PENSA meetingCancer: impact of nutrition intervention outcome—nutrition issues for patients☆
Introduction
In Western countries, cancer is the second leading cause of death. More than 1.2 million new cases of cancer were expected to be diagnosed in the United States in 1998 (a 2% decrease from 1997 incidence statistics), and in Australia there are about 345 000 new cases a year, 270 000 of which are skin cancers.1, 2 More than 500 000 Americans were expected to die from cancer in 1998—that is, approximately 1500 people a day.1 In Australia 28% of male deaths and 25% of female deaths are from cancer.2 Survival rates have improved, with the 5-y relative survival rate increasing from 52% (1980–1982 data) to an estimated 60% (based on 1986–1993 data).1
Section snippets
Prevalence of malnutrition and weight loss in patients with cancer
Nutritional decline is often accepted as part of the cancer course and its treatment. The prevalence of weight loss and malnutrition in patients has been reported to range from 9% in patients with breast cancer to 80% in patients with esophageal cancer.3, 4, 5 In addition, as many as 20% of patients with cancer die from the effects of malnutrition rather than the malignancy.6
Patients with cancer of the lung, esophagus, stomach, colon, rectum, liver, and pancreas are at greatest risk of weight
Etiology of malnutrition in patients with cancer
The etiology of malnutrition in patients with cancer is multifactorial.8 Malnutrition can result from the systemic effects of the tumor, the local effects of the tumor, or the side effects of anticancer treatment.11, 12 Systemic effects, such as anorexia and altered metabolism seen with cachexia, are multiple and differ in type and severity depending on the form of cancer. Local effects usually are associated with malabsorption, obstruction, diarrhea, and vomiting.13 Fatigue, depression,
Anorexia and cachexia
Anorexia, or the involuntary decline of food intake, occurs in at least half of newly diagnosed cancer patients. Mechanical anorexia, such as the inability of patients with esophageal cancer to consume adequate energy, is a major contributor to the development of malnutrition but often can be overcome by enteral feeding. Cancer cachexia is a complex metabolic syndrome in which patients experience anorexia, early satiety, weakness, anemia, sarcopenia, and severe weight loss.15, 16, 17 The
Surgery
The stress response observed with surgery is associated with hypermetabolism, tissue breakdown, and protein loss. This response leads to weight loss, fatigue, and a deterioration in functional status.25 Post-operative weight loss results from an increased energy expenditure due to the stress response and a decreased dietary intake.25
Patients who have undergone surgery of the head-and-neck area such as the oropharynx or esophagus might experience malnutrition due to a decreased ability to ingest
Chemotherapy
Chemotherapeutic drugs are toxic to the malignant tissue and normal host cells that have a high turnover rate, such as cells in the bone marrow; hair follicles; oral, esophageal, and gastrointestinal mucosa; and reproductive system.13 Damage to the mucosa of the gastrointestinal tract can adversely affect the digestion and absorption of nutrients. Antineoplastic agents such as cisplatin, doxorubicin, and fluorouracil can indirectly affect food intake, absorption, or use by inducing severe
Radiotherapy
The severity and extent to which patients undergoing radiation treatment experience side effects depend on the tumor and treatment site, duration of treatment, and radiation dose. Radiotherapy is toxic to tumor cells and normal host cells within the area of treatment. As with chemotherapy, rapidly dividing tissue cells, such as blood cells, hair follicles, and cells lining the gastrointestinal tract, are the most susceptible to radiation damage.13 Therefore, any treatment directed at the
Impact of malnutrition on outcomes in patients with cancer
Cancer cachexia regardless of its etiology has been associated with poor outcomes in patients with cancer. Malnutrition not only affects morbidity and mortality but also can lead to lower quality of life and a change in self-image.37, 38 The social aspects of eating are affected by reduced appetite, nausea, or vomiting. Nutrition affects functional status and well-being as malnourished patients experience weakness and fatigue, which can affect the ability to work or carry out activities of
Nutritional support in patients with cancer
The goal of nutritional support is to prevent or reverse the weight loss that often accompanies malignancy. As previously demonstrated, weight loss is associated with poor patient outcomes such as response to therapy, quality of life, and survival. Thus, preventing or reversing weight loss through nutritional support should improve patient outcomes, e.g., performance status, functional status, appetite, and quality of life. Total parenteral nutrition, enteral nutrition, nutritional supplements,
Summary
Malnutrition is prevalent in cancer patients, especially those with solid tumors. Poor nutritional status can result in decreased quality of life, functional status, and response to therapy. Nutrition decline does not have to be an accepted part of cancer therapy. Screening cancer patients can determine who is at risk for malnutrition. Nutrition intervention, in the form of oral supplements and tube feeding, can affect patient outcomes. Nutrition is more than just food—it is a component of care
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Financial support was provided by Abbott Laboratories, Columbus, Ohio, USA.