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.

A European survey on the practice of nutritional interventions in head-neck cancer patients undergoing curative treatment with radio(chemo)therapy.

PURPOSE: As the practice of nutritional support in patients with head and neck cancer (HNC) during curative radio(chemo)therapy is quite heterogeneous, we carried out a survey among European specialists. METHODS: A 19-item questionnaire was drawn up and disseminated via the web by European scientific societies involved in HNC and nutrition. RESULTS: Among 220 responses, the first choice was always for the enteral route; naso-enteral tube feeding was preferred to gastrostomy in the short term, while the opposite for period longer than 1 month. Indications were not solely related to the patient's nutritional status, but also to the potential burden of the therapy. CONCLUSION: European HNC specialists contextualize the use of the nutritional support in a comprehensive plan of therapy. There is still uncertainty relating to the role of naso-enteral feeding versus gastrostomy feeding in patients requiring < 1 month nutritional support, an issue that should be further investigated.

ESPEN practical guideline: Clinical nutrition in chronic intestinal failure.

BACKGROUND: This practical guideline is based on the ESPEN Guidelines on Chronic Intestinal Failure in Adults. METHODOLOGY: ESPEN guidelines have been shortened and transformed into flow charts for easier use in clinical practice. The practical guideline is dedicated to all professionals including physicians, dieticians, nutritionists, and nurses working with patients with chronic intestinal failure. RESULTS: This practical guideline consists of 112 recommendations with short commentaries for the management and treatment of benign chronic intestinal failure, including home parenteral nutrition and its complications, intestinal rehabilitation, and intestinal transplantation. CONCLUSION: This practical guideline gives guidance to health care providers involved in the management of patients with chronic intestinal failure.

Chemotherapy-Induced Sarcopenia.

OPINION STATEMENT: Sarcopenia is being consistently recognized as a condition not only associated with the presence of a malignancy but also induced by the oncologic therapies. Due to its negative impact on tolerance to chemotherapy and final outcome in both medical and surgical cancer patients, sarcopenia should be always considered and prevented, and, if recognized, should be appropriately treated. A CT scan at the level of the third lumbar vertebra, using an appropriate software, is the more common and easily available way to diagnose sarcopenia. It is now acknowledged that mechanisms involved in iatrogenic sarcopenia are several and depending on the type of molecule included in the regimen of chemotherapy, different pharmacologic antidotes will be required in the future. However, progression of the disease and the associated malnutrition per se are able to progressively erode the muscle mass and since sarcopenia is the hallmark of cachexia, the therapeutic approach to chemotherapy-induced sarcopenia parallels that of cachexia. This approach mainly relies on those strategies which are able to increase the lean body mass and include the use of anabolic/anti-inflammatory agents, nutritional interventions, physical exercise and, even better, a combination of different therapies. There are some phase II studies and some small controlled randomized trials which have validated these treatments using single agents or combined multimodal approaches. While these approaches may require the cooperation of some specialists (nutritionists with a specific knowledge on pathophysiology of catabolic states, accredited exercise physiologists and physiotherapists), the oncologist too should directly enter these issues to coordinate the choice and priority of the treatments. Who better than the oncologist knows the natural history of the disease, its evolution, and the probability of tolerance and response to the oncologic therapy? Only the oncologist knows when it is essential to potentiate any effort to better achieve a control of the disease, using all the available armamentarium, and when the condition is too advanced and hence requires a more palliative than supporting care. The oncologist also knows when to expect a gastrointestinal toxicity (mucositis, nausea, vomiting, and diarrhea) and hence it is more convenient using a parenteral than an enteral nutritional intervention or, on the contrary, when patient is suitable for discharge from hospital and oral supplements should be promptly tested for compliance and then prescribed. When patients are at high risk for malnutrition or if, regardless of their nutritional status, they are candidate to aggressive and potentially toxic treatments, they should undergo a jointed evaluation by the oncologist and the nutritionist and physical therapist to assess together a combined approach. In conclusion, the treatment of both cancer- or chemotherapy-related sarcopenia represents a challenge for the modern oncologist who must be able to coordinate a new panel of specialists with the same skill necessary to decide the priority of different oncologic treatments within a complex multidisciplinary context.

Nutritional interventions in elderly gastrointestinal cancer patients: the evidence from randomized controlled trials.

Literature concerning nutritional interventions in elderly patients with gastrointestinal cancer, with special reference to randomized clinical trials, has been critically reviewed. This segment of oncologic population was found to be penalized by a high prevalence of malnutrition and sarcopenia which translated in an increased rate of toxicity from chemotherapy, poor compliance with oncologic treatments, and, finally, with a poor prognosis. Attempts to reverse this condition included a potentiation of nutrients intake which should sequentially proceed through the use of dietary counseling and administration of standard or ω-3 fatty acid-enriched oral supplements to finally come to enteral or parenteral nutrition. Randomized clinical trials investigating the effects of simple dietary advice and use of standard oral supplements were disappointing as regards long-term compliance and results. Nutritional and clinical benefits were reported with the use of ω-3 fatty acid-enriched oral supplements and especially with long-term supplemental parenteral nutrition. Despite the general recommendation of the scientific community that emphasizes the use of the enteral route, whenever possible, for delivering the nutritional support, it appears from the literature that more consistent benefits can be achieved, especially in the long-term nutritional support, when an insufficient oral nutrition is partnered with intravenous nutrition.

Clinical approach to the management of Intestinal Failure Associated Liver Disease (IFALD) in adults: A position paper from the Home Artificial Nutrition and Chronic Intestinal Failure Special Interest Group of ESPEN.

We recommend that intestinal failure associated liver disease (IFALD) should be diagnosed by the presence of abnormal liver function tests and/or evidence of radiological and/or histological liver abnormalities occurring in an individual with IF, in the absence of another primary parenchymal liver pathology (e.g. viral or autoimmune hepatitis), other hepatotoxic factors (e.g. alcohol/medication) or biliary obstruction. The presence or absence of sepsis should be noted, along with the duration of PN administration. Abnormal liver histology is not mandatory for a diagnosis of IFALD and the decision to perform a liver biopsy should be made on a case-by-case basis, but should be particularly considered in those with a persistent abnormal conjugated bilirubin in the absence of intra or extra-hepatic cholestasis on radiological imaging and/or persistent or worsening hyperbilirubinaemia despite resolution of any underlying sepsis and/or any clinical or radiological features of chronic liver disease. Nutritional approaches aimed at minimising PN overfeeding and optimising oral/enteral nutrition should be instituted to prevent and/or manage IFALD. We further recommend that the lipid administered is limited to less than 1 g/kg/day, and the prescribed omega-6/omega-3 PUFA ratio is reduced wherever possible. For patients with any evidence of progressive hepatic fibrosis or overt liver failure, combined intestinal and liver transplantation should be considered.

Evidence-based nutritional support of the elderly cancer patient.

The papers included in this section represent the effort of the Task Force on Nutrition of the International Society of Geriatric Oncology to synthetize the evidence-based concepts on nutritional support of the elderly cancer patients. In the attempt of presenting a comprehensive overview of the topic, the panel included experts from different specialties: basic researchers, nutritionists, geriatricians, nurses, dieticians, gastroenterologists, oncologists. Cancer in elderly people is a growing problem. Not only in almost every country, the proportion of people aged over 60 years is growing faster than any other age group, but cancer per se is also a disease of old adult-elderly people, hence the oncologists face an increasing number of these patients both now and in the next years. The are several studies on nutrition of elderly subjects and many other on nutrition of cancer patients but relatively few specifically devoted to the nutritional support of the elderly cancer patients. However, the awareness that elderly subjects account for a high proportion of the mixed cancer patients population, in some way legitimates us to extend some conclusions of the literature also to the elderly cancer patients. Although the topics of this Experts' Consensus have been written by specialists in different areas of nutrition, the final message is addressed to the oncologists. Not only they should be more directly involved in the simplest steps of the nutritional care (recognition of the potential existence of a "nutritional risk" which can compromise the planned oncologic program, use of some oral supplements, etc.) but, as the true experts of the natural history of their cancer patient, they should also coordinate the process of the nutritional support, integrating this approach in the overall multidisciplinary cancer care.

The oncologist as coordinator of the nutritional approach.

Although the nutritional approach, especially when delivered through a gastric or jejunal tube or in a central vein, is handled by the nutritional support team or a specialist in nutrition, it is the responsibility of the oncologist, who knows the natural history of the disease and the impact of the oncologic therapy, to identify the potential candidates for the nutritional support, to recommend the nutritional strategy and to integrate it within the oncologic program. If gastrointestinal function is preserved, the initial nutritional approach should be through oral supplementation, followed by tube feeding if previous attempts are unsuccessful or upper gastrointestinal tract is not accessible. Parenteral nutrition is the obligatory resort when patients are (sub)obstructed but it may also be a practical way to integrate an insufficient oral nutrient intake (so called "supplemental" parenteral nutrition). Depending on the patient's condition and the disease's stage, artificial nutrition may have a "permissive" role in patients receiving aggressive oncologic therapy or represent just a supportive treatment in patients likely to succumb from starvation sooner than from tumor progression.

Nutritional support of the oncology patient.

This review focuses on the nutritional support of the non-surgical cancer patient. The following topics are reviewed: cancer cachexia (definition and staging, prevalence and impact on clinical outcome); nutritional screening to identify potential candidates for nutritional support; nutritional requirements in terms of macro-and micro-nutrients of the advanced cancer patient. Finally, the indications and results of nutritional support are presented with a special focus on the following issues: routes of delivering nutritional support, the use of standard or n-3 fatty acids-enriched oral nutritional supplements during radiation therapy and/or chemotherapy, tube feeding during RT (with/without chemotherapy), parenteral nutrition during chemotherapy, nutritional support during hematopoietic stem cell transplantation, (home) enteral or total and supplemental parenteral nutrition in the incurable patient. Lastly, the bioethical aspects of feeding patients with incurable disease are briefly reviewed.

Is the intravenous supplementation of amino acid to cancer patients adequate? A critical appraisal of literature.

BACKGROUND & AIMS: International guidelines are quite vague regarding the optimal doses of amino acid to administer to cancer patients and standard practice appears not to be supported by specific investigations. The purpose of this study is to determine from the literature whether there are some correlates among amino acid infusions and nutritional-metabolic or clinical outcomes. METHODS: Through the help of PubMed (www.ncbi.nlm.nih.gov) and the use of a personal database we analysed papers reporting details of infused amino acid and metabolic-nutritional or clinical effects. RESULTS: Five short-term metabolic studies using isotopes showed that infusion of about 2 g amino acid/kg/day (including high doses of branched chain amino acid) positively affects protein metabolism of severely malnourished cancer patients. In eight studies in less malnourished patients receiving longer periods of parenteral nutrition, to allow the administration of oncologic therapy or to compensate for a decline in oral alimentation, the intravenous addition of 1.5 g amino acid/kg/day to the oral diet achieved positive results. These findings are concordant with recent metabolic results achieved in cancer patients receiving amino acid orally. CONCLUSION: We think that a higher quantity of parenteral amino acids than that usually administered might be useful to cancer patients and further studies on this issue are warranted.

Perioperative intravenous glutamine supplemetation in major abdominal surgery for cancer: a randomized multicenter trial.

OBJECTIVE: To investigate whether perioperative intravenous glutamine supplementation may affect surgical morbidity. SUMMARY BACKGROUND DATA: Small-sized randomized trials showed a trend toward a reduction of postoperative infections in surgical patients receiving glutamine. METHODS: : A randomized, multicentre trial was carried out in 428 subjects who were candidates for elective major gastrointestinal surgery. Inclusion criteria were: documented gastrointestinal cancer, weight loss <10% in previous 6 months, and age >18 years. Patients received either intravenous infusion of L-alanine-L-glutamine dipeptide (0.40 g/kg/d; equal to 0.25 g of free glutamine) (Ala-Glu group, n = 212), or no supplementation (control group, n = 216). Glutamine infusion began the day before operation and continued postoperatively for at least 5 days. No postoperative artificial nutrition was allowed unless patients could not adequately eat by day 7. Postoperative morbidity was assessed by independent observers according to a priori definition. RESULTS: Patients were homogenous for baseline and surgical characteristics. Mean percent of weight loss was 1.4 (2.7) in controls and 1.4 (2.4) in Ala-Glu group. Overall postoperative complication rate was 34.9% (74/212) in Ala-Glu and 32.9% (71/216) in control group (P = 0.65). Infectious morbidity was 19.3% (41/212) in Ala-Glu group and 17.1% (37/216) in controls (P = 0.55). The rate of major complications was 7.5% (16/212) in Ala-Glu group and 7.9% (17/216) in controls (P = 0.90). Mean length of hospitalization was 10.2 days (4.8) in Ala-Glu group versus 9.9 days (3.9) in controls (P = 0.90). The rate of patients requiring postoperative artificial nutrition was 13.2% (28/212) in Ala-Glu group and 12.0% (26/216) in controls (P = 0.71). CONCLUSIONS: Perioperative glutamine does not affect outcome in well-nourished GI cancer patients.

Quality of life and enteral nutrition.

PURPOSE OF REVIEW: The quality of life is in essence, the patients' subjective view of their own health status and can add another dimension to the evaluation of a treatment as the enteral nutrition.The recent clinical investigations on this topic are critically summarized in this review. RECENT FINDINGS: Three areas of potential impact of enteral nutrition on quality of life of patients have been identified: elderly and neurological patients, cancer patients and patients with anorexia nervosa.A major problem is the difficulty to define quality of life, due to the holistic and subjective nature of this dimension. Moreover, many patients require help to complete the forms of the questionnaire. Finally, many factors besides the enteral nutrition can affect the quality of life of these patients, namely the basic condition and the primary disease of the patients. SUMMARY: Although the enteral nutrition often represents a life-saving procedure, this does not necessarily translate in an appreciation of a better quality of life by the patients.Additional factors as the gustatory deprivation and the loss of social contacts usually associated with eating and the frequent problems related to tube function and tube-feeding represent severe limitations to a good quality of life of these patients.

Nutritional issues in the care of the elderly patient.

Aging is associated with a progressive decline in the function of many organs and apparatus. In a medical context, depletion of lean body mass and muscle mass in particular, and alteration of the immune system are of utmost importance. A defective immune response is associated with an increased incidence of inflammatory, infective and neoplastic diseases in the elderly as well as with a slow and sluggish recovery after illness or other injury. Depletion of muscle mass, the so-called sarcopenia, is responsible for the typical frailty of the elderly. Moreover, since muscle represents the protein reserve of the body, its progressive erosion not only results in a poor mobility and disability of these subjects, with associated complications, but with a diminished capacity to meet the extra demand of protein synthesis associated with disease and injury. In cancer patients, as in other elderly patients with different pathologies, it is important to evaluate the nutritional status, since frailty of these individuals recognizes as a relevant etiopathogenetic cofactor, a defective food intake. Nutritional support should aim at meeting the requirements in macronutrients, in water and in micronutrients. Requirements are not so different from those of adult subjects, since the decrease in energy expenditure due to a lower physical activity is compensated by the increase due to the disease. Particular attention must be given to fluid administration, since the elderly tolerate fluid overload less than hypohydration. Elderly patients quite frequently suffer from long-standing undernutrition; this means that nutritional repletion will take more time than is usually expected with use of medication. If a correct feeding program is performed for a few weeks, a benefit can be observed not only on the nutritional status but also in the clinical outcome. In fact nutritional support may have a permissive role in the administration of aggressive (oncologic) treatment than may be otherwise denied to elderly patients.