Bethesda Handbook of Clinical Oncology, 2nd Edition
Nutrition for Oncology Patients
National Institutes of Health Clinical Center, Department of Nutrition, Bethesda, Maryland
The incidence of malnutrition and its effect on oncology patients as well as suggested efforts to minimize this effect are presented in this chapter.
- Incidence: more than 40% of oncology patients develop signs of malnutrition during treatment.
- Malnourished patients have impaired responses to treatment (1,2).
- They incur higher costs for their care.
- They have increased rates of mortality and morbidity (2).
- As many as 20% of oncology patients die from nutritional complications rather than from their primary diagnosis (3).
- Efforts to minimize malnutrition: Nutritional deterioration in oncology patients is not inevitable and can be minimized dramatically with appropriate screening and timely intervention.
IDENTIFYING NUTRITIONAL RISK
For nutritional interventions to be effective, patients at risk for malnutrition must be identified before irreversible deficits occur.
Parameters most useful in identifying patients at nutritional risk include (see Fig. 41.1)
FIG. 41.1. Parameters most useful in identifying patients at nutritional risk. R.D., registered dietitian; BMI, body mass index; GI, (gastrointestinal; pt, patient; WNL, within normal limits; NCI, national cancer institute.)
- weight change
- functional status
- symptom status
- changes in food intake
- changes in body composition
- visceral protein markers.
Simple, validated tools have been developed to allow the timely identification of patients at risk.
- The Subjective Global Assessment (SGA) form developed by Dr. Jeejeebhoy et al. (1987) has been adapted for use with oncology patients by Dr. Faith Ottery (Contact Ottery & Associates Inc., phone, 215-351-4050) (4,5).
- This patient-generated tool (PG-SGA) helps identify patients at nutritional risk and may improve patient satisfaction because attention to a patient's nutritional health is a major concern for patients and their families.
EFFECTIVE NUTRITION INTERVENTION
Continual reassessment, pharmacologic management, and nutrition counseling can help avoid costly, risky nutrition support options.
When nutritional risk is identified early and realistic nutritional interventions implemented in a timely manner, there can be
- improvement in quality of life and nutritional status
- weight maintenance.
Nutrition counseling by registered dietitians (RDs) is associated with improvement in quality of life, with improvement in nutritional parameters, and with success of oral nutritional intervention for oncology patients (see Table 41.1).
TABLE 41.1. Simple Food/Oral Nutrition Supplement Recommendations
Refer to registered dietitian (R.D.), for comparable products at your facility. Brand names provided as examples only—does not imply endorsement.
Neutropenia: emphasize food-borne illness prevention (well-washed products are safe)
Early satiety: calorically dense foods/nutrition products (e.g., Scandi and Polycose)
Poor appetite/fatigue: to ↓ dependence on appetite >5 scheduled feedings/day, reliance on nutritious liquids (quenching thirst) without need for appetite
Nausea: ↓ fat foods/supplements (e.g., Biocare, Boost, Resource drink)
Malabsorption: semi-elemental palatable products (e.g., Propeptide oral formulation)
Diarrhea: ↓ lactose, ↓ fat, ↓ insoluble fiber, ↓ soluble fiber (e.g., Benefiber and Ensure light)
Fat malabsorption: ↓ fat diet and MCT<–oil fortified foods/products (e.g., Lipisorb)
Aversion to canned “milkshake-type” products: fortification of preferred foods (e.g., soups) with modular kcal or protein supplements (Polycose, Promod)MCT, medium chain triglycerides.
Effective nutritional intervention by an RD may include:
- modifications of foods and feeding schedules
- fortification of foods with modular nutritional products
- supplementation with meal-replacement products.
Eating is extremely individualized and complex, affected by such factors as food aversions or associations, cultural influences, and family dynamics.
Nutritional recommendations must be tailored to the individual's needs, incorporating input from the patient and family in order to be successful.
Providing nutritional samples and written information alone is not associated with nutritional success.
Self-imposed diets and the use of dietary supplements should be evaluated by an RD for possible risks and for the potential to confound results of protocols (see Table 41.2)
TABLE 41.2. Quick Nutrition Reference for Adult Oncology Patients
UUN, urinary urea nitrogen concentration; RDA, reference daily intake; BMI, body mass index; TPN, total parenteral nutrition; PPN, peripheral parenteral nutrition; DHEA, dehydro-3-epiandrosterone; IU, international unit.
· Kilocalories: 20 kcal/kg (actual wt) for obese patients
· 25–30 kcal/kg for sedentary patients
· 35 kcal/kg for hypermetabolic patients or in cases of malabsorption
· Fluid: 1 mL/kcal; 35 mL/kg of body weight; 1,500 mL/m2of body surface
· 1,500 mL/kg of body weight for first 20 kg, plus 25 mL/kg for the remaining wt
· Protein: 1.2 g/kg; Weekly 24-hr urine for UUN to assess adequacy; 0.8 g protein/kg = RDA and is appropriate for nondialyzed renal insufficiency
· Wt (kg)/Ht(m2); BMI 19–25, healthy wt range
Nutrient Limitations for Nutrition Support:
· Dextrose (parenteral nutrition by central-line TPN):
· Maximal glucose oxidation rate ~4–6 mg/kg/min (TPN)
· Initial dextrose concentration: 10%–15%; final, 20%–25% (PPN): final dextrose concentration, 10%.
· Lipids to provide 30% of total kcals usually (up to 60% total kcals for PPN)
Diets and Supplements That Pose a Risk:
· Gerson diet, strict macrobiotic diet; Chaparral, Peau D'arco, Mistletoe, (DHEA); Vit A >5,000 (IU)/d, B6 >200 mg/d, chromium >200 mg/d
· Vitamin D >1,600 IU/d, Fe >15 mg/d (unless Fe deficiency clear), Zn >25 mg/d.
· Vitamin C >250 mg/d may alter renal excretion of chemotherapy.
· Any single antioxidant taken in excess (e.g., α-carotene) may cause a pro-oxidant state or malabsorption of other antioxidants (Vitamin E <800 IU/d has not been found to be harmful in vitamin K–sufficient adults not taking anticoagulants).
Although tumor growth is stimulated by a number of nutrients, limitation of the nutrients preferred by tumors can lead to detriments in the patient.
- Maintenance of good nutritional status does not appear to have deleterious effects on tumor growth.
- In more than 200 patients with Hodgkin disease (HD), malnourished patients had greater rates of tumor growth (demonstrated by incorporation of [3H]thymidine-labeling index in the tumor tissue) than well-nourished patients (6).
The superiority of enteral over parenteral nutrition has been reviewed in many references (7).
- If the gut works, it should be used.
- To be successful, enteral nutrition should be implemented as soon as the need arises.
- Surgeons may approve of enteral feeding of the patient within 4 hours of placement of gastrostomy tubes and immediately after jejunostomy (because bowel sounds are not needed).
- Prophylactic placement of gastrointestinal (GI) tubes can reduce the amount of weight loss during radiotherapy considerably and can reduce the incidence of hospitalization for dehydration, weight loss, or other complications of mucositis (8).
- Reviews of nutrition support practices indicate that parenteral nutrition is often instituted even when safer, more physiologic enteral nutrition support could have been provided (7,9).
- Total parenteral nutrition (TPN) can be beneficial to patients with cancer when response to treatment is good but the associated nutritional morbidity high and when the GI tract is unavailable to support nutrition.
- The use of perioperative TPN should be limited to patients who are severely malnourished, with surgery expected to prevent oral intake for more than 10 days after surgery (8,10) (Table 41.2).
- Feeding is synonymous with caring by many family members. Provision of nominal supportive care for preterminal patients can reduce family tension as well as readmissions because of hydration and electrolyte maintenance problems.
- Data indicate that parenteral nutrition can improve quality of life and functional status for preterminal patients with a Karnofsky performance status greater than 50. The risks and benefits of nutrition support must be addressed individually and evaluated for each case with patient and family input.
- Aker SN. Oral feedings in the cancer patient. Cancer 1979;43(Suppl):2103–2107.
- Ottery FD. Nutritional oncology: a proactive, integrated approach to the cancer patient. In: R Chernoff, ed. Nutrition support theory and therapeutics,. New York: Chapman & Hall, 1997:395–409.
- Ambrus J, Ambrus CM, Mink IB, et al. Causes of death in cancer patients. J Med Clin Exp Ther 1975;6:61–64.
- Ottery FD. Supportive nutrition to prevent cachexia and improve quality of life. Semin Oncol 1995;22(2 Suppl. 3):98–111.
- Osoba D. Current applications of health-related quality of life assessment in oncology. Support Care Cancer 1997;5:100–104.
- Bozzetti FEA. Relationship between nutritional status and tumor growth in humans. Tumori 1995;81:1–6.
- Mercadante S. Parenteral versus enteral nutrition in cancer patients: indications and practice. Support Care Cancer 1998;6:85–93.
- Lee JH, Machtay M, Unger LD, et al. Prophylactic gastrostomy tubes in patients undergoing intensive irradiation for cancer of the head and neck. Arch Otolaryngol Head Neck Surg 1998;124:871–875.
- Bowman LEA. Algorithm for nutritional support: experience of the metabolic and infusion support service of St. Jude Children's research hospital. Int J Cancer 1998;11:76–80.
- Kelly CJ, Daly JM. Perioperative care of the oncology patient. World J Surg 1993;17:199–206.