Value of nutritional support in adult cancer patients

Palliative nutritional intervention in addition to cyclooxygenase and erythropoietin treatment for patients with malignant disease: Effects on survival, metabolism, and function

BACKGROUND

The role of nutrition in the palliative treatment of patients with malignancy-related cachexia is unclear. The goal of the current study was to determine whether specialized, nutrition-focused patient care could improve integrated whole-body metabolism and functional outcome in unselected weight-losing patients with malignant disease who were receiving systemic antiinflammatory (cyclooxygenase [COX]-inhibitory) treatment along with erythropoietin (EPO) support.

METHODS

Three hundred nine patients with malignant disease who experienced progressive cachexia due to solid tumors (primarily gastrointestinal lesions) were randomized to receive a COX inhibitor (indomethacin, 50 mg twice daily) and EPO (15-40,000 units per week) along with specialized, nutrition-focused patient care (oral nutritional support and home total parenteral nutrition [TPN]) provided on a patient-by-patient basis to attenuate inflammation, prevent anemia, and improve nutritional status. Control patients received the same indomethacin and EPO doses that study patients received without the added nutritional support. All patients were treated and followed until death. Biochemical assays (blood, liver, kidney, and thyroid), nutritional state assessment (food intake and body composition), and exercise testing with simultaneous measurement of whole-body respiratory gas exchange before and during exercise were performed before the start of treatment and then at regular intervals during the treatment period (every 2-30 months after treatment initiation). Statistical analyses were performed on 'intention-to-treat' and 'as-treated' bases.

RESULTS

Home TPN was provided to approximately 50% of the study patients without severe complications. Over the entire observation period, rhEPO prevented the development of anemia in both study patients and control patients. Intention-to-treat analysis revealed an improvement in energy balance for nutritionally supported patients (P < 0.03); no other significant differences in outcome between study patients and control patients were observed. As-treated analysis demonstrated that patients receiving nutrition experienced prolonged survival (P < 0.01), which was accompanied by improved energy balance (P < 0.001), increasing body fat (P < 0.05), and a greater maximum exercise capacity (P < 0.04). A trend toward increased metabolic efficiency at maximum exercise (P < 0.06) for study patients relative to control patients also was observed.

CONCLUSIONS

The results of the current study strongly support that nutrition is a limiting factor influencing survival and that nutritional support protects integrated metabolism and metabolic function in patients with progressive cachexia secondary to malignant disease.

A study of forty-nine consecutive Whipple resections for periampullary adenocarcinoma

BACKGROUND

We designed a program to evaluate the morbidity, mortality, survival rates, and patient's quality of life after Whipple resection for pancreatic and other periampullary adneocarcinoma.

PATIENTS AND METHODS

After studying 11 fresh and unembalmed cadavers to learn the regional anatomy and to practice the surgical techniques for traditional Whipple procedure by the senior author (JS), 49 patients aged 56 to 84 years old were treated with Whipple's pancreatoduocenectomy.

RESULTS

There was no postoperative mortality or morbidity from anastomotic leakage. All 49 patients were discharged in an improved condition following surgery, including 5 patients with emergency resection. Eight patients are alive at the time of this writing, including 2 patients who had their pancreatic cancer resected 168 and 139 months ago.

CONCLUSIONS

In the opinion of these authors, treatment of all resectable cancers with Whipple's pancreatoduodenectomy offers not only a superior palliation but also the hope of cure.

The effects of cyclooxygenase inhibitors on tumor-induced anorexia in rats

BACKGROUND

Interleukin-1 (IL-1) and tumor necrosis factor (TNF) are potent induces of prostaglandin (PG) synthesis and injection of PGE, IL-1, or TNF decreases food intake in healthy animals, whereas the anorexigenic effects of injected IL-1 and TNF are blocked by inhibitors of PG synthesis. It has been hypothesized that host secretion of IL-1 and TNF contribute to tumor-induced anorexia. This study was undertaken to determine whether administration of PG inhibitors alters food intake in anorectic rats implanted with Walker 256 carcinoma.

METHODS

Groups of six tumor-bearing rats were implanted with slow-release pellets containing ibuprofen, indomethacin, or acetylsalicylic acid. Food intake, tumor growth, and body temperature were monitored for 14 days and compared with control tumor-bearing animals implanted with placebo pellets.

RESULTS

Tumor growth was associated with anorexia, fever, weight loss, and increased leukocyte secretion of IL-1 and TNF. Indomethacin and ibuprofen retarded tumor growth 30-40% and lowered body temperature compared with controls, but had no effect on food intake or body weight of tumor-bearing animals.

CONCLUSIONS

Prostaglandins do not mediate tumor-induced anorexia.

The effect of diet consistency on food intake of anorectic tumor-bearing rats

Delayed gastric emptying has been shown to occur in cancer patients complaining of anorexia and early satiety. Given that liquids are emptied from the stomach faster than solid food, the present study was undertaken to determine if diet consistency would affect food intake of hypophagic rats implanted with the Walker 256 carcinosarcoma. By Day 15 of tumor-growth, caloric intake of tumor-bearing animals was 20% less than controls. The caloric intake of tumor-bearing animals fed a liquid diet was not significantly different from animals fed a solid diet. Furthermore, a delay in gastric emptying was not seen in this animal model of tumor-induced anorexia.

Methods of nutritional support in the home

Recent advances in nutrition support methods now offer home patients the possibility of maintaining nutritional adequacy when intake is compromised. Using either enteral or parenteral feeding when appropriate allows patients to achieve an improved quality of life at home. Options for management offer a wide variety of choices in feeding methods, formulations, delivery systems, rates and scheduling as well as services provided for a given need. Team management of these patients is necessary to assure proper medical care and support.

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

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