Nutrition Assessment in Oncology

Nutrition and Dietary Intervention in Cancer: Gaps, Challenges, and Future Perspectives

The term "cancer" refers to the state in which cells in the body develop mutations and lose control over their replication. Malignant cancerous cells invade in various other tissue sites of the body. Chemotherapy, radiation, and surgery are the first-line modalities for the majority of solid cancers. These treatments work by mitigating the DNA damage of cancerous cells, but they can also cause harm to healthy cells. These side effects might be immediate or delayed, and they can cause a high rate of morbidity and mortality. Dietary interventions have a profound impact on whole-body metabolism, including immunometabolism and oncometabolism which have been shown to reduce cancer growth, progression, and metastasis in many different solid tumor models with promising outcomes in early phase clinical studies. Dietary interventions can improve oncologic or quality-of-life outcomes for patients that are undergoing chemotherapy or radiotherapy. In this chapter, we will focus on the impact of nutritional deficiencies, several dietary interventions and their proposed mechanisms which are used as a novel therapy in controlling and managing cancers.

The Relationship between Malnutrition and Subjective Taste Change Experienced by Patients with Cancer Receiving Outpatient Chemotherapy Treatment

Taste changes and malnutrition are two important problems in patients with different types of cancer. This study was conducted to evaluate the relationship between malnutrition and subjective taste changes experienced by cancer patients receiving outpatient chemotherapy. The study used a cross-sectional design and was carried out with 1382 patients with cancer receiving outpatient chemotherapy. Of the patients, 63.1% experienced taste changes. It was determined that 8.8% of patients had malnutrition according to the Mini Nutritional Assessment. The mean scores of patients experiencing malnutrition and being at risk for malnutrition from all sub-dimensions of The Chemotherapy-induced Taste Alteration Scale (CiTAS) were found to be higher than the patient group evaluated to have normal nutrition. It was determined that a unit increase in the scores of the parageusia and phantogeusia subscales of the CiTAS increased the risk of malnutrition by 3.36 times (%95 CI= 2.68-4.02). In line with these results, we recommend that patients with cancer receiving chemotherapy should be routinely evaluated in terms of taste changes in clinical practice and that they should be followed up in terms of malnutrition in the presence of taste changes.

Physical, psychological and nutritional outcomes in a cohort of Irish patients with metastatic peritoneal malignancy scheduled for cytoreductive surgery (CRS) and heated intrapertioneal chemotherapy (HIPEC): An exploratory pilot study

Background

Treatment for peritoneal malignancy (PM) can include cytoreductive surgery (CRS) and heated intrapertioneal chemotherapy (HIPEC) and is associated with morbidity and mortality. Physical, psychological and nutritional outcomes are important pre-operatively. The aim of this pilot study was to investigate these outcomes in patients with PM before and after CRS-HIPEC.

Methods

Between June 2018 and November 2019, participants were recruited to a single-centre study. Primary outcome was cardiopulmonary exercise testing (CPET) variables oxygen uptake (VO₂) at anaerobic threshold (AT) and at peak. Secondary outcome measures were upper and lower body strength, health related quality of life (HRQoL) and the surgical fear questionnaire. Exploratory outcomes included body mass index, nutrient intake and post-operative outcome. All participants were asked to undertake assessments pre CRS-HIPEC and 12 weeks following the procedure.

Results

Thirty-nine patients were screened, 38 were eligible and 16 were recruited. Ten female and 6 male, median (IQR) age 53 (42–63) years. Of the 16 patients recruited, 14 proceeded with CRS-HIPEC and 10 competed the follow up assessment at week 12. Pre-operative VO₂ at AT and peak was 16.8 (13.7–18) ml.kg^-1.min^-1 and 22.2 (19.3–25.3) ml.kg^-1.min^-1, upper body strength was 25.9 (20.3–41.5) kg, lower body strength was 14 (10.4–20.3) sec, HRQoL (overall health status) was 72.5 (46.3–80) % whilst overall surgical fear was 39 (30.5–51). The VO₂ at AT decreased significantly (p = 0.05) and HRQoL improved (p = 0.04) between pre and post- CRS-HIPEC. There were no significant differences for any of the other outcome measures.

Conclusion

This pilot study showed a significant decrease in VO₂ at AT and an improvement in overall HRQoL at the 12 week follow up. The findings will inform a larger study design to investigate a prehabilitation and rehabilitation cancer survivorship programme.

We report performance status in oncology-but not nutritional status?

Performance status (PS) scales are used routinely in clinical oncology to evaluate functional status and help direct treatment decisions. PS is also used to determine research protocol eligibility, indicate treatment response, and evaluate toxicity in oncology clinical trials. Malnutrition (like poor PS) is associated with adverse outcomes such as lower tolerance to anti-tumor treatment, poor quality of life, and decreased survival. Nutritional status is therefore arguably as important as PS for cancer outcomes. Despite well-documented adverse consequences for patients, malnutrition also often goes undiagnosed until severe depletion is evident. If the predictive importance of nutritional status is comparable to PS, why is nutritional status not routinely used along with PS to guide treatment decisions? There is compelling evidence to support the predictive abilities of both PS and nutritional status in cancer outcomes and treatment decision-making. Perhaps, PS may be a proxy for nutritional status. Nutritional status might also serve as an effective tool for patient selection and stratification in oncology trials. Together with PS, it might provide important and distinct prognostic information; we propose both should be routinely included in outcome studies. The extent to which impaired PS may be a surrogate for malnutrition warrants investigation. Given its comparable importance to PS, it is inexcusable that nutritional status is not given the prominence it deserves as a key patient-reported outcome.

Pancreas Cancer-Associated Weight Loss

Unintentional weight loss in patients with pancreatic cancer is highly prevalent and contributes to low therapeutic tolerance, reduced quality of life, and overall mortality. Weight loss in pancreatic cancer can be due to anorexia, malabsorption, and/or cachexia. Proper supportive care can stabilize or reverse weight loss in patients and improve outcomes. We review the literature on supportive care relevant to pancreatic cancer patients, and offer evidence-based recommendations that include expert nutritional assessment, counseling, supportive measures to ensure adequate caloric intake, pancreatic enzyme supplementation, nutritional supplement replacement, orexigenic agents, and exercise. Pancreatic Cancer Action Network-supported initiatives will spearhead the dissemination and adoption of these best supportive care practices. IMPLICATIONS FOR PRACTICE: Weight loss in pancreatic cancer patients is endemic, as 85% of pancreatic cancer patients meet the classic definition of cancer cachexia. Despite its significant prevalence and associated morbidity, there is no established approach to this disease entity. It is believed that this is due to an important knowledge gap in understanding the underlying biology and lack of optimal treatment approaches. This article reviews the literature regarding pancreas cancer-associated weight loss and establishes a new framework from which to view this complex clinical problem. An improved approach and understanding will help educate clinicians, improve clinical care, and provide more clarity for future clinical investigation.