Nutritional Management of Oncological Symptoms: A Comprehensive Review

Throughout their experience of illness and during the course of treatment, a substantial proportion of cancer patients are prone to develop nutritional and/or metabolic disturbances. Additionally, cancer patients often encounter long-term side effects from therapies, which may lead to impaired digestion, nutrient absorption or bowel motility. Therefore, the preservation and maintenance of an optimal and balanced nutritional status are pivotal to achieving a better prognosis, increasing the tolerance and adherence to cancer therapies and improving the overall quality of life. In this context, personalized nutritional programs are essential for addressing conditions predisposing to weight loss, feeding difficulties, digestion problems and intestinal irregularity, with the goal of promoting adequate nutrient absorption and minimizing the detrimental effects of treatment regimens. The focus of this research is to examine the most common clinical conditions and metabolic changes that cancer patients may experience, including stomatitis, xerostomia, diarrhea, nausea, vomiting, dysphagia, sub-occlusion, dysgeusia, dysosmia, anorexia, and cachexia. Furthermore, we present a pragmatic example of a multidisciplinary workflow that incorporates customized recipes tailored to individual clinical scenarios, all while maintaining the hedonic value of the meals.

Medical management of malignant bowel obstruction in patients with advanced cancer: 2021 MASCC guideline update

BACKGROUND

Malignant bowel obstruction (MBO) is a frequent complication in patients with advanced cancer, particularly colon or gynecological malignancies. MASCC previously published a guideline for symptom management of MBO in 2017. This is a 5-year update.

METHOD

A systematic search and review of relevant literature includes a review published in 2010 and 2017. The guideline update used the same literature search process as followed in 2015. The dates of the new search included 2015 up to February 2, 2021. The guidelines involved the pharmacologic management of nausea and vomiting in malignant bowel obstruction (MBO) only. Only randomized trials were included in the updated guideline as evidence. The evidence was reviewed by the panel and the MASCC criteria for establishing a guideline were followed using MASCC level of grading and category of evidence.

RESULTS

There was one systematic review and 3 randomized trials accepted as evidence from 257 abstracts. Octreotide is effective in reducing gastrointestinal secretions and colic and thereby reduces nausea and vomiting caused by MBO. Scopolamine butylbromide is inferior to octreotide in the doses used in the comparison study. Olanzapine or metoclopramide may be effective in reducing nausea and vomiting secondary to partial bowel obstructions. The panel suggests using either drug. Additional studies are needed to clarify benefits. Haloperidol has been used by convention as an antiemetic but has not been subjected to a randomized comparison. Ranitidine plus dexamethasone may be effective in reducing nausea and vomiting from MBO but cannot be recommended until there is a comparison with octreotide.

DISCUSSION

Octreotide remains the drug of choice in managing MBO. Ranitidine was used in one randomized trial in all participants and so its effectiveness as a single drug is not known until there is a randomized comparison with octreotide. Antiemetics such as metoclopramide and olanzapine may be effective, but we have very few randomized trials of antiemetics in MBO.

CONCLUSION

The panel recommends octreotide in non-operable MBO. Randomized trials are needed to clarify ranitidine and antiemetic choices.

The Management of Nausea and Vomiting Not Related to Anticancer Therapy in Patients with Cancer

OPINION STATEMENT

In cancer patients, the management of nausea and vomiting that is not directly related to treatment is challenging. Much current practice is based on expert opinion and anecdote. Fortunately, over recent years, a number of quality trials have been undertaken to strengthen the evidence base that guides the care of our patients with these distressing symptoms. Much is still unknown however. In this article, we present the latest literature that addresses some of the outstanding issues.

Tropisetron attenuates tumor growth and progression in an experimental model of mouse lung cancer

The antineoplastic effects of 5-hydroxytryptamine (5-HT) receptor antagonists have been shown in previous studies. However, the exact underlying mechanisms mediating these antineoplastic effects are unclear. In the present study, we assessed the antineoplastic effects of tropisetron, a 5-HT receptor antagonist, in an experimental model of lung cancer in BALB/c mouse. Lewis lung carcinoma cell line was used to induce lung cancer. Mice were divided into four groups (n = 6) as follows: tumor-bearing mice + tropisetron (5 mg/kg intraperitoneally [IP]), tumor-bearing mice + tropisetron (10 mg/kg IP), tumor-bearing mice + saline, healthy mice + tropisetron (10 mg/kg). Tumor burden, interferon-γ (IFN-γ), interleukin (IL)-4, pathological response, Ki-67, and E-cadherin were assessed using enzyme-linked immunosorbent assay, and real-time polymerase chain reaction. Comet assay was used to assess DNA toxicity. Tropisetrone-treated animals (either 5 or 10 mg/kg) showed significantly lower tumor sizes at the day 24th after tumor induction. Tropisetron received animals also showed significantly higher levels of IFN-γ, E-cadherin, pathologic response, and necrotic cells compared to the saline-treated counterparts. In addition, the levels of IL-4, and Ki-67 were significantly lower in tropisetrone treated mice in comparison with control. Furthermore, tropisteron coadministration signifcantly reduced H₂ O₂ -induced DNA toxicity while treatment with tropisteron alone showed no adverse effect on DNA. Tropisetrone can be used as a potential antineoplastic drug in lung cancer. This agent can promote its antineoplastic effects in part through modulating inflammatory and proliferating markers.

Strategies for diagnosis and treatment of benign and malignant colorectal obstruction

Colorectal obstruction is one of the most common acute abdominal diseases in surgery department. Because of complex etiological factors, severe condition, and rapid progression, timely diagnosis and proper treatment are necessary for colorectal obstruction. By searching the literature and based on our experience in clinical practice, we performed a comprehensive and systematic analysis of the etiology, diagnosis and treatment of benign and malignant colorectal obstruction, and summarize the main points of diagnosis and treatment of benign and malignant colorectal obstruction as follows: identifying the etiology of benign and malignant colorectal obstruction; flexible application of colonography with meglumine diatrizoate, CT virtual endoscopy, and colonoscopy; preoperative colonoscopic drainage as a bridge to surgery; strict control of surgical indication; precise surgical procedures; and active symptomatic treatment. These measures are of important significance in improving the diagnosis and treatment of benign and malignant colorectal obstruction.

Effect of Mirtazapine on Gastric Emptying in Patients with Cancer-associated Anorexia

BACKGROUND/AIMS

The tetracyclic antidepressant mirtazapine is widely used in cancer patients suffering from anorexia. Although it is known to restore appetite, the exact mechanism remains unknown. The aim of the study was to evaluate if mirtazapine has any effect on gastric emptying in patients suffering from cancer-related anorexia.

MATERIALS AND METHODS

Solid-meal gastric-emptying study using radiolabeled meal was performed in 28 patients suffering from cancer anorexia once at baseline and repeated after 15 days of mirtazapine therapy.

RESULTS

At baseline, only 7 (25%) patients had normal gastric motility (emptying >70% at 3 h postingestion) whereas after treatment, 18 (64.2%) patients achieved this limit. Mean % gastric emptying increased from 55.2% ±21.0% to 68.9% ±21.3% (P < 0.001). Mean gastric emptying time (t_1/2) before intervention was 314.7 ± 421.0 min which decreased to 116.0 ± 106.7 min after intervention. Results were further analyzed by dividing the patients into two groups based on baseline gastric-emptying study. Group A (normal gastric emptying) consisted of seven patients, mean % gastric emptying at baseline and postintervention was 75.0% ±5.25% and 87.57% ±5.94%, respectively (P < 0.018). Group B (delayed gastric emptying) consisted of 21 patients, mean % gastric emptying at baseline and postintervention was 48.71% ±18.82% and 62.76% ±16.86%, respectively (P < 0.001).

CONCLUSION

Mirtazapine significantly improves gastric emptying in patients of prostate and breast cancer suffering from cancer-associated anorexia.

Palliative percutaneous endoscopic gastrostomy placement for gastrointestinal cancer: Roles, goals, and complications

Percutaneous endoscopic gastrostomy tube placement is an invaluable tool in clinical practice that has an important role in the palliative care of patients with gastrointestinal cancer. While there is no extensive data regarding the use of this procedure in patients with gastrointestinal malignancy, inferences can be made from the available information derived from studies of similar or mixed populations. Percutaneous endoscopic gastrostomy tubes can be used to provide enteral nutrition for terminal malignancies of the upper gastrointestinal tract as well as for decompression of malignant obstructions. The rates of successful placement for cancer patients with either of these indications are high, similar to those in mixed populations. There is no conclusive evidence that the procedure will help patients reach nutritional goals for those needing alimental supplementation. However, it is effective at relieving symptoms caused by malignant obstruction. A high American Society of Anesthesiologist physical status score and an advanced tumor stage have been shown to be independent predictors of poor outcomes following placement in cancer patients. This suggests the potential for similar outcomes in the palliative care of patients with advanced stage gastrointestinal cancer who may be in relatively poor physiologic condition. However, this potential should not preclude its use in patients with terminal gastrointestinal cancer considering the high rate of successful tube placement, the possible benefits and the ultimate goal of comfort in palliative care.

Effectiveness of antiemetics in control of antineoplastic chemotherapy-induced emesis at home

Objective Evaluating if antiemetics are effective in the prevention or treatment at home, of chemotherapy-induced emesis. Methods In total, were included 42 women with breast cancer in moderately emetogenic chemotherapy, using dexamethasone/ondansetron before each cycle. The frequency of nausea and vomiting was obtained by applying the instrument in the pre-chemotherapy period, and 24h, 48h, 72h and 96h after chemotherapy. The use of antiemetics was considered in accordance with adherence to medical prescription. Results All patients (n = 42, 100%) reported emesis at some point. Only five cases (11.9%) were anticipatory. In the first 24 hours (acute emesis), 38 (90.5%)ayed), emesis was reported by all despite the regular use (n = 20, 47.6%) or not (n = 22, 52.4%) of antiemetics (ondansetron, dexamethasone and metoclopramide/or dimenhydrinate). Conclusion Antiemetics were not effective in the prevention or treatment at home, of chemotherapy-induced emesis.

Efficacy and safety of pharmacotherapy in cancer-related psychiatric disorders across the trajectory of cancer care: a review

At least 25-30% of patients with cancer and an even higher percentage of patients in an advanced phase of illness meet the criteria for a psychiatric diagnosis, including depression, anxiety, stress-related syndromes, adjustment disorders, sleep disorders and delirium. A number of studies have accumulated over the last 35 years on the use of psychotropic drugs as a pillar in the treatment of psychiatric disorders. Major advances in psycho-oncology research have also shown the efficacy of psychotropic drugs as adjuvant treatment of cancer-related symptoms, such as pain, hot flushes, pruritus, nausea and vomiting, fatigue, and cognitive impairment. The knowledge about pharmacokinetics and pharmacodynamics, clinical use, safety, side effects and efficacy of psychotropic drugs in cancer care is essential for an integrated and multidimensional approach to patients treated in different settings, including community-based centres, oncology, and palliative care. A search of the major databases (MEDLINE, Embase, PsycLIT, PsycINFO, the Cochrane Library) was conducted in order to summarize relevant data concerning the efficacy and safety of pharmacotherapy for cancer-related psychiatric disorders in cancer patients across the trajectory of the disease.

Palliative venting percutaneous endoscopic gastrostomy tube is safe and effective in patients with malignant obstruction

BACKGROUND AND STUDY AIMS

Obstructive symptoms are common in advanced malignancies. Venting percutaneous endoscopic gastrostomy (VPEG) tubes can be placed for palliation. The aim of this study was to determine the outcomes of VPEG placement in patients with advanced malignancy.

METHODS

We retrospectively reviewed patients in whom a VPEG tube was attempted for a malignant indication from 1998 to 2010 at a tertiary care center. Clinical information, procedure details, and adverse events (AEs) were recorded.

RESULTS

Ninety-six patients meeting the inclusion criteria were identified. Colorectal (27 %), pancreas (18.8 %), and gynecologic (17.7 %) malignancies were most common. Overall, 46.9 % of patients had ascites, with 35.6 % undergoing drainage prior to VPEG placement. VPEG placement was successful in 89 patients (92.7 %), and relief of obstructive symptoms was observed in 91.0 % of patients. Seven patients had refractory symptoms despite functioning VPEG tube. Ten post-procedural AEs were noted in nine patients, with one death. Infectious complications were more common in patients with ascites (12.2 %) versus those without (0 %; p = 0.02). There was a trend towards decreased infectious AEs when ascites was drained prior to VPEG (14.8 vs. 7.1 %; p = 0.64) in our patient cohort. We observed a decreased survival when AEs occurred (73 ± 47.8 days) compared with when they did not occur (141 ± 367.8 days; p = 0.61).

CONCLUSIONS

VPEG tubes can be safely placed in patients with obstructive symptoms due to inoperable malignancy, with complete relief in the majority of patients. Ascites was a risk factor for post-procedural infectious AEs. Drainage of ascites prior to VPEG tube placement may decrease this risk, although this requires further study.

Psychopharmacology in psycho-oncology

Psychopharmacological intervention is a major clinical and research area in oncology and palliative care. Over the last 35 years, psychotropic drugs have been shown to have a number of important indications for the treatment of the most common psychiatric disorders, such as depression, anxiety, stress-related syndromes, severe adjustment disorders, sleep disorders and delirium, which combined affect at least 30-40% of patients with cancer and even a higher percentage of patients in an advanced phase of illness. The availability of new drugs, with less side-effects and safer pharmacological profiles, has been a major advance in clinical psycho-oncology. Interestingly, several drugs have also been found to be helpful for the adjuvant treatment of cancer-related symptoms, such as pain, hot flashes, pruritus, nausea and vomiting, fatigue, and cognitive impairment, making psychopharmacology an important tool for the improvement of cancer patients' quality of life. The aim of this paper is to summarize recent relevant data concerning the use of psychotropic drugs, namely antidepressants, anxiolytics, antipsychotics, anticonvulsants and psychostimulants in patients with cancer.

Predictors of response to palliative care intervention for chronic nausea in advanced cancer outpatients

PURPOSE

Nausea is a frequent and distressing symptom in advanced cancer patients. The objective of this retrospective study was to determine predictors of response to palliative care consultation for chronic nausea in advanced cancer outpatients.

METHODS

Eligible patients included were outpatient supportive care center seen consecutively for an initial consultation and who had one follow-up visit within 30 days of the initial consultation. We reviewed the medical records of 1,273 consecutive patients, and 444 (35 %) were found to meet the eligibility criteria. All patients were assessed using the Edmonton Symptom Assessment Scale (ESAS). Nausea response was defined as an improvement of at least 30% between the initial visit and the first follow-up. We used logistic regression models to assess the possible predictors of improvement in nausea.

RESULTS

Overall, 112 of 444 patients (25%) experienced moderate/severe chronic nausea (ESAS item score ≥4/10). Higher baseline nausea intensity was significantly related to constipation (r = 0.158; p = 0.046) and all the symptoms assessed by the ESAS (p < 0.001). Sixty-eight of the 112 (61%) patients with moderate/severe nausea at baseline showed a significant improvement at the follow-up visit (p < 0.001). The main predictors for nausea response were improvement of fatigue (p = 0.005) and increased appetite (p = 0.003).

CONCLUSIONS

Baseline nausea was associated with all the ESAS symptom and improvement of fatigue and lack of appetite predicted a lower frequency of nausea at follow-up. More research is necessary to better understand the association between nausea severity and other symptoms and to predict which interventions will yield the best outcomes depending on the mix and severity of symptoms.

Current pharmacotherapy options for cancer anorexia and cachexia

INTRODUCTION

Anorexia and cachexia syndrome represents a complex clinical picture that occurs in the late stage of several chronic inflammatory diseases, including cancer. Unless counteracted cancer-related anorexia and cachexia syndrome affects quality of life (QL) and survival. However, to date a standard effective treatment is lacking.

AREAS COVERED

The aim of this review is to describe the current pharmacological approaches for anorexia and cachexia syndrome, focusing on cancer-related syndrome. The several pharmacological agents tested so far are discussed, distinguishing them in unproven drugs, effective drugs, and drugs under investigation. Moreover, a section is devoted to the promising use of nutritional supplements and nutraceuticals. The emerging role of a multitargeted combined treatment approach is exhaustively reviewed.

EXPERT OPINION

Considering the complex clinical picture and the multifactorial pathogenesis of anorexia and cachexia syndrome, we believe that its clinical management requires a multidisciplinary and multipharmacological approach. In our opinion the anorexia and cachexia syndrome treatment should include drugs that target the following conditions: inflammatory status, oxidative stress, nutritional disorders, muscle catabolism, anemia, immunosuppression, and fatigue. The multidimensional therapies for anorexia and cachexia syndrome should ideally be introduced within a context of the "best supportive care," which includes optimal symptom management and careful psychosocial counseling.

A scoring system for the prognosis and treatment of malignant bowel obstruction

BACKGROUND

Malignant bowel obstruction is a common result of end-stage abdominal cancer that is a treatment dilemma for many physicians. Little has been reported predicting outcomes or determining the role of surgical intervention. We sought to review our experience with surgical and nonsurgical management of malignant bowel obstruction to identify predictors of 30-day mortality and of who would most likely benefit from surgical intervention.

METHODS

A chart review of 523 patients treated between 2000 and 2007 with malignant bowel obstruction were evaluated for factors present at admission to determine return to oral intake, 30-day mortality, and overall survival. Propensity score matching was used to homogenize patients treated with and without surgery to identify those who would benefit most from operative intervention.

RESULTS

Radiographic evidence of large bowel obstruction was predictive of return to oral intake. Hypoalbuminemia and radiographic evidence of ascites or carcinomatosis were all predictive of increased 30-day mortality and overall survival. A nomogram of 5 identified risk factors correlated with increased 30-day mortality independent of therapy. Patients with large bowel or partial small bowel obstruction benefited most from surgery. A second nomogram was created from 4 identified risk factors that revealed which patients with complete small bowel obstruction might benefit from surgery.

CONCLUSION

Two nomograms were created that may guide decisions in the care of patients with malignant bowel obstruction. These nomograms are able to predict 30-day mortality and who may benefit from surgery for small bowel obstruction.

Percutaneous endoscopic gastrostomy tube placement for end-stage palliation of malignant gastrointestinal obstructions

BACKGROUND/AIM

Decompression of malignant gastrointestinal obstructions is an uncommon indication for percutaneous endoscopic gastrostomy (PEG) tubes. The purpose of this study is to determine the efficacy of venting PEG tubes in relieving nausea and vomiting and assessing complications associated with tube placement.

PATIENTS AND METHODS

This study is a retrospective chart review of patients with PEG tubes placed to decompress malignant gastrointestinal obstructions between January 2005 and September 2010 by the gastroenterology service at our institute. Patient demographics, symptom relief, procedural complications, diet tolerability and home palliation were reviewed.

RESULTS

Seven PEG tubes were inserted to decompress malignant gastrointestinal obstructions. The mean patient age was 62 years (range 37-82 years). The underlying primary malignancies were small intestine (1), appendiceal (1), pancreatic (2), and colon (3) cancer. Gastric outlet obstruction was present in 3 (43%) patients while small bowel obstruction occurred in 4 (57%) patients. There was relief of nausea and vomiting in 6 (86%) patients. Procedural complications were present in 1 (14%) patient and involved superficial cellulitis followed by peristomal leakage. Patients with gastric outlet obstruction continued to have limited oral intake while patients with small bowel obstruction tolerated varying degrees of oral nutrition. Six (86%) patients were discharged home after PEG tube placement, but only 2 (33%) were able to undergo end-stage palliation at home without re-admission for hospital palliation.

CONCLUSIONS

Venting PEG tubes significantly reduce the symptoms of nausea and vomiting in patients with metastatic gastrointestinal obstruction due to primary gastrointestinal malignancies. Complications associated with tube placement were minimal.

The management of nausea and vomiting in advanced cancer

Nausea and vomiting are distressing and debilitating symptoms frequently reported in advanced disease. They are also complex and multifactorial in nature, which can make palliation difficult. The primary method of treatment is pharmacological, with current recommendations based on the presumed cause, knowledge of the emetogenic pathways, and matching of the emetogenic stimulus with the drug most likely to act on the relevant receptors. This is often complicated by the difficulty in identifying the cause(s) and the fact that many antiemetics work on multiple receptors. This article offers an overview of the physiology of the emetogenic pathways, the pathophysiology of common aetiologies, the clinical assessment required and tools available, and the pharmacological and non-pharmacological management of these symptoms.