Nutrition Support in Patient with Cancer Altered intake 胃腸道功能與生理影響 Dysphagia, particularly in head and neck cancer Obstruction of any area of the G-I tract Decreased intake secondary to depression, sadness, and fear and anxiety Multiple modalities used to treat cancer patient adversely affect intake –Operative therapy –Chemotherapeutic agents –Radiation therapy Alterations in taste secondary to treatment, specific nutrient deficiencies

Weight loss can be prevented and reversed postsurgical complications and deaths diminished, but lean tissue accrual or conservation CRC Crit Rev in Oncology/Hematology vol 7, Issue Nutritional support cures malnutrition, not cancer Brennan; N. Engl. J. Med. 305;

Multifactorial etiology of cancer- associated malnutrition Inadequate intake from primary tumor induced anorexia and/or obstructing lesion Toxicity from chemotherapy or radiotherapy Primary catabolic effects of the tumor Abnormal metabolism of nutritients

Components of cancer Cachexia 50% - 80 % of cancer patients have symptoms and signs of cachexia –weight loss –anorexia –weakness –asthenia –anemia –abnormalities in protein, lipid, and carbohydrate metabolism Hematology/Oncology Clinics of North America; 5:Feb , 1991

Weight loss Over 20 % of death are due simply to malnutrition and host tissue wasting 50% of newly diagnosed cancer patients are anorexia Nutrition; 12: , 1996

Nutritional Oncology: A Proactive, Integrated Approach to the Cancer Patient Loss of at least 5% of pre-illness weight in one third of patient with malignancy 20% of cancer patients succumb to progressive nutritional deterioration or inanition rather than to the malignancy Adversely impact the outcomes, quality, and cost of care Malnourished patients have an average length of stay that is twice that of diagnosis- adjusted well-nourished patients

Major goals of supportive nutrition Adjunctive to the specific oncology treatment goal maintain adequate nutritional status, body composition, performance status, immune function, and quality of life Stabilize or improve nutritional status as well as increasing the potential of a favorable response to therapy and enhancing recovery from any adverse effect of therapy early supportive nutritional intervention is to avoid irreversible nutritional and physiological deficits Weight loss in the cancer patient can often be prevented, but generally only of addressed proactively

Questions concerning the effectiveness of nutritional care Inherent part of cancer –Several treatable impediments to adequate nutritional intake –Appropriate pharmacological, behavioral or surgical treatment will alleviate many of these impediments –Just as one treats a cancer patient’s diabetes or congestive heart failure as a separate disease from the cancer, so should one treat the malnutrition or symptoms impacting nutrient intake as separate from the cancer

Questions concerning the effectiveness of nutritional care Inappropriate study design –have often times used inappropriate eligibility and ineligibility criteria ineligible or nutritional intervention was not initiated until end-stage cancer and/or malnutrition supportive nutrition should not be put in the same category as phase I chemotherapy - only used when all other treatment fails

Questions concerning the effectiveness of nutritional care Quality of Intervention –Assessment of the quality of nutritional intervention regiments and meeting of the individual patient’s requirements have not generally been addressed in individual reports of nutrition support –nutritional intervention is not consistent in a number of reports of the use of parenteral or enteral nutrition in treating malnutrition of the cancer patient

Questions concerning the effectiveness of nutritional care Nutrition Support is High-Technology Nutrition –usually parenteral nutrition, but it may also include enteral tube feedings –In the oncology patient, the concept of nutrition support is used primarily in the context of the severely malnourished, terminal, or end-stage patient rather than proactive, often oral intervention

Questions concerning the effectiveness of nutritional care Cost –Generally considered to be a costly intervention –one that is to be avoided if possible –Combined with poorly defined indicators for initiation of supportive nutrition, has led to delayed and/or inappropriate use of supportive nutritional intervention –Consideration of the use of nutritional counseling and aggressive symptom management is less often considered in the development of nutritional intervention protocols

Questions concerning the effectiveness of nutritional care Poor Performance Status –Placed on nutritional intervention are frequently malnourished, with decreased performance status, marked decrease in muscle mass and function –Although function may improve with nutrition per se, mass loss is generally not reversible without a component of physical activity or exercise

Proactive Nutritional Assessment of the Oncology Patient Easy of use, cost-effectiveness, and reproducibility in several clinical settings Ability to predict those patients who need nutritional intervention Little interobserver variability Patient-Generated Subjective Global Assessment (PG-SGA) of Nutritional Status

Patient-Generated Subjective Global Assessment (PG-SGA) of Nutritional Status Lack of time on the part of oncologists or oncology nurses to incorporate an additional assessment procedure or instrument Perception on the part of p’ts and family that nutrition and weight loss are import in the overall oncology course PG-SGA add less than a minute to the overall clinic process and add directly to the quality of nutritional and other components of supportive care In addition to outcome-based, cost-effective results, patient satisfaction is increasingly becoming as important component of physician and institution report cards

Nutritional Intervention Options Presence or absence of a functional gastrointestinal tract Treatment plans: surgery, radiation, chemo/hormonal/biological response modifier therapy Degree of baseline nutritional deficit Issues of quality of life and prognosis Issues of cost effectiveness and utility

Components of Successful Oral Intervention Aggressive and Proactive Symptom Management GI symptoms: nausea and vomiting, constipation or diarrhea, mucositis/stomatitis, delayed gastric emptying/slowed GI transit time, food intolerances Anorexia Pain Depression/anxiety/psychosocial considerations

Components of Successful Oral Intervention Inclusion of the following principles of oral nutrition Definition of calorie and protein goals Removal of dietary restrictions Management of sensory changes Definition food intolerances with avoidance, treatment Education of patient to thinks of food as medicine Addressing patient issues of control and self-image Timing of nutritional counseling and timing of trials of nutritional supplements to optimize compliance Addressing appropriate vitamin use in terms of timing and dose