Nutritional support and parenteral nutrition in cancer patients: an expert consensus report

Cancer-Related Malnutrition and the Role of Parenteral Nutrition in Cancer; A Narrative Review

The growing incidence rate of cancer and its associated morbidity and mortality prompts the need to identify factors that could improve the quality of life (QoL) and survival of a patient with cancer. Cancer-associated malnutrition is a common complication that could start at the early stages of cancer and could further develop into advanced cachexia. Response to treatment, length of hospital stay, progression of infection, and other complications of cancer including chemotherapy adverse events could all be influenced by the progression of malnutrition. Nutritional interventions may vary from oral to enteral and parenteral therapy. Parenteral nutrition (PN) therapy may benefit patients at certain stages of cancer in whom contraindications or inefficacy of other modalities of nutritional support are present. This method may seem invasive, costly, and risky but at the same time may improve certain patients' QoL and chance of survival. In trained settings with proper facilities, this method of nutritional support can benefit patients; However, the indication for starting PN must be carefully supervised considering that other nutritional support methods may be equally efficient and at the same time easier to access and apply.

Effect of preoperative frailty on postoperative infectious complications and prognosis in patients with colorectal cancer: a propensity score matching study

BACKGROUND

Few studies have explored the impact of preoperative frailty on infectious complications in patients with a diagnosis of colorectal cancer (CRC). Therefore, this study aimed to investigate the effect of preoperative frailty on postoperative infectious complications and prognosis in patients with CRC using propensity score matching (PSM).

METHODS

This prospective single-centre observational cohort study included 245 patients who underwent CRC surgery at the Department of Gastrointestinal Surgery, The Affiliated Lianyungang Hospital of Xuzhou Medical University between August 2021 to May 2023. Patients were categorised into two groups: frail and non-frail. They were matched for confounders and 1:1 closest matching was performed using PSM. Rates of infectious complications, intensive care unit (ICU) admission, 30-day mortality, and 90-day mortality, as well as postoperative length of hospital stay, total length of hospital stay, and hospital costs, were compared between the two groups. Binary logistic regression using data following PSM to explore independent factors for relevant outcome measures.

RESULTS

After PSM, each confounding factor was evenly distributed between groups, and 75 pairs of patients were successfully matched. The incidence of intra-abdominal infectious complications was significantly higher in the frail group than in the non-frail group (10.7% vs. 1.3%, P < 0.05). There were no significant differences in ICU admission rate, postoperative length of hospital stay, total length of hospital stay, hospital costs, 30-day mortality rate, or 90-day mortality rate between the two groups (P > 0.05). Our logistic regression analysis result showed that preoperative frailty (OR = 12.014; 95% CI: 1.334-108.197; P = 0.027) was an independent factor for intra-abdominal infection.

CONCLUSIONS

The presence of preoperative frailty elevated the risk of postoperative intra-abdominal infectious complications in patients undergoing CRC surgery. Therefore, medical staff should assess preoperative frailty in patients with CRC early and provide targeted prehabilitation interventions.

SEOM clinical guidelines for cancer anorexia-cachexia syndrome (2023)

Cancer-related anorexia-cachexia syndrome (CACS) is a debilitating condition afflicting up to 80% of advanced-stage cancer patients. Characterized by progressive weight loss, muscle wasting, and metabolic abnormalities, CACS significantly compromises patients' quality of life and treatment outcomes. This comprehensive review navigates through its intricate physiopathology, elucidating its stages and diagnostic methodologies. CACS manifests in three distinct stages: pre-cachexia, established cachexia, and refractory cachexia. Early detection is pivotal for effective intervention and is facilitated by screening tools, complemented by nutritional assessments and professional evaluations. The diagnostic process unravels the complex interplay of metabolic dysregulation and tumor-induced factors contributing to CACS. Management strategies, tailored to individual patient profiles, encompass a spectrum of nutritional interventions. These include dietary counseling, oral nutritional supplements, and, when necessary, enteral nutrition and a judicious use of parenteral nutrition. Specific recommendations for caloric intake, protein requirements, and essential nutrients address the unique challenges posed by CACS. While pharmacological agents like megestrol acetate may be considered, their use requires careful evaluation of potential risks. At its core, this review underscores the imperative for a holistic and personalized approach to managing CACS, integrating nutritional interventions and pharmacological strategies based on a nuanced understanding of patient's condition.

Influence of malnutrition according to the glim criteria on the chemotherapy toxicities in patients with advanced lung cancer

BACKGROUND

Cancer-associated malnutrition is highly prevalent in advanced lung cancer, and 50% of global cancer-related deaths are attributed to cancer-associated malnutrition. Platinum-containing chemotherapy is the standard treatment for advanced lung cancer. Unfortunately, it can cause exacerbated toxicities, which can also have a negative impact on patient's prognosis and quality of life. The Global Leadership Initiative on Malnutrition (GLIM) criteria have been proposed as the world's first accepted diagnostic criteria for malnutrition. However, the effectiveness of GLIM criteria in predicting chemotherapy toxicities in patients with advanced lung cancer is unclear. The aim of this study was to apply the GLIM criteria to assess the prevalence of pre-treatment diagnosis of malnutrition in patients with advanced non-small cell lung cancer (NSCLC) and to determine the impact of nutritional status on patient's chemotherapy toxicity.

METHODS

We conducted a study of hospitalized patients with pathologically and clinically diagnosed advanced NSCLC who presented to our hospital from May 2021 to January 2022. Initially, the Nutritional Risk Screening-2002 (NRS-2002) was used for nutritional risk screening, and nutritional status was assessed using the Scored Patient-Generated Subjective Global Assessment (PG-SGA) and GLIM criteria. Chemotherapy toxicity was assessed and graded according to CTCAE5.0, and chemotherapy efficacy was assessed according to RECIST1.1. Kappa test was used to analyze the agreement between PG-SGA and GLIM criteria. Univariate and multivariate logistic regression analyses were used to determine the relationship between malnutrition and chemotherapy toxicity.

RESULTS

A total of 215 patients with advanced NSCLC were evaluated for nutritional status. Most of the patients had normal BMI (61.86%) before the start of treatment, 40% were well-nourished as assessed by the PG-SGA tool, and 51.17% were well-nourished as assessed by GLIM criteria. Consistency analysis showed moderate agreement (Kappa = 0.463, P < 0.001) and their correlation was also moderate (Spearman, rs = 0.475, P < 0.001). The objective response rate (ORR) (P = 0.040) and disease control rate (DCR) (P < 0.001) were significantly lower in malnourished patients diagnosed according to GLIM criteria than in well-nourished patients. Multivariate analysis showed that malnutrition (OR = 1.531,95%CI 0.757-3.009; OR = 6.623,95%CI 1.390-31.567, P = 0.046) diagnosed by GLIM criteria was an independent predictor of chemotherapy toxicity. Conclusions Malnutrition diagnosed by GLIM criteria better predicts toxicity during chemotherapy, determines the degree of clinical benefit of chemotherapy, and may affect patient prognosis.

Three-Stage Nutrition Diagnosis for surgical patients at the perioperative period

Medical nutrition therapy has been widely applied in various diseases as a fundamental or even a first-line treatment. Patient who undergoes a disease state especially at the perioperative period can be much improved with the help of nutrition therapy. Precise nutrition diagnosis should be conducted before applying any nutrition therapy. Traditional malnutrition diagnostic process, however, is a two-stage process (nutrition screening and nutrition assessment) which cannot precisely assess nutritional status of surgical patients or the consequences of being malnourished. This article systematically introduced a new nutrition diagnostic process - Three-Stage Diagnosis (nutrition screening, nutrition assessment, and comprehensive evaluation) and discussed its applications during perioperative period.

A Narrative Review Comparing Nutritional Screening Tools in Outpatient Management of Cancer Patients

Malnutrition during cancer has a negative impact on prognosis and quality of life. Therefore, it is important to identify those patients at higher nutritional risk to prevent its development. There are nutritional screening tools, such as MUST and NRS-2002, that focus on the patient on admission to hospital. However, most patients will develop malnutrition in the outpatient or ambulatory setting. This study aims to determine which nutritional screening tool is most effective in assessing nutritional risk in the outpatient oncology patient, highlighting the parameters analysed by these tools. Seventeen articles were reviewed, with the most important variables being tumour location, tumour stage, age, and gender, as well as recent weight loss, dietary intake, and digestive disorders. The Nutriscore, NRS-2002, and MUST tools are considered suitable, but the choice varies depending on these parameters. MNA is suitable for elderly patients, while SNAQ was not considered reliable in this population. In conclusion, MUST, NRS-2002, and Nutriscore are suitable tools, but their choice depends on specific characteristics. There is currently no universal tool for nutritional risk assessment in outpatients.

NUTRISCORE as a tool to predict greater weight loss and longer hospital stay in cancer patients

Introduction

Introduction: malnutrition in cancer patients is quite common and can cause various types of harm such as reduced tolerance to therapeutic measures and increased hospital stay. Identification of nutritional risk for these patients may minimize these problems. NUTRISCORE screening has been associated with Global Subjective Assessment Produced by Patient (ASG-PPP) screening, which is considered as the gold standard in cancer patients. No study has evaluated its predictive value in relation to weight loss and length of hospital stay in Brazil. Thus, the present study aims to analyze the NUTRISCORE tool, translated and adapted to the Brazilian population, as a predictor of longer hospital stays, as well as greater hospital weight loss. Methods: first, the NUTRISCORE tool was translated and adapted to the Brazilian population and subsequently applied to patients of both sexes, over 20 years old, admitted to the Cancer Hospital of Pernambuco. The patients were screened and classified as nutritionally "at risk" or "not at risk", their weight was measured at the time of admission and time of discharge from the hospital, and they were followed up throughout their stay to assess their weight loss and length of hospital stay. Results: one hundred and one patients participated in the study, with a higher prevalence of adults and males. The NUTRISCORE showed that patients "at nutritional risk" had a higher risk of greater weight loss (p = 0.001) and longer hospital stay (p = 0.007). Conclusion: NUTRISCORE proved to be a good predictor of longer hospital stay and greater weight loss among hospitalized patients.

Impact of Nutritional Status of Patients with Head and Neck Squamous Cell Carcinoma on the Expression Profile of Ghrelin, Irisin, and Titin

The goal of this paper was the evaluation of the changes in the expression profile of irisin, ghrelin, and titin in the carcinoma tissue and in the blood of patients with head and neck squamous cell carcinoma (HNSCC), including determining the profile of their expression in relation to patient nutrition. The study included 56 patients with diagnosed squamous cell carcinoma of HNSCC in the T3 and T4 stages of the disease. Healthy control tissue specimens were collected from an area 10 mm outside the histologically negative margin. In turn, the blood and serum from the control group came from healthy volunteers treated for non-oncologic reasons (n = 70). The molecular analysis allowed us to determine the profile of irisin, ghrelin, and titin methylation, evaluate their expression on the level of mRNA (quantitative Reverse Transcription Polymerase Chain Reaction; qRT-PCR) and protein (Enzyme-Linked Immunosorbent Assay Reaction; ELISA) in the carcinoma tissue and the margin of healthy tissue, as well as in serum of patients in the study and control groups. At the start of our observations, a Body Mass Index (BMI) < 18.5 was noted in 42 of the patients, while six months after the treatment a BMI < 18.5 was noted in 29 patients. We also noted a decrease in the expression of irisin, ghrelin, and titin both on the level of mRNA and protein, as well as a potential regulation of their expression via DNA methylation. There is no convincing evidence that the proteins assayed in the present work are specific with regard to HNSSC.

Body composition is associated with postoperative complications in perihilar cholangiocarcinoma

BACKGROUND

Perihilar cholangiocarcinoma (pCCA) is a malignant tumor of the hepatobiliary system which is still associated with a challenging prognosis. Postoperative complications play a crucial role in determining the overall prognosis of patients with pCCA. Changes in body composition (BC) have been shown to impact the prognosis of various types of tumors. Therefore, our study aimed to investigate the correlation between BC, postoperative complications and oncological outcome in patients with pCCA.

METHODS

All patients with pCCA who underwent curative-intent surgery for pCCA between 2010 and 2022 were included in this analysis. BC was assessed using preoperative computed tomography and analyzed with the assistance of a 3D Slicer software. Univariate and multivariate binary logistic regression analyses were conducted to examine the relationship between BC and clinical characteristics including various measurements of postoperative complications and Cox regressions and Kaplan-Meier analysis to evaluate oncological risk factors in the study cohort.

RESULTS

BC was frequently altered in patients undergoing curative-intent liver resection for pCCA (n = 204) with 52.5% of the patients showing obesity, 55.9% sarcopenia, 21.6% sarcopenic obesity, 48.5% myosteatosis, and 69.1% visceral obesity. In multivariate analysis, severe postoperative complications (Clavien-Dindo ≥3b) were associated with body mass index (BMI) (Odds ratio (OR) = 2.001, p = 0.024), sarcopenia (OR = 2.145, p = 0.034), and myosteatosis (OR = 2.097, p = 0.017) as independent predictors. Furthermore, sarcopenia was associated with reduced overall survival (OS) in pCCA patients (sarcopenia vs. no-sarcopenia, 21 months vs. 32 months, p = 0.048 log rank).

CONCLUSIONS

BC is highly associated with severe postoperative complications in patients with pCCA and shows tendency to be associated impaired overall survival. Preoperative assessment of BC and interventions to improve BC might therefore be key to improve outcome in pCCA patients undergoing surgical therapy.

Routine laboratory parameters to support decision on parenteral nutrition in palliative care

Introduction

Parenteral nutrition (PN) is widely used in palliative care (PC), but there is limited evidence to support its use at the end of life (EOL). This aim of this was to investigate the relationship between routine laboratory parameters and survival in patients receiving PN, and to develop a decision tree model to support clinicians decide whether to start or forgo PN.

Methods

The laboratory parameters of 113 patients with advanced diseases who were admitted to a specialized palliative care unit (PCU) were analyzed at two points in time: T0 = before PN, T1 = two weeks after initiation of PN. Univariate Mann-Whitney U-tests and multivariate linear regression models, as well as a decision tree analysis were computed; all in relation to survival time.

Results

The final regression model was significant with p = 0.001 (adjusted R2 = 0.15) and included two predictors for survival time after PN initiation: the CRP/albumin ratio and urea at T1 (ps = 0.019). Decision tree analysis revealed three important predictors for classification of survival time after PN initiation: CRP, urea, and LDH (all at T0).

Discussion

The decision tree model may help to identify patients likely to benefit from PN, thus supporting the clinical decision whether or not to start PN.

Nutrient-Based Approaches for Melanoma: Prevention and Therapeutic Insights

Melanoma, a prevalent and lethal form of skin cancer, remains a formidable challenge in terms of prevention and treatment. While significant progress has been made in understanding its pathogenesis and treatment, the quest for effective prevention strategies and therapeutic approaches remains ongoing. Considering the increased advancements in understanding the dynamic interplay between nutrients and melanoma, we aim to offer a refreshed perspective on nutrient-based approaches for melanoma prevention and adjunctive therapy. In contrast to other studies, we have innovatively provided a detailed exposition of the nutrients' influences on melanoma prognosis and treatment. This review firstly examines various nutrients, including antioxidants (namely vitamins A, D, C, and E; selenium; and caffeine), polyunsaturated fatty acids, and flavonoids, for their effects and underlying mechanisms in reducing melanoma risk. Among these nutrients, caffeine shows the most promising potential, as it is supported by multiple cohort studies for its protective effect against melanoma. In contrast, there is a certain degree of inconsistency in the research of other nutrients, possibly due to inherent differences between animal studies and epidemiological research, as well as variations in the definition of nutrient intake. To comprehensively investigate the impact of nutrients on melanoma progression and therapeutic approaches, the following sections will explore how nutrients influence immune responses and other physiological processes. While there is robust support from cell and animal studies regarding the immunomodulatory attributes of vitamins D and zinc, the anti-angiogenic potential of polyphenols, and the cell growth-inhibitory effects of flavonoids, the limited availability of human-based research substantially constrains their practical relevance in clinical contexts. As for utilizing nutrients in adjuvant melanoma treatments, multiple approaches have garnered clinical research support, including the utilization of vitamin D to decrease the postoperative recurrence rates among melanoma patients and the adoption of a high-fiber diet to enhance the effectiveness of immunotherapy. In general, the effects of most nutrients on reducing the risk of melanoma are not entirely clear. However, several nutrients, including vitamin D and dietary fiber, have demonstrated their potential to improve the melanoma prognosis and enhance the treatment outcomes, making them particularly deserving of clinical attention. A personalized and interdisciplinary approach, involving dermatologists, oncologists, nutritionists, and researchers, holds the promise of optimizing melanoma treatment strategies.

Synergistic Strategies for Gastrointestinal Cancer Care: Unveiling the Benefits of Immunonutrition and Microbiota Modulation

Gastrointestinal (GI) cancers are a group of highly prevalent malignant tumors affecting the gastrointestinal tract. Globally, one in four cancer cases and one in three cancer deaths are estimated to be GI cancers. They can alter digestive and absorption functions, leading to severe malnutrition which may worsen the prognosis of the patients. Therefore, nutritional intervention and monitoring play a fundamental role in managing metabolic alterations and cancer symptoms, as well as minimizing side effects and increasing the effectiveness of chemotherapy. In this scenario, the use of immunonutrients that are able to modulate the immune system and the modification/regulation of the gut microbiota composition have gained attention as a possible strategy to improve the conditions of these patients. The complex interaction between nutrients and microbiota might contribute to maintaining the homeostasis of each individual's immune system; therefore, concurrent use of specific nutrients in combination with traditional cancer treatments may synergistically improve the overall care of GI cancer patients. This work aims to review and discuss the role of immunonutrition and microbiota modulation in improving nutritional status, postoperative recovery, and response to therapies in patients with GI cancer.

Expert design thinking workshops to analyze users' perceived applicability of NUTRI-ONCOCARE algorithm to prevent and treat malnutrition in cancer patients under routine clinical practice conditions in Spain: the ALLIANCE study

PURPOSE

NUTRI-ONCOCARE algorithm has been developed to identify and treat patients with solid tumors who are at risk of malnutrition. The present study is aimed at analyzing users' opinion about this new tool and at assessing whether it is perceived as useful to achieve the behavioral change required for a successful integration of nutritional assessment into routine cancer care.

METHODS

Design thinking Double Diamond process was applied. A multidisciplinary team composed of ten potential end-users (four oncologists, three endocrinologists, one nutritionist, and two hospital pharmacists) participated in three different workshops aiming to analyze the different tasks included within the NUTRI-ONCOCARE algorithm.

RESULTS

Users agreed on the need to perform nutritional assessment around cancer diagnosis and through the course of the disease using standardized tools included in hospital nutritional protocols and involving healthcare professionals with nutrition expertise. Nutritional evaluation and intervention should be individual and comprehensive, considering not only nutritional parameters but also patients' functional status. According to participants' opinion, the implementation of nutritional screening in routine clinical practice is limited by the lack of time and staff to conduct nutritional assessments, the low level of nutrition expert participation, and the poor support provided by hospital managers, which are often unaware of nutrition's impact in cancer care.

CONCLUSIONS

Experts recognized the importance of considering nutritional status in cancer patients and identified the opportunity provided by the NUTRI-ONCOCARE algorithm for this purpose, as it meets main requirements for being used routinely in clinical practice.

Comparative efficacy of oral drugs for chronic radiation proctitis - a systematic review

BACKGROUND

Chronic radiation proctitis (CRP) is a long-term complication of pelvic radiotherapy that manifests as rectal bleeding, diarrhoea, fistula formation and obstruction. Treatments such as endoscopic argon plasma coagulation, hyperbaric oxygen therapy and rectal topical formalin have imposed a significant medical burden on CRP patients. In contrast, oral therapies offer a more accessible and acceptable option for managing CRP. Here, we conducted a systematic review of the efficacy of oral treatments for CRP to assess their potential as an effective and convenient treatment option for this condition.

METHODS

We searched the Cochrane Central Register of Controlled Trials, PubMed, Web of Science, China National Knowledge Infrastructure and Chinese VIP in February 2021. We included post-radiotherapy participants with CRP that compared oral medicine alone or in combination with other treatments versus control treatments. The primary outcomes were bleeding, diarrhoea and symptom score. Heterogeneity between studies was checked using Cochrane Q test statistics and I2 test statistics. The Cochrane risk-of-bias tool was used to assess the quality of the included studies.

RESULTS

We included 10 randomised controlled trials (RCTs) and 1 retrospective study with 898 participants. Three placebo-controlled trials evaluated the effects of oral sucralfate on CRP, with meta-analysis showing no significant different with placebo arm. Four trials on TCM demonstrated significant improvement of symptoms, especially for the 3 trials on oral TCM drinks. Retinyl palmitate and high-fibre diet were found to reduce rectal bleeding. The combination of oral pentoxifylline and tocopherol did not significantly change the process of CRP.

CONCLUSIONS

Our study implies that oral TCM drinks, retinyl palmitate and a high-fiber diet showed significant improvement in CRP symptoms, but not with the combination of oral pentoxifylline and tocopherol. Further multicentre, larger-scale RCTs are needed to confirm the efficacy and safety of these treatments and optimize treatment strategies, ultimately improving the quality of life for patients with CRP.

Antiemetic Drugs Compatibility Evaluation with Paediatric Parenteral Nutrition Admixtures

Chemotherapy-induced nausea and vomiting are defined as the most common of side effects of treatment and, at the same time, are very difficult to accept for patients', frequently causing changes in the therapy regimen, significantly reducing its effectiveness. Thus, an antiemetic prophylactic is essential to the provision of such a therapy for the patient. Pharmacotherapy often includes various drugs, including antiemetics, with the administration of such drugs by injection through two separate catheters being the preferred method. However, the co-administration of drugs and parenteral nutrition admixtures (PNAs) requires the consideration of compatibility, stability and potential negative interactions. To meet the purposes of clinical pharmacy, a compatibility test of ondansetron, dexamethasone and hydrocortisone with paediatric PNAs was conducted. PNAs differ in the composition of amino acid source (Primene® or Aminoplasmal Paed® 10%) and the type of injectable lipid emulsion (Lipidem® 200 mg/mL, Clinoleic® 20%, SMOFlipid® 200 mg/mL, Intralipid® 20%). An in vitro evaluation was performed in a static way as a simulated co-administration through a Y-site. The drug PNA ratios were determined based on the extreme infusion rates contained in the characteristics of medicinal products. All calculations were performed for a hypothetical patient aged 7 years weighing 24 kg. As a result of this study, it can be concluded that all tested PNAs showed the required stability in the range of parameters such as pH, osmolality, turbidity, zeta potential, MDD and homogeneity. The co-administration of antiemetic drugs does not adversely affect lipid emulsion stability. This combination was consistently compatible during the evaluation period.

Randomized Double-Blind Placebo-Controlled Study of Olanzapine for Chemotherapy-Related Anorexia in Patients With Locally Advanced or Metastatic Gastric, Hepatopancreaticobiliary, and Lung Cancer

PURPOSE

Anorexia occurs in 30%-80% of patients with advanced malignancies, which may be worsened with chemotherapy. This trial assessed the efficacy of olanzapine in stimulating appetite and improving weight gain in patients receiving chemotherapy.

METHODS

Adults (≥18 years) with untreated, locally advanced, or metastatic gastric, hepatopancreaticobiliary (HPB), and lung cancers were randomly assigned (double-blind) to receive olanzapine (2.5 mg once a day for 12 weeks) or placebo along with chemotherapy. Both groups received standard nutritional assessment and dietary advice. The primary outcomes were the proportion of patients with weight gain > 5% and the improvement in appetite (assessed by the visual analog scale [VAS] and the Functional Assessment of Chronic Illness Therapy system of Quality-of-Life questionnaires Anorexia Cachexia subscale [FAACT ACS]). Secondary end points were change in nutritional status, quality of life (QOL), and chemotherapy toxicity.

RESULTS

We enrolled 124 patients (olanzapine, 63 and placebo, 61) with a median age of 55 years (18-78 years), of whom 112 (olanzapine, 58 and placebo, 54) were analyzable. The majority (n = 99, 80%) had metastatic cancer (gastric [n = 68, 55%] > lung [n = 43, 35%] > HPB [n = 13, 10%]). The olanzapine arm had a greater proportion of patients with a weight gain of > 5% (35 of 58 [60%] v 5 of 54 [9%], P < .001) and improvement in appetite by VAS (25 of 58 [43%] v 7 of 54 [13%], P < .001) and by FAACT ACS (scores ≥37:13 of 58 [22%] v 2 of 54 [4%], P = .004). Patients on olanzapine had better QOL, nutritional status, and lesser chemotoxicity. Side effects attributable to olanzapine were minimal.

CONCLUSION

Low-dose, daily olanzapine is a simple, inexpensive, well-tolerated intervention that significantly improves appetite and weight gain in newly diagnosed patients on chemotherapy.

Critical evaluation and comparison of nutritional clinical practice guidelines for cancer patients

BACKGROUND

The growing incidence of cancer globally, and the importance of nutrition support for these patients, emphasize the need for the development of nutritional clinical practice guidelines and consensus papers (CPGs) in the field. Numerous relevant CPGs have been published by several organizations worldwide. The aim of this systematic review was to compare the content of the existing CPGs and evaluate the quality of their development using the AGREE-II tool.

METHODS

A systematic literature search in PubMed, Embase and Web of Science databases was conducted for the identification of relevant CPGs and consensus papers. Eligible CPGs was blindly evaluated by four appraisers according to the Appraisal of Guidelines for Research and Evaluation ΙΙ (AGREE-II) tool.

RESULTS

In total 15 CPGs were identified and were evaluated. All but one set of CPGs underlined the importance of nutritional screening and assessment, whereas recommendations on nutritional interventions, supplements, management of complications and nutritional follow-up were also reported by several organizations. AGREE-II results showed that two CPGs were characterized as high, eight as moderate and five as low regarding their quality of development.

CONCLUSIONS

Variety on recommendations could be observed between CPGs that should be considered when applied into clinical practice. Limitations of the existing CPGs could be the fact that they are non-specific and only a minority of them are focused to specific cancer types. Frequent updates for CPGs and inclusion of more nutritional topics should be considered for some CPGs. Improvement of the quality of the CPGs development should also be pursued in future.

Biomarkers for predicting the prognosis of intrahepatic cholangiocarcinoma: A retrospective single-center study

The aim of this retrospective study was to investigate the association between preoperative serological and clinical indicators and postoperative recovery in patients who had undergone resection of intrahepatic cholangiocarcinoma (ICC). We collected data form the medical records of patients who underwent operations for the treatment of ICC at Qingdao University Affiliated Hospital from 2015 to 2021. We analyzed the data to explore the independent predictors of disease prognosis after surgery for ICC. By univariate analysis, we found that the following factors were significantly associated with overall survival and tumor-free survival in patients with ICC: TNM stage; degree of vascular invasion; levels of hemoglobin, carcinoembryonic antigen, carbohydrate antigen 125, direct bilirubin, alkaline phosphatase, and albumin; prothrombin time; neutrophil to lymphocyte ratio; prothrombin time to albumin ratio; albumin to alkaline phosphatase ratio; albumin to gamma-glutamyl transferase ratio; prognostic nutrition Index, and incisional margin. However, only carbohydrate antigen 24-2 and glutamyl transpeptidase were correlated with overall survival in patients with ICC. However, only a positive history of biliary surgery was significantly associated with tumor-free survival in patients with ICC. Preoperative prothrombin time, vascular invasion, N-stage, incisal edge, and carcinoembryonic antigen levels may be simple predictors of disease progression in ICC after hepatectomy.

Preoperative prognostic nutritional index predicts short-term complications after radical resection of distal cholangiocarcinoma

Background

The occurrence of postoperative complications of distal cholangiocarcinoma (dCCA) is an indicator of poor patient prognosis. This study aimed to determine the immune-nutritional indexes (INIs) that can predict short-term postoperative complications.

Methods

A retrospective analysis of 148 patients with dCCA who were operated radical pancreaticoduodenectomy at the First Hospital of Lanzhou University from December 2015 to March 2022 was conducted to assess the predictive value of preoperative INIs and preoperative laboratory tests for short-term postoperative complications, and a decision tree model was developed using classification and regression tree (CART) analysis to identify subgroups at risk for overall complications.

Results

In this study, 83 patients (56.08%) experienced overall complications. Clavien-Dindo grade III-V complications occurred in 20 patients (13.51%), and 2 patients died. The areas under curves (AUCs) of the preoperative prognostic nutritional index (PNI), controlling nutritional status (CONUT) score, and neutrophil-to-lymphocyte ratio (NLR) were compared; the PNI provided the maximum discrimination for complications (AUC = 0.685, 95% CI = 0.600-0.770), with an optimal cutoff value of 46.9, and the PNI ≤ 46.9 group had higher incidences of overall complications (70.67% vs. 40.00%, P < 0.001) and infectious complications (28.77% vs. 13.33%, P = 0.035). Multivariate logistic regression analysis identified PNI (OR = 0.87, 95% CI: 0.80-0.94) and total bilirubin (OR = 1.01, 95% CI: 1.00-1.01) were independent risk factors for overall complications (P < 0.05). According to CART analysis, PNI was the most important parameter, followed by the total bilirubin (TBIL) level. Patients with a PNI lower than the critical value and TBIL higher than the critical value had the highest overall complication rate (90.24%); the risk prediction model had an AUC of 0.714 (95% CI, 0.640-0.789) and could be used to stratify the risk of overall complications and predict grade I-II complications (P < 0.05).

Conclusion

The preoperative PNI is a good predictor for short-term complications after the radical resection of dCCA. The decision tree model makes PNI and TBIL easier to use in clinical practice.

Evaluation of Nutritional Interventions in the Care Plan for Cancer Patients: The NOA Project

The NOA (Oncological Nutrition in Andalusia) project analyses the degree of integration and areas of improvement in implementing nutritional support in the care plans of cancer patients in Andalusia. The aim was to analyse nutritional interventions for better care of cancer patients and for the improvement of the management of malnutrition in cancer. A prospective evaluation of the implementation of two areas of improvement in nutrition was conducted in three hospitals. Data were collected from each hospital over a six-month period using an online platform. A standardised care plan was designed for hospitals in Andalusia, in which proposed improvements were devised and prioritised, selecting nutritional screening in oncology services and the participation of the Nutrition Support Team (NST) on the tumour boards, as well as the assessment of the patients presented at these sessions. Our results indicated an increase in the number of medical records with nutritional evaluation results six months later, regardless of the type of tumour or hospitalisation; and there was greater participation of the NST on the tumour boards, mainly for head and neck and oesophagogastric cases. Solutions for improvement have been pinpointed and implemented that have positively impacted the nutritional care plan in the course of oncological disease.

Clinical nutrition in surgical oncology: Young AIOM-AIRO-SICO multidisciplinary national survey on behalf of NutriOnc research group

Malnutrition is a common condition in cancer patients which is usually associated with functional limitations, as well as increased morbidity and mortality. Based on the support of the young sections of Italian Association of Medical Oncology (AIOM), Italian Association of Radiotherapy and Clinical Oncology (AIRO) and Italian Society of Surgical Oncology (SICO) merged into the NutriOnc Research Group, we performed a multidisciplinary national survey with the aim to define the awareness of nutritional issues among healthcare professionals delivering anticancer care. The questionnaire was organized in four sections, as follows: Knowledge and practices regarding Nutritional Management of cancer patients; Timing of screening and assessment of Nutritional Status; Nutritional Treatment and prescription criteria; Immunonutrition and educational topics. The modules focused on esophagogastric, hepato-bilio-pancreatic and colorectal malignancies. Overall, 215 physicians completed the survey. As regards the management of Nutritional Status of cancer patients, many responders adopted the ERAS program (49.3%), while a consistent number of professionals did not follow a specific validated nutritional care protocol (41.8%), mainly due to lack of educational courses (14.5%) and financial support (15.3%). Nearly all the included institutions had a multidisciplinary team (92%) to finalize the treatment decision-making. Cancer patients routinely underwent nutritional screening according to 57.2% of interviewed physicians. The timing of nutritional assessment was at diagnosis (37.8%), before surgery (25.9%), after surgery (16.7%), before radiochemotherapy (13.5%) and after radiochemotherapy (7%). Most of the responders reported that nutritional status was assessed throughout the duration of cancer treatments (55.6%). An important gap between current delivery and need of nutritional assessment persists. The development of specific and defined care protocols and the adherence to these tools may be the key to improving nutritional support management in clinical practice.

The evolving strategies for the management of patients with metastatic gastric cancer: A narrative review and expert opinion

Gastric cancer (GC) is recognized as one of the most common deadly malignancies worldwide and about 40-50% of patients present at diagnosis with an unresectable disease due to a locally advanced or already metastatic condition. Recently, therapeutic options for management of metastatic GC (mGC) have been approved allowing a potential improvement of patient cancer treatment response and also an establishment of a continuum of care for this aggressive disease. This report is the result of a literature review by an expert panel. The aim of this document is to provide evidence, wherever it is lacking, to provide expert opinion directed at strategic management of mGC, and in particular aspect at practical management where appropriate guidelines are not available. Treatment landscape with new therapeutic strategies for third line and beyond, role of imaging, prognostic factors, symptoms, and markers as well as the importance of multidisciplinary approach particularly the nutritional aspects are discussed.

Malnutrition diagnosed by the Global Leadership Initiative on Malnutrition criteria predicting survival and clinical outcomes of patients with cancer: A systematic review and meta-analysis

Objectives

Recently, some cohorts have looked into the use of Global Leadership Initiative on Malnutrition (GLIM) criteria in cancer patients. The objective of the current meta-analysis was to determine its utility in predicting clinical and survival outcomes for cancer patients.

Method

Searching and screening literature from PubMed, Web of Science and Embase until September 13, 2022 was performed by two researchers independently. According to the exclusion and inclusion criteria, articles reporting the impact of malnutrition diagnosed by GLIM on long-term survival and clinical outcomes were included. Data of interest were also extracted from the included papers. The stability of the pooled results was evaluated using sensitivity analysis. With the aid of subgroup analysis, heterogeneity was revealed. To assess publication bias, Egger's and Begg's tests were conducted. The influence of publication bias on the pooling risk estimate was examined using a trim-and-fill analysis.

Results

15 studies that qualified for our study were identified. Pooled hazard ratio (HR) from both multivariate and univariate regression analysis showed a worse overall survival in GLIM-defined malnourished cancer patients than those in well-nourished status. Meanwhile, disease-free survival was also poorer in malnourished patients. Moreover, pooled odds ratio (OR) demonstrated that malnourished cancer patients were more likely to develop overall postoperative complications, complications ≥ Clavien-Dindo grade IIa and complications ≥ Clavien-Dindo grade IIIa. Two articles reported negative relation between GLIM-defined malnutrition and 30-day readmission/mortality.

Conclusion

GLIM-defined malnutrition possesses value in predicting poorer survival and clinical outcomes for cancer patients.

Systematic review registration

[https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=321094], identifier [CRD42022321094].

Knowledge and Practices of Digestive Surgeons concerning Specialized Nutritional Support in Cancer Patients: A Survey Study

A survey study based on a 21-item questionnaire was conducted to assess knowledge and practices of digestive surgeons focused on nutritional support in gastrointestinal cancer patients. At least 5 staff digestive surgeons from 25 tertiary care hospitals throughout Spain were invited to participate and 116 accepted. Malnutrition was correctly defined by 81.9% of participants. In patients undergoing major abdominal surgery, 55.2% considered that preoperative nutritional support is indicated in all patients with malnutrition for a period of 7-14 days. For the diagnosis of malnutrition, only 18.1% of participants selected unintentional weight loss together with a fasting or semi-fasting period of more than one week. Regarding the advantages of enteral infusion, 93.7% of participants considered preservation of the integrity of the intestinal mucosa and barrier function, and in relation to peripheral parenteral nutrition, 86.2% selected the definition of nutrient infusion through a peripheral vein and 81.9% its indication for less than 7 days. Digestive surgeons had a limited knowledge of basic aspects of clinical nutrition in cancer patients, but there was some variability regarding clinical practice in individual cases. These findings indicate the need to develop standardized clinical protocols as well as a national consensus on nutrition support in cancer patients.

Evaluating a serious game to improve childhood cancer patients' treatment adherence

Objective

Childhood cancer patients need to have good treatment adherence. Unfortunately, treatment non-adherence often occurs due to high side-effect burdens of treatment and the lack of knowledge of one's illness and treatment. Therefore, a serious game intervention based on the Protection Motivation Theory (PMT) was designed and developed to motivate childhood cancer patients to undergo treatment and to motivate them to undergo treatment, perform daily self-care and educate them about their illness.

Methods

Childhood cancer patients (6–17 years old) and their caregivers were recruited in a multi-centre, single-arm intervention in Malaysia. A total of 24 child-caregiver dyads have completed the study. This study used PMT-based surveys to collect quantitative data regarding children's motivation to adhere to treatment and perform daily self-care. Additionally, a 20-question multiple-choice quiz was used to determine children's knowledge levels. These surveys were conducted pre-test and post-test. Children's and caregivers' feedback were also gathered post-test as qualitative data.

Results

The results showed that overall, the children's intention to undergo cancer treatment had increased significantly. A significant increase in the intention to perform daily self-care was found among younger children, while older children showed significant improvement in their cancer knowledge levels. The post-test feedback suggested that the game was liked by both children and caregivers and it provided various benefits to children with cancer.

Conclusions

Findings suggest that the intervention has the potential to improve childhood cancer patients’ motivation for treatment adherence and daily self-care, in addition to educating them about cancer and treatment.

A difficult-to-diagnose pericardial fistula

Pericardial fistula is a rare complication. Generally, the diagnosis can be confirmed by imaging examination, but our patient was an exception. We present a 71-year-old female patient that complained of remnant gastric cancer for five months and dyspnea for seven days; the dyspnea became aggravated during the last two days. After admission, emergency thoracic computed tomography and echocardiography showed pericardial effusion, and pericardiocentesis was performed. After conventional treatment, the pericardial effusion was unchanged and no cancer cells were found in the pericardial drainage. However, the color changed from turbid to golden yellow and, finally, to green. After 20 days of repeated laboratory, imaging, and gastrointestinal contrast examinations, no cause was found. Moreover, a clinical diagnosis could not be obtained following numerous comprehensive clinical analyses. Given the color change of the pericardial drainage, we strongly suspected pericardial fistula, but the imaging examinations were negative. Finally, a methylene blue test confirmed the existence of a pericardial fistula. When the color of the pericardial effusion changes, the existence of a pericardial fistula must be considered in advance, and other methods should be evaluated if imaging cannot assist in the diagnosis.

Supplemental parenteral nutrition in cancer care: why, who, when

Malnutrition is an often-overlooked challenge for patients with cancer. It is associated with muscle mass reduction, poor compliance and response to cancer treatments, decreased quality of life, and reduced survival time. The nutritional assessment and intervention should be a vital part of any comprehensive cancer treatment plan. However, data on artificial nutrition supplied based on caloric needs during cancer care are scarce. In this review, we discuss the recommendations of the European and American societies for clinical nutrition on the use of nutritional interventions in malnourished patients with cancer in the context of current clinical practice. In particular, when enteral nutrition (oral or tube feeding) is not feasible or fails to meet the complete nutritional needs, supplemental parenteral nutrition (SPN) can bridge the gap. We report the available evidence on SPN in cancer patients and identify the perceived barriers to the wider application of this intervention. Finally, we suggest a ‘permissive’ role of SPN in cancer care but highlight the need for rigorous clinical studies to further evaluate the use of SPN in different populations of cancer patients.

Nutritional Support in Older Patients with Esophageal Cancer Undergoing Chemoradiotherapy

Esophageal cancer (EC) is the eighth most prevalent malignancy and the sixth leading cause of cancer-related death worldwide. The proportion of older adults with EC has increased dramatically in recent decades due to increased life expectancy. Older patients with EC are at a highest risk of malnutrition and this predicts early death. In older patients with EC, dysphagia is a common symptom; additionally, comorbidities, polypharmacy, and physiological changes of aging such as decreased muscle mass and geriatric issues including altered cognition, mobility, and mood contribute to malnutrition. Chemoradiotherapy (CRT) is the primary treatment for unresectable locally advanced EC patients, as it successfully reduces local recurrence and distant metastases while also extending survival. In older patients with EC, nutrition is an interventional condition, unlike many other geriatric risk factors. Optimizing nutritional support may reduce treatment toxicity and facilitate the completion of definitive or neoadjuvant CRT. The relevance of nutritional status and food intake is becoming more widely acknowledged, and it now encompasses the entire spectrum of EC treatment in older patients, from diagnosis to perioperative care to long-term care. This review aims to discuss the current research on nutritional support in older patients with esophageal cancer undergoing CRT.

Association between preoperative nutritional status, inflammation, and intestinal permeability in elderly patients undergoing gastrectomy: a prospective cohort study

Background

Malnutrition is relatively common among elderly patients with gastric cancer. This study sought to analyze whether preoperative nutritional status, inflammatory cytokines, and intestinal permeability were correlated in elderly gastric cancer patients undergoing surgery, and their effects on postoperative recovery.

Methods

This study was a single-center prospective cohort study. Patients aged 65-90 years who underwent gastrectomy were included. Preoperative nutritional status was assessed by the Mini Nutritional Score (MNA), Nutritional Risk Screening-2002 (NRS2002), body mass index (BMI), free fatty acids (FFAs), albumin, and prealbumin concentrations. Intestinal permeability was assessed by D-lactate and intestinal fatty acid-binding protein (i-FABP). The inflammatory factors included interleukin (IL)-6, IL-10, neutrophil, and lymphocyte counts. The time to first defecation, time to first liquid diet, length of hospital stay (LOS), and postoperative complications were recorded.

Results

A total of 134 patients were included. According to the MNA, 50.7% and 32.1% of the cohort had mild to moderate malnutrition, and severe malnutrition, respectively. According to the NRS2002, 38.8% of the patients scored >4 points. I-FABP was significantly negatively correlated with albumin (r=-0.409, P<0.001) and prealbumin (r=-0.397, P<0.001), and significantly positively correlated with MNA (r=0.291, P=0.001), the NRS2002 (r=0.284, P=0.001), and LOS (r=0.245, P=0.004). D-lactate was significantly negatively correlated with BMI (r=-0.229, P=0.008), albumin (r=-0.426, P<0.001), and prealbumin (r=-0.358, P<0.001), and significantly positively correlated with the NRS2002 (r=0.187, P=0.030), time to first defecation (r=0.264, P=0.002), and LOS (r=0.409, P<0.001). There were significant differences in BMI, prealbumin, FFAs, i-FABP, time to first defecation, and time to first fluid diet (P<0.05) among groups based on MNA score. The multivariate logistic analysis showed that D-lactate was an independent risk factor of postoperative complications [odds ratio (OR) =1.354, 95% confidence interval (CI): 1.099-1.669, P=0.004].

Conclusions

The preoperative intestinal permeability indicators (i.e., D-lactate and i-FABP) are significantly correlated with some nutritional indicators and postoperative recovery indicators. The preoperative D-lactate level is an independent risk factor of postoperative complications, suggesting that altered gut barrier function before surgery could to some extent influence postoperative recovery in the elderly.

Low geriatric nutritional risk index is a risk factor for death within 1 year following hip fracture

PURPOSE

Hip fracture is common in older patients and is associated with high mortality and functional impairment. The Geriatric Nutritional Risk Index (GNRI) evaluates the risk of malnutrition-related complications, and the Barthel Index (BI) evaluates older patients' functional status. The study aim was to determine the risk factors for both death and decreased BI within 1 year after hip fracture.

METHODS

We retrospectively reviewed the records of 108 patients who were treated for hip fractures in 10 public or private hospitals from February to July 2007. Participating facilities comprised eight public or private hospitals with 200-499 beds, and two private or orthopedic hospitals with 20-199 beds. We evaluated several risk factors for death and lower BI within 1 year after hip fracture.

RESULTS

The mortality rate within 1 year postoperatively for patients who survived inpatient stay was 6.5% (7/108). The proportion of patients with decreased postoperative BI was 43.6% (44/101). Binomial logistic regression analysis showed that several factors, including low GNRI (odds ratio [OR]: 0.80; 95% confidence interval [CI: 0.68-0.93]), were risk factors for death within 1 year. Postoperative delirium (OR: 8.84 [1.52-51.6]), postinjury dementia (OR: 34.8 [3.01-402]), preinjury BI (OR: 1.05 [1.02-1.08]), and preinjury dementia (OR: 6.22 [1.73-22.4]) were risk factors for decreased postoperative BI.

CONCLUSIONS

Our findings indicated that lower GNRI was a risk factor for death within 1 year of hip surgery and that delirium and dementia were among the risk factors for decreased BI 1 year after hip fracture.

Impact of Resistance Exercise and Nutritional Endorsement on physical performance in patients with GvHD (IRENE-G study) - design and rational of a randomized controlled trial

BACKGROUND

Graft-versus-host disease (GvHD) remains a major complication and limitation to successful allogeneic hematopoietic stem cell transplantation. Treatment of GvHD is challenging due to its heterogeneous nature of presentation, with steroids remaining the established first-line treatment. Long-term doses of systemic corticosteroids have many well-known side-effects including muscle atrophy. Despite the fact that reports in non-cancer clinical populations treated with glucocorticoids demonstrated that resistance training can reverse atrophy and weakness, no RCT has evaluated the potential of resistance training on preventing the disease- and treatment-induced loss of skeletal muscle mass and function in GvHD patients yet. In this context, ensuring adequate nutrition is important as protein deprivation may accelerate the wasting process. As GvHD patients are commonly found to be malnourished, nutritional medical care should be considered when investigating the effect of exercise in GvHD patients. Therefore, the aim of the present "Impact of Resistance Exercise and Nutritional Endorsement on physical performance in patients with GvHD" - Study (IRENE-G) is to evaluate the effects of resistance exercise in combination with nutritional endorsement on physical, nutritional and patient-reported outcomes in GvHD patients.

METHODS

IRENE-G is a 24-week prospective interventional RCT. One hundred twelve participants will be randomly allocated (1:1) to one of two arms: resistance exercise and nutritional optimization (experimental) vs. nutritional optimization only (control). Participants in the experimental group will engage in a supervised, progressive moderate-to-high intensity resistance training that is consistent with exercise guidelines for cancer patients, while additionally receiving nutritional support/therapy. Subjects of the control group solely receive nutritional support/therapy based on individual needs. Participants will be assessed at baseline, at 8, 16, 24 weeks for physical performance and various physiological, nutritional and patient-reported outcomes. Follow-up will be 6 months after intervention completion.

DISCUSSION

To our knowledge, this will be the first RCT to assess and compare the effects of a resistance intervention supplemented by nutritional support/therapy against nutritional support only on various health-related outcomes in GvHD patients. The study will contribute to our understanding of the value of exercise and nutritional endorsement in counteracting the negative consequences of GvHD and its treatment.

TRIAL REGISTRATION

ClinicalTrials.gov : NCT05111834 . Registered 8 November 2021 - Retrospectively registered.

Preoperative C-reactive protein to prealbumin ratio is independently associated with prognosis in patients with resectable colorectal cancer

BACKGROUND

Increasing attention has been drawn the prognostic value of inflammatory indices for colorectal cancer (CRC). However, the prognostic value of the preoperative C-reactive protein to prealbumin ratio (CPAR) in CRC remains unclear.

METHODS

A retrospective study was conducted with 794 patients who had CRC and underwent radical surgical resection. The predictive performance of the inflammatory indices was analyzed and compared using the area under the time-dependent receiver operating characteristic curve. A competing risk regression model and Cox proportional hazard model were used to analyze the effects of CPAR on disease-free survival (DFS) and overall survival (OS), respectively.

RESULTS

Patients with high CPAR (>7.25) had poor survival outcome. The CPAR had the best predictive performance among all inflammatory indices, and was significantly associated with several characteristics of tumor invasion, including histological grade, tumor stage, and tumor size. Multivariate analysis showed that high CPAR was independently associated with poor DFS (subdistribution hazard ratio = 2.28, 95% confidence interval [CI]: 1.74-2.82) and OS (hazard ratio = 1.78, 95% CI: 1.60-1.96).

CONCLUSION

Preoperative CPAR assessment could serve as an effective and reliable tool for prognostic prediction in patients with resectable CRC.

Kidney Function Worsening is Linked to Parenteral-Nutrition-Dependent Survival in Palliative Care Patients

Background. Parenteral nutrition (PN) is frequently administered in palliative care patients suffering from cachexia. The evidence regarding the use of PN in terminally ill patients is scarce. Routine laboratory parameters might help to decide whether to start or forgo PN, which could decrease overtreatment at the end of life. Kidney failure was frequently associated with survival. However, a relation between kidney function parameters and parenteral nutrition has not been observed thus far. The aim of this retrospective cohort study was to analyze kidney function parameters in palliative care patients under PN, as well as the relation between these parameters and overall survival. Methods. Patients who were admitted to the Department of Palliative Medicine at the Medical University of Vienna were screened for PN treatment. Whether kidney function parameters at baseline or their dynamics over the course of two weeks were associated with survival was assessed with descriptive and interferential statistics. Results. In total, 113 of 443 palliative care patients were administered parenteral nutrition for the first time. The overall survival (OS) for all patients with increased kidney function parameters at baseline was lower (creatinine: hazard ratio (HR) = 1.808, p < 0.001; urea: HR = 1.033, p < 0.001; uric acid HR = 1.055, p = 0.015). No significant increase in creatinine blood levels was observed in the first 2 weeks after the initiation of PN when compared to the non-PN group (p = 0.86). However, if creatinine blood levels increased within the PN group, lower overall survival was found (HR = 2.046, p = 0.007). Conclusion. Increased kidney function parameters, such as creatinine, urea and uric acid, might be used as negative prognostic markers in palliative care patients under PN. Moreover, an increase in creatinine during the administration of parenteral nutrition in the first 2 weeks is linked to worse outcomes. These findings may help future studies to establish objective markers for clinicians to determine whether to start or end PN in palliative cancer patients and decrease potential overtreatment at the end of life.

Nutritional status of patients with lymphoproliferative neoplasms before and after the first-line treatment

BACKGROUND

Nutritional disorders in cancer patients, including lymphoproliferative neoplasms, occur with varying frequency.

OBJECTIVES

The primary aim of the study was to analyze the changes in the nutritional status of patients with lymphoproliferative neoplasms following first-line chemotherapy.

MATERIALS AND METHODS

46 patients, with a median age of 62 years, participated in a prospective single-center study. Their demographic, biochemical and clinical features were analyzed. The study consisted of several stages that were conducted at two time points. P values < 0.05 were considered statistically significant.

RESULTS

The study included patients with multiple myeloma (48%), non-Hodgkin's lymphoma (28%) or chronic lymphocytic leukemia (24%). After the end of the first-line chemotherapy, a decrease in the concentration of albumin (p = 0.04), transferrin (p = 0.38) and total cholesterol (p = 0.76) were found. Statistically greater unintended weight loss occurred before treatment initiation (p < 0.001). Moreover, a significant decrease in the mean values ​​of the phase angle (p < 0.01) was noted.

CONCLUSIONS

Most patients before the oncological therapy did not show clinical or biochemical symptoms of malnutrition. However, after the treatment was completed, the parameters of the nutritional status showed its deterioration.

Diet/Nutrition: Ready to Transition from a Cancer Recurrence/Prevention Strategy to a Chronic Pain Management Modality for Cancer Survivors?

Evidence for the relationship between chronic pain and nutrition is mounting, and chronic pain following cancer is gaining recognition as a significant area for improving health care in the cancer survivorship population. This review explains why nutrition should be considered to be an important component in chronic pain management in cancer survivors by exploring relevant evidence from the literature and how to translate this knowledge into clinical practice. This review was built on relevant evidence from both human and pre-clinical studies identified in PubMed, Web of Science and Embase databases. Given the relationship between chronic pain, inflammation, and metabolism found in the literature, it is advised to look for a strategic dietary intervention in cancer survivors. Dietary interventions may result in weight loss, a healthy body weight, good diet quality, systemic inflammation, and immune system regulations, and a healthy gut microbiota environment, all of which may alter the pain-related pathways and mechanisms. In addition to being a cancer recurrence or prevention strategy, nutrition may become a chronic pain management modality for cancer survivors. Although additional research is needed before implementing nutrition as an evidence-based management modality for chronic pain in cancer survivors, it is already critical to counsel and inform this patient population about the importance of a healthy diet based on the data available so far.

A Novel Nomogram for Early Identification and Intervention in Colorectal Cancer Patients at Risk for Malnutrition

BACKGROUND

Malnutrition is under-recognized in cancer patients and can lead to poor treatment outcomes. We aim to develop an outpatient-focused score based on the Malnutrition Screening Tool (MST) to help identify colorectal cancer (CRC) profiles at high risk for malnutrition.

METHODS

506 CRC patients during initial outpatient oncology consultation at our tertiary referral outpatient oncology clinic completed the MST. Objective and subjective data were collected through chart review. Data gathered are as follows: demographics, anthropometrics, laboratory values, patient-reported symptoms, MST score, cancer history, performance status, socioeconomic status, and Charlson Comorbidity. Predictors of malnutrition were identified by logistic regression. Receiver operating curve (ROC), area under the curve (AUC), and our model's predictability were determined.

RESULTS

Significant predictors of malnutrition are as follows: younger age (20-39 vs >40 years) (P = .007), normal-to-low body mass index at presentation (P = .019), Eastern Cooperative Oncology Group classification 2-3 (P = .012), metastatic disease (P = .046), albumin <3.0 g/dL (P = .033), fatigue (P < .001), and change in stool/bowel habits (P = .002). In our derived malnutrition score, risk of malnutrition increased from 11% for score 0, to 100% for scores 9-10. Receiver operating curve showed AUC .745 (95% CI, .697-.793).

DISCUSSION

An outpatient clinic-derived malnutrition score obtained from objective and patient-reported variables may facilitate identification of CRC patients at highest risk for malnutrition. Rapid identification and intervention in high-risk patients may improve treatment recovery, therapy tolerance, and quality of life. Our tool requires external validation before application in clinical practice.

Fibrinogen/Albumin Ratio (FAR) in Patients with Triple Negative Breast Cancer and Its Relationship with Epidermal Growth Factor Receptor Expression

OBJECTIVE

To investigate the potential prognostic significance of fibrinogen/albumin ratio (FAR) in triple negative breast cancer (TNBC) patients and its relationship with epidermal growth factor receptor (EGFR) expression.

METHODS

There were 164 patients with TNBC enrolled in this study in our hospital from January 2010 to December 2015. The optimal cutoff value of FAR was evaluated by the receiver operating characteristic curve (ROC). The associations between TNBC and clinicopathological variables by FAR were performed by Chi-square test. Kaplan-Meier method and Log rank test were used for survival analysis. The independent prognostic factors were determined by univariate and multivariate Cox's proportional hazards regression model. The EGFR expression was analyzed by the immunohistochemistry assay.

RESULTS

One hundred and sixty-four TNBC patients were divided into: low FAR group (FAR < 0.08) and high FAR group (FAR ≥ 0.08) by ROC. The preoperative FAR was associated to BMI, menopause, red blood cell, albumin, fibrinogen (P < 0.05). FAR was an independent prognostic factor for TNBC. In low FAR group, the mean disease-free survival (DFS) and overall survival (OS) were 33.62 months and 52.99 months; in high FAR group, the mean DFS and OS were 30.18 months and 48.27 months, respectively. The DFS and OS survival curve were performed by Log rank assay and were statistically significant (P < 0.05). The mean DFS and OS after operation in patients with EGFR negative expression were longer than that in patients with EGFR positive expression. In EGFR positive group, the mean DFS and OS of low FAR group were higher than that of high FAR group, and the difference was statistically significant (P < 0.05).

CONCLUSION

Pretreatment FAR is the independent prognostic factor in TNBC, and with low cost, strong repeatability, and high safety. It can be acted as an effective indicator to predict the prognosis of TNBC.

A systematic review on the guidelines for nutritional assessment for head and neck cancer patients managed by surgery

There are a number of guidelines to assess the nutrition status of cancer cases. None of these guidelines are specifically head and neck cancer related; except for the European guidelines. This article reviews the different guidelines in nutrition for cancer cases and also their drawbacks.

Multinational Association of Supportive Care in Cancer (MASCC) expert opinion/guidance on the use of clinically assisted nutrition in patients with advanced cancer

Purpose

The pro vision of clinically assisted nutrition (CAN) in patients with advanced cancer is controversial, and there is a paucity of specific guidance, and so a diversity in clinical practice. Consequently, the Palliative Care Study Group of the Multinational Association of Supportive Care in Cancer (MASCC) formed a Subgroup to develop evidence-based guidance on the use CAN in patients with advanced cancer.

Methods

This guidance was developed in accordance with the MASCC Guidelines Policy. A search strategy for Medline was developed, and the Cochrane Database of Systematic Reviews and the Cochrane Central Register of Controlled Trials were explored for relevant reviews/trials respectively. The outcomes of the review were categorised by the level of evidence, and a “category of guideline” based on the level of evidence (i.e. “recommendation”, “suggestion”, or “no guideline possible”).

Results

The Subgroup produced 11 suggestions, and 1 recommendation (due to the paucity of evidence). These outcomes relate to assessment of patients, indications for CAN, contraindications for CAN, procedures for initiating CAN, and re-assessment of patients.

Conclusions

This guidance provides a framework for the use of CAN in advanced cancer, although every patient needs individualised management.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00520-021-06613-y.

Perioperative nutrition management for gastric cancer

Gastric cancer is one of the most frequently diagnosed and the leading cause of cancer death worldwide. Malnutrition is a substantial problem in patients with gastric cancer, associated with poor treatment tolerance and increased morbidity. It has also been recognized as an independent prognostic factor in individuals with cancer. Early detection of malnutrition and effective perioperative nutrition intervention play an important role in the treatment of gastric cancer. Nutrition screening and assessment are the first steps in nutrition management and provide a basis for further nutrition support. Several tools, including the Nutrition Risk Screening-2002 and Patient-Generated Subjective Global Assessment, have been developed for nutrition screening and assessment. Effective nutrition support can significantly improve nutritional and immune status, reduce the incidence of postoperative complications, and accelerate recovery. The aim of this review was to focus on preoperative nutrition risk screening and assessment, and perioperative nutrition support, which may serve as a framework of perioperative nutrition management for gastric cancer.

Clinical nutrition as part of the treatment pathway of pancreatic cancer patients: an expert consensus

Purpose

Malnutrition is a common problem among pancreatic cancer (PC) patients that negatively impacts on their quality of life (QoL) and clinical outcomes. The main objective of this consensus is to address the role of Medical Nutrition Therapy (MNT) into the comprehensive therapeutic management of PC patients.

Methods

A Spanish multidisciplinary group of specialists from the areas of Medical Oncology; Radiation Oncology; Endocrinology and Nutrition; and General Surgery agreed to assess the role of MNT as part of the best therapeutic management of PC patients.

Results

The panel established different recommendations focused on nutritional screening and nutritional screening tools, MNT strategies according to PC status, and MNT in palliative treatment.

Conclusions

There is an unmet need to integrate nutritional therapy as a crucial part of the multimodal care process in PC patients. Health authorities, health care professionals, cancer patients, and their families should be aware of the relevance of nutritional status and MNT on clinical outcomes and QoL of PC patients.

Nutrition Care Process Model Approach to Surgical Prehabilitation in Oncology

The nutrition care process is a standardized and systematic method used by nutrition professionals to assess, diagnose, treat, and monitor patients. Using the nutrition care process model, we demonstrate how nutrition prehabilitation can be applied to the pre-surgical oncology patient.

Preoperative prognostic nutritional index predicts postoperative infectious complications and oncological outcomes after hepatectomy in intrahepatic cholangiocarcinoma

Background

In the surgical treatment of intrahepatic cholangiocarcinoma (ICC), postoperative complications may be predictive of long-term survival. This study aimed to identify an immune-nutritional index (INI) that can be used for preoperative prediction of complications.

Patients and methods

Multi-institutional data from 316 patients with ICC who had undergone surgical resection were retrospectively analysed, with a focus on various preoperative INIs.

Results

Severe complications (Clavien-Dindo grade III–V) were identified in 66 patients (20.8%), including Grade V complications in 7 patients (2.2%). Comparison of areas under the receiver operating characteristic curve (AUCs) among various INIs identified the prognostic nutritional index (PNI) as offering the highest predictive value for severe complications (AUC = 0.609, cut-off = 50, P = 0.008). Multivariate analysis revealed PNI <  50 (odds ratio [OR] = 2.22, P = 0.013), hilar lesion (OR = 2.46, P = 0.026), and long operation time (OR = 1.003, P = 0.029) as independent risk factors for severe complications. In comparing a high-PNI group (PNI ≥ 50, n = 142) and a low-PNI group (PNI <  50, n = 174), the low-PNI group showed higher rates of both major complications (27% vs. 13.4%; P = 0.003) and infectious complications (14.9% vs. 3.5%; P = 0.0021). Furthermore, median survival time and 1- and 5-year overall survival rates were 34.2 months and 77.4 and 33.8% in the low-PNI group, respectively, and 52.4 months and 89.3 and 47.5% in the high-PNI group, respectively (P = 0.0017).

Conclusion

Preoperative PNI appears useful as an INI correlating with postoperative severe complications and as a prognostic indicator for ICC.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-021-08424-0.

Role of nutritional care and general guidance for patients with advanced or metastatic gastric cancer

Patients with advanced or metastatic gastric cancer often suffer from malnutrition, which can have an impact on quality of life, increase the toxicity of chemotherapy and reduce overall survival. Options available to the clinician to manage a patient's nutritional status include screening and assessment of malnutrition at diagnosis, monitoring during the 'cancer journey', early detection of precachexia and the ongoing use of a multidisciplinary team (oncologists, other medical specialists and nutritionists). Because malnutrition is frequently overlooked and under treated in patients with advanced or metastatic gastric cancer, this narrative review focuses on the clinical meaning of nutritional status in gastric cancer and provides general guidance regarding nutritional care management for patients with advanced or metastatic gastric cancer.

Preoperative Fibrinogen-Albumin Ratio, Potential Prognostic Factors for Bladder Cancer Patients Undergoing Radical Cystectomy: A Two-Center Study

Background

We conducted a two-center study to investigate the prognostic value of preoperative fibrinogen–albumin ratio (FAR) in patients undergoing radical cystectomy (RC).

Methods

The clinical and survival data of 267 patients with bladder cancer (BCa) treated with RC were collected, of which 140 patients from Xuzhou Central Hospital were divided into training set and 127 patients from The Second Affiliated Hospital of Nantong University were divided into validation set. X-tile software was used to obtain the optimal cut-off values for preoperative platelet-to-lymphocyte ratio (PLR), neutrophil-to-lymphocyte ratio (NLR) and FAR. Receiver operating characteristic (ROC) curves were used to compare the predictive ability of PLR, NLR, FAR and modified Glasgow prognostic score (mGPS). Kaplan–Meier curves were used to assess overall survival (OS) and progression-free survival (PFS) of patients in different FAR groups. Univariate and multivariate Cox regression were used to assess patients’ independent risk factors, and R software was used to construct prognostic nomograms.

Results

In the training set, the optimal cut-off values for PLR, NLR and FAR were 76.76, 3.97 and 0.08, respectively. Both in the training and validation sets, FAR had better ability to predict OS and PFS than PLR and NLR, and patients in the higher FAR group had worse OS and PFS. In the multivariate Cox regression analysis, FAR was an independent risk factor for OS [hazard ratio (HR) 3.569, 95% confidence interval (CI): 1.015–12.546, P=0.047] and PFS [HR 5.071, 95% CI: 1.394–18.451, P=0.014]. In addition, FAR-based prognostic nomograms had high predictive ability than TNM staging.

Conclusion

Preoperative FAR is an independent prognostic factor for OS and PFS in BCa patients treated with RC, and a high FAR predicted a poor prognosis. In addition, a prognostic nomogram based on FAR can better predict individual survival.

Choice of access route for artificial nutrition in cancer patients: 30 y of activity in a home palliative care setting

OBJECTIVES

Malnutrition negatively affects the quality of life, survival, and clinical outcome of patients with cancer. Home artificial nutrition (HAN) is an appropriate nutritional therapy to prevent death from cachexia and to improve quality of life, and it can be integrated into a home palliative care program. The choice to start home enteral nutrition (HEN) or home parenteral nutrition (HPN) is based on patient-specific indications and contraindications. The aim of this observational study was to analyze the changes that occurred in the criteria for choosing the access route to artificial nutrition during 30 y of activity of a nutritional service team (NST) in a palliative home care setting, as well as to compare indications, clinical nutritional outcomes, and complications between HEN and HPN.

METHODS

The following parameters were analyzed and compared for HEN and HPN: tumor site and metastases; nutritional status (body mass index, weight loss in the past 6 mo); basal energy expenditure and oral food intake; Karnofsky performance status; access routes to HEN (feeding tubes) and HPN (central venous catheters); water and protein-calorie support; and survival and complications of HAN.

RESULTS

From 1990 to 2020, HAN was started in 1014 patients with cancer (592 men, 422 women; 65.6 ± 12.7 y of age); HPN was started in 666 patients (66%); and HEN was started in 348 patients (34%). At the end of the study, 921 patients had died, 77 had suspended HAN for oral refeeding and 16 were in the progress of HAN. The oral caloric intake was <50% basal energy expenditure in all patients: 721 (71.1%) were unable to eat at all (HEN 270, HPN 451), whereas in 293 patients (28.9%), artificial nutrition was supplementary to oral intake. From 2010 to 2020, the number of central venous catheters for HPN, especially peripherally inserted central catheters, doubled compared with that in the previous 20 y, with a decrease of 71.6% in feeding tubes for HEN. At the beginning, patients on HEN and HPN had comparable nutrition and performance status, and there was no difference in nutritional outcome after 1 mo of HAN. In 215 patients who started supplemental parenteral nutrition to oral feeding, total protein-calorie intake allowed a significant increase in body mass index and Karnofsky performance status. The duration of HEN was longer than that of HPN but was similar to that of supplemental parenteral nutrition.

CONCLUSIONS

Over 30 y of nutritional service team activity, the choice of central venous catheters as an access route to HAN increased progressively and significantly due to personalized patient decision-making choices. Nutritional efficacy was comparable between HEN and HPN. In patients who maintained food oral intake, supplemental parenteral nutrition improved weight, performance status, and survival better than other types of HAN.