Nutrition And Cancer Flashcards
Nutritional issues for patients with cancer
- physical effects of the tumour: pain, obstruction, fatigue, malabsorption, taste change, nausea, vomiting
- treatment: effects of surgery and radiotherapy/chemotherapy
- tumour related factors: pro-inflammatory cytokines, metabolic dysregulation, systemic inflammation
Symptoms experienced by >50% of cancer patients
- loss of appetite
- fatigue
- loss of energy
- pain
- weakness
How impaired nutrition impacts cancer patients
- reduces: survival, QoL, performance status, tumour response to treatment, ability to tolerate treatment
- increases: treatment toxicity, complications after surgery
- weight loss can significantly negatively impact on survival
Definition of cancer cachexia and different severities
- multi factorial syndrome characterised by loss of skeletal muscle mass (with or without fat mass), that cannot be fully reversed by conventional nutritional support and leads to progressive functional impairment
- pre-cachexia: weight loss <5%, anorexia and metabolic change
- cachexia: weight loss of >5%, BMI <20, often accompanied by reduced food intake and systemic inflammation
- refractory cachexia: low performance score and likely <3 months survival, cancer is procatabolic and unresponsive to treatment
Definition of sarcopenia and impact on cancer patients
- loss of muscle mass, strength, function and quality (fat infiltration in muscle)
- impact on cancer patients: increases infection risk, length of hospital stay and need for rehabilitation
Issues with sarcopenia and cachexia screening in cancer patients
- comparing nutritional screening tools with CT scans (gold-standard) can see that in some cases >50% of cases were missed
Examples of simple nutritional interventions for cancer patients
- more food
- nutritional supplements
- enteral feeding
- parental nutrition
Oral nutritional interventions for cancer: what does the evidence say?
- significant benefit to QoL, and some studies suggested improved energy intake and treatment toxicity (2 studies)
- no difference was shown in weight, survival, response to treatment, treatment interruptions and treatment toxicity (5 studies)
- no evidence for reduced cost
ESPEN recommendations for oral nutrition intervention
- recommend nutritional intervention to increase oral intake for cancer patients who are able to eat but are malnourished or at risk of malnourishment (moderate level of evidence)
- STRONG strength of recommendation (i.e most patients will likely want this intervention)
Steroids and progestins for cancer cachexia: what does the evidence say and what are ESPEN recommendations?
- progestagens: megestrol acetate
- corticosteroids: medroxyprogeaterone acetate
- evidence: increases appetite and weight gain (mostly water and fat), not effective at increasing lean body mass, no conclusions on QoL, use is limited by side effects
- ESPEN: recommend use of progestins/corticosteroids to increase appetite, but should be used with caution for SE (high level of evidence, but weak recommendation).
Omega 3 for cancer cachexia: what does the evidence tell us and what does ESPEN say?
- omega 3 can be supplemented in capsules or by fortified ONS (but would have to ingest very high amount to have benefit- low compliance)
- EPA supplements have shown increase in lean mass but only in post-hoc analysis. If given in combination with progestins there is no improvement in weight or appetite. Meta-analysis data insufficient to show adequate effect
- issues with data: lack of compliance (pill burden), contamination of control group, timings of intervention (should perhaps use in less severe patients earlier on?)
- ESPEN recommendations: recommend supplementation in advanced cancer patients and those undergoing chemotherapy and at risk of weight loss or who are malnourished (weak level of evidence with weak recommendation)
What does a multi-modal approach to nutritional care look like?
Oral nutritional support + novel therapy + patient-centered approach
Patient-centered approach: what are the considerations? What are cancer patients experience of weight loss? How are they managing weight loss? What is their experience with early palliative care?
- considerations: the burden of artificial nutrition support, and alleviating consequences of cachexia (symptoms)
- patient experience with weight loss: feeling proximity to death, physical/emotional weakness
- healthcare professional experience: helplessness, feeling like weight loss is a ‘taboo’
- how patients manage weight loss: taking control, promoting self-worth, relationship work, distractions
- macmillian approach to weight loss and eating found to be acceptable for patients
- early palliative care improves survival
Optimal management for cancer cachexia patients
- patient-centered care: management of practical and psychological aspects
- nutritional needs: early identification of simple nutritional interventions
- more accurate diagnosis of cachexia to allow for early intervention
- multimodal interventions: combinations of ACCEPTABLE treatments for patients
