Long-Term Enteral Nutrition Facilitates Optimization of Body Weight

Survival of patients with advanced cancer in Enteral Nutritional Therapy: a comparison between caloric estimates

ABSTRACT Objective To assess factors related to the achievement of the caloric estimates of enteral nutritional therapy and the survival of patients with advanced cancer in exclusively palliative care. Methods Retrospective study, where patients using enteral nutrition admitted from March 2019 to February 2020 were divided into two groups: Group 1 included patients who reached 75% of the estimated caloric goals, and Group 2 included those who did not. The data were extracted from the patients’ electronic medical records. Logistic regression analyzes were performed to assess associations between the studied sociodemographic, clinical, and nutritional variables, and the Kaplan-Meier curve and Cox regression were used to assess the survival of the groups. Results A total of 158 patients participated in the study, with a median age of 63 (IIQ: 55-70) years. 57% reached the caloric goal (Group 1). In the logistic regression, the functional capacity (OR: 5.82; CI: 2.28-14.84; p<0.001) and symptoms of nausea or vomiting (OR: 0.050; CI: 0.005-0.455; p=0.008) were independent variables for achieving the caloric goal. Cox regression showed Karnofsky Performance Status as an independent predictor for survival (HR: 1.85; CI: 1.13-3.04). Conclusion Patients with better functionality have longer survival and are potential candidates for reaching the caloric goals proposed by national and international guidelines for cancer patients.

Malnutrition Identified by the Academy of Nutrition and Dietetics and American Society for Parenteral and Enteral Nutrition Consensus Criteria and Other Bedside Tools Is Highly Prevalent in a Sample of Individuals Undergoing Treatment for Head and Neck Cancer

BACKGROUND

Using the Academy of Nutrition and Dietetics and American Society for Parenteral and Enteral Nutrition (Academy/ASPEN) Consensus malnutrition definition, we estimated malnutrition prevalence in a sample of individuals with head and neck cancer (HNC) and compared it with the Patient-Generated Subjective Global Assessment (PG-SGA). We also investigated the utility of the 50-kHz phase angle (PA) and 200-kHz/5-kHz impedance ratio (IR) to identify malnutrition.

MATERIALS AND METHODS

Nineteen individuals (18 males, 1 female) scheduled to undergo chemoradiotherapy were seen at 5 time points during and up to 3 months after treatment completion. Multiple-frequency bioelectrical impedance analysis, PG-SGA, nutrition-focused physical examination, anthropometry, dietary intake, and handgrip strength data were collected.

RESULTS

Using the Consensus, 67% were found to be malnourished before treatment initiation; these criteria diagnosed malnutrition with overall good sensitivity (94%) and moderate specificity (43%) compared with PG-SGA. Over all pooled observations, "malnourished" (by Consensus but not PG-SGA category) had a lower mean PA (5.2 vs 5.9; P = .03) and higher IR (0.82 vs 0.79; P = .03) than "well-nourished" categorizations, although the clinical relevance of these findings is unclear. PA and IR were correlated with higher PG-SGA score (r = -0.35, r = 0.36; P < .01) and handgrip strength (r = 0.48, r = -0.47; P < .01).

CONCLUSION

The Academy/ASPEN Consensus and the PG-SGA were in good agreement. It is unclear whether PA and IR can be used as surrogate markers of nutrition status or muscle loss.

Enteral Nutrition Support of Head and Neck Cancer Patients

Patients with head and neck cancer are at high risk for malnutrition due to dysphagia from the tumor and treatment. Despite difficulty with oral intake, these patients usually have a normal stomach and lower gastrointestinal tract. Enteral nutrition support via percutaneous endoscopic gastrostomy (PEG) administered in the home by the patient helps to prevent weight loss, dehydration, nutrient deficiencies, treatment interruptions, and hospitalizations. It also improves quality of life. Successful management of these patients requires orderly care and follow-up by a multidisciplinary nutrition team.

Prophylactic percutaneous endoscopic gastrostomy tube placement in treatment of head and neck cancer: a comprehensive review and call for evidence-based medicine

BACKGROUND

Patients with head and neck cancers (HNCs) are at increased risk of experiencing malnutrition, which is associated with poor outcomes. Advances in the treatment of HNCs have resulted in improved outcomes that are associated with severe toxic oral side effects, placing patients at an even greater risk of malnutrition. Prophylactic placement of percutaneous endoscopic gastrostomy (PEG) tubes before treatment may be beneficial in patients with HNC, especially those undergoing more intense treatment regimens. PEG tube placement, however, is not without risks.

METHODS

A comprehensive review of the literature was conducted.

RESULTS

Systematic evidence assessing both the benefits and harm associated with prophylactic PEG tube placement in patients undergoing treatment for HNC is weak, and benefits and harm have not been established.

CONCLUSIONS

More research is necessary to inform physician behavior on whether prophylactic PEG tube placement is warranted in the treatment of HNC.

Guidelines for identification and management of outpatient percutaneous endoscopic gastrostomy tube placement

INTRODUCTION

We sought to determine if percutaneous endoscopic gastrostomy (PEG) could be safely performed in an outpatient fashion.

METHODS

One hundred consecutive inpatient (IP) and outpatient (OP) PEGs were analyzed. Patient demographics, PEG indication, nutritional status, complications, and 30-day mortality were determined. Data were analyzed with Student t tests (STTs) and Fisher exact tests (FETs). All OP PEG candidates were evaluated by our dietician, and postprocedure management was discussed before PEG placement.

RESULTS

Seventy-four IP and 26 OP PEGs were attempted. All OP PEGs were placed for head and neck cancers, whereas only 18 of 74 (24%) of IP PEGs were performed for that reason (P<.0001 by FET). Mean pre-PEG albumin levels in OP patients were 3.86 g/dL versus 2.79 g/dL for IP patients (P<.0001 by STT). No differences were found in complication rates (OP vs IP, P=.56 by FET). Thirty-day mortality for OP patients was 0% and 9.5% for IP patients.

DISCUSSION

OP PEG placement is safe and feasible in carefully selected patients. It requires a care path-driven team approach.

Non-surgical oncology - Guidelines on Parenteral Nutrition, Chapter 19

Reduced nutritional state is associated with unfavourable outcomes and a lower quality of life in patients with malignancies. Patients with active tumour disease frequently have insufficient food intake. The resting energy expenditure in cancer patients can be increased, decreased, or remain unchanged compared to predicted values. Tumours may result in varying degrees of systemic pro-inflammatory processes with secondary effects on all significant metabolic pathways. Therapeutic objectives are to stabilise nutritional state with oral/enteral nutrition and parenteral nutrition (PN) and thus to prevent or reduce progressive weight loss. The maintenance or improvement of quality of life, and the increase in the effectiveness and a reduction in the side-effects of antitumor therapy are further objectives. Indications for PN in tumour patients are essentially identical to those in patients with benign illnesses, with preference given to oral or enteral nutrition when feasible. A combined nutritional concept is preferred if oral or enteral nutrition are possible but not sufficient. There are generally no accepted standards for ideal energy and nutrient intakes in oncological patients, particularly when exclusive artificial nutrition is administered. The use of PN as a general accompaniment to radiotherapy or chemotherapy is not indicated, but PN is indicated in chronic severe radiogenic enteritis or after allogenic transplantation with pronounced mucositis or GvH-related gastrointestinal damage for prolonged periods, with particular attention to increased risk of bleeding and infection. No PN is necessary in the terminal phase.

The role of pretreatment percutaneous endoscopic gastrostomy in facilitating therapy of head and neck cancer and optimizing the body mass index of the obese patient

BACKGROUND

Chemoradiation of head and neck cancer induces severe dysphagia and malnutrition, which may lead to interruptions in therapy and reduction in its efficacy. Percutaneous endoscopic gastrostomy (PEG) feedings bypass the oropharynx, allowing administration of nutrients and medications into the stomach, thus preventing malnutrition, dehydration, and treatment interruption.

METHODS

Medical records of 161 patients treated for head and neck cancer who had PEGs placed prior to chemoradiation and 2 PEGs placed during chemoradiation were reviewed from the date of PEG placement throughout treatment and utilization. The objective was to determine the contribution of pretreatment PEGs to the therapy of patients with head and neck cancer and to optimize their body mass index.

RESULTS

Severe chemoradiation-induced dysphagia developed in 160 patients (98%), necessitating PEG utilization for feeding and hydration. PEGs were used for a mean 251 +/- 317 days. Significant complications related to PEG placement and utilization were infrequent. PEG feeding allowed chemoradiation to continue without interruption in 93% of patients. Individualized feeding regimens optimized body mass index in obese and overweight patients with a decline from 33.0 +/- 3.4 to 28.4 +/- 4.8 kg/m(2) (P < .001) and 27.3 +/- 1.5 to 24.6 +/- 2.7 kg/m(2) (P < .001), respectively. Radiation-induced strictures developed in 12% of patients, requiring endoscopic dilatation.

CONCLUSIONS

Enteral feeding through prechemoradiation-placed PEGs is an effective and safe method for nutrition and hydration of patients with head and neck cancer undergoing chemoradiation. PEGs allowed chemoradiation to proceed with minimal interruptions despite severe dysphagia, which excluded oral intake for prolonged periods.

Quality of life and enteral nutrition

PURPOSE OF REVIEW

The quality of life is in essence, the patients' subjective view of their own health status and can add another dimension to the evaluation of a treatment as the enteral nutrition.The recent clinical investigations on this topic are critically summarized in this review.

RECENT FINDINGS

Three areas of potential impact of enteral nutrition on quality of life of patients have been identified: elderly and neurological patients, cancer patients and patients with anorexia nervosa.A major problem is the difficulty to define quality of life, due to the holistic and subjective nature of this dimension. Moreover, many patients require help to complete the forms of the questionnaire. Finally, many factors besides the enteral nutrition can affect the quality of life of these patients, namely the basic condition and the primary disease of the patients.

SUMMARY

Although the enteral nutrition often represents a life-saving procedure, this does not necessarily translate in an appreciation of a better quality of life by the patients.Additional factors as the gustatory deprivation and the loss of social contacts usually associated with eating and the frequent problems related to tube function and tube-feeding represent severe limitations to a good quality of life of these patients.