ESPEN Congress Geneva 2014 ESPEN GUIDELINES. ESPEN Guidelines: nutrition support in cancer J. Arends (DE)

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1 ESPEN Congress Geneva 2014 ESPEN GUIDELINES ESPEN Guidelines: nutrition support in cancer J. Arends (DE)

2 espen and epaac guidelines nutrition in cancer Jann Arends Tumor Biology Center Freiburg

3 Ethical dilemmas Bioethical principles Application of bioethical principles to Nutrition at the endof-life The decision-making process

4 sponsors

5

6 aim of the guideline Translate current evidence and expert opinion into recommendations for the multi disciplinary team responsible for prevention, identification and treatment of reversible elements of malnutrition in cancer patients and contribute to decreasing the risk of cancer recurrence.

7 Guideline: Problems Evidence of high quality is very limited Recommendations triggered solely by the level of evidence are not helpful for clinical practice ESPEN Cancer GL 2006&2009 AGREE ratingof applicability: 0 7/100 [van den Berg T et al. JPEN 2011]

8 Evidence Recommendations: GRADE : initially after adjustment RCT: high very low.. high Observ. Study: low very low.. high Expert opinion: very low very low adjusting for: study quality, inconsistencies, indirectness, imprecision, bias magnitude of effect, dose response relationship STRONG: desirable effects clearly outweigh harms WEAK: trade offs are uncertain ESPEN disease specific guideline framework. Preiser JC & Schneider SM, Clin Nutr 2011 Grading quality of evidence and strength of recommendations. Oxman AD et al., Br Med J 2004 GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. Guyatt GH et al., Br Med J 2008

9 time frame and methodology experts, 2 ESPEN leaders, 2 methodologists evidence search and GRADE technique* recommendations consensus process online review, ESPEN website *ESPEN disease specific guideline framework; Clin Nutr 2011

10 outline 0 Methods Goals, target population, professional groups involved patient views, target users, conflict of interest and funding design, searches, recommendations, consensus professional review, updating of GL facilitators/barriers, costs, monitoring/auditing A B C Introduction Major alterations in cancer patients effects on clinical outcome aims of nutritional interventions General concepts relevant to all cancer patients Interventions relevant to specific patient categories

11 outline 0 Methods A B C Introduction General concepts relevant to all cancer patients B1 Screening and assessment B2 Energy and substrate requirements B3 Nutritional interventions B4 Physical exercise B5 Pharmacological agents Interventions relevant to specific patient categories

12 outline 0 Methods A B C Introduction General concepts relevant to all cancer patients Interventions relevant to specific patient categories C1 Surgery C2 Radiotherapy C3 Curative medical anticancer treatment C4 High dose chemotherapy and HSCT C5 Cancer survivors C6 Incurable cancer patients

13 Section B1, Statement 1 B1 1 STRONG Screening To detect nutritional disturbances at an early stage, we recommend to regularly evaluate nutritional intake, weight change and BMI, beginning with cancer diagnosis and repeated depending on the stability of the clinical situation. Very low relationship of screening to assessment interventions and clinical outcomes

14 Section B1, Statement 2 B1 2 STRONG Assessment In patients with abnormal screening, we recommend objective and quantitative assessment of nutritional intake, nutrition impact symptoms, physical performance and the degree of systemic inflammation. Very low Linking outcomes from current and future intervention trials with appropriate screening and assessment tools

15 Section B2, Statement 1 B2 1 STRONG Energy requirements We recommend, for practical purposes, that total energy expenditure of cancer patients, if not measured individually, be assumed to be rather similar to healthy subjects and ranging between 25 and 30 kcal/kg/day. Low improve prediction of energy requirements in the individual patient

16 Section B2, Statement 2 B2 2 WEAK Protein intake We suggest that protein intake should be above 1 g/kg/day and if possible up to 1.5 g/kg/day Moderate effect on outcome of increased supply and composition of protein/amino acids

17 Section B2, Statement 3 B2 3 STRONG Choice of energy substrates In most patients general recommendations are applicable. In weight losing patients with advanced cancer we recommend a fat intake of 35 50% of total energy requirement. Low effect of high fat on outcome in specific patient groups

18 Section B2, Statement 4 B2 4 STRONG Vitamins and trace elements We recommend that vitamins and minerals be supplied in amounts approximately equal to the RDA and discourage the use of high dose micronutrients in the absence of specific deficiencies. Low Assessment of micronutrient status in cancer patients and effect of supplementation

19 Section B3, Statement 1 B3 1 STRONG Efficacy of nutritional intervention We recommend nutritional intervention to increase oral intake in cancer patients who are able to eat but are malnourished or at risk of malnutrition. This includes dietary advice, the treatment of symptoms and derangements impairing food intake, and offering oral nutritional supplements. Moderate effect of advice and ONS on outcome

20 Section B3, Statement 2 B3 2 STRONG Low efficacy of special diets We recommend against dietary provisions like anticancer diets which restrict energy intake in patients with or at risk of malnutrition. Low

21 Section B3, Statement 3 B3 3 STRONG Modes of nutrition We recommend enteral nutrition if oral nutrition remains inadequate despite nutritional interventions, and parenteral nutrition if enteral nutrition is not sufficient or feasible. Moderate effect of EN or PN or combinations on outcome

22 Section B3, Statement 4 B3 4 STRONG Refeeding syndrome If oral food intake has been decreased severely for a prolonged period of time, we recommend to increase enteral or parenteral nutrition only slowly over several days and to take additional precautions to prevent a refeeding syndrome. Low Assessment of phosphate, potassium and magnesium levels in malnourished cancer patients and response to artificial feeding

23 Section B3, Statement 5 B3 5 STRONG Home artificial nutrition In patients with chronic insufficient dietary intake and/or uncontrollable malabsorption we recommend home artificial nutrition in suitable patients Low Effect of long term EN and PN on clinical outcome

24 Section B4, Statement 1 B4 1 STRONG Exercise in combination with nutrition We recommend maintenance or increased level of physical activity in cancer patients during and after treatment to support muscle mass, physical function and metabolic pattern. High effect of physical activity on outcome

25 Section B4, Statement 2 B4 2 WEAK Type of exercise recommended We suggest individualized resistance exercise to maintain muscle strength and muscle mass during treatment. Low effect of resistance and endurance exercise on outcome

26 Section B5, Statement 1 B5 1 WEAK Corticosteroids to increase appetite We suggest to consider using corticosteroids to increase the appetite of anorectic cancer patients for a restricted period of time but to be aware of potential side effects (e.g. muscle wasting). High Methods to counteract corticosteroid related muscle wasting

27 Section B5, Statement 2 B5 2 WEAK Progestins to increase appetite We suggest to consider using progestins to increase the appetite of anorectic cancer patients for a limited period of time but to be aware of potential serious side effects. High Prospective studies to evaluate the combined effects of appropriate nutritional support and progestins

28 Section B5, Statement 3 B5 3 WEAK Cannabinoids to improve appetite We suggest to consider cannabinoids to attempt to improve taste disorders and anorexia in cancer patients Low Effects of cannabinoids on nutritional state in anorectic cancer patients with taste alterations

29 Section B5, Statement 4 B5 4 Androgens to increase muscle mass NONE There are insufficient data to recommend on androgenic steroids to increase muscle mass High Mechanism and long term effects of SARMs in patients with cachexia.

30 Section B5, Statement 5 B5 5 NONE Amino acids There is not enough clinical data to recommend the supplementation with branched chain amino acids or metabolites to improve fat free mass. Low Effects of leucine or HMB (hydroxy methylbutyrate) in weight losing patients studied in large randomized trials

31 Section B5, Statement 6 B5 6 NONE Non steroidal antiinflammatory drugs There is not enough data to recommend non steroidal antiinflammatory drugs to improve body weight in weight losing cancer patients. Low Effect of NSAIDs on body composition and clinical outcome in cancer patients with systemic inflammation

32 Section B5, Statement 7 B5 7 WEAK N 3 fatty acids to improve appetite and body weight In cancer patients undergoing chemotherapy at risk of weight loss, we suggest to use the supplementation with long chain n 3 fatty acids or fish oil to stabilize/improve appetite, food intake, lean body mass and body weight. Moderate Questions forresearch Effectoflong chain N 3 fatty acids on body composition and clinical outcome in cancer patients undergoing antineoplastic treatment

33 Section C1, Statement 1 C1 1 STRONG Enhanced recovery after surgery (ERAS) care For all cancer patients undergoing either curative resectional or palliative surgery we recommend management within an enhanced recovery after surgery program. High optimal components including nutrition of ERAS protocol for oncology patients

34 Section C1, Statement 2 C1 2 STRONG Surgery: Multimodal oncological pathway For a patient undergoing repeated surgery as part of a multimodal oncological pathway, management of each surgical episode should be within an ERAS programme. Low role of multimodal rehabilitation during prolonged oncological therapy

35 Section C1, Statement 3 C1 3 STRONG Surgery: Care after hospital discharge In surgical cancer patients at moderate or severe nutritional risk we recommend appropriate ONS/enteral nutritional support both before and following discharge from hospital. Moderate The role of immunonutrition when upper GI cancer patients are managed within an ERAS pathway. The optimal post operative regimen in terms of type, preparation and access to normal food +/ oral nutritional supplements for patients managed within an ERAS pathway. The role of n 3 enriched oral supplements/enteral nutrition in upper GI cancer patients for preservation of lean body mass and optimisation of organ function.

36 Section C1, Statement 4 C1 4 STRONG Traditional peri operative care In upper GI cancer patients undergoing surgical resection in the context of traditional perioperative care we recommend oral/enteral immunonutrition. High Role of immunonutrition for upper GI cancer patients managed within an ERAS pathway

37 Section C2, Statement 1 C2 1 STRONG RT: Ensuring adequate nutritional intake We recommend that during RT to the head neck, upper and low GI tract and thorax, an adequate nutritional intake should be ensured primarily by individualized nutritional counseling and/or with use of ONS, in order to avoid nutritional deterioration, maintain intake and avoid RT interruptions Moderate

38 Section C2, Statement 2 C2 2 STRONG RT: Use of tube feeding We recommend that tube feeding may be done using transnasal or PEG in RT induced severe mucositis or in headneck/throracic cancers with obstructive tumor masses. Low

39 Section C2, Statement 3 C2 3 STRONG RT: Maintaining swallowing function We recommend that patients should be encouraged and educated on how to maintain their swallowing function during EN. Low

40 Section C2, Statement 4 C2 4 STRONG Radiation induced diarrhea: glutamine We do not recommend using glutamine during pelvic RT to prevent RT induced enteritis/diarrhea. Low

41 Section C2, Statement 5 C2 5 NONE Radiation induced diarrhea: probiotics There is not enough data to recommend Lactobacilluscontaining probiotics to reduce radiation induced diarrhea. Low

42 Section C2, Statement 6 C2 6 STRONG RT: Use of parenteral nutrition Parenteral nutrition (PN) is not recommended in general in RT; it should only be initiated if adequate oral/enteral nutrition is not possible, e.g. severe RT enteritis, severe mucositis or head neck/oesophageal obstructive cancer masses. Moderate

43 Section C3, Statement 1 C3 1 STRONG Medical anticancer treatment: Ensuring adequate nutrition During anticancer drug treatment we recommend to ensure an adequate nutritional intake and to maintain physical activity. Very low

44 Section C3, Statement 2 C3 2 STRONG Medical anticancer treatment: Use of artificial nutrition If oral food intake is inadequate despite counselling and ONS, we recommend to initiate enteral or, if this is not sufficient or possible, parenteral nutrition. Very low

45 Section C3, Statement 3 C3 3 NONE Medical anticancer treatment: use of glutamine There is insufficient evidence to recommend glutamine supplementation during conventional cytotoxic or targeted therapy. Low

46 Section C3, Statement 4 C3 4 NONE Medical anticancer treatment: fish oil For oncological outcomes there is insufficient evidence to recommend for or against fish oil supplementation during chemotherapy. Low Questions forresearch Effectsoflong chain N 3 fatty acids on the therapeutic index of chemotherapy

47 Section C4, Statement 1 C4 1 STRONG HSCT: ensuring adequate nutrition and physical activity During high dose anticancer drug treatment and stem cell transplantation we recommend to maintain physical activity and to ensure an adequate nutritional intake. This may often require artificial nutrition. Very low Effects of physical actvity on clinical outcome

48 Section C4, Statement 2 C4 1 WEAK HSCT: Artificial nutrition If artificial nutrition is required we suggest to prefer enteral tube feeding over parenteral nutrition, unless there is severe mucositis or symptomatic gastrointestinal GvHD. Low

49 Section C4, Statement 3 C4 3 NONE HSCT:Germ free food There is not enough evidence to recommend germ free food for patients more than 30 days after allogeneic transplantation Low

50 Section C4, Statement 4 C4 4 NONE HSCT:glutamine There is not enough evidence to recommend for or against glutamine to reduce anticancer therapy side effects especially in high dose protocols. Low

51 Section C5, Statement 1 C5 1 STRONG Cancer survivors: Physical activity We recommend that cancer continue to engage in regular physical activity and avoid physical inactivity. Low Effects of physical activity on physical function, recurrence and survival in cancer survivors

52 Section C5, Statement 2 C5 2 STRONG Cancer survivors: Healthy lifestyle In cancer survivors we recommend a healthy weight and a healthy (primarily plant based) diet, high in fruits, vegetables and whole grains, and low in fat, red meat and alcohol. Low Effects of healthy diet on outcome

53 Section C6, Statement 1 C6 1 STRONG Incurable patients: screening and assessment We recommend to routinely screen all advanced, incurable cancer patients whether receiving or not receiving anticancer treatment for inadequate nutritional intake, weight loss and low body mass index, and if found at risk, to assess these patients further. Low Effects of malnutrition screening programs on quality of life in incurable cancer patients

54 Section C6, Statement 2 C6 2 STRONG Incurable patients: ensuring nutritional intake Nutritional interventions should be used in patients with advanced incurtable cancer if their expected benefit outweighs the potential harm and the patient wants it. Low Effects of nutrtional care on quality of life in incurable cancer patients

55 Section C6, Statement 3 C6 3 STRONG Very advanced terminal phase In patients who are imminently dying treatment should be based on comfort. Artificial hydration and nutrition are unlikely to provide any benefit for most patients. Low

56 espen epaac gl group CA AU oncology anesthesiology physiology radiooncology hematology surgery surgery dietitian radiooncology gastroenterology nutrition palliative medicine nursing pharmacology internal medicine health science nutrition Nutrition oncology palliative medicine ESPEN Arends Bachmann Baracos Barthelemy Bertz Bozzetti Fearon Hütterer Kaasa Krznaric Isenring Laird Larsson Mühlebach Muscaritol Oldervoll Ravasco v.d. Schueren Solheim Strasser Laviano Preiser (some experts have several affiliations)