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

Cancer-Related Malnutrition and the Role of Parenteral Nutrition in Cancer; A Narrative Review

The growing incidence rate of cancer and its associated morbidity and mortality prompts the need to identify factors that could improve the quality of life (QoL) and survival of a patient with cancer. Cancer-associated malnutrition is a common complication that could start at the early stages of cancer and could further develop into advanced cachexia. Response to treatment, length of hospital stay, progression of infection, and other complications of cancer including chemotherapy adverse events could all be influenced by the progression of malnutrition. Nutritional interventions may vary from oral to enteral and parenteral therapy. Parenteral nutrition (PN) therapy may benefit patients at certain stages of cancer in whom contraindications or inefficacy of other modalities of nutritional support are present. This method may seem invasive, costly, and risky but at the same time may improve certain patients' QoL and chance of survival. In trained settings with proper facilities, this method of nutritional support can benefit patients; However, the indication for starting PN must be carefully supervised considering that other nutritional support methods may be equally efficient and at the same time easier to access and apply.

Malnutrition management and the application of medical nutrition therapy in hospitalized patients at the end of life

OBJECTIVES

(1) To determine the prevalence of malnutrition risk in hospitalized patients at the end of life (EOL), (2) to evaluate which nutritional interventions are administered in hospitalized end-of-life patients with malnutrition risk and (3) to assess the association of end-of-life care and the administration of medical nutrition therapy in patients with malnutrition risk.

DESIGN

Cross-sectional multi-center study SETTING: Hospital PARTICIPANTS: Hospitalized adult patients MEASUREMENTS: Based on the valid and reliable questionnaire of the Nursing Quality Measurement 2.0 (LPZ), the parameters of demographic data, medical diagnoses, end-of-life phase, care dependency, malnutrition risk according to the Malnutrition Universal Screening Tool (MUST) and nutritional interventions conducted in patients at risk of malnutrition were assessed. Descriptive statistics and statistical tests were conducted. Logistic regression models were established to identify odds ratios (OR) and confidence intervals (CI) for the association of end-of-life care and the provision of medical nutrition therapy. This was done separately for oral nutritional supplements (ONS), enteral nutrition and parenteral nutrition as the respective dependent variables.

RESULTS

Of all 12,947 participants, 706 (5.5%) were in an end-of-life phase. The prevalence of malnutrition risk in end-of-life patients was 41.1% compared to 24.7% in other patients (p < 0.001). End-of-life patients with malnutrition risk received more nutritional interventions than other patients with malnutrition risk. The regression models showed that being at the end of life (CI 1.30, 2.63; p < 0.001), being treated by a dietitian (OR 6.02; CI 4.86, 7.45; p < 0.001), suffering from dementia (OR 1.85; CI 1.10, 3.12; p = 0.02) or cancer (OR 1.56; CI 1.25, 1.96; p < 0.001) increased the chance of receiving oral nutritional supplements. For receiving parenteral nutrition, being at the end of life (OR 1.68; CI 1.04, 2.71; p = 0.04), being treated by a dietitian (OR 5.80; CI 4.07, 8.25; p < 0.001), surgery within the previous two weeks (OR 1.58; CI 1.09, 2.30; p = 0.02), younger age (OR 0.99; CI 0.98, 1.00; p = 0.04), care dependency (OR 0.97; CI 0.96, 0.98; p < 0.001), suffering from a disease of the digestive system (OR 2.92; CI 2.07, 4.11; p < 0.001) or cancer (OR 2.44; CI 1.71, 3.49; p < 0.001) were independent predictors. Being at the end of life did not influence the application of enteral nutrition.

CONCLUSION

This study showed that nutritional interventions are often applied in end-of-life patients admitted to general hospitals. Being at the end of life was positively associated with the application of oral nutritional supplementation and parenteral nutrition. This data does not allow a conclusion about the appropriateness of using medical nutrition therapy in this study sample. Judging the appropriateness of medical nutrition therapy at the end of life is challenging because of the high variability of prognostication as well as the wishes and needs of the specific patients and their relatives that influences the appraisal of adequate interventions. Every decision about nutrition and hydration in end-of-life patients should be a shared decision and be based on advanced care planning principles.

Effects of parenteral nutrition + best supportive nutritional care vs. best supportive nutritional care alone on quality of life in patients with pancreatic cancer-a secondary analysis of PANUSCO

PURPOSE

Parenteral nutrition (PN) can be an effective treatment to improve the nutritional status of patients with pancreatic cancer, but the effects of PN on quality of life (QoL) are still understudied. Therefore, we aimed at investigating whether the best supportive nutritional care (BSNC) in combination with PN at home compared to BSNC alone changed QoL in patients with advanced pancreatic cancer undergoing chemotherapy over a period of 7 weeks.

METHODS

n = 12 patients in the PANUSCO study received nutritional counseling only (control group (CG)) and n = 9 patients were also given supportive PN (intervention group (IG)). The primary endpoint was the change of QoL (EORTC-QLQ-C30 and QLQ-PAN26) over 7 weeks between the groups.

RESULTS

There was a significant worsening in social functioning in IG (p = 0.031) and a significant difference between groups in change of social functioning (p = 0.020). In all other domains of QoL, there was no significant difference between groups. Within groups, there was a significant improvement in the domain weight loss in IG (p = 0.031), showing that patients were less worried about their weight being too low. Furthermore, there was a significant difference in the change of BW over time between groups (p < 0.001) with IG showing an increase (p = 0.004) and CG showing no change (p = 0.578).

CONCLUSION

The administration of PN had in one of five domains negative consequences on QoL. The decision to administer PN should always be made individually and together with the patient, and the impact on QoL should be included in the decision to administer PN.

Quality of life endpoints in cancer cachexia clinical trials: Systematic review 3 of the cachexia endpoints series

The use of patient-reported outcomes (PROMs) of quality of life (QOL) is common in cachexia trials. Patients' self-report on health, functioning, wellbeing, and perceptions of care, represent important measures of efficacy. This review describes the frequency, variety, and reporting of QOL endpoints used in cancer cachexia clinical trials. Electronic literature searches were performed in Medline, Embase, and Cochrane (1990-2023). Seven thousand four hundred thirty-five papers were retained for evaluation. Eligibility criteria included QOL as a study endpoint using validated measures, controlled design, adults (>18 years), ≥40 participants randomized, and intervention exceeding 2 weeks. The Covidence software was used for review procedures and data extractions. Four independent authors screened all records for consensus. Papers were screened by titles and abstracts, prior to full-text reading. PRISMA guidance for systematic reviews was followed. The protocol was prospectively registered via PROSPERO (CRD42022276710). Fifty papers focused on QOL. Twenty-four (48%) were double-blind randomized controlled trials. Sample sizes varied considerably (n = 42 to 469). Thirty-nine trials (78%) included multiple cancer types. Twenty-seven trials (54%) featured multimodal interventions with various drugs and dietary supplements, 11 (22%) used nutritional interventions alone and 12 (24%) used a single pharmacological intervention only. The median duration of the interventions was 12 weeks (4-96). The most frequent QOL measure was the EORTC QLQ-C30 (60%), followed by different FACIT questionnaires (34%). QOL was a primary, secondary, or exploratory endpoint in 15, 31 and 4 trials respectively, being the single primary in six. Statistically significant results on one or more QOL items favouring the intervention group were found in 18 trials. Eleven of these used a complete multidimensional measure. Adjustments for multiple testing when using multicomponent QOL measures were not reported. Nine trials (18%) defined a statistically or clinically significant difference for QOL, five with QOL as a primary outcome, and four with QOL as a secondary outcome. Correlation statistics with other study outcomes were rarely performed. PROMs including QOL are important endpoints in cachexia trials. We recommend using well-validated QOL measures, including cachexia-specific items such as weight history, appetite loss, and nutritional intake. Appropriate statistical methods with definitions of clinical significance, adjustment for multiple testing and few co-primary endpoints are encouraged, as is an understanding of how interventions may relate to changes in QOL endpoints. A strategic and scientific-based approach to PROM research in cachexia trials is warranted, to improve the research base in this field and avoid the use of QOL as supplementary measures.

The role of the nutrition in malnourished cancer patients: Revisiting an old dilemma

BACKGROUND & AIMS

GLIM definition of malnutrition is recognised all over the world and, when is referring to cancer, it specifies that weight or muscle loss are associated with an inflammatory status. However, the real-world practice shows that GLIM definition cannot encompass all the wide and heterogenous clinical presentations of cancer patients with malnutrition, which involves many other drivers beyond inflammation. Moreover, placing an excessive emphasis on the inflammation can overshadow, in the clinical practice, the role of the nutritional support in malnourished cancer patients. The aim of this paper is not to criticize the rationale of the GLIM definition of cancer cachexia, but to show the complexity and heterogeneity of malnutrition of cancer patients and reasons why nutritional support should deserve such a better consideration among the oncologists.

METHODS

Literature pertinent to pathophysiology of malnutrition of cancer patients is scrutinised and reasons for the frequent underuse of nutritional support are critically analysed.

RESULTS

The appraisal of the literature shows that there are various pathophysiological patterns of malnutrition among cancer patients and inflammatory markers are not universally present in weight-losing cancer patients. Inflammation alone does not account for weight loss in all cancer patients and factors other than inflammation can drive hypophagia and weight loss, and hypophagia appears to be a primary catalyst for weight loss. Furthermore, malnutrition may be the consequence of the presence of several Nutrition Impact Symptoms or of the oncologic therapy. The nutritional support may fail to show benefits in malnourished cancer patients because the golden standard to validate a therapy relies on RCT, but it is ethically impossible to have an unfed control group of malnourished patients. Furthermore, nutritional interventions often fell short of the optimal standards, adherence to treatment plans was often poor, nutritional support was mainly reserved for very advanced patients and the primary endpoints of the studies on nutritional support were sometimes unrealistic.

CONCLUSION

There is a gap between the suggestion of the guidelines which advocate the use of nutritional support to improve the compliance of patients facing intensive oncologic treatments or to prevent an early demise when patients enter a chronic phase of slow nutritional deterioration, and the poor use of nutrition in the real-world practice. This requires a higher level of awareness of the oncologists concerning the reasons for the lacking evidence of efficacy of the nutritional support and an understanding of its potential contribute to improve the outcome of the patients. Finally, this paper calls for a change of the oncologist's approach to the cancer patient, from only focusing on the cure of the tumour to taking care of the patient as a whole.

Body weight and composition endpoints in cancer cachexia clinical trials: Systematic Review 4 of the cachexia endpoints series

Significant variation exists in the outcomes used in cancer cachexia trials, including measures of body composition, which are often selected as primary or secondary endpoints. To date, there has been no review of the most commonly selected measures or their potential sensitivity to detect changes resulting from the interventions being examined. The aim of this systematic review is to assess the frequency and diversity of body composition measures that have been used in cancer cachexia trials. MEDLINE, Embase and Cochrane Library databases were systematically searched between January 1990 and June 2021. Eligible trials examined adults (≥18 years) who had received an intervention aiming to treat or attenuate the effects of cancer cachexia for >14 days. Trials were also of a prospective controlled design and included body weight or at least one anthropometric, bioelectrical or radiological endpoint pertaining to body composition, irrespective of the modality of intervention (e.g., pharmacological, nutritional, physical exercise and behavioural) or comparator. Trials with a sample size of <40 patients were excluded. Data extraction used Covidence software, and reporting followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidance. This review was prospectively registered (PROSPERO: CRD42022276710). A total of 84 clinical trials, comprising 13 016 patients, were eligible for inclusion. Non-small-cell lung cancer and pancreatic cancer were studied most frequently. The majority of trial interventions were pharmacological (52%) or nutritional (34%) in nature. The most frequently reported endpoints were assessments of body weight (68 trials, n = 11 561) followed by bioimpedance analysis (BIA)-based estimates (23 trials, n = 3140). Sixteen trials (n = 3052) included dual-energy X-ray absorptiometry (DEXA)-based endpoints, and computed tomography (CT) body composition was included in eight trials (n = 841). Discrepancies were evident when comparing the efficacy of interventions using BIA-based estimates of lean tissue mass against radiological assessment modalities. Body weight, BIA and DEXA-based endpoints have been most frequently used in cancer cachexia trials. Although the optimal endpoints cannot be determined from this review, body weight, alongside measurements from radiological body composition analysis, would seem appropriate. The choice of radiological modality is likely to be dependent on the trial setting, population and intervention in question. CT and magnetic resonance imaging, which have the ability to accurately discriminate tissue types, are likely to be more sensitive and provide greater detail. Endpoints are of particular importance when aligned with the intervention's mechanism of action and/or intended patient benefit.

Nutrition Risk Screening 2002 for Adult Cancer Patients: A Systematic Review and Meta-Analysis

It is critical to screen and assess malnutrition in cancer patients early. However, there is no uniform standard for nutritional risk screening and malnutrition assessment. We aimed to analyze the effects of the Nutrition Risk Screening 2002 (NRS2002) in screening for nutritional risk among adult cancer patients, using the Patient-Generated Subjective Global Assessment (PG-SGA) as the reference standard. A systematic search was performed using PubMed, Embase, Web of Science, the Cochrane Library, China National Knowledge Infrastructure (CNKI), Wanfang Database, and China Science and Technology Journal Database (VIP). Studies comparing NRS2002 with PG-SGA in adult cancer patients were included. To assess the quality of the included studies, the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) was used. The combined sensitivity, specificity, diagnostic odds ratio (DOR), and the area under the receiver-operating characteristic curve (AUC) were calculated. In addition, sensitivity, subgroup, and publication bias analyses were performed. Thirteen articles involving 3,373 participants were included. The combined sensitivity, specificity, DOR, and AUC were 0.62 (95% CI, 0.60-0.64), 0.86 (95% CI, 0.84-0.88), 11.23 (95% CI, 8.26-15.27), and 0.85 (95% CI, 0.82-0.88), respectively. For adult cancer patients, NRS2002 has moderate sensitivity, high specificity, and high AUC in screening for nutritional risk.

Parenteral Nutrition in Palliative Cancer Care: Detrimental, Futile, or Beneficial?

Palliative cancer care patients may live for a long time, but malnutrition worsens the prognosis. Parenteral nutrition (PN) is suitable for replenishing a calorie deficit, but its advantages and tolerance late in the cancer trajectory are debated. We examined symptom development in hospitalized patients with and without PN. A total of 21 palliative cancer care patients receiving PN and 155 palliative cancer care patients not receiving PN during hospitalization in a specialized unit were retrospectively compared. We studied symptom intensity at admission, symptom relief during the hospital stay, and survival. The patients had locally advanced or metastatic cancer, a mean age of 70 years, and their median ECOG performance status was III. Symptom burden at admission was similar in the compared groups. Symptom relief during hospitalization was also similar. However, patients already on PN at admission reported more nausea and patients receiving PN during hospitalization reported better nausea relief compared to patients not receiving this intervention. Overall median survival was less than two months and similar in the compared groups. Based on a limited number of observations and a suboptimal study design, we were not able to demonstrate an increased symptom burden for palliative cancer care patients receiving PN late in the disease trajectory.

Updates in Cancer Cachexia: Clinical Management and Pharmacologic Interventions

Despite a better understanding of the mechanisms causing cancer cachexia (CC) and development of promising pharmacologic and supportive care interventions, CC persists as an underdiagnosed and undertreated condition. CC contributes to fatigue, poor quality of life, functional impairment, increases treatment related toxicity, and reduces survival. The core elements of CC such as weight loss and poor appetite should be identified early. Currently, addressing contributing conditions (hypothyroidism, hypogonadism, and adrenal insufficiency), managing nutrition impact symptoms leading to decreased oral intake (nausea, constipation, dysgeusia, stomatitis, mucositis, pain, fatigue, depressed mood, or anxiety), and the addition of pharmacologic agents when appropriate (progesterone analog, corticosteroids, and olanzapine) is recommended. In Japan, the clinical practice has changed based on the availability of Anamorelin, a ghrelin receptor agonist that improved lean body mass, weight, and appetite-related quality of life (QoL) compared to a placebo, in phase III trials. Other promising therapeutic agents currently in trials include Espindolol, a non-selective β blocker and a monoclonal antibody to GDF-15. In the future, a single therapeutic agent or perhaps multiple medications targeting the various mechanisms of CC may prove to be an effective strategy. Ideally, these medications should be incorporated into a multimodal interdisciplinary approach that includes exercise and nutrition.

Appetite and dietary intake endpoints in cancer cachexia clinical trials: Systematic Review 2 of the cachexia endpoints series

There is no consensus on the optimal endpoint(s) in cancer cachexia trials. Endpoint variation is an obstacle when comparing interventions and their clinical value. The aim of this systematic review was to summarize and evaluate endpoints used to assess appetite and dietary intake in cancer cachexia clinical trials. A search for studies published from 1 January 1990 until 2 June 2021 was conducted using MEDLINE, Embase and Cochrane Central Register of Controlled Trials. Eligible studies examined cancer cachexia treatment versus a comparator in adults with assessments of appetite and/or dietary intake as study endpoints, a sample size ≥40 and an intervention lasting ≥14 days. Reporting was in line with PRISMA guidance, and a protocol was published in PROSPERO (2022 CRD42022276710). This review is part of a series of systematic reviews examining cachexia endpoints. Of the 5975 articles identified, 116 were eligible for the wider review series and 80 specifically examined endpoints of appetite (65 studies) and/or dietary intake (21 studies). Six trials assessed both appetite and dietary intake. Appetite was the primary outcome in 15 trials and dietary intake in 7 trials. Median sample size was 101 patients (range 40-628). Forty-nine studies included multiple primary tumour sites, while 31 studies involved single primary tumour sites (15 gastrointestinal, 7 lung, 7 head and neck and 2 female reproductive organs). The most frequently reported appetite endpoints were visual analogue scale (VAS) and numerical rating scale (NRS) (40%). The appetite item from the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ) C30/C15 PAL (38%) and the appetite question from North Central Cancer Treatment Group anorexia questionnaire (17%) were also frequently applied. Of the studies that assessed dietary intake, 13 (62%) used food records (prospective registrations) and 10 (48%) used retrospective methods (24-h recall or dietary history). For VAS/NRS, a mean change of 1.3 corresponded to Hedge's g of 0.5 and can be considered a moderate change. For food records, a mean change of 231 kcal/day or 11 g of protein/day corresponded to a moderate change. Choice of endpoint in cachexia trials will depend on factors pertinent to the trial to be conducted. Nevertheless, from trials assessed and available literature, NRS or EORTC QLQ C30/C15 PAL seems suitable for appetite assessments. Appetite and dietary intake endpoints are rarely used as primary outcomes in cancer cachexia. Dietary intake assessments were used mainly to monitor compliance and are not validated in cachexia populations. Given the importance to cachexia studies, dietary intake endpoints must be validated before they are used as endpoints in clinical trials.

Potentially Lethal But Rarely Considered. Risk of Developing Refeeding Syndrome in Primary Oral Squamous Cell Carcinoma

Presurgical preparation and postoperative care are cornerstones of all surgical procedures. Surgeons should be especially vigilant with malnourished cancer patients. Refeeding syn-drome (RFS) is a serious, potentially fatal complication of initiating appropriate nutrition in malnourished patients or after a period of starvation, although no standard precise definition has been proposed. The rarity of its une-quivocally life-threatening course means that its risk may be underestimated in clinical practice. The study's main goal was to assess the degree of malnutrition and the risk of RFS in the presurgical status of patients with oral cavity cancer and to identify risk factors for the occurrence of RFS. This single-center prospective observational study included patients diagnosed with oral squamous cell carcinoma. We investigated the relationship of RFS with age, BMI, features of the malignant tumor process selected internal medicine comorbidities, inflam-matory markers, renal and hepatic parameters, plasma levels of diverse electrolytes, and microelements were assessed. In the work, we utilized the National Institute for Health and Clinical Excellence (NICE) criteria. The study included 90 patients: 35 women and 55 men, aged 64.2±10.5. A robust statistical correlation at a significance level of p < 0.05 was demonstrated between advanced age, lower BMI, lymph node metastases, and a relatively low LDH as positive predictors of the onset of RFS and confirmed the high predictive value of the NRS-2002 scale. This paper seeks to call attention to RFS and identify critical issues that may be useful for its prevention.

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.

Routine laboratory parameters to support decision on parenteral nutrition in palliative care

Introduction

Parenteral nutrition (PN) is widely used in palliative care (PC), but there is limited evidence to support its use at the end of life (EOL). This aim of this was to investigate the relationship between routine laboratory parameters and survival in patients receiving PN, and to develop a decision tree model to support clinicians decide whether to start or forgo PN.

Methods

The laboratory parameters of 113 patients with advanced diseases who were admitted to a specialized palliative care unit (PCU) were analyzed at two points in time: T0 = before PN, T1 = two weeks after initiation of PN. Univariate Mann-Whitney U-tests and multivariate linear regression models, as well as a decision tree analysis were computed; all in relation to survival time.

Results

The final regression model was significant with p = 0.001 (adjusted R2 = 0.15) and included two predictors for survival time after PN initiation: the CRP/albumin ratio and urea at T1 (ps = 0.019). Decision tree analysis revealed three important predictors for classification of survival time after PN initiation: CRP, urea, and LDH (all at T0).

Discussion

The decision tree model may help to identify patients likely to benefit from PN, thus supporting the clinical decision whether or not to start PN.

Physical function endpoints in cancer cachexia clinical trials: Systematic Review 1 of the cachexia endpoints series

In cancer cachexia trials, measures of physical function are commonly used as endpoints. For drug trials to obtain regulatory approval, efficacy in physical function endpoints may be needed alongside other measures. However, it is not clear which physical function endpoints should be used. The aim of this systematic review was to assess the frequency and diversity of physical function endpoints in cancer cachexia trials. Following a comprehensive electronic literature search of MEDLINE, Embase and Cochrane (1990-2021), records were retrieved. Eligible trials met the following criteria: adults (≥18 years), controlled design, more than 40 participants, use of a cachexia intervention for more than 14 days and use of a physical function endpoint. Physical function measures were classified as an objective measure (hand grip strength [HGS], stair climb power [SCP], timed up and go [TUG] test, 6-min walking test [6MWT] and short physical performance battery [SPPB]), clinician assessment of function (Karnofsky Performance Status [KPS] or Eastern Cooperative Oncology Group-Performance Status [ECOG-PS]) or patient-reported outcomes (physical function subscale of the European Organisation for the Research and Treatment of Cancer Quality of Life Questionnaires [EORTC QLQ-C30 or C15]). Data extraction was performed using Covidence and followed PRISMA guidance (PROSPERO registration: CRD42022276710). A total of 5975 potential studies were examined and 71 were eligible. Pharmacological interventions were assessed in 38 trials (54%). Of these, 11 (29%, n = 1184) examined megestrol and 5 (13%, n = 1928) examined anamorelin; nutritional interventions were assessed in 21 trials (30%); and exercise-based interventions were assessed in 6 trials (8%). The remaining six trials (8%) assessed multimodal interventions. Among the objective measures of physical function (assessed as primary or secondary endpoints), HGS was most commonly examined (33 trials, n = 5081) and demonstrated a statistically significant finding in 12 (36%) trials (n = 2091). The 6MWT was assessed in 12 trials (n = 1074) and was statistically significant in 4 (33%) trials (n = 403), whereas SCP, TUG and SPPB were each assessed in 3 trials. KPS was more commonly assessed than the newer ECOG-PS (16 vs. 9 trials), and patient-reported EORTC QLQ-C30 physical function was reported in 25 trials. HGS is the most commonly used physical function endpoint in cancer cachexia clinical trials. However, heterogeneity in study design, populations, intervention and endpoint selection make it difficult to comment on the optimal endpoint and how to measure this. We offer several recommendations/considerations to improve the design of future clinical trials in cancer cachexia.

Nutrition support in pancreatic cancer: An expert statement on practical implementation of French guidelines

The European Society for Clinical Nutrition and Metabolism (ESPEN) guidelines, shortened in 2021, are widely used for providing the most suitable nutrition support to patients with cancer. However, there is a lack of specialized guidelines for different cancer types. In 2020, members of the French medical and surgical societies involved in digestive oncology, nutrition and supportive care developed the Thésaurus National de Cancérologie Digestive (TNCD) practice guidelines which are specific nutritional and physical activity guidelines for patients with digestive cancers. These guidelines were recently updated in 2022. This review discusses the French intergroup guidelines, specifically in the context of pancreatic cancer at different stages of the disease. Pancreatic cancer is highly prevalent in Europe, with an increasing worldwide incidence over the last three decades. In France alone, about 14,000 new cases of pancreatic cancer are reported annually. More than 60% of patients with pancreatic cancer reportedly experience malnutrition and other nutritional issues which are known to have a negative impact on quality of life, treatment tolerability, general morbidity, and mortality. Given that the recommendations of TNCD guidelines correlate to other guidelines like the International Study Group on Pancreatic Surgery (ISGPS; for the perioperative setting), ESPEN and Spanish Society of Medical Oncology (SEOM) guidelines, their use can be suitably applied in other European countries. This review discusses the recommendations issued by nutrition guidelines, the challenges with effective integration of nutrition support in oncologic treatment, and the proposed algorithms on patient care pathways for pancreatic cancer management in the clinical setting.

Nutrition as prevention for improved cancer health outcomes: a systematic literature review

BACKGROUND

Among adults with cancer, malnutrition is associated with decreased treatment completion, more treatment harms and use of health care, and worse short-term survival. To inform the National Institutes of Health Pathways to Prevention workshop, "Nutrition as Prevention for Improved Cancer Health Outcomes," this systematic review examined the evidence for the effectiveness of providing nutrition interventions before or during cancer therapy to improve outcomes of cancer treatment.

METHODS

We identified randomized controlled trials enrolling at least 50 participants published from 2000 through July 2022. We provide a detailed evidence map for included studies and grouped studies by broad intervention and cancer types. We conducted risk of bias (RoB) and qualitative descriptions of outcomes for intervention and cancer types with a larger volume of literature.

RESULTS

From 9798 unique references, 206 randomized controlled trials from 219 publications met the inclusion criteria. Studies primarily focused on nonvitamin or mineral dietary supplements, nutrition support, and route or timing of inpatient nutrition interventions for gastrointestinal or head and neck cancers. Most studies evaluated changes in body weight or composition, adverse events from cancer treatment, length of hospital stay, or quality of life. Few studies were conducted within the United States. Among intervention and cancer types with a high volume of literature (n = 114), 49% (n = 56) were assessed as high RoB. Higher-quality studies (low or medium RoB) reported mixed results on the effect of nutrition interventions across cancer and treatment-related outcomes.

CONCLUSIONS

Methodological limitations of nutrition intervention studies surrounding cancer treatment impair translation of findings into clinical practice or guidelines.

Evolution of parenteral nutrition practices in a comprehensive cancer center: Comparative audits

INTRODUCTION

Malnutrition affects 20% to 70% of oncology patients depending on the patient's age, type and stage of cancer. Two audits were carried out in 2016 and 2019 to evaluate the practice of Parenteral Nutrition (PN).

METHODS

Records of adult medical inpatients who received PN between January 1, 2018 and April 30, 2019 were retrospectively analysed. Twenty criteria were defined. We conducted a statistical analysis to compare the two audit data.

RESULTS

Between January 1, 2018 and April 30, 2019, 86 hospitalizations with a PN prescription were analysed. Of the 69 patients, 66% were female, the mean and median age was 60 years. These were most often medical oncology patients in palliative care. Gynecological and digestive tumors were the two main tumor localization. Bowel obstruction and palliative care management were the two main reasons for hospitalization. Nutritional assessment, amount of energy prescribed, monitoring, and duration of PN remain with poor results.

CONCLUSION

Our study seems to show improvements in the relevance of PN indications, the prescription, and monitoring in patients due to the computerization of prescription and training of professionals. PN remains often prescribed in exclusive palliative situations. We need to continue our improvements, particularly for the initial clinical and biological assessment, and the monitoring. It requires a referral team to improve management of patients treated with PN.

Development and validation of a nomogram for patients with stage II/III gastric adenocarcinoma after radical surgery

BACKGROUND

We aimed to construct nomograms based on clinicopathological features and routine preoperative hematological indices to predict cancer-specific survival (CSS) and disease-free survival (DFS) in patients with stage II/III gastric adenocarcinoma (GA) after radical resection.

METHODS

We retrospectively analyzed 468 patients with stage II/III GA after curative gastrectomy between 2012 and 2018; 70% of the patients were randomly assigned to the training set (n = 327) and the rest were assigned to the validation set (n = 141). The nomogram was constructed from independent predictors derived from the Cox regression in the training set. Using the consistency index, the calibration and the time-dependent receiver operating characteristic curves were used to evaluate the accuracy of the nomogram. Decision curve analysis was used to assess the value of the model in clinical applications. Patients were further divided into low- and high-risk groups based on the nomogram risk score.

RESULTS

Multivariate Cox model identified depth of invasion, lymph node invasion, tumor differentiation, adjuvant chemotherapy, CA724, and platelet-albumin ratio as covariates associated with CSS and DFS. CA199 is a risk factor unique to CSS. The nomogram constructed using the results of the multivariate analysis showed high accuracy with a consistency index of 0.771 (CSS) and 0.771 (DFS). Moreover, the area under the curve values for the 3-and 5-year CSS were 0.868 and 0.918, and the corresponding values for DFS were 0.872 and 0.919, respectively. The nomogram had a greater clinical benefit than the TNM staging system. High-risk patients based on the nomogram had a worse prognosis than low-risk patients.

CONCLUSION

The prognostic nomogram for patients with stage II/III GA after radical gastrectomy established in this study has a good predictive ability, which is helpful for doctors to accurately evaluate the prognosis of patients to make more reasonable treatment plans.

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.

Effects of specialised nutritional interventions in patients with incurable cancer: a systematic review

Objective

To evaluate current evidence of the effect of specialised nutritional interventions on nutritional status, survival, quality of life and measures of functionality in patients with incurable cancer.

Methods

Systematic literature review according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines using PubMed/MEDLINE, EMBASE, Scopus, LILACS and Cochrane Library databases. Clinical studies that evaluated different specialised nutritional interventions, such as nutritional counselling, oral nutritional supplementation (ONS), enteral nutrition (EN) and parenteral nutrition (PN), were eligible. Only studies classified as being of high methodological quality (ie, low or moderate risk of bias) were included.

Results

A total of 22 studies reporting on 2448 patients were deemed eligible. Five types of specialised nutrition were observed: mixed (multimodal nature, ie, dietary counseling, ONS, physical activity and/or drugs) (n=12), ONS (n=5), PN (n=3), EN (n=1) and multidisciplinary team counselling (n=1). Benefits of any kind from the interventions were reported in 14 (63.6%) studies, mainly resulting from mixed intervention. Nutritional status improved in 12 (60.0%) of 20 studies and quality of life improved in eight (50.0%) of 16 studies. Few studies have evaluated the influence of nutritional interventions on survival and measure of functionality, and have not shown improvement in these outcomes.

Conclusion

Despite the limited evidence, specialised nutritional interventions can yield positive effects for patients with incurable cancer, mainly in their nutritional status and quality of life.

Effect of supplemental parenteral nutrition on all-cause mortality in critically Ill adults: A meta-analysis and subgroup analysis

Objective

Several observational studies have demonstrated that increased nutritional delivery by supplemental parenteral nutrition (SPN) plus enteral nutrition (EN) reduces the rate of all-cause mortality in critically ill patients. Therefore, we aimed to compare and evaluate the effect of SPN plus EN on all-cause mortality in critically ill adults.

Methods

Randomized controlled trials were retrieved from PubMed, Embase, Google Scholar, Cochrane Library, and Sinomed (up to May 2021). Adults with severe illness treated with SPN plus EN or with EN alone were enrolled. The risk of bias was evaluated using the Newcastle-Ottawa scale, and a meta-analysis was conducted using Stata software. The primary outcome was all-cause mortality and was evaluated by pooled odds ratio (OR) with the fixed-effects model. Required information size was also calculated using trial sequential analysis.

Results

We identified 10 randomized controlled trials, with a total of 6,908 patients. No significant differences in rate of all-cause mortality (OR = 0.96, 95% CI: 0.84-1.09, P = 0.518), intensive care unit (ICU) mortality (OR = 0.90, 95% CI: 0.75-1.07, P = 0.229), and hospital mortality (OR = 0.95, 95% CI: 0.82-1.10, P = 0.482) were found between the SPN plus EN and EN alone groups. SPN plus EN support was associated with a significantly decreased risk of infection (OR = 0.83, 95% CI: 0.74-0.93, P = 0.001), although the duration of mechanical ventilation [standardized mean difference (SMD) = - 0.20], length of hospital stay (SMD = 0.12), and ICU stay (SMD = - 0.57) were similar between the two groups (all P > 0.05). Meta-regression analyses showed no significant correlations between all-cause mortality and baseline clinical factors, including patients' age, the Acute Physiology and Chronic Health Evaluation II (APACHE II) score, time of SPN initiation, and follow-up duration (all P > 0.05). Subgroup analysis showed that SPN plus EN support was associated with a trend toward decreased rate of all-cause mortality in studies with follow-up < 30 days (OR = 0.61, 95% CI: 0.36-1.02, P = 0.058). Trial sequence analysis showed that the required information size for all-cause mortality was 16,972, and the cumulative Z-curve indicated no significant differences in the risk of all-cause mortality between the two groups (P > 0.05).

Conclusion

SPN plus EN support can significantly reduce the risk of infection, although it has no significant effect on all-cause mortality among critically ill patients. More studies are warranted to confirm these findings.

[Research Progress of Pharmacological Therapy and Nutritional Support for Cachexia in Lung Cancer Patients]

Cachexia is a common complication in patients with lung cancer. It aggravates the toxic and side effects of chemotherapy, hinders the treatment plan, weakens the responsiveness of chemotherapy, reduces the quality of life, increases complications and mortality, and seriously endangers the physical and mental health of patients with lung cancer. The causes and pathogenesis of tumor cachexia are extremely complex, which makes its treatment difficult and complex. Controlling cachexia in lung cancer patients requires many means such as anti-tumor therapy, inhibition of inflammatory response, nutritional support, physical exercise, and relief of symptoms to exert the synergistic effect of multimodal therapy against multiple mechanisms of tumor cachexia. To date, there has been a consensus within the discipline that no single therapy can control the development of cachexia. Some therapies have made some progress, but they need to be implemented in combination with multimodal therapy after fully assessing the individual characteristics of lung cancer patients. This article reviews the application of drug therapy and nutritional support in lung cancer patients, and looks forward to the research direction of cachexia control in lung cancer patients.
.

[Nutrition and physical activity (AP) during and after cancer treatment: Therapeutic benefits, pathophysiology, recommendations, clinical management]

Lifestyle behaviors, such as diet and physical activity, are factors that influence risk of numerous cancers. They are also decisive during and after cancer for the course of oncological treatment, but also in the immediate and long-term prognosis, and quality of life during and after treatment. Separately, physical activity and nutritional support can reduce the risk of sarcopenia and its consequences, and improve quality of life during treatment. Whan introduced early, such a combination, increases the prognostic benefits. In remission, particularly in overweight patients, the APA-diet combination reduces the risk of cancer relapse and improves cardiovascular performance. These programs require a precise assessment of capacities and habits of each patient, and interventions of trained professionals (certified exercise instructor, dietician trained in oncology). The funding conditions for these programs exist for cancer survivors and should be considered for oncological treatment period.

Kidney Function Worsening is Linked to Parenteral-Nutrition-Dependent Survival in Palliative Care Patients

Background. Parenteral nutrition (PN) is frequently administered in palliative care patients suffering from cachexia. The evidence regarding the use of PN in terminally ill patients is scarce. Routine laboratory parameters might help to decide whether to start or forgo PN, which could decrease overtreatment at the end of life. Kidney failure was frequently associated with survival. However, a relation between kidney function parameters and parenteral nutrition has not been observed thus far. The aim of this retrospective cohort study was to analyze kidney function parameters in palliative care patients under PN, as well as the relation between these parameters and overall survival. Methods. Patients who were admitted to the Department of Palliative Medicine at the Medical University of Vienna were screened for PN treatment. Whether kidney function parameters at baseline or their dynamics over the course of two weeks were associated with survival was assessed with descriptive and interferential statistics. Results. In total, 113 of 443 palliative care patients were administered parenteral nutrition for the first time. The overall survival (OS) for all patients with increased kidney function parameters at baseline was lower (creatinine: hazard ratio (HR) = 1.808, p < 0.001; urea: HR = 1.033, p < 0.001; uric acid HR = 1.055, p = 0.015). No significant increase in creatinine blood levels was observed in the first 2 weeks after the initiation of PN when compared to the non-PN group (p = 0.86). However, if creatinine blood levels increased within the PN group, lower overall survival was found (HR = 2.046, p = 0.007). Conclusion. Increased kidney function parameters, such as creatinine, urea and uric acid, might be used as negative prognostic markers in palliative care patients under PN. Moreover, an increase in creatinine during the administration of parenteral nutrition in the first 2 weeks is linked to worse outcomes. These findings may help future studies to establish objective markers for clinicians to determine whether to start or end PN in palliative cancer patients and decrease potential overtreatment at the end of life.

Prognostic Significance of Preoperative Prognostic Nutritional Index for Overall Survival and Postoperative Complications in Esophageal Cancer Patients

Background

Prognostic nutritional index (PNI), neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and systemic immune-inflammation index (SII) are the most common factors to estimate nutritional and inflammatory status. The aim of this study is to systematically evaluate the prognostic significance of above nutritional and inflammatory indexes for overall survival (OS) and surgical complications in esophageal cancer patients.

Methods

Esophageal cancer patients who underwent esophagectomy were retrospectively collected. PNI, NLR, PLR, and SII were introduced to evaluate the baseline nutritional and inflammatory status.

Results

A total of 407 patients were included in the present study. Kaplan-Meier survival analysis revealed that PNI-low group, NLR-high group and PLR-high group, all showed a significantly shorter OS (34.38% vs 49.46%, P < 0.001; 36.13% vs 48.26%, P = 0.026 and 33.33% vs 48.52%, P = 0.001 respectively), while no significant difference was found in SII groups (42.33% vs 46.31%, P = 0.067). Multivariable analyses identified PNI (P = 0.002) was an independent prognostic factor for OS, but NLR (P = 0.672) and PLR (P = 0.186) were not. Postoperative complications occurred significantly more frequently in the low-PNI group (29.69% vs 13.26%, P < 0.001). However, no significant differences were found in the postoperative complication rates between different NLR (16.67% vs 22.69%, P = 0.124), PLR (18.03% vs 19.61%, P = 0.867) and SII (15.34% vs 20.49%, P = 0.326) groups. Multivariate logistic regression analysis showed only PNI (P = 0.008) was an independent prognostic factor for postoperative complications.

Conclusion

Preoperative low PNI was not only an independent prognostic factor for worse survival in esophageal cancer patients but also associated with high incidence of postoperative complications.

Multinational Association of Supportive Care in Cancer (MASCC) expert opinion/guidance on the use of clinically assisted nutrition in patients with advanced cancer

Purpose

The pro vision of clinically assisted nutrition (CAN) in patients with advanced cancer is controversial, and there is a paucity of specific guidance, and so a diversity in clinical practice. Consequently, the Palliative Care Study Group of the Multinational Association of Supportive Care in Cancer (MASCC) formed a Subgroup to develop evidence-based guidance on the use CAN in patients with advanced cancer.

Methods

This guidance was developed in accordance with the MASCC Guidelines Policy. A search strategy for Medline was developed, and the Cochrane Database of Systematic Reviews and the Cochrane Central Register of Controlled Trials were explored for relevant reviews/trials respectively. The outcomes of the review were categorised by the level of evidence, and a “category of guideline” based on the level of evidence (i.e. “recommendation”, “suggestion”, or “no guideline possible”).

Results

The Subgroup produced 11 suggestions, and 1 recommendation (due to the paucity of evidence). These outcomes relate to assessment of patients, indications for CAN, contraindications for CAN, procedures for initiating CAN, and re-assessment of patients.

Conclusions

This guidance provides a framework for the use of CAN in advanced cancer, although every patient needs individualised management.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00520-021-06613-y.

Identification of Remaining Life Expectancy Less Than Two Weeks by C-Reactive Protein/Albumin Ratio, Prognostic Nutritional Index, Fibrosis-4 Index, and Albumin-Bilirubin Score in Terminal Cancer Patients

Background: Accurate prognosis in terminal cancer patients is useful to improve their quality of life and also to decide the cessation of fluid administration. Nonetheless, few prognostic indicators are available for prediction of such a short-term life expectancy. Objectives: The present study aimed at evaluating the efficacy of C-reactive protein (CRP)/albumin (CRP/Alb) ratio, prognostic nutritional index (PNI), fibrosis-4 (FIB-4) index, and albumin-bilirubin (ALBI) score in identifying terminal cancer patients who have a life expectancy less than two weeks. Design: Retrospective study. Setting/Subjects: Of 483 patients who died between April 2019 and March 2020 at a single center in Japan, 102 who met the inclusion criteria were enrolled in this study. Measurements: CRP/Alb, PNI, FIB-4, and ALBI were calculated from the laboratory data collected 1-13, 14-27, 28-83, and 168-365 days before death and subjected to statistical analyses. Results: CRP/Alb, PNI, FIB-4, and ALBI values were significantly associated with the time before death during terminal 365 days. CRP/Alb ≥4.4, PNI <30, FIB-4 ≥ 9.4, and ALBI ≥ -1.26 were significantly associated with the transition from the first half to the second half of terminal four weeks. Of those prognostic indicators, three and four combinations provided significantly reliable estimation of a life expectancy less than two weeks. Conclusions: CRP/Alb, PNI, FIB-4, ALBI, and their combinations are considered to help identify cancer patients who have a life expectancy less than two weeks, which is useful to make appropriate end-stage treatment decisions, for example, cessation of artificial hydration therapy.

Mortality and overall and specific infection complication rates in patients who receive parenteral nutrition: systematic review and meta-analysis with trial sequential analysis

BACKGROUND

Parenteral nutrition (PN) is an available option for nutritional therapy and is often required in the hospital setting to overcome malnutrition.

OBJECTIVES

The aim of this study was to assess whether PN is associated with an increased risk of mortality or infectious complications in all groups of hospitalized patients compared with those receiving other nutritional support strategies.

METHODS

For this systematic review and meta-analysis MEDLINE, Embase, Cochrane Central, Scopus, clinicaltrials.gov, and Web of Science were searched for randomized controlled trials (RCTs) and observational studies with parallel groups that explored the effect of PN on mortality and infectious complications, published until March 2021. Two independent reviewers extracted the data and assessed the risk of bias. Fixed-effects meta-analysis was performed to compare the groups from RCTs. Trial sequential analysis (TSA) was used to identify whether the results were sufficient to reach definitive conclusions.

RESULTS

Of the 83 included studies that compared patients receiving PN with those receiving other strategies, 67 RCTs were included in the meta-analysis. PN was not associated with a higher risk of mortality (RR: 1.01; 95% CI: 0.95, 1.07). On the other hand, PN was associated with a higher risk of infectious events (RR: 1.23; 95% CI: 1.12, 1.36). PN was specifically associated with abdominal infection and catheter infection. The TSA showed that there were sufficient data to make numerical conclusions about mortality, any infectious event, and abdominal infectious complications.

CONCLUSIONS

This study suggests that although PN is not associated with greater mortality in hospitalized patients, it is associated with infectious complications. Through TSA, definite conclusions about survival and infection rates could be made.This review was registered at www.crd.york.ac.uk/prospero/ as CRD42018075599.

Benefits, for patients with late stage chronic obstructive pulmonary disease, of being cared for in specialized palliative care compared to hospital. A nationwide register study

Background

In early stage chronic obstructive pulmonary disease (COPD), dyspnea has been reported as the main symptom; but at the end of life, patients dying from COPD have a heavy symptom burden. Still, specialist palliative care is seldom offered to patients with COPD; they more often receive end of life care in hospitals. Furthermore, symptoms, symptom relief and care activities in the last week of life for COPD patients are rarely studied. The aim of this study was to compare patient and care characteristics in late stage COPD patients treated in specialized palliative care (SPC) versus hospital.

Methods

Two nationwide registers were merged, the Swedish National Airway Register (SNAR) and the Swedish Register of Palliative Care (SRPC). Patients with COPD and < 50% of predicted forced expiratory volume in 1 s (FEV₁), who had died in inpatient or outpatient SPC (n = 159) or in hospital (n = 439), were identified. Clinical COPD characteristics were extracted from the SNAR, and end of life (EOL) care characteristics from the SRPC. Descriptive statistics were used to describe the sample and the registered care and treatments. Independent samples t-test, Mantel–Haenszel chi-square test and Fisher’s exact test was used to compare variables. To examine predictors of place of death, bivariate and multivariate logistic regression analyses were performed with a dependent variable with demographic and clinical variables used as independent variables.

Results

The patients in hospitals were older and more likely to have heart failure or hypertension. Pain was more frequently reported and relieved in SPC than in hospitals (p = 0.001). Rattle, anxiety, delirium and nausea were reported at similar frequencies between the settings; but rattle, anxiety, delirium, and dyspnea were more frequently relieved in SPC (all p < 0.001). Compared to hospital, SPC was more often the preferred place of care (p < 0.001). In SPC, EOL discussions with patients and families were more frequently held than in hospital (p < 0.001). Heart failure increased the probability of dying in hospital while lung cancer increased the probability of dying in SPC.

Conclusion

This study provides evidence for referring more COPD patients to SPC, which is more focused on symptom management and psychosocial and existential support.

Clinical nutrition as part of the treatment pathway of pancreatic cancer patients: an expert consensus

Purpose

Malnutrition is a common problem among pancreatic cancer (PC) patients that negatively impacts on their quality of life (QoL) and clinical outcomes. The main objective of this consensus is to address the role of Medical Nutrition Therapy (MNT) into the comprehensive therapeutic management of PC patients.

Methods

A Spanish multidisciplinary group of specialists from the areas of Medical Oncology; Radiation Oncology; Endocrinology and Nutrition; and General Surgery agreed to assess the role of MNT as part of the best therapeutic management of PC patients.

Results

The panel established different recommendations focused on nutritional screening and nutritional screening tools, MNT strategies according to PC status, and MNT in palliative treatment.

Conclusions

There is an unmet need to integrate nutritional therapy as a crucial part of the multimodal care process in PC patients. Health authorities, health care professionals, cancer patients, and their families should be aware of the relevance of nutritional status and MNT on clinical outcomes and QoL of PC patients.

Care of the adult cancer patient at the end of life: ESMO Clinical Practice Guidelines

•This ESMO Clinical Practice Guideline provides key recommendations for end-of-life care for patients with advanced cancer. •It details care that is focused on comfort, quality of life and approaching death of patients with advanced cancer. •All recommendations were compiled by a multidisciplinary group of experts. •Recommendations are based on available scientific data and the authors’ collective expert opinion.

Does nutrition support during chemotherapy increase long-term survival of cancer patients? Lessons from the past and future perspectives

PURPOSE

The aim of this review was to analyze the potential effect of the nutritional support (oral supplementation/counseling, tube feeding, parenteral nutrition) combined with chemotherapy on long-term survival of cancer patients.

METHODS

Using various electronic databases, we retrieved all English language papers on the combination nutritional support and chemotherapy and including data on long-term survival.

RESULTS

29 trials (4 non-RCT) were retrieved. No significant benefit was observed except for a longer survival in a few selected subgroups of patients, depending on the tumor stage and compliance with the nutritional support. However, no study included survival as primary endpoint or was adequately powered for this purpose, and patients were seldom affected by malnutrition, a condition which would have made them extremely vulnerable and unsafe during an intensive chemotherapy with significant gastrointestinal toxicity. Finally, nutritional regimens were often inappropriate as regards quality and quantity of nutrients or too similar in the two arms of the trial to expect a result.

CONCLUSION

From the review of these trials, it appears clear that there is absence of evidence more than evidence of absence of effect of the supplemental nutritional support. This poor scenario should not discourage future large multicenter trials to assess the potential of an early versus a delayed support in mildly malnourished patients. From the practical point of view, a nutritional supplementation should be considered when severe malnutrition caused by the disease or following repeated oncologic treatments can make the patients poorly compliant with further chemotherapy cycles, as recommended by the international guidelines.

Prognostic Value of Combined Preoperative Carcinoembryonic Antigen and Prognostic Nutritional Index in Patients With Stage II-III Colon Cancer

Background: Tumor status can affect patient prognosis. Prognostic nutritional index (PNI), as a nutritional indicator, is closely related to the prognosis of cancer. However, few studies have examined the combined prognostic value of CEA and PNI in patients. This study investigated the relationship between CEA/PNI and prognosis of colon cancer patients.

Methods: A total of 513 patients with stage II–III colon cancer who underwent curative resection at two medical centers from 2009 to 2019 were included. Clinicopathological factors were assessed and overall survival (OS) was assessed in a cohort of 413 patients. Multivariate analysis was used to identify independent prognostic variables to construct histograms predicting 1-year and 3-year OS. Data from 100 independent patients in the validation group was used to validate the prognostic model.

Results: The median OS time was 33.6 months, and mortality was observed in 54 patients. Multivariate analysis revealed that preoperative CEA/PNI, lymph node metastasis, peripheral nerve invasion, operation mode, and postoperative chemotherapy were independent factors for prognosis evaluation and thus were utilized to develop the nomogram. The C-index was 0.788 in the learning set and 0.836 in the validation set. The calibration curves reached favorable consensus among the 1-, 3-year OS prediction and actual observation.

Conclusion: The combined use of CEA and PNI is an independent prognostic factor and thus can serve as a basis for a model to predict the prognosis of patients with stage II–III colon cancer.

Effects of parenteral nutrition and hydration on survival in advanced cancer patients with malignant bowel obstruction: secondary analysis of a multicenter prospective cohort study

PURPOSE

The benefits of parenteral nutrition and hydration (PNH) in patients with advanced cancer remain unknown. Therefore, we conducted a prospective multicenter cohort study to assess the effects of PNH on survival in patients with malignant bowel obstruction (MBO).

METHODS

The present study was a secondary analysis. Data on primary nutritional administration routes during the first week of admission to palliative care units, i.e., parenteral nutrition and parenteral hydration, were obtained. Data on the averaged calorie sufficiency rate/total calorie intake (75% ≤ or 750 kcal/day ≤ , 50-75% or 500-750 kcal/day, 25-50% or 250-500 kcal/day, and < 25% or < 250 kcal/day) were also obtained. Participants with MBO were included and divided into two groups: PNH-high (25% ≤ or 250 kcal/day ≤) and PNH-low (< 25% or < 250 kcal/day). We performed time-to-event analyses using the Kaplan-Meier method, log-rank test, and univariate and multivariate Cox regression analyses.

RESULTS

Patients were divided into the PNH-high (n = 68) and PNH-low (n = 76) groups. A significant difference was observed in survival rates between the two groups (log-rank P < 0.001). Median survival times were 35.5 (95% CI 27-44) and 17.5 (95% CI 13-21) days, respectively. In the multivariate-adjusted model, a significantly lower risk of mortality was observed in Cox's proportional hazard model in the PNH-high group (HR 0.55 (95% CI 0.36-0.83), P = 0.005) than in the PNH-low group.

CONCLUSION

The present results indicated the beneficial effects of PNH for prolonging survival in advanced cancer patients with MBO in palliative care units.

Cancer cachexia in adult patients: ESMO Clinical Practice Guidelines☆

•This ESMO Clinical Practice Guideline provides key recommendations for managing cancer-related cachexia. •It covers screening, assessment and multimodal management of cancer cachexia. •All recommendations were compiled by a multidisciplinary group of experts. •Recommendations are based on available scientific data and the author's expert opinion.

Association of Nutritional Support With Clinical Outcomes in Malnourished Cancer Patients: A Population-Based Matched Cohort Study

Malnutrition is prevalent in hospitalized cancer patients and has been associated with poor therapy response and unfavorable clinical outcome. While recent studies have shown a survival benefit through nutritional support in a hospitalized malnourished medical population including cancer patients, we aimed to investigate the association of nutritional support with in-hospital mortality and other clinical outcomes in a nationwide inpatient cancer population. In this population-based cohort study, using a large Swiss administrative claims database from April 2013 to December 2018, we created two cohorts of malnourished cancer patients on medical wards. We generated two pairwise cohorts of malnourished patients who received nutritional support by 1:1 propensity-score matching to patients not receiving nutritional support. The primary outcome was all-cause in-hospital mortality. Secondary outcomes were 30-days all-cause hospital readmission and discharge to a post-acute care facility. To account for disease activity, we stratified patients either admitted for cancer as main diagnosis or admitted with cancer as comorbidity. Among 1,851,498 hospitalizations on medical ward, we identified a total of 32,038 malnourished cancer patients. After matching, 11,906 (37%) cases were included in the “cancer main diagnosis cohort” and 5,954 (18.6%) in the “cancer comorbidity cohort.” Patients prescribed a nutritional support showed a lower in-hospital mortality in both cohorts as compared to their respective matched controls not receiving nutritional support [cancer main diagnosis cohort: 15.4 vs. 19.4 %, OR 0.76 (95% CI 0.69–0.83); cancer comorbidity cohort: 7.4 vs. 10.2%, OR 0.71 (95% CI 0.59–0.85)]. While we found no difference in 30-days readmission rates, discharge to a post-acute care facility was less frequent in the nutritional support group of both cohorts. In this large cohort study, nutritional support in hospitalized patients with either cancer as main diagnosis or comorbidity was associated with a lower risk of in-hospital mortality and discharge to a post-acute care facility.

In Reply: Randomized Studies Are Needed to Improve Knowledge of Nutritional Interventions for Advanced Cancer Patients

This letter to the editor continues a discussion about parenteral nutrition for patients with advanced cancer and calls for future randomized studies assessing both enteral and parenteral nutrition.

Nutritional interventions for older adults in palliative care: a scoping review

Abstract Objective To analyze the nutritional interventions adopted in older people in palliative care found in the literature. Method A scoping review was conducted involving a search of the following databases: PubMed, LILACS, CINAHL, Scopus, Web of Science, EMBASE and of the gray literature through Google Scholar, OpenGrey and ProQuests & Theses Global, without restrictions on publication date or language. The searches were performed using the descriptors and keywords, combined using Boolean operators AND and OR: “Nutritional Intervention”, “Intervenção Nutricional”, “Palliative Care”, “Cuidados Paliativos”, “Aged” and “Idosos”. Results Of the 5,942 studies found, 13 studies were selected. The backward citation search strategy identified 13 additional studies, giving a final total of 26 studies. Nutritional interventions adopted in older people in palliative care predominantly comprised nutritional counseling, oral nutritional supplementation and artificial nutrition through enteral and parenteral nutrition. These interventions focused on quality of life, symptom management and nutritional status. Conclusion Although there are gaps in the literature regarding nutritional interventions for older adults in palliative care, the importance of the role of nutritionists in promoting quality of life and relieving suffering of this population is clear.

Nutrition and physical activity: French intergroup clinical practice guidelines for diagnosis, treatment and follow-up (SNFGE, FFCD, GERCOR, UNICANCER, SFCD, SFED, SFRO, ACHBT, AFC, SFP-APA, SFNCM, AFSOS)

This document is a summary of the French intergroup guidelines regarding the nutrition and physical activity (PA) management in digestive oncology. This collaborative work was produced under the auspices of all French medical and surgical societies involved in digestive oncology, nutrition and supportive care. It is based on published guidelines, recent literature review and expert opinions. Recommendations are graded according to the level of evidence. Malnutrition affects more than half of patients with digestive cancers and is often underdiagnosed. It has multiple negative consequences on survival, quality of life and risk of treatment complications. Consequently, in addition to anticancer treatments, supportive care including nutritional support and PA plays a central role in the management of digestive cancers. It is crucial to detect malnutrition (diagnostic criteria updated in 2019) early, to prevent it and to act against it at all stages of the cancer and at all times of the care pathway. In this context, we proposed recommendations for the evaluation and management in nutrition and PA in digestive oncology for each stage of the disease (perioperative setting, during radiation therapy, during systemic treatments, at the palliative phase, after cancer). Guidelines for nutrition and PA management aim at increasing awareness about malnutrition in oncology. They are continuously evolving and need to be regularly updated.

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.