were further evaluated for peptide hormone responses to meal stimulation before and after treatment (mean: 1.5 months). These subjects had a mean weight loss of 4.3 +/- 1.6 kg or 7.0 +/- 3.5% of prestudy weight. Blood was drawn from subjects before and six times after they had consumed a defined formula liquid meal to provoke enteroinsular peptide release. It was discovered that one-half of this group (n = 3; Group A) had some glucose intolerance following IFN therapy, despite increased response of insulin, gastric inhibitory polypeptide (GIP), and pancreatic polypeptide (PP) to meal stimulation. Further, patients in Group A had a weight loss of -11.7 +/- 2.7% of prestudy weight, whereas the other three patients (Group B) experienced a mean loss of -2.3 +/- 1.2% (p less than 0.04). The three subjects characterized by the smaller loss of prestudy weight (Group B) had decreased glucose response to meal stimulation, despite decreased responses of insulin and GIP. Response of PP was slightly increased with treatment in group B, but the increase was not as large as that in Group A. These data may suggest that extreme weight loss and altered peptide hormone response occur in a subset of cancer patients receiving interferon therapy.

Metabolic abnormalities in cancer patients: carbohydrate metabolism

Weight loss in patients with a variety of cancers is associated with a poor prognosis. Consistent abnormalities of carbohydrate metabolism are seen in cancer patients with weight loss and appear to represent derangements in host metabolism that are induced by the presence of cancer. To define therapeutic strategies to improve the poor clinical outcome for patients with cancer cachexia, investigations are under way to define the relationships among glucose metabolism, altered energy expenditure, caloric intake, weight loss, and clinical outcome.

Adverse metabolic consequences of nutritional support: micronutrients

The role of total parenteral nutrition in cancer patients is still a matter of controversy. Over the last decade there has been a heightened interest in the interaction of micronutrients with tumor cells. A review of the literature reveals that the question of feeding or suppressing the tumor by supplementing micronutrients remains unanswered. Prospective studies are needed to define the requirements of vitamins and trace elements in the cancer patient.

Total parenteral nutrition and cancer clinical trials

Twenty-eight prospective randomized controlled clinical trials evaluating the use of total parenteral nutrition (TPN) in cancer patients were identified through a search of major indexing sources. The data were pooled across studies to increase the ability to detect therapeutic effects. The impact of publication bias and the quality of reporting each trial were used to critically assess the conclusions drawn from the pooled analysis. The authors conclude that TPN may be useful when used preoperatively in patients with gastrointestinal tract cancer. It appears to be beneficial in reducing major surgical complications (pooled P = 0.01) and operative mortality (pooled P = 0.02). No statistically significant benefit from TPN could be demonstrated in survival, treatment tolerance, treatment toxicity, or tumor response in patients receiving chemotherapy or radiotherapy. An increase in the risk of developing an infection in chemotherapy patients given TPN (pooled P less than 0.0001) underscores the importance of demonstrating significant benefits in randomized trials before TPN is used routinely in these patients.

Influence of nandrolone decanoate on weight loss in advanced non-small cell lung cancer

The short term addition of nandrolone decanoate to combination chemotherapy given to patients with unresectable non-small cell lung cancer was evaluated in a randomized, prospective trial. Patients were treated with doxorubicin 50 mg/M2 intravenously, cyclophosphamide 300 mg/M2 intravenously, CCNU 50 mg/M2 orally, vincristine 1.4 mg/M2 intravenously, with and without cisplatin 50 mg/M2 intravenously, all given every 28 days. In addition, patients were randomized to receive either nandrolone decanoate 200 mg intramuscularly weekly for 4 weeks or no additional therapy. Patient age, disease extent, performance score, and pretreatment weight loss were similar in the two treatment arms. Objective antitumor response frequency was comparable on both treatment arms with median survival somewhat longer for patients receiving the androgen (median survival 5.5 months without and 8.2 months with nandrolone decanoate). There was a trend for less severe weight loss on the nandrolone decanoate arm (average weight loss 0.8 +/- 0.15 kg versus 0.21 +/- 0.18 kg, respectively), with half as many patients experiencing weight loss on nandrolone decanoate (25% versus 12%). A separate concurrent study has demonstrated decreased free testosterone levels in 66% of patients with advanced cancer studied prior to chemotherapy treatment, therefore, further prospective studies in which pretreatment testosterone levels are used to guide androgen administration are needed to define more precisely a role for androgen replacement therapy in non-small cell lung cancer.

Significance of altered nutritional status in acquired immune deficiency syndrome (AIDS)

Severe unrelenting weight loss appears to be a major component of the clinical picture seen in the patients with Acquired Immune Deficiency Syndrome (AIDS). Weight loss has been associated with a poor prognosis for AIDS patients with Kaposi's sarcoma. Strong evidence from a variety of clinical situations indicates that malnutrition per se adversely affects the cellular immune system and the susceptibility of individuals to infectious problems. In addition, weight loss of the degree commonly seen in the AIDS population places patients at risk of death because of resultant organ dysfunction. Moreover, severe weight loss may preclude recovery from infectious complications that otherwise would not represent a lethal challenge to the host. Because even appropriately directed therapies may not be successful when used in patients with severe weight loss, it is crucial to identify the mechanism of the weight loss associated with AIDS and to rapidly initiate evaluation of agents capable of altering or reversing this potentially lethal complication.

Micronutrient requirements of cancer patients

Several major factors may influence the micronutrient requirements of the patient with cancer. These factors include the metabolic state of the malignancy and its effects on host metabolism, the catabolic effects of antineoplastic therapy, and other physiologic stresses commonly associated with the treatment of cancer, i.e., surgery, fever and infection. Although the nutritional importance of vitamins, minerals and trace elements is recognized, the optimal daily dose that will preserve lean body mass without enhancing tumor growth, is not known. Recommended Dietary Allowances (RDAs), where established, are based on populations with nonmalignant diseases. However, supplementation with vitamins, minerals, and certain trace elements is recommended for the cancer patient who requires prolonged parenteral support, since clinically relevant deficiency states have been described. The effect of malignancy on the metabolism of several of these micronutrients (iron, ascorbic acid, alpha tocopherol, selenium, zinc, copper) is discussed.