Nutrition Support in Patient with Cancer Altered intake

1
Nutrition Support in Patient with Cancer Altered
intake

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• 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

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Nutritional support cures malnutrition, not
cancer Brennan N. Engl. J. Med. 305375. 1981

• 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
4. 1987 289-327
3
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

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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
5Feb103-110, 1991
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Weight loss

• Over 20 of death are due simply to malnutrition
  and host tissue wasting
• 50 of newly diagnosed cancer patients are
  anorexia

Nutrition 12 358-371, 1996
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Nutritional OncologyA 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

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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

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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 patients 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

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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

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Questions concerning the effectiveness of
nutritional care

• Quality of Intervention
• Assessment of the quality of nutritional
  intervention regiments and meeting of the
  individual patients 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

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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

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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

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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

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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
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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 pts 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

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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

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Components of Successful Oral InterventionAggress
ive 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

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Components of Successful Oral InterventionInclusi
on 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