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

May Nutritional Status Positively Affect Disease Progression and Prognosis in Patients with Esophageal and Pharyngeal Cancers? A Scoping Review of the Current Clinical Studies

BACKGROUND

Malnutrition in esophageal and pharyngeal cancer patients constitutes a common and serious concern, which significantly reduces patients' prognoses. Cancers of the esophagus and the pharynx can considerably impair feeding in patients, resulting in severe undernutrition. This is a scoping review that intends to critically analyze the most well-designed clinical studies investigating the potential beneficial impact of diverse nutritional assessment tools on the prognosis of patients with esophageal and pharyngeal cancers.

METHODS

The most accurate and remarkable scientific databases were comprehensively explored utilizing relative keywords to detect clinical studies that investigate whether nutritional status may affect disease prognosis.

RESULTS

Several assessment tools have evaluated and highlighted the potential beneficial impact of nutritional status on disease progression and patients' prognosis in both esophageal and pharyngeal cancers. Regarding esophageal cancer, CONUT, PNI, PG-SGA, and NRS-2002 are more commonly used, while albumin is also frequently evaluated. Regarding pharyngeal cancers, fewer studies are currently available. PNI has been evaluated, and its significance as a factor for shorter survival' times has been highlighted. The Comprehensive Nutritional Index has also been evaluated with positive results, as well as NRS 2002, GPS, and body-weight status. However, there is currently a lack of studies with an adequate number of women with cancer. An international literature gap was identified concerning follow-up studies with adequate methodology.

CONCLUSIONS

Nutritional status may significantly affect disease progression and patients' survival, highlighting the significance of a great nutritional status in individuals with esophageal and pharyngeal cancers. Further large-scale and well-designed prospective surveys should be performed to verify the potential beneficial effects of adequate nourishment in people suffering from cancer of the esophagus and pharynx.

Unmet needs in cancer patients: Creating recommendations to overcome geographical disparities in economic growth

Cancer is a major clinical, economic and societal challenge across different world regions. Effective anticancer therapies are now available, yet the impact of these treatments on the needs of patients with cancer remains questionable, since improved survival is not frequently associated with improved quality of life. In an effort to raise patients' needs at the core of anticancer therapies, the importance of nutritional support has become recognized by international scientific societies. It is recognized that the needs of patients with cancer are universal, yet the economic and societal status of any country influence the availability and implementation of nutritional care. The Middle East is a geographic area in which major differences in economic growth coexist. Consequently, it appears reasonable that international guidelines on nutritional care in oncology are reviewed to highlight those recommendations which could be universally adopted and those which may need a progressive implementation. To this end, a group of Middle East healthcare professionals working in cancer centers across the region gathered to develop a list of recommendations to be implemented in daily practice. This would translate in a likely better acceptance and delivery of nutritional care, aligning all Middle East cancer centers to the quality standards now available only in selected hospital across the region.

Derivation and validation of a nutrition-covered prognostic scoring system for extranodal NK/T-cell lymphoma

Introduction

Patients with aggressive lymphomas are at high risk of losing body resources, resulting in malnutrition, immunodeficiency and inferior outcomes. Nutritional status is closely associated with survival, but often neglected in the prognostic assessment. This study aimed to explore the significance of nutritional status in extranodal NK/T-cell lymphoma (ENKTL).

Methods

Univariate and multivariate Cox regression analyses were conducted to examine the significance of nutritional index on overall survival (OS) and progression-free survival (PFS). A nutrition-incorporated score system was constructed based on the multivariate results, and its calibration, discrimination and clinical utility were tested in the training and validation cohort.

Results

Multivariate analysis revealed controlling nutritional status (CONUT) score could independently predict OS (HR 10.247, P=0.001) and PFS (HR 5.587, P=0.001) in addition to prognostic index of natural killer lymphoma plus EBV (PINK-E). Herein, a reformative model, CONUT-PINK-E, was developed and further verified in external validation cohort. CONUT-PINK-E classified patients into three risk grades with significant survival differences (P < 0.001). Compared with the current models, CONUT-PINK-E presented superior discrimination, calibration and clinical benefit.

Discussion

In this study, we firstly verified that CONUT score was efficient to screen prognosis-related malnutrition in ENKTL. Moreover, we developed the first nutritional assessment-covered scoring system, CONUT-PINK-E, which might be a promising tool to provide references for clinical decision-making of ENKTL patients.

Brazilian Nutritional Consensus in Hematopoietic Stem Cell Transplantation: children and adolescents

The Brazilian Nutritional Consensus in Hematopoietic Stem Cell Transplantation: Children and Adolescents was developed by dietitians, physicians, and pediatric hematologists from 10 Brazilian reference centers in hematopoietic stem cell transplantation. The aim was to emphasize the importance of nutritional status and body composition during treatment, as well as the main characteristics related to patient´s nutritional assessment. This consensus is intended to improve and standardize nutrition therapy during hematopoietic stem cell transplantation. The consensus was approved by the Brazilian Society of Bone Marrow Transplantation.

Molecular and Neural Mechanism of Dysphagia Due to Cancer

Cancer is one of the most common causes of death worldwide. Along with the advances in diagnostic technology achieved through industry–academia partnerships, the survival rate of cancer patients has improved dramatically through treatments that include surgery, radiation therapy, and pharmacotherapy. This has increased the population of cancer “survivors” and made cancer survivorship an important part of life for patients. The senses of taste and smell during swallowing and cachexia play important roles in dysphagia associated with nutritional disorders in cancer patients. Cancerous lesions in the brain can cause dysphagia. Taste and smell disorders that contribute to swallowing can worsen or develop because of pharmacotherapy or radiation therapy; metabolic or central nervous system damage due to cachexia, sarcopenia, or inflammation can also cause dysphagia. As the causes of eating disorders in cancer patients are complex and involve multiple factors, cancer patients require a multifaceted and long-term approach by the medical care team.

Oral Nutritional Supplementation Affects the Dietary Intake and Body Weight of Head and Neck Cancer Patients during (Chemo) Radiotherapy

Considering the symptoms of (chemo) radiotherapy and the reduction in food intake in head and neck cancer (HNC) patients, this study aimed to investigate the association between treatment time points and oral nutritional supplementation (ONS) on dietary intake to estimate the frequency of energy and nutrient inadequacy, and also to evaluate body weight changes (BWC). Dietary intake data of 65 patients were obtained from 24-h dietary recalls and prevalence of inadequacy was calculated before or at the beginning (T0), in the middle (T1), and at the end of treatment (T2). BWC were calculated as the weight difference considering the previous weight reported and/or measured. Energy and macronutrient intake decreased in T1 and then improved in T2 (p < 0.001 for both). Micronutrient intake increased during treatment due to ONS use, but still presented a high probability of inadequate intake. In particular, calcium, magnesium, and vitamin B6 showed almost 100% of probability of inadequacy for those who did not use ONS. Finally, overweight patients suffered a higher weight accumulated deficit with a delta of −15 kg compared to other BMI (body mass index) categories. Therefore, we strongly recommend initiating nutritional counseling in conjunction with prophylactic ONS prescription from diagnosis to adjust nutrient intake and minimize weight loss.

End-user perceptions of a patient- and family-centred intervention to improve nutrition intake among oncology patients: a descriptive qualitative analysis

Background

People with cancer are at high risk of malnutrition. Nutrition education is an effective strategy to improve patient outcomes, however, little is known regarding the impact of family and/or carer involvement in nutrition education and requires investigation. The purpose of the study was to evaluate PIcNIC (Partnering with families to promote nutrition in cancer care) intervention acceptability from the perspective of patients, families and health care providers.

Methods

A descriptive qualitative study was undertaken at an inpatient and an outpatient hospital setting in Australia and an outpatient/home setting in Hong Kong. A patient-and-family centred intervention including nutrition education, goals setting/nutrition plans, and food diaries, was delivered to patients and/or families in the inpatient, outpatient or home setting. Semi-structured interviews were used to explore perceptions of the intervention. 64 participants were interviewed; 20 patients, 15 family members, and 29 health care professionals. Data were analysed using deductive and inductive content analysis.

Results

Two categories were identified; 1) ‘context and intervention acceptability’; and 2) ‘benefits of patient- and family-centred nutrition care’. Within each category redundant concepts were identified. For category 1 the redundant concepts were: the intervention works in outpatient settings, the food diary is easy but needs to be tailored, the information booklet is a good resource, and the intervention should be delivered by a dietitian, but could be delivered by a nurse. The redundant concepts for category 2 were: a personalised nutrition plan is required, patient and family involvement in the intervention is valued and the intervention has benefits for patients and families. Converging and diverging perceptions across participant groups and settings were identified.

Conclusions

In this paper we have described an acceptable patient- and family-centred nutrition intervention, which may be effective in increasing patient and family engagement in nutrition care and may result in improved nutrition intakes. Our study highlights important contextual considerations for nutrition education; the outpatient and home setting are optimal for engaging patients and families in learning opportunities.

Nutritional assessment of female patients newly diagnosed with breast cancer in a northern region of Spain

Introduction

Background: evidence from research suggests that the development of cancer disease is associated with environmental factors. There are few studies evaluating nutritional status in women suffering from cancer in Spain. Objectives: this study aimed to assess the nutritional status in breast cancer female patients at diagnosis in a northern region of Spain (Asturias), where breast cancer rates are particularly high when compared to the rest of Spain. Material and methods: a cross-sectional study was conducted in a sample of 76 newly diagnosed female cancer patients. Lifestyle factors, anthropometry, biochemical, and dietary intake data were collected immediately after diagnosis and prior to the initiation of the prescribed treatment. Results: a high percentage of these women diagnosed with cancer were sedentary (59.2%). Their average body mass index (BMI) was 27.3 ± 5.5 kg/m2. They also showed a high percentage of body fat, 38.3%, as well as a large waist circumference of 92.2 cm. Patients reported a low intake of fruits, vegetables, legumes, and nuts, and a high intake of red meat, meat products, and sweet foodstuffs as compared to the Spanish dietary guidelines (p < 0.01). Conclusion: the results showed a low intake of folate, calcium, and vitamin D, which is particularly relevant in women. In conclusion, these breast cancer patients showed overweight and high sedentarism levels, and reported unbalanced dietary patterns at the time of diagnosis.

Inadequate Nutrition Coverage in Outpatient Cancer Centers: Results of a National Survey

Cancer-related malnutrition is associated with poor health outcomes, including decreased tolerance to cancer therapy, greater treatment toxicities, and increased mortality. Medical nutrition therapy (MNT) optimizes clinical outcomes, yet registered dietitian nutritionists (RDNs), the healthcare professionals specifically trained in MNT, are not routinely employed in outpatient cancer centers where over 90% of all cancer patients are treated. The objective of this study was to evaluate RDN staffing patterns, nutrition services provided in ambulatory oncology settings, malnutrition screening practices, and referral and reimbursement practices across the nation in outpatient cancer centers. An online questionnaire was developed by the Oncology Nutrition Dietetic Practice Group (ON DPG) of the Academy of Nutrition and Dietetics and distributed via the ON DPG electronic mailing list. Complete data were summarized for 215 cancer centers. The mean RDN full-time equivalent (FTE) for all centers was 1.7 ± 2.0. After stratifying by type of center, National Cancer Institute-Designated Cancer Centers (NCI CCs) employed a mean of 3.1 ± 3.0 RDN FTEs compared to 1.3 ± 1.4 amongst non-NCI CCs. The RDN-to-patient ratio, based on reported analytic cases, was 1 : 2,308. Per day, RDNs evaluated and counseled an average of 7.4 ± 4.3 oncology patients. Approximately half (53.1%) of the centers screened for malnutrition, and 64.9% of these facilities used a validated malnutrition screening tool. The majority (76.8%) of centers do not bill for nutrition services. This is the first national study to evaluate RDN staffing patterns, provider-to-patient ratios, and reimbursement practices in outpatient cancer centers. These data indicate there is a significant gap in RDN access for oncology patients in need of nutritional care.

Nutritional Aspect of Cancer Care in Medical Oncology Patients

PURPOSE

Awareness of advances in the nutritional aspects of cancer care and translation of this information into clinical practice are important for oncology practitioners to effectively couple oncologic and nutritional approaches throughout the cancer journey. The goal of this consensus statement by a panel of medical oncologists was to provide practical and implementable guidance addressing nutritional aspects of cancer care from the perspective of the medical oncologist.

METHODS

A panel of medical oncologists agreed on a series of statements supported by scientific evidence and expert clinical opinion.

FINDINGS

Participating experts emphasized that both poor nutritional intake and metabolic alterations underlie cancer-related malnutrition. The use of liquid and high energy-dense oral nutritional supplements may enable better patient compliance, whereas higher efficacy is more likely with the use of pharmaconutrient-enriched oral nutritional supplements in terms of improved weight, lean body mass, functional status, and quality of life, as well as better tolerance to antineoplastic treatment. A multimodal approach is currently believed to be the best option to counteract the catabolism leading to cancer-related malnutrition; this treatment is scheduled in parallel with anticancer therapies and includes nutritional interventions, multitarget drug therapies, and exercise and rehabilitation programs. Participating experts emphasized the role of the oncologist as a reference professional figure in the coordination of nutritional care for patients with cancer within the context of complex and different clinical scenarios, particularly for permissive-adjunctive nutritional support.

IMPLICATIONS

This review article provides practical guidance addressing major nutritional aspects of cancer care from the medical oncologist's perspective. Thus, this document is expected to assist oncology practitioners in terms of awareness of advances in the nutritional aspects of cancer care and translation of this information into their clinical practice to effectively couple oncologic and nutritional approaches as part of the continuum of care for patients with cancer.

Compliance and Adherence to Enteral Nutrition Treatment in Adults: A Systematic Review

OBJECTIVE

To review the scientific literature that has verified and/or assessed compliance and adherence to enteral nutrition (EN) in adult patients.

METHOD

This study involved a critical analysis of articles retrieved from MEDLINE (PubMed), The Cochrane Library, Embase, Scopus and Web of Science using the terms "Treatment Adherence and Compliance" and "Enteral Nutrition", applying the filters "Comparative Study" or "Clinical Trial", "Humans" and "Adults". Date of the search: 25 October 2018.

RESULTS

A total of 512 references were retrieved, of which 23 documents were selected after applying the inclusion and exclusion criteria. The techniques measuring adherence to EN were determined by dietary intake, self-reporting, counts of leftover containers or presence of complications; however, in no case were validated questionnaires used. The time and periodicity of the assessment presented very heterogeneous results, with measurement predominantly being done at the beginning and at the end of the study. The best adherence rates were obtained in hospitalized patients (approximately 80%).

CONCLUSIONS

Frequent and regular monitoring of the adherence of patients under prolonged treatment with EN is necessary, and the use of measurement techniques that allow obtaining information on the causes of non-adherence facilitates early interventions to optimize treatment outcomes. Patient and/or caregiver education in the management of EN and the intervention of the community pharmacy in monitoring patients can be key to improving the adherence to EN.

Effects of whole-body electromyostimulation combined with individualized nutritional support on body composition in patients with advanced cancer: a controlled pilot trial

BACKGROUND

Physical exercise and nutritional treatment are promising measures to prevent muscle wasting that is frequently observed in advanced-stage cancer patients. However, conventional exercise is not always suitable for these patients due to physical weakness and therapeutic side effects. In this pilot study, we examined the effect of a combined approach of the novel training method whole-body electromyostimulation (WB-EMS) and individualized nutritional support on body composition with primary focus on skeletal muscle mass in advanced cancer patients under oncological treatment.

METHODS

In a non-randomized controlled trial design patients (56.5% male; 59.9 ± 12.7 years) with advanced solid tumors (UICC III/IV, N = 131) undergoing anti-cancer therapy were allocated to a usual care control group (n = 35) receiving individualized nutritional support or to an intervention group (n = 96) that additionally performed a supervised physical exercise program in form of 20 min WB-EMS sessions (bipolar, 85 Hz) 2×/week for 12 weeks. The primary outcome of skeletal muscle mass and secondary outcomes of body composition, body weight and hand grip strength were measured at baseline, in weeks 4, 8 and 12 by bioelectrical impedance analysis and hand dynamometer. Effects of WB-EMS were estimated by linear mixed models. Secondary outcomes of physical function, hematological and blood chemistry parameters, quality of life and fatigue were assessed at baseline and week 12. Changes were analyzed by t-tests, Wilcoxon signed-rank or Mann-Whitney-U-tests.

RESULTS

Twenty-four patients of the control and 58 of the WB-EMS group completed the 12-week trial. Patients of the WB-EMS group had a significantly higher skeletal muscle mass (0.53 kg [0.08, 0.98]; p = 0.022) and body weight (1.02 kg [0.05, 1.98]; p = 0.039) compared to controls at the end of intervention. WB-EMS also significantly improved physical function and performance status (p < 0.05). No significant differences of changes in quality of life, fatigue and blood parameters were detected between the study groups after 12 weeks.

CONCLUSIONS

Supervised WB-EMS training is a safe strength training method and combined with nutritional support it shows promising effects against muscle wasting and on physical function in advanced-stage cancer patients undergoing treatment.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02293239 (Date: November 18, 2014).

Nutrition and neuroendocrine tumors: An update of the literature

Neuroendocrine tumors (NETs) are a heterogeneous group of neoplasms with worldwide increasing incidence, high prevalence and survival. Both the tumor itself and the systemic therapy may have an impact on patients' nutrition. Malnutrition negatively impacts on outcome in NETs patients. Moreover, it has been demonstrated that body mass index was a risk factor for NET development and that metabolic syndrome was associated with worse prognosis in these patients. Of note, food could also interact with the metabolism of oral target therapy and antineoplastic agents used for the treatment of progressive NETs. Therefore, the nutritional assessment, based on body composition, and lifestyle modifications should be an integral component of management of the NET patients. The nutrition care plans are an integral part of the multidisciplinary management team for patients with NETs. Nutritionists with expertise in NETs can provide dietary approaches to improve the quality of life and nutritional status during various therapeutic modalities used in patients with NETs. The aim of this review is to critically discuss the importance of nutrition and body composition in patients with NETs.

Evaluation of Dietitian Counselling Access Revealed Reduced Pediatrician-Reported Hospital Admissions and Increased Parental Knowledge and Confidence

Based on a 1999 needs assessment a pediatric community-based outpatient dietitian counselling service was created. By 2010 annual referrals had grown to almost 1500 (62% from physicians; 38% from public health nurses). An evaluation was undertaken to gather perspectives of practitioners and parents about access, satisfaction, referral practices, and changes in knowledge, attitudes, behaviour, and child well-being. Health professionals surveyed via email were 62 pediatricians (response rate 71%), 25 family physicians (21%), 87 public health nurses (31%), and 7 dietitian providers (100%). Parents (n = 93, response rate 75% of those contacted) were interviewed by telephone. Pediatricians reported a significantly lower rate of 7% (95% confidence interval (CI), 0.8%–23%) for admitting children to hospital to access a dietitian, compared to 1999 of 39% (95% CI, 22%–59%) (P = 0.005). Health professionals reported a high degree of agreement on benefits of the service to their practice and on child health problems and a high degree of satisfaction with the service. Parents reported gaining knowledge (76%), confidence (93%), and making behaviour changes in foods offered (77%). Our evaluation demonstrated health practitioners saw a need for access to dietitians for pediatric dietitian counselling and parents reported more confidence and improved child feeding practices after dietitian counselling.

The Effects of Compliance with Nutritional Counselling on Body Composition Parameters in Head and Neck Cancer Patients under Radiotherapy

Background. Radiotherapy (RT) has been associated with increased risk of malnutrition in cancer patients, particularly in those with head and neck cancer (HNC). The aim of this prospective study was to evaluate the effects of compliance of patients with individual dietary counselling on body composition parameters in HNC patients under RT. Material and Methods. Sixty-nine consecutive patients (mean age: 61.0 ± 13.8) were prospectively followed. Bioelectrical impedance analysis (BIA) was performed to determine body composition parameters before, in the middle of, and at the end of RT. All patients received nutritional counselling and majority of them (94.6%) received oral nutritional supplement (ONS) during RT or chemoradiotherapy. If a patient consumed ≥75% of the recommended energy and protein intake via ONS and regular food, he/she was considered to be “compliant” (n = 18), while those who failed to meet this criteria were considered to be “noncompliant” (n = 30). Results. Body mass index, weight, fat percentage, fat mass, fat free mass, and muscle mass did not decrease significantly over time in compliant patients, but in noncompliant patients, all of these indices decreased significantly from baseline compared to the end of treatment (p < 0.001). Hand grip strength did not differ significantly between the two groups at baseline and over time in each group. When retrospectively evaluated, heavy mucositis was less commonly observed in compliant than noncompliant patients (11.1% versus 88.9%, resp.) (p < 0.009). Conclusion. We conclude that body composition parameters were better in head and neck cancer patients considered as compliant with nutritional counselling than noncompliant ones during RT period.

Dietary intake variability in the cycle of cytotoxic chemotherapy

PURPOSE

This study was conducted to evaluate the dietary intake at different time points of the chemotherapeutic cycle.

METHODS

Fifty-five ovarian cancer patients receiving at least 2 cycles of chemotherapy were deemed eligible for this study, of which 41 participants completed the study. Anthropometrical measurements and Subjective Global Assessment were used to estimate nutritional status. The dietary intake was evaluated by 3-day food records: 3 days prior to, the day of, and the following day after chemotherapy.

RESULTS

Mean energy intake was the lowest on the day of chemotherapy and the highest 3 days before treatment (mean difference, 413.8 kcal; p < 0.001). Similarly, some vitamins and macro- and micronutrients (K, Ca, vit D, folate, vit C) failed to reach 50 % of the recommended dietary allowances. When dividing patients into BMI categories, the energy intake per kilogram of body weight, in the normal-weight patients, was statistically higher than that in overweight and obese subjects (23.6 vs. 20.9 vs. 12.3 kcal, respectively; p = 0.0015). Similarly, the statistically significant differences were observed by the intake of fats (0.80 vs. 0.69 vs. 0.39 g, p = 0.0283) and carbohydrates (3.52 vs. 3.05 vs. 1.71 g, p = 0.0004).

CONCLUSIONS

Dietary intake varies in the cycle of chemotherapy, with the lowest intake at the day of cytotoxic treatment and the highest before the next chemotherapy. Further studies evaluating dietary intake in patients undergoing chemotherapy should include in the protocol the exact time point of dietary assessment. The intake of energy, fats, and carbohydrates differs significantly across BMI categories.

Opportunities for targeting the fatigue-anorexia-cachexia symptom cluster

Cancer patients experience multiple symptoms throughout their illness trajectory. Symptoms consistently occurring together, known as symptom clusters, share common pathophysiologic mechanisms. Understanding and targeting such symptom clusters may allow for more effective and efficient use of treatments for a variety of symptoms. Fatigue-anorexia-cachexia is one of the most prevalent symptom clusters and significantly impairs quality of life. In this review, we explore the fatigue-anorexia-cachexia symptom cluster and focus on current and emerging therapies with an emphasis on pharmacologic management.

Oral cancer malnutrition impacts weight and quality of life

Diet is important for both quality of life (QoL) and survival of patients with oral cancer. Their intake of food is impeded by functional restrictions in chewing and swallowing. In the DÖSAK REHAB STUDY 1652 patients from 38 hospitals within the German-language area of Germany; Austria and Switzerland were examined with regard to functional and psychological variables having an impact on diet. Chewing and swallowing are correlated with mobility of the tongue and the mandible as well as opening of the mouth. Thirty five percent of the patients lost weight; 41% maintained their weight and 24% gained weight. The QoL of patients who were able to maintain their weight and of those who gained weight was significantly better than that of patients who lost weight. A normal diet was important for maintaining weight. Mashed food; liquid food and loss of appetite were closely associated with loss of weight; although it was possible for nutritional counseling and dietary support to be implemented particularly favorably in this respect. Due to problems with eating patients' strength deteriorated; thus restricting activity. Radiotherapy had a negative impact on diet and weight. It influenced sense of taste; dryness of the mouth; swelling and discomfort when ingesting food. Pain and scars in the region of the operation also cause patients to dislike hard; spicy and sour food. Support from a nutritional counselor in implementing a calorie-rich diet remedied this and such support needs to be integrated into patient management. The fact that a poor nutritional status is of such great importance is well-known; but what is often lacking is the systematic implementation of continued professional nutritional counseling over a long period of time; weight control and psycho-social support of the operated patients; particularly those who also have had radiotherapy.

Nutritional counseling and nutritional supplements: a cornerstone of multidisciplinary cancer care for cachectic patients

PURPOSE OF REVIEW

The challenge with cancer cachexia is that it is not fully reversed by nutrition support. The purpose of this review is to provide an opinion on the nutritional management of cancer cachexia based on the most recent available evidence.

RECENT FINDINGS

There continues to be a paucity of nutrition intervention studies in patients with cancer cachexia. In patients with cancer undergoing radiotherapy, there is strong evidence that nutrition counseling increases dietary intake, body weight, nutritional status and quality of life with some suggestion that dietary counseling may improve nutrition impact symptoms, treatment response and survival. In patients with cancer undergoing chemotherapy, the evidence is less clear. The use of n-3 polyunsaturated fatty acids may have some positive effects in patients with cancer; however, clinical judgment and care need to be taken in its application. Preliminary results of studies in the use of L-carnitine in improving fatigue are promising; however, the largest trial in 'healthy' cancer patients showed no benefit.

SUMMARY

Further research into the most appropriate methods for identifying and treating cancer cachexia is required. Regardless of whether patients are experiencing reduced dietary intake resulting in malnutrition or due to cachexia, nutrition remains a cornerstone of multimodal treatment.

A novel, automated nutrition screening system as a predictor of nutritional risk in an oncology day treatment unit (ODTU)

PURPOSE

Paper-based nutrition screening tools can be challenging to implement in the ambulatory oncology setting. The aim of this study was to determine the validity of the Malnutrition Screening Tool (MST) and a novel, automated nutrition screening system compared to a 'gold standard' full nutrition assessment using the Patient-Generated Subjective Global Assessment (PG-SGA).

METHODS

An observational, cross-sectional study was conducted in an outpatient oncology day treatment unit (ODTU) within an Australian tertiary health service. Eligibility criteria were as follows: ≥ 18 years, receiving outpatient anticancer treatment and English literate. Patients self-administered the MST. A dietitian assessed nutritional status using the PG-SGA, blinded to the MST score. Automated screening system data were extracted from an electronic oncology prescribing system. This system used weight loss over 3 to 6 weeks prior to the most recent weight record or age-categorised body mass index (BMI) to identify nutritional risk. Sensitivity and specificity against PG-SGA (malnutrition) were calculated using contingency tables and receiver operating curves.

RESULTS

There were a total of 300 oncology outpatients (51.7% male, 58.6 ± 13.3 years). The area under the curve (AUC) for weight loss alone was 0.69 with a cut-off value of ≥ 1% weight loss yielding 63% sensitivity and 76.7% specificity. MST (score ≥ 2) resulted in 70.6% sensitivity and 69.5% specificity, AUC 0.77.

CONCLUSIONS

Both the MST and the automated method fell short of the accepted professional standard for sensitivity (~≥ 80%) derived from the PG-SGA. Further investigation into other automated nutrition screening options and the most appropriate parameters available electronically is warranted to support targeted service provision.

A prospective analysis of factors that influence weight loss in patients undergoing radiotherapy

Malnutrition occurs frequently in patients with cancer. Indeed, a variety of nutritional and tumor-related factors must be taken into account in these patients. Recognizing this relationship, we aimed to prospectively evaluate the risk factors that influence weight loss in patients undergoing radiotherapy with oral nutritional supplementation and dietetic counseling. Weight loss of 74 patients during radiotherapy and 1 month after treatment was analyzed. Parameters such as age, gender, tumor location, tumor stage, Eastern Cooperative Oncology Group performance status (ECOG PS) score, and the use of chemotherapy were analyzed to evaluate their influence on weight loss. All patients underwent oral nutritional supplementation and dietetic counseling. Forty-six (65.7%) patients lost weight, with a mean weight loss of (4.73 ± 3.91) kg, during radiotherapy. At 1 month after treatment, 45 (66.2%) patients lost weight, presenting a mean weight loss of (4.96 ± 4.04) kg, corresponding to a (6.84 ± 5.24)% net reduction from their baseline weight. Head and neck cancer patients had a mean weight loss of (3.25 ± 5.30) kg, whereas the remaining patients had a mean weight loss of (0.64 ± 2.39) kg (P = 0.028) during radiotherapy. In the multivariate analysis, the head and neck tumor location (P = 0.005), use of chemotherapy (P = 0.011), and ECOG PS score of 2-3 (P = 0.026) were considered independent risk factors. Nutritional status and parameters, such as tumor location (especially the head and neck), the use of chemotherapy, and the ECOG PS score, should be evaluated before radiotherapy because these factors can influence weight loss during radiotherapy and 1 month after treatment.

Exercise and nutrition interventions in advanced lung cancer: a systematic review

In this systematic review, we sought to evaluate the effect of physical activity or nutrition interventions (or both) in adults with advanced non-small-cell lung cancer (nsclc).

METHODS

A systematic search for relevant clinical trials was conducted in 6 electronic databases, by hand searching, and by contacting key investigators. No limits were placed on study language. Information about recruitment rates, protocol adherence, patient-reported and clinical outcome measures, and study conclusions was extracted. Methodologic quality and risk of bias in each study was assessed using validated tools.

MAIN RESULTS

Six papers detailing five studies involving 203 participants met the inclusion criteria. Two of the studies were single-cohort physical activity studies (54 participants), and three were controlled nutrition studies (149 participants). All were conducted in an outpatient setting. None of the included studies combined physical activity with nutrition interventions.

CONCLUSIONS

Our systematic review suggests that exercise and nutrition interventions are not harmful and may have beneficial effects on unintentional weight loss, physical strength, and functional performance in patients with advanced nsclc. However, the observed improvements must be interpreted with caution, because findings were not consistent across the included studies. Moreover, the included studies were small and at significant risk of bias. More research is required to ascertain the optimal physical activity and nutrition interventions in advanced inoperable nsclc. Specifically, the potential benefits of combining physical activity with nutrition counselling have yet to be adequately explored in this population.

Examination of the association of diet and persistent cancer-related fatigue: a pilot study

PURPOSE/OBJECTIVES

To examine associations between diet and persistent cancer-related fatigue (PCRF) in cancer survivors.

DESIGN

A cross-sectional pilot study.

SETTING

A university cancer center in Michigan.

SAMPLE

40 adult cancer survivors who were recruited from July 2007 to August 2008 and had completed all cancer treatments at least 12 weeks prior to recording their dietary intakes and fatigue severity.

METHODS

Participants' fatigue was assessed with the Brief Fatigue Inventory (BFI). Based on the BFI score, participants were placed into one of three fatigue levels: no fatigue, moderate fatigue, or severe fatigue. Dietary data were collected using a four-day food diary and analyzed using Nutrition Data System for Research software. Diet data were collected during the same week that fatigue was measured.

MAIN RESEARCH VARIABLES

Fatigue and dietary intake.

FINDINGS

Mean daily intake of whole grains, vegetables, and, in particular, green leafy vegetables and tomatoes were significantly higher in the nonfatigued group compared to fatigued cancer survivors. Also, cancer survivors reporting no fatigue had significantly higher intakes of certain anti-inflammatory and antioxidant nutrients.

CONCLUSIONS

Increased consumption of whole grains, vegetables, and foods rich in certain anti-inflammatory nutrients was associated with decreased levels of PCRF. Additional rigorous studies are required to investigate possible mechanisms and causal relationships regarding the benefits of particular diets on PCRF.

IMPLICATIONS FOR NURSING

Nurses, as one of the main providers of care to cancer survivors, should continue to follow National Comprehensive Cancer Network recommendations until additional data on diet and fatigue are evaluated.

KNOWLEDGE TRANSLATION

Nurses should be aware of national guidelines for nutritional recommendations for treating cancer-related fatigue. In addition, nurses should ask about and record the cancer survivor's typical dietary intake. Referrals to registered dietitians, in accordance with national guidelines for cancer survivors, should be considered when advising a fatigued patient.

Cancer cachexia--pathophysiology and management

About half of all cancer patients show a syndrome of cachexia, characterized by anorexia and loss of adipose tissue and skeletal muscle mass. Cachexia can have a profound impact on quality of life, symptom burden, and a patient's sense of dignity. It is a very serious complication, as weight loss during cancer treatment is associated with more chemotherapy-related side effects, fewer completed cycles of chemotherapy, and decreased survival rates. Numerous cytokines have been postulated to play a role in the etiology of cancer cachexia. Cytokines can elicit effects that mimic leptin signaling and suppress orexigenic ghrelin and neuropeptide Y (NPY) signaling, inducing sustained anorexia and cachexia not accompanied by the usual compensatory response. Furthermore, cytokines have been implicated in the induction of cancer-related muscle wasting. Cytokine-induced skeletal muscle wasting is probably a multifactorial process, which involves a protein synthesis inhibition, an increase in protein degradation, or a combination of both. The best treatment of the cachectic syndrome is a multifactorial approach. Many drugs including appetite stimulants, thalidomide, cytokine inhibitors, steroids, nonsteroidal anti-inflammatory drugs, branched-chain amino acids, eicosapentaenoic acid, and antiserotoninergic drugs have been proposed and used in clinical trials, while others are still under investigation using experimental animals. There is a growing awareness of the positive impact of supportive care measures and development of promising novel pharmaceutical agents for cachexia. While there has been great progress in understanding the underlying biological mechanisms of cachexia, health care providers must also recognize the psychosocial and biomedical impact cachexia can have.

Impact of an early education multimedia intervention in managing nutrition-related chemotherapy side effects: a pilot study

Background

The purpose of the educational intervention was to measure changes in knowledge, perceived benefit of nutrition, and perceived self efficacy in handling side effects of chemotherapy before and after viewing a 15 minute DVD among patients with cancer.

Methods

A convenience sample of 14 (4 male, 10 female, 61 ± 9 years) patients with cancer, early to chemotherapy, participated in the study. Participants completed a survey with demographic, knowledge items, and perceived health belief and self efficacy statements; viewed the DVD; and were then sent home with a one page handout. Two weeks after the nutrition education intervention, a second survey was completed including an item about tips used. Change was measured using paired t-test and wilcoxon signed rank tests.

Findings

The mean score on the four knowledge items significantly increased (p < 0.05). No significant differences were noted in statements intended to evaluate changes in perceived health beliefs. However, perceived knowledge and skills related to managing side effects increased (p < 0.05). All participants responded that the DVD was informative and most (n = 11, 79%) responded that it was useful. The majority reported (n = 10, 71%) a tip they used from the DVD.

Conclusions

This short multimedia nutrition education intervention was found primarily to increase knowledge and could form a useful component of counseling services for patients undergoing chemotherapy.

Expertise regarding dental management of oral cancer patients receiving radiation therapy among Western Australian dentists

OBJECTIVES

Dental care forms an important part of the multidisciplinary management of oral cancer patients. The aim of this study was to examine actual and self-perceived knowledge and clinical expertise regarding dental management of oral cancer patients receiving radiation therapy among Western Australian general dentists.

MATERIALS AND METHODS

An invitation to participate in a web-based questionnaire was emailed to 1095 dentists registered with the Australian Dental Association (ADA), WA branch. To assess dentists' knowledge and expertise, actual and perceived knowledge was investigated. Information regarding type of practice, practice location, year of graduation and number of oral cancer patients treated in the preceding 12 months was also obtained.

RESULTS

One hundred and ninety one dentists responded to the survey. General dentists who took part in the study appeared to possess some knowledge regarding dental management of oral cancer patients treated with radiation therapy. The majority of responders however identified deficiencies in their knowledge and willingness to participate in continuing education programs.

CONCLUSION

In view of the rising incidence of oral cancer in Western Australia, efforts should be made to provide more clinically relevant training to dentists in this area.

Mini-nutritional assessment predicts functional status and quality of life of patients with hepatocellular carcinoma in Taiwan

This study aimed to determine the possibility of using the Mini-Nutritional Assessment (MNA) to evaluate the quality of life and functional status in patients with hepatocellular carcinoma (HCC). The study recruited 300 outpatients with HCC from a teaching hospital in Central Taiwan to serve as subjects. All subjects were interviewed with a structured questionnaire for rating the nutritional status with the MNA (long-form and short-form), and for evaluating quality of life and functional status with Global Quality of Life (GQL) and Global Functional Status (GFS), respectively, of the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 version-3. Cancer staging and liver cirrhosis indicators, blood biochemical indicators, and self-rated health status and mobility were used as reference standards. Results showed that based on the strength of the correlation and association with the reference standards, both the long-form and short-form of the MNA performed better than GQL and GFS in predicting quality of life and functional status of patients with HCC. These results suggest that the MNA is suitable for identifying the risk of deteriorating quality of life or functional status, in addition to identifying the risk of malnutrition, in patients with HCC.

Clinical and nutritional status of surgical patients with and without malignant diseases: cross-sectional study

CONTEXT

Malnutrition is frequently observed in inpatients with malignant diseases and may contribute to longer hospital stays.

OBJECTIVE

To compare the nutritional status, lymphocyte count, hemoglobin values and length of hospital stay of patients with and without malignant diseases.

METHODS

This comparative study assessed indicators of nutritional status, namely body mass index, recent weight loss, lymphocyte count, hemoglobin and length of hospital stay, of 928 surgical patients with and without malignant diseases (50.2% females and 49.8% males). The chi-square test was used to compare proportions and the Mann-Whitney test was used to compare continuous measurements between two groups. The significance level was set at 5%.

RESULTS

Patients with malignant diseases had longer hospital stays (P<0.0001), furthermore, a higher percentage of patients with malignant diseases had body mass index <18.5 (P<0.0001) and experienced recent weight changes (P<0.0002). Lymphocyte count also differed statistically between the groups (P = 0.0131), which lower levels were identified among patients with malignant diseases.

CONCLUSION

The lymphocyte count, hemoglobin values and weight loss are important findings of nutritional depletion in patients with malignant diseases.

Nutritional status independently affects quality of life of patients with systemic immunoglobulin light-chain (AL) amyloidosis

Nutritional status is an independent prognostic factor in immunoglobulin light-chain amyloidosis (AL), but its influence on quality of life (QoL) is unknown. The aim of this cross-sectional study was to investigate the association between nutritional status and QoL in AL patients at diagnosis. One hundred and fifty consecutive patients with biopsy-proven AL were assessed for nutritional status by anthropometry [body mass index, unintentional weight loss (WL) in the previous 6 months and mid-arm muscle circumference (MAMC)], biochemistry (serum prealbumin), and semiquantitative food intake at referral. QoL was assessed by the Medical Outcomes Study 36-item Short Form General Health Survey. The composite physical component summary (PCS) and the mental component summary (MCS) for AL outpatients were 36.2 ± 10.1 and 44.9 ± 11.3, respectively (p < 0.001 for both vs the population norms of 50). In multivariate linear regression models adjusted for gender, age, Eastern Cooperative Oncology Group performance status, the number of organs involved, the severity of cardiac damage, C-reactive protein, energy intake, and WL, PCS was significantly lower for serum prealbumin <200 mg/L and MAMC <10th percentile (adjusted difference 3.8, 95% CI 0.18-7.5, p = 0.040 and 5.3, 95% CI 2.0-8.7, p = 0.002, respectively). MCS was decreased by 0.47 (95% CI 0.18-0.75, p = 0.002) for each kilogram of body weight lost in the previous 6 months. Nutritional status independently affects QoL in AL patients since diagnosis. Nutritional evaluation should be integral part of the clinical assessment of AL patients. Nutritional support intervention trials are warranted in such patients' population.

Teaching nutrition integration: MUST screening in cancer

RATIONALE

Nutritional risk screening should be routine in order to select patients in need of nutrition care; this conduct change has to rely on education. In this project, radiotherapy department health professionals were trained on how to use the Malnutrition Universal Screening Tool (MUST), to foster its integration into cancer outpatient management; we also aimed to identify those more adherent to screening.

METHODS

Research dieticians (the standard) conducted interactive sessions with all physicians, nurses, and radiotherapy (RT) technicians, who were closely supervised to facilitate routine MUST integration. There were two phases: after the first session, phase 1 assessed 200 patients over 4 months; after the second session, phase 2 screened 450 patients, always before RT. Validity was evaluated comparing results from the standard against all other health professionals, adjusted for number.

RESULTS

RT technicians were most adherent to the MUST: 80% of patients in phase 1, increasing to 85% in phase 2. Nurses doubled their input, from 19% to 36%. Physicians had poor MUST integration, yet they progressively incorporated percentage weight loss into patient records, increasing from 57% in phase 1 to 84% in phase 2, independently of diagnosis and stage. The highest concordance (κ coefficient) with dieticians was found with RT technicians' use of the MUST (p < .002) and percentage weight loss determination by physicians (p < .001).

CONCLUSIONS

We show that systematic screening in cancer is feasible by all professionals involved, once a proximity teaching project is put into practice. RT technicians, who daily treat patients, were highly adherent to integrate the MUST and might be in charge of selecting at-risk patients. Physicians are unlikely to use the MUST, but acknowledged nutrition value and changed their routine by integrating recent percentage weight loss into their approach to patients. Our structured methodology may be used as a model for the development of teaching adapted to different departments with other realities.

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

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

Nutritional status of patients with locally advanced pancreatic cancer: a pilot study

PURPOSE

Nutritional status may influence quality of life and prognosis among pancreatic cancer patients, yet few studies describe measures of nutritional status during treatment. We evaluated the nutritional status of locally advanced pancreatic cancer (LAPC) patients undergoing chemoradiotherapy who received baseline nutritional assessment and counseling.

METHODS

Fourteen newly diagnosed LAPC patients enrolled in phase I/II trials of capecitabine with concomitant radiotherapy were assessed for baseline clinical nutrition measures (body mass index, albumin, weight loss, total energy, and protein intake). Participants completed the Anorexia/Cachexia Subscale (A/CS) questionnaire at baseline and during the 6 weeks of treatment. We evaluated associations between baseline characteristics and subsequent A/CS scores with linear regression and changes in A/CS were assessed with the paired t test.

RESULTS

We observed a statistically significant increase in mean A/CS between baseline [24.9, standard deviation (SD) = 9.7] and end of treatment (29.9, SD = 6.2). Controlling for baseline A/CS score, only weight loss greater than 5% of body weight over 1 month was associated with A/CS scores at 6 weeks (β = 10.558, standard error = 3.307, p value = 0.009) and mean A/CS scores during the last 3 weeks of treatment (β = 12.739, standard error = 2.251, p value = 0.001).

CONCLUSIONS

After 6 weeks of chemoradiotherapy, LAPC patients reported a statistically significant improvement in appetite and weight concerns. Increases in AC/S scores were associated with higher baseline A/CS scores and weight loss of 5% or more during 1 month. Further research is needed to determine the impact of nutritional support during treatment, as improvements in this domain may impact LAPC patients' overall quality of life.

Cancer-related anorexia-cachexia syndrome

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