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Løhre ET, Solheim TS, Jakobsen G, Vagnildhaug OM, Schmidberger Karlsen TL, Habberstad RH, Balstad TR, Thronæs M. Parenteral Nutrition in Palliative Cancer Care: Detrimental, Futile, or Beneficial? Curr Oncol 2024; 31:2748-2757. [PMID: 38785489 PMCID: PMC11120543 DOI: 10.3390/curroncol31050208] [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: 04/30/2024] [Revised: 05/07/2024] [Accepted: 05/09/2024] [Indexed: 05/25/2024] Open
Abstract
Palliative cancer care patients may live for a long time, but malnutrition worsens the prognosis. Parenteral nutrition (PN) is suitable for replenishing a calorie deficit, but its advantages and tolerance late in the cancer trajectory are debated. We examined symptom development in hospitalized patients with and without PN. A total of 21 palliative cancer care patients receiving PN and 155 palliative cancer care patients not receiving PN during hospitalization in a specialized unit were retrospectively compared. We studied symptom intensity at admission, symptom relief during the hospital stay, and survival. The patients had locally advanced or metastatic cancer, a mean age of 70 years, and their median ECOG performance status was III. Symptom burden at admission was similar in the compared groups. Symptom relief during hospitalization was also similar. However, patients already on PN at admission reported more nausea and patients receiving PN during hospitalization reported better nausea relief compared to patients not receiving this intervention. Overall median survival was less than two months and similar in the compared groups. Based on a limited number of observations and a suboptimal study design, we were not able to demonstrate an increased symptom burden for palliative cancer care patients receiving PN late in the disease trajectory.
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Affiliation(s)
- Erik Torbjørn Løhre
- Cancer Clinic, St. Olavs Hospital, Trondheim University Hospital, 7030 Trondheim, Norway
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, NTNU-Norwegian University of Science and Technology, 7030 Trondheim, Norway
- Centre for Crisis Psychology, Faculty of Psychology, University of Bergen, 5007 Bergen, Norway
| | - Tora Skeidsvoll Solheim
- Cancer Clinic, St. Olavs Hospital, Trondheim University Hospital, 7030 Trondheim, Norway
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, NTNU-Norwegian University of Science and Technology, 7030 Trondheim, Norway
| | - Gunnhild Jakobsen
- Cancer Clinic, St. Olavs Hospital, Trondheim University Hospital, 7030 Trondheim, Norway
- Department of Public Health and Nursing, Faculty of Medicine and Health Sciences, NTNU-Norwegian University of Science and Technology, 7030 Trondheim, Norway
| | - Ola Magne Vagnildhaug
- Cancer Clinic, St. Olavs Hospital, Trondheim University Hospital, 7030 Trondheim, Norway
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, NTNU-Norwegian University of Science and Technology, 7030 Trondheim, Norway
| | - Terese Louise Schmidberger Karlsen
- Cancer Clinic, St. Olavs Hospital, Trondheim University Hospital, 7030 Trondheim, Norway
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, NTNU-Norwegian University of Science and Technology, 7030 Trondheim, Norway
| | | | - Trude Rakel Balstad
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, NTNU-Norwegian University of Science and Technology, 7030 Trondheim, Norway
- Department of Clinical Medicine, Clinical Nutrition Research Group, UiT, The Arctic University of Norway, 9019 Tromsø, Norway
| | - Morten Thronæs
- Cancer Clinic, St. Olavs Hospital, Trondheim University Hospital, 7030 Trondheim, Norway
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, NTNU-Norwegian University of Science and Technology, 7030 Trondheim, Norway
- Centre for Crisis Psychology, Faculty of Psychology, University of Bergen, 5007 Bergen, Norway
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Patterson M, Greenley S, Ma Y, Bullock A, Curry J, Smithson J, Lind M, Johnson MJ. Inoperable malignant bowel obstruction: palliative interventions outcomes - mixed-methods systematic review. BMJ Support Palliat Care 2024; 13:e515-e527. [PMID: 38557409 PMCID: PMC10850628 DOI: 10.1136/bmjspcare-2021-003492] [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: 12/01/2021] [Accepted: 05/27/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND Parenteral nutrition (PN) and palliative venting gastrostomies (PVG) are two interventions used clinically to manage inoperable malignant bowel obstruction (MBO); however, little is known about their role in clinical and quality-of-life outcomes to inform clinical decision making. AIM To examine the impact of PN and PVG on clinical and quality-of-life outcomes in inoperable MBO. DESIGN A mixed-methods systematic review and narrative synthesis. DATA SOURCES The following databases were searched (from inception to 29 April 2021): MEDLINE, Embase, Cochrane Central Register of Controlled Trials, Web of Science, CINAHL, Bielefeld Academic Search Engine, Health Technology Assessment and CareSearch for qualitative or quantitative studies of MBO, and PN or PVG. Titles, abstracts and papers were independently screened and quality appraised. RESULTS A total of 47 studies representing 3538 participants were included. Current evidence cannot tell us whether these interventions improve MBO survival, but this was a firm belief by patients and clinicians informing their decision. Both interventions appear to allow patients valuable time at home. PVG provides relief from nausea and vomiting. Both interventions improve quality of life but not without significant burdens. Nutritional and performance status may be maintained or improved with PN. CONCLUSION PN and PVG seem to allow valuable time at home. We found no conclusive evidence to show either intervention prolonged survival, due to the lack of randomised controlled trials that have to date not been performed due to concerns about equipoise. Well-designed studies regarding survival for both interventions are needed. PROSPERO REGISTRATION NUMBER CRD42020164170.
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Affiliation(s)
- Michael Patterson
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
| | - Sarah Greenley
- Institute of Clinical and Applied Health Research, Hull York Medical School, Hull, UK
| | - Yangmyung Ma
- Department of Plastic Surgery, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, UK
| | - Alex Bullock
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
| | - Jordan Curry
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
| | - Jacquelyn Smithson
- Gastrointestinal and Liver services, Hull University Teaching Hospitals NHS Trust, Hull, UK
| | - Michael Lind
- Hull York Medical School, University of Hull, Hull, UK
| | - Miriam J Johnson
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
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Buchan EJ, Haywood A, Syrmis W, Good P. Medically assisted hydration for adults receiving palliative care. Cochrane Database Syst Rev 2023; 12:CD006273. [PMID: 38095590 PMCID: PMC10720602 DOI: 10.1002/14651858.cd006273.pub4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2023]
Abstract
BACKGROUND Many people receiving palliative care have reduced oral intake during their illness, and particularly at the end of their life. Management of this can include the provision of medically assisted hydration (MAH) with the aim of improving their quality of life (QoL), prolonging their life, or both. This is an updated version of the original Cochrane Review published in Issue 2, 2008, and updated in February 2011 and March 2014. OBJECTIVES To determine the effectiveness of MAH compared with placebo and standard care, in adults receiving palliative care on their QoL and survival, and to assess for potential adverse events. SEARCH METHODS We searched for studies in the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, CINAHL, CANCERLIT, CareSearch, Dissertation Abstracts, Science Citation Index and the reference lists of all eligible studies, key textbooks, and previous systematic reviews. The date of the latest search conducted on CENTRAL, MEDLINE, and Embase was 17 November 2022. SELECTION CRITERIA We included all relevant randomised controlled trials (RCTs) of studies of MAH in adults receiving palliative care aged 18 and above. The criteria for inclusion was the comparison of MAH to placebo or standard care. DATA COLLECTION AND ANALYSIS Three review authors independently reviewed titles and abstracts for relevance, and two review authors extracted data and performed risk of bias assessment. The primary outcome was QoL using validated scales; secondary outcomes were survival and adverse events. For continuous outcomes, we measured the arithmetic mean and standard deviation (SD), and reported the mean difference (MD) with 95% confidence interval (CI) between groups. For dichotomous outcomes, we estimated and compared the risk ratio (RR) with 95% CIs between groups. For time-to-event data, we planned to calculate the survival time from the date of randomisation and to estimate and express the intervention effect as the hazard ratio (HR). We assessed the certainty of evidence using GRADE and created two summary of findings tables. MAIN RESULTS: We identified one new study (200 participants), for a total of four studies included in this update (422 participants). All participants had a diagnosis of advanced cancer. With the exception of 29 participants who had a haematological malignancy, all others were solid organ cancers. Two studies each compared MAH to placebo and standard care. There were too few included studies to evaluate different subgroups, such as type of participant, intervention, timing of intervention, and study site. We considered one study to be at high risk of performance and detection bias due to lack of blinding; otherwise, risk of bias was assessed as low or unclear. MAH compared with placebo Quality of life One study measured change in QoL at one week using Functional Assessment of Cancer Therapy - General (FACT-G) (scale from 0 to 108; higher score = better QoL). No data were available from the other study. We are uncertain whether MAH improves QoL (MD 4.10, 95% CI -1.63 to 9.83; 1 study, 93 participants, very low-certainty evidence). Survival One study reported on survival from study enrolment to last date of follow-up or death. We were unable to estimate HR. No data were available from the other study. We are uncertain whether MAH improves survival (1 study, 93 participants, very low-certainty evidence). Adverse events One study reported on intensity of adverse events at two days using a numeric rating scale (scale from 0 to 10; lower score = less toxicity). No data were available from the other study. We are uncertain whether MAH leads to adverse events (injection site pain: MD 0.35, 95% CI -1.19 to 1.89; injection site swelling MD -0.59, 95% CI -1.40 to 0.22; 1 study, 49 participants, very low-certainty evidence). MAH compared with standard care Quality of life No data were available for QoL. Survival One study measured survival from randomisation to last date of follow-up at 14 days or death. No data were available from the other study. We are uncertain whether MAH improves survival (HR 0.36, 95% CI 0.22 to 0.59; 1 study, 200 participants, very low-certainty evidence). Adverse events Two studies measured adverse events at follow-up (range 2 to 14 days). We are uncertain whether MAH leads to adverse events (RR 11.62, 95% CI 1.62 to 83.41; 2 studies, 242 participants, very low-certainty evidence). AUTHORS' CONCLUSIONS: Since the previous update of this review, we have found one new study. In adults receiving palliative care in the end stage of their illness, there remains insufficient evidence to determine whether MAH improves QoL or prolongs survival, compared with placebo or standard care. Given that all participants were inpatients with advanced cancer at end of life, our findings are not transferable to adults receiving palliative care in other settings, for non-cancer, dementia or neurodegenerative diseases, or for those with an extended prognosis. Clinicians will need to make decisions based on the perceived benefits and harms of MAH for each individual's circumstances, without the benefit of high-quality evidence to guide them.
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Affiliation(s)
| | - Alison Haywood
- School of Pharmacy and Medical Sciences, Griffith University, Gold Coast, Australia
- Mater Research Institute - The University of Queensland, Brisbane, Australia
| | - William Syrmis
- Department of Palliative Care, St Vincent's Private Hospital, Brisbane, Australia
| | - Phillip Good
- Mater Research Institute - The University of Queensland, Brisbane, Australia
- Department of Palliative Care, St Vincent's Private Hospital, Brisbane, Australia
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Nonogaki T, Maeda K, Shimizu A, Ueshima J, Nagano A, Kato R, Ishida Y, Yamanaka R, Yamanaka Y, Mori N. Nutrition provided during the final weeks to patients with non-gastrointestinal solid malignancies. Clin Nutr ESPEN 2023; 57:494-500. [PMID: 37739697 DOI: 10.1016/j.clnesp.2023.07.085] [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: 12/10/2022] [Revised: 05/25/2023] [Accepted: 07/25/2023] [Indexed: 09/24/2023]
Abstract
BACKGROUND & AIMS Data regarding the delivery of nutrition and nutritional infusions to patients with terminal cancer remain limited; therefore, this real-world analysis investigated differences in nutrition delivery and infusion statuses for patients with terminal-stage cancers. METHODS Patients who had died following hospitalization for more than seven days due to neoplasms between April 2014 and December 2018 were identified using the medical claims database of Japan. Data regarding oral diets, enteral feeding, infusion volumes, and infusion energies were extracted. The maximum observation period was 28 days prior to patient death. RESULTS A total of 12,908 patients were included in our analysis. The proportion of patients without dietary or enteral nutrition increased closer to their dates of death. Observations were recorded at 28 (18.9%), 21 (20.9%), 14 (24.6%), 7 (33.0%), and 0 (80.2%) days prior to death. The infusion volumes given to the patients, as well as their energy contents, decreased near death (P-value for the trend <0.001). CONCLUSIONS Our study revealed the current status of nutritional therapy for patients with terminal cancer in Japan. The number of patients receiving only parenteral nutrition increased near death, while the amount of nutritional intake was low.
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Affiliation(s)
- Tomoyuki Nonogaki
- Department of Pharmacy, Aichi Medical University Hospital, 1-1 Yazakokarimata, Nagakute, Aichi 480-1195, Japan; Palliative and Supportive Medicine, Graduate School of Medicine, Aichi Medical University, 1-1, Yazakokarimata, Nagakute, Aichi 480-1195, Japan
| | - Keisuke Maeda
- Palliative and Supportive Medicine, Graduate School of Medicine, Aichi Medical University, 1-1, Yazakokarimata, Nagakute, Aichi 480-1195, Japan; Nutrition Therapy Support Center, Aichi Medical University Hospital, Japan; Department of Geriatric Medicine, Hospital, National Center for Geriatrics and Gerontology, 7-430 Morioka, Obu, Aichi 474-8511, Japan.
| | - Akio Shimizu
- Palliative and Supportive Medicine, Graduate School of Medicine, Aichi Medical University, 1-1, Yazakokarimata, Nagakute, Aichi 480-1195, Japan; Department of Health Science, Faculty of Health and Human Development, The University of Nagano, 8-49-7, Nagano, Japan
| | - Junko Ueshima
- Palliative and Supportive Medicine, Graduate School of Medicine, Aichi Medical University, 1-1, Yazakokarimata, Nagakute, Aichi 480-1195, Japan; Department of Nutritional Service, NTT Medical Center Tokyo, 5-9-22 Higashi-Gotanda, Shinagawa, Tokyo 141-8625, Japan
| | - Ayano Nagano
- Palliative and Supportive Medicine, Graduate School of Medicine, Aichi Medical University, 1-1, Yazakokarimata, Nagakute, Aichi 480-1195, Japan; Department of Nursing Care, Nishinomiya Kyoritsu Neurosurgical Hospital, 11-1 Imazuyamanaka-cho, Nishinomiya, Hyogo 663-821, Japan
| | - Ryoko Kato
- Department of Pharmacy, Aichi Medical University Hospital, 1-1 Yazakokarimata, Nagakute, Aichi 480-1195, Japan; Palliative and Supportive Medicine, Graduate School of Medicine, Aichi Medical University, 1-1, Yazakokarimata, Nagakute, Aichi 480-1195, Japan
| | - Yuria Ishida
- Palliative and Supportive Medicine, Graduate School of Medicine, Aichi Medical University, 1-1, Yazakokarimata, Nagakute, Aichi 480-1195, Japan; Department of Nutrition, Aichi Medical University Hospital, 1-1 Yazakokarimata, Nagakute, Aichi, 480-1195, Japan
| | - Remi Yamanaka
- Palliative and Supportive Medicine, Graduate School of Medicine, Aichi Medical University, 1-1, Yazakokarimata, Nagakute, Aichi 480-1195, Japan; Department of Dentistry and Oral Surgery, Aichi Medical University 1-1, Yazakokarimata, Nagakute, Aichi, 480-1195, Japan
| | - Yosuke Yamanaka
- Palliative and Supportive Medicine, Graduate School of Medicine, Aichi Medical University, 1-1, Yazakokarimata, Nagakute, Aichi 480-1195, Japan; Department of Dentistry and Oral Surgery, Aichi Medical University 1-1, Yazakokarimata, Nagakute, Aichi, 480-1195, Japan
| | - Naoharu Mori
- Palliative and Supportive Medicine, Graduate School of Medicine, Aichi Medical University, 1-1, Yazakokarimata, Nagakute, Aichi 480-1195, Japan; Nutrition Therapy Support Center, Aichi Medical University Hospital, Japan
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Gonzalez-Ochoa E, Alqaisi HA, Bhat G, Jivraj N, Lheureux S. Inoperable Bowel Obstruction in Ovarian Cancer: Prevalence, Impact and Management Challenges. Int J Womens Health 2022; 14:1849-1862. [PMID: 36597479 PMCID: PMC9805709 DOI: 10.2147/ijwh.s366680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Accepted: 12/17/2022] [Indexed: 12/29/2022] Open
Abstract
Malignant bowel obstruction (MBO) is one of the most severe complications in patients with advanced ovarian cancer, with an estimated incidence up to 50%. Its presence is related to poor prognosis and a life expectancy measured in weeks for inoperable cases. Symptoms are usually difficult to manage and often require hospitalization, which carries a high burden on patients, caregivers and the healthcare system. Management is complex and requires a multidisciplinary approach to improve clinical outcomes. Patients with inoperable MBO are treated medically with analgesics, antiemetics, steroids and antisecretory agents. Parenteral nutrition and gut decompression with nasogastric tube, venting gastrostomy or stenting may be used as supportive therapy. Treatment decision-making is challenging and often based on clinical expertise and local policies, with lack of high-quality evidence to optimally standardize management. The present review summarizes current literature on inoperable bowel obstruction in ovarian cancer, focusing on epidemiology, prognostic factors, clinical outcomes, medical management, multidisciplinary interventions and quality of life.
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Affiliation(s)
- Eduardo Gonzalez-Ochoa
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Husam A Alqaisi
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Gita Bhat
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Nazlin Jivraj
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Stephanie Lheureux
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada,Department of Medicine, University of Toronto, Toronto, Ontario, Canada,Correspondence: Stephanie Lheureux, Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, 610 University Avenue, Toronto, Ontario, M5G 2M9, Canada, Tel +1 416-946-2818, Email
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Bravington A, Obita G, Baddeley E, Johnson MJ, Murtagh FE, Currow DC, Boland EG, Nelson A, Seddon K, Oliver A, Noble SI, Boland JW. The range and suitability of outcome measures used in the assessment of palliative treatment for inoperable malignant bowel obstruction: A systematic review. Palliat Med 2022; 36:1336-1350. [PMID: 36131489 PMCID: PMC10150264 DOI: 10.1177/02692163221122352] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Malignant bowel obstruction, a complication of certain advanced cancers, causes severe symptoms which profoundly affect quality of life. Clinical management remains complex, and outcome assessment is inconsistent. AIM To identify outcomes evaluating palliative treatment for inoperable malignant bowel obstruction, as part of a four-phase study developing a core outcome set. DESIGN The review is reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA); PROSPERO (ID: CRD42019150648). Eligible studies included at least one subgroup with obstruction below the ligament of Treitz undergoing palliative treatment for inoperable malignant bowel obstruction. Study quality was not assessed because the review does not evaluate efficacy. DATA SOURCES Medline, Embase, the Cochrane Database, CINAHL, PSYCinfo Caresearch, Open Grey and BASE were searched for trials and observational studies in October 2021. RESULTS A total of 4769 studies were screened, 290 full texts retrieved and 80 (13,898 participants) included in a narrative synthesis; 343 outcomes were extracted verbatim and pooled into 90 unique terms across six domains: physiological, nutrition, life impact, resource use, mortality and survival. Prevalent outcomes included adverse events (78% of studies), survival (54%), symptom control (39%) and mortality (31%). Key individual symptoms assessed were vomiting (41% of studies), nausea (34%) and pain (33%); 19% of studies assessed quality of life. CONCLUSIONS Assessment focuses on survival, complications and overall symptom control. There is a need for definitions of treatment 'success' that are meaningful to patients, a more consistent approach to symptom assessment, and greater consideration of how to measure wellbeing in this population.
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Affiliation(s)
- Alison Bravington
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Kingston upon Hull, UK
| | | | - Elin Baddeley
- Marie Curie Palliative Care Research Centre, Cardiff University, Cardiff, UK
| | - Miriam J Johnson
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Kingston upon Hull, UK
| | - Fliss Em Murtagh
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Kingston upon Hull, UK
| | | | - Elaine G Boland
- Queen's Centre for Oncology and Haematology, Cottingham, Hull, UK
| | - Annmarie Nelson
- Marie Curie Palliative Care Research Centre, Cardiff University, Cardiff, UK
| | - Kathy Seddon
- Marie Curie Palliative Care Research Centre, Cardiff University, Cardiff, UK
| | - Alfred Oliver
- National Cancer Research Institute, Consumer Liaison Group, Trans-Humber Consumer Research Panel, London, UK
| | - Simon Ir Noble
- Marie Curie Palliative Care Research Centre, Cardiff University, Cardiff, UK
| | - Jason W Boland
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Kingston upon Hull, UK
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de Oliveira LC, Calixto-Lima L, Cunha GDC, Silva NFD, Souza-Silva RD, Fonseca TSM, Souza TD, Santos CDM, Santos DAD, Varea Maria Wiegert E. Effects of specialised nutritional interventions in patients with incurable cancer: a systematic review. BMJ Support Palliat Care 2022; 12:388-402. [DOI: 10.1136/spcare-2022-003893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 08/21/2022] [Indexed: 11/04/2022]
Abstract
ObjectiveTo evaluate current evidence of the effect of specialised nutritional interventions on nutritional status, survival, quality of life and measures of functionality in patients with incurable cancer.MethodsSystematic literature review according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines using PubMed/MEDLINE, EMBASE, Scopus, LILACS and Cochrane Library databases. Clinical studies that evaluated different specialised nutritional interventions, such as nutritional counselling, oral nutritional supplementation (ONS), enteral nutrition (EN) and parenteral nutrition (PN), were eligible. Only studies classified as being of high methodological quality (ie, low or moderate risk of bias) were included.ResultsA total of 22 studies reporting on 2448 patients were deemed eligible. Five types of specialised nutrition were observed: mixed (multimodal nature, ie, dietary counseling, ONS, physical activity and/or drugs) (n=12), ONS (n=5), PN (n=3), EN (n=1) and multidisciplinary team counselling (n=1). Benefits of any kind from the interventions were reported in 14 (63.6%) studies, mainly resulting from mixed intervention. Nutritional status improved in 12 (60.0%) of 20 studies and quality of life improved in eight (50.0%) of 16 studies. Few studies have evaluated the influence of nutritional interventions on survival and measure of functionality, and have not shown improvement in these outcomes.ConclusionDespite the limited evidence, specialised nutritional interventions can yield positive effects for patients with incurable cancer, mainly in their nutritional status and quality of life.
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Aguilar-Cazares D, Chavez-Dominguez R, Marroquin-Muciño M, Perez-Medina M, Benito-Lopez JJ, Camarena A, Rumbo-Nava U, Lopez-Gonzalez JS. The systemic-level repercussions of cancer-associated inflammation mediators produced in the tumor microenvironment. Front Endocrinol (Lausanne) 2022; 13:929572. [PMID: 36072935 PMCID: PMC9441602 DOI: 10.3389/fendo.2022.929572] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Accepted: 08/01/2022] [Indexed: 12/15/2022] Open
Abstract
The tumor microenvironment is a dynamic, complex, and redundant network of interactions between tumor, immune, and stromal cells. In this intricate environment, cells communicate through membrane-membrane, ligand-receptor, exosome, soluble factors, and transporter interactions that govern cell fate. These interactions activate the diverse and superfluous signaling pathways involved in tumor promotion and progression and induce subtle changes in the functional activity of infiltrating immune cells. The immune response participates as a selective pressure in tumor development. In the early stages of tumor development, the immune response exerts anti-tumor activity, whereas during the advanced stages, the tumor establishes mechanisms to evade the immune response, eliciting a chronic inflammation process that shows a pro-tumor effect. The deregulated inflammatory state, in addition to acting locally, also triggers systemic inflammation that has repercussions in various organs and tissues that are distant from the tumor site, causing the emergence of various symptoms designated as paraneoplastic syndromes, which compromise the response to treatment, quality of life, and survival of cancer patients. Considering the tumor-host relationship as an integral and dynamic biological system, the chronic inflammation generated by the tumor is a communication mechanism among tissues and organs that is primarily orchestrated through different signals, such as cytokines, chemokines, growth factors, and exosomes, to provide the tumor with energetic components that allow it to continue proliferating. In this review, we aim to provide a succinct overview of the involvement of cancer-related inflammation at the local and systemic level throughout tumor development and the emergence of some paraneoplastic syndromes and their main clinical manifestations. In addition, the involvement of these signals throughout tumor development will be discussed based on the physiological/biological activities of innate and adaptive immune cells. These cellular interactions require a metabolic reprogramming program for the full activation of the various cells; thus, these requirements and the by-products released into the microenvironment will be considered. In addition, the systemic impact of cancer-related proinflammatory cytokines on the liver-as a critical organ that produces the leading inflammatory markers described to date-will be summarized. Finally, the contribution of cancer-related inflammation to the development of two paraneoplastic syndromes, myelopoiesis and cachexia, will be discussed.
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Affiliation(s)
- Dolores Aguilar-Cazares
- Laboratorio de Investigacion en Cancer Pulmonar, Departamento de Enfermedades Cronico-Degenerativas, Instituto Nacional de Enfermedades Respiratorias “Ismael Cosio Villegas”, Mexico City, Mexico
| | - Rodolfo Chavez-Dominguez
- Laboratorio de Investigacion en Cancer Pulmonar, Departamento de Enfermedades Cronico-Degenerativas, Instituto Nacional de Enfermedades Respiratorias “Ismael Cosio Villegas”, Mexico City, Mexico
- Posgrado en Ciencias Biologicas, Universidad Nacional Autonoma de Mexico, Mexico City, Mexico
| | - Mario Marroquin-Muciño
- Laboratorio de Investigacion en Cancer Pulmonar, Departamento de Enfermedades Cronico-Degenerativas, Instituto Nacional de Enfermedades Respiratorias “Ismael Cosio Villegas”, Mexico City, Mexico
- Laboratorio de Quimioterapia Experimental, Departamento de Bioquimica, Escuela Nacional de Ciencias Biologicas, Instituto Politecnico Nacional, Mexico City, Mexico
| | - Mario Perez-Medina
- Laboratorio de Investigacion en Cancer Pulmonar, Departamento de Enfermedades Cronico-Degenerativas, Instituto Nacional de Enfermedades Respiratorias “Ismael Cosio Villegas”, Mexico City, Mexico
- Laboratorio de Quimioterapia Experimental, Departamento de Bioquimica, Escuela Nacional de Ciencias Biologicas, Instituto Politecnico Nacional, Mexico City, Mexico
| | - Jesus J. Benito-Lopez
- Laboratorio de Investigacion en Cancer Pulmonar, Departamento de Enfermedades Cronico-Degenerativas, Instituto Nacional de Enfermedades Respiratorias “Ismael Cosio Villegas”, Mexico City, Mexico
- Posgrado en Ciencias Biologicas, Universidad Nacional Autonoma de Mexico, Mexico City, Mexico
| | - Angel Camarena
- Laboratorio de Human Leukocyte Antigen (HLA), Instituto Nacional de Enfermedades Respiratorias “Ismael Cosio Villegas”, Mexico City, Mexico
| | - Uriel Rumbo-Nava
- Clinica de Neumo-Oncologia, Instituto Nacional de Enfermedades Respiratorias “Ismael Cosio Villegas”, Mexico City, Mexico
| | - Jose S. Lopez-Gonzalez
- Laboratorio de Investigacion en Cancer Pulmonar, Departamento de Enfermedades Cronico-Degenerativas, Instituto Nacional de Enfermedades Respiratorias “Ismael Cosio Villegas”, Mexico City, Mexico
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Bozzetti F. Survival of the starving cancer patient a food for thought for oncologists. Eur J Surg Oncol 2022; 48:2119-2126. [DOI: 10.1016/j.ejso.2022.05.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 05/18/2022] [Accepted: 05/31/2022] [Indexed: 11/16/2022] Open
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10
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Lokeshwar SD, Press BH, Nie J, Klaassen Z, Kenney PA, Leapman MS. Cachexia and bladder cancer: clinical impact and management. Curr Opin Support Palliat Care 2021; 15:260-265. [PMID: 34698663 DOI: 10.1097/spc.0000000000000580] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
PURPOSE OF REVIEW The purpose of this review is to describe the causes, management, and clinical outcomes associated with cachexia and related components including sarcopenia, among patients with bladder cancer (BCa). RECENT FINDINGS Cachexia in patients with BCa is associated with poorer outcomes after radical cystectomy (RC), radiation, and chemotherapy. Nutritional supplements and novel pharmaceutical agents including magnolol, flucoidan and Anamorelin are currently undergoing investigation for their potential use in BCa patients with cachexia. SUMMARY Cachexia is a hypercatabolic state thought to be caused by an immune-regulated release of cytokines and disruptions of molecular pathways within the tumor microenvironment and systemically. Nutritional deficiencies in patients with BCa also contribute to cachexia and sarcopenia. Patients with BCa -related cachexia and sarcopenia experience worse survival and therapeutic outcomes after RC, chemotherapy, and radiation therapy. Patients with cachexia also experience more postoperative complications after RC. The management of cachexia in patients with BCa remains challenging and requires timely identification, and multidisciplinary management including nutritional supplementation, physical therapy, palliative care, and pharmacological agents. Clinical trials and human studies are still required to determine which pharmacological agents are optimal for BCa cachexia.
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Affiliation(s)
- Soum D Lokeshwar
- Department of Urology, Yale University School of Medicine, New Haven, Connecticut
| | - Benjamin H Press
- Department of Urology, Yale University School of Medicine, New Haven, Connecticut
| | - James Nie
- Department of Urology, Yale University School of Medicine, New Haven, Connecticut
| | - Zachary Klaassen
- Department of Urology, Medical College of Georgia, Augusta, Georgia, USA
| | - Patrick A Kenney
- Department of Urology, Yale University School of Medicine, New Haven, Connecticut
| | - Michael S Leapman
- Department of Urology, Yale University School of Medicine, New Haven, Connecticut
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11
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Multinational Association of Supportive Care in Cancer (MASCC) expert opinion/guidance on the use of clinically assisted nutrition in patients with advanced cancer. Support Care Cancer 2021; 30:2983-2992. [PMID: 34665311 PMCID: PMC8857106 DOI: 10.1007/s00520-021-06613-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 10/03/2021] [Indexed: 01/06/2023]
Abstract
Purpose The pro
vision of clinically assisted nutrition (CAN) in patients with advanced cancer is controversial, and there is a paucity of specific guidance, and so a diversity in clinical practice. Consequently, the Palliative Care Study Group of the Multinational Association of Supportive Care in Cancer (MASCC) formed a Subgroup to develop evidence-based guidance on the use CAN in patients with advanced cancer. Methods This guidance was developed in accordance with the MASCC Guidelines Policy. A search strategy for Medline was developed, and the Cochrane Database of Systematic Reviews and the Cochrane Central Register of Controlled Trials were explored for relevant reviews/trials respectively. The outcomes of the review were categorised by the level of evidence, and a “category of guideline” based on the level of evidence (i.e. “recommendation”, “suggestion”, or “no guideline possible”). Results The Subgroup produced 11 suggestions, and 1 recommendation (due to the paucity of evidence). These outcomes relate to assessment of patients, indications for CAN, contraindications for CAN, procedures for initiating CAN, and re-assessment of patients. Conclusions This guidance provides a framework for the use of CAN in advanced cancer, although every patient needs individualised management. Supplementary Information The online version contains supplementary material available at 10.1007/s00520-021-06613-y.
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12
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Saavedra R, Fahy BN. Artificial Nutrition in Patients with Advanced Malignancy. Surg Oncol Clin N Am 2021; 30:505-518. [PMID: 34053665 DOI: 10.1016/j.soc.2021.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Cancer is a progressive disease that can lead to malnutrition and cachexia. Artificial nutrition is a medical therapy used to combat malnutrition in these patients. In this article, the authors discuss factors affecting the decision to use artificial nutrition, including the patient's mental and physical health, technical factors of the procedures used to deliver artificial nutrition, and the oncologic factors affecting treatment. Through this review, the authors provide guidelines on who is and is not likely to benefit from therapy, available routes of administration, and necessary factors to consider for appropriate decision-making for palliative patients and those with advanced cancers."
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Affiliation(s)
- Ramses Saavedra
- Department of Surgery, University of New Mexico, 1 University of New Mexico, MSC 07-4025, Albuquerque, NM 87131, USA
| | - Bridget N Fahy
- Department of Surgery, University of New Mexico, 1 University of New Mexico, MSC 07-4025, Albuquerque, NM 87131, USA; Division of Palliative Medicine, University of New Mexico, Albuquerque, NM, USA.
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13
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Effects of parenteral nutrition and hydration on survival in advanced cancer patients with malignant bowel obstruction: secondary analysis of a multicenter prospective cohort study. Support Care Cancer 2021; 29:7541-7549. [PMID: 34114097 DOI: 10.1007/s00520-021-06293-8] [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: 11/16/2020] [Accepted: 05/11/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE The benefits of parenteral nutrition and hydration (PNH) in patients with advanced cancer remain unknown. Therefore, we conducted a prospective multicenter cohort study to assess the effects of PNH on survival in patients with malignant bowel obstruction (MBO). METHODS The present study was a secondary analysis. Data on primary nutritional administration routes during the first week of admission to palliative care units, i.e., parenteral nutrition and parenteral hydration, were obtained. Data on the averaged calorie sufficiency rate/total calorie intake (75% ≤ or 750 kcal/day ≤ , 50-75% or 500-750 kcal/day, 25-50% or 250-500 kcal/day, and < 25% or < 250 kcal/day) were also obtained. Participants with MBO were included and divided into two groups: PNH-high (25% ≤ or 250 kcal/day ≤) and PNH-low (< 25% or < 250 kcal/day). We performed time-to-event analyses using the Kaplan-Meier method, log-rank test, and univariate and multivariate Cox regression analyses. RESULTS Patients were divided into the PNH-high (n = 68) and PNH-low (n = 76) groups. A significant difference was observed in survival rates between the two groups (log-rank P < 0.001). Median survival times were 35.5 (95% CI 27-44) and 17.5 (95% CI 13-21) days, respectively. In the multivariate-adjusted model, a significantly lower risk of mortality was observed in Cox's proportional hazard model in the PNH-high group (HR 0.55 (95% CI 0.36-0.83), P = 0.005) than in the PNH-low group. CONCLUSION The present results indicated the beneficial effects of PNH for prolonging survival in advanced cancer patients with MBO in palliative care units.
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14
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Arends J, Strasser F, Gonella S, Solheim TS, Madeddu C, Ravasco P, Buonaccorso L, de van der Schueren MAE, Baldwin C, Chasen M, Ripamonti CI. Cancer cachexia in adult patients: ESMO Clinical Practice Guidelines ☆. ESMO Open 2021; 6:100092. [PMID: 34144781 PMCID: PMC8233663 DOI: 10.1016/j.esmoop.2021.100092] [Citation(s) in RCA: 176] [Impact Index Per Article: 58.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 02/09/2021] [Accepted: 02/24/2021] [Indexed: 12/15/2022] Open
Abstract
•This ESMO Clinical Practice Guideline provides key recommendations for managing cancer-related cachexia. •It covers screening, assessment and multimodal management of cancer cachexia. •All recommendations were compiled by a multidisciplinary group of experts. •Recommendations are based on available scientific data and the author's expert opinion.
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Affiliation(s)
- J Arends
- Department of Medicine I, Medical Center - University of Freiburg Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - F Strasser
- Integrated Cancer Rehabilitation and Cancer Fatigue Clinic, Klinik Gais/Kliniken Valens; Clinic Medical Oncology and Hematology, Cantonal Hospital St Gallen, St Gallen, Switzerland
| | - S Gonella
- Direction of Health Professions, Azienda Ospedaliero Universitaria Città della Salute e della Scienza of Turin, University of Turin, Turin, Italy; Department of Public Health and Pediatrics, University of Turin, Turin, Italy
| | - T S Solheim
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), Trondheim, Norway; Cancer Clinic, Trondheim University Hospital, Trondheim, Norway
| | - C Madeddu
- Medical Oncology Unit, Azienda Ospedaliero Universitaria Cagliari, Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - P Ravasco
- Immuno-Hemotherapy and Oncology, University Hospital of Santa Maria, CHULN, Lisbon, Portugal; Center for Interdisciplinary Research in Health, Universidade Católica Portuguesa, Lisbon, Portugal; University of Lisbon, Portugal
| | - L Buonaccorso
- Psycho-Oncology Unit, Azienda USL-IRCCS, Reggio Emilia, Italy
| | - M A E de van der Schueren
- Department of Nutrition, Dietetics and Life Style, School of Allied Health, HAN University of Applied Sciences, Nijmegen, The Netherlands; Division of Human Nutrition and Health, Wageningen University & Research, Wageningen, The Netherlands
| | - C Baldwin
- Department of Nutritional Sciences, King's College London, London, UK
| | - M Chasen
- Department of Medicine, University of Toronto, Toronto, Canada; Department of Family Medicine, McMaster University, Hamilton, Canada; William Osler Health Services, Brampton, Canada
| | - C I Ripamonti
- Oncology-Supportive Care in Cancer Unit, Department of Onco-Haematology, Fondazione IRCCS Istituto Nazionale dei Tumori Milano, Milan, Italy
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15
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Salonen BR, Mundi MS, Hurt RT, Bonnes SL. The Role of Parenteral Nutrition for Incurable Cancer: Bridging Expectations and Reality. Curr Nutr Rep 2021; 10:226-231. [PMID: 34047939 DOI: 10.1007/s13668-021-00361-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/20/2021] [Indexed: 12/12/2022]
Abstract
PURPOSE OF REVIEW In this review, we examine the role for parenteral nutrition (PN) for nutritional support of patients with advanced, incurable cancer with an emphasis on bridging the divide between expectations and reality. RECENT FINDINGS As the rates of cancer have continued to rise worldwide, the utility of PN has continued to be studied. Due to multiple reasons, high-quality research studies have been scarce, and much of the data is based on observational studies. The recent trend appears to support the use of PN in carefully selected patients. Importantly, the effect on quality of life also should be considered when deciding to initiate PN. PN can be a supportive lifeline for patients with advanced, incurable cancer. The medical team should consider each patient individually to decide if PN should be offered. It is of paramount important for the medical team to engage in shared decision-making with the patient and caregiver(s) to ensure that PN is aligned with their goals and wishes.
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Affiliation(s)
- Bradley R Salonen
- Division of General Internal Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
| | - Manpreet S Mundi
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, MN, USA
| | - Ryan T Hurt
- Division of General Internal Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.,Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, MN, USA.,Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA.,Division of Gastroenterology, Hepatology and Nutrition, University of Louisville, Louisville, KY, USA
| | - Sara L Bonnes
- Division of General Internal Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
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16
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Amano K, Maeda I, Ishiki H, Miura T, Hatano Y, Tsukuura H, Taniyama T, Matsumoto Y, Matsuda Y, Kohara H, Morita T, Mori M, Inoue S, Yokomichi N, Imai K, Yamauchi T, Naito AS, Uneno Y, Yoshioka A, Hiramoto S, Kikuchi A, Hori T, Funaki H, Tanaka K, Suzuki K, Kamei T, Azuma Y, Uno T, Miyamoto J, Katayama H, Kashiwagi H, Matsumoto E, Oya K, Yamaguchi T, Okamura T, Hashimoto H, Kosugi S, Ikuta N, Matsumoto Y, Ohmori T, Nakai T, Ikee T, Unoki Y, Kitade K, Koito S, Ishibashi N, Ehara M, Kuwahara K, Ueno S, Nakashima S, Ishiyama Y, Sakashita A, Matsunuma R, Takatsu H, Yamaguchi T, Ito S, Terabayashi T, Nakagawa J, Yamagiwa T, Inoue A, Yamaguchi T, Miyashita M, Yoshida S, Hiratsuka Y, Tagami K, Watanabe H, Odagiri T, Ito T, Ikenaga M, Shimizu K, Hayakawa A, Kamura R, Okoshi T, Nishi T, Kosugi K, Shibata Y, Hisanaga T, Higashibata T, Yabuki R, Hagiwara S, Shimokawa M, Miyake S, Nozato J, Iriyama T, Kaneishi K, Baba M, Okizaki A, Watanabe YS, Uehara Y, Satomi E, Nishijima K, Shimoinaba J, Nakahori R, Hirohashi T, Hamano J, Kawashima N, Kawaguchi T, Uchida M, Sato K, Matsuda Y, Tsuneto S, Maeda S, Kizawa Y, Otani H. Effects of enteral nutrition and parenteral nutrition on survival in patients with advanced cancer cachexia: Analysis of a multicenter prospective cohort study. Clin Nutr 2021; 40:1168-1175. [DOI: 10.1016/j.clnu.2020.07.027] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 07/07/2020] [Accepted: 07/20/2020] [Indexed: 12/18/2022]
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17
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Loofs TS, Haubrick K. End-of-Life Nutrition Considerations: Attitudes, Beliefs, and Outcomes. Am J Hosp Palliat Care 2020; 38:1028-1041. [PMID: 32945174 DOI: 10.1177/1049909120960124] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
OBJECTIVE To assess the physiological outcomes and interpersonal influences that should be considered when making the decision to provide artificial nutrition and hydration (AN&H) for patients in hospice/palliative programs. METHODS A systematic review was conducted using items from the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols 2015 checklist. Distinct search strategies were employed to find primary research articles that addressed: General health outcomes of artificial nutrition and hydration interventions and nutrition therapy interventions (n = 16), nutrition-related symptoms in end-of-life care (n = 8), and the attitudes of patients and providers toward artificial nutrition and hydration (n = 21). RESULTS The effect of AN&H on health outcomes, quality-of-life measures and nutrition-related symptoms is limited and may vary by patient setting and diagnosis. In the absence of consistent evidence for specific health outcomes, decisions regarding AN&H should be made in context of the desires and beliefs of a patient, their family, and their medical providers. These beliefs may not be consistent with likely outcomes or may be inconsistent between individuals involved in the decision-making process, and individuals of different cultures or geographic regions may approach AN&H decisions from different perspectives. To help navigate the intersection of nutrition-related health outcomes and patient/provider beliefs, palliative care teams may employ a variety of strategies for approaching the decision-making process, and may benefit from specific involvement of a Registered Dietitian to help contribute to or lead these discussions.
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Affiliation(s)
- Tyler S Loofs
- St. David's Georgetown Hospital, Georgetown, TX, USA
| | - Kevin Haubrick
- 165982The University of Houston College of Liberal Arts and Social Sciences, TX, USA
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18
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Cotogni P, Ossola M, Passera R, Monge T, Fadda M, De Francesco A, Bozzetti F. Home parenteral nutrition versus artificial hydration in malnourished patients with cancer in palliative care: a prospective, cohort survival study. BMJ Support Palliat Care 2020; 12:114-120. [PMID: 32826263 DOI: 10.1136/bmjspcare-2020-002343] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 06/18/2020] [Accepted: 06/29/2020] [Indexed: 12/22/2022]
Abstract
OBJECTIVE The evidence base for home parenteral nutrition (HPN) in patients with advanced cancer is lacking. To compare the survival of malnourished patients with cancer undergoing palliative care who received HPN with a homogeneous group of patients, equally eligible for HPN, who did not receive HPN. DESIGN Prospective, cohort study; tertiary university hospital, home care, hospice. METHODS Patients were assessed for HPN eligibility according to the guidelines. In the eligible population, who received both HPN and chemotherapy was excluded, while who received only HPN was included in the HPN+ group and who received neither HPN nor chemotherapy but artificial hydration (AH) was included in the HPN- group. RESULTS 301 patients were assessed for HPN eligibility and 86 patients (28.6%) were excluded for having severe organ dysfunction or Karnofsky performance status <50. In outcome analysis, 90 patients (29.9%) were excluded for receiving both HPN and chemotherapy, while 125 (41.5%) were included, 89 in HPN+ group (29.5%) and 36 in HPN- group (12%). The survival of the two groups showed a significant difference favouring patients receiving HPN (median overall survival: 4.3 vs 1.5 months, p<0.001). The multivariate analysis of the risk factors for mortality showed that not receiving HPN accounted for the strongest one (HR 25.72, 95% CI 13·65 to 48.44). CONCLUSIONS Comparative survival associated with the use of HPN versus AH showed significantly longer survival in malnourished patients with advanced cancer receiving HPN. These data support the guideline recommendation that HPN should be considered when malnutrition represents the overriding threat for the survival of these patients.
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Affiliation(s)
- Paolo Cotogni
- Internal Medicine, Unit of Parenteral Nutrition in Oncology, Molinette Hospital, Turin, Italy .,Anesthesia, Intensive Care and Emergency, Pain Management and Palliative Care, Molinette Hospital, University of Turin, Turin, Italy
| | - Marta Ossola
- Internal Medicine, Unit of Parenteral Nutrition in Oncology, Molinette Hospital, Turin, Italy.,Internal Medicine, Clinical Nutrition, Molinette Hospital, Turin, Italy
| | - Roberto Passera
- Radiology, Nuclear Medicine Division, Molinette Hospital, Turin, Italy
| | - Taira Monge
- Internal Medicine, Unit of Parenteral Nutrition in Oncology, Molinette Hospital, Turin, Italy.,Internal Medicine, Clinical Nutrition, Molinette Hospital, Turin, Italy
| | - Maurizio Fadda
- Internal Medicine, Clinical Nutrition, Molinette Hospital, Turin, Italy
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19
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Roeland EJ, Bohlke K, Baracos VE, Bruera E, del Fabbro E, Dixon S, Fallon M, Herrstedt J, Lau H, Platek M, Rugo HS, Schnipper HH, Smith TJ, Tan W, Loprinzi CL. Management of Cancer Cachexia: ASCO Guideline. J Clin Oncol 2020; 38:2438-2453. [DOI: 10.1200/jco.20.00611] [Citation(s) in RCA: 154] [Impact Index Per Article: 38.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
PURPOSE To provide evidence-based guidance on the clinical management of cancer cachexia in adult patients with advanced cancer. METHODS A systematic review of the literature collected evidence regarding nutritional, pharmacologic, and other interventions, such as exercise, for cancer cachexia. PubMed and the Cochrane Library were searched for randomized controlled trials (RCTs) and systematic reviews of RCTs published from 1966 through October 17, 2019. ASCO convened an Expert Panel to review the evidence and formulate recommendations. RESULTS The review included 20 systematic reviews and 13 additional RCTs. Dietary counseling, with or without oral nutritional supplements, was reported to increase body weight in some trials, but evidence remains limited. Pharmacologic interventions associated with improvements in appetite and/or body weight include progesterone analogs and corticosteroids. The other evaluated interventions either had no benefit or insufficient evidence of benefit to draw conclusions on efficacy. Limitations of the evidence include high drop-out rates, consistent with advanced cancer, as well as variability across studies in outcomes of interest and methods for outcome assessment. RECOMMENDATIONS Dietary counseling may be offered with the goals of providing patients and caregivers with advice for the management of cachexia. Enteral feeding tubes and parenteral nutrition should not be used routinely. In the absence of more robust evidence, no specific pharmacological intervention can be recommended as the standard of care; therefore, clinicians may choose not to prescribe medications specifically for the treatment of cancer cachexia. Nonetheless, when it is decided to trial a drug to improve appetite and/or improve weight gain, currently available pharmacologic interventions that may be used include progesterone analogs and short-term (weeks) corticosteroids.
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Affiliation(s)
| | - Kari Bohlke
- American Society of Clinical Oncology, Alexandria, VA
| | | | | | | | | | - Marie Fallon
- Edinburgh Oncology Centre, University of Edinburgh, UK
| | - Jørn Herrstedt
- Zealand University Hospital Roskilde and University of Copenhagen, Denmark
| | - Harold Lau
- University of Calgary, Calgary, Alberta, Canada
| | - Mary Platek
- Roswell Park Comprehensive Cancer Center and D’Youville College, Buffalo, NY
| | - Hope S. Rugo
- University of California San Francisco, San Francisco, CA
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20
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Roeland EJ, Bohlke K, Baracos VE, Bruera E, del Fabbro E, Dixon S, Fallon M, Herrstedt J, Lau H, Platek M, Rugo HS, Schnipper HH, Smith TJ, Tan W, Loprinzi CL. Management of Cancer Cachexia: ASCO Guideline. J Clin Oncol 2020. [DOI: 10.1200/jco.20.00611 10.1200/jco.20.00611] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
PURPOSE To provide evidence-based guidance on the clinical management of cancer cachexia in adult patients with advanced cancer. METHODS A systematic review of the literature collected evidence regarding nutritional, pharmacologic, and other interventions, such as exercise, for cancer cachexia. PubMed and the Cochrane Library were searched for randomized controlled trials (RCTs) and systematic reviews of RCTs published from 1966 through October 17, 2019. ASCO convened an Expert Panel to review the evidence and formulate recommendations. RESULTS The review included 20 systematic reviews and 13 additional RCTs. Dietary counseling, with or without oral nutritional supplements, was reported to increase body weight in some trials, but evidence remains limited. Pharmacologic interventions associated with improvements in appetite and/or body weight include progesterone analogs and corticosteroids. The other evaluated interventions either had no benefit or insufficient evidence of benefit to draw conclusions on efficacy. Limitations of the evidence include high drop-out rates, consistent with advanced cancer, as well as variability across studies in outcomes of interest and methods for outcome assessment. RECOMMENDATIONS Dietary counseling may be offered with the goals of providing patients and caregivers with advice for the management of cachexia. Enteral feeding tubes and parenteral nutrition should not be used routinely. In the absence of more robust evidence, no specific pharmacological intervention can be recommended as the standard of care; therefore, clinicians may choose not to prescribe medications specifically for the treatment of cancer cachexia. Nonetheless, when it is decided to trial a drug to improve appetite and/or improve weight gain, currently available pharmacologic interventions that may be used include progesterone analogs and short-term (weeks) corticosteroids.
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Affiliation(s)
| | - Kari Bohlke
- American Society of Clinical Oncology, Alexandria, VA
| | | | | | | | | | - Marie Fallon
- Edinburgh Oncology Centre, University of Edinburgh, UK
| | - Jørn Herrstedt
- Zealand University Hospital Roskilde and University of Copenhagen, Denmark
| | - Harold Lau
- University of Calgary, Calgary, Alberta, Canada
| | - Mary Platek
- Roswell Park Comprehensive Cancer Center and D’Youville College, Buffalo, NY
| | - Hope S. Rugo
- University of California San Francisco, San Francisco, CA
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21
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Ni J, Zhang L. Cancer Cachexia: Definition, Staging, and Emerging Treatments. Cancer Manag Res 2020; 12:5597-5605. [PMID: 32753972 PMCID: PMC7358070 DOI: 10.2147/cmar.s261585] [Citation(s) in RCA: 117] [Impact Index Per Article: 29.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 06/26/2020] [Indexed: 12/26/2022] Open
Abstract
Cachexia is a multifactorial disease characterized by weight loss via skeletal muscle and adipose tissue loss, an imbalance in metabolic regulation, and reduced food intake. It is caused by factors of catabolism produced by tumors in the systemic circulation as well as physiological factors such as the imbalanced inflammatory activation, proteolysis, autophagy, and lipolysis that may occur with gastric, pancreatic, esophageal, lung cancer, liver, and bowel cancer. Cancer cachexia not only negatively affects the quality of life of patients with cancer but also reduces the effectiveness of anti-cancer chemotherapy and increases its toxicity, leading to increased cancer-related mortality and expenditure of medical resources. Currently, there are no effective medical interventions to completely reverse cachexia and no approved drugs. Adequate nutritional support is the main method of cachexia treatment, while drugs that target the inhibition of catabolism, cell damage, and excessive activation of inflammation are under study. This article reviews recent advances in the diagnosis, staging, and evaluation of cancer cachexia.
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Affiliation(s)
- Jun Ni
- Department of Pulmonary and Critical Care Medicine, Peking Union Medical Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Beijing 100730, People's Republic of China
| | - Li Zhang
- Department of Pulmonary and Critical Care Medicine, Peking Union Medical Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Beijing 100730, People's Republic of China
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22
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Bozzetti F. Is there a place for nutrition in palliative care? Support Care Cancer 2020; 28:4069-4075. [PMID: 32417968 DOI: 10.1007/s00520-020-05505-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2020] [Accepted: 04/27/2020] [Indexed: 12/13/2022]
Abstract
PURPOSE Although nutritional interventions are becoming widely used in cancer patients, purposes and results of such treatment are not always well-defined. This is because nutrition is traditionally considered a palliative treatment to be confined to the area of palliative cares, whereas the modern approach includes nutrition as an early supplemental support to improve compliance of patients with the oncologic therapies and total parenteral nutrition may be recommended in patients who would be destined to succumb prior from starvation-malnutrition than from tumour progression. Purpose of this paper if to define the potential as well as the limitations of nutritional interventions on both the survival and the quality of life of the advanced cancer patients. RECENT FINDINGS Some RCT on the use of oral, enteral and supplemental parenteral nutrition in patients on oncologic therapy show some benefit on compliance with therapy and in some domains of quality of life. Some malnourished (hypo)aphagic incurable cancer patients may survive longer thanks to parenteral nutrition, while few data suggest that quality of life may be maintained for a limited period of time. With a few exceptions, oncology and nutrition have till recently travelled on parallel tracks without talking each other. The oncologist who knows the natural history of the patients should understand which risk of complication and of poor tolerance to the treatment can malnourished patients carry and which is the potential of parenteral nutrition in hypophagic incurable patients.
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23
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Cotogni P, Monge T, Passera R, Brossa L, De Francesco A. Clinical characteristics and predictive factors of survival of 761 cancer patients on home parenteral nutrition: A prospective, cohort study. Cancer Med 2020; 9:4686-4698. [PMID: 32412178 PMCID: PMC7333857 DOI: 10.1002/cam4.3064] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Revised: 03/14/2020] [Accepted: 03/31/2020] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Robust data reporting the survival of cancer patients on home parenteral nutrition (HPN) are lacking. The aim of this prospective, cohort study was to investigate clinical characteristics, predictive factors, and overall survival (OS) of adult-malnourished cancer patients eligible for HPN according to the European guideline recommendations. METHODS During the study period, 1658 cancer patients were consecutively evaluated in a tertiary university hospital. Of these, 761 who received HPN were grouped into four cohorts according to the provision of supplemental PN (SPN) or total (TPN) and whether they received chemotherapy (CT+ or CT- ): SPN/CT+ (n = 376), TPN/CT+ (n = 99), SPN/CT- (n = 191), and TPN/CT- (n = 95). Patient demographics, nutritional status, cancer-related characteristics, and prognostic scores assessed at HPN start. The primary outcome was OS. RESULTS Median OS was 8.9, 4.3, 5.7, and 2.2 months for the SPN/CT+ , TPN/CT+ , SPN/CT- , and TPN/CT- cohorts, respectively. In multivariable analysis, predictors showing significant association with decreased survival were patient cohorts, modified Glasgow Prognostic Score (1 and 2 scores), weight loss (>15%) in the 3 months before HPN start, and TNM IV stage while protective factors of survival were Karnofsky Performance Status (>50), albumin level (>3.5 g/dL), oral protein intake, BMI (>20.5), and weight at HPN start. CONCLUSION For the first time, in four different cohorts of cancer patients on HPN, clinical characteristics and survival were compared. This large study showed that survival is significantly correlated with patient characteristics at HPN start and that the presence of favorable factors may determine even a fourfold increase in survival. These data are expected to assist physicians in the appropriate prescription of HPN.
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Affiliation(s)
- Paolo Cotogni
- Unit of Parenteral Nutrition in Oncology, Department of Internal Medicine, Molinette Hospital, Turin, Italy
| | - Taira Monge
- Unit of Parenteral Nutrition in Oncology, Department of Internal Medicine, Molinette Hospital, Turin, Italy.,Clinical Nutrition, Department of Internal Medicine, Molinette Hospital, Turin, Italy
| | - Roberto Passera
- Nuclear Medicine Division, Department of Radiology, Molinette Hospital, Turin, Italy
| | - Laura Brossa
- Unit of Parenteral Nutrition in Oncology, Department of Internal Medicine, Molinette Hospital, Turin, Italy.,Clinical Nutrition, Department of Internal Medicine, Molinette Hospital, Turin, Italy
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Bozzetti F. The role of parenteral nutrition in patients with malignant bowel obstruction. Support Care Cancer 2019; 27:4393-4399. [DOI: 10.1007/s00520-019-04948-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2019] [Accepted: 06/18/2019] [Indexed: 01/13/2023]
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Effects of current parenteral nutrition treatment on health-related quality of life, physical function, nutritional status, survival and adverse events exclusively in patients with advanced cancer: A systematic literature review. Crit Rev Oncol Hematol 2019; 139:96-107. [DOI: 10.1016/j.critrevonc.2019.04.014] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Revised: 03/22/2019] [Accepted: 04/13/2019] [Indexed: 12/25/2022] Open
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Sowerbutts AM, Lal S, Sremanakova J, Clamp A, Todd C, Jayson GC, Teubner A, Raftery A, Sutton EJ, Hardy L, Burden S. Home parenteral nutrition for people with inoperable malignant bowel obstruction. Cochrane Database Syst Rev 2018; 8:CD012812. [PMID: 30095168 PMCID: PMC6513201 DOI: 10.1002/14651858.cd012812.pub2] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND People with advanced ovarian or gastrointestinal cancer may develop malignant bowel obstruction (MBO). They are able to tolerate limited, if any, oral or enteral (via a tube directly into the gut) nutrition. Parenteral nutrition (PN) is the provision of macronutrients, micronutrients, electrolytes and fluid infused as an intravenous solution and provides a method for these people to receive nutrients. There are clinical and ethical arguments for and against the administration of PN to people receiving palliative care. OBJECTIVES To assess the effectiveness of home parenteral nutrition (HPN) in improving survival and quality of life in people with inoperable MBO. SEARCH METHODS We searched the following electronic databases: Cochrane Central Register of Controlled Trials (CENTRAL; 2018, Issue 1), MEDLINE (Ovid), Embase (Ovid), BNI, CINAHL, Web of Science and NHS Economic Evaluation and Health Technology Assessment up to January 2018, ClinicalTrials.gov (http://clinicaltrials.gov/) and in the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) search portal (http://apps.who.int/trialsearch/). In addition, we handsearched included studies and used the 'Similar articles' feature on PubMed for included articles. SELECTION CRITERIA We included any studies with more than five participants investigating HPN in people over 16 years of age with inoperable MBO. DATA COLLECTION AND ANALYSIS We extracted the data and assessed risk of bias for each study. We entered data into Review Manager 5 and used GRADEpro to assess the quality of the evidence. MAIN RESULTS We included 13 studies with a total of 721 participants in the review. The studies were observational, 12 studies had only one relevant treatment arm and no control and for the one study with a control arm, very few details were given. The risk of bias was high and the certainty of evidence was graded as very low for all outcomes. Due to heterogeneity of data, meta-analysis was not performed and therefore the data were synthesised via a narrative summary.The evidence for benefit derived from PN was very low for survival and quality of life. All the studies measured overall survival and 636 (88%) of participants were deceased at the end of the study. However there were varying definitions of overall survival that yielded median survival intervals between 15 to 155 days (range three to 1278 days). Three studies used validated measures of quality of life. The results from assessment of quality of life were equivocal; one study reported improvements up until three months and two studies reported approximately similar numbers of participants with improvements and deterioration. Different quality of life scales were used in each of the studies and quality of life was measured at different time points. Due to the very low certainty of the evidence, we are very uncertain about the adverse events related to PN use. Adverse events were measured by nine studies and data for individual participants could be extracted from eight studies. This revealed that 32 of 260 (12%) patients developed a central venous catheter infection or were hospitalised because of complications related to PN. AUTHORS' CONCLUSIONS We are very uncertain whether HPN improves survival or quality of life in people with MBO as the certainty of evidence was very low for both outcomes. As the evidence base is limited and at high risk of bias, further higher-quality prospective studies are required.
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Affiliation(s)
- Anne Marie Sowerbutts
- The University of Manchester, and Manchester Academic Health Science CentreSchool of Health SciencesOxford RoadManchesterUKM13 9PL
| | - Simon Lal
- Salford Royal Foundation TrustIntestinal Failure UnitSalfordUKM6 8HD
| | - Jana Sremanakova
- The University of Manchester, and Manchester Academic Health Science CentreSchool of Health SciencesOxford RoadManchesterUKM13 9PL
| | - Andrew Clamp
- The Christie NHS Foundation Trust and University of ManchesterDivision of Cancer ServicesWilmslow RoadManchesterUKM20 4BX
| | - Chris Todd
- The University of Manchester, and Manchester Academic Health Science CentreSchool of Health SciencesOxford RoadManchesterUKM13 9PL
| | - Gordon C Jayson
- The Christie NHS Foundation Trust and University of ManchesterDivision of Cancer ServicesWilmslow RoadManchesterUKM20 4BX
| | - Antje Teubner
- Salford Royal Foundation TrustIntestinal Failure UnitSalfordUKM6 8HD
| | - Anne‐Marie Raftery
- The Christie NHS Foundation TrustSupportive/Palliative Care TeamWilmslow RoadManchesterUK
| | - Eileen J Sutton
- University of BristolPopulation Health Sciences, Bristol Medical School39 Whatley RoadBristolUKBS8 2PS
| | - Lisa Hardy
- Manchester University NHS Foundation TrustDepartment of Nutrition & DieteticsWythenshawe HospitalManchesterUK
| | - Sorrel Burden
- The University of Manchester, and Manchester Academic Health Science CentreSchool of Health SciencesOxford RoadManchesterUKM13 9PL
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Feinberg J, Nielsen EE, Korang SK, Halberg Engell K, Nielsen MS, Zhang K, Didriksen M, Lund L, Lindahl N, Hallum S, Liang N, Xiong W, Yang X, Brunsgaard P, Garioud A, Safi S, Lindschou J, Kondrup J, Gluud C, Jakobsen JC. Nutrition support in hospitalised adults at nutritional risk. Cochrane Database Syst Rev 2017; 5:CD011598. [PMID: 28524930 PMCID: PMC6481527 DOI: 10.1002/14651858.cd011598.pub2] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND The prevalence of disease-related malnutrition in Western European hospitals is estimated to be about 30%. There is no consensus whether poor nutritional status causes poorer clinical outcome or if it is merely associated with it. The intention with all forms of nutrition support is to increase uptake of essential nutrients and improve clinical outcome. Previous reviews have shown conflicting results with regard to the effects of nutrition support. OBJECTIVES To assess the benefits and harms of nutrition support versus no intervention, treatment as usual, or placebo in hospitalised adults at nutritional risk. SEARCH METHODS We searched Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library, MEDLINE (Ovid SP), Embase (Ovid SP), LILACS (BIREME), and Science Citation Index Expanded (Web of Science). We also searched the World Health Organization International Clinical Trials Registry Platform (www.who.int/ictrp); ClinicalTrials.gov; Turning Research Into Practice (TRIP); Google Scholar; and BIOSIS, as well as relevant bibliographies of review articles and personal files. All searches are current to February 2016. SELECTION CRITERIA We include randomised clinical trials, irrespective of publication type, publication date, and language, comparing nutrition support versus control in hospitalised adults at nutritional risk. We exclude trials assessing non-standard nutrition support. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane and the Cochrane Hepato-Biliary Group. We used trial domains to assess the risks of systematic error (bias). We conducted Trial Sequential Analyses to control for the risks of random errors. We considered a P value of 0.025 or less as statistically significant. We used GRADE methodology. Our primary outcomes were all-cause mortality, serious adverse events, and health-related quality of life. MAIN RESULTS We included 244 randomised clinical trials with 28,619 participants that met our inclusion criteria. We considered all trials to be at high risk of bias. Two trials accounted for one-third of all included participants. The included participants were heterogenous with regard to disease (20 different medical specialties). The experimental interventions were parenteral nutrition (86 trials); enteral nutrition (tube-feeding) (80 trials); oral nutrition support (55 trials); mixed experimental intervention (12 trials); general nutrition support (9 trials); and fortified food (2 trials). The control interventions were treatment as usual (122 trials); no intervention (107 trials); and placebo (15 trials). In 204/244 trials, the intervention lasted three days or more.We found no evidence of a difference between nutrition support and control for short-term mortality (end of intervention). The absolute risk was 8.3% across the control groups compared with 7.8% (7.1% to 8.5%) in the intervention groups, based on the risk ratio (RR) of 0.94 (95% confidence interval (CI) 0.86 to 1.03, P = 0.16, 21,758 participants, 114 trials, low quality of evidence). We found no evidence of a difference between nutrition support and control for long-term mortality (maximum follow-up). The absolute risk was 13.2% in the control group compared with 12.2% (11.6% to 13%) following nutritional interventions based on a RR of 0.93 (95% CI 0.88 to 0.99, P = 0.03, 23,170 participants, 127 trials, low quality of evidence). Trial Sequential Analysis showed we only had enough information to assess a risk ratio reduction of approximately 10% or more. A risk ratio reduction of 10% or more could be rejected.We found no evidence of a difference between nutrition support and control for short-term serious adverse events. The absolute risk was 9.9% in the control groups versus 9.2% (8.5% to 10%), with nutrition based on the RR of 0.93 (95% CI 0.86 to 1.01, P = 0.07, 22,087 participants, 123 trials, low quality of evidence). At long-term follow-up, the reduction in the risk of serious adverse events was 1.5%, from 15.2% in control groups to 13.8% (12.9% to 14.7%) following nutritional support (RR 0.91, 95% CI 0.85 to 0.97, P = 0.004, 23,413 participants, 137 trials, low quality of evidence). However, the Trial Sequential Analysis showed we only had enough information to assess a risk ratio reduction of approximately 10% or more. A risk ratio reduction of 10% or more could be rejected.Trial Sequential Analysis of enteral nutrition alone showed that enteral nutrition might reduce serious adverse events at maximum follow-up in people with different diseases. We could find no beneficial effect of oral nutrition support or parenteral nutrition support on all-cause mortality and serious adverse events in any subgroup.Only 16 trials assessed health-related quality of life. We performed a meta-analysis of two trials reporting EuroQoL utility score at long-term follow-up and found very low quality of evidence for effects of nutritional support on quality of life (mean difference (MD) -0.01, 95% CI -0.03 to 0.01; 3961 participants, two trials). Trial Sequential Analyses showed that we did not have enough information to confirm or reject clinically relevant intervention effects on quality of life.Nutrition support may increase weight at short-term follow-up (MD 1.32 kg, 95% CI 0.65 to 2.00, 5445 participants, 68 trials, very low quality of evidence). AUTHORS' CONCLUSIONS There is low-quality evidence for the effects of nutrition support on mortality and serious adverse events. Based on the results of our review, it does not appear to lead to a risk ratio reduction of approximately 10% or more in either all-cause mortality or serious adverse events at short-term and long-term follow-up.There is very low-quality evidence for an increase in weight with nutrition support at the end of treatment in hospitalised adults determined to be at nutritional risk. The effects of nutrition support on all remaining outcomes are unclear.Despite the clinically heterogenous population and the high risk of bias of all included trials, our analyses showed limited signs of statistical heterogeneity. Further trials may be warranted, assessing enteral nutrition (tube-feeding) for different patient groups. Future trials ought to be conducted with low risks of systematic errors and low risks of random errors, and they also ought to assess health-related quality of life.
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Affiliation(s)
- Joshua Feinberg
- Department 7812, Rigshospitalet, Copenhagen University HospitalCopenhagen Trial Unit, Centre for Clinical Intervention ResearchBlegdamsvej 9CopenhagenDenmark2100
| | - Emil Eik Nielsen
- Department 7812, Rigshospitalet, Copenhagen University HospitalCopenhagen Trial Unit, Centre for Clinical Intervention ResearchBlegdamsvej 9CopenhagenDenmark2100
| | - Steven Kwasi Korang
- Department 7812, Rigshospitalet, Copenhagen University HospitalCopenhagen Trial Unit, Centre for Clinical Intervention ResearchBlegdamsvej 9CopenhagenDenmark2100
| | - Kirstine Halberg Engell
- Department 7812, Rigshospitalet, Copenhagen University HospitalCopenhagen Trial Unit, Centre for Clinical Intervention ResearchBlegdamsvej 9CopenhagenDenmark2100
| | - Marie Skøtt Nielsen
- Department 7812, Rigshospitalet, Copenhagen University HospitalCopenhagen Trial Unit, Centre for Clinical Intervention ResearchBlegdamsvej 9CopenhagenDenmark2100
| | - Kang Zhang
- Beijing University of Chinese MedicineCentre for Evidence‐Based Chinese MedicineBeijingChina
| | - Maria Didriksen
- Department 7812, Rigshospitalet, Copenhagen University HospitalCopenhagen Trial Unit, Centre for Clinical Intervention ResearchBlegdamsvej 9CopenhagenDenmark2100
| | - Lisbeth Lund
- Danish Committee for Health Education5. sal, Classensgade 71CopenhagenDenmark2100
| | - Niklas Lindahl
- Department 7812, Rigshospitalet, Copenhagen University HospitalCopenhagen Trial Unit, Centre for Clinical Intervention ResearchBlegdamsvej 9CopenhagenDenmark2100
| | - Sara Hallum
- Cochrane Colorectal Cancer Group23 Bispebjerg BakkeBispebjerg HospitalCopenhagenDenmarkDK 2400 NV
| | - Ning Liang
- Beijing University of Chinese MedicineCentre for Evidence‐Based Chinese MedicineBeijingChina
| | - Wenjing Xiong
- Beijing University of Chinese MedicineCentre for Evidence‐Based Chinese MedicineBeijingChina
| | - Xuemei Yang
- Fujian University of Traditional Chinese MedicineResearch Base of TCM syndromeNo。1,Qiu Yang RoadShangjie town,Minhou CountyFuzhouFujian ProvinceChina350122
| | - Pernille Brunsgaard
- Department 7812, Rigshospitalet, Copenhagen University HospitalCopenhagen Trial Unit, Centre for Clinical Intervention ResearchBlegdamsvej 9CopenhagenDenmark2100
| | - Alexandre Garioud
- Department 7812, Rigshospitalet, Copenhagen University HospitalCopenhagen Trial Unit, Centre for Clinical Intervention ResearchBlegdamsvej 9CopenhagenDenmark2100
| | - Sanam Safi
- Department 7812, Rigshospitalet, Copenhagen University HospitalCopenhagen Trial Unit, Centre for Clinical Intervention ResearchBlegdamsvej 9CopenhagenDenmark2100
| | - Jane Lindschou
- Department 7812, Rigshospitalet, Copenhagen University HospitalCopenhagen Trial Unit, Centre for Clinical Intervention ResearchBlegdamsvej 9CopenhagenDenmark2100
| | - Jens Kondrup
- Rigshospitalet University HospitalClinical Nutrition UnitAmager Boulevard 127, 2th9 BlegdamsvejKøbenhavn ØDenmark2100
| | - Christian Gluud
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University HospitalThe Cochrane Hepato‐Biliary GroupBlegdamsvej 9CopenhagenDenmarkDK‐2100
| | - Janus C Jakobsen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University HospitalThe Cochrane Hepato‐Biliary GroupBlegdamsvej 9CopenhagenDenmarkDK‐2100
- Holbaek HospitalDepartment of CardiologyHolbaekDenmark4300
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Abstract
A decade ago, "Nutrition Support and The Troubling Trichotomy: A Call To Action" was published in this journal, identifying existing conflicts among technological, ethical, and legal aspects of nutrition support therapy, particularly in terminal or end-of-life situations. Over the past 10 years, the American Society for Parenteral and Enteral Nutrition and others have responded to the action call. A "state of the trichotomy" reveals that while much has been achieved, differences in all 3 aspects will continue to exist due to their dynamic and ever-changing states. The technology arena has made it possible to increase the delivery of nutrition support in alternative settings with the use of telemedicine and social media. Critical/crucial conversations and earlier declarations of individual wishes for care and treatment while having decision-making capacity have been enhanced with the focus on patient-centered and family-centered care. The definition of death as brain death has been challenged in at least one instance. Conflicts between the state's interests and the individual's interests have added to recent legal controversies. Notwithstanding the progress made over the past 10 years, several challenges remain. The future challenges presented by the Troubling Trichotomy can be best confronted if we ACT-Accountability, Communication, and Teamwork. The focus of teamwork should move from multidisciplinary and interdisciplinary teams to transdisciplinary teams, reflecting the shift to function rather than form presented by the new healthcare environment. The transdisciplinary team will be able address the opportunities of the Troubling Trichotomy in the next decade by incorporating the 12 Cs, as detailed in the article.
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