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Muscaritoli M, Arends J, Bachmann P, Baracos V, Barthelemy N, Bertz H, Bozzetti F, Hütterer E, Isenring E, Kaasa S, Krznaric Z, Laird B, Larsson M, Laviano A, Mühlebach S, Oldervoll L, Ravasco P, Solheim TS, Strasser F, de van der Schueren M, Preiser JC, Bischoff SC. ESPEN practical guideline: Clinical Nutrition in cancer. Clin Nutr 2021; 40:2898-2913. [PMID: 33946039 DOI: 10.1016/j.clnu.2021.02.005] [Citation(s) in RCA: 419] [Impact Index Per Article: 139.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Accepted: 01/23/2021] [Indexed: 01/05/2023]
Abstract
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.
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Affiliation(s)
- Maurizio Muscaritoli
- Department of Translational and Precision Medicine University La Sapienza, Rome, Italy.
| | - Jann Arends
- Department of Medicine I, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Germany
| | - Patrick Bachmann
- Centre Regional de Lutte Contre le Cancer Leon Berard, Lyon, France
| | - Vickie Baracos
- Department of Oncology, University of Alberta, Edmonton, Canada
| | | | - Hartmut Bertz
- Department of Medicine I, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Germany
| | | | - Elisabeth Hütterer
- Division of Oncology, Department of Medicine I, Medical University of Vienna, Austria
| | | | - Stein Kaasa
- Norwegian University of Science and Technology, Trondheim, Norway
| | - Zeljko Krznaric
- University Hospital Center and School of Medicine, Zagreb, Croatia
| | - Barry Laird
- Institute of Genetics and Molecular Medicine, University of Edinburgh, Edinburgh, UK
| | | | - Alessandro Laviano
- Department of Translational and Precision Medicine University La Sapienza, Rome, Italy
| | | | - Line Oldervoll
- Center for Crisis Psychology, University of Bergen, Norway/Department of Public Health and Nursing, Faculty of Medicine and Health Sciences, The Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Paula Ravasco
- Faculty of Medicine, University of Lisbon, Lisbon, Portugal
| | - Tora S Solheim
- Cancer Clinic, St.Olavs Hospital, Trondheim University Hospital, Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Norway
| | - Florian Strasser
- Oncological Palliative Medicine, Clinic Oncology/Hematology, Department Internal Medicine and Palliative Center, Cantonal Hospital St. Gallen, Switzerland
| | - Marian de van der Schueren
- HAN University of Applied Sciences, Nijmegen, the Netherlands; Wageningen University and Research, Wageningen, the Netherlands
| | | | - Stephan C Bischoff
- Department for Clinical Nutrition, University of Hohenheim, Stuttgart, Germany
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Ye Y, Xu Y, Fu Q, Shen P, Chen Y, Zheng P, Song L, Chen Y, Wang J. Enteral Nutrition Support Does Not Improve PNI in Radiotherapy Patients with Locally Advanced Esophageal Cancer. Nutr Cancer 2019; 71:223-229. [PMID: 30663378 DOI: 10.1080/01635581.2018.1559939] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVE The assessment of prognostic nutritional index (PNI) before and during radiotherapy is an important parameter for the prognosis in patients with cancer. In this study, enteral tube feeding (ETF) was used during radiotherapy in patients with EC. Dynamic changes of various nutritional indicators (including PNI) were monitored. METHODS Patients with EC who underwent radiotherapy between June 2016 and July 2017 were enrolled. ETF was performing with the energy of 25 kcal × kg/d. Nutritional status were evaluated. Least significant difference (LSD) was used for multiple comparisons between groups. RESULTS A total of 148 patients were admitted, including 51 patients fed via ETF. For patients who were not scheduled to nutritional support, significant difference were observed in albumin (ALB) (P < 0.001), prealbimnin (PA) (P = 0.05) and PNI (P < 0.001) compared to levels before radiotherapy. In the patients fed via enteral tube, no significant difference were found in weight, BMI, ALB, retinol binding protein (RBP) and PA before and after radiotherapy, while PNI significantly decreased (P < 0.001). CONCLUSION After preforming ETF with the energy of 25 kcal × kg/d in patients with EC during radiotherapy, PNI, the key nutritional index reflecting prognosis, significantly decreased.
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Affiliation(s)
- Yingjun Ye
- a Department of Radiation Oncology , Zhejiang Cancer Hospital , Hangzhou , China.,b Zhejiang Provincial Key Laboratory of Radiation Oncology , Hangzhou , China
| | - Yujin Xu
- a Department of Radiation Oncology , Zhejiang Cancer Hospital , Hangzhou , China.,b Zhejiang Provincial Key Laboratory of Radiation Oncology , Hangzhou , China
| | - Qinglan Fu
- a Department of Radiation Oncology , Zhejiang Cancer Hospital , Hangzhou , China.,b Zhejiang Provincial Key Laboratory of Radiation Oncology , Hangzhou , China
| | - Pingqun Shen
- a Department of Radiation Oncology , Zhejiang Cancer Hospital , Hangzhou , China.,b Zhejiang Provincial Key Laboratory of Radiation Oncology , Hangzhou , China
| | - Yaqing Chen
- a Department of Radiation Oncology , Zhejiang Cancer Hospital , Hangzhou , China.,b Zhejiang Provincial Key Laboratory of Radiation Oncology , Hangzhou , China
| | - Ping Zheng
- c Hospital Nutrition Department , Zhejiang Cancer Hospital , Hangzhou , China
| | - Linlan Song
- c Hospital Nutrition Department , Zhejiang Cancer Hospital , Hangzhou , China
| | - Yuanyuan Chen
- a Department of Radiation Oncology , Zhejiang Cancer Hospital , Hangzhou , China.,b Zhejiang Provincial Key Laboratory of Radiation Oncology , Hangzhou , China
| | - Jin Wang
- a Department of Radiation Oncology , Zhejiang Cancer Hospital , Hangzhou , China.,b Zhejiang Provincial Key Laboratory of Radiation Oncology , Hangzhou , China
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Wang J, Yu B, Ye Y, Shen J, Ding N, Tang H, Xu Y, Song L, Zhu Z, Chen Y, Xie S, Chen M. Predictive Value of Nutritional Risk Screening 2002 and Prognostic Nutritional Index for Esophageal Cancer Patients Undergoing Definitive Radiochemotherapy. Nutr Cancer 2018; 70:879-885. [PMID: 30273001 DOI: 10.1080/01635581.2018.1470656] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Affiliation(s)
- Jin Wang
- Department of Radiation Oncology, Zhejiang Cancer Hospital, Hangzhou, 310022, China
- Zhejiang Provincial Key Laboratory of Radiation Oncology, Hangzhou, 310022, China
| | - Binqi Yu
- Department of Radiation Oncology, Zhejiang Hospital, Hangzhou, 310011, China
| | - Yinjun Ye
- Department of Radiation Oncology, Zhejiang Cancer Hospital, Hangzhou, 310022, China
- Zhejiang Provincial Key Laboratory of Radiation Oncology, Hangzhou, 310022, China
| | - Jiaqing Shen
- Department of Radiation Oncology, Zhejiang Cancer Hospital, Hangzhou, 310022, China
- Zhejiang Provincial Key Laboratory of Radiation Oncology, Hangzhou, 310022, China
| | - Na Ding
- Department of Radiation Oncology, Zhejiang Cancer Hospital, Hangzhou, 310022, China
- Zhejiang Provincial Key Laboratory of Radiation Oncology, Hangzhou, 310022, China
| | - Huarong Tang
- Department of Radiation Oncology, Zhejiang Cancer Hospital, Hangzhou, 310022, China
- Zhejiang Provincial Key Laboratory of Radiation Oncology, Hangzhou, 310022, China
| | - Yujin Xu
- Department of Radiation Oncology, Zhejiang Cancer Hospital, Hangzhou, 310022, China
- Zhejiang Provincial Key Laboratory of Radiation Oncology, Hangzhou, 310022, China
| | - Linlan Song
- Zhejiang Provincial Key Laboratory of Radiation Oncology, Hangzhou, 310022, China
- Hospital Nutrition Department, Zhejiang Cancer Hospital, Hangzhou, 310022, China
| | - Ziyu Zhu
- School of Stomatology, Zhejiang Chinese Medical University, Hangzhou, China
| | - Yuanyuan Chen
- Department of Radiation Oncology, Zhejiang Cancer Hospital, Hangzhou, 310022, China
- Zhejiang Provincial Key Laboratory of Radiation Oncology, Hangzhou, 310022, China
| | - Shuping Xie
- Department of Radiation Oncology, Zhejiang Cancer Hospital, Hangzhou, 310022, China
- Zhejiang Provincial Key Laboratory of Radiation Oncology, Hangzhou, 310022, China
| | - Ming Chen
- Department of Radiation Oncology, Zhejiang Cancer Hospital, Hangzhou, 310022, China
- Zhejiang Provincial Key Laboratory of Radiation Oncology, Hangzhou, 310022, China
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Nakatani M, Migita K, Matsumoto S, Wakatsuki K, Ito M, Nakade H, Kunishige T, Kitano M, Sho M. Prognostic Significance of the Prognostic Nutritional Index in Patients with Recurrent Esophageal Squamous Cell Carcinoma. Nutr Cancer 2018. [DOI: 10.1080/01635581.2018.1445771] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
| | - Kazuhiro Migita
- Department of Surgery, Nara Medical University, Kashihara, Nara, Japan
| | - Sohei Matsumoto
- Department of Surgery, Nara Medical University, Kashihara, Nara, Japan
| | - Kohei Wakatsuki
- Department of Surgery, Nara Medical University, Kashihara, Nara, Japan
| | - Masahiro Ito
- Department of Surgery, Nara Medical University, Kashihara, Nara, Japan
| | - Hiroshi Nakade
- Department of Surgery, Nara Medical University, Kashihara, Nara, Japan
| | | | - Mutsuko Kitano
- Department of Surgery, Nara Medical University, Kashihara, Nara, Japan
| | - Masayuki Sho
- Department of Surgery, Nara Medical University, Kashihara, Nara, Japan
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Ruggeri E, Agostini F, Fettucciari L, Giannantonio M, Pironi L, Pannuti F. Home Artificial Nutrition in Advanced Cancer Patients. TUMORI JOURNAL 2018; 99:218-24. [DOI: 10.1177/030089161309900216] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Aims and background Malnutrition is over 50% in advanced cancer patients and is related to a decreased survival. Cachexia is the first reason for death in 4–23% of cases. The aim of the study was to estimate the appropriateness of the criteria to select patients for home artificial nutrition and its effectiveness to avoid death from cachexia and to improve quality of life in patients with advanced cancer assisted at home by the National Tumor Association (ANT) Foundation. Methods and study design The criteria for patient selection are: inadequate caloric intake ± malnutrition; life expectancy ≥6 weeks; suitable psycho-physical conditions; informed consent. The measured parameters were sex, age, tumor site, food intake, nutritional status, Karnofsky performance status, indication for home artificial nutrition, type of home artificial nutrition (enteral or parenteral), and survival after starting home artificial nutrition. Results The ANT Foundation assisted 29,348 patients in Bologna and its province from July 1990 to July 2012. Home artificial nutrition had been submitted to 618 patients (2.1%): enteral to 285/618 (46.1%) and parenteral to 333/618 (53.9%). Access routes for home artificial nutrition were: 39% nasogastric tube, 26% percutaneous endoscopic gastrostomy, 33% digiunostomy, and 2% gastrostomy. The central venous catheters used for home artificial nutrition were: 61% non-tunneled, 13 peripherally inserted, 8% partially tunneled, and 18% totally implanted. By July 2012, all the patients had died. Duration of life ≥6 weeks was 78% (484/618). Karnofsky performance status was related to survival (P <0.0001): one month after starting home artificial nutrition, it decreased in 73 patients (12%), was unchanged in 414 (67%), and increased in 131 (21%). Conclusions The low incidence of home artificial nutrition over all the patients assisted by the ANT Foundation and the achievement to avoid death from cachexia in 78% prove the efficacy of the criteria of patient selection in order to prevent its excessive and indiscriminate use. It was effective in maintaining and improving the performance status in 88% of patients. Karnofsky performance status is a reliable prognostic index to start home artificial nutrition.
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Affiliation(s)
- Enrico Ruggeri
- ANT (Associazione Nazionale Tumori) Foundation, S Orsola-Malpighi Hospital, Bologna, Italy
| | - Federica Agostini
- ANT (Associazione Nazionale Tumori) Foundation, S Orsola-Malpighi Hospital, Bologna, Italy
| | - Luana Fettucciari
- ANT (Associazione Nazionale Tumori) Foundation, S Orsola-Malpighi Hospital, Bologna, Italy
| | - Marilena Giannantonio
- ANT (Associazione Nazionale Tumori) Foundation, S Orsola-Malpighi Hospital, Bologna, Italy
| | - Loris Pironi
- Department of Internal Medicine and Gastroenterology, S Orsola-Malpighi Hospital, Bologna, Italy
| | - Franco Pannuti
- ANT (Associazione Nazionale Tumori) Foundation, S Orsola-Malpighi Hospital, Bologna, Italy
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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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Arends J, Bachmann P, Baracos V, Barthelemy N, Bertz H, Bozzetti F, Fearon K, Hütterer E, Isenring E, Kaasa S, Krznaric Z, Laird B, Larsson M, Laviano A, Mühlebach S, Muscaritoli M, Oldervoll L, Ravasco P, Solheim T, Strasser F, de van der Schueren M, Preiser JC. ESPEN guidelines on nutrition in cancer patients. Clin Nutr 2017. [DOI: 10.1016/j.clnu.2016.07.015 10.1016/j.clnu.2016.07.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Abstract
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.
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Predictive Factors for Prophylactic Percutaneous Endoscopic Gastrostomy (PEG) Tube Placement and Use in Head and Neck Patients Following Intensity-Modulated Radiation Therapy (IMRT) Treatment: Concordance, Discrepancies, and the Role of Gabapentin. Dysphagia 2016; 31:206-13. [PMID: 26753929 DOI: 10.1007/s00455-015-9679-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2015] [Accepted: 12/09/2015] [Indexed: 10/22/2022]
Abstract
The prophylactic placement of a percutaneous endoscopic gastrostomy (PEG) tube in the head and neck cancer (HNC) patient is controversial. We sought to identify factors associated with prophylactic PEG placement and actual PEG use. Since 2010, data regarding PEG placement and use were prospectively recorded in a departmental database from January 2010 to December 2012. HNC patients treated with intensity-modulated radiation therapy (IMRT) were retrospectively evaluated from 2010 to 2012. Variables potentially associated with patient post-radiation dysphagia from previous literature, and our experience was evaluated. We performed multivariate logistic regression on these variables with PEG placement and PEG use, respectively, to compare the difference of association between the two arms. We identified 192 HNC patients treated with IMRT. Prophylactic PEG placement occurred in 121 (63.0 %) patients, with PEG use in 97 (80.2 %) patients. PEG placement was associated with male gender (p < .01), N stage ≥ N2 (p < .05), pretreatment swallowing difficulties (p < .01), concurrent chemotherapy (p < .01), pretreatment KPS ≥80 (p = .01), and previous surgery (p = .02). Concurrent chemotherapy (p = .03) was positively associated with the use of PEG feeding by the patient, whereas pretreatment KPS ≥80 (p = .03) and prophylactic gabapentin use (p < .01) were negatively associated with PEG use. The analysis suggests there were discrepancies between prophylactic PEG tube placement and actual use. Favorable pretreatment KPS, no pretreatment dysphagia, no concurrent chemotherapy, and the use of gabapentin were significantly associated with reduced PEG use. This analysis may help refine the indications for prophylactic PEG placement.
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Cools-Lartigue J, Jones D, Spicer J, Zourikian T, Rousseau M, Eckert E, Alcindor T, Vanhuyse M, Asselah J, Ferri LE. Management of Dysphagia in Esophageal Adenocarcinoma Patients Undergoing Neoadjuvant Chemotherapy: Can Invasive Tube Feeding be Avoided? Ann Surg Oncol 2014; 22:1858-65. [DOI: 10.1245/s10434-014-4270-9] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2014] [Indexed: 12/17/2022]
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Nutritional advice in older patients at risk of malnutrition during treatment for chemotherapy: a two-year randomized controlled trial. PLoS One 2014; 9:e108687. [PMID: 25265392 PMCID: PMC4181649 DOI: 10.1371/journal.pone.0108687] [Citation(s) in RCA: 87] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2014] [Accepted: 08/22/2014] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE We tested the effect of dietary advice dedicated to increase intake in older patients at risk for malnutrition during chemotherapy, versus usual care, on one-year mortality. METHOD We conducted a multicentre, open-label interventional, stratified (centre), parallel randomised controlled trial, with a 1∶1 ratio, with two-year follow-up. Patients were aged 70 years or older treated with chemotherapy for solid tumour and at risk of malnutrition (MNA, Mini Nutritional Assessment 17-23.5). Intervention consisted of diet counselling with the aim of achieving an energy intake of 30 kCal/kg body weight/d and 1.2 g protein/kg/d, by face-to-face discussion targeting the main nutritional symptoms, compared to usual care. Interviews were performed 6 times during the chemotherapy sessions for 3 to 6 months. The primary endpoint was 1-year mortality and secondary endpoints were 2-year mortality, toxicities and chemotherapy outcomes. RESULTS Between April 2007 and March 2010 we randomised 341 patients and 336 were analysed: mean (standard deviation) age of 78.0 y (4·9), 51.2% male, mean MNA 20.2 (2.1). Distribution of cancer types was similar in the two groups; the most frequent were colon (22.4%), lymphoma (14.9%), lung (10.4%), and pancreas (17.0%). Both groups increased their dietary intake, but to a larger extent with intervention (p<0.01). At the second visit, the energy target was achieved in 57 (40.4%) patients and the protein target in 66 (46.8%) with the intervention compared respectively to 13 (13.5%) and 20 (20.8%) in the controls. Death occurred during the first year in 143 patients (42.56%), without difference according to the intervention (p = 0.79). No difference in nutritional status changes was found. Response to chemotherapy was also similar between the groups. CONCLUSION Early dietary counselling was efficient in increasing intake but had no beneficial effect on mortality or secondary outcomes. Cancer cachexia antianabolism may explain this lack of effect. TRIAL REGISTRATION ClinicalTrials.gov NCT00459589.
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Chevalier S, Farsijani S. Cancer cachexia and diabetes: similarities in metabolic alterations and possible treatment. Appl Physiol Nutr Metab 2013; 39:643-53. [PMID: 24869969 DOI: 10.1139/apnm-2013-0369] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Cancer cachexia is a metabolic syndrome featuring many alterations typical of type 2 diabetes (T2D). While muscle wasting is a hallmark of cachexia, epidemiological evidence also supports an accelerated age-related muscle loss in T2D. Insulin resistance manifests in both conditions and impairs glucose disposal and protein anabolism by tissues. A greater contribution of gluconeogenesis to glucose production may limit amino acid availability for muscle protein synthesis, further aggravating muscle loss. In the context of inter-dependence between glucose and protein metabolism, the present review summarizes the current state of knowledge on alterations that may lead to muscle wasting in human cancer. By highlighting the similarities with T2D, a disease that has been more extensively studied, the objective of this review is to provide a better understanding of the pathophysiology of cancer cachexia and to consider potential treatments usually targeted for T2D. Nutritional approaches aimed at stimulating protein anabolism might include specially formulated food with optimal protein and amino acid composition. Because the gradual muscle loss in T2D may be attenuated by diabetes treatment, anti-diabetic drugs might be considered in cachexia treatment. Metformin emerges as a choice candidate as it acts both on reducing gluconeogenesis and improving insulin sensitivity, and has demonstrated tumour suppressor properties in multiple cancer types. Such a multimodal approach to slow or reverse muscle wasting in cachexia warrants further investigation.
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Affiliation(s)
- Stéphanie Chevalier
- a Department of Medicine and School of Dietetics and Human Nutrition, Crabtree Nutrition Laboratories, McGill University Health Centre-Royal Victoria Hospital, 687 ave des Pins Ouest, room H6.61, Montreal, QC H3A 1A1, Canada
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Saira Chowdhury, Orla Hynes. Nutrition in Upper Gastrointestinal Cancer. Nutr Cancer 2013. [DOI: 10.1002/9781118788707.ch12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Bozzetti F. Nutritional support of the oncology patient. Crit Rev Oncol Hematol 2013; 87:172-200. [DOI: 10.1016/j.critrevonc.2013.03.006] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2012] [Revised: 01/28/2013] [Accepted: 03/06/2013] [Indexed: 01/06/2023] Open
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Crenn P, Bouteloup C, Michallet M, Senesse P. Nutrition chez le patient adulte atteint de cancer : place de la nutrition artificielle dans la prise en charge des patients atteints de cancer. NUTR CLIN METAB 2012. [DOI: 10.1016/j.nupar.2012.10.011] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Miyata H, Yano M, Yasuda T, Hamano R, Yamasaki M, Hou E, Motoori M, Shiraishi O, Tanaka K, Mori M, Doki Y. Randomized study of clinical effect of enteral nutrition support during neoadjuvant chemotherapy on chemotherapy-related toxicity in patients with esophageal cancer. Clin Nutr 2011; 31:330-6. [PMID: 22169459 DOI: 10.1016/j.clnu.2011.11.002] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2011] [Revised: 10/18/2011] [Accepted: 11/08/2011] [Indexed: 11/16/2022]
Abstract
BACKGROUND & AIMS Enteral nutrition (EN) is provided for patients with cancer. However, Little is known about the clinical efficacy of EN support during chemotherapy in patients with cancer. METHODS Ninety-one patients who received neoadjuvant chemotherapy (5-fluorouracil, cisplatin and adriamycin) for esophageal cancer were enrolled to receive either EN (n = 47) or PN (n = 44) at random. The primary endpoint was the incidence of chemotherapy-related toxicities during chemotherapy. RESULTS Total and dietary intake calories during chemotherapy were equal in the two groups. There were no significant differences in serum albumin level and body weight change after chemotherapy between the two groups. There was no significant difference in tumor response to chemotherapy between the two groups (EN: 51%, PN: 55%, p = 0.886). Leukopenia and neutropenia of grade 3 or 4, defined according to the Common Toxicities Criteria of the National Cancer Institute, were significantly less frequent in the EN group than PN group (leukopenia: 17% vs 41%, p = 0.011, neutropenia: 36% vs 66%, p = 0.005). Lymphopenia and thrombocytopenia tended to be less frequent in the EN group, albeit insignificantly. CONCLUSIONS Compared with PN support, EN support during neoadjuvant chemotherapy reduced the incidence of chemotherapy-related hematological toxicities in patients with esophageal cancers.
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Affiliation(s)
- Hiroshi Miyata
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Osaka, Japan.
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Marin FA, Lamônica-Garcia VC, Henry MACDA, Burini RC. Grade of esophageal cancer and nutritional status impact on postsurgery outcomes. ARQUIVOS DE GASTROENTEROLOGIA 2011; 47:348-53. [PMID: 21225144 DOI: 10.1590/s0004-28032010000400006] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/25/2009] [Accepted: 03/18/2010] [Indexed: 12/13/2022]
Abstract
CONTEXT Undernutrition is a well known underlying cause in both disease onset and outcome. OBJECTIVE To associate disease severity with pre surgical nutritional status, the main postsurgical complications, and mortality in esophagus cancer patients. METHOD Retrospective data from 100 patients (38-81 years old, 85% males) who had undergone esophagectomy (G1/n = 25) or gastro/jejunostomy (G2/n = 75) between 1995 and 2004. Data included clinical, endoscopic, histological (TNM-UICC), dietary, anthropometric, blood chemistry, and postsurgical (>30 days) complications and mortality. Surgical groups were compared by Student's test and existing associations between variables by either c² or Fisher exact tests with P = 0.05. RESULTS The studied sample was predominantly male (85%), white (80%), smokers and alcoholics (95%), dysphagics (95%) mostly presenting body weight loss before cancer diagnosis (78%). TNM III and IV predominated over I and II, associated (P≤0.005) with higher body mass index and hypoalbuminemia (<3.5 mg/dL) frequency. Esophagic obstructions (n = 77) were associated (P = 0.002) with lower body mass index (kg/m²). Postsurgical complications were more common in G1 (69.2%) than G2, predominantly with infections in G2 (80%) and pleura-pulmonary in G1 (61%). Body mass index and lower lymphocyte counts were associated with early infections and postsurgical complications in G2. Plasma albumin levels were lower in this group than G1, and were associated with postsurgical complications and mortality whereas lower lymphocyte counts was associated with mortality in G1. CONCLUSIONS Disease severity (or late diagnosis) is associated with poor nutritional status and palliative surgery which lead to more complicated postsurgery outcome and mortality. Early diagnosis and nutritional intervention are the recommended actions.
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Bower M, Jones W, Vessels B, Scoggins C, Martin R. Role of esophageal stents in the nutrition support of patients with esophageal malignancy. Nutr Clin Pract 2010; 25:244-9. [PMID: 20581317 DOI: 10.1177/0884533610368710] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Endoluminal stents are commonly used for palliative treatment of dysphagia in patients with advanced esophageal malignancies. The most frequently used esophageal stents are self-expanding metal stents. Removable self-expanding plastic stents have recently been used in the management of esophageal cancer patients treated with curative intent. Esophageal stents effectively alleviate dysphagia in most patients, and stent placement is associated with a low rate of complications. This article reviews the use of self-expanding esophageal stents in patients with esophageal cancer. Nutrition considerations following stent placement are addressed.
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Affiliation(s)
- Matthew Bower
- Division of Surgical Oncology, Department of Surgery, and James Graham Brown Cancer Center, University of Louisville, 315 East Broadway, Louisville, KY 40202, USA
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Abdelgadir MA, Mahadi SEI, Nasr AO, Ahmed ME. Role of jejunostomy feeding catheter as a model for nutritional support. Int J Surg 2010; 8:439-43. [DOI: 10.1016/j.ijsu.2010.05.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2010] [Revised: 04/19/2010] [Accepted: 05/18/2010] [Indexed: 01/10/2023]
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August DA, Huhmann MB. A.S.P.E.N. clinical guidelines: nutrition support therapy during adult anticancer treatment and in hematopoietic cell transplantation. JPEN J Parenter Enteral Nutr 2009; 33:472-500. [PMID: 19713551 DOI: 10.1177/0148607109341804] [Citation(s) in RCA: 301] [Impact Index Per Article: 20.1] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Affiliation(s)
- David Allen August
- Department of Surgery, Division of Surgical Oncology, Robert Wood Johnson Medical School, University of Medicine and Dentistry of New Jersey, Newark, New Jersey, USA
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Bower M, Jones W, Vessels B, Scoggins C, Martin R. Nutritional Support with Endoluminal Stenting During Neoadjuvant Therapy for Esophageal Malignancy. Ann Surg Oncol 2009; 16:3161-8. [DOI: 10.1245/s10434-009-0630-2] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2009] [Revised: 07/02/2009] [Accepted: 07/02/2009] [Indexed: 11/18/2022]
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Nutritional support in patients with oesophageal cancer. Support Care Cancer 2009; 18 Suppl 2:S41-50. [DOI: 10.1007/s00520-009-0664-9] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2009] [Accepted: 05/13/2009] [Indexed: 12/11/2022]
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Bower MR, Martin RC. Nutritional management during neoadjuvant therapy for esophageal cancer. J Surg Oncol 2009; 100:82-7. [DOI: 10.1002/jso.21289] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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The Effects of Nutrition Status of Patients With Digestive System Cancers on Prognosis of the Disease. Cancer Nurs 2008; 31:462-7; quiz 468-9. [DOI: 10.1097/01.ncc.0000339247.60700.86] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Undernutrition in elderly patients with cancer: Target for diagnosis and intervention. Crit Rev Oncol Hematol 2008; 67:243-54. [DOI: 10.1016/j.critrevonc.2008.04.005] [Citation(s) in RCA: 81] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2007] [Revised: 04/18/2008] [Accepted: 04/24/2008] [Indexed: 12/22/2022] Open
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Evidence based practice guidelines for the nutritional management of patients receiving radiation therapy. Nutr Diet 2008. [DOI: 10.1111/j.1747-0080.2008.00252.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Arends J, Bodoky G, Bozzetti F, Fearon K, Muscaritoli M, Selga G, van Bokhorst-de van der Schueren MAE, von Meyenfeldt M, Zürcher G, Fietkau R, Aulbert E, Frick B, Holm M, Kneba M, Mestrom HJ, Zander A. ESPEN Guidelines on Enteral Nutrition: Non-surgical oncology. Clin Nutr 2006; 25:245-59. [PMID: 16697500 DOI: 10.1016/j.clnu.2006.01.020] [Citation(s) in RCA: 386] [Impact Index Per Article: 21.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2006] [Accepted: 01/20/2006] [Indexed: 02/06/2023]
Abstract
Enteral nutrition (EN) by means of oral nutritional supplements (ONS) and tube feeding (TF) offers the possibility of increasing or ensuring nutrient intake in cases where normal food intake is inadequate. These guidelines are intended to give evidence-based recommendations for the use of ONS and TF in cancer patients. They were developed by an interdisciplinary expert group in accordance with officially accepted standards, are based on all relevant publications since 1985 and were discussed and accepted in a consensus conference. Undernutrition and cachexia occur frequently in cancer patients and are indicators of poor prognosis. EN should be started if undernutrition already exists or if food intake is markedly reduced for more than 7-10 days. Standard formulae are recommended for EN. Nutritional needs generally are comparable to non-cancer subjects. In cachectic patients metabolic modulators such as progestins, steroids and possibly eicosapentaenoic acid may help to improve nutritional status. EN is indicated preoperatively for 5-7 days in cancer patients undergoing major abdominal surgery. During radiotherapy of head/neck and gastrointestinal regions dietary counselling and ONS prevent weight loss and interruption of radiotherapy. Routine EN is not indicated during (high-dose) chemotherapy.
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Affiliation(s)
- J Arends
- Department of Medical Oncology, Tumor Biology Center, Albert-Ludwigs-Universität, Freiburg, Germany.
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McClave SA, Ritchie CS. The role of endoscopically placed feeding or decompression tubes. Gastroenterol Clin North Am 2006; 35:83-100. [PMID: 16530112 DOI: 10.1016/j.gtc.2005.12.003] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
The minimally invasive nature of endoscopically placed gastrostomy tubes makes them a viable consideration in palliative care. Complications related to the procedure appear to correlate with age and underlying comorbidities.However, in many instances, the scientific basis for establishing benefit or harm from tube placement is methodologically inadequate. Decisions must be preceded by a discussion of the value and potential risk of artificial nutrition in a particular setting, respecting the wishes and beliefs of each patient and his or her family. The decision to use PEG placement for any reason should be consistent with legal and ethical principles, reflect patient autonomy over any other consideration (including beneficence), and arise from a clear determination of the goals of care (and whether the PEG placement will truly help meet those goals). Whenever possible, further studies with better design are needed to evaluate whether the use of PEG truly affects quality of life and patient outcome in palliative care. PEG tubes for decompression are placed successfully most of the time. Symptom relief occurs usually within 7 days of the procedure. Overall, the morbidity related to the PEG procedure for decompression is only slightly higher than when the same technique is used for nutritional purposes. The appropriate timing for PEG tube placement for nutritional support and for decompression throughout the course of disease progression may be difficult to determine and yet may be a factor in its overall efficiency. Only minor modifications of the basic technique used for PEG placement for nutritional purposes are required to adapt the technique to a variety of other applications in palliative care.
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Affiliation(s)
- Stephen A McClave
- Division of Gastroenterology/Hepatology, University of Louisville School of Medicine, 550 South Jackson Street, KY 40202, USA.
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Odelli C, Burgess D, Bateman L, Hughes A, Ackland S, Gillies J, Collins CE. Nutrition support improves patient outcomes, treatment tolerance and admission characteristics in oesophageal cancer. Clin Oncol (R Coll Radiol) 2006; 17:639-45. [PMID: 16372491 DOI: 10.1016/j.clon.2005.03.015] [Citation(s) in RCA: 98] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
AIMS Patients with oesophageal cancer undergoing chemoradiation with curative intent are at high risk of malnutrition and its complications, including increased side effects of treatment. We have developed a nutrition pathway (NP), involving the early then periodic nutrition assessment of all patients presenting to the multidisciplinary oesophageal clinic who were planned to receive definitive chemoradiation. MATERIALS AND METHODS Patients were assessed as at 'low', 'moderate' or 'severe' nutrition risk, and were provided with appropriate nutrition intervention ranging from preventative advice (low risk), oral nutrition support (moderate risk) to enteral feeding (severe risk). Outcomes for 24 patients treated before implementation of the NP were compared with those of 24 patients treated using the NP. RESULTS Patients managed using the NP experienced less weight loss (mean weight change -4.2 kg +/-6.4 cf. -8.9 kg +/- 5.9, P = 0.03), greater radiotherapy completion rates (92% cf. 50%, P = 0.001), fewer patients had an unplanned hospital admission (46% cf. 75%, P = 0.04), and those that did had a shorter length of stay (3.2 days +/- 5.4 cf. 13.5 days +/- 14.1, P = 0.002). CONCLUSION Early and regular nutrition assessment/intervention and a multidisciplinary approach to nutrition care results in improved treatment tolerance for patients with oesophageal cancer receiving chemoradiation.
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Affiliation(s)
- C Odelli
- Department of Nutrition and Dietetics, Newcastle Mater Misericordiae Hospital, New South Wales, Australia.
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van Bokhorst-de van der Schueren MAE. Nutritional support strategies for malnourished cancer patients. Eur J Oncol Nurs 2005; 9 Suppl 2:S74-83. [PMID: 16437760 DOI: 10.1016/j.ejon.2005.09.004] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
A large body of evidence exists, which demonstrates the importance of nutritional support in cancer. The nutritional needs of patients with cancer may differ from those of the healthy population due to hypermetabolism, impaired organ function, increased nutrient losses and therapy-related malnutrition. Patients with cancer often have increased requirements for both macro- and micronutrients due to long periods of undernutrition prior to diagnosis. The aim of nutritional support should be the prevention or reversal of malnutrition, and this should be initiated as early as possible to improve outcomes. Oral supplementation is a simple, non-invasive method of increasing the nutrient intake of those patients who are unable to meet nutritional requirements, despite dietary counselling. Enteral tube feeding is indicated for patients who are unable to meet their nutritional needs by oral intake alone, and has been shown to improve clinical outcomes. Novel approaches in oral supplementation include the use of eicosapentaenoic acid (EPA), a compound under investigation for its role in preventing and treating cancer-associated malnutrition. Individual studies suggest that EPA attenuates cancer-associated wasting and improves immune function. In addition, it has been shown to have anti-tumour effects and improve clinical outcomes. However, results are not consistent for all patient groups and further research is required.
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Abstract
Malnutrition is a common and significant problem in patients with cancer. Enteral nutrition support is an important therapy and is preferred over parenteral nutrition in the setting of a functional gastrointestinal tract. Familiarity with the indications for enteral support, the choice of an enteral access device, and the selection of an enteral formula are critical for the care of patients with cancer and malnutrition. Enteral nutrition has proven efficacy in patients receiving radiation to the head and neck, those with persistent dysphagia, and critically ill patients with impaired gastric emptying. Placement of feeding tubes through the nose or percutaneously provides a mechanism to deliver nutrients when proximal obstructions or oropharyngeal dysphagia prevent adequate oral intake. Direct access to the jejunum can be safely obtained endoscopically and is very useful in patients who require enteral nutrition support following a gastrectomy or esophagectomy or have impaired gastric emptying. Standard polymeric formulas are appropriate for most patients. Specialized formulas designed to enhance immune function may decrease infectious complications but do not improve survival.
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Affiliation(s)
- Mark Schattner
- Gastroenterology and Nutrition Service, Department of Medicine, Memoiral Sloan-Kettering Cancer Center, New York, NY, USA.
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Xiao HB, Cao WX, Yin HR, Lin YZ, Ye SH. Influence of L-methionine-deprived total parenteral nutrition with 5-fluorouracil on gastric cancer and host metabolism. World J Gastroenterol 2001; 7:698-701. [PMID: 11819857 PMCID: PMC4695577 DOI: 10.3748/wjg.v7.i5.698] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate the influence of L-methionine-deprived total parenteral nutrition with 5-FU on gastric cancer and host metabolism.
METHODS: N-methyl-N’-nitro-nitrosoguanidine (MNNG) induced gastric cancer rats were randomly divided into four groups: Met-containing TPN group (n = 11), Met-deprived TPN group (n = 12), Met-containing TPN+5-FU group (n = 11) and Met-deprived TPN+5-FU group (n = 12). Five rats in each group were sacrificed after 7 d of treatment and the samples were taken for examination. The remaining rats in each group were then fed separately with normal diet after the treatment until death, the life span was noted.
RESULTS: The tumors were enlarged in Met-containing group and shrank in Met-deprived group markedly after the treatment. The DNA index (DI) of tumor cells and the body weight (BW) of rats had no significant change in the two groups, however, the ratio of tumor cells’ S phase was increased. The ratio of G2M phase went up in Met-containing group, but down in Met-deprived group. In the other two groups that 5-FU was added, the BW of rats, and the diameter of tumors, the DI of tumor cells, the S and G2M phase ratio of tumor cells were all decreased, particularly in Met-deprived plus 5-FU group. Pathological examination revealed that the necrotic foci of the tumor tissue increased after Met-deprived TPN treatment, and the nucleoli of tumor cells enlarged. In -MetTPN+5-FU group, severe nuclear damage was also found by karyopyknosis and karyorrhexis, meanwhile there was slight degeneration in some liver and kidney cells. The serum free Met and Cysteine decreased markedly (P < 0.001), while other amino acids, such as serum free serine and glutamine increased significantly (P < 0.005). All the rats died of multiple organ failure caused by cancer metastasis. The average survival time was 18.6 d in Met-containing TPN group, 31 d in Met-deprived TPN group, 27.5 d in Met-containing TPN+5-FU group, and 43 d in Met-deprived TPN+5-FU group (P < 0.05).
CONCLUSION: Met-deprived TPN causes methionine starvation of tumor cells, and can enhance the anti-tumor effect of 5-FU and prolong the life span of gastric cancer-bearing rats.
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Affiliation(s)
- H B Xiao
- Department of Surgery, Affiliated Railway Hospital, Tongji University, Shanghai 200072, China.
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Capra S, Ferguson M, Ried K. Cancer: impact of nutrition intervention outcome--nutrition issues for patients. Nutrition 2001; 17:769-72. [PMID: 11527676 DOI: 10.1016/s0899-9007(01)00632-3] [Citation(s) in RCA: 131] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
OBJECTIVE We examined nutritional issues, assessment, and intervention strategies for patients with cancer. METHODS Reviews of practice guidelines and published reports were used to identify nutritional issues and strategies that can benefit patients with cancer. RESULTS Assessment tools such as the Patient-Generated Subjective Global Assessment are useful in terms of identifying patients with nutrition issues and guiding intervention. However, quality of life and other measures should also be considered. There is a need for early and ongoing nutrition interventions. CONCLUSIONS Encourage patients to try a new food or supplement on days when they are not receiving chemotherapy or radiation therapy because it may result in better tolerance. Screen patients to determine their nutritional status. Closely monitor changes in weight, food intake, and symptoms such as nausea and vomiting. Refer to a registered dietitian for a complete nutrition assessment and individualized counseling.
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Affiliation(s)
- S Capra
- School of Public Health, Queensland University of Technology, Kelvin Grove, Queensland, Australia.
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Kiriyama Y, Tsuchiya H, Murakami T, Satoh K, Tokumitsu Y. Calcitonin induces IL-6 production via both PKA and PKC pathways in the pituitary folliculo-stellate cell line. Endocrinology 2001; 142:3563-9. [PMID: 11459804 DOI: 10.1210/endo.142.8.8328] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
It has been demonstrated that calcitonin-binding sites are present in a variety of tissue types, including in the pituitary gland. Interleukin-6 (IL-6) is also produced in the pituitary and it regulates the secretion of various hormones. In this study, we examined the expression of the calcitonin receptor and the mechanism of IL-6 production induced by calcitonin in the pituitary folliculo-stellate cell line (TtT/GF). The mRNA of calcitonin receptor subtype C1a, but not that of C1b, was detected by RT-PCR in TtT/GF cells and in the normal mouse pituitary. Calcitonin increased cAMP accumulation and IL-6 production in a concentration-dependent manner in TtT/GF cells. As calcitonin activates the PKA and PKC pathways, we investigated the contributions of PKA and PKC to IL-6 production. IL-6 production was only slightly increased by either 8-bromo-cAMP (1 mM) or phorbol 12-myristate 13-acetate (100 nM) alone. However, IL-6 was synergistically induced in the presence of both 8-bromo-cAMP (1 mM) and phorbol 12myristate 13-acetate (100 nM). Furthermore, calcitonin-induced IL-6 production was completely suppressed by H-89 (PKA inhibitor) or GF109203X (PKC inhibitor), indicating that the activation of both PKA and PKC is necessary for calcitonin-induced IL-6 production. On the other hand, pertussis toxin (G(i)/G(o) signaling inhibitor) treatment achieved an approximately 9-fold increase in calcitonin-induced IL-6 production. These results show that calcitonin-stimulated IL-6 production is mediated via both PKA- and PKC-signaling pathways, whereas calcitonin also suppresses IL-6 production by activating G(i)/G(o) proteins in folliculo-stellate cells.
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Affiliation(s)
- Y Kiriyama
- Department of Physiological Chemistry, Graduate School of Pharmaceutical Sciences, Hokkaido University, Japan
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