1
|
Liu Z, Lei T, Guo Y, Zheng C. The impact of sarcopenia on the efficacy of PD-1 inhibitors in non-small cell lung cancer and potential strategies to overcome resistance. Front Pharmacol 2024; 15:1377666. [PMID: 39101140 PMCID: PMC11294093 DOI: 10.3389/fphar.2024.1377666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2024] [Accepted: 06/18/2024] [Indexed: 08/06/2024] Open
Abstract
Recent studies have revealed that sarcopenia can adversely affect the efficacy of PD-1 inhibitors in the treatment of non-small cell lung cancer (NSCLC). PD-1 inhibitors are immune checkpoint inhibitors widely used in the treatment of various cancers. However, NSCLC patients may have poorer outcomes when receiving PD-1 inhibitor treatment, and sarcopenia may affect the efficacy of PD-1 inhibitors through immune and metabolic mechanisms. In this article, we summarize the reported negative impact of sarcopenia on the effectiveness of PD-1 inhibitors in the treatment of NSCLC in recent years. Based on existing research results, we analyze the possible mechanisms by which sarcopenia affects the efficacy of PD-1 inhibitors and discuss possible strategies to address this issue. This could help to understand the impact of sarcopenia on the treatment of PD-1 inhibitors and provide more accurate expectations of treatment outcomes for clinicians and patients. Additionally, we present tailored intervention strategies for sarcopenic patients undergoing PD-1 inhibitor therapy, aiming to optimize treatment efficacy and enhance patient quality of life. Nevertheless, further research is warranted to elucidate the mechanisms through which sarcopenia impacts PD-1 inhibitors and to identify more efficacious intervention approaches for improving the effectiveness of PD-1 inhibitor treatment in sarcopenic patients.
Collapse
Affiliation(s)
- Zhenchao Liu
- School of Pharmacy, Qingdao University, Qingdao, Shandong, China
| | - Tianxiang Lei
- Institute of Integrative Medicine, Qingdao University, Qingdao, Shandong, China
| | - Yunliang Guo
- Institute of Integrative Medicine, Qingdao University, Qingdao, Shandong, China
| | - Chongwen Zheng
- Department of Neurology, The 2nd Affiliated Hospital of Fujian University of Traditional Chinese Medicine, Fuzhou, China
| |
Collapse
|
2
|
Mora S, Mann G, Adegoke OAJ. Sex differences in cachexia and branched-chain amino acid metabolism following chemotherapy in mice. Physiol Rep 2024; 12:e16003. [PMID: 38631892 PMCID: PMC11023815 DOI: 10.14814/phy2.16003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Revised: 03/17/2024] [Accepted: 03/18/2024] [Indexed: 04/19/2024] Open
Abstract
Chemotherapy is a major contributor to cachexia, but studies often investigate male animals. Here, we investigated whether sex modifies the effects of chemotherapy on cachexia and BCAA metabolism. Ten-week-old CD2F1 male and female mice were treated with the chemotherapy drug cocktail folfiri (50 mg/kg 5-fluorouracil, 90 mg/kg leucovorin, and 24 mg/kg CPT11) (drug) or vehicle twice a week for 6 weeks. Insulin tolerance tests were conducted and BCAA levels and metabolism were measured in plasma and tissues. Drug treatment reduced body and skeletal muscle weights and anabolic signaling in both sexes, with females showing worsened outcomes (p < 0.05 for all). Drug treatment increased plasma BCAA only in males, but BCAA concentrations in the skeletal muscle of both sexes were decreased; this decrease was more profound in males (p = 0.0097). In addition, muscle expression of the BCAA transporter LAT1 was reduced; this reduction was more severe in females (p = 0.0264). In both sexes, the (inhibitory) phosphorylation of BCKD-E1αser293 was increased along with decreased BCKD activity. In the liver, drug treatment increased BCAA concentrations and LAT1 expression, but BCKD activity was suppressed in both sexes (p < 0.05 for all). Our results demonstrate that altered BCAA metabolism may contribute to chemotherapy-induced cachexia in a sex-dependent manner.
Collapse
Affiliation(s)
- Stephen Mora
- Muscle Health Research Centre, School of Kinesiology and Health ScienceYork UniversityTorontoOntarioCanada
| | - Gagandeep Mann
- Muscle Health Research Centre, School of Kinesiology and Health ScienceYork UniversityTorontoOntarioCanada
| | - Olasunkanmi A. J. Adegoke
- Muscle Health Research Centre, School of Kinesiology and Health ScienceYork UniversityTorontoOntarioCanada
| |
Collapse
|
3
|
Xiao YL, Gong Y, Qi YJ, Shao ZM, Jiang YZ. Effects of dietary intervention on human diseases: molecular mechanisms and therapeutic potential. Signal Transduct Target Ther 2024; 9:59. [PMID: 38462638 PMCID: PMC10925609 DOI: 10.1038/s41392-024-01771-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 02/05/2024] [Accepted: 02/18/2024] [Indexed: 03/12/2024] Open
Abstract
Diet, serving as a vital source of nutrients, exerts a profound influence on human health and disease progression. Recently, dietary interventions have emerged as promising adjunctive treatment strategies not only for cancer but also for neurodegenerative diseases, autoimmune diseases, cardiovascular diseases, and metabolic disorders. These interventions have demonstrated substantial potential in modulating metabolism, disease trajectory, and therapeutic responses. Metabolic reprogramming is a hallmark of malignant progression, and a deeper understanding of this phenomenon in tumors and its effects on immune regulation is a significant challenge that impedes cancer eradication. Dietary intake, as a key environmental factor, can influence tumor metabolism. Emerging evidence indicates that dietary interventions might affect the nutrient availability in tumors, thereby increasing the efficacy of cancer treatments. However, the intricate interplay between dietary interventions and the pathogenesis of cancer and other diseases is complex. Despite encouraging results, the mechanisms underlying diet-based therapeutic strategies remain largely unexplored, often resulting in underutilization in disease management. In this review, we aim to illuminate the potential effects of various dietary interventions, including calorie restriction, fasting-mimicking diet, ketogenic diet, protein restriction diet, high-salt diet, high-fat diet, and high-fiber diet, on cancer and the aforementioned diseases. We explore the multifaceted impacts of these dietary interventions, encompassing their immunomodulatory effects, other biological impacts, and underlying molecular mechanisms. This review offers valuable insights into the potential application of these dietary interventions as adjunctive therapies in disease management.
Collapse
Affiliation(s)
- Yu-Ling Xiao
- Key Laboratory of Breast Cancer in Shanghai, Department of Breast Surgery, Fudan University Shanghai Cancer Center, Shanghai, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, China
| | - Yue Gong
- Key Laboratory of Breast Cancer in Shanghai, Department of Breast Surgery, Fudan University Shanghai Cancer Center, Shanghai, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, China
| | - Ying-Jia Qi
- Key Laboratory of Breast Cancer in Shanghai, Department of Breast Surgery, Fudan University Shanghai Cancer Center, Shanghai, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, China
| | - Zhi-Ming Shao
- Key Laboratory of Breast Cancer in Shanghai, Department of Breast Surgery, Fudan University Shanghai Cancer Center, Shanghai, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, China
| | - Yi-Zhou Jiang
- Key Laboratory of Breast Cancer in Shanghai, Department of Breast Surgery, Fudan University Shanghai Cancer Center, Shanghai, China.
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, China.
| |
Collapse
|
4
|
Cotogni P, Shaw C, Jimenez-Fonseca P, Partridge D, Pritchett D, Webb N, Crompton A, Garcia-Lorda P, Shepelev J. High-protein home parenteral nutrition in malnourished oncology patients: a systematic literature review. Support Care Cancer 2023; 32:52. [PMID: 38129578 PMCID: PMC10739567 DOI: 10.1007/s00520-023-08218-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Accepted: 11/30/2023] [Indexed: 12/23/2023]
Abstract
INTRODUCTION Up to 83% of oncology patients are affected by cancer-related malnutrition, depending on tumour location and patient age. Parenteral nutrition can be used to manage malnutrition, but there is no clear consensus as to the optimal protein dosage. The objective of this systematic literature review (SLR) was to identify studies on malnourished oncology patients receiving home parenteral nutrition (HPN) where protein or amino acid delivery was reported in g/kg bodyweight/day, and to compare outcomes between patients receiving low (< 1 g/kg bodyweight/day), standard (1-1.5 g/kg/day), and high-protein doses (> 1.5 g/kg/day). METHODS Literature searches were performed on 5th October 2021 in Embase, MEDLINE, and five Cochrane Library and Centre for Reviews and Dissemination databases. Searches were complemented by hand-searching of conference proceedings, a clinical trial registry, and bibliographic reference lists of included studies and relevant SLRs/meta-analyses. RESULTS Nineteen publications were included; sixteen investigated standard protein, two reported low protein, and one included both, but none assessed high-protein doses. Only one randomised controlled trial (RCT) was identified; all other studies were observational studies. The only study to compare two protein doses reported significantly greater weight gain in patients receiving 1.15 g/kg/day than those receiving 0.77 g/kg/day. CONCLUSION At present, there is insufficient evidence to determine the optimal protein dosage for malnourished oncology patients receiving HPN. Data from non-HPN studies and critically ill patients indicate that high-protein interventions are associated with increased overall survival and quality of life; further studies are needed to establish whether the same applies in malnourished oncology patients.
Collapse
Affiliation(s)
- Paolo Cotogni
- Pain Management and Palliative Care, Department of Anesthesia, Intensive Care and Emergency, Molinette Hospital and University of Turin, Turin, Italy.
| | - Clare Shaw
- Biomedical Research Centre at The Royal Marsden and Institute of Cancer Research, London and Sutton, UK
| | | | | | | | | | | | | | - Julian Shepelev
- Worldwide Medical, Health Economics and Outcomes Research, Baxter Healthcare SA, Zurich, Switzerland
| |
Collapse
|
5
|
Long Z, Huang S, Zhang J, Zhang D, Yin J, He C, Zhang Q, Xu H, He H, Sun HC, Xie K. A Digital Smartphone-Based Self-administered Tool (R+ Dietitian) for Nutritional Risk Screening and Dietary Assessment in Hospitalized Patients With Cancer: Evaluation and Diagnostic Accuracy Study. JMIR Form Res 2022; 6:e40316. [PMID: 36287601 PMCID: PMC9647468 DOI: 10.2196/40316] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 09/22/2022] [Accepted: 09/23/2022] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND Malnutrition is a common and severe problem in patients with cancer that directly increases the incidence of complications and significantly deteriorates quality of life. Nutritional risk screening and dietary assessment are critical because they are the basis for providing personalized nutritional support. No digital smartphone-based self-administered tool for nutritional risk screening and dietary assessment among hospitalized patients with cancer has been developed and evaluated. OBJECTIVE This study aims to develop a digital smartphone-based self-administered mini program for nutritional risk screening and dietary assessment for hospitalized patients with cancer and to evaluate the validity of the mini program. METHODS We have developed the R+ Dietitian mini program, which consists of 3 parts: (1) collection of basic information of patients, (2) nutritional risk screening, and (3) dietary energy and protein assessment. The face-to-face paper-based Nutritional Risk Screening (NRS-2002), the Patient-Generated Subjective Global Assessment Short Form (PG-SGA-SF), and 3 days of 24-hour dietary recall (3d-24HRs) questionnaires were administered according to standard procedure by 2 trained dietitians as the reference methods. Sensitivity, specificity, positive predictive value, negative predictive value, κ value, and correlation coefficients (CCs) of nutritional risk screened in R+ Dietitian against the reference methods, as well as the difference and CCs of estimated dietary energy and protein intakes between R+ Dietitian and 3d-24HRs were calculated to evaluate the validity of R+ Dietitian. RESULTS A total of 244 hospitalized patients with cancer were recruited to evaluate the validity of R+ Dietitian. The NRS-2002 and PG-SGA-SF tools in R+ Dietitian showed high accuracy, sensitivity, and specificity (77.5%, 81.0%, and 76.7% and 69.3%, 84.5%, and 64.5%, respectively), and fair agreement (κ=0.42 and 0.37, respectively; CC 0.62 and 0.56, respectively) with the NRS-2002 and PG-SGA-SF tools administered by dietitians. The estimated intakes of dietary energy and protein were significantly higher (P<.001 for both) in R+ Dietitian (mean difference of energy intake: 144.2 kcal, SD 454.8; median difference of protein intake: 10.7 g, IQR 9.5-39.8), and showed fair agreement (CC 0.59 and 0.47, respectively), compared with 3d-24HRs performed by dietitians. CONCLUSIONS The identified nutritional risk and assessment of dietary intakes of energy and protein in R+ Dietitian displayed a fair agreement with the screening and assessment conducted by dietitians. R+ Dietitian has the potential to be a tool for nutritional risk screening and dietary intake assessment among hospitalized patients with cancer. TRIAL REGISTRATION Chinese Clinical Trial Registry ChiCTR1900026324; https://www.chictr.org.cn/showprojen.aspx?proj=41528.
Collapse
Affiliation(s)
| | - Shan Huang
- Department of Oncology, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, Chengdu, China
- School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Jie Zhang
- Department of Oncology, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, Chengdu, China
- School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Deng Zhang
- Department of Oncology, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, Chengdu, China
| | - Jun Yin
- Recovery Plus Clinic, Chengdu, China
| | | | - Qinqiu Zhang
- Recovery Plus Clinic, Chengdu, China
- College of Food Science, Sichuan Agricultural University, Ya'an, China
| | - Huilin Xu
- Recovery Plus Clinic, Chengdu, China
| | - Huimin He
- Recovery Plus Clinic, Chengdu, China
| | | | - Ke Xie
- Department of Oncology, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, Chengdu, China
- School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| |
Collapse
|
6
|
Connolly-Schoonen J, Biamonte SF, Danowski L, Montrose DC. Modifying dietary amino acids in cancer patients. INTERNATIONAL REVIEW OF CELL AND MOLECULAR BIOLOGY 2022; 373:1-36. [PMID: 36283763 DOI: 10.1016/bs.ircmb.2022.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
Limiting nutrient utilization by cancer cells in order to disrupt their metabolism and suppress their growth represents a promising approach for anti-cancer therapy. Recently, studies demonstrating the anti-neoplastic effects of lowering amino acid (AA) availability have opened up an exciting and quickly growing field of study. Although intracellular synthesis can often provide the AAs necessary to support cancer cells, diet and the tumor microenvironment can also be important sources. In fact, studies carried out in vitro and in animal tumor models have supported the anti-cancer potential of restricting exogenous sources of AAs. However the potential benefit of reducing AA intake in cancer patients requires further investigation. Furthermore, implementation of such an approach clinically, even if proven useful, could be challenging. In the enclosed review, we (1) summarize the pre-clinical studies showing the anti-tumorigenic effects of restricting exogenously available AAs, including through reducing dietary protein, (2) consider the role of microbiota in this process, (3) report on current recommendations for protein intake in cancer patients and studies that applied these guidelines, and (4) propose considerations for studies to test the potential therapeutic benefit of reducing protein/AA consumption in patients with cancer.
Collapse
Affiliation(s)
- Josephine Connolly-Schoonen
- Department of Family, Population & Preventive Medicine, Stony Brook University, Stony Brook, NY, United States
| | - Steven F Biamonte
- Department of Family, Population & Preventive Medicine, Stony Brook University, Stony Brook, NY, United States
| | - Lorraine Danowski
- Department of Family, Population & Preventive Medicine, Stony Brook University, Stony Brook, NY, United States
| | - David C Montrose
- Department of Pathology, Stony Brook University, Stony Brook, NY, United States; Stony Brook Cancer Center, Stony Brook, NY, United States.
| |
Collapse
|
7
|
Barreto CS, Borges TC, Valentino NP, Gomes TLN, Soares JDP, Siqueira JM, Pichard C, Laviano A, Pimentel GD. Absence of risk of sarcopenia protects cancer patients from fatigue. Eur J Clin Nutr 2022; 76:206-211. [PMID: 33986491 DOI: 10.1038/s41430-021-00931-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Revised: 04/12/2021] [Accepted: 04/19/2021] [Indexed: 02/05/2023]
Abstract
BACKGROUND Cancer and its treatments often lead to sarcopenia and fatigue. However, whether these factors are associated remains unproven. OBJECTIVE To evaluate whether the risk of sarcopenia predicts the presence of fatigue. METHODS A cross-sectional study was completed and included 198 cancer patients of both sexes, undergoing in- and outpatient treatment. The Strength, Assistance for walking, Rise from a chair, Climb stairs, and Falls (SARC-F) and the Functional Assessment of Cancer Therapy Fatigue (FACT-F) were used to assess the risk of sarcopenia and the presence of fatigue, respectively. The cut-off values used to identify the risk of sarcopenia and the severity of fatigue scale were SARC-F ≥ 4 and Fatigue <34, respectively. Logistic regression analysis was performed to evaluate the association between SARC-F and the FACT-F. RESULTS Out of 198 patients, 35% were at risk of sarcopenia and of these 87% had fatigue. Patients at risk of sarcopenia had lower scores in the FACT-F subscales, lower handgrip strength, lower performance status, were mostly hospitalized and were sedentary. Logistic regression analysis revealed that patients with SARC-F < 4 had a lower risk of fatigue in both models, crude (OR: 0.83; CI 95% [0.79-0.88], p < 0.0001) as well as adjusted for age, gender, BMI, physical activity, current use of alcoholic beverages, smoking, performance status, cancer type, clinical setting and use of supplements (OR: 0.87; CI 95% [0.81-0.92], p < 0.0001). CONCLUSION In patients with cancer, 35% presented risk of sarcopenia and of these 87% had fatigue. In addition, the absence of sarcopenia was considered protective against fatigue.
Collapse
Affiliation(s)
- Cleidiana S Barreto
- Laboratory of Research in Clinical Nutrition and Sports (Labince), Faculty of Nutrition, Federal University of Goiás, Goiânia, Brazil
| | - Thaís C Borges
- Laboratory of Research in Clinical Nutrition and Sports (Labince), Faculty of Nutrition, Federal University of Goiás, Goiânia, Brazil
| | - Nathalia P Valentino
- Laboratory of Research in Clinical Nutrition and Sports (Labince), Faculty of Nutrition, Federal University of Goiás, Goiânia, Brazil
| | - Tatyanne L N Gomes
- Laboratory of Research in Clinical Nutrition and Sports (Labince), Faculty of Nutrition, Federal University of Goiás, Goiânia, Brazil
| | - Jéssika D P Soares
- Laboratory of Research in Clinical Nutrition and Sports (Labince), Faculty of Nutrition, Federal University of Goiás, Goiânia, Brazil
| | - Jéssika M Siqueira
- Laboratory of Research in Clinical Nutrition and Sports (Labince), Faculty of Nutrition, Federal University of Goiás, Goiânia, Brazil
| | - Claude Pichard
- Clinical Nutrition, Geneva University Hospital, Geneva, Switzerland
| | - Alessandro Laviano
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Gustavo D Pimentel
- Laboratory of Research in Clinical Nutrition and Sports (Labince), Faculty of Nutrition, Federal University of Goiás, Goiânia, Brazil.
| |
Collapse
|
8
|
Reply - Letter to the editor: "Energy and protein intake may have an impact on survival in patients with advanced cancer". Clin Nutr 2021; 41:268. [PMID: 34876302 DOI: 10.1016/j.clnu.2021.11.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 11/18/2021] [Indexed: 11/23/2022]
|
9
|
Arends J. Energy and protein intake may have an impact on survival in patients with advanced cancer. Clin Nutr 2021; 41:266-267. [PMID: 34865908 DOI: 10.1016/j.clnu.2021.11.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 11/03/2021] [Indexed: 11/24/2022]
Affiliation(s)
- Jann Arends
- Department of Medicine I, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Germany, Hugstetter Strasse 55, 79106, Freiburg, Germany.
| |
Collapse
|
10
|
Bozzetti F. Does nutrition support during chemotherapy increase long-term survival of cancer patients? Lessons from the past and future perspectives. Support Care Cancer 2021; 29:7269-7277. [PMID: 34309702 DOI: 10.1007/s00520-021-06213-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 04/08/2021] [Indexed: 11/28/2022]
Abstract
PURPOSE The aim of this review was to analyze the potential effect of the nutritional support (oral supplementation/counseling, tube feeding, parenteral nutrition) combined with chemotherapy on long-term survival of cancer patients. METHODS Using various electronic databases, we retrieved all English language papers on the combination nutritional support and chemotherapy and including data on long-term survival. RESULTS 29 trials (4 non-RCT) were retrieved. No significant benefit was observed except for a longer survival in a few selected subgroups of patients, depending on the tumor stage and compliance with the nutritional support. However, no study included survival as primary endpoint or was adequately powered for this purpose, and patients were seldom affected by malnutrition, a condition which would have made them extremely vulnerable and unsafe during an intensive chemotherapy with significant gastrointestinal toxicity. Finally, nutritional regimens were often inappropriate as regards quality and quantity of nutrients or too similar in the two arms of the trial to expect a result. CONCLUSION From the review of these trials, it appears clear that there is absence of evidence more than evidence of absence of effect of the supplemental nutritional support. This poor scenario should not discourage future large multicenter trials to assess the potential of an early versus a delayed support in mildly malnourished patients. From the practical point of view, a nutritional supplementation should be considered when severe malnutrition caused by the disease or following repeated oncologic treatments can make the patients poorly compliant with further chemotherapy cycles, as recommended by the international guidelines.
Collapse
Affiliation(s)
- Federico Bozzetti
- Faculty of Medicine, University of Milan, Via Festa del Perdono 11, 20100, Milan, Italy.
| |
Collapse
|