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Tan GHC, Chia CS, Wong JSM, Ong WS, Zhu HY, Ong CAJ, Teo MCC. Randomized Controlled Trial Investigating Perioperative Immunonutrition for Patients Undergoing Cytoreductive Surgery (CRS) and Hyperthermic Intraperitoneal Chemotherapy (HIPEC). Ann Surg Oncol 2023; 30:777-789. [PMID: 36180619 DOI: 10.1245/s10434-022-12509-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Accepted: 08/15/2022] [Indexed: 01/06/2023]
Abstract
BACKGROUND Immunonutrition has been shown to reduce hospital stay and postoperative morbidity in patients undergoing gastrointestinal, and head and neck surgery. However, its use has not been demonstrated in patients undergoing cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS-HIPEC). This study aims to determine the effectiveness of perioperative immunonutrition on patients undergoing CRS-HIPEC in reducing length of hospitalization and postoperative complications. PATIENTS AND METHODS From April 2017 to December 2018, patients undergoing CRS-HIPEC for peritoneal metastases in a single center were enrolled in a randomized controlled trial. Patients with evidence of intestinal obstruction or with diabetes mellitus were excluded. Patients were randomly assigned in a 1:1 fashion to receive perioperative oral immunonutrition or standard nutritional feeds. Length of hospital stay and rates of wound infection and complications were recorded and compared between the two groups in an intention-to-treat manner. RESULTS A total of 62 patients were recruited and randomized into two groups. Compliance to nutritional feeds in the preoperative period was significantly higher in the standard nutrition group (95.2% versus 75.4%, p = 0.004). There was no difference in postoperative compliance rates. Length of hospital stay and rates of wound infection and postoperative complications were higher in the standard nutrition group when compared with patients on immunonutrition (15.5 versus 11.1 days, p = 0.186; 19% versus 9.7%, p = 0.473; 16% versus 9.7%, p = 0.653; respectively). CONCLUSIONS Patients undergoing CRS-HIPEC who received perioperative immunonutrition had shorter hospitalization and less wound infections and postoperative complications, although the differences with the standard nutrition group were not statistically significant. Potential benefits of perioperative immunonutrition need to be further evaluated in larger studies.
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Affiliation(s)
- Grace Hwei Ching Tan
- Department of Sarcoma, Peritoneal and Rare Tumours (SPRinT), Division of Surgery and Surgical Oncology, National Cancer Centre, Singapore, Singapore. .,Department of Sarcoma, Peritoneal and Rare Tumours (SPRinT), Division of Surgery and Surgical Oncology, Singapore General Hospital, Singapore, Singapore.
| | - Claramae Shulyn Chia
- Department of Sarcoma, Peritoneal and Rare Tumours (SPRinT), Division of Surgery and Surgical Oncology, National Cancer Centre, Singapore, Singapore.,Department of Sarcoma, Peritoneal and Rare Tumours (SPRinT), Division of Surgery and Surgical Oncology, Singapore General Hospital, Singapore, Singapore.,Duke-NUS Medical School, SingHealth Duke-NUS Oncology Academic Clinical Program, Singapore, Singapore.,Division of Clinical Trials & Epidemiological Sciences, National Cancer Centre Singapore, Singapore, Singapore
| | - Jolene Si Min Wong
- Department of Sarcoma, Peritoneal and Rare Tumours (SPRinT), Division of Surgery and Surgical Oncology, National Cancer Centre, Singapore, Singapore.,Department of Sarcoma, Peritoneal and Rare Tumours (SPRinT), Division of Surgery and Surgical Oncology, Singapore General Hospital, Singapore, Singapore.,Duke-NUS Medical School, SingHealth Duke-NUS Oncology Academic Clinical Program, Singapore, Singapore.,Division of Clinical Trials & Epidemiological Sciences, National Cancer Centre Singapore, Singapore, Singapore
| | - Whee Sze Ong
- Division of Clinical Trials & Epidemiological Sciences, National Cancer Centre Singapore, Singapore, Singapore
| | - Hong-Yuan Zhu
- Department of Sarcoma, Peritoneal and Rare Tumours (SPRinT), Division of Surgery and Surgical Oncology, National Cancer Centre, Singapore, Singapore.,Department of Sarcoma, Peritoneal and Rare Tumours (SPRinT), Division of Surgery and Surgical Oncology, Singapore General Hospital, Singapore, Singapore.,Laboratory of Applied Human Genetics, Division of Medical Sciences, National Cancer Centre Singapore, Singapore, Singapore
| | - Chin-Ann Johnny Ong
- Department of Sarcoma, Peritoneal and Rare Tumours (SPRinT), Division of Surgery and Surgical Oncology, National Cancer Centre, Singapore, Singapore.,Department of Sarcoma, Peritoneal and Rare Tumours (SPRinT), Division of Surgery and Surgical Oncology, Singapore General Hospital, Singapore, Singapore.,Duke-NUS Medical School, SingHealth Duke-NUS Oncology Academic Clinical Program, Singapore, Singapore.,Division of Clinical Trials & Epidemiological Sciences, National Cancer Centre Singapore, Singapore, Singapore.,Laboratory of Applied Human Genetics, Division of Medical Sciences, National Cancer Centre Singapore, Singapore, Singapore.,Institute of Molecular and Cell Biology, A*STAR Research Entities, Singapore, Singapore
| | - Melissa Ching Ching Teo
- Department of Sarcoma, Peritoneal and Rare Tumours (SPRinT), Division of Surgery and Surgical Oncology, National Cancer Centre, Singapore, Singapore.,Department of Sarcoma, Peritoneal and Rare Tumours (SPRinT), Division of Surgery and Surgical Oncology, Singapore General Hospital, Singapore, Singapore.,Duke-NUS Medical School, SingHealth Duke-NUS Oncology Academic Clinical Program, Singapore, Singapore.,Division of Clinical Trials & Epidemiological Sciences, National Cancer Centre Singapore, Singapore, Singapore
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2
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Caccialanza R, Laviano A, Bosetti C, Nardi M, Casalone V, Titta L, Mele R, De Pergola G, De Lorenzo F, Pedrazzoli P. Clinical and economic value of oral nutrition supplements in patients with cancer: a position paper from the Survivorship Care and Nutritional Support Working Group of Alliance Against Cancer. Support Care Cancer 2022; 30:9667-9679. [PMID: 35792925 DOI: 10.1007/s00520-022-07269-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 06/27/2022] [Indexed: 10/17/2022]
Abstract
Malnutrition is a common clinical and public health problem that can frequently affect patients in hospital and community settings. In particular, cancer-related malnutrition results from a combination of metabolic dysregulation and anorexia, caused both by the tumor itself and by its treatment. Patients with head-neck cancer, or with gastroesophageal, pancreatic, lung, and colorectal cancer, are particularly at risk of developing malnutrition, with a prevalence varying between 30 and 50% depending on tumor location and anti-cancer treatment complications. Prevention and adequate management of malnutrition is now considered an essential key point of therapeutic pathways of patients with cancer, with the aim to enhance their quality of life, reduce complications, and improve clinical outcomes. Oral nutritional supplements (ONS) are part of the nutritional therapy and represent an effective tool to address cancer-related malnutrition, as supported by growing literature data. However, patients' access to ONS - which is regulated by different national and regional policies in terms of reimbursement - is quite heterogeneous. This narrative review aims to summarize the current knowledge about the role of ONS in terms of cost-effectiveness in the management of actively treated patients with cancer, following surgery and/or radiotherapy/chemotherapy treatment and to present the position on this issue of the Alliance Against Cancer, the Italian National Oncology Network, coming up from a focused virtual roundtable of the Survivorship Care and Nutritional Support Working Group.
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Affiliation(s)
- Riccardo Caccialanza
- Clinical Nutrition and Dietetics Unit, Fondazione IRCCS Policlinico San Matteo, Viale Golgi 19, 27100, Pavia, Italy.
| | - Alessandro Laviano
- Department of Translational and Precision Medicine, Sapienza University, Rome, Italy
| | - Cristina Bosetti
- Unit of Cancer Epidemiology, Department of Oncology, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | - Mariateresa Nardi
- Nutritional Support Unit, Veneto Institute of Oncology IOV-IRCCS, Padua, Italy
| | - Valentina Casalone
- Clinical Nutrition and Dietetics Unit, Candiolo Cancer Institute, FPO-IRCCS, Turin, Italy
| | - Lucilla Titta
- Department of Experimental Oncology, European Institute of Oncology, Milan, Italy
| | - Roberto Mele
- Hospital Health Direction, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Giovanni De Pergola
- Unit of Geriatrics and Internal Medicine, National Institute of Gastroenterology "Saverio de Bellis" Research Hospital, Castellana Grotte, Bari, Italy
| | | | - Paolo Pedrazzoli
- Medical Oncology Unit, Fondazione IRCCS Policlinico San Matteo and Department of Internal Medicine, University of Pavia, Pavia, Italy
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Li W, Guo H, Li L, Cui J. Cost-Effectiveness Analyses of Home Parenteral Nutrition for Incurable Gastrointestinal Cancer Patients. Front Oncol 2022; 12:858712. [PMID: 35664760 PMCID: PMC9157576 DOI: 10.3389/fonc.2022.858712] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 04/13/2022] [Indexed: 11/18/2022] Open
Abstract
Background Appropriate nutritional support, including supplemental home parenteral nutrition (sHPN), may improve prognosis and quality of life (Qol) of malnourished cancer patients. We aimed to explore the cost-effectiveness of sHPN for incurable gastrointestinal cancer patients from the Chinese healthcare perspective. Method Clinical data were extracted from a randomized controlled trial (NCT02066363). Patients were randomized into the sHPN group or the non-sHPN group (receiving best practice nutritional care). A Markov model was established with a 6-week cycle length. Costs were acquired from local hospitals, effect parameters included quality-adjusted life year (QALY), Qol, body mass index, fat-free mass (FFM), FFM index, handgrip strength, and a 6-min walking test. Sensitivity analyses were conducted with a willingness-to-pay (WTP) set at 3 per capita gross domestic product ($29,307/QALY). Results When considering QALY as a utility, the incremental cost-effectiveness ratio (ICER) was $24,289.17, with an incremental cost of $2,051.18 and an incremental QALY of 0.0844 between the sHPN group and the non-sHPN group. Furthermore, we explored the cost-effectiveness of sHPN from multidimensions, where we analyzed various effect parameters at different visits; the results showed a superior benefit for patients in the sHPN group except for the handgrip parameter at visit 2. Sensitivity analysis demonstrated the influence of utilities in the sHPN group, but the sHPN group was still cost-effective with a WTP of $2,500/QALY. Conclusion In China, sHPN was cost-effective for patients with incurable gastrointestinal cancer, which suggested further applications in clinical practice and provided references for clinical decisions and pricing.
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Affiliation(s)
| | | | | | - Jiuwei Cui
- Cancer Center, The First Hospital of Jilin University, Changchun, China
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Niu JW, Zhou L, Liu ZZ, Pei DP, Fan WQ, Ning W. A Systematic Review and Meta-Analysis of the Effects of Perioperative Immunonutrition in Gastrointestinal Cancer Patients. Nutr Cancer 2020; 73:252-261. [PMID: 32285694 DOI: 10.1080/01635581.2020.1749291] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Jin-Wei Niu
- Department of General Surgery, China-Japan Friendship Hospital, Beijing, China
| | - Lei Zhou
- Department of General Surgery, China-Japan Friendship Hospital, Beijing, China
| | - Zhi-Ze Liu
- Department of General Surgery, China-Japan Friendship Hospital, Beijing, China
| | - Dong-Po Pei
- Department of General Surgery, China-Japan Friendship Hospital, Beijing, China
| | - Wen-Qiang Fan
- Department of General Surgery, China-Japan Friendship Hospital, Beijing, China
| | - Wu Ning
- Department of General Surgery, China-Japan Friendship Hospital, Beijing, China
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Tumas J, Jasiūnas E, Strupas K, Šileikis A. Effects of Immunonutrition on Comprehensive Complication Index in Patients Undergoing Pancreatoduodenectomy. MEDICINA (KAUNAS, LITHUANIA) 2020; 56:E52. [PMID: 31991566 PMCID: PMC7074545 DOI: 10.3390/medicina56020052] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Revised: 01/19/2020] [Accepted: 01/21/2020] [Indexed: 02/07/2023]
Abstract
Background and objectives: Immunonutrition is recommended by enhanced recovery after surgery in patients undergoing pancreatoduodenectomy for 5-7 days perioperatively as it may reduce the rate of infectious complications. However, data on effect of immunonutrition on the overall complication rate are contradictory and it is not clear, which groups of patients benefit most. The aims of this study are to evaluate the effects of immunonutrition on the overall complication rate and the rate of severe and/or multiple complications in patients with pancreatic tumours stratified according to final histological diagnosis-patients with pancreatic ductal adenocarcinoma (PDAC) vs. other tumours-and nutritional state, using more sensitive Comprehensive Complication Index. Materials and Methods: Seventy consecutive patients scheduled for pancreatoduodenectomy because of pancreatic tumours were randomised into immunonutrition vs. control groups and stratified according to final histological diagnosis and nutritional status. Surgical outcomes were assessed postoperatively using Clavien-Dindo classification (CDC) and Comprehensive Complication Index (CCI). Results: No significant differences in the overall complication rates in immunonutrition vs. control, patients with malnutrition vs. no malnutrition, PDAC vs. other pancreatic tumours groups were detected. However, significant differences in the rates of severe and/or multiple complications in immunonutrition vs. control groups and in PDAC patients segregated according to immunonutrition were obtained using CCI. Conclusions: Patients with PDAC may experience greater benefits of immunonutrition as compared to patients with benign pancreatic diseases or less aggressive tumours, while nutritional status was not a determining factor for the efficacy of immunonutrition.
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Affiliation(s)
- Jaroslav Tumas
- Clinic of Gastroenterology, Nephrourology and Surgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, 03101 Vilnius, Lithuania; (K.S.); (A.Š.)
| | - Eugenijus Jasiūnas
- Centre of Informatics and Development, Vilnius University Hospital Santaros Klinikos, 08406 Vilnius, Lithuania;
| | - Kęstutis Strupas
- Clinic of Gastroenterology, Nephrourology and Surgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, 03101 Vilnius, Lithuania; (K.S.); (A.Š.)
| | - Audrius Šileikis
- Clinic of Gastroenterology, Nephrourology and Surgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, 03101 Vilnius, Lithuania; (K.S.); (A.Š.)
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Claudino MM, Lopes JR, Rodrigues VD, de Pinho NB, Martucci RB. Postoperative complication rate and survival of patients with gastric cancer undergoing immunonutrition: A retrospective study. Nutrition 2019; 70:110590. [PMID: 31739174 DOI: 10.1016/j.nut.2019.110590] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2019] [Revised: 08/26/2019] [Accepted: 08/27/2019] [Indexed: 12/19/2022]
Abstract
OBJECTIVES This study aimed to evaluate the effect of preoperative immunonutrition on the rate of postoperative complication and survival of patients with gastric cancer. METHODS A retrospective cohort was formed after data collection of patients hospitalized with gastric cancer. Postoperative complications classified according to the Clavien-Dindo classification system, length of hospital stay, readmissions, and rates of survival at 6 mo, 1 y, and 5 y were analyzed. A χ2 or Fisher's exact test, Student or Mann-Whitney t test, and Kaplan-Meier and Cox regressions were used in the statistical analysis. RESULTS A total of 164 patients were included in the study, with 56 patients assigned to the immunonutrition group and 108 to the conventional group. There were no significant differences in postoperative complications between the immunonutrition and conventional groups (51.8% versus 58.3%; P = 0.423). The most frequent complications were fistula and surgical wound infection. Length of hospital stay did not differ between the groups (median of 7.0 d: P = 0.615) and the presence of readmissions did not differ either (12.5% versus 15.7%; P = 0.648). In the multivariate Cox regression, in a pooled model for group, age, sex, body mass index, Charlson comorbidity index, staging, neoadjuvant chemotherapy, and type of surgery, there was a significant difference in survival rates at 6 mo (P = 0.011), 1 y (P = 0.006), and 5 y (P < 0.001). CONCLUSIONS Preoperative immunonutrition in patients with gastric cancer did not reduce postoperative complications or length of hospital stay. More studies are needed to confirm the benefit of immunonutriton supplementation for overall survival when associated with other protective factors.
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Affiliation(s)
| | | | - Viviane Dias Rodrigues
- National Cancer Institute José Alencar Gomes da Silva (INCA), Rio de Janeiro, Brazil; Brazilian Society of Oncology Nutrition, Rio de Janeiro, Brazil
| | - Nivaldo Barroso de Pinho
- National Cancer Institute José Alencar Gomes da Silva (INCA), Rio de Janeiro, Brazil; Brazilian Society of Oncology Nutrition, Rio de Janeiro, Brazil
| | - Renata Brum Martucci
- National Cancer Institute José Alencar Gomes da Silva (INCA), Rio de Janeiro, Brazil; Brazilian Society of Oncology Nutrition, Rio de Janeiro, Brazil; Nutrition Institute, State University of Rio de Janeiro, Rio de Janeiro, Brazil.
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Howes N, Atkinson C, Thomas S, Lewis SJ. Immunonutrition for patients undergoing surgery for head and neck cancer. Cochrane Database Syst Rev 2018; 8:CD010954. [PMID: 30160300 PMCID: PMC6513580 DOI: 10.1002/14651858.cd010954.pub2] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Patients with head and neck cancer are often malnourished. Surgery for such cancers is complex and may be undertaken after a course of radiotherapy. As a result, patients may have postoperative complications such as fistulae and wound infections, as well as more generalised infections such as pneumonia. One possible way to enhance recovery, and reduce the incidence of these complications, is by improving nutrition. Nutritional formulas that deliver basic nutrients as well as amino acids (arginine and glutamine), ribonucleic acid (RNA) and/or lipids (omega-3 fatty acids) are known as immunonutrition. OBJECTIVES To assess the effects of immunonutrition treatment, compared to standard feeding, on postoperative recovery in adult patients undergoing elective (non-emergency) surgery for head and neck cancer. SEARCH METHODS The Cochrane ENT Information Specialist searched the ENT Trials Register; Central Register of Controlled Trials (CENTRAL); PubMed; Ovid Embase; CINAHL; Web of Science; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 14 February 2018. SELECTION CRITERIA We included randomised controlled trials (RCTs) comparing immunonutrition given either preoperatively, postoperatively or perioperatively to adult patients (18 years of age or older) undergoing an elective surgical procedure for head and neck cancer, compared with a control group receiving either standard polymeric nutritional supplements or no supplements. DATA COLLECTION AND ANALYSIS We used the standard methodological procedures expected by Cochrane. The primary outcomes were: length of hospital stay (days), wound infection, fistula formation and adverse events/tolerance of feeds, as defined by trial authors. Secondary outcomes were: all-cause mortality and postoperative complications (as defined by trial authors). We used GRADE to assess the quality of the evidence for each outcome; this is indicated in italics. MAIN RESULTS We included 19 RCTs (1099 participants). The mean age of participants ranged from 47 to 66 years. Most studies (12/19) had fewer than 25 patients in each treatment group. Most studies (16/19) used immunonutrition formulas containing arginine, but there was variation in the actual products and amounts used, and in the length of intervention postoperatively. Follow-up time for outcome measurement varied considerably across studies, ranging from five days to greater than or equal to 16 months.Primary outcomesWe found no evidence of a difference in the length of hospital stay (mean difference -2.5 days, 95% confidence interval (CI) -5.11 to 0.12; 10 studies, 757 participants; low-quality evidence). Similarly, we found no evidence of an effect of immunonutrition on wound infection (risk ratio (RR) 0.94, 95% CI 0.70 to 1.26; 12 studies, 812 participants; very low-quality evidence). Fistula formation may be reduced with immunonutrition; the absolute risks were 11.3% and 5.4% in the standard care and immunonutrition groups, with a RR of 0.48 (95% CI 0.27 to 0.85; 10 studies, 747 participants; low-quality evidence). We found no evidence of a difference in terms of tolerance of feeds ('adverse events') between treatments (RR 1.33, 95% CI 0.86 to 2.06; 9 studies, 719 participants; very low-quality evidence).Secondary outcomesWe found no evidence of a difference between treatments in all-cause mortality (RR 1.33, 95% CI 0.48 to 3.66; 14 studies, 776 participants; low-quality evidence). Other postoperative complications such as pneumonia and urinary tract infections were not commonly reported. AUTHORS' CONCLUSIONS The risk of postoperative fistula formation may be reduced with immunonutrition, but we found no evidence of an effect of immunonutrition on any of the other outcomes that we assessed. The studies included in this review were generally small or at high risk of bias (or both). We judged the overall quality of the evidence to be low for the outcomes length of hospital stay and all-cause mortality, and very low for wound infection and adverse events. Further research should include larger, better quality studies.
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Affiliation(s)
| | - Charlotte Atkinson
- University Hospitals Bristol NHS Foundation Trust and the University of BristolNIHR Bristol Biomedical Research CentreUpper Maudlin StreetBristolAvonUKBS2 8AE
| | - Steven Thomas
- University Hospitals Bristol NHS TrustHead & Neck SurgeryMarlborough StreetBristolUKBS1 3NU
| | - Stephen J Lewis
- Derriford HospitalDepartment of GastroenterologyDerriford RoadPlymouthDevonUKPL6 8DH
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