Bioelectrical impedance analysis for monitoring cancer patients receiving chemotherapy and home parenteral nutrition

The effect of preoperative supplementary parenteral nutrition on nutrition and inflammation in gastric cancer patients

OBJECTIVES

Supplemental parenteral nutrition (SPN) is recommended to add when enteral nutrition alone is not sufficient. This research aims to evaluate the effect of preoperative SPN in patients with gastric cancer.

METHODS

A total of 180 patients with gastric cancer were divided into three groups (60 patients per group) according to different nutritional support scheme. The primary endpoint was the changes in nutrition and inflammatory, while the secondary endpoint included the changes in prognosis.

RESULTS

Compared with the control group, there were significant differences in nutrition and inflammation related indicators in the oral nutrition supplement (ONS) group and the SPN + ONS group (P < 0.05). Compared with the ONS group, the SPN + ONS group showed significant differences in the above indicators (P < 0.05). However, no significant changes were observed in the incidence of complications, the postoperative exhaust time, and the hospitalization time.

CONCLUSIONS

Preoperative SPN had a positive effect on nutrition and inflammation of gastric cancer patients undergoing surgery, but had no significant effect on their prognosis.

Advancements in nutritional diagnosis and support strategies during the perioperative period for patients with liver cancer

Liver cancer represents a grave hepatic condition and constitutes a significant global health concern. Surgical resection remains the principal therapeutic modality for liver cancer. Nevertheless, perioperative malnutrition exerts a notable impact on patients with liver cancer, emerging as an independent risk factor for disease mortality and adverse outcomes. Hence, precise nutritional diagnosis and timely nutritional support hold the potential to enhance therapeutic efficacy and quality of life for liver cancer patients. This study represents a meticulous foray into the literature, extracting data from PubMed, Web of Science, and EMBASE databases, with a focus on the past 5 years. It scrutinizes the impact of malnutrition on patients undergoing liver cancer surgery, the etiological underpinnings of malnutrition within this patient cohort, the critical assessment of perioperative nutritional status, and the strategic approaches to nutritional support. Utilizing rigorous inclusion and exclusion criteria, the amassed scholarly works are meticulously synthesized, methodically organized, and categorically elaborated upon. Ultimately, the authors propose the incorporation of a multidisciplinary nutrition management team during the perioperative period, comprising nutritionists, pharmacists, physicians, nurses, psychologists, and rehabilitation therapists, among other specialized professionals. Together, they collaborate to devise and implement personalized nutritional support plans, monitor patients' nutritional status, and make necessary adjustments as required. Through comprehensive management and intervention, improvements in the nutritional status of liver cancer patients can be achieved, thereby enhancing surgical success rates and facilitating postoperative recovery. It is believed that this manuscript will offer valuable insights to advance the nutritional management during the perioperative phase of liver cancer, aiding in ameliorating patients' nutritional status and treatment outcomes.

High-protein home parenteral nutrition in malnourished oncology patients: a systematic literature review

INTRODUCTION

Up to 83% of oncology patients are affected by cancer-related malnutrition, depending on tumour location and patient age. Parenteral nutrition can be used to manage malnutrition, but there is no clear consensus as to the optimal protein dosage. The objective of this systematic literature review (SLR) was to identify studies on malnourished oncology patients receiving home parenteral nutrition (HPN) where protein or amino acid delivery was reported in g/kg bodyweight/day, and to compare outcomes between patients receiving low (< 1 g/kg bodyweight/day), standard (1-1.5 g/kg/day), and high-protein doses (> 1.5 g/kg/day).

METHODS

Literature searches were performed on 5th October 2021 in Embase, MEDLINE, and five Cochrane Library and Centre for Reviews and Dissemination databases. Searches were complemented by hand-searching of conference proceedings, a clinical trial registry, and bibliographic reference lists of included studies and relevant SLRs/meta-analyses.

RESULTS

Nineteen publications were included; sixteen investigated standard protein, two reported low protein, and one included both, but none assessed high-protein doses. Only one randomised controlled trial (RCT) was identified; all other studies were observational studies. The only study to compare two protein doses reported significantly greater weight gain in patients receiving 1.15 g/kg/day than those receiving 0.77 g/kg/day.

CONCLUSION

At present, there is insufficient evidence to determine the optimal protein dosage for malnourished oncology patients receiving HPN. Data from non-HPN studies and critically ill patients indicate that high-protein interventions are associated with increased overall survival and quality of life; further studies are needed to establish whether the same applies in malnourished oncology patients.

The Effect of Fasting on Body Composition Assessment in Hospitalized Cancer Patients

Guidelines for bioelectrical impedance analysis (BIA) recommend fasting before measurements, but how it affects the outcomes is unclear. This descriptive, before-and-after study examines the effect of fasting on BIA results and its impact on the diagnosis of malnutrition in hospitalized cancer patients. Fifty-three oncology patients (admitted in January-March 2020) were consecutively enrolled regardless of their nutritional status. Patients were assessed by the same dietician 24-48 h after admission, following the usual clinical practice. The measurements were taken after 12-h fasting (fasting state) and 60-90 min after breakfast (non-fasting state). Bioimpedance parameters (resistance [R], reactance [Xc], phase angle [PA]) and body composition indices (free-fat mass index [FFMI] and appendicular skeletal muscle index [ASMI]) were calculated. On average, R values did not significantly differ between fasting and non-fasting states (mean difference: +1.82 Ω; p = 0.64). The non-fasting Xc and PA were reduced (mean differences: -1.55 Ω, p = 0.93 and 0.09°, p = 0.82, respectively). Fasting and non-fasting FFMI and ASMI were similar (mean differences: -0.13 kg/m2 (p = 0.5) and -0.10 kg/m2 (p not calculated)). These results suggest that BIA does not require fasting, facilitating its routine use in hospitalized cancer patients.

Exercise-Based Cancer Rehabilitation Program Improves Phase Angle in Breast Cancer Survivors

Phase angle (PhA) is an index of cell membrane integrity and prognostic indicator of survival and quality of life in cancer survivors. The efficacy of exercise-based cancer rehabilitation programs (ExCR) on PhA is unknown. To assess the effect of ExCR on PhA in breast cancer survivors. Fifty-nine female breast cancer survivors (61 ± 9 years) were referred to the ExCR by their oncologist and participated in one-on-one exercise-based training for 90 minutes, 3 times a week, for 12 weeks. Training sessions included 45 minutes of resistance training at intensities between 40-85% of 1-repetition maximum with a rate of perceived exertion (RPE) between 3-8, 30 minutes of cardiorespiratory training at intensities between 40-85% of heart rate reserve with an RPE between 3-8, and 15 minutes of flexibility training. Participants completed pre- and post-measurements of body composition, cardiorespiratory endurance, flexibility, muscular endurance, muscular strength, and PhA (Inbody 770). PhA significantly increased (p < 0.05) after ExCR (PhA_pre = 4.56; PhA_post = 4.64; Δ = 1.8%). Changes in measures of muscular strength have a weak but significant positive relationship (r = 0.20-0.39; p < 0.05) with changes in PhA. There was no relationship between changes in PhA and changes in cardiorespiratory endurance or muscular endurance. A 12-week ExCR significantly improves PhA in breast cancer survivors. Training muscular strength may be an integral component of ExCR with the objective of improving PhA.

Influence of the type of electrodes in the assessment of body composition by bioelectrical impedance analysis in the supine position

BACKGROUND & AIMS

The main source of error in body composition assessment of bedridden patients by bioelectrical impedance analysis (BIA) is the electrode inadequacy and placement. As electrocardiogram (ECG) electrodes are often used for BIA measurements, this study aimed to compare three of them with a reference BIA electrode.

METHODS

BIA was performed sequentially on 24 healthy subjects in the supine position, using 3 different ECG electrodes (3M® Red Dot® 2330; Ambu® BlueSensor 2300; Ambu® BlueSensor SU-00-C) and the reference electrode (Bianostic AT®) for the BIA device (Nutriguard-M®, Data Input, Germany). Resistance (R), reactance (Xc), phase angle (PhA), appendicular skeletal muscle index (ASMI), fat-free mass index (FFMI) and fat mass percentage (FM%) obtained with the different electrodes were compared using Bland-Altman plots, repeated measures one-way ANOVA and paired t-test. Patient characteristics potentially involved in BIA measurement differences were assessed using linear regression analysis.

RESULTS

The study population consisted of 9 men and 15 women, 33% and 47% of whom were overweight, respectively. The measured R was within the physiological range for all men (428-561 Ω) and women (472-678 Ω), regardless of the type of electrodes used. Compared to the reference electrode, the 3M® Red Dot® 2330 and Ambu® BlueSensor SU-00-C electrodes gave significantly different Xc and PhA values, but only the Ambu® BlueSensor SU-00-C gave significantly different ASMI, FFMI and FM% at 50 kHz, with biases of -0.2 kg/m², -0.3 kg/m² and +1.4%, respectively. The higher the current frequency, the lower was the Xc and PhA measured by the Ambu® BlueSensor SU-00-C compared to the reference electrode. These measurement differences seemed mainly due to the too small gel area of the Ambu® BlueSensor SU-00-C (154 mm²) compared to the reference electrode (1311 mm²).

CONCLUSIONS

The use of electrodes with small gel area affects BIA measurement in the supine position, especially when PhA is used as an indicator of the nutritional status. Therefore, it is essential to specify the type of electrodes and carry out comparative tests before changing consumables for body composition assessment, to ensure BIA measurement reliability in clinical and research settings.

Supplemental parenteral nutrition in cancer care: why, who, when

Malnutrition is an often-overlooked challenge for patients with cancer. It is associated with muscle mass reduction, poor compliance and response to cancer treatments, decreased quality of life, and reduced survival time. The nutritional assessment and intervention should be a vital part of any comprehensive cancer treatment plan. However, data on artificial nutrition supplied based on caloric needs during cancer care are scarce. In this review, we discuss the recommendations of the European and American societies for clinical nutrition on the use of nutritional interventions in malnourished patients with cancer in the context of current clinical practice. In particular, when enteral nutrition (oral or tube feeding) is not feasible or fails to meet the complete nutritional needs, supplemental parenteral nutrition (SPN) can bridge the gap. We report the available evidence on SPN in cancer patients and identify the perceived barriers to the wider application of this intervention. Finally, we suggest a ‘permissive’ role of SPN in cancer care but highlight the need for rigorous clinical studies to further evaluate the use of SPN in different populations of cancer patients.

Randomised controlled trial testing the feasibility of an exercise and nutrition intervention for patients with ovarian cancer during and after first-line chemotherapy (BENITA-study)

OBJECTIVES

Advanced ovarian cancer is a severe disease with major side effects caused by peritoneal carcinomatosis, ascites and gastrointestinal involvement as well as exhaustive treatment like debulking surgery and combination chemotherapy. Two most frequently reported side effects are muscle wasting and malnutrition, leading to frailty, decreased health-related quality of life (HRQoL) and cancer-related fatigue (CRF). As muscle wasting and malnutrition often commence during first-line chemotherapy and develop progressively into a refractory state, an early intervention is warranted. This pilot study aimed to evaluate the safety and acceptance of a combined exercise and nutrition intervention during and after first-line chemotherapy.

DESIGN

The pilot study was conducted as a monocentric 1:1 randomised controlled trial (RCT) with an intervention group (IG) and a control group (CG). Participants were divided by chance into IG or CG. Information on group allocation was conveyed to the study coordinator responsible for making an appointment with the patients for the baseline assessment as well as the physiotherapist and nutritionist responsible for the intervention and outcome assessment in both groups.

PARTICIPANTS

Eligibility criteria included women ≥18 years of age, diagnosed with ovarian cancer, tubal cancer or peritoneal cancer and primary or interval debulking, scheduled but not started adjuvant or neoadjuvant chemotherapy and sufficient German-language skills.

INTERVENTION

The IG received a 12-month exercise and nutrition programme, the CG continued to follow usual care.

PRIMARY AND SECONDARY OUTCOME MEASURES

Primary outcomes were recruitment rate, adherence to intervention, completion rate and adverse events. In addition, in-person assessments (eg, HRQoL, CRF, muscle quality and function and dietary intake and quality) were conducted at baseline (T0, before chemotherapy), week 9 (T1, mid-chemotherapy), week 19 (T2, after completion of chemotherapy) and after 12 months of intervention (T3).

RESULTS

Of 60 eligible patients, 15 patients signed informed consent (recruitment rate=25.0%) and were randomised into IG (n=8) and CG (n=7). Eleven participants completed the study (completion rate, 73.3%), one patient dropped out due to loss of interest, one due to poor health, one was lost to follow-up and one patient died.

CONCLUSION

The BENITA (Bewegungs- und Ernährungsintervention bei Ovarialkrebs) study demonstrated the safety and acceptance of an exercise and nutrition intervention integrated into first-line therapy and follow-up care of ovarian cancer. A large multicentre RCT is planned to investigate the effectiveness of the intervention on HRQoL, CRF and survival and to establish means of implementation into oncology guidelines and clinic routine.

TRIAL REGISTRATION NUMBER

DRKS00013231.

Exercise-Based Interventions to Counteract Skeletal Muscle Mass Loss in People with Cancer: Can We Overcome the Odds?

Addressing skeletal muscle mass loss is an important focus in oncology research to improve clinical outcomes, including cancer treatment tolerability and survival. Exercise is likely a necessary component of muscle-mass-preserving interventions for people with cancer. However, randomized controlled trials with exercise that include people with cancer with increased susceptibility to more rapid and severe muscle mass loss are limited. The aim of the current review is to highlight features of cancer-related skeletal muscle mass loss, discuss the impact in patients most at risk, and describe the possible role of exercise as a management strategy. We present current gaps within the exercise oncology literature and offer several recommendations for future studies to support research translation, including (1) utilizing accurate and reliable body composition techniques to assess changes in skeletal muscle mass, (2) incorporating comprehensive assessments of patient health status to allow personalized exercise prescription, (3) coupling exercise with robust nutritional recommendations to maximize the impact on skeletal muscle outcomes, and (4) considering key exercise intervention features that may improve exercise efficacy and adherence. Ultimately, the driving forces behind skeletal muscle mass loss are complex and may impede exercise tolerability and efficacy. Our recommendations are intended to foster the design of high-quality patient-centred research studies to determine whether exercise can counteract muscle mass loss in people with cancer and, as such, improve knowledge on this topic.

Applied nutritional investigation The clinical application value of the extracellular-water-to-total-body-water ratio obtained by bioelectrical impedance analysis in people with advanced cancer

OBJECTIVES

Body-composition analysis using bioelectrical impedance analysis is gradually becoming more widely used in clinical practice. The ratio of extracellular water (ECW) to total body water (TBW) is thought to be related to the prognosis of a variety of diseases. However, its performance in people with advanced cancer deserves further discussion.

METHODS

A retrospective analysis was performed on 784 people with advanced cancer. Anthropometric indicators, serologic indicators, nutritional status, health-related quality of life, and body composition were analyzed. Participants were grouped into two groups according to ECW/TBW ratio. We used t tests and χ² tests to analyze differences between the groups. Univariate and multivariate Cox regressions were conducted to analyze the factors influencing overall survival. Logistic regression was used to analyze the related factors of malnutrition, and linear regression for factors of health-related quality of life.

RESULTS

Age, body mass index, Patient-Generated Subjective Global Assessment score, Karnofsky Performance Status questionnaire score, skeletal muscle mass index, and fat-free mass index were statistically different between the non-overhydrated and overhydrated groups. Univariate and multivariate Cox regression models showed that an ECW/TBW ≥ 0.40 is a risk factor for poor prognosis in people with advanced cancer (hazard ratio = 1.511; 95% confidence interval, 1.103-2.070; P = 0.010). Subgroup analyses were next conducted according to tumor type, with ECW/TBW ≥ 0.40 emerging as a risk factor for poor prognosis for people with advanced breast cancer and advanced gastric cancer. Logistic regression showed that ECW/TBW ≥ 0.40 is a risk factor for malnutrition in people with advanced cancer (odds ratio = 1.988; 95% confidence interval, 1.049-3.767; P = 0.035). The univariate and multivariate linear regression models showed that the ECW/TBW ratio is an influencing factor for health-related quality of life in the domains of physical functioning, role functioning, and constipation.

CONCLUSION

We found that in people with cancer, an ECW/TBW ≥ 0.40 was a risk factor for malnutrition and lower health-related quality of life, and in people with advanced cancer, it was a risk factor for poor prognosis.

Degradation of skeletal mass in locally advanced oesophageal cancer between initial diagnosis and recurrence

BACKGROUND

The prognostic value of a low skeletal mass index (SMI) has been investigated in locally advanced oesophageal (LAE) cancer at diagnosis. However, nothing is known about its evolution and clinical impact between initial diagnosis and recurrence.

METHODS

A total of 89 patients treated for LAE cancer between January 2009 and December 2019 were included in this study. Computed tomography (CT) scans before treatment and at recurrence were evaluated. SMI and other body composition parameters were analysed by the L3 scan method.

RESULTS

Participants were aged 66.0 (36.0-86) years. The incidence of low SMI increased by 12.3% between diagnosis and recurrence (70.7% vs. 83.0%, respectively) over a median follow-up of 16.9 (1.7-101.6) months. Patients with high SMI at diagnosis showed loss of muscle mass (58.0 vs. 55.2 cm²/m², respectively; P < 0.001) and decreased body mass index (BMI) (27.9 vs. 26.3 kg/m², respectively; P = 0.05), but fat mass was increased (68.9 vs. 72.0 cm²/m², respectively; P = 0.01). Patients with low SMI at diagnosis showed no significant changes in body composition parameters and no improvement of SMI, even with nutritional support. Low SMI (hazard ratio [HR]: 1.8; 95% confidence interval [CI]: 1.02-3.16) was an independent predictor (P = 0.041) of high nutritional risk index (HR: 1.79; 95% CI: 1.03-3.11; P = 0.039) at diagnosis.

CONCLUSIONS

The percentage of patients with a low SMI increased during follow-up. Our data suggest that an assessment of skeletal muscle parameters and nutrition support may be more useful in patients with a high SMI.

Impact of body-mass index on treatment and outcome in locally advanced rectal cancer: A secondary, post-hoc analysis of the CAO/ARO/AIO-04 randomized phase III trial

BACKGROUND

A better understanding of the impact of body-mass index (BMI) on the course of multimodal therapy and oncologic outcome in locally advanced rectal cancer could provide new insights for optimization of treatment and supportive strategies.

PATIENTS AND METHODS

Correlations of BMI with pretreatment clinical, surgical, and pathological characteristics, toxicity and treatment adherence using the Pearson's Chi-squared test or logistic regression were analyzed in the CAO/ARO/AIO-04 III trial cohort (n = 1236). One-way ANOVA or Welch test were used to analyze correlations of baseline blood-parameters and BMI. The prognostic role of BMI was examined with log-rank test and multivariate cox regression.

RESULTS

Obese had a better ECOG performance status (P = 0.027) but were less likely to undergo sphincter preserving surgery (P = 0.01). Post-surgical complications did not differ significantly between BMI classes, whereas underweight was associated with increased neutrophil (P = 0.025) and platelet counts (P < 0.001), poorer TME quality (P = 0.007) and increased incidence of acute organ toxicity (P < 0.001). After a median follow-up of 50 months, underweight [HR 1.896, P = 0.014] and overweight [HR 1.392, P = 0.042] were associated with worse DFS. Obese patients had an increased risk of death [HR 1.653, P = 0.032]. Normalweight men showed superior OS compared to underweight [HR 4.070, P = 0.002], overweight [HR 2.077, P = 0.010], severe overweight [HR 1.886, P = 0.026] and obese [HR 2.046, P = 0.015] men. Adding oxaliplatin to standard CRT significantly improved DFS in obese patients (P = 0.034).

CONCLUSION

In our study, underweight and overweight correlated with inferior DFS, underweight experienced more organ toxicity and obesity was associated with an increased risk of abdominoperineal resection and poorer overall survival.

Artificial Nutrition in Patients with Advanced Malignancy

Cancer is a progressive disease that can lead to malnutrition and cachexia. Artificial nutrition is a medical therapy used to combat malnutrition in these patients. In this article, the authors discuss factors affecting the decision to use artificial nutrition, including the patient's mental and physical health, technical factors of the procedures used to deliver artificial nutrition, and the oncologic factors affecting treatment. Through this review, the authors provide guidelines on who is and is not likely to benefit from therapy, available routes of administration, and necessary factors to consider for appropriate decision-making for palliative patients and those with advanced cancers."

Molecular and physical technologies for monitoring fluid and electrolyte imbalance: A focus on cancer population

Several clinical examinations have shown the essential impact of monitoring (de)hydration (fluid and electrolyte imbalance) in cancer patients. There are multiple risk factors associated with (de)hydration, including aging, excessive or lack of fluid consumption in sports, alcohol consumption, hot weather, diabetes insipidus, vomiting, diarrhea, cancer, radiation, chemotherapy, and use of diuretics. Fluid and electrolyte imbalance mainly involves alterations in the levels of sodium, potassium, calcium, and magnesium in extracellular fluids. Hyponatremia is a common condition among individuals with cancer (62% of cases), along with hypokalemia (40%), hypophosphatemia (32%), hypomagnesemia (17%), hypocalcemia (12%), and hypernatremia (1-5%). Lack of hydration and monitoring of hydration status can lead to severe complications, such as nausea/vomiting, diarrhea, fatigue, seizures, cell swelling or shrinking, kidney failure, shock, coma, and even death. This article aims to review the current (de)hydration (fluid and electrolyte imbalance) monitoring technologies focusing on cancer. First, we discuss the physiological and pathophysiological implications of fluid and electrolyte imbalance in cancer patients. Second, we explore the different molecular and physical monitoring methods used to measure fluid and electrolyte imbalance and the measurement challenges in diverse populations. Hydration status is assessed in various indices; plasma, sweat, tear, saliva, urine, body mass, interstitial fluid, and skin-integration techniques have been extensively investigated. No unified (de)hydration (fluid and electrolyte imbalance) monitoring technology exists for different populations (including sports, elderly, children, and cancer). Establishing novel methods and technologies to facilitate and unify measurements of hydration status represents an excellent opportunity to develop impactful new approaches for patient care.

Nutritional Status in Patients with Medication-Related Osteonecrosis of the Jaw (MRONJ)

Medication-related osteonecrosis of the jaw (MRONJ) is a potentially severe side effect of mostly antiresorptive drugs. The aim of this prospective clinical study was to evaluate the nutritional status in MRONJ patients scheduled for surgical treatment (intraoral soft tissue closure). The following parameters were evaluated: body weight, body height, BMI, nutritional risk index (NRI), bioelectric impedance analysis (BIA), vitamins A, B12, D3, E, K1, folic acid, iron, total protein, transferrin, ferritin, prealbumin, albumin, and zinc. All subjects were admitted to hospital four to five days before surgery and sip-fed with Nutritia Fortimel Compact Protein in addition to regular oral food intake. During surgery, a nasogastric tube was inserted and only removed on hospital discharge five days postoperatively. A total of 58 patients could be included. Half of the MRONJ patients were identified to be at risk for malnutrition. Deficiencies regarding protein levels were revealed, whereas hardly any relevant deficits of micronutrients were noted. The intraoral wound healing four weeks post-surgery was highly satisfactory with a low dehiscence rate of intraoral mucosal sites. Of all parameters analyzed, the dehiscence rate at the last follow-up four weeks post-surgery was significantly influenced by vitamin K, transferrin, and ferritin levels (p = 0.030, p = 0.004, and p = 0.023, respectively). In conclusion, perioperative dietary counselling and appropriate nutritional therapy are important supportive measures in MRONJ patients scheduled for intraoral soft tissue closure.

Management of Home Parenteral Nutrition: Complications and Survival

BACKGROUND AND AIMS

Parenteral nutrition (PN) has become an efficient, safe, and convenient treatment over years for patients suffering from intestinal failure. Home PN (HPN) enables the patients to have a high quality of life in their own environment. The therapy management however implies many restrictions and potentially severe lethal complications. Prevention and therapy of the latter are therefore of utmost importance. This study aims to assess and characterize the situation of patients with HPN focusing on prevalence of catheter-related complications and mortality.

METHODS

Swiss multicentre prospective observational study collecting demographic, anthropometric, and catheter-related data by means of questionnaires every sixth month from 2017 to 2019 (24 months), focusing on survival and complications. Data were analysed using descriptive statistics. Logistic regression models were fitted to investigate association between infection and potential co-factors.

RESULTS

Seventy adult patients (50% women) on HPN were included (≈5 patients/million adult inhabitants/year). The most common underlying diseases were cancer (23%), bariatric surgery (11%), and Crohn's disease (10%). The most prevalent indication was short bowel syndrome (30%). During the study period, 47% of the patients were weaned off PN; mortality rate reached 7% for a median treatment duration of 1.31 years. The rate of catheter-related infection was 0.66/1,000 catheter-days (0.28/catheter-year) while the rate of central venous thrombosis was 0.13/1,000 catheter-days (0.05/catheter-year).

CONCLUSION

This prospective study gives a comprehensive overview of the adult Swiss HPN patient population. The collected data are prerequisite for evaluation, comparison, and improvement of recommendations to ensure best treatment quality and safety.

Is phase angle a valuable prognostic tool in cancer patients' survival? A systematic review and meta-analysis of available literature

BACKGROUND & AIMS

The phase angle (PA), expressed via bioelectrical impedance, is an indicator of cell membrane health and integrity, hydration, and nutritional status, and may have further application as a prognostic marker in cancer survival. However, the associations between PA and cancer survival are inconsistent and unclear. The present systematic review and meta-analysis investigated the relationship between PA and survival among adult patients diagnosed with cancer.

METHODS

A systematic search of observational studies up to November 2020 was conducted through PubMed, Scopus, and ISI Web of Science. The critical appraisal of the eligible studies was performed using the Newcastle-Ottawa Quality Assessment Scale. Statistical analyses were performed using STATA 11.2 software. A P-value <0.05 was considered statistically significant.

RESULTS

A total of 14 studies covering 2625 participants were included in this study. There was a positive and significant correlation between PA and cancer survival (Fisher's Z: 0.30; 95% CI, 0.21-0.40; P < 0.001; I² = 0.0%). Also, there was a significant prognostic role for PA on patients' survival (HR 0.77; 95% CI, 0.74-0.81; P < 0.001; I² = 0.0%). In other words, patients with low values of PA were 23% less likely to survive than patients with high values of PA.

CONCLUSIONS

Given that predicting survival in advanced cancer patients remains a challenge, the findings of this systematic review and meta-analysis suggest that phase angle may be an important prognostic factor of survival in this population.

Relationship between Phase Angle and Objective and Subjective Indicators of Nutritional Status in Cancer Patients: A Systematic Review

To investigate the relationship between phase angle (PA) and objective and subjective indicators of nutritional status in cancer patients, as well as to identify cutoff points for PA, to detect malnutrition in these patients. The study was a systematic review, carried out following the guidelines of the Preferred Reporting Items for Systematic Reviews and meta-analyses (PRISMA). Literature search was performed for two authors, in indexed databases, including the National Library of Medicine, Bethesda, MD (PubMed), Latin American and Caribbean Literature in Health Sciences (LILACS), and Scopus (Elsevier). We used the checklist from the Joanna Briggs Institute for assessing the risk of bias. The review was registered with the Systematic Review Registration (PROSPERO), number CRD42020134324. In total, nine papers were eligible. PA was correlated with several objective and subjective indicators of nutritional status in most cases. Cutoff point values for the PA, capable of detecting malnutrition, varied from 4.73° to 6°, despite the modest diagnostic accuracy. We assume that PA may be considered an indicator of nutritional status, when complementing additional data and assisting health practitioners in evaluating individuals with malignant neoplasms. However, a single cutoff point with fair and concomitant sensitivity and specificity was not identified.

Nutrition and gastroenterological support in end of life care

Malnutrition and the broad spectrum of cancer cachexia frequently occur in patients with malignant disease of all tumour stages and impact on survival and quality of life of patients. Structured screening for the risk of malnutrition with validated tools and nutritional assessment are the prerequisite for adequate nutritional support in cancer patients. In patients receiving tumour directed therapy, the patients diet should meet the requirements to give optimal support, while later on comfort feeding is part of symptom focused palliation. The basis of nutritional support in a malnourished patient is nutritional counselling, and nutritional support can be offered within a step-up approach meeting the patient's needs. A combination of nutritional support with interventions targeting metabolic changes and physical exercise is suggested to treat cancer cachexia.

Bioelectrical impedance vector analysis-derived phase angle predicts survival in patients with systemic immunoglobulin light-chain amyloidosis

Background: The aim of the present prospective study (ClinicalTrials.gov Identifier: NCT02111538) was to assess the prognostic value of phase angle (PhA), derived from bioimpedance vectorial analysis (BIVA), in patients affected by systemic amyloid light-chain (AL) amyloidosis.Methods: One hundred-twenty seven consecutive newly diagnosed, treatment-naïve patients with histologically confirmed AL amyloidosis were enrolled. Nutritional assessment including BIVA-derived PhA was performed before treatment initiation.Results: PhA was associated with unintentional weight loss, caloric intake and the physical component of quality of life (QoL). After a median follow-up of 16.3 months (25th-75th percentile: 8.4-28.9 months), 49 (38.6%) subjects had died. At multivariable Cox proportional hazard analysis, PhA ≤4.3 independently predicted survival (HR = 2.26 [95%CI, 1.04-4.89]; p = .038]) after controlling for hydration status, haematologic response to treatment and modified Mayo Clinic cardiac stage. There was no effect modification of PhA on mortality by cardiac stage (P for interaction = 0.61).Conclusions: In AL amyloidosis, BIVA-derived PhA is associated with the common parameters implied in malnutrition assessment and QoL, and adjusted for hydration independently predicts survival. Due to its feasibility, BIVA should be systematically considered for the nutritional and clinical assessment of AL patients, in whom nutritional intervention trials are warranted.

Home parenteral nutrition versus artificial hydration in malnourished patients with cancer in palliative care: a prospective, cohort survival study

OBJECTIVE

The evidence base for home parenteral nutrition (HPN) in patients with advanced cancer is lacking. To compare the survival of malnourished patients with cancer undergoing palliative care who received HPN with a homogeneous group of patients, equally eligible for HPN, who did not receive HPN.

DESIGN

Prospective, cohort study; tertiary university hospital, home care, hospice.

METHODS

Patients were assessed for HPN eligibility according to the guidelines. In the eligible population, who received both HPN and chemotherapy was excluded, while who received only HPN was included in the HPN+ group and who received neither HPN nor chemotherapy but artificial hydration (AH) was included in the HPN- group.

RESULTS

301 patients were assessed for HPN eligibility and 86 patients (28.6%) were excluded for having severe organ dysfunction or Karnofsky performance status <50. In outcome analysis, 90 patients (29.9%) were excluded for receiving both HPN and chemotherapy, while 125 (41.5%) were included, 89 in HPN+ group (29.5%) and 36 in HPN- group (12%). The survival of the two groups showed a significant difference favouring patients receiving HPN (median overall survival: 4.3 vs 1.5 months, p<0.001). The multivariate analysis of the risk factors for mortality showed that not receiving HPN accounted for the strongest one (HR 25.72, 95% CI 13·65 to 48.44).

CONCLUSIONS

Comparative survival associated with the use of HPN versus AH showed significantly longer survival in malnourished patients with advanced cancer receiving HPN. These data support the guideline recommendation that HPN should be considered when malnutrition represents the overriding threat for the survival of these patients.

Nutritional Status and Quality of Life in Hospitalised Cancer Patients Who Develop Intestinal Failure and Require Parenteral Nutrition: An Observational Study

(1) Background: Malnutrition in cancer patients impacts quality of life (QoL) and performance status (PS). When oral/enteral nutrition is not possible and patients develop intestinal failure, parenteral nutrition (PN) is indicated. Our aim was to assess nutritional status, QoL, and PS in hospitalised cancer patients recently initiated on PN for intestinal failure. (2) Methods: The design was a cross-sectional observational study. The following information was captured: demographic, anthropometric, biochemical and medical information, as well as nutritional screening tool (NST), patient-generated subjective global assessment (PG-SGA), functional assessment of cancer therapy-general (FACT-G), and Karnofsky PS (KPS) data. (3) Results: Among 85 PN referrals, 30 oncology patients (56.2 years, 56.7% male) were identified. Mean weight (60.3 ± 16.6 kg) corresponded to normal body mass index values (21.0 ± 5.1 kg/m2). However, weight loss was significant in patients with gastrointestinal tumours (p < 0.01). A high malnutrition risk was present in 53.3-56.7% of patients, depending on the screening tool. Patients had impaired QoL (FACT-G: 26.6 ± 9.8) but PS indicated above average capability with independent daily activities (KPS: 60 ± 10). (4) Conclusions: Future research should assess the impact of impaired NS and QoL on clinical outcomes such as survival, with a view to encompassing nutritional and QoL assessment in the management pathway of this patient group.

Home Parenteral Nutrition in Patients with Advanced Cancer: A Systematic Review and Meta-Analysis

The use of home parenteral nutrition (HPN) in patients with incurable cancer remains controversial with significant variation worldwide. We aimed to systematically evaluate the literature from 1960 to 2018 examining the use of HPN in advanced cancer patients for all intestinal failure indications and assess the potential benefits/burdens of HPN in this cohort of patients. The primary end point was survival and secondary end points were quality of life and nutritional/performance status. Meta-analysis was performed with a random effects model, where suitable. Of 493 studies retrieved, 22 met the quality inclusion criteria. Studies were mainly conducted in Western countries (Italy, USA, Canada, Germany), including a total of 3564 patients (mean age 57.8 years). Mean duration for HPN was 5.0 mo. Mean overall survival was 7.3 mo. Patients with improved performance status survived for longer on HPN. Quality of life was sparsely reported though there was no observed negative impact of PN. HPN-related complications were reported in eight studies only and were mainly catheter-related blood stream infections. In conclusion, HPN is used for several indications in advanced cancer, though there is significant heterogeneity of results. Disparities in geographical distribution of the studies may reflect variation in accessing HPN.

Monitoring Response to Home Parenteral Nutrition in Adult Cancer Patients

Current guidelines recommend home parenteral nutrition (HPN) for cancer patients with chronic deficiencies of dietary intake or absorption when enteral nutrition is not adequate or feasible in suitable patients. HPN has been shown to slow down progressive weight loss and improve nutritional status, but limited information is available on the monitoring practice of cancer patients on HPN. Clinical management of these patients based only on nutritional status is incomplete. Moreover, some commonly used clinical parameters to monitor patients (weight loss, body weight, body mass index, and oral food intake) do not accurately reflect patient’s body composition, while bioelectrical impedance analysis (BIA) is a validated tool to properly assess nutritional status on a regular basis. Therefore, patient’s monitoring should rely on other affordable indicators such as Karnofsky Performance Status (KPS) and modified Glasgow Prognostic Score (mGPS) to also assess patient’s functional status and prognosis. Finally, catheter-related complications and quality of life represent crucial issues to be monitored over time. The purpose of this narrative review is to describe the role and relevance of monitoring cancer patients on HPN, regardless of whether they are receiving anticancer treatments. These practical tips may be clinically useful to better guide healthcare providers in the nutritional care of these patients.

The clinical and cost-effectiveness of supplemental parenteral nutrition in oncology

BACKGROUND

Clinical guidelines recommend that parenteral nutrition (PN) is added to enteral nutrition (EN; supplemental parenteral nutrition (SPN)) in order to meet energy and protein needs in patients with cancer when EN alone is insufficient. However, although cancer-related malnutrition is common, there is poor awareness of the value of nutritional care, resulting in SPN being chronically underused.

METHODS

We performed a targeted literature review and exploratory cost-utility analysis to gather evidence on the clinical effectiveness of SPN, and to estimate the potential cost-effectiveness of SPN versus EN alone in an example cancer setting.

RESULTS

The literature review identified studies linking SPN with malnutrition markers, and studies linking malnutrition markers with clinical outcomes. SPN was linked to improvements in body mass index (BMI), fat-free mass, phase angle (PhA) and prealbumin. Of these markers, BMI and PhA were strong predictors of survival. By combining published data, we generated indirect estimates of the overall survival HR associated with SPN; these ranged from 0.80 to 0.99 (mode 0.87). In patients with Stage IV inoperable pancreatic cancer, the incremental cost-effectiveness ratio versus EN alone was estimated to be £41 350 or £91 501 depending on whether nursing and home delivery costs for EN and SPN were combined or provided separately.

CONCLUSION

Despite a lack of direct evidence, the results of the literature review demonstrate that SPN may provide important clinical and quality of life benefits to patients with cancer. The potential for any improvement in outcomes in the modelled patient population is very limited, so cost-effectiveness may be greater in patients with less severe disease and other types of cancer.

Clinical characteristics and predictive factors of survival of 761 cancer patients on home parenteral nutrition: A prospective, cohort study

BACKGROUND

Robust data reporting the survival of cancer patients on home parenteral nutrition (HPN) are lacking. The aim of this prospective, cohort study was to investigate clinical characteristics, predictive factors, and overall survival (OS) of adult-malnourished cancer patients eligible for HPN according to the European guideline recommendations.

METHODS

During the study period, 1658 cancer patients were consecutively evaluated in a tertiary university hospital. Of these, 761 who received HPN were grouped into four cohorts according to the provision of supplemental PN (SPN) or total (TPN) and whether they received chemotherapy (CT⁺ or CT^- ): SPN/CT⁺ (n = 376), TPN/CT⁺ (n = 99), SPN/CT^- (n = 191), and TPN/CT^- (n = 95). Patient demographics, nutritional status, cancer-related characteristics, and prognostic scores assessed at HPN start. The primary outcome was OS.

RESULTS

Median OS was 8.9, 4.3, 5.7, and 2.2 months for the SPN/CT⁺ , TPN/CT⁺ , SPN/CT^- , and TPN/CT^- cohorts, respectively. In multivariable analysis, predictors showing significant association with decreased survival were patient cohorts, modified Glasgow Prognostic Score (1 and 2 scores), weight loss (>15%) in the 3 months before HPN start, and TNM IV stage while protective factors of survival were Karnofsky Performance Status (>50), albumin level (>3.5 g/dL), oral protein intake, BMI (>20.5), and weight at HPN start.

CONCLUSION

For the first time, in four different cohorts of cancer patients on HPN, clinical characteristics and survival were compared. This large study showed that survival is significantly correlated with patient characteristics at HPN start and that the presence of favorable factors may determine even a fourfold increase in survival. These data are expected to assist physicians in the appropriate prescription of HPN.

Impact on Health-Related Quality of Life of Parenteral Nutrition for Patients with Advanced Cancer Cachexia: Results from a Randomized Controlled Trial

BACKGROUND

Malnutrition worsens health-related quality of life (HRQoL) and the prognosis of patients with advanced cancer. This study aimed to assess the clinical benefits of parenteral nutrition (PN) over oral feeding (OF) for patients with advanced cancer cachexia and without intestinal impairment.

MATERIAL AND METHODS

In this prospective multicentric randomized controlled study, patients with advanced cancer and malnutrition were randomly assigned to optimized nutritional care with or without supplemental PN. Zelen's method was used for randomization to facilitate inclusions. Nutritional and performance status and HRQoL using the European Organization for Research and Treatment of Cancer QLQ-C15-PAL questionnaire were evaluated at baseline and monthly until death. Primary endpoint was HRQoL deterioration-free survival (DFS) defined as a definitive deterioration of ≥10 points compared with baseline, or death.

RESULTS

Among the 148 randomized patients, 48 patients were in the experimental arm with PN, 63 patients were in the control arm with OF only, and 37 patients were not included because of early withdrawal or refused consent. In an intent to treat analysis, there was no difference in HRQoL DFS between the PN arm or OF arm for the three targeted dimensions: global health (hazard ratio [HR], 1.31; 95% confidence interval [CI], 0.88-1.94; p = .18), physical functioning (HR, 1.58; 95% CI, 1.06-2.35; p = .024), and fatigue (HR, 1.19; 95% CI, 0.80-1.77; p = .40); there was a negative trend for overall survival among patients in the PN arm. In as treated analysis, serious adverse events (mainly infectious) were more frequent in the PN arm than in the OF arm (p = .01).

CONCLUSION

PN improved neither HRQoL nor survival and induced more serious adverse events than OF among patients with advanced cancer and malnutrition. Clinical trial identification number. NCT02151214 IMPLICATIONS FOR PRACTICE: This clinical trial showed that parenteral nutrition improved neither quality of life nor survival and generated more serious adverse events than oral feeding only among patients with advanced cancer cachexia and no intestinal impairment. Parenteral nutrition should not be prescribed for patients with advanced cancer, cachexia, and no intestinal failure when life expectancy is shorter than 3 months. Further studies are needed to assess the useful period with a potential benefit of artificial nutrition for patients with advanced cancer.

Can Bioelectrical Impedance Analysis and BMI be a Prognostic Tool in Head and Neck Cancer Patients? A Review of the Evidence

Background: Malnutrition can significantly affect disease progression and patient survival. The efficiency of weight loss and bioimpedance analysis (BIA)-derived measures in the evaluation of malnutrition, and disease progression and prognosis in patients with head and neck cancer (HNC) are an important area of research. Method: The PubMed database was thoroughly searched, using relative keywords in order to identify clinical trials that investigated the role of BIA-derived measures and weight loss on the disease progression and prognosis of patients with HNC. Twenty-seven studies met the criteria. More specifically, six studies examined the prognostic role of the tissue electrical properties in HNC patients; five examined the role of the tissue electrical properties on identifying malnutrition; four studies looked at the changes in the tissue electrical properties of HNC patients; and 12 examined the prognostic role of weight loss on survival and/or treatment outcomes. Results: Several studies have investigated the role of nutritional status tools on prognosis in HNC patients. Current studies investigating the potential of BIA-derived raw data have shown that phase angle (PA) and capacitance of the cell membrane may be considered prognostic factors of survival. Weight loss may be a prognostic factor for treatment toxicity and survival, despite some conflicting evidence. Conclusions: Further studies are recommended to clarify the role of BIA-derived measures on patients’ nutritional status and the impact of PA on clinical outcomes as well as the prognostic role of weight loss.

Early intravenous administration of nutritional support (IVANS) in metastatic gastric cancer patients at nutritional risk, undergoing first-line chemotherapy: study protocol of a pragmatic, randomized, multicenter, clinical trial

Background

Malnutrition is common in cancer patients, particularly in those affected by gastrointestinal malignancies, and negatively affects treatment tolerance, survival, functional status, and quality of life (QoL). Nutritional support, including supplemental parenteral nutrition (SPN), has been recommended at the earliest opportunity in malnourished cancer patients. The limited available evidence on the efficacy of SPN in gastrointestinal cancer patients is positive, particularly with regards to QoL, body composition, and energy intake, but the evidence on survival is still scanty. Furthermore, studies regarding the early administration of SPN in combination with nutritional counseling from the beginning of first-line chemotherapy (CT) are lacking. We hypothesize that early systematic SPN in combination with nutritional counseling (NC), compared with NC alone, can benefit patients with previously untreated metastatic gastric cancer at nutritional risk undergoing first-line CT.

Methods

The aim of this pragmatic, multicenter, randomized (1:1), parallel-group, open-label, controlled clinical trial is to evaluate the efficacy in terms of survival, weight maintenance, body composition, QoL and feasibility of cancer therapy of early systematic SNP. This is in combination with NC, compared with NC alone, in treatment-naïve metastatic gastric cancer patients at nutritional risk undergoing first-line CT.

Discussion

Malnutrition in oncology remains an overlooked problem. Although the importance of SPN in gastrointestinal cancer patients has been acknowledged, no studies have yet evaluated the efficacy of early SPN in metastatic gastric patients undergoing CT. The present study, which guarantees the early provision of nutritional assessment and support to all the enrolled patients in accordance with the recent guidelines and recommendations, could represent one of the first proofs of the clinical effectiveness of early intensive nutritional support in cancer patients undergoing CT. This study could stimulate further large randomized trials in different cancer types, potentially resulting in the improvement of supportive care quality.

Trial registration

This study is registered on ClinicalTrials.gov: NCT03949907.

Validation and improvement of the predictive equation for resting energy expenditure in advanced gastrointestinal cancer

OBJECTIVES

The usual predictive equations for estimating resting energy expenditure (REE) seem to be associated with significant inaccuracy in patients with advanced cancer. Recently, our group developed a predictive equation for patients with advanced head and neck cancer, showing a better accuracy when compared with indirect calorimetry. The aim of this study was to validate this predictive equation and, if necessary, to elaborate a new predictive equation for patients with advanced gastrointestinal (GI) cancer.

METHODS

This was a retrospective, unicentric observational study. Data regarding the characteristics of the study were collected using an electronic medical record from June 2016 to January 2018. The nutritional status was calculated by the body mass index (BMI). Patients with nutritional risk, by the Nutritional Risk Screening 2002, were subjectively evaluated in relation to the nutritional status by the Patient-Generated Subjective Global Assessment (PG-SGA). Sarcopenia was defined as fat-free mass index ≤17.4 kg/m² for men and ≤15 kg/m² for women. Body composition and phase angle values were evaluated by electrical bioimpedance. REE was measured by indirect calorimetry.

RESULTS

The study included 109 patients with advanced GI tract cancer. Most were male (72.5%), ≥60 y of age (61.5%), and had cancer in the esophagus region (62.4%). Most patients had not undergone any treatment at the time of the examination. Regarding nutritional characteristics, the majority of the patients were malnourished by BMI (71.6%), with a deficit of lean mass (79.8%), sarcopenia (83.5%), and a phase angle below the fifth percentile for age, sex, and BMI, showing in addition to a poor nutritional condition, an impaired cellular integrity. Most of the patients were hypermetabolic (56.9%) and their caloric intake in the preceding 3 d was insufficient in 43.1%. Through the intraclass correlation coefficient (ICC), it was possible to observe the satisfactory agreement between the REE measured by the gold standard (calorimetry) versus the Souza-Singer's formula (ICC, 0.730; 95% confidence interval, 0.659-0.789; P < 0.001). When we did the multiple linear regression model, we figured that in this group of patients with GI cancer, only lean mass, phase angle, and sex were the age-adjusted independent variables that influenced REE, which was different from the Souza-Singer formula. This way a new prediction formula for this population has been created and needs to be validated.

CONCLUSION

A new equation considering phase angle and body composition can improve the accuracy of the predictive equation.

Clinical Impact of Highly Purified, Whey Proteins in Patients Affected With Colorectal Cancer Undergoing Chemotherapy: Preliminary Results of a Placebo-Controlled Study

Background and Aims: Sarcopenia, the loss of both lean body and skeletal muscle mass, may interfere in cancer patients outcome. As investigated, whey proteins could prevent the onset of sarcopenia. We have conducted a study to evaluate the effects of whey protein in colorectal cancer patients, undergoing 5-fluorouracil-based chemotherapy. Methods: After written informed consent, patients were blind randomized 1:1 to whey protein (ProLYOtin; arm A) versus placebo (arm B). The patients were assessed both physically and nutritionally before chemotherapy and after 3 (T2) and 6 months (T3) by body impedance assessment, L3-computed tomography scan, Mini Nutritional Assessment (MNA), and Malnutrition Universal Screening Tool (MUST) tests. Results: Forty-seven patients were included in this preliminary analysis. Baseline characteristics were well balanced between the 2 arms. During chemotherapy, 33 patients were reevaluated: anthropometric parameters (lean body mass from 68.5% to 71.2% vs 68.7% to 66.3%, and sarcopenia from 84% to 54% and 83% to 77% from baseline to T2 evaluation in arms A and B, respectively), nutritional status (MNA >24 = 100% [A] vs 73.7% [B]), and toxicity (no adverse effects in 86% [A] vs 29% [B] and 94% [A] vs 29% [B] for hematological and gastrointestinal toxicities, respectively) resulted to be significantly different. At univariate analysis, a condition of malnutrition risk according to MUST (relative risk [RR] = 7.5, P = .02) or MNA (RR = 1.45, P = .02) and ProLYOtin intake (RR = 0.12, P = .01) were found to be significantly predictive of chemotherapy toxicity. Conclusions: At present, our study shows how whey protein could be an important therapeutic option to improve nutritional status, and particularly to prevent severe toxicity during chemotherapy.

Nutritional Therapy in Cancer Patients Receiving Chemoradiotherapy: Should We Need Stronger Recommendations to Act for Improving Outcomes?

One of the challenges during chemotherapy and radiotherapy is to complete the planned cycles and doses without dose-limiting toxicity. Growing evidence clearly demonstrates the relationship between dose-limiting toxicity and low muscle mass. Moreover, malnutrition leads to low performance status, impaired quality of life, unplanned hospital admissions, and reduced survival.

In the past, the lack of clear and authoritative recommendations and guidelines has meant that oncologists have not always fully appreciated the importance of nutritional therapy in patients receiving anticancer treatments. Therefore, collaboration between oncologists and clinical nutrition specialists needs to be urgently improved.

Recent guidelines from scientific societies and practical recommendations by inter-society consensus documents can be summarized as follows: 1) timely nutritional therapy should be carefully considered if patients undergoing anticancer treatments are malnourished or at risk of malnutrition due to inadequate oral intake; 2) if oral intake is inadequate despite counseling and oral nutritional supplements, supplemental enteral nutrition or, if this is not sufficient or feasible, parenteral nutrition should be considered; 3) home artificial nutrition should be prescribed and regularly monitored using defined protocols developed between oncologists and clinical nutrition specialists; 4) appropriate nutritional management in the context of simultaneous care should become a guaranteed right for all patients with cancer.

The purpose of this review is to provide oncologists with an overview of the aims and current evidence about nutrition in oncology, together with updated practical and concise recommendations on the application of nutritional therapy in cancer patients receiving chemoradiotherapy.