Nutritional support in critically ill patients with cancer

Assessment of Nutritional Status and Correlation of Factors With Body Mass Index of Cancer Patients: A Cross-Sectional Study

BACKGROUND

Decreased diet intake and malnourishment have profound implications on cancer patients' quality of life and survival. Malnutrition increases the risk of postoperative complications, increases hospital length stays, reduces patient's tolerance to radiation and chemotherapy treatment, and results in poor response to treatment. In the present study, we intended to assess the nutritional status of cancer patients and find the correlation of body mass index with anthropometric and blood parameters.

MATERIAL & METHODS

The study was prospective and cross-sectional, and 104 patients with newly diagnosed solid tumors were included. Patient demographics, symptoms, and anthropometric and blood parameters were collected. The correlation was estimated with Pearson's correlation coefficient. A p-value of less than 0.05 was considered significant.

RESULTS

The association between stages of the disease, dental status, type of diet, and BMI was p=0.701, 0.216, and 0.422, respectively, and was not statistically significant. The anthropometric parameters mid upper arm circumference (MUAC cm), mid arm circumference (MAC cm), and triceps skinfold thickness (TSF mm) correlated with body mass index (BMI kg/m2) and had statistically significant p values of 0.0001, 0.0001, and 0.033, respectively. The correlation was assessed between hemoglobin, red cell distribution width, neutrophil-to-lymphocyte ratio, and serum albumin levels with BMI, but except for albumin (p=0.05), no other blood parameter correlated.

CONCLUSION

Nutritional assessment is vital in recognizing patients at risk of treatment-associated complications and poor responders to treatment. In this study, BMI correlated with anthropometric parameters MUAC, MAMC, and TSF. Baseline dietary assessments of patients will help focus on the nutritional build-up of patients before starting treatment.

Emerging Concepts in Nutrient Needs

Dietary reference intakes (DRIs) are quantitative, nutrient intake-based standards used for assessing the diets and specific nutrient intakes of healthy individuals and populations and for informing national nutrition policy and nutrition programs. Because nutrition needs vary by age, sex, and physiological state, DRIs are often specified for healthy subgroups within a population. Diet is known to be the leading modifiable risk factor for chronic disease, and the prevalence of chronic disease is growing in all populations globally and across all subgroups, but especially in older adults. It is known that nutrient needs can change in some chronic disease and other clinical states. Disease states and/or disease treatment can cause whole-body or tissue-specific nutrient depletion or excess, resulting in the need for altered nutrient intakes. In other cases, disease-related biochemical dysfunction can result in a requirement for a nonessential nutrient, rendering it as conditionally essential, or result in toxicity for a food component at levels usually tolerated by healthy people, as seen in inborn errors of metabolism. Here we summarize examples from a growing body of literature of disease-altering nutrient requirements, supporting the need to give more consideration to special nutrient requirements in disease states.

Sequential Versus Concurrent Thoracic Radiotherapy in Combination With Cisplatin and Etoposide for N3 Limited-Stage Small-Cell Lung Cancer

At present, concurrent chemoradiotherapy (CRT) is considered the standard treatment of limited-stage small cell lung cancer (LS-SCLC). However, LS-SCLC is highly heterogeneous in the T stage, N stage, and prognosis. Increasing evidence has shown that individual treatment should be considered when treating LS-SCLC patients. The aim of the present study was to explore the optimal combination model of thoracic radiotherapy (TRT) and chemotherapy in N3 LS-SCLC. We retrospectively analyzed 93 N3 LS-SCLC patients treated in the Department of Oncology of Binzhou Medical University Hospital (Shandong, China) between March 2010 and October 2015. A total of 52 (52/93; 55.9%) patients received sequential CRT, and 41 (41/93; 44.1%) patients received concurrent CRT. All patients received 4-6 cycles of chemotherapy and TRT (50-60 Gy). The median follow-up time was 25.4 months (range was 6-65 months).The overall response rate was 88.5% in the sequential CRT group (9.6% complete response rate and 78.8% partial response rate) and 90.2% in the concurrent CRT group (14.6% complete response rate and 75.6% partial response rate). The PFS and OS were 15.4 months and 19.1 months in sequential CRT group, and 16.9 months and 20.5 months in concurrent CRT group. There was no significant difference in treatment response rate, PFS, and OS between sequential and concurrent CRT patients. The most common treatment-related toxicities were nausea/vomiting, neutropenia, and esophagitis. In conclusion, when concurrent CRT is performed in N3 LS-SCLC patients, tolerance to treatment should be fully considered. In our study, sequential CRT and concurrent CRT showed the same efficacy, and sequential CRT demonstrated better tolerance. However, these results require confirmation in future follow-up studies.

Nutritional risk assessment in critically ill cancer patients: systematic review

Objective

To systematically review the main methods for nutritional risk assessment used in critically ill cancer patients and present the methods that better assess risks and predict relevant clinical outcomes in this group of patients, as well as to discuss the pros and cons of these methods according to the current literature.

Methods

The study consisted of a systematic review based on analysis of manuscripts retrieved from the PubMed, LILACS and SciELO databases by searching for the key words “nutritional risk assessment”, “critically ill” and “cancer”.

Results

Only 6 (17.7%) of 34 initially retrieved papers met the inclusion criteria and were selected for the review. The main outcomes of these studies were that resting energy expenditure was associated with undernourishment and overfeeding. The high Patient-Generated Subjective Global Assessment score was significantly associated with low food intake, weight loss and malnutrition. In terms of biochemical markers, higher levels of creatinine, albumin and urea were significantly associated with lower mortality. The worst survival was found for patients with worse Eastern Cooperative Oncologic Group - performance status, high Glasgow Prognostic Score, low albumin, high Patient-Generated Subjective Global Assessment score and high alkaline phosphatase levels. Geriatric Nutritional Risk Index values < 87 were significantly associated with mortality. A high Prognostic Inflammatory and Nutritional Index score was associated with abnormal nutritional status in critically ill cancer patients. Among the reviewed studies that examined weight and body mass index alone, no significant clinical outcome was found.

Conclusion

None of the methods reviewed helped to define risk among these patients. Therefore, assessment by a combination of weight loss and serum measurements, preferably in combination with other methods using scores such as Eastern Cooperative Oncologic Group - performance status, Glasgow Prognostic Score and Patient-Generated Subjective Global Assessment, is suggested given that their use is simple, feasible and useful in such cases.

Epidemiology of infections in cancer patients

Although major advances in the care of cancer patients over the past several decades have resulted in improved survival, infectious complications remain a significant cause of morbidity and mortality. To successfully identify, treat, and prevent infections, a comprehensive understanding of risk factors that predispose to infection and of commonly encountered pathogens is necessary. In addition, clinicians must keep abreast of the changing epidemiology of infections in this population. As therapeutic modalities continue to evolve, as established pathogens become increasingly drug resistant, and as new pathogens are discovered, successful management of infections will continue to present challenges in the years to come.

Avaliação nutricional e atividade inflamatória sistêmica de pacientes com câncer colorretal submetidos à suplementação com simbiótico

RACIONAL: A depleção nutricional é observada em pacientes com câncer colorretal em estado avançado mesmo com medidas de peso adequadas. Esta perda pode estar associada a fatores de co-morbidades como: redução da imunidade, aumento de infecções, cicatrização prejudicada e fraqueza muscular. Atualmente, dietas imunomoduladoras estão sendo utilizadas na abordagem nutricional de pacientes com câncer. O uso de prebióticos e probióticos ou, a mistura dos dois, os simbióticos, estão entre os estudados. OBJETIVO: Avaliar o estado nutricional e a atividade inflamatória sistêmica em pacientes com câncer colorretal submetidos à utilização de suplemento simbiótico. MÉTODOS: Foi realizado um estudo longitudinal prospectivo com pacientes com câncer colorretal. Todos os pacientes foram submetidos à avaliação do estado nutricional e subsequente análise sorológica, uso diário do suplemento simbiótico e à avaliação antropométrica e bioquímica a cada três meses. Foram coletados dados antropométricos e exames de sangue para avaliação da proteína C-reativa (PCR), antígeno carcionoembrionário (CEA) e albumina. RESULTADOS: Os índices médio da proteína C-reativa eram de 11 mg/dL no início do estudo, antes da administração do simbiótico, e reduziram-se para valores menores que 6 mg/dL no final do estudo. CONCLUSÃO: A suplementação com o simbiótico foi benéfica, pois, embora tendo os níveis de albumina e CEA mantido-se estáveis, os índices de PCR diminuíram ao longo do estudo.

Gastrointestinal symptoms and weight loss in cancer patients receiving chemotherapy

Cancer patients receiving chemotherapy have a high risk of malnutrition secondary to the disease and treatment, and 40–80 % of cancer patients suffer from different degrees of malnutrition, depending on tumour subtype, location, staging and treatment strategy. Malnutrition in cancer patients affects the patient's overall condition, and it increases the number of complications, the adverse effects of chemotherapy and reduces the quality of life. The aim of the present study was to evaluate weight-loss prevalence depending on the tumour site and the gastrointestinal (GI) symptoms of oncology patients receiving chemotherapy. We included 191 cancer patients receiving chemotherapy. Files of all patients were reviewed to identify symptoms that might potentially influence weight loss. The nutritional status of all patients was also determined. The cancer sites in the patients were as follows: breast (31·9 %); non-colorectal GI (18·3 %); colorectal (10·4 %); lung (5·8 %); haematological (13·1 %); others (20·5 %). Of these patients, 58 % experienced some degree of weight loss, and its prevalence was higher among the non-colorectal GI and lung cancer patients. Common symptoms included nausea (59·6 %), anorexia (46 %) and constipation (31·9 %). A higher proportion of patients with ≥ 5 % weight loss experienced anorexia, nausea and vomiting (OR 9·5, 2·15 and 6·1, respectively). In conclusion, these results indicate that GI symptoms can influence weight loss in cancer patients, and they should be included in early nutritional evaluations.

Comparison of different nutritional assessments in detecting malnutrition among gastric cancer patients

AIM: To evaluate the prevalence of preoperative and postoperative malnutrition and the relationships between objective and subjective nutritional assessment of gastric cancer patients.

METHODS: From October 2005 to July 2006, we studied 80 patients with no evidence of recurrent disease and no loss to follow-up after curative surgery for gastric cancer. In this group, 9 patients underwent total gastrectomy and 71 patients subtotal gastrectomy. At admission, 6 and 12 mo after surgery, the patients were assessed on the subjective global assessment (SGA), nutritional risk screening (NRS-2002), nutritional risk index (NRI) and by anthropometric measurements and laboratory data. Differences between the independent groups were assessed with the Student’s t test and one-way analysis of variance. Spearman’s rank correlation coefficients were calculated to evaluate the association between the scores and variables.

RESULTS: The prevalence of malnutrition at admission was 31% by SGA and 43% by NRS-2002. At admission, the anthropometric data were lower in the malnourished groups defined by the SGA and NRS-2002 assessments, but did not differ between the groups using the NRI assessment. Body weight (BW), body mass index (BMI), triceps skin fold and midarm circumference were significantly reduced, but the total lymphocyte count, albumin, protein, cholesterol and serum iron levels did not decrease during the postoperative period. Six months after surgery, there was a good correlation between the nutritional assessment tools (SGA and NRS-2002) and the other nutritional measurement tools (BW, BMI, and anthropometric measurements). However, 12 mo after surgery, most patients who were assessed as malnourished by SGA and NRS-2002 had returned to their preoperative status, although their BW, BMI, and anthropometric measurements still indicated a malnourished status.

CONCLUSION: A combination of objective and subjective assessments is needed for the early detection of the nutritional status in case of gastric cancer patients after gastrectomy.

An overview of the therapeutic effects of leucine supplementation on skeletal muscle under atrophic conditions

The characterization of the mechanisms underlying skeletal muscle atrophy under different conditions has been a constant focus of research. Among anti-atrophic therapies, amino acid supplementation, particularly with leucine, has received a lot of attention. Supplementation has been shown to have remarkable effects on muscle remodeling through protein turnover modulation. This may then impact physiological parameters related to muscle function, and even quality of life. In light of this, leucine supplementation could be a useful therapy for mitigating the atrophic effects of catabolic conditions. The purpose of this review is to present the major results of human studies evaluating the effects of leucine supplementation on structure and function of skeletal muscle in atrophic conditions such as muscle disuse, sarcopenia, and cancer.

Nutritional status of cancer patients in chemotherapy; dietary intake, nitrogen balance and screening

OBJECTIVE

To evaluate a short screening sheet (SSM) for malnutrition and to investigate the nutritional status of patients receiving chemotherapy for cancer of the lungs, colon or breast at an outpatient clinic.

DESIGN

Full nutritional assessment was conducted to define malnutrition and validate the SSM. Additionally, weight change from earlier healthy weight was evaluated, and calculations for intake of energy-giving nutrients (three-day-weighed food records) and protein balance were performed. After the evaluation study, the SSM was tested in clinical routine and data collected about patients' need for nutritional counseling.

SUBJECTS

Patients at the outpatient clinic of the Department of Oncology at Landspitali-University Hospital (n=30 with lung-, colon- or breast cancer in the study population, n=93 with all cancer type in clinical routine screening).

RESULTS

Malnutrition was defined by full nutritional assessment in 20% of the participating patients and SSM had high sensitivity and specificity. Declining nutritional status of the patients was seen as a negative nitrogen balance and unintentional weight loss from healthy weight, but not as total energy intake, recent weight loss or underweight. The test of SSM in clinical routine showed that 40% were malnourished. According to the patients, 80% needed nutritional counseling but only 17% had such counseling.

CONCLUSION

Screening (SSM) for malnutrition in cancer patients is a valid simple approach to define cancer patients for nutritional care. More patients regard themselves in need for nutritional counseling than the number of patients really achieving any.

Nutritional support in gastrointestinal surgery: an overview

Nutritional status is important in determining the outcome of surgical patients. This is particularly so in patients undergoing gastrointestinal (GI) surgical procedures. It is important for the GI surgeon to be always aware that he has to assess the nutritional status of his patient, provide supplementation when required and have the means to get enteral and/or parenteral access when required. He must have the knowledge to choose the right route and formula for nutritional support. This evidence-based review gives an overview of the subject with the purpose of increasing awareness about the science of surgical nutrition.

Obstruction in patients with colorectal cancer increases morbidity and mortality in association with altered nutritional status

Intestinal obstruction aggravates the prognosis of colorectal cancer (CRC) patients. The aim of this study was to carry out a comparative analysis of nutritional status and inflammatory response in CRC patients with or without intestinal obstruction. The study was carried out on 43 patients with CRC. Twenty-three of these patients had intestinal obstruction. Anthropometric measurements, serum protein content, acute phase reactants, and diagnostic and risk nutritional indices were analyzed. The presence of intestinal obstruction reduced albumin (31 +/- 5.2 vs. 36 +/- 4.2 g/l; P = 0.0025) and prealbumin (0.13 +/- 0.047 vs. 0.21 +/- 0.042 g/l; P = 0.0001) and increased C-reactive protein (49 +/- 43.8 vs. 14 +/- 16.7 mg/l; P = 0.006) and alpha1-antitrypsin (189 +/- 34.7 vs. 148 +/- 35.4 mg/dl; P = 0.0011). Intestinal obstruction was related to malnutrition (86% vs. 33%; P = 0.019) and Mullen's prognostic nutritional index (48 +/- 21.7 vs. 31 +/- 17.9; P = 0.038) in CRC patients. Mullen's nutritional risk index was inversely correlated to total cholesterol (r = -0.51; P = 0.0002) and albumin (r = -0.81; P = 0.0001). No correlation was found between Duke's tumor stages and acute phase response, inflammatory parameters, and malnutrition. In conclusion, intestinal obstruction occurred more frequently in CRC patients with malnutrition. The increased morbidity and mortality of CRC patients was also associated with acute phase response, inflammation, and low serum cholesterol and triglyceride concentration.

Energy expenditure in children with severe head injury: lack of agreement between measured and estimated energy expenditure

BACKGROUND

The purpose of this study was to test the hypotheses that estimates of resting energy expenditure (REE) vary significantly from measured energy expenditure in a population of head-injured children and are not accurate for use in determining nutrition needs in this population.

METHODS

This is a retrospective study of 30 children with severe head injury, with Glasgow Coma Scale (GCS) score of <8 and needing mechanical ventilation. Measured REE was obtained using indirect calorimetry. Estimated REEs were calculated using Harris-Benedict, World Health Organization (WHO), Schofield, and White formulas. Severity of illness was calculated using Pediatric Risk of Mortality (PRISM) score. Agreement between measured REE and estimated REE was tested using the Bland-Altman method. Correlation coefficient between PRISM score and measured REE was calculated using Spearman test.

RESULTS

More than half of the estimates of REE differed from measured REE by >10%. Significant disagreement between estimated REE and measured REE was demonstrated using the Bland-Altman method. There was no correlation between severity of illness and measured REE to explain the inaccuracies of REE estimates.

CONCLUSION

Energy expenditure in critically ill children cannot be estimated accurately; hence, nutrition for critically ill children with head injury should be provided according to measurement of REE to avoid the consequences of overfeeding or malnutrition.

Resting energy expenditure in severely burned children: Analysis of agreement between indirect calorimetry and prediction equations using the Bland–Altman method

INTRODUCTION

Knowledge of a child's resting energy expenditure (REE) is essential in optimizing nutritional support for severely burned children. The provision of adequate nutritional support is vital in order to avoid the consequences of malnutrition or overfeeding. Nutritional requirements for severely burned children are often based on equations for estimates of REE. The accuracy of the predictive equations of REE has been questioned and many authors have advocated the measurement of REE. This study tests the hypothesis that estimates of REE vary significantly from measured REE (MREE) in a population of severely burned children, and are not accurate for determining nutritional requirements.

METHODS

In 91 severely burned children aged between 3 and 18 years, REE was measured by indirect calorimetry (MREE) at the height of the hypermetabolic response and compared with predicted equations (PREE) from the Food and Agriculture/World Health Organization/United Nations University (FAO/WHO/UNU), Schofield-HW and Harris-Benedict. Agreement between indirect calorimetry and predicted equations was assessed following the Bland-Altman method.

RESULTS

In the entire cohort group, predicted REE from all three equations were significantly lower compared to MREE (p<0.05). There was poor agreement between the MREE and predicted using all three equations. The Schofield-HW equation showed the lowest mean MREE-PREE difference: 635+/-526 kcal/day (limits of agreement -608 and 1878 kcal/day; 95% confidence interval for the bias 525-745 kcal/day). Additionally, all three equations under predicted REE and were not significantly different from one another (p=0.98).

CONCLUSIONS

Until more accurate predicted equations are developed, we recommend indirect calorimetry measurements for determining resting energy expenditure in severely burned children.

Geriatric neutrophils: implications for older adults

OBJECTIVES

To review the intersection of immunosenescence and neutropenia, focusing on innate immunity, and implications for research and practice for neutropenic older adults with cancer.

DATA SOURCES

Research studies, journal articles, and web sites.

CONCLUSION

Immunosenescence, age-related changes within the immune system renders older adults more vulnerable to infection. This vulnerability is magnified by cancer and its treatment. Unfortunately, there has been little consideration of immunosenescence as it relates to supportive care for this population.

IMPLICATIONS FOR NURSING PRACTICE

Studies detailing the impact of immunosenescence on neutropenia and outcomes for neutropenic older adults are necessary to advance clinical research and practice.