Unmet needs in cancer patients: Creating recommendations to overcome geographical disparities in economic growth

Cancer is a major clinical, economic and societal challenge across different world regions. Effective anticancer therapies are now available, yet the impact of these treatments on the needs of patients with cancer remains questionable, since improved survival is not frequently associated with improved quality of life. In an effort to raise patients' needs at the core of anticancer therapies, the importance of nutritional support has become recognized by international scientific societies. It is recognized that the needs of patients with cancer are universal, yet the economic and societal status of any country influence the availability and implementation of nutritional care. The Middle East is a geographic area in which major differences in economic growth coexist. Consequently, it appears reasonable that international guidelines on nutritional care in oncology are reviewed to highlight those recommendations which could be universally adopted and those which may need a progressive implementation. To this end, a group of Middle East healthcare professionals working in cancer centers across the region gathered to develop a list of recommendations to be implemented in daily practice. This would translate in a likely better acceptance and delivery of nutritional care, aligning all Middle East cancer centers to the quality standards now available only in selected hospital across the region.

ESPEN practical guideline: Clinical Nutrition in cancer

BACKGROUND

This practical guideline is based on the current scientific ESPEN guidelines on nutrition in cancer patients.

METHODS

ESPEN guidelines have been shortened and transformed into flow charts for easier use in clinical practice. The practical guideline is dedicated to all professionals including physicians, dieticians, nutritionists and nurses working with patients with cancer.

RESULTS

A total of 43 recommendations are presented with short commentaries for the nutritional and metabolic management of patients with neoplastic diseases. The disease-related recommendations are preceded by general recommendations on the diagnostics of nutritional status in cancer patients.

CONCLUSION

This practical guideline gives guidance to health care providers involved in the management of cancer patients to offer optimal nutritional care.

A Comparative Study of Spatial Distribution of Gastrointestinal Cancers in Poverty and Affluent Strata (Kermanshah Metropolis, Iran)

INTRODUCTION

The trend of cancers has witnessed a twofold rise in the last three decades, which is expected to be fivefold by 2030. On the other hand, gastrointestinal cancers have turned into one of the health issues in many societies. Given the presence of gastrointestinal cancer hot spots and evidence of health inequalities across Kermanshah Metropolis and the results of studies signaling the association between gastrointestinal cancers and socioeconomic status of individuals as well as evidence of unequal socioeconomic opportunities in this metropolis, the present study aimed to investigate the spatial distribution of gastrointestinal cancers in the poverty and affluent strata of Kermanshah Metropolis, Iran.

MATERIALS AND METHODS

In this descriptive-analytical study, the recorded data of patients, suffering from gastrointestinal cancers, in Kermanshah-based Pathology Centers and Vice Chancellery of Kermanshah University of Medical Sciences (2007-2012) were used. Moreover, to examine the status of gastrointestinal cancers in socioeconomic classes based on the census data collected during 2007-2012, 33 social, cultural, and structural indexes were extracted from the statistical blocks. Additionally, for data analysis and factor analysis, Kruskal-Wallis Test in the environment of SPSS and kernel density estimation (KDE) and Moran's I tests in the GIS environment were employed.

FINDINGS

The results of the present study revealed that the distribution of poverty (Z score = 48.916518, p value = 0.000000) and affluent strata (Z score = 14.345028, p value = 0.000000) followed clustered patterns (p < 0.01). Additionally, the results indicated that the spatial distribution pattern of the upper gastrointestinal cancer was clustered (Z score = 1.896996, p value = 0.007828), whereas the spatial distribution pattern of the lower gastrointestinal cancer was inclined to a randomized clustered pattern (Z score = 1.338121, p value = 0.000857) (p < 0.01). Finally, seven main hot spots were identified from the poverty stratum in Kermanshah, which perfectly overlapped the hot spots of upper gastrointestinal cancer. Similarly, four main hot spots were identified from the affluent stratum in Kermanshah, which overlapped the hot spots of lower gastrointestinal cancer. The results of the Kruskal-Wallis Test demonstrated that the poverty and affluent strata were significantly different from each other in terms of gastrointestinal cancer: upper gastrointestinal cancer (p < 0.05 and X²=10.064) and lower gastrointestinal cancer (p < 0.05 and X²=10.253).

CONCLUSION

The results of the present study showed that the ratio of patients with lower gastrointestinal cancers was higher than the incidence of upper gastrointestinal cancers over the 5-year period under study. Moreover, in Kermanshah Metropolis, there was a significant difference between the upper gastrointestinal cancer in the poverty stratum and the lower gastrointestinal cancer in the affluent stratum. Hence, it is suggested that GIS be applied as a tool for identifying the patterns of effective factors of this type of cancer in each social class, and it is recommended that some effective policies be presented and adopted by health managers according to the role and importance of socioeconomic, environmental, and nutritional factors in the poverty and affluent strata of society, and people at risk be equipped with preventive training programs in this respect.

Plasma Lipid Profile and Systemic Inflammation in Patients With Cancer Cachexia

Cancer cachexia affects about 80% of advanced cancer patients, it is linked to poor prognosis and to date, there is no efficient treatment or cure. The syndrome leads to progressive involuntary loss of muscle and fat mass induced by systemic inflammatory processes. The role of the white adipose tissue (WAT) in the onset and manifestation of cancer cachexia gained importance during the last decade. WAT wasting is not only characterized by increased lipolysis and release of free fatty acids (FFA), but in addition, owing to its high capacity to produce a variety of inflammatory factors. The aim of this study was to characterize plasma lipid profile of cachectic patients and to correlate the FA composition with circulating inflammatory markers; finally, we sought to establish whether the fatty acids released by adipocytes trigger and/or contribute to local and systemic inflammation in cachexia. The study selected 65 patients further divided into 3 groups: control (N); weight stable cancer (WSC); and cachectic cancer (CC). The plasma FA profile was significantly different among the groups and was positively correlated with pro-inflammatory cytokines expression in the CC patients. Therefore, we propose that saturated to unsaturated FFA ratio may serve as a means of detecting cachexia.

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.

Is home parenteral nutrition safe for cancer patients? Positive effects and potential catheter-related complications: A systematic review

PURPOSE

Total Parenteral Nutrition began to be applied frequently in the houses of patients starting from the 1990s and is stated in literature as Home Parenteral Nutrition (HPN). The purpose of this review is to answer the question of whether or not HPN is safe for cancer patients.

METHODS

Searches were conducted in Cochrane, CINAHL, PubMed, Springer, Google Scholar, and the Web of Science databases.

RESULTS

The 1,949 articles were accessed in the total, and 20 articles have been included in the review. In the studies being evaluated, it can be determined that HPN has influenced the quality of life, performance status, and the nutrition level of cancer patients positively. Most frequently seen complications were infections relating to the catheter, the mechanical obstruction in the catheter and venous thrombosis. For each 1,000 days with HPN or a catheter, infections in the interval of 0.05 and 3.08, mechanical problems in the interval of 0.07 and 2.13, and thrombosis in the interval of 0.05 and 0.20 were determined.

CONCLUSIONS

While HPN influenced quality of life, nutrition, and the personal performance of cancer patients positively, the rate of complications is at a level that can be managed at home.

Effect of home enteral nutrition after pancreaticoduodenectomy

OBJECTIVES

Providing home enteral nutrition (HEN) might prevent further deterioration of nutritional status and reduce complication risk after very invasive abdominal surgery. The aim of this study was to assess the effect of HEN after pancreaticoduodenectomy (PD).

METHODS

Between January 2013 and July 2016, 150 consecutive patients underwent PD. All patients received postoperative enteral nutrition until discharge. HEN (400 or 800 kcal/d) was introduced in March 2015 for patients with reduced food intake (daily, <15 kcal/kg ideal body weight) at discharge (HEN group). Patients with low intake at discharge treated before March 2015 were considered historical controls (non-HEN group). All patients received postoperative enteral nutrition until discharge. Primary outcomes measures included morbidity rate and nutritional status including body weight and blood examination from discharge until postoperative day (POD) 90.

RESULTS

The HEN and non-HEN groups included 24 and 39 patients, respectively. HEN was provided for a median of 68 d (range, 21-90 d) and two patients (8.4%) developed tube obstruction during HEN. The HEN group showed significantly lower rate of morbidity of Clavien-Dindo grade II from discharge to POD 90 or higher (4 of 24, 16.7% versus 17 of 39, 46.1%; P = 0.031) and significantly higher rate of increase in body weight (median: 4.9% versus -4%; P = 0.003), serum albumin levels on POD 90 (median: 3.8 versus 3.5 g/dL; P = 0.020), and prognostic nutritional index (median: 48.5 versus 42.5; P = 0.012). Multivariate logistic analysis demonstrated that body weight at discharge (odds ratio [OR], 0.63; 95% confidence interval [CI], 0.53-0.97) and not receiving HEN (OR, 3.86; 95% CI, 1.81-15.2) were prognostic factors for morbidity after discharge.

CONCLUSION

HEN is safe and may reduce postdischarge morbidity and improve nutritional status after PD.

The development of CHAMP: a checklist for the appraisal of moderators and predictors

Background

Personalized healthcare relies on the identification of factors explaining why individuals respond differently to the same intervention. Analyses identifying such factors, so called predictors and moderators, have their own set of assumptions and limitations which, when violated, can result in misleading claims, and incorrect actions. The aim of this study was to develop a checklist for critically appraising the results of predictor and moderator analyses by combining recommendations from published guidelines and experts in the field.

Methods

Candidate criteria for the checklist were retrieved through systematic searches of the literature. These criteria were evaluated for appropriateness using a Delphi procedure. Two Delphi rounds yielded a pilot checklist, which was tested on a set of papers included in a systematic review on reinforced home-based palliative care. The results of the pilot informed a third Delphi round, which served to finalize the checklist.

Results

Forty-nine appraisal criteria were identified in the literature. Feedback was obtained from fourteen experts from (bio)statistics, epidemiology and other associated fields elicited via three Delphi rounds. Additional feedback from other researchers was collected in a pilot test. The final version of our checklist included seventeen criteria, covering the design (e.g. a priori plausibility), analysis (e.g. use of interaction tests) and results (e.g. complete reporting) of moderator and predictor analysis, together with the transferability of the results (e.g. clinical importance). There are criteria both for individual papers and for bodies of evidence.

Conclusions

The proposed checklist can be used for critical appraisal of reported moderator and predictor effects, as assessed in randomized or non-randomized studies using individual participant or aggregate data. This checklist is accompanied by a user’s guide to facilitate implementation. Its future use across a wide variety of research domains and study types will provide insights about its usability and feasibility.

Electronic supplementary material

The online version of this article (10.1186/s12874-017-0451-0) contains supplementary material, which is available to authorized users.

ESPEN guidelines on nutrition in cancer patients

Cancers are among the leading causes of morbidity and mortality worldwide, and the number of new cases is expected to rise significantly over the next decades. At the same time, all types of cancer treatment, such as surgery, radiation therapy, and pharmacological therapies are improving in sophistication, precision and in the power to target specific characteristics of individual cancers. Thus, while many cancers may still not be cured they may be converted to chronic diseases. All of these treatments, however, are impeded or precluded by the frequent development of malnutrition and metabolic derangements in cancer patients, induced by the tumor or by its treatment. These evidence-based guidelines were developed to translate current best evidence and expert opinion into recommendations for multi-disciplinary teams responsible for identification, prevention, and treatment of reversible elements of malnutrition in adult cancer patients. The guidelines were commissioned and financially supported by ESPEN and by the European Partnership for Action Against Cancer (EPAAC), an EU level initiative. Members of the guideline group were selected by ESPEN to include a range of professions and fields of expertise. We searched for meta-analyses, systematic reviews and comparative studies based on clinical questions according to the PICO format. The evidence was evaluated and merged to develop clinical recommendations using the GRADE method. Due to the deficits in the available evidence, relevant still open questions were listed and should be addressed by future studies. Malnutrition and a loss of muscle mass are frequent in cancer patients and have a negative effect on clinical outcome. They may be driven by inadequate food intake, decreased physical activity and catabolic metabolic derangements. To screen for, prevent, assess in detail, monitor and treat malnutrition standard operating procedures, responsibilities and a quality control process should be established at each institution involved in treating cancer patients. All cancer patients should be screened regularly for the risk or the presence of malnutrition. In all patients - with the exception of end of life care - energy and substrate requirements should be met by offering in a step-wise manner nutritional interventions from counseling to parenteral nutrition. However, benefits and risks of nutritional interventions have to be balanced with special consideration in patients with advanced disease. Nutritional care should always be accompanied by exercise training. To counter malnutrition in patients with advanced cancer there are few pharmacological agents and pharmaconutrients with only limited effects. Cancer survivors should engage in regular physical activity and adopt a prudent diet.

Impact of home enteral nutrition in malnourished patients with upper gastrointestinal cancer: A multicentre randomised clinical trial

BACKGROUND

Weight loss is frequent in patients with gastrointestinal (GI) cancer. Nutritional status deteriorates throughout anti-cancer treatment, mostly after major surgery, increasing complications, reducing tolerance and worsening the final prognosis. Enteral nutrition is safe and effective in malnourished patients undergoing major GI surgery. Randomised trials aimed at investigating the effects of home enteral nutrition (HEN) in post-surgical patients with GI cancer are lacking. This study compares HEN and counselling in limiting weight loss during oncologic treatment.

PATIENTS AND METHODS

Patients with upper GI cancer and candidate to major surgery were included in the protocol when the nutritional risk screening (NRS 2002) score was ≥3. All patients were supported with enteral nutrition through a jejunostomy after surgery and randomly assigned to continue enteral nutrition or receiving nutritional counselling after discharge. Nutritional and performance status, quality of life (QoL) and tolerance to cancer treatment have been evaluated at 2 and 6 months after discharge.

RESULTS

Seventy-nine patients were randomised; 38 continued enteral nutrition at home and 41 patients received nutritional counselling only. After 2 months, patients on HEN maintained their mean body weight, while patients in the nutritional counselling group showed a weight loss of 3.6 kg. Patients supported on HEN had a higher chance to complete chemotherapy as planned (48% versus 34%). QoL was not worsened by HEN. No complications were reported.

CONCLUSIONS

HEN is a simple and feasible treatment to support malnourished patients with upper GI cancer after major surgery and during chemotherapy in order to limit further weight loss.